OAR 410-200-0105
Hospital Presumptive Eligibility

This rule sets out when an individual is presumptively eligible for MAGI Medicaid/CHIP, BCCTP, and FFCYM (OAR 410-200-0407 (Specific Requirements—Former Foster Care Youth Medical Program)) based on the determination of a qualified hospital.
(1) A qualified hospital shall, with the consent of the individual or someone acting on the individual’s behalf, determine Hospital Presumptive Eligibility (HPE) for MAGI Medicaid/CHIP, BCCTP, or FFCYM.
(2) The qualified hospital shall determine Hospital Presumptive Eligibility based on the following information attested by the individual:
(a) Family size;
(b) Household income;
(c) Receipt of other health coverage;
(d) Residency
(e) US citizenship, US national, or non-citizen status.
(3) To be eligible via Hospital Presumptive Eligibility, an individual must be a US citizen, US National, or meet the citizenship and non-citizen status requirements found in 410-200-0215 (Citizenship and Non-Citizen Status Requirements) and one of the following:
(a) A child under the age of 19 with income at or below 300 percent of the federal poverty level;
(b) A parent or caretaker relative of a dependent child with income at or below the MAGI Parent or Caretaker Relative income standard for the appropriate family size in OAR 410-200-0315 (Standards and Determining Income Eligibility);
(c) A pregnant individual with income at or below 185 percent of the federal poverty level;
(d) A non-pregnant adult between the ages of 19 through 64 with income at or below 133 percent of the federal poverty level; or
(e) An individual under the age of 65 who has been screened by a licensed healthcare provider and determined to need treatment for breast or cervical cancer, or who has been determined eligible for the Breast and Cervical Cancer Treatment Program (OAR 410-200-0400 (Specific Requirements; Breast and Cervical Cancer Treatment Program (BCCTP)));
(f) An individual under the age of 26 who was in Oregon foster care on their 18th birthday.
(4) To be eligible via Hospital Presumptive Eligibility, an individual may not:
(a) Be receiving Supplemental Security Income benefits;
(b) Be a Medicaid/CHIP beneficiary; or
(c) Have received a Hospital Presumptive Eligibility approval start date within the year (365 days) prior to a new Hospital Presumptive Eligibility period start date.
(5) In addition to the requirements outlined in sections (3) and (4) above, the following requirements also apply:
(a) To receive MAGI Adult benefits via Hospital Presumptive Eligibility, an individual may not be entitled to or enrolled in Medicare benefits under part A or B of Title XVIII of the Act;
(b) To receive MAGI CHIP benefits via Hospital Presumptive Eligibility, an individual may not be covered by any minimum essential coverage that is accessible (OAR 410-200-0410 (Specific Requirements; MAGI CHIP)(2)(c));
(c) To receive BCCTP benefits via Hospital Presumptive Eligibility, an individual may not be covered by any minimum essential coverage.
(6) The Hospital Presumptive Eligibility period begins on the earlier of:
(a) The date the qualified hospital determines the individual is eligible; or
(b) The date that the individual received a covered medical service from the qualified hospital, if the hospital determines the individual is eligible and submits the decision to the Authority within five calendar days following the date of service.
(7) The Hospital Presumptive Eligibility period ends:
(a) For individuals on whose behalf a Medicaid/CHIP application has been filed by the last day of the month following the month in which the hospital presumptive eligibility period begins, the day on which the state makes an eligibility determination for MAGI Medicaid/CHIP and sends basic decision notice; or
(b) If subsection (a) is not completed, the last day of the month following the month in which the hospital presumptive eligibility period begins.
(8) A Hospital Presumptive Eligibility approval is not a full eligibility determination and does not entitle beneficiaries to the following:
(a) A child is not entitled to continuous eligibility (OAR 410-200-0135 (Assumed, Continuous, and Protected Eligibility for Children and Pregnant Individuals)) based solely on the receipt of benefits during a period of Hospital Presumptive Eligibility;
(b) A baby born to an individual receiving benefits during a period of hospital presumptive eligibility is not assumed eligible (OAR 410-200-0135 (Assumed, Continuous, and Protected Eligibility for Children and Pregnant Individuals)) based solely the Hospital Presumptive Eligibility determination of the parent;
(c) An individual is not entitled to EXT (OAR 410-200-0440 (Specific Requirements; Extended Medical Assistance)) based solely on the receipt of MAGI PCR during a period of Hospital Presumptive Eligibility;
(d) An individual whose Hospital Presumptive Eligibility period is terminated due to incarceration is not entitled to automatic restoration of benefits upon release (OAR 410-200-0140 (Eligibility for Inmates));
(e) Individuals are not entitled to hearing rights (OAR 410-200-0145 (Contested Case Hearing)) for benefits received during a period of Hospital Presumptive Eligibility.

Source: Rule 410-200-0105 — Hospital Presumptive Eligibility, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-200-0105.

410‑200‑0010
Overview 410‑200‑0015
General Definitions 410‑200‑0100
Coordinated Eligibility and Enrollment Process with the Department of Human Services and the Federally Facilitated Marketplace 410‑200‑0105
Hospital Presumptive Eligibility 410‑200‑0110
Application and Renewal Processing and Timeliness Standards 410‑200‑0111
Authorized Representatives 410‑200‑0115
HSD Medical Programs—Effective Dates 410‑200‑0120
Notices 410‑200‑0125
Acting on Reported Changes 410‑200‑0130
Retroactive Medical 410‑200‑0135
Assumed, Continuous, and Protected Eligibility for Children and Pregnant Individuals 410‑200‑0140
Eligibility for Inmates 410‑200‑0145
Contested Case Hearing 410‑200‑0146
Final Orders, Dismissals and Withdrawals 410‑200‑0200
Residency Requirements 410‑200‑0205
Concurrent and Duplicate Program Benefits 410‑200‑0210
Requirement to Provide Social Security Number 410‑200‑0215
Citizenship and Non-Citizen Status Requirements 410‑200‑0220
Requirement to Pursue Assets 410‑200‑0225
Assignment of Rights 410‑200‑0230
Verification 410‑200‑0235
Changes That Must Be Reported 410‑200‑0240
Eligibility for Individuals Who Do Not Meet the Citizen and Non-Citizen Status Requirements 410‑200‑0305
Eligibility Determination Group — MAGI Medicaid/CHIP 410‑200‑0310
Eligibility and Budgeting 410‑200‑0315
Standards and Determining Income Eligibility 410‑200‑0400
Specific Requirements 410‑200‑0405
Specific Requirements 410‑200‑0407
Specific Requirements—Former Foster Care Youth Medical Program 410‑200‑0410
Specific Requirements 410‑200‑0415
Specific Requirements 410‑200‑0420
Specific Requirements 410‑200‑0425
Specific Requirements 410‑200‑0435
Specific Requirements 410‑200‑0440
Specific Requirements 410‑200‑0520
COVID-19 Emergency Policies
Last Updated

Jun. 8, 2021

Rule 410-200-0105’s source at or​.us