Bill Text: OR HB2464 | 2011 | Regular Session | Introduced

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Bill Title: Relating to medical assistance for individuals with disabilities who are under 19 years of age.

Spectrum: Partisan Bill (Democrat 4-0)

Status: (Failed) 2011-06-30 - In committee upon adjournment. [HB2464 Detail]

Download: Oregon-2011-HB2464-Introduced.html

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     76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session

NOTE:  Matter within  { +  braces and plus signs + } in an
amended section is new. Matter within  { -  braces and minus
signs - } is existing law to be omitted. New sections are within
 { +  braces and plus signs + } .

LC 1057

                         House Bill 2464

Sponsored by Representative GELSER; Representatives BARKER,
  DEMBROW, TOMEI (Presession filed.)

                             SUMMARY

The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.

  Expands definition of categorically needy persons eligible for
medical assistance to include individuals with disabilities who
are under 19 years of age. Authorizes Oregon Health Authority to
impose premiums or cost-sharing for specified individuals subject
to limits. Creates Medicaid buy-in program for individuals with
disabilities whose family income exceeds 300 percent of federal
poverty guidelines.

                        A BILL FOR AN ACT
Relating to medical assistance for individuals with disabilities
  who are under 19 years of age; creating new provisions; and
  amending ORS 414.025.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + Sections 2 and 3 of this 2011 Act are added to
and made a part of ORS chapter 414. + }
  SECTION 2.  { + (1) The Oregon Health Authority shall adopt by
rule standards for premiums, copayments or deductibles,
consistent with federal law, for individuals who are
categorically needy as described in ORS 414.025 (2)(v) and whose
family income does not exceed 300 percent of the federal poverty
guidelines, subject to the following:
  (a) The authority may not require copayments or deductibles if
the family income is at or below 250 percent of the federal
poverty guidelines.
  (b) The combined copayments and deductibles may not exceed five
percent of the cost of the treatment or service and may not be
required for:
  (A) Preventive services such as well-baby and well-child care
and immunizations.
  (B) Services furnished to a terminally ill individual who is
receiving hospice care.
  (C) Services to an individual who is described in ORS 414.025
(2)(a), (m), (o) or (p).
  (D) Pregnancy-related services.
  (E) Services furnished to an individual who is an inpatient in
a medical institution and is required to pay for costs of medical
care all of the individual's income except for a minimal amount
required for personal needs.
  (F) Emergency services.
  (G) Family planning services and supplies.
  (H) Services to an individual who is receiving medical
assistance under ORS 414.534.
  (c) Premiums shall be based upon the capitation rate paid to
prepaid managed care health services organizations under
contracts described in ORS 414.725 for coverage of categorically
needy persons under the age of 19 years. A premium:
  (A) May not be imposed if the family income is at or below 250
percent of the federal poverty guidelines; and
  (B) If the family income is above 250 percent and at or below
300 percent of the federal poverty guidelines, must be on a
sliding scale based upon:
  (i) Family income;
  (ii) Family size;
  (iii) Number of persons with a disability in a household; and
  (iv) Other factors established by the authority by rule.
  (d) The combined premiums, copayments and deductibles may not
exceed five percent of the family income, as applied on a
quarterly or monthly basis.
  (2) The authority shall adopt by rule methods for determining
family income under this section and section 3 of this 2011 Act,
including the use of income disregards.
  (3) If an employer of a parent of an individual described in
ORS 414.025 (2)(v) contributes at least 50 percent of the total
cost of annual premiums for family coverage under a health
benefit plan as defined in ORS 743.730, the parent must apply
for, enroll in and pay premiums for such coverage as a condition
of the individual being or remaining eligible for medical
assistance under this section.
  (4) The amount of the premiums paid under subsection (3) of
this section shall be deducted from premiums due the authority
under subsection (1)(c) of this section and section 3 of this
2011 Act.
  (5) The authority may not impose a prior period of uninsurance
on an individual who is categorically needy under ORS 414.025
(2)(v) and otherwise meets the requirements of this section.
  (6) The Office for Oregon Health Policy and Research shall be
responsible for analyzing and reporting on the implementation and
operation of this section and section 3 of this 2011 Act,
including an analysis of the impact of premiums, deductibles and
copayments on utilization of and access to health care by
individuals with disabilities who are under the age of 19.
  (7) Except as provided in subsection (3) of this section, this
section does not require the authority to impose premiums,
copayments or deductibles upon categorically needy persons whose
family income is at or below 300 percent of the federal poverty
guidelines. + }
  SECTION 3.  { + (1)(a) Subject to available funds, persons who
are categorically needy as described in ORS 414.025 (2)(v) with
family income exceeding 300 percent of the federal poverty
guidelines may qualify for medical assistance under this chapter
upon payment of a premium according to standards prescribed by
the Oregon Health Authority by rule.
  (b) A premium under this subsection:
  (A) Must be based upon the following factors:
  (i) Family income;
  (ii) Family size;
  (iii) Number of persons with disabilities in a household; and
  (iv) Other factors established by the authority by rule; and
  (B) May not exceed the capitation rate paid to prepaid managed
care health services organizations under contracts described in
ORS 414.725 for coverage of categorically needy persons under the
age of 19 years.
  (2) The authority may adopt rules prescribing copayments and
deductibles required for health services provided to persons who
qualify for medical assistance under this section. + }

  SECTION 4. ORS 414.025, as amended by section 1, chapter 73,
Oregon Laws 2010, is amended to read:
  414.025. As used in this chapter, unless the context or a
specially applicable statutory definition requires otherwise:
  (1) 'Category of aid' means assistance provided by the Oregon
Supplemental Income Program, aid granted under ORS 412.001 to
412.069 and 418.647 or federal Supplemental Security Income
payments.
  (2) 'Categorically needy' means, insofar as funds are available
for the category, a person who is a resident of this state and
who:
  (a) Is receiving a category of aid.
  (b) Would be eligible for a category of aid but is not
receiving a category of aid.
  (c) Is in a medical facility and, if the person left such
facility, would be eligible for a category of aid.
  (d) Is under the age of 21 years and would be a dependent child
as defined in ORS 412.001 except for age and regular attendance
in school or in a course of professional or technical training.
  (e)(A) Is a caretaker relative, as defined in ORS 412.001, who
cares for a child who would be a dependent child except for age
and regular attendance in school or in a course of professional
or technical training; or
  (B) Is the spouse of the caretaker relative.
  (f) Is under the age of 21 years and:
  (A) Is in a foster family home or licensed child-caring agency
or institution and is one for whom a public agency of this state
is assuming financial responsibility, in whole or in part; or
  (B) Is 18 years of age or older, is one for whom federal
financial participation is available under Title XIX or XXI of
the federal Social Security Act and who met the criteria in
subparagraph (A) of this paragraph immediately prior to the
person's 18th birthday.
  (g) Is a spouse of an individual receiving a category of aid
and who is living with the recipient of a category of aid, whose
needs and income are taken into account in determining the cash
needs of the recipient of a category of aid, and who is
determined by the Department of Human Services to be essential to
the well-being of the recipient of a category of aid.
  (h) Is a caretaker relative as defined in ORS 412.001 who cares
for a dependent child receiving aid granted under ORS 412.001 to
412.069 and 418.647 or is the spouse of the caretaker relative.
  (i) Is under the age of 21 years, is in a youth care center and
is one for whom a public agency of this state is assuming
financial responsibility, in whole or in part.
  (j) Is under the age of 21 years and is in an intermediate care
facility which includes institutions for persons with mental
retardation.
  (k) Is under the age of 22 years and is in a psychiatric
hospital.
  (L) Is under the age of 21 years and is in an independent
living situation with all or part of the maintenance cost paid by
the Department of Human Services.
  (m) Is a member of a family that received aid in the preceding
month under ORS 412.006 or 412.014 and became ineligible for aid
due to increased hours of or increased income from employment. As
long as the member of the family is employed, such families will
continue to be eligible for medical assistance for a period of at
least six calendar months beginning with the month in which such
family became ineligible for assistance due to increased hours of
employment or increased earnings.
  (n) Is an adopted person under 21 years of age for whom a
public agency is assuming financial responsibility in whole or in
part.

  (o) Is an individual or is a member of a group who is required
by federal law to be included in the state's medical assistance
program in order for that program to qualify for federal funds.
  (p) Is an individual or member of a group who, subject to the
rules of the department, may optionally be included in the
state's medical assistance program under federal law and
regulations concerning the availability of federal funds for the
expenses of that individual or group.
  (q) Is a pregnant woman who would be eligible for aid granted
under ORS 412.001 to 412.069 and 418.647, whether or not the
woman is eligible for cash assistance.
  (r) Except as otherwise provided in this section, is a pregnant
woman or child for whom federal financial participation is
available under Title XIX or XXI of the federal Social Security
Act.
  (s) Is not otherwise categorically needy and is not eligible
for care under Title XVIII of the federal Social Security Act or
is not a full-time student in a post-secondary education program
as defined by the Department of Human Services by rule, but whose
family income is less than the federal poverty level and whose
family investments and savings equal less than the investments
and savings limit established by the department by rule.
  (t) Would be eligible for a category of aid but for the receipt
of qualified long term care insurance benefits under a policy or
certificate issued on or after January 1, 2008. As used in this
paragraph, 'qualified long term care insurance' means a policy or
certificate of insurance as defined in ORS 743.652 (6).
  (u) Is eligible for the Health Care for All Oregon Children
program established in ORS 414.231.
   { +  (v) Is under the age of 19 years and meets the disability
criteria for Supplemental Security Income but whose family income
or resources exceed the eligibility limits established by the
Social Security Administration for Supplemental Security Income
payments. + }
  (3) 'Income' has the meaning given that term in ORS 411.704.
  (4) 'Investments and savings' means cash, securities as defined
in ORS 59.015, negotiable instruments as defined in ORS 73.0104
and such similar investments or savings as the Department of
Human Services may establish by rule that are available to the
applicant or recipient to contribute toward meeting the needs of
the applicant or recipient.
  (5) 'Medical assistance' means so much of the following medical
and remedial care and services as may be prescribed by the Oregon
Health Authority according to the standards established pursuant
to ORS 413.032, including payments made for services provided
under an insurance or other contractual arrangement and money
paid directly to the recipient for the purchase of medical care:
  (a) Inpatient hospital services, other than services in an
institution for mental diseases;
  (b) Outpatient hospital services;
  (c) Other laboratory and X-ray services;
  (d) Skilled nursing facility services, other than services in
an institution for mental diseases;
  (e) Physicians' services, whether furnished in the office, the
patient's home, a hospital, a skilled nursing facility or
elsewhere;
  (f) Medical care, or any other type of remedial care recognized
under state law, furnished by licensed practitioners within the
scope of their practice as defined by state law;
  (g) Home health care services;
  (h) Private duty nursing services;
  (i) Clinic services;
  (j) Dental services;
  (k) Physical therapy and related services;
  (L) Prescribed drugs, including those dispensed and
administered as provided under ORS chapter 689;
  (m) Dentures and prosthetic devices; and eyeglasses prescribed
by a physician skilled in diseases of the eye or by an
optometrist, whichever the individual may select;
  (n) Other diagnostic, screening, preventive and rehabilitative
services;
  (o) Inpatient hospital services, skilled nursing facility
services and intermediate care facility services for individuals
65 years of age or over in an institution for mental diseases;
  (p) Any other medical care, and any other type of remedial care
recognized under state law;
  (q) Periodic screening and diagnosis of individuals under the
age of 21 years to ascertain their physical or mental
impairments, and such health care, treatment and other measures
to correct or ameliorate impairments and chronic conditions
discovered thereby;
  (r) Inpatient hospital services for individuals under 22 years
of age in an institution for mental diseases; and
  (s) Hospice services.
  (6) 'Medical assistance' includes any care or services for any
individual who is a patient in a medical institution or any care
or services for any individual who has attained 65 years of age
or is under 22 years of age, and who is a patient in a private or
public institution for mental diseases. 'Medical assistance '
includes 'health services' as defined in ORS 414.705. 'Medical
assistance' does not include care or services for an inmate in a
nonmedical public institution.
  (7) 'Medically needy' means a person who is a resident of this
state and who is considered eligible under federal law for
medically needy assistance.
  (8) 'Resources' has the meaning given that term in ORS 411.704.
For eligibility purposes, 'resources' does not include charitable
contributions raised by a community to assist with medical
expenses.
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