Government Health Insurance Programs in Oregon

Medicaid/Oregon Health Plan

OHP is a public health insurance program for certain categories of people with low incomes. Some of those categories are: children, pregnant women and newborns, people with disabilities, and people who need long-term care.

Eligibility
There are different eligibility requirements for different programs. Children and pregnant adults, for example, qualify for insurance at higher income levels than non-pregnant adults. Everyone completes the same application. OHP eligibility specialists match the person (or each person in a family) to programs.

For example: You are a family of four, two adults and two children. You earn just a bit too much for the adults to qualify (plus there are no adult openings). However, your children qualify for insurance because the program for them takes higher incomes and has immediate openings.

Program
Most OHP clients belonged to managed care plans. This means they get a list of doctors and services to use. In some areas, there are no managed care plans. In this case, clients receive an "open card." This means they can go to any doctor who takes OHP clients.

Different clients have different benefits. For example, OHP Plus and OHP Standard are different benefit packages. Your package determines what medical services are covered. Oregon's budget also is a factor. Because the state doesn't have enough money to pay for everything, it ranks services and covers those that are most effective.

Learn more at: http://www.oregon.gov/DHS/healthplan

OHP for Seniors
OHP has programs that help people pay some of their Medicare costs as well as programs to pay for nursing homes and other types of residential care. Learn more at: http://www.oregon.gov/DHS/spwpd/hlth_med/healthmed.shtml#medicaid

Non-citizens
The Citizen Alien-Waived Emergency Medical Assistance (CAWEM) clients are not U.S. citizens and do not qualify for Medicaid based on their immigration status. Coverage is limited to emergency services and childbirth. For details: http://www.dhs.state.or.us/spd/tools/program/cawem.htm

Other Oregon Health Plan Programs

Family Health Insurance Assistance Program (FHIAP)
FHIAP helps Oregonians pay the monthly premium for high-quality, private health insurance plans. FHIAP pays from 50 percent to 95 percent of the premium for people who are uninsured and meet income and other guidelines. Individuals and families use FHIAP subsidies to pay for insurance at work or to buy individual health plans if insurance is not available through an employer. Learn more: www.fhiap.oregon.gov

Oregon Medical Insurance Pool (OMIP)
This state program provides health insurance for adults and children who can't get private medical insurance. There are three ways to be eligible. None are based on income. The Family Health Insurance Assistance Program (FHIAP) subsidies may be used to help pay OMIP premiums. OMIP contracts with Regence BlueCross BlueShield to administer this program.

Who qualifies for OMIP?

Medical eligibility: These individuals can't obtain commercial medical insurance because of health conditions. You can apply to OMIP if an insurance company turns you down for coverage. People with certain medical conditions can apply directly to OMIP. There are four comprehensive health plans. Premiums vary by age and plan. There is a six-month wait for coverage of pre-existing conditions. You may not have this wait if you had health insurance within 63 days of the start of the new OMIP policy.

Portability eligibility: These plans are for people who are leaving group coverage and exhaust COBRA benefits or can't get a portability plan from a commercial insurer. Individuals who are eligible for portability coverage must apply within 63 days of losing their group coverage or exhausting their COBRA coverage. There is no waiting period for coverage of pre-existing conditions.

Health Care Tax Credit (HCTC) eligibility: The U.S. Department of Labor certified that these people lost jobs due to competition from foreign trade. As such, they qualify for a Federal Health Care Tax Credit to subsidize 65 percent of their health insurance premiums. They must enroll in OMIP to get this subsidy. The federal government decides who is eligible for the credit. To qualify for OMIP coverage with this credit, you must apply for OMIP coverage within 63 days of losing your most recent prior health insurance coverage and you must have had the prior coverage for at least 90 days. Enrollees may select from the same four plans as those who are medically eligible.

• www.omip.state.or.us
• 1-800-848-7280

Medicare

Medicare is the federal health insurance program for:

• Americans age 65 and older
• People of all ages with certain disabilities
• People with end-stage renal disease (ESRD).

Original Medicare is a fee-for-service plan that is managed by the federal government. It pays for many but not all health care services and supplies.

To avoid a late penalty, enroll in Medicare when you first become eligible. If you already have health insurance from an employer or another source, talk to your benefits administrator about whether you should join Medicare while still covered.

Medicare has four parts:

• Hospital insurance (Part A)
• Medical insurance (Part B)
• Prescription Drug Insurance (Part D)

What happened to Part C? Medicare Part C gives you the choice of receiving the benefits of Medicare A, B, and D through a private health plan, like a Health Maintenance Organization (HMO) or Preferred Provider Organization. This coverage is called Medicare Advantage and is Part C.

Costs

• Most people don't pay a premium for Part A. There is a monthly premium for Medicare Part B. It changes yearly. People with incomes of more than $80,000 pay a higher premium.
• Because Parts A and B don't cover many costs, many people with Medicare buy additional insurance. It might be a Medigap supplement plan or a Medicare Advantage plan. All Medigap plans and most Medicare Advantage plans have a separate monthly premium.
• Prescription drug coverage typically has a separate premium although it may be part of a Medicare Advantage plan.
• In addition to the monthly premium, you share in other costs of your medical and/or prescription drug coverage when you use services.

Extra Help with Drug Coverage
People with limited income and resources may be eligible for extra help paying for prescription drug coverage. To find out if you qualify for extra help, contact Social Security at 1-800-772-1213 or online at http://www.socialsecurity.gov.

If you already have prescription drug coverage from an employer, former employer, or other source, you may be better off keeping that coverage. Contact your benefits administrator to find out how your existing coverage works with Medicare drug coverage before you make a decision.

Be sure to consult with your employer before leaving the employer's drug plan. If you leave your employer coverage and later change your mind, you probably will not be able to return for health or prescription drug coverage.

Help with Medicare

Local
The Senior Health Insurance Benefits Assistance (SHIBA) program provides free counseling to people with Medicare and those who assist them. Volunteers who are trained in Medicare can help you select a Medicare prescription drug plan; find out if you are receiving all possible benefits; compare supplemental health insurance policies; review a bill; and file an appeal or complaint. This program is part of the Oregon Department of Consumer and Business Services and is funded by a federal grant.

• Call (800) 722-4134. You will be routed to a volunteer in your area.
• Or visit: www.oregonshiba.org

Federal

• www.medicare.gov
• 1-800-633-4227