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Oregon Health Plan Background Brief on … Oregon Health Plan Prepared by: Rick Berkobien June 2008 The Oregon Health Plan (OHP) expands access to health care using a combination of public and private insurance plans and a prioritized list of health care services. Currently, more than 400,000 Oregonians Inside this Brief have access to health care under the OHP. The program has three components, two of which (OHP Plus and OHP Standard) are offered through Medicaid and the Children’s Health Insurance Program • OHP Plus (CHIP). The third component is offered through the Office of Private Health Partnerships as premium subsidies through the Family Health Insurance Assistance Program (FHIAP). • OHP Standard FHIAP provides subsidies for the purchase of private health insurance by low-income, uninsured families. FHIAP provides assistance to people with incomes up to a certain percentage of the federal poverty • The OHP Service Delivery level (FPL) and subsidizes commercial premiums based on family System size and income. The Department of Human Services, Division of Medical Assistance • Family Health Insurance Programs administers the public insurance components of the OHP, Assistance Program including Medicaid and the CHIP. CHIP is a separate federally and state-funded program to provide health care services to certain low- income children. Office of Private Health • Partnerships OHP Plus Eligibility - As of February 2008, there were 359,146 children and adults in the OHP Plus population. People eligible for the OHP Plus • Oregon Medical Insurance include low-income elderly and people with disabilities, people Pool eligible for Temporary Assistance for Needy Families (TANF), children eligible for Medicaid and CHIP up to 185 percent FPL, pregnant women up to 185 percent FPL, and low-income foster • Staff and Agency children. Pregnant women and children may opt to enroll in private Contacts coverage under FHIAP instead of Medicaid and CHIP. Generally, many Medicaid-eligible enrollees cannot have assets over $2,000 and CHIP children cannot have assets over $10,000 (with some items excluded for both groups). Coverage - Benefits and services that people on the OHP Plus receive include (with some co-pays and limitations): • Prescriptions Legislative Committee Services • Physician services State Capitol Building • Check-ups (medical and dental) Salem, Oregon 97301 • Diagnostic services for all conditions (503) 986-1813 Background Brief - Legislative Committee Services Page 1 of 4 Oregon Health Plan – June 2008 approximately 3,000 people from the reservation • Family planning services • Maternity, prenatal, and newborn care list. Monthly drawings will continue for 11 • Hospital services months, or until the program once again reaches its projected budget capacity. • Comfort care and hospice • Dental services Coverage - The OHP Standard covers basic • Alcohol and drug treatment services (with some limitations), such as: • Mental health services • Vision services • Emergent and urgent hospital care • Physician services Services not covered include: • Lab/X-ray • Prescription drugs • Conditions that get better on their own • Outpatient mental health and chemical • Conditions that have no useful treatment dependency treatment • Treatments that are not generally • Emergency transportation effective • Emergency dental • Cosmetic surgery • Some durable medical equipment and • Gender changes supplies (diabetic supplies, respiratory, oxygen) • Most services to aid in fertility • Weight loss programs Services not covered include: OHP Standard • Non-emergency transportation Eligibility - As of February 2008, there are • Routine vision services 17,854 people in the OHP Standard. Eligibility • Services related to hearing aids for the program includes parents and • Dental services (besides emergency) adults/couples who are not eligible for the OHP • Most medical equipment and supplies Plus. Enrollees must be age 19 and older, not be eligible for Medicare, and family income must be • Acupuncture (except for treatment of under 100 percent FPL. Enrollees cannot have chemical dependency) over $2,000 in assets (with some items excluded • Chiropractic and osteopathic manipulation such as the person’s house or car). • Home health care • Nutritional supplements The OHP Standard has been closed to new • Occupational, Physical and Speech Therapy enrollment since July 2004 due to budget cuts. • Private duty nursing Currently, the program is supported by taxes on hospitals and managed care plans that provide Some OHP Standard clients pay premiums for enough revenue to cover an average of 24,000 their coverage. Monthly premiums are based on clients biennially. Through attrition, enrollment the person’s income, and range from $9 (for has dropped below that number and, for the first those whose incomes are at 10 to 50 percent of time in over three years, a limited number of FPL) up to $20 per month for those with incomes adults are able to apply for the OHP Standard at 85-100 percent of FPL. Persons with incomes benefits. Because of the high demand for this below ten percent of FPL do not pay premiums. coverage and the limited number of openings People who owe past premium payments at their available, a reservation process was semi-annual eligibility determination are implemented. From January 28, 2008 through disenrolled. These individuals are not eligible to February 2008, over 91,000 people placed their re-enroll until they pay their past premiums and names on a reservation list. In March, names the program is open to new enrollment. were drawn and applications mailed to Background Brief - Legislative Committee Services Page 2 of 4 Oregon Health Plan – June 2008 The OHP Service Delivery System contribution, based on family size and income. People in the OHP receive health care services Enrollees who do not pay their share of the through managed care organizations. There are premium are disenrolled. Eligibility is for 12 three managed care delivery systems: fully months. The asset level for FHIAP is $10,000. capitated health plans (FCHPs), primary care Qualified individuals must also have been management (PCM), and physician care uninsured for at least six months, except for organizations (PCOs). those leaving the Medicaid program, those previously enrolled in FHIAP or those enrolled Approximately 77 percent of people in the OHP in Tri Care military insurance. are enrolled in FCHP/PCOs. These programs are similar to health maintenance organizations Coverage - There are minimum benchmarks that (HMOs) in that FCHPs receive a set amount of group and individual plans must meet to qualify money per enrollee in return for providing the for the FHIAP program. Plans must include at services for which the person is eligible, least the following: including inpatient hospital care. There are currently 14 FCHPs in the state that serve OHP • Coverage in 19 defined benefit categories clients. PCOs provide the same range of services • $750/year (or less) individual deductible as FCHPs, except for inpatient hospital services. • $4,750 maximum out-of-pocket per person There is one PCO. (includes deductible) or $20,000 stop-loss • $1,000,000 (or higher) lifetime maximum Approximately two percent of OHP enrollees benefit receive their care through a PCM. This care includes preventive, primary care, and specialty Prescription drugs can have cost sharing up to 50 services managed by a physician, nurse percent with no out-of-pocket maximum for practitioner, or other provider. drugs. Plans can have up to a six-month pre- existing condition waiting period. Due to federal law, state policies, or because a managed care organization may not provide Subsidy - FHIAP subsidizes both employer- services in some parts of the state, approximately sponsored (group) and individual health plans. 21 percent of OHP clients receive health care on The backbone of FHIAP is the private-sector a fee-for-service basis. These clients receive their health insurance market. To leverage state and health care from a provider who bills the state federal funds (on average, the program receives directly for services. approximately 65 percent federal match on expended state dollars), as well as private-sector Enrollees who are eligible for dental and mental dollars and encourage participation in the health services through the OHP receive care employer-based market, members who have through stand-alone dental care organizations health insurance available to them through an and mental health organizations. These services employer are required to enroll in that coverage operate similarly to FCHPs in that dental and if the employer pays any part of the premium mental health plans receive a set amount of (these plans must also meet the benchmarks money per enrollee to provide health care above). This allows the state to leverage the benefits for which the person is eligible. employer dollars. However, members who do not have group insurance available can purchase a Family Health Insurance Assistance policy in the individual health insurance market Program from one of eight FHIAP-certified insurance Eligibility - Families with average monthly gross companies. income up to 185 percent FPL may be eligible for FHIAP. Subsidies range from 50 to 95 Enrollment - As of March 2008, FHIAP had percent of the premium costs after any employer approximately 16,200 lives enrolled in the Background Brief - Legislative Committee Services Page 3 of 4 Oregon Health Plan – June 2008 program, with 32 percent of these members Credit. enrolled in employer
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