Oregon Health Insurance Guide
Oregon Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
If you are a resident of Oregon you can choose from a variety of private health insurance plans including plans for individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for Oregon State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
Oregon is not a guarantee issue state. By law, private insurance companies that sell individual policies must medically underwrite them and are required to sell you an individual health insurance policy if you do not meet their criteria. You can be turned down for any number of reasons including your past or current health and lifestyle habits. In Oregon, insurers are permitted a 12-month exclusionary period and a six-month look-back period for pre-existing conditions. Oregon does require an insurer to give you credit for prior creditable coverage. If you have at least six months of prior creditable coverage, insurers must guarantee issue of coverage. Elimination Riders are not permitted by law in Oregon. However, if you are a new applicant, you may have to wait 90 days before you can claim benefits under your individual policy. Under Oregon law, your insurer can base your premium on any factor other than your health status. Premiums, which are not regulated by the state, can be based on your health, your age and lifestyle factors. Oregon insurers are not required to offer standardized policies for individuals.
Oregon is a guarantee issue state for group health plans issued to small businesses. If your Oregon health insurance is provided through your employer, your coverage cannot be denied because of your past or current health. However, you must work more than 17.5 hours per week for more than 26 weeks per year. The insurer can impose a six-month exclusionary period and a six-month look-back period for pre-existing medical conditions, but must give credit for prior creditable coverage. HMOs may impose a two-month waiting period, but you will not be required to pay premiums during that time. Your employer may impose a waiting period for eligibility for new hires, but it must be applied equally to all new hires. Premiums for small group health insurance may be underwritten and rates can be adjusted by a factor of 1.43, based on modified community rates that take into account family composition, age and location of the business.
Oregon is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. Your policy can be canceled if your insurer discontinues a plan or no longer sells insurance in the state.
Oregon Mandated Health Benefits
Oregon laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism and Drug Abuse Treatment
- Breast Reconstruction
- Cervical Cancer and HPV Screening
- Colorectal Cancer Screening
- Contraceptives
- Diabetes Supplies and Self Management
- Emergency Services
- Long Term Care
- Mammography
- Mastectomy
- Maternity and Maternity Stays
- General and Parity Mental Health
- Off Label Drug Use
- Orthotics and Prosthetics
- PKU/Formula
- Prostate Cancer Screening
- Coverage for newborns under their parent’s policy
- Coverage adopted children under their parent’s policy
- Coverage for non-custodial children under their parent’s policy
- Coverage for continuation/dependents under their parent’s policy
- Coverage for dependent students under their parent’s policy
- Coverage for conversion to non-group
- Coverage for continuation/employees
Types Health Insurance Plans Available in Oregon
The following major medical health insurance plans are generally available in Oregon. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in Oregon
Oregon Medical Insurance Pool
OMIP is the state-sponsored high-risk pool that offers health insurance to state residents who have been unable to secure coverage from private insurers because of health or certain other qualifiers. You can choose from four PPO plans. Deductibles, co-pays, coinsurance and out-of-pocket expenses will vary based on the plan you choose. Premiums are based on the plan you select, your age and your eligibility category, but are capped at 125% of the average rate charged for similar coverage in Oregon. OMIP enrollment is open, but coverage effective dates will vary based on your eligibility category. There is a six-month exclusionary period for pre-existing conditions, but it can be waived if you are HIPAA-eligible.
Oregon State Children’s Health Insurance Program
SCHIP is the program providing comprehensive
This program provides comprehensive low-cost health care for resident children up to age 19, whose families meet income requirements and other eligibility requirements. One plan is available with assignment based on family income. Modest premiums depend on family income and size. A minimal $5 co-pay is assessed for some services. There may be a waiting period but it can be waived in certain circumstances. Enrollment is open but is subject to review and renewal every six months.
Regulating Agency
The Oregon Insurance Division is responsible for regulating Oregon’s health insurance industry.
Get access to Oregon health insurance quotes from http://www.einsurance.com/health-insurance.
Oregon Department of Consumer & Business Services – Insurance Division
PO Box 14480
Salem, OR 97309-0405
(503) 947-7980
http://www.cbs.state.or.us/external/ins/index.html
Oregon Medical Insurance Pool
C/O Regence BlueCross BlueShield of Oregon MS 5k
PO Box 1271
Portland, OR 97207-1271
(503) 225-6620 or (800) 848-7280
http://www.omip.state.or.us
Oregon State Children’s Health Insurance Program
Division of Medical Assistance Programs
Administrative Office
500 Summer St, NE
Salem, OR 97301-1079
(503) 945-5772 or (800) 527-5772
http://www.oregon.gov/DHS/healthplan/app_benefits/schip.shtml
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/