Qualifying for Medicaid in Oregon

Oregon provides Medicaid services through Oregon Health Plan (OHP).

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Medicaid is a federal program that is managed by each state to provide health insurance for some low-income individuals. The State of Oregon provides Medicaid services through a program that it calls the Oregon Health Plan (OHP). Oregon offers different benefit packages and has different income guidelines for different categories of recipients. In general, though, you must be low-income to qualify. The Department of Human Services (DHS) administers Oregon's Medicaid program.

Oregon provides a Medicaid package called OHP Plus to low-income residents who are seniors (over age 65); children under age 19; pregnant, blind, disabled persons; and those who qualify to receive Temporary Aid to Needy Families (TANF). There is also a Medicaid package called OHP Standard for low-income adults who don't fit into one of the above categories.

How to Qualify for Medicaid Because of Disability

If you are an Oregonian who receives SSI benefits, then you automatically qualify to receive OHP Plus. However, you do not need to apply for disability from Social Security to receive OHP Plus on the basis of your disability. Instead, you can indicate on your OHP application that you are disabled, and the state will review your medical records and determine whether you qualify.

Oregon uses the same definition of disability as the Social Security Administration -- that is, a disability is a condition that prevents you from working that has lasted, or will last, more than one year or will result in your death.

When you apply for OHP on the basis of disability, your application is referred to a group called the Presumptive Medicaid Disability Determination Team (PMDDT). The PMDDT will need a release of information from you to get your medical records. If you don't have enough information in your medical records to allow the PMDDT to decide if your condition meets a Social Security impairment listing, the PMDDT may arrange for you to see a particular doctor or have a certain test. The state pays for any medical exams and tests that the PMDDT orders.

Reapplying for OHP

If you have already applied for disability benefits from Social Security and been denied, then the PMDDT will not make its own decision about your disability until a year after the unfavorable Social Security decision. However, if your condition has gotten worse or you have a new condition since the Social Security decision, then the PMDDT will review your disability before the year passes.

How a Social Security Denial Affects Your Medicaid Eligibility

If you are approved for OHP Plus on the basis of your disability but Social Security later finds that you are not disabled, you can keep receiving OHP Plus while you appeal your Social Security case. If Social Security finds you are not disabled, you will be disqualified from getting OHP Plus. But only a final decision from the Social Security Appeals Council will end your OHP Plus eligibility.

How to Apply for OHP Plus

You can apply for OHP Plus at any Oregon Department of Human Services (DHS) office in the state, by calling 800-359-9517, or by completing the online application at https://apps.state.or.us/mbs/. The DHS must make a decision about your application within 45 days, or within 90 days when you are applying on the basis of a disability.

If you are denied OHP, you have the right to request a hearing. The best way to do that is to complete the hearing request form at https://apps.state.or.us/Forms/Served/de0443.pdf and turn it in to a DHS office in person, where you can get a date-stamped copy as your receipt.

If You Don't Qualify for OHP Plus

Oregon runs another health insurance program, called OHP Standard, for low-income adults who don't fit into any of the categories to qualify for OHP Plus (see above). OHP Standard only opens for new applicants when the state provides additional funding for the program. There is a lottery to apply for OHP Standard; to reserve a spot, complete the application for OHP Standard.

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