Oregon Health Plan - Information
Authored By: Oregon Law Center, Legal Aid Services of Oregon
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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.