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Obtaining Health Care Coverage

Individual Coverage

Underwriting standards are rules an insurance company uses to evaluate the risks associated with providing you with health insurance. Some companies provide protection for individual health and dental insurance needs. The company will review a standard health statement you complete when applying for insurance to determine if it will insure you and how much it will charge.

The health statement requests medical information for the last five years. You should disclose health conditions even if they were not confirmed or diagnosed by a medical provider. be sure to indicate if you no longer have a medical problem. An insurance company may request medical records from your physicians for questions that you marked "yes" on the health statement. The company will use information from your application, health statement, and medical records to determine if you will be offered health insurance.

Be sure to fill out the health statement and application completely and accurately. If you make an error on the application, cross it out and initial the changes (don't use liquid whiteout). The application becomes part of your policy and is considered a legal document. Your insurance company can investigate and cancel your policy for up to two years if you provide inaccurate information or fail to disclose information on your application.

Oregon Medical Insurance Pool

OMIP provides medical insurance coverage for all Oregonians denied adequate medical insurance coverage because of current or prior health conditions. It also provides health benefit portability coverage to Oregonians who have exhausted COBRA benefits and have no other portability options available to them.

Employer sponsored coverage

Employers aren't required to provide health insurance for their employees. However, if an employer chooses to offer health coverage, the policy must be available to new employees after any predefined waiting period. If you don't enroll in the employer's insurance within 30 days of initial eligibility, the insurance company can require you to complete the standard health statement. The health statement must only be used to determine pre-existing medical conditions.

You may also enroll during an employers open enrollment period. Employers usually have company representatives that can provide additional information about your eligibility options, specific open enrollment date, and premiums.

Specific regulations pertain to coverage offered to employers of 50 or fewer employees. The Insurance Division reviews health insurance premiums for plans sold to small-employer health insurance (SEHI) employers with 2-25 employees. geographic average rates (GAR) are rounded off to the nearest dollar and represent an insurance company's closest equivalent to three standard benefit plans designs.

The Insurance Division provides a summary of Part B geographic average rates for historical and future trends.

Continuation of coverage

The Consolidated Omnibus Reconciliation Act (COBRA) may allow terminated employees or those who lost coverage because of reduced work hours to purchase group coverage for themselves and their families for limited periods of time. Spouses and dependents may be eligible for coverage in the event of the primary insureds death or in the event of a divorce. COBRA is regulated by the U.S. Department of Labor.

You may be eligible to continue your group policy if your benefits are affected by termination from employment, dissolution of marriage or legal separation, or you are a surviving spouse and you do not qualify for COBRA coverage. A continuation of coverage policy will provide protection for a maximum of six months or until you are eligible for Medicare, whichever is shorter. The coverage may or may not include optional benefits such as vision, dental or prescription coverage.

Portability of coverage

Portability of health insurance means that ongoing coverage is available if you were enrolled in an employer-sponsored group health plan for at least six months immediately before your coverage needed.

To qualify you must:

  • Be an Oregon resident.
  • Apply for portability of coverage within 63 days of losing your group coverage.
  • Not be eligible to remain enrolled in your prior group coverage, not be eligible for Medicare coverage, and not be enrolled in another health insurance plan.

You can qualify under Oregon rules or the federal Health Insurance Portability and Accountability Act (HIPAA) rules.

You can qualify under Oregon rules if either of the following is true:

  • You were enrolled in Oregon-based group coverage for at least six months.
  • You were enrolled in non-Oregon based group coverage for at least six months while residing in Oregon.

If your prior group coverage was in a self-insured plan, you must exhaust your state or federal continuation coverage (commonly known as COBRA) before electing portability coverage.

You can qualify under federal HIPAA rules if both of the following are true:

  • You have at least 18 months of prior health insurance coverage and the most recent coverage was in a group plan.
  • You have exausted your state or federal continuation coverage (COBRA). Note: YOu may become eligible under Oregon rules before your continuation coverage is exhausted.

You have a choice of two portability plans:

In most cases, portability coverage is provided by the same insurance company that provided your group coverage. In the following cases, however, portability coverage is provided by the Oregon Medical Insurance Pool (OMIP):

  • You were enrolled in non-Oregon based group coverage.
  • You were enrolled in self-insured group coverage sponsored by an employer or a group of employers (including one or more public sector employers in Oregon).
  • You qualify for portability coverage from an Oregon insurance company, but you move out of the insurer's service areas (yet still reside in Oregon) or the insurance company discontinues serving the area where you live.

You are not charged an extra amount or surcharge for your premium if you want to qualify for a portability plan through OMIP.

Hightlights of portability

  • Portability plans can't restrict coverage for preexisting conditions.
  • Premium rates must match typical community rates. The Insurance Division compiles a Part B list of portability geographic average rates of historical and future trends.
  • Your current health plan must provide a "certificate of creditable coverage" when your group coverage ends. This will help you determine if you qualify for portability coverage.
  • After you enroll, you can keep your portability plan even if you obtain other coverage.

Family Health Insurance Assistance Program (FHIAP)

FHIAP helps qualified families and individuals obtain health insurance by paying a large part of their premiums.

Oregon Health Plan Medicaid Program (OHP)

The Oregon Health Plan provides health-insurance for low-income Oregonians. You may qualify for medical assistance through Oregon's Medicaid program. The Oregon Health Plan (OHP) began in February, 1994, under a federal waiver from the Health Care Financing Administration.

Medicare

Medicare is a federal program providing hospital and medical insurance for people who are 65 or older, disabled, or with permanent kidney failure. The Senior Health Insurance Benefits Assistance Program (SHIBA) has volunteers throughout Oregon who provide one-on-one counseling assistance with Medicare, Medicare supplement insurance, Medicare health maintainance organizations, and long-term care insurance.

File a complaint with the Insurance Division

 

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This document was last revised on July 12, 2005 .