Oregon Administrative Rules › Chapter 943 - OREGON HEALTH AUTHORITY › Division 120 - PROVIDER RULES › Section 943-120-0300 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
In addition to the definitions in OAR chapter 410
				division 120, the following definitions apply to OAR 943-120-0300  to
				943-120-0350:
(1) "Claim"
			 means a bill for services, a line item of a service, or all services
			 for one client within a bill. Claim includes a bill or an encounter
			 associated with requesting reimbursement, whether submitted on paper
			 or electronically. Claim also includes any other methodology for
			 requesting reimbursement that may be established in contract or
			 program-specific rules.
(a)
			 Temporary Assistance to Needy Families (TANF) are categorically
			 eligible families with income levels under current TANF eligibility
			 rules;
(b) CHIP children
			 under one year of age whose household has income under 185% Federal
			 Poverty Level (FPL) and do not meet one of the other eligibility
			 classifications;
(c)
			 Poverty Level Medical (PLM) adults under 100% of the FPL and clients
			 who are pregnant women with income under 100% of FPL;
(d) PLM adults over 100% of the FPL
			 are clients who are pregnant women with income between 100% and 185%
			 of the FPL;
(e) PLM
			 children under one year of age who have family income under 133% of
			 the FPL or were born to mothers who were eligible as PLM adults at
			 the time of the child's birth;
(f) PLM or CHIP children one
			 through five years of age who have family income under 185% of the
			 FPL and do not meet one of the other eligibility
			 classifications;
(g) PLM
			 or CHIP children six through 18 years of age who have family income
			 under 185% of the FPL and do not meet one of the other eligibility
			 classifications;
(h) OHP
			 adults and couples are clients age 19 or over and not Medicare
			 eligible, with income below 100% of the FPL who do not meet one of
			 the other eligibility classifications, and do not have an unborn
			 child or a child under age 19 in the household;
(i) OHP families are clients, age
			 19 or over and not Medicare eligible, with income below 100% of the
			 FPL who do not meet one of the other eligibility classifications, and
			 have an unborn child or a child under the age of 19 in the
			 household;
(j) General
			 Assistance (GA) recipients are clients who are eligible by virtue of
			 their eligibility under the GA program, ORS
			 411.710 et
			 seq.;
(k) Assistance to
			 Blind and Disabled (AB/AD) with Medicare eligibles are clients with
			 concurrent Medicare eligibility with income levels under current
			 eligibility rules;
(l)
			 AB/AD without Medicare eligibles are clients without Medicare with
			 income levels under current eligibility rules;
(m) Old Age Assistance (OAA) with
			 Medicare eligibles are clients with concurrent Medicare Part A or
			 Medicare Parts A and B eligibility with income levels under current
			 eligibility rules;
(n)
			 OAA with Medicare Part B only are OAA eligibles with concurrent
			 Medicare Part B only with income under current eligibility
			 rules;
(o) OAA without
			 Medicare eligibles are clients without Medicare with income levels
			 under current eligibility rules; or
(p) Children, Adults and Families
			 (CAF) children are clients with medical eligibility determined by CAF
			 or Oregon Youth Authority (OYA) receiving OHP under ORS
			 414.025,
			 418.034, and
			 418.189 to
			 418.970. These
			 individuals are generally in placement outside of their homes and in
			 the care or custody of CAF or OYA.