What is redetermination?
- Historically Medicaid recipients in Oregon - and every other state - have had to reapply for Medicaid coverage every 12 months. This process ensured they still met eligibility requirements
- If approved, the current 1115 waiver submitted to Centers for Medicare & Medicaid Services would change this in Oregon: Children age 0-5 would only need to apply for Medicaid once and would stay on Medicaid until their 6th birthday; everyone over age 6 would reapply every 24 months
How did the Federal Public Health Emergency (PHE) change redetermination?
- While the Federal PHE is in place, the process of redetermining eligibility has been paused. This pause began March 2020
- Oregon Health Authority (OHA) has continued to ask individuals to turn in the necessary eligibility paperwork but has not removed anyone’s Medicaid coverage if they did not respond or were deemed ineligible
When will redetermination begin again in Oregon?
- The pause in redetermination is tied to the Federal Public Health Emergency declaration, which is still in force
- Once the Federal PHE ends, OHA will have 60 days to start the redetermination process
- The State of Oregon's emergency declaration and redetermination are not linked. The state's declaration does not affect members in terms of Medicaid eligibility. It is the federal declaration that matters for Medicaid purposes
Who will need to redetermine once the process is started again?
- Every individual who is currently covered by Medicaid will have to redetermine at some point during the 14 months after the Federal PHE ends
When will each individual need to redetermine?
- OHA is planning to carry out redetermination through a 12-month calendar, divided up by populations or aid eligibility categories
- OHA has not released a draft of their proposed plan by population or aid category. We will share that once it is released
What timeframe do Medicaid individuals have to respond to the redetermination documentation request from OHA?
- Normally individuals have 30 days to respond to the request for documentation, but OHA is going to allow individuals 90 days to respond
What happens if someone is no longer eligible or does not submit the required documentation?
- If someone is over income for Medicaid (which varies by aid category), they will no longer be covered by Medicaid 60 days after they have been determined ineligible
- Adults with income falling within the Federal Poverty Level (FPL) of 139% - 200% they may be eligible for the new “basic health plan” that OHA is proposing for Oregon
- Adult from 200% - 400% FPL will be eligible for the exchange
- Children are eligible for Medicaid up to 300% FPL
- There are other individuals that have different FPL requirements such as pregnant individuals, those living with disabilities, and those in foster care
How will individuals know they need to “redetermine” and where can they go for assistance?
- OHA will notify every individual through the mail that they need to submit documentation. This notice will have detailed instructions on where and how to do this as well as contact information for where they can get help with the process
What does Health Share plan to do to assist individuals during this time?
Health Share has been and will continue to work with the OHA on the plan for redetermination. We will also be doing an awareness campaign through mail, social media, buses, etc., to make sure the word is out about how important it is for them to complete the redetermination process.
As a Coordinated Care Organization (CCO), Health Share is not allowed to directly assist members redetermine, but will have information at customer service, through our navigators and our community and provider partners on where they can go for assistance.
How do members get assigned a CCO during redetermination?
Members can choose their CCO during the redetermination process. If they were a prior Health Share member, they will stay with Health Share unless they actively choose another CCO.