Background Brief on …

Oregon

June 2010 Health Plan

Inside this Brief The Health Plan (OHP) expands access to health

care through a combination of public and private • OHP Plus insurance plans and a prioritized list of health care services. Currently, more than 500,000 Oregonians have access to health care under the OHP. The program has • OHP Standard three components, two of which (OHP Plus and OHP Standard) are offered through and the Children’s Health Insurance Program (CHIP). The third • The OHP Service component is offered through the Office of Private Delivery System Health Partnerships as premium subsidies through the Family Health Insurance Assistance Program (FHIAP).

• Family Health FHIAP provides subsidies for the purchase of private health insurance by low-income, uninsured families. Insurance Assistance FHIAP provides assistance to people with incomes up to Program a certain percentage of the federal poverty level (FPL) and subsidizes commercial premiums based on family

size and income. • Office of Private Health Partnerships The Department of Human Services’ Division of Medical Assistance Programs administers the public

insurance components of the OHP, including Medicaid • Oregon Medical and the CHIP. CHIP is a separate federally and state- Insurance Pool funded program to provide health care services to certain low-income children.

• Additional Resources OHP Plus

Eligibility - As of January 2010, there were 448,789 • Staff and Agency children and adults in the OHP Plus population. People eligible for the OHP Plus include low-income elderly Contacts and people with disabilities, people eligible for Temporary Assistance for Needy Families (TANF),

Legislative Committee Services children eligible for Medicaid and CHIP up to 200 State Capitol Building percent FPL, pregnant women up to 185 percent FPL, Salem, Oregon 97301 and low-income foster children. Pregnant women and (503) 986-1813 children may opt to enroll in private coverage under FHIAP instead of Medicaid and CHIP. Generally, many

Background Brief - Legislative Committee Services Page 1 of 4 Medicaid-eligible adult enrollees may not have an average of 24,000 clients on OHP Standard. assets (with some items excluded such as a During the current biennium, only hospitals pay person’s house and car) over $2,000 or $2,500, taxes to support the program but at a higher tax depending on the individual program. There is rate than last biennium. The revenue generated no asset limit for pregnant women and most is enough to cover approximately 60,000 by the children. end of the 2009-2011 biennium. Because OHP Standard enrollment is limited by the tax Coverage - Benefits and services that people on revenue, the department uses a reservation list to the OHP Plus receive include (with some co- add new people to the program. In October pays and limitations): 2009, the department opened the reservation list • Prescriptions; to gather more names. By May 2010, the list • Physician services; contained the names of approximately 111,000 • Check-ups (medical and dental); individuals. The department randomly selects • Diagnostic services for all conditions; names and mails applications to individuals on a • Family planning services; monthly basis to achieve caseload targets. • Maternity, prenatal, and newborn care; Coverage - The OHP Standard covers basic • Hospital services; services (with some limitations), such as: • Comfort care and hospice; • Emergent and urgent hospital care; • Dental services*; • Physician services; • Alcohol and drug treatment; • Lab/X-ray; • Mental health services; and • Prescription drugs; • Vision services*. • Outpatient mental health and chemical

*OHP Plus dental and vision benefits were reduced for dependency treatment; non-pregnant adults (21 years and older), effective January • Emergency transportation; 1, 2010. • Emergency dental; and • Some durable medical equipment and Services not covered include: supplies (diabetic supplies, respiratory, • Conditions that get better on their own; oxygen). • Conditions that have no useful treatment; • Treatments that are not generally Services not covered include: Effective; • Non-emergency transportation; • Cosmetic surgery; • Routine vision services; • Gender changes; • Services related to hearing aids; • Most services to aid in fertility; and • Dental services (besides emergency); • Weight loss programs. • Most medical equipment and supplies; • Acupuncture (except for treatment of OHP Standard chemical dependency); Eligibility - As of January 2010, there are 25,188 • Chiropractic and osteopathic manipulation; people in the OHP Standard. Eligibility for the • Home health care; program includes parents and adults/couples • Nutritional supplements; who are not eligible for the OHP Plus. Enrollees • Occupational, Physical and Speech Therapy; must be age 19 and older, not be eligible for and , and family income must be under 100 • Private duty nursing. percent FPL. Enrollees cannot have over $2,000 in assets (with some items excluded such as the Some OHP Standard clients pay premiums for person’s house or car). their coverage. Monthly premiums are based on the person’s income, and range from $9 (for Last biennium, both hospitals and Medicaid those whose incomes are at 10 to 50 percent of organizations paid taxes to cover FPL) up to $20 per month for those with

Background Brief - Legislative Committee Services Page 2 of 4 incomes at 85-100 percent of FPL. Persons with Family Health Insurance Assistance incomes below 10 percent of FPL do not pay Program premiums. People who owe past premium Eligibility - Families with average monthly gross payments at their semi-annual eligibility income up to 185 percent FPL may be eligible determination are disenrolled. These individuals for FHIAP. Subsidies range from 50 to 95 are not eligible to re-enroll until they pay their percent of the premium costs after any employer past premiums and the program is open to new contribution, based on family size and income. enrollment. Enrollees who do not pay their share of the premium are disenrolled. Eligibility is for 12 The OHP Service Delivery System months. The asset level for FHIAP is $10,000. People in the OHP receive health care services Qualified individuals must also have been through managed care organizations. There are uninsured for at least six months, except for three managed care delivery systems: fully those leaving the Medicaid program, those capitated health plans (FCHPs), primary care previously enrolled in FHIAP or those enrolled management (PCM), and physician care in Tri Care military insurance. organizations (PCOs). Coverage - There are minimum benchmarks that Approximately 80 percent of people in the OHP group and individual plans must meet to qualify are enrolled in FCHP/PCOs. These programs are for the FHIAP program. Plans must include at similar to health maintenance organizations least the following: (HMOs) in that FCHPs receive a set amount of • Coverage in 19 defined benefit categories; money per enrollee in return for providing the • $750/year (or less) individual deductible; services for which the person is eligible, • $4,750 maximum out-of-pocket per person including inpatient hospital care. There are (includes deductible) or $20,000 stop-loss; currently 14 FCHPs in the state that serve OHP and clients. PCOs provide the same range of services • $1,000,000 (or higher) lifetime maximum as FCHPs, except for inpatient hospital services. benefit. There is one PCO. Prescription drugs can have cost sharing up to Approximately one percent of OHP enrollees 50 percent with no out-of-pocket maximum for receive their care through a PCM. This care drugs. Plans can have up to a six-month pre- includes preventive,