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Case name: / Worker ID:
Date of notice: / Effective date:
Notice of Self Sufficiency Medical Program Eligibility Decision
/ If your circumstances change, you might qualify at a later date. You may reapply for any of our medical assistance programs at any time.You told us you have a disability. Your application has been referred to a Seniors and People
with Disabilities office.
Seniors and People with Disabilities will check to see if you qualify for medical benefits based on your disability. They will send you a separate notice about the medical application.
The medical assistance application for / will be denied
effective / . We reviewed all the Children, Adults and Families’ Self Sufficiency
medical assistance programs.
This notice applies to Self Sufficiency medical programs only.
For each Children, Adults and Families Self Sufficiency medical program, you do not meet one or more of the financial, non-financial or general requirements. Below are some of the general requirements for our programs.
Breast and Cervical Cancer Medical: You must have been found to need treatment for breast or cervical cancer following screening through the Breast and Cervical Cancer screening program. [ORS 414.534, OAR 461-135-1060(2) and (3)]
Continued eligibility for Medicaid (CEM): You must be younger than age 19. You must have received Medicaid benefits for less than 12 months. [OAR 461-120-0510(3), OAR 461-135-1149(1)]
Continued eligibility for Child Health Insurance Program (CHIP) pregnant women (CEC): You must be younger than age 20 and lose eligibility for CHIP while pregnant. You must not be receiving private major medical health insurance. [OAR 461-120-0510(4), OAR 461-135-1149(2), (3) and (4)]
Medical Coverage for Children in Substitute or Adoptive Care: You must be younger than 21 and residing in a state psychiatric hospital, substitute care, foster care, or adoptive care, receiving independent living payments from the State, or you must have lived in a foster care setting that an Oregon public agency was assuming financial responsibility for on your 18th birthday. If you are 21 or over, you must have been institutionalized and either determined to be blind or to have a disability before you turned 21. [OAR 461-120-0510(15), OAR 461-135-0150(1), (2), (3), (4) and (5) OAR 461-135-0960(1) and (2)]
Medical Assistance Assumed (MAA): You must be caring for a related, dependent child who lives with you, be a child, an essential person, or the parent of an unborn whose pregnancy has reached the month before the due date. Your income and resources must be below the limits. [OAR 461-135-0070(1), OAR 461-155-0030(1) and (2), OAR 461-160-0100(1)]
Medical Assistance to Families (MAF): You must not be eligible for the MAA program because your income or resources are over the limits. You must be caring for a related, dependent child who lives with you, be a child, an essential person, or the parent of an unborn whose pregnancy has reached the month before the due date. Your income and resources must be below the limits. [OAR 461-101-0010(20), OAR 461-135-0070(1), OAR 461-155-0030(1) and (2) OAR 461-160-0100(1)]
Extended Medical Assistance: You must be caring for a related, dependent child in your home. You must have been properly receiving medical benefits through the MAA or MAF programs and lost eligibility because your income from earnings or child support increased. [OAR 461-135-0095(1), (2) and (3)]
Oregon Health Plan (OHP): If you are at least 19 and you are not pregnant, you only qualify for OHP Standard if you applied before July 1, 2004 and have been continuously eligible for medical assistance, you were selected from the reservation list or you transferred from another medical benefit program. You must not have had private health insurance in the last 6 months. For other OHP programs, you must be either pregnant or be under age 19. [OAR 461-120-0510(9), OAR 461-135-1100(1), (2), (3), (4), (5), (6), (7), (8), (9) and (10), OAR 461-135-1102, OAR 461-135-1110(1), (2) and (3), OAR 461-135-1125(1) and (2)]
Citizen/Alien-Waived Emergent Medical: You must be ineligible for one of the programs listed above solely because you do not meet the citizenship or alien status requirements. [OAR 461-135-1070]
Healthy KidsConnect: You must be under 19 years of age. You must not have private health insurance. You must not have had private health insurance in the past 2 months. [OAR 461-135-1101(1)]
Medicare savings programs (Qualified Medicare Beneficiary (QMB): You must be receiving benefits under Part A of Medicare. [OAR 461-135-0010, 461-135-0730(1), (2), (3) and (4)
Refugee Assistance Medical: You must have been lawfully admitted to the United States as a refugee or lawfully granted asylum in the United States. [OAR 461-120-0120(1), (2), (3), (4), (5), (6), (7) and (8)]
You must have income and resources below the program’s income and resource limits and meet the other non-financial eligibility requirements in Chapter 461 of the Oregon Administrative Rules: OAR 461-001-0000, In Division 110, Rules 0210, 0310, 0330, 0340, 0350, 0370, 0390, 0400, 0410, 0430, 0510, 0530, 0610, 0630, 0720, 0750, OAR 461-115-0010, In Division 120, Rules 0010, 0030, 0050, 0110, 0115, 0120, 0125, 0130, 0160, 0180, 0210, 0315, 0350, 0360, 0510, 0530, 0610, 0630, In Division 125, Rules 0010, 0030, 0050, 0060, 0090, 0110, 0120, 0130, 0150, 0170, 0190, 0230, 0250, 0310, 0330, 0350, 0370, In Division 150, Rules, 0050, 0055, 0060, 0070, 0080, 0090, In Division 155, Rules 0010, 0020, 0030, 0175, 0180, 0225, 0250, 0290, 0291, 0295, In Division 160, Rules 0010, 0015, 0100, 0160, 0190, 0200, 0540, 0700. OAR 410-120-0006. OAR 410-120-0006
If you disagree with this decision you have the right to a hearing.
OHP Standard Reservation List: The Oregon Standard reservation list is currently open. For more information, call 1-800-699-9075, TTY: 711 or visit www.oregon.gov/DHS/open.
To apply for medical assistance online, visit www.oregon.gov/DHS/healthplan/app_benefits/main.shtml
Worker signature: / DHS local office: / Phone:
This document can be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. E-mail , call 503-945-5600 (voice) or
call 711 (TTY) to arrange for the alternative format that will work best for you
Case number: Original: Client Copy: File DHS 0462C (07/11), recycle prior versions
Hearing authority ORS 183.415(2)(b) Page 3 of 3
What You Can Do When You Do Not Agree with This Decision
Please contact your local office if you need this form in another language or alternate format· You have the right to challenge this decision by requesting a hearing. Hearings are held by the Office of Administrative Hearings, which is independent from the Department of Human Services (DHS) or Oregon Health Authority (OHA). DHS or OHA may make decisions affecting your medical benefits. If you want a hearing, you must request it on time. For more information, see part 1 below.
· You can also talk with a manager. Ask for a meeting by contacting your local office. To find the closest office, call 1-800-442-5238 or go online to http://egov.oregon.gov/DHS/localoffices/localoffices.pdf. Your deadline to request a hearing (part 1 below) does not change even if you are in contact with a manager or trying to reach one.
Part 1 — Ask for a hearing.What must I do to get a hearing? For all benefits except Supplemental Nutrition Assistance Program (SNAP) food benefits, you must fill out an Administrative Hearing Request form (DHS 0443) and return it to a DHS or OHA office. You can get this form at a DHS or OHA office or on the web at https://apps.state.or.us/Forms/Served/DE0443.pdf. For food benefits, you can ask for a hearing on DHS form 0443, by phone, in writing or by asking a DHS employee in person. Your local office can help you. In most cases, DHS or OHA must receive your request within 45 days from the date identified as the sending date on the decision notice. You have 90 days for food benefits and for Temporary Assistance for Needy Families (TANF) reductions for not cooperating with your case plan. You may request a hearing at any time if you disagree with the current amount of your food benefits.
Who can help with my hearing? In the SNAP and medical programs, any adult may represent you. In all other programs, you must represent yourself or have a lawyer or a legal assistant (supervised by a Legal Aid attorney) represent you. You may call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 1-800-520-5292 for advice and possible representation.
What are my other hearing rights? At the hearing, you can tell why you do not agree with the decision. You can have people testify for you. The laws about your hearing rights and the hearing process are at OAR 137-003-0501 to 0700, 410-120-1860, 410-141-0264, 461-025-0300 to 0375, ORS 183.411 to 183.470 and ORS 411.095.
What happens if there is no hearing? If you do not ask for a hearing on time, or if you withdraw the hearing request or miss your hearing, you may lose your right to a hearing. This notice will be the final DHS or OHA decision (called a “final order by default”). You will not get a separate final order by default. The case file, along with any materials you submitted in this matter, is the record. The record is used to support the DHS decision upon default. You may appeal the final order by default by filing a petition in the Oregon Court of Appeals. (ORS 183.482) If you do not ask for a hearing, this appeal must be filed within 60 days of the date this notice becomes a final order by default. If you withdraw a hearing request or miss your hearing, the appeal deadline is set out in the dismissal order.
Part 2 — How can I keep getting benefits until my hearing?· You can ask for your benefits to stay the same until the hearing decision (“continuing benefits”). In all programs other than SNAP, you must ask on the Administrative Hearing Request form (DHS 0443). For SNAP benefits, use DHS form 0443, phone, write or ask a DHS employee in person.
· You must ask your branch for continuing benefits by either the “effective date” on the notice or 10 days after the date identified as the sending date of the notice. To keep getting benefits, you must ask by whichever date is later.
· If you keep getting benefits but lose the hearing, you must pay back the benefits you should not have received.
· If you don’t keep getting benefits and win the hearing, DHS or OHA will give you the benefits you should have received.
Part 3 — Can I have my hearing within five working days?You may have the right to an “expedited hearing” for any of the following types of benefits or events:
· Expedited or emergency food benefits
· JOBS and Pre-TANF payments
· Temporary Assistance for Domestic Violence Survivors (TA-DVS) eligibility and payments
· While receiving medical benefits, you are denied a medical service for an immediate, serious threat to your life or health
· DHS or OHA denied your request to keep getting benefits until your hearing
DHS will not discriminate against anyone. This means DHS will help all who qualify. DHS will not deny help to anyone based on age, race, color, national origin, sex, sexual orientation, religion, political beliefs, or disability. You can file a complaint if you think DHS discriminated against you because of any of these reasons.DHS 0447 (07/11), recycle prior versions
Case number: Original: Client Copy: File DHS 0462C (07/11), recycle prior versions
Hearing authority ORS 183.415(2)(b) Page 3 of 3