Ohp income limits 2020 pregnant

DO YOU NEED HEALTH CARE?

DO YOU HAVE A DISABILITY AND NO HEALTH INSURANCE?

How Can I Get The Oregon Health Plan?

There are different programs within the Oregon Health Plan (OHP). Each program has different eligibility rules. Most children in low income families are eligible for OHP. For a child to be eligible for OHP, the family income must be 200% of poverty or below.

There are also OHP programs for some low income adults:

• Pregnant women,
• People who are disabled,
• People who are on Supplemental Security Income (SSI),
• People who are low income and live in a nursing home, adult foster home, assisted living, or receive care in their own home paid for by DHS
• Families getting TANF cash benefits or Pre-TANF or who would be eligible for TANF
• Families who go off of TANF because of child support or employment income (this program lasts for up to one year)
• Some people who have been diagnosed with breast or cervical cancer
• Certain refugees

All of the adults who are eligible for those programs, and all children on OHP receive OHP Plus benefits.

There other programs with different benefit packages:

• CAWEM for people who would be eligible for any of the OHP programs if they were US citizens or met the immigration requirements for those programs. CAWEM pays for emergency medical services and for delivering babies. In Benton, Clackamas, Deschutes, Hood River, Jackson, Lane and Multnomah Counties, pregnant women eligible for CAWEM receive OHP Plus benefits
• OHP Standard for adults who are not eligible for any of the OHP plus programs and have income at or below 100% of the poverty level.

There are other requirements that you must meet to be eligible for the OHP programs, such as income and resource requirements. You must also be a US citizen or meet other immigration requirements if you are not a US citizen. You will be asked to prove your immigration status or US citizenship by showing DHS certain documents. For US citizens, that usually means your birth certificate. For people who are not citizens, that means your papers from Immigration.

I Applied For The Oregon Health Plan And They Say The Standard Plan Is Closed. What Can I Do?

OHP standard will open and close periodically, depending on the amount of funding that is available for that program. When DHS opens the program to new clients, they have a "reservation list". Be sure to get your name on the reservation list, in addition to applying for the other OHP programs.

When you ask for an application for the Oregon Health Plan (OHP) you should receive one, even if OHP standard is closed. You have the right to apply for OHP at any time. You must be considered for all of the OHP programs. If you think you may be eligible for any of the programs, but DHS denies your application, you have the right to request a hearing. Section 5 below tells you how to request a hearing.

If you have a disability, be sure to write that in the lines provided on the application. This will lead to your being considered for the OHP program based on disability. In this program the Department of Human Services (DHS) will look at your disabilities and see if they match up with the ones that the Social Security Administration uses to determine if you are disabled. If you meet the requirements for OHP based on your disability, you will receive OHP Plus.

If you have already been denied Social Security or Supplemental Security Income (SSI) within the last year, the state can use this information to deny you OHP based on disability unless you have a change in your condition. Be sure to list all of your medical conditions in your OHP application. You do not have to apply for Social Security or SSI in order to apply for OHP.

I Applied For OHP And I Am Disabled. What Does It Mean If I'm Referred To "PMDDT"?

PMDDT is the short name for the Presumptive Medicaid Disability Determination Team. If you applied for OHP and you said that you have a disability, or if you told DHS that you have a disability after you applied, your application should be handled by this team in DHS. They will decide if your disabilities match up with the ones that the Social Security Administration uses to decide if you are disabled and can get OHP because of your disability.

How Long Does The State Have To Make A Decision?

If you are applying for OHP, DHS must decide if you qualify within 45 days. If your application for OHP is based on disability, the state has 90 days from the date of your OHP application to decide if you qualify. If more than 90 days go by, you have the right to request an administrative hearing. You will probably receive two different decision notices. The one you receive first will let you know if you are eligible for the OHP programs that are not based on disability. The second notice will tell you if you are eligible for OHP based on your disability. You have the right to a hearing if you don't agree with either of those decisions.

DHS Denied My Ohp Application. How Do I Get A Hearing?

In order to have a hearing, you must fill out a hearing request form. To obtain this form go to your local DHS office and ask the receptionist for a DHS Form 443 (Administrative Hearing Request) or get it on the Internet. (Go to www.dhs.state.or.us. Click on "Forms" at the top. Then click on "Find a DHS Form." Type in "443" for the number and click on "Search.").

To find out about your hearing rights, call the Public Benefits Hotline (1-800-520-5292) or your local Legal Aid office for possible advice or representation. Go to www.oregonlawhelp.org for a directory of legal aid programs.

The State Says I'm Disabled, But The Social Security Administration Says I'm Not. Will I Lose My OHP?

No. Even if Social Security denies you, you have the right to stay on OHP through any Social Security and SSI appeals, including a hearing, all the way up to the Appeals Council. If the Appeals Council says you aren't disabled, then you should be placed into the OHP Standard program.

I Am Losing My OHP Plus Benefits. Can I Get Into Another OHP Plus Program? Can I Get OHP Standard?

Before DHS ends your OHP Plus benefits, they must look at whether you are eligible for any other OHP Plus program. For example, a woman may be on OHP Plus because she is on TANF. If she goes off of TANF and she is disabled, she will be able to go into the OHP Plus program for people who are disabled.

Even if you are not eligible for any other OHP Plus program, DHS must look at whether you are eligible for OHP Standard. Although OHP Standard is closed to new applicants, if you are on OHP Plus, you are not considered a new applicant, and you can transfer into OHP Standard. You still must meet the eligibility requirements for OHP Standard. Your family income must be 100% of the poverty level or below for the adults to receive OHP Standard. Children are eligible for OHP Plus as long as the family income is 185% of poverty or below.

If you are on OHP Standard, you can also go into OHP Plus if you meet the requirements for one of those programs. For example, if you are on OHP Standard and then you become disabled, if you meet the disability requirements for OHP Plus, you will go from OHP Standard to OHP Plus.

Some family members can stay on OHP Plus, while other family members may only be eligible for OHP Standard, or may not be eligible for OHP at all. For example, the adults may not be eligible for OHP Standard because the family income is too high (more than 100% of poverty), but the children may be eligible for OHP Plus since the income level for children is 185% of poverty.

REMEMBER, if you are on OHP, every time you reapply, DHS must look to see if you are eligible for any OHP Plus program. If you are not, DHS will put you into OHP Standard if you meet the requirements for that program.

It is very important for you to reapply on time for OHP. It is especially important if you are on OHP Standard. Since OHP Standard is closed to new applicants, missing the deadline may mean that you lose your health coverage unless you can show that you are eligible for one of the OHP Plus programs.

Are There Special OHP Programs For Children?

Yes. Oregon has the "Healthy Kids" program for children under the age of 19.

Your child must have been without health insurance for two months (though there are exceptions to this rule for special circumstances, like a parent's job loss or a child's serious medical need).

For free or low-cost coverage, household income can't be more than 300 percent of the federal poverty level, which is about $66,000 for a family of four. Income level depends on family size, so for smaller families, income is less. For larger families, income is more. For households with income greater than 300 percent of federal poverty level, there is an option for affordable coverage without a subsidy.

The health insurance coverage is free if the family income is 200% of poverty or below. From 201% to 250%, the state will pay for 90% of the cost of the insurance. From 251% to 300%, the state will pay 85% of the cost of insurance. For families with incomes above 300%, the family will have to pay the insurance premium, but the state will make the same health insurance plans available.

To apply for the Healthy Kids Program, call 877-314-5678.

Are There Other Ways To Get Help With Questions About The Oregon Health Plan?

Yes. You can call the Public Benefits Hotline at 1-800-520-5292, or call your local Legal Aid office for possible advice or representation. Click here for a directory of legal aid programs.

Another way to get help is to call the Governor's Advocacy Office at

1-800-442-5238 or the Client Advocate Services Office of OMAP at 1-800-273-0557.

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Who gets which OHP benefit package?

The main benefit packages are:

• OHP Plus (BMH): For people eligible for Medicaid or the Children's Health Insurance Program (CHIP), such as children, pregnant women, seniors and people with disabilities.
• OHP with Limited Drug (BMD, BMM): For people who are eligible for both Medicaid and Medicare Part D.​

What does OHP Plus Supplemental cover?

OHP Plus Supplemental covers the following services for pregnant women age 21 and over:

• Glasses 
• Contact lenses 
• Fittings for glasses or contacts 
• Eye exams for prescribing glasses or contacts 
• Dental crowns 
• Dental visits for observation 
• Replacement of full dentures 
• Root canals on molars and some other tooth root procedures 
• Some gum or oral surgery 
• Some types of dentures and partials
  

Does OHP cover preventive services?

Yes. The OHP Plus, CAWEM Plus, and OHP with Limited Drug benefit packages cover preventive services, which include immunizations, check-ups, and screening tests (such as mammograms and PAP tests).

Will OHP pay for treatment when there is an accident or injury to the eye(s)?

Yes. Urgent/emergent treatment is a covered service for all benefit packages.​

Medicaid expansion in Oregon

Oregon was far ahead of the pack on Medicaid expansion and reform.  The state expanded Medicaid (Oregon Health Plan) to cover people with incomes up to 100 percent of poverty in 1994.  Budget woes resulted in benefits being scaled back over the years and enrollment was suspended from 2004 to 2008.

Who is eligible for Medicaid in Oregon?

• Adults with household incomes up to 138 percent of poverty.
• Pregnant women and infants with household incomes up to 185 percent of poverty.
• Children under age 19 with household incomes up to 305 percent of poverty, regardless of immigration status.
• The Oregon Breast and Cervical Cancer program is available to women with household income up to 250 percent of poverty (women 40 and older, or younger women who have symptoms consistent with breast or cervical cancer).

How do I enroll in Medicaid in Oregon?

If you are under 65 and don’t have Medicare:

• The best way to enroll in Oregon Health Plan is online at HealthCare.gov or One Oregon.
• You can also contact HealthCare.gov by phone to enroll at 1-800-318-2596.
• Residents with certain special-eligibility status can enroll through Oregonhealthcare.gov.
• You can also get in-person assistance with an application by contacting a community partner.  This link will help you find assistance in your area.
• Those who are currently enrolled Oregon Health Plan and Healthy Kids need to renew their benefits annually. They will receive a notice from the state when it’s time to do this, and the Oregon Health Plan website has renewal forms and full renewal applications available for existing members.

If you are 65 or older or have Medicare:

• You can apply for Medicaid or a Medicare Savings Program (MSP) using One Oregon.
• You can also receive free assistance with applying through an Area Agency on Aging (AAA) or a Department of Human Services Office for Aging and People with Disabilities.

Oregon Medicaid enrollment

Prior to 2014, it was anticipated that Oregon would enroll 400,000 new members in the Medicaid program by 2022. While that prediction may ultimately prove accurate, Medicaid enrollment in Oregon has fluctuated rather dramatically from the launch of the ACA and Medicaid expansion.

In the fall of 2013, prior to the launch of the ACA’s exchanges, Oregon’s total Medicaid/CHIP enrollment stood at more than 626,000.

By March 2016, enrollment in Oregon Medicaid/CHIP was 1,076,961 (a 72 percent increase compared to 2013 enrollment, which was at that point tied with Colorado for the third highest percentage growth in the country, behind only Kentucky and Nevada).

Then, Oregon Medicaid enrollment dropped sharply from early 2016 to early 2017. Not coincidentally, Oregon had experienced glitches with its Medicaid enrollment platform prior to 2016, and applicants’ eligibility had not been properly screened. Between March 2016 and August 2017, nearly 300,000 enrollees were removed from the Medicaid program once it was determined that they weren’t actually eligible for benefits.

By June 2018, Oregon Medicaid/CHIP enrollment had rebounded to 963,857 people.

As of July 2020, total Medicaid/CHIP enrollment was 1,066,371  — an increase of about 440,000 or 70 percent since the fall of 2013 and the sixth largest percentage increase among all states and Washington, DC over the time period.

Fast-track enrollment

Oregon is one of a handful of states that used a fast-track enrollment process prior to 2014 that let them identify Medicaid-eligible residents based on their participation in other state-run programs. Since their income and immigration status were already verified, the people who were identified as fast-track eligible did not have to go through the full application process for Medicaid.

The state sent out notifications to about 300,000 residents, letting them know they were eligible for Medicaid. People who received one of these letters were able to simply fill out the enclosed form and returned it in the postage-paid envelope to be automatically enrolled in Medicaid. Oregon also had a system that let eligible fast-track enrollees complete the enrollment process by telephone.

Oregon Medicaid history

The Oregon Health Plan is Oregon’s Medicaid program, overseen by the Oregon Health Authority.  The Oregon Health Plan was conceived and implemented in the late 80s and early 90s. Oregon Medicaid was on the cutting edge of health care reform, addressing the issue of access to healthcare long before most other states.

During that time, physician John Kitzhaber was a state senator and was instrumental in shaping Oregon’s Medicaid program. Kitzhaber went on to be governor of Oregon from 2011 to 2015. During the late 80s/early 90s, Oregon’s uninsured rate was about 18 percent. According to a Gallup data, that rate had dropped to 14 percent by mid-2014, and to just 8.8 percent by mid-2015. That put Oregon third in the nation in terms of percentage drop in the uninsured rate by the first half of 2015. However in 2020, the coronavirus and Covid-19 pandemic triggered widespread job losses across the United States and subsequent losses of employer-sponsored health insurance. Oregon’s uninsured rate climbed to 13 percent as of May 2020.

In 1994, Oregon expanded Medicaid to cover all residents with incomes below the poverty level under a basic benefits package (OHP Standard, as opposed to the OHP Plus program that applies to pregnant women, children, disabled residents, and others who were already eligible for Medicaid). That year, 120,000 newly-eligible residents enrolled, and Portland area hospitals saw a 16 percent reduction in unpaid medical bills.

In 1995, Medicaid in Oregon began to add mental health and chemical dependency coverage, although these services were removed from the basic benefits package in 2003. In most states, Medicaid was only available to pregnant women, children, seniors, and adults with disabilities prior to 2014 — Oregon was way ahead of its time in expanding basic coverage to everyone living in poverty.

Pre-ACA: Years of budget woes

Over the last two decades, Oregon Health Plan has instituted numerous cost-containment measures, including a requirement that limits beneficiaries to a single pharmacy (chosen by the insured member), a disease management program providing case management to clients with specific chronic illnesses, and copays for most adult clients who are not part of exempt groups (tribal members, pregnant women, etc.).  Coverage for vision/hearing, and durable medical equipment was eventually discontinued as the state worked to reduce Medicaid expenses.

In addition, the state began requiring small premiums to participate in OHP Standard, and that led to roughly 40,000 enrollees dropping their coverage because they were unable to pay the premiums (now that Medicaid has been expanded, they are once again eligible for coverage without premiums).

By 2004, considerable budget issues led to a ballot initiative that would have generated revenue for OHP via additional income taxes, corporate taxes, and tobacco taxes.  The ballot measure failed though, and OHP Standard ceased new enrollments on July 1, 2004.  It didn’t open back up again until 2008, at which point there was a lottery to claim 3,000 available spots in the program (tens of thousands of people applied to get one of the spots, and many people applied more than once over the ensuing years).

It was a natural progression for Oregon to accept federal funding to expand Medicaid in 2014.  Coverage is now available for all legally present residents with incomes up to 138 percent of poverty, and the federal government is picking up most of the tab for the newly-eligible enrollees (94 percent in 2018, although this will drop to 90 percent in 2020 and future years). There’s no longer a lottery system in Oregon — everyone who qualifies can enroll in the program.

Coordinated Care Organizations: A $1.9 billion reward for reducing Medicaid cost growth, and a new focus on social determinants of health

In 2012, Oregon Health Plan started using Coordinated Care Organizations (CCOs) which divide the state into 16 regions and include a network of various types of providers who work together to provide all-encompassing care for their clients.  The CCOs coordinate mental, physical, and dental care and the focus is on improving patient outcomes while also lowering total costs for the Medicaid program.

Part of the impetus for the CCO system is a deal that former Governor Kitzhaber struck with the federal government in 2011.  The state had a $2 billion shortfall in its Medicaid budget, and the federal government agreed to give them $1.9 billion over five years — but only if they could find a way to have their Medicaid costs grow 2 percent slower than the national average (taking spending growth from 5.4 percent down to 3.4 percent). Because so much money was at stake, Oregon once again set itself up as a Medicaid vanguard — attempting to maximize patient outcomes and quality of care, while minimizing costs.

Oregon’s CCO Medicaid waiver ran from 2012 to 2017. In December 2017, the Center for Health Systems Effectiveness at Oregon Health & Science University prepared a report analyzing the impact of the waiver. And the state reported in early 2018 that per member per month Medicaid spending had been “at or below sustainable growth targets from 2013 to 2017.”

In 2017, Oregon proposed an extension of their 1115 demonstration waiver, asking for federal approval to build on the success of the CCO model and include a new focus on the social determinants of health and value-based payments. CMS granted approval of the demonstration waiver extension in 2017, and it will remain in effect until mid-2022.

Dispute with FamilyCare

The CCOs were given different rates based on the overall health of their members. And in September 2015, Oregon Health Authority retroactively reset rates back to January 2015 (the state has noted that “limiting state spending growth in order to meet the waiver terms and requirements has been largely a rate setting
task.”) Overall, rates fell by 0.8 percent, but the impact was felt the most by FamilyCare, which has more than 130,000 members and was hit with a 17 percent rate decrease. Oregon Health Authority noted that they “agonized” over the need to retroactively reduce rates for the CCOs, but said that the move was required by the federal government.

Oregon Health Plan and FamilyCare were in mediation for months over the payment issue. In March 2016, the Oregon Health Authority announced that it was proposing a settlement with FamilyCare, but FamilyCare fired back, stating in a press release that the state’s proposed settlement “demonstrate[d] an abuse of power.” FamilyCare also noted that the state had failed to “provide critical information used to develop and calculate the coordinated care organization (CCO) Medicaid reimbursement rates despite multiple requests by FamilyCare” and pointed out that such data had previously been publicly available.

In late March, FamilyCare announced that Oregon Health Plan had rejected the CCO’s offer to resume mediation, and FamilyCare indicated their intent to take legal action on the issue. But in late May, FamilyCare and Oregon Health Plan reached a settlement agreement which called for FamilyCare to drop their litigation, and for Oregon Health Plan to retract their plans to terminate FamilyCare as a CCO. Under the terms of the settlement, FamilyCare was expected to reimburse the state for $55 million in overpayments.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.