A Guide to the Oregon Medicaid Plan

How To Apply for OHP Coverage

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:

• Name, address, and contact information
• Details about each person in your household applying for benefits, including the Social Security numbers or document numbers for legal immigrants and dates of birth
• Details about income and employment for each person who earns money from W-2s, wage statements, or pay stubs
• Information about any current health insurance policy you may have
• Information about any employer health insurance options you can access
• Details about your assets, like owned property, retirement plans, and life insurance policies
• Details about veteran’s benefits, if applicable

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.

Eligibility Requirements

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.

Getting an Oregon Medicaid Card

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.

Renewing or Replacing Your Oregon Medicaid Card

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.

Oregon Medicaid Coverage

The list of what OHP covers is long. Although specifics vary by program or policy, Medicaid enrollees can access:

• Primary care provider office visits
• Preventive care, including well-child visits, vaccines, mammograms, and screenings
• Physical, occupational, and speech therapy
• Gender-affirming services
• Inpatient/outpatient hospital care
• Alternative medicine, including chiropractic and acupuncture
• Family planning services
• Maternity care
• Vision care
• Dental care
• Behavioral Health services
• Transportation to medical appointments

Dental

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:

• Citizenship Waived Medical (CWM), which covers dental emergencies
• CWM Plus, which provides full dental coverage during pregnancy and for 60 days after birth
• OHP Dental, for veterans and some COFA citizens

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.

Prescription Drugs

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.

Extended Health Care

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.

Travel and Out-of-State Coverage

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.

Students and Seniors

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:

• Qualified Medicare Beneficiary (QMB), which adds additional covered services to Medicare Part A
• Specified Low-Income Medicare Beneficiaries and Qualified Individual-1 (QI-1), which pays the monthly Medicare Part B premium
• Qualified Individual-2, which reduces the cost of Medicare Part B premiums

Seniors who need assistance with long-term care, either at home or in a facility, can access help through several state programs.

• Program for All-Inclusive Care for the Elderly (PACE) provides coordinated assistance to older people in their communities rather than in a facility.
• Long-term care coverage varies by income and other factors.
• Home health and hospice

Coverage for Subgroups

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

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:

• Plans with zero out-of-pocket costs: Eligible members with income at or below the family size limit ($77,250 for a family of four) can enroll in a cost-free plan, covering deductibles, co-pays, co-insurance, and prescriptions.
• Plans with reduced out-of-pocket costs: Regardless of income, Tribal members can opt for a plan with no out-of-pocket expenses when seeking care from Indian Health Services, Tribal Clinics, or Urban Indian Clinics. They may also incur zero costs when referred by their Tribal clinic to another provider.

Additional benefits:

• Flexible enrollment: Tribal members can enroll in a private health plan at any time and change plans on a monthly basis.
• No out-of-pocket costs for Indian health programs.
• Consistent care: Members can maintain care with community providers at Tribal and Urban Clinics, potentially with financial savings to lower monthly premium costs for private health insurance.
• Premium sponsorship: Tribes, tribal organizations, and urban Indian organizations may choose to cover premiums for qualified health plans for tribal members. For details on the Tribal Premium Sponsorship Program, contact us or your tribal organization.

Oregon Breast and Cervical Health Care Program

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.