omip, oregon medical insurance pool

• I have received a declination of individual health insurance coverage due to health reasons.
  
   
• I have one or more of the conditions listed in Section C of the OMIP application.
  
   
• I was offered individual health insurance coverage that contained a restrictive waiver that substantially reduced the coverage offered by excluding coverage for a specific medical condition.
  
   
• I was offered individual health insurance coverage but was limited by the choice of plans the carrier was willing to offer me due to a specific medical condition.

Portability eligibility. You may be eligible if one of the following is true for you and you must apply for coverage within 63 days of losing your prior coverage:
 

• I have exhausted my COBRA benefits.
  
   
• No COBRA or Portability coverage available through my previous plan.
  
   
• I am eligible for Oregon Portability coverage but moved from the prior insurance carrier's service area.
  
   
• I was covered by Portability coverage, but my insurance carrier no longer serves the area where I live.
  
   
• I am moving to Oregon and have been continuously covered by health insurance for 18 or more months, with no single gap in coverage greater than 63 days and the last coverage was group coverage.

Federal health care tax credit eligibility. To be eligible for Federal Health Care Tax Credit, you must have been certified by the US Department of Labor as being affected by competition from foreign trade, and are receiving a Federal Health Coverage Tax Credit under Section 35 of the Internal Revenue Code.

If you qualify for OMIP under this eligibility category, OMIP is assuming you are eligible for a Federal Health Coverage Tax Credit (HCTC), which pays 65% of the cost of your monthly OMIP premium. However, the federal government will make the final determination about eligibility for the HCTC. 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 in place for a period of not less than 90 days. Please provide a copy of your HCTC Eligibility Notice and a Certificate of Creditable Coverage from your prior health insurance carrier proving that you have 90 days of prior health insurance coverage and are applying within 63 days of losing your most recent prior health insurance coverage.


What does portability mean again?
Portability refers to an individual health benefit coverage offered to a person who is leaving employer-provided group health benefit coverage. The employer's health benefit insurer would be the entity offering the portability plan.

I qualify for OMIP both medically and through portability - which way should I apply?
The portability route may be more advantageous to you because you would not be subject to pre-existing limitations and your monthly premium may be cheaper. However, if you do qualify through portability, you would have to pay the premium for the portability insurance coverage from the date that you no longer had group coverage.

How does someone prove they are an Oregon resident?
A person can provide a copy of their Oregon Driver License, a voter registration card, an Oregon income tax return, a dated rental agreement showing your residence, a current utility bill with your name and address on it, or any other documentation that may be deemed appropriate by the administering insurer, RBCBSO.

If I'm a resident of Oregon, but not a US citizen can I still apply to OMIP?
Yes. You do not have to be a US citizen but you do have to permanently reside in Oregon.

I live out of state but plan to move to Oregon, can OMIP help me now?
You may apply to OMIP up to 90 days before the requested effective date. However, your application may be pended until we ascertain that you have established your permanent residency in Oregon.

My spouse qualifies for OMIP; can I be on his/her OMIP plan?
Yes. However, you may want to look into individual (or group, if available) health coverage for yourself and just keep your spouse on OMIP for a more favorable premium rate.

How much does an OMIP premium cost?
All of our plans are rated based on the age of the oldest insured, the number of people on the plan and the plan selected.

How are premium rates determined?
Premiums are limited to 125 percent of the prevailing market rate and are based on the age of the member, the number of people insured, and the plan selected.

What do the plans cover?
All the plans cover doctor visits, hospital, surgery, prescription drugs, ambulance and medical equipment. For more specific coverage, refer to our Health Benefit Plan Summary.

What's the difference among the four plans that OMIP offers?
All four plans are Preferred Provider Organization (PPO) Plans. They differ primarily by the medical deductible amount, the maximum out of pocket expenses, and the co-insurance amounts.

Are the plans available everywhere in the state?
Yes.

Do the plans pay for health care services from the first dollar?
No. All the plans require the insured to pay for some services before the plan provides benefits. This is called a deductible. The plans have deductible options of $500, $750, $1,000 and $1,500. The lower the deductible, the higher the premium amount.

What is the maximum I will have to pay with OMIP each year?
 

• If you choose Plan 500, your maximum out of pocket expense would be $1,500 per member, per calendar year, assuming you use in network providers.

• If you choose Plan 750, your maximum out of pocket expense would be $3,750 per member, per calendar year.

• If you choose Plan 1000, your maximum out of pocket expense would be $5,000 per member, per calendar year.

• If you choose Plan 1500, your maximum out of pocket expense would be $7,500 per member, per calendar year.

These include medical deductibles but do not count any co-payments or monthly premiums. They also assume you use an in network provider. Using an out of network provider will increase your out of pocket expenses substantially.

Will OMIP pay for my prescription medications?
Most likely, yes. In general, generic drugs cost $10. Preferred-brand drugs cost only $40. Non-preferred brand drugs cost $70. However, there are certain medications that are excluded such as; non-prescription medications, fertility medications, contraceptives, prescriptions for smoking cessation, prescriptions for weight loss, prescriptions for cosmetic purposes and newly approved FDA prescriptions. For a complete list of exclusions, please refer to the OMIP Plan Contract you select.
Also, if you enroll in Plan 1500 you will have an annual $1,000 prescription deductible. This means you will be responsible for paying for the first $1,000 in prescription expenses before OMIP begins paying.

I like the doctor I currently have. If I enroll with OMIP will I be able to keep this same doctor?
Maybe. You may see any doctor you like. However, if your doctor is an in-network provider then you will pay less for covered services than if you see a doctor who is not a provider in the network. To verify if your doctor participates in the OMIP provider network, you may contact customer service at 1-800-848-7280.

How does someone apply to OMIP?
You may obtain an application on line at www.omip.state.or.us. Or call RBCBSO to request an OMIP Packet: 1-800-848-7280. You must complete the application in full and attach proof of Oregon residency. Also, send a declination letter if you are turned down for health insurance because of a medical condition or a Certificate of Creditable Coverage if you are applying for portability coverage.

If you need assistance filling out the application, you may want to seek the assistance of a health insurance producer in your area.

If you need a Spanish interpreter, we do have one available when you call 1-800-848-7280.

How long does it take to process an application?
If the application is complete and all required documentation is attached, it generally takes 30 days or less from the date it is received.

If I apply, how soon would my coverage be effective?
Coverage generally begins for medical enrollees on the first of the month following the date we receive, accept and approve your eligibility. For portability enrollees, coverage generally begins the day you lost your prior coverage.

What is a pre-existing condition?
Pre-existing conditions are those for which medical services, diagnosis, care or treatment were recommended or received in the six months before you obtained health insurance coverage.

I have a pre-existing condition. Will OMIP be able to help me?
Yes and no. The OMIP benefit plans have a six-month limitation for pre-existing conditions, including pregnancy. This means we will not pay benefits during the first six months you or your enrolled dependents are enrolled under an OMIP plan for coverage of expenses incurred for a pre-existing condition.

In summary, NO, you would not be covered for the first six months of your policy for anything related to the pre-existing condition. However, after you have had your policy in force for six months or more, you would be covered for that condition.

Note: There is no pre-existing waiting period if you are coming to OMIP via the portability route and you have had continuous group coverage for the past six months. We will also give month-to-month credit towards the waiting period if the member can provide a valid Certificate of Creditable Coverage showing the start and termination dates of the prior coverage. To receive credits, the effective date must be within 63 days from the previous coverage end date.

So, how long is OMIP's pre-existing waiting period?
Six months unless you have credit for prior coverage.

I have not had insurance for years. I am pregnant and need insurance coverage. Can OMIP help me?
Maybe. Again, the OMIP benefit plans have a six-month limitation for pre-existing conditions, including pregnancy. Therefore, depending on when your baby is delivered (regardless of when the due date is), you may be covered. If the baby is delivered after you have had your policy in force for six months or more, you would be covered for that delivery. Having a policy in force means from the date you were enrolled and received an effective date, not the date you submitted your application.

Note: for those coming to OMIP via the portability route, there would be no limitation for pre-existing conditions as that applicant would have had at least six months prior insurance and no lapse beyond 63 days in coverage.

What happens if I am enrolled in OMIP and then become eligible for Medicare due to turning 65?
You would become ineligible for OMIP effective the first of the month following the date in which you turned 65.

What is FHIAP?
FHIAP is an acronym for Family Health Insurance Assistance Program. FHIAP offers subsidies for low income Oregonians, below the 185 percent federal poverty level, who have been without health insurance for at least six months (except for people leaving OHP/Medicaid). The subsidy pays a large portion of the premium cost for health insurance plans for group plan policies. It is possible to have a FHIAP subsidy pay for OMIP coverage.

Can I have the FHIAP subsidy and OMIP coverage at the same time?
FHIAP is an acronym for Family Health Insurance Assistance Program. FHIAP offers subsidies for low income Oregonians, below the 185 percent federal poverty level, who have been without health insurance for at least six months (except for people leaving OHP/Medicaid). The subsidy pays a large portion of the premium cost for health insurance plans for group plan policies. It is possible to have a FHIAP subsidy pay for OMIP coverage.

Can I have OMIP and Medicaid (OHP) coverage at the same time?
No. If it is discovered that you are receiving both, your OMIP coverage will be retroactively termed as far back as your original effective date and you will be responsible for any claim payments made on your behalf.

I don't have health insurance coverage because I can't afford it.
I make too much for the Oregon Health Plan and the FHIAP subsidy. Can OMIP help me?
Unfortunately, OMIP depends upon premium payments for a large portion of their funding. OMIP is not a subsidy program. If you do not have a medical condition that you believe would disqualify you in the open market, you may want to apply directly to an insurance carrier in the State of Oregon as those rates most likely will be less than OMIP rates.

If you do have a medical condition that you know would disqualify you, you may apply to OMIP. However there are premium payments involved. You may want to contact Oregon SafeNet (1-800-SAFENET) for assistance.

Does OMIP recognize domestic partners?
Yes, as of January 1, 2008.

How can I lose my OMIP coverage?
 

• Become eligible or entitled to Medicare.

• Become eligible for Medicaid (OHP).

• You terminate your OMIP coverage within the last 12 months for a reason other than becoming Medicaid eligible. This includes non-payment of OMIP premiums.

• Have received $2 million in OMIP benefits.

• Are already enrolled in a group plan, or a substantially equivalent health benefit plan when your OMIP coverage becomes effective.

• Have OMIP premiums paid or reimbursed by a public entity or a health care provider for the sole purpose of reducing the payer's financial loss or obligation.

• Are employed by a business with two or more employees and you have applied to OMIP for coverage at the direction of an insurance producer, insurance company, or an employer to separate yourself from the rest of the employees being offered or provided heath benefit coverage in connection with your employment.

• Move out of state.

Who would I contact to see if I might qualify for individual insurance in the open market?
You can apply directly to any health insurance carrier or you can utilize a health insurance producer. For a current listing of insurance companies that sell individual plans in Oregon, click here.

COBRA or portability insurance
When would an employer's health insurance carrier not have to offer COBRA or portability Insurance?
The law generally requires that group health plans maintained by employers with 20 or more employees in the prior year offer COBRA benefits. It applies to plans in the private sector and those sponsored by state and local governments. The law does not, however, apply to plans sponsored by the federal government and certain church-related organizations. For more information about COBRA laws, you may contact your local Department of Labor.