What has changed? 
The Oregon Health Plan (OHP) Medicaid program will change in many ways.
The changes made to OHP are listed below.
These changes take effect on February 1 and March 1.
- Replace the former OHP
Basic Benefit Package with two new benefit packages.
- Move current clients
to one of two new benefit packages. The benefit package they get is based
on how they qualify for Medicaid.
- Offer coverage to pregnant women and children with incomes up to 185% of the federal poverty level.
- Adopt new policies under the OHP Standard benefit package for applicants and clients with access to employer-sponsored health insurance.
- Adopt new eligibility criteria for the OHP Standard benefit package.
- Employ new policies under the OHP Standard benefit package for premiums.
- Charge copayments based on the benefit package. They are added to the Basic Benefit Package on January 1. They are added to the OHP Standard benefit package on February 1.
- Reduce benefits for the OHP Standard benefit package. This happens on March 1.
How has the benefit package changed?
We are replacing the Basic Benefit Package with two new benefit packages. They are called the OHP Plus benefit package and the OHP Standard benefit package. Both of these new benefit packages are based on the Prioritized List of Health Services. The Health Services Commission creates the list. The Oregon Legislature adopts it.
What is the OHP Plus benefit package?
The OHP Plus benefit package is the same as the former Basic Benefit Package. It has small copayments for outpatient services and prescription drugs. These copayments do not apply to the following clients:
- Clients enrolled in a managed care plan that has a contract to cover outpatient services.
- Children under age 19.
- Pregnant women.
- Clients who get services
under the Home and Community Based Waiver.
- Clients who get services
under the Developmental Disability Waiver.
- Clients who are a patient
of a hospital nursing facility.
- American Indians and
Alaska Natives who are members of federally recognized Indian tribes.
- American Indians and
Alaska Natives who get services through Indian Health Clinics, a federally
recognized Indian tribe, tribal organization, or at an Urban Tribal Health
Clinic.
- Youths in State Foster
Care or Residential Treatment.
- Clients who get services
under the Citizen Alien Waived Emergency Medical program.
What is the OHP Standard benefit package?
The OHP Standard benefit
package has copayments for many services. All clients, even
those enrolled in a managed care plan, must pay these copayments.
There are only two exceptions:
- The first group includes
American Indians and Alaska Natives who are members of federally recognized
Indian tribes.
- The second group includes
American Indians and Alaska Natives who get services through Indian Health
Clinics, a federally recognized Indian tribe, tribal organization, or at an
Urban Tribal Health Clinic.
Who will get each of these new benefit packages?
On February 1, we will
move our clients to one of these two new benefit packages. The benefit package
they get depends on how they qualify for medical assistance.
We will move about 110,000
adults to the OHP Standard benefit package. They qualify based primarily on
income, residency and limited assets. We sometimes called them non-categorical
clients.
We will move about 290,000
adults and children to the OHP Plus benefit package. They qualify based primarily
on age, pregnancy, disability or other traditional eligibility categories. We
sometimes called them categorical clients.
Who will gain coverage as part of the expansion?
On February 1, we will increase the income limit for some categorical clients.
The limit will rise from
170% to 185% of the federal poverty level for pregnant women and children under
age 19. They will get the OHP Plus benefit package.
We got federal approval
to increase the income limit for non-categorical clients too. It allows us to
expand coverage up to 185% of the federal poverty level. We plan to increase
the income limit in small increments. The Oregon Legislature asked us to do
this on July 1, 2002. But our budget may prevent us from increasing the income
limit. These clients will get the OHP Standard benefit package.
Are there other criteria, in addition to income, that will influence an applicant's eligibility for medical assistance under the OHP Standard benefit package?
Yes. Applicants must
meet all of the criteria listed below:
- Be uninsured at the time of application.
- Have been without health insurance for the last six months. (Participation in the Family
Health Insurance Assistance Program is not considered health insurance
for this purpose.)
- Be a U.S. citizen or qualified immigrant.
- Be an Oregon resident.
- Have less than $2,000 in liquid assets.
- Agree to pay monthly premiums.
If any of these applicants have access to employer-sponsored health insurance, they must report it on the application. They must also seek coverage under the Family
Health Insurance Assistance Program (FHIAP). FHIAP is a premium subsidy
program.
An applicant is not expected to enroll in FHIAP under some conditions. For example, the employer does not pay part of the premium, FHIAP enrollment is closed, or the employer's benefits
do not meet FHIAP standards.
How many more people will the Medicaid program cover based on this change?
By June 30, 2003, this
change is expected to add about 11,250 people to the OHP Standard
benefit package. It is expected to add about 950 people to the OHP
Plus
benefit package. Most OHP Plus enrollment will come from children. They will
qualify because of the new income limit.
By June 30, 2005, this change is expected to add about 35,050 people to the OHP Standard
benefit package. It is expected to add about 1,600 people to the OHP
Plus benefit package. About 67% of the OHP Standard enrollment will
come from households with income below the federal poverty level.
Why is Oregon making this change?
Oregon was at risk of
losing gains made in expanding health care access without these program changes.
We could not sustain the old program. The federal government did not allow us
to change the Basic Benefit Package. We needed that ability to keep within the
Medicaid budget. Rising health care costs made it even more difficult to keep
within our budget.
Oregonians still believe
that access to basic health care will improve the health of all citizens. Health
insurance provides access to health care. That access allows people to get treatment
for health conditions before they get worse or cost more to treat. Also, early
access to health care results in better outcomes. Access to health care also
can reduce the incidence of infectious diseases.
Based on these beliefs,
we wrote a request to change the program. The new program allows us to partner
with our clients in paying for their health care coverage. It also allows us
to increase the number of Oregonians with health insurance. The change also
helps us manage our budget.
The new OHP Standard benefit
package looks like commercial health insurance. Clients who get that benefit
package are better prepared for coverage found in the private sector. Most people
with private coverage pay premiums and make copayments.
How much will this change to the Medicaid program cost taxpayers?
This change to the Medicaid
program will cost taxpayers no more than the previous design. It may even cost
less. We achieve savings by offering a leaner benefit package to clients. Plus,
we ask them to help pay part of the cost of that coverage. Clients who get OHP
Standard pay monthly premiums and copayments.
