When families have trouble making ends meet, an unexpected illness or injury can take a huge bite from a strained budget. Medicaid programs like OHP help families who wouldn’t otherwise be able to afford healthcare get what they need. In Oregon, about 35% (1,456,893) of the population receives free healthcare through OHP, which makes it possible for them to stay healthy and get the care they need for chronic and acute health concerns.
Eligible Oregonians can apply for one of three OHP (Oregon Health Plan) programs, which include coverage for basic health needs like physicals and screenings to treatment for complex medical emergencies. Unlike other states, which limit benefits for adults who do not have children or a disability, Oregon allows individuals of all ages to access the benefits if they meet the income requirements. For many people, Oregon Medicaid is a lifeline to the critical healthcare they need.
The following guide explains Oregon’s Medicaid program, answers your questions about OHP coverage, details how to apply for OHP, and what you can expect as a beneficiary of state healthcare insurance. You’ll learn how the program works, the eligibility requirements, what you get for coverage, and how to keep your benefits. Armed with this information, you can make informed choices about your family’s health insurance options and determine whether you need to purchase additional insurance to help cover the expenses that the state program doesn’t. To prevent shouldering the debt of unexpected medical expenses, many Oregonians extend their Medicaid coverage to include a more comprehensive range of benefits and services by way of private health insurance.
OHO (Oregon Health Plan) is the name for Medicaid in Oregon. Like the 49 other states, Oregon cooperates with the federal government to give qualifying individuals access to healthcare at no or minimal cost.
OHP works like any other insurance program. Members receive a Medicaid ID card they present to the healthcare provider or pharmacy when they seek care. The provider then bills the state directly at the agreed-upon rates and receives reimbursement from the state funds.
Low-income Oregonians can apply for medical benefits via several programs, including:
The state also offers dental-only benefits and programs for designated groups, including veterans. For example, the Compact of Free Association (COFA) Premium Assistance Program includes full dental benefits for low-income residents of Oregon who emigrated from the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.
Coordinated care organizations (CCOs) manage OHP benefits. Your ZIP code determines your CCO as follows:
All CCOs offer the same benefits and insurance coverage to members. The primary differences are the extra services and participating pharmacies. If you live in a county with multiple CCO options, you can select your preferred organization when you apply for OHP if it’s available in your ZIP code.
If you earn too much for OHP, you may qualify for financial help from the state to purchase a health plan on the federal marketplace during the annual enrollment period.
When you have an OHP plan, you do not have to pay out of pocket for healthcare services. The plan does not charge copayments or fees at the time of service or for any prescription medications. If you have Medicare and Medicaid, you may have to pay part of your premium for Medicare Part B, depending on your income and which program you qualify for.
When you receive health insurance through the Oregon Medicaid program, you will receive two cards: An OHP identification card and a card from your CCO (not shown above as they vary in appearance depending on the carrier). You must present both cards whenever you use your benefits (at the doctor’s office, a hospital, or a pharmacy).
Medicare beneficiaries also receive an identification card when they enroll. You must bring all your cards to medical appointments if you have Medicare and Medicaid.
Although you can apply for the OHP in person or over the phone, the Oregon Health Authority recommends applying online and establishing a ONE Eligibility account. You can apply for benefits at any time and don’t have to wait for an open enrollment period.
Before you apply for OHP, the state recommends completing the online pre-screening to pre-qualify for benefits. By answering a few simple questions about your income, household size, and medical needs, you can determine whether the OHP or another insurance coverage option is better for your situation.
If OHP is appropriate for your needs, you can apply online immediately. Doing so requires submitting information, including:
The Oregon Health Authority requires documentation of information you include on your application, which you can submit electronically. You may receive immediate approval confirmation if you provide all the required details. Otherwise, it could take several weeks to process your application.
Even when you get instant online approval, you’ll receive a letter regarding your application. Approved applications will receive their enrollment information and ID card, and you can start using your benefits immediately.
Oregon’s requirements for Medicaid eligibility are less stringent than some other states, but you must demonstrate financial need to qualify. The general eligibility requirements are as follows:
While most states don’t expand Medicaid benefits to childless adults, individuals in Oregon who meet the income guidelines may apply. The state also provides expanded eligibility for children. Children who qualify for Medicaid between ages 0 and 6 can keep their benefits until age six, regardless of family income, and families with incomes up to 300% of the federal poverty level can apply for the Children’s Health Insurance Program (CHIP).
Seniors aged 65 and over who meet income requirements can also apply for OHP benefits, even if they have Medicare. Medicare and Medicaid are separate programs; most people enroll in Medicare at age 65 regardless of income. Qualifying seniors can use Medicaid benefits to cover some expenses that Medicare doesn’t, and in many cases, pay no or reduced premiums for their Medicare coverage.
Upon approval for OHP (Oregon Health Plan), the Oregon Health Authority will mail you an identification card and details about your new health insurance benefits. The local CCO will also send you an ID card and information about the specifics of the plan and local providers within 30 days. Your card will identify your primary care provider (PCP); if you want to change your PCP, call the CCO directly.
OHP members can remain in the program as long as they are eligible. Program rules require enrollees to renew their benefits every year via a redetermination process on the anniversary of their enrollment date.
During redetermination, the Oregon Health Authority will request documentation of your current circumstances to confirm your ongoing eligibility. You will have 90 days to submit the documentation. If you don’t provide the information, your Medicaid benefits expire in 60 days, and you’ll have to find alternate coverage.
Medicaid recipients are responsible for notifying the Oregon Health Authority if their circumstances change before their redetermination date. Notify the office of address or job changes, significant income changes, and changes to your family size.
You must also notify the Oregon Health Authority about a lost, stolen, or damaged ID card. Call immediately to request a replacement. If you lose your CCO card, contact the plan provider for a new one.
The list of what OHP covers is long. Although specifics vary by program or policy, Medicaid enrollees can access:
OHP includes dental benefits for adults and children. Adults can get urgent care, general dental services (exams, cleanings, etc.), dentures, and stainless steel crowns on their back teeth. Children’s dental benefits add root canals, sealants, and limited orthodontia.
The OHP Plus Supplemental Plan for pregnant women expands the dental benefits to ensure healthy teeth during pregnancy. The state also provides dental-only programs for specific individuals, including:
While dental coverage is quite comprehensive for those enrolled in Oregon Medicaid, it doesn’t cover everything. For those who have more serious dental issues and anticipate requiring more visits to the dentists, investing in private dental plans in Oregan is advisable.
OHP includes prescription drug coverage to ensure you can access medication. Individual CCO plans use a preferred drug formulary to determine which drugs you can get at no charge. If a provider prescribes a medication that is not on the list, they must seek pre-authorization from Medicaid. For general reference as to what drugs are covered under the plan, refer to this page, which is maintained by the Oregon Health Authority.
According to the recommended schedule, Medicaid also covers vaccinations (shots) for adults and children. These vaccines include influenza and COVID-19 vaccinations as well as MMT, varicella, rotavirus, and HPV. Adults can access vaccines for pneumonia, shingles, hepatitis B, DTaP, and other recommended shots.
Oregon is one of 34 states to outline coverage for gender-affirming services, including hormone therapy, counseling, and some surgeries. Other extended services include smoking cessation assistance, like counseling, and benefits for nicotine replacement therapy and prescription medications.
OHP (Oregon Health Plan) benefits do not transfer outside the state. You can only use your Medicaid elsewhere if you have a life-threatening emergency and cannot return home for care or if the services you need aren’t available from an Oregon provider. You can never use Oregon Medicaid for care outside the United States. If you are traveling outside of Oregon for leisure, invest in proper travelers insurance.
No one in Oregon needs to go without health insurance, including individuals between ages 19 and 64 who don’t have children. Thanks to the Affordable Care Act, college students can remain on their parents’ insurance policies until they turn 26, but if that’s not an option, they can apply for OHP.
At age 65, seniors can enroll in Medicare. Most people contribute to the federal entitlement program through payroll taxes, and there is no income eligibility requirement. Although the monthly Medicare premiums are significantly lower than other insurance options, low-income seniors may need extra help, which they can access through a special needs program.
Which program you can join depends on your income. The options include:
Seniors who need assistance with long-term care, either at home or in a facility, can access help through several state programs.
The state of Oregon offers Medicaid coverage for specific subgroups such as Native Americans, Alaskan Native and those who require treatment for breast and cervical cancer.
Native Americans and Alaska Natives enrolled in federally recognized Tribes, bands, or pueblos through private health plans on HealthCare.gov and public plans like the Oregon Health Plan can take advantage of special options pertaining to their healthcare.
For Tribal members acquiring private health insurance via HealthCare.gov:
Individuals who require treatment for breast or cervical cancer but do not have adequate health coverage can apply for the Breast and Cervical Cancer Treatment Program (BCCTP). This program covers the cost of treatment for those under age 65 with incomes less than 250% of the federal poverty level. Individuals who are already covered by Medicaid automatically qualify for this benefit.
Services that Oregon Medicaid do not cover include the following:
It’s also important to note that while Oregon Medicaid provides a small amount of funds toward the cost of a funeral, it most definitely doesn’t cover all expenses. Considering the rising cost of burial and related fees, ensure that your family is secured with comprehensive funeral insurance.
Oregon offers generous benefits to Medicaid recipients that go well above and beyond the federal requirements for state plans. You can review the plan materials to determine the specific coverage limits, but the following list provides a good overview of what OHP covers.
|Primary care visits
|Preventive care and screening services
|Routine lab work and X-rays
|Mental health care
|X-Rays and exams
|Yes, for children.
|Yes, for children. Adults are covered only for specific conditions.
|Yes, for medical conditions.
|Inpatient hospital stays
|Outpatient hospital services
|Newborn in-home visits
|Alternative and complementary medicine
|Durable medical equipment and supplies
|Diabetes testing equipment
|Home care services
|Non-emergency medical appointment transportation
OHP (Oregon Health Plan) is comprehensive, but there are gaps in its insurance coverage. For example, if you wear contact lenses or glasses, Medicaid doesn’t pay for them, and you will need to find an alternative source of coverage. When you need access to more providers, want to explore alternative treatments that Medicaid doesn’t cover, or don’t qualify for full OHP benefits, additional or extended health insurance may be necessary to ensure you have everything you need.
The ever-increasing costs of medical care mean that many people put off necessary treatment and put their well-being at risk. For others, a single accident or unexpected injury can result in significant financial hardship. Coverage beyond Medicaid ensures this doesn’t happen while providing access to the care you need when you need it. Other types of private insurance, such as life insurance, can help pay for medical costs Medicaid will not cover, especially in the event of your passing.
Consider these benefits of additional insurance coverage:
Evaluating your health insurance choices and finding the best one for your needs can feel overwhelming. With help from Insurdinary, it doesn’t have to be. Our simple quoting tool allows you to explore of all your options, including OHP (Oregon Health Plan), and find the ideal plan for your budget and medical needs.
Visit Insurdinary to get your free, no-obligation health insurance quotes from local companies today, and relax, knowing you can get the healthcare you need.
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