Outreach Services successfully appealed the denial of Oregon Medicaid benefits to a patient injured in a Montana trucking accident in November 2005. As a result, Oregon Medicaid will provide coverage for the patient’s medical care from November 2005 until May 2006, when he became eligible for Montana Medicaid.

The patient – a long-time Oregon resident -- was hospitalized in Montana for seven months following the accident. The hospital was advised by Oregon DHS that the patient was not eligible for Oregon Medicaid because he was in Montana. Nevertheless, the patient applied for medical benefits in April 2006. Even though the patient was disabled, DHS found he was not eligible for any Oregon medical programs. DHS then mailed the denial to the patient’s Oregon residence, rather than the mailing address on his application. The patient learned of the denial long after the time for requesting a fair hearing had passed.

The matter was referred by the hospital to Outreach Services in October 2006. Outreach Services’ TPL manager and a patient advocate diligently followed-up, establishing eligibility, and ascertaining the basis for the denial. After determining the patient should have been referred for a disability-related Medicaid program, Outreach Services requested a fair hearing. The agency initially denied the request as untimely, but later scheduled a hearing after Outreach Services contacted the director’s office.

Outreach Services’ TPL Manager and in-house counsel worked together to prepare for the hearing. In doing so, they discovered what they believed was a significant discrepancy between the form of application submitted to DHS and the form relied upon by the hearing representative. Prior to the hearing, Outreach Services sent documentation supporting reversal to the hearing representative. At the commencement of the hearing, the hearing representative indicated she had forwarded those materials to a policy analyst, who determined the denial should be reversed.