Oregon Public Health Plan for Patient - Hospital Presumptive Eligibility (PE)

Hospital Presumptive Eligibility (PE)

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Zip Code97229
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Program Details

What is Hospital Presumptive Eligibility (PE)?

Provides individuals with temporary, no cost, Oregon Health Plan benefits for up to two months

Who is it for?

Patient

Who is Eligible?

Must be a U.S. Citizen or legal alien. Must be an Oregon resident. Must be at a hospital where Presumptive Eligibility is recognized. Must fall within one of the following income limits:

  • Parents/Caretaker Relatives: 138 FPL
  • Pregnant Woman: 190% FPL
  • Children Ages 0-1:190% FPL
  • Children Ages 1-18: 138% FPL
  • CHIP 0-1: above 190% below 300% FPL
  • CHIP 1-18: above 138% below 300% FPL
  • Adults without dependents: through 133% FPL
  • Former Foster Youth: No Income Limits
  • Individuals in the Breast and Cervical Cancer Treatment Program (BCCTP): 250% FPL

What is Covered?

PE lasts up to 60 days, beginning the first day of the month the Application is approved, and ending the last day of the following month. Covers doctor visits, mental health care, addictions treatment, basic dental services: cleaning, fillings and extractions, hearing aids and hearing aid exams, medical equipment and supplies, medical transportation, physical therapy, occupational therapy, speech therapy, home health services such as physical therapy, acupuncture, and some vision services for eye health. Pregnant women are covered only for ambulatory prenatal care.

What is not Covered?

Pregnant women are covered only for "ambulatory prenatal care" (all OHP Plus services except inpatient labor and delivery). Labor and delivery are not covered under HPE.

  • If women who had HPE when they were pregnant are determined to be Medicaid eligible, based on the timely submission of the OHA 7210, the period including the date of birth and the labor and delivery will often be covered retroactively.
  • For a pregnant woman applying while in labor, it may be best for the hospital to submit a full OHA 7210 the first date medical benefits were provided, or use the Hospital Hold process.

How much is it?

$0 or minimal share of cost

How to Apply?

Your provider will use this Application or Web Portal to enroll you. Make certain you know your income, household size, and residency status, as it will be needed to complete your determination.

Who can apply for coverage?

Any individual seeking immediate medical coverage may apply. There is no requirement that the individual be admitted to the hospital or be seeking hospital services, or any medical services, in order to apply. HPE is a path to ongoing eligibility as weel as temporary coverage.

How long does coverage last?

  • Coverage start date:If eligible, an individual's temporary coverage starts at midnight on the earlier of:
    • The date the hospital determines the individual is eligible (for individuals not seeking/receiving immediate services); or,
    • The date the individual received a covered medical service, if the hospital submits the decision to the Authority within 5 working days following the date of service (for individuals receiving/seeking immediate services).
  • Coverage end date: Temporary coverage ends based on submission of the completed full OHP application (OHA 7210).
    • If OHA 7210 is submitted by the last day of the month determines MAGI Medicaid/CHIP eligibility, and HPE is in effect until the determination is made.
    • If OHA 7210 is not submitted by the date described above, HPE coverage ends on that day.
Only one period of HPE coverage is allowed in any 12-month period, calculated from the last day of the most recent previous period of HPE.

Can newborns be covered?

A separate HPE determination is required to cover newborns.

  • Newborns born to women during the hospital presumptive (temporary) period are not considered Assumed Eligible Newborns (AEN).
  • If women who had HPE when pregnant are later determined to be eligible for OHP based on the timely submission of an OHA 7210, the newborn's status changes to AEN.

What eligibility groups are included?

Hospital Presumptive Eligibility uses the following income guidelines in determining eligibility:

  • Parents and Caretaker Relatives (specific $ limits)
  • Pregnant Woman (through 185% FPL)
  • Medicaid Children
    • Under age 1: (through 185% FPL)
    • Age 1-18: (through 133% FPL)
  • CHIP Children
    • Under age 1: (above 185% FPL through 300% FPL)
    • Age 1-18: (above 133% FPL through 300% FPL)
  • Newly Eligible Adults (through 133% FPL)
  • Individuals (to age 26) formerly in Foster Care in Oregon (no FPL limit)
  • Individuals in the Breast and Cervical Cancer Treatment Program (BCCTP) (through 250% FPL)
Income guidelines may change yearly. OHA will email HPE providers with updated income determination guidelines. Please be sure you are using the most recent version. These may also be found at www.oregon.gov/oha/healthplan/Pages/HPE.aspx.

What to do before making HPE determinations?

Check MMIS to see if the applicant is currently receiving OHP. Do not treat the "Admin Exam" benefit package as current Medicaid/CHIP coverage.
If the individual currently receives OHP, then the individual is not eligible for HPE.

Physicians that accept medicaid assignment

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HUI-CHANG, HU
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CAROLYN, CONCIA
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BERNARD, CONWAY
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CORNELL EYECARE GROUP
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STEPHANIE, SPINDLER
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CONNOR, HURLEY
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MARTIN, MENDELSON
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PAUL, COOLEY
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CHRISTOPHER, KIM
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JOSHUA, RAJ
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FAMILY WALK IN MEDICAL CENTER, PC
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WENDY, KELLAM
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KYLE, GREEN
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JESSICA, BLIEVERNICHT
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MARCY, CROUCH
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JERRY, LAWRENCE
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GARY, GATES
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ROXANA, ABBOTT
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MATTHEW, BLIEVERNICHT
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BARBARA A GRAHAM MD PC
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RONALD, STIBAL
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NORTHWEST PEDIATRIC KIDNEY SPECIALISTS LLC
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MAUREEN, MAYS
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HUI-CHANG HU, PH.D.
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  • Phone Number
    (503) 439-0514
  • Office Locations
    15188 NW CENTRAL DR
    PORTLAND, OR 97229
15188 NW CENTRAL DR PORTLAND OR, 97229

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