Frequently Asked Questions
What is OMIP?
OMIP is an acronym for the Oregon Medical Insurance Pool. OMIP was established in 1989 by the Legislature to provide health insurance to Oregonians who have been denied individual health coverage because of their medical conditions. In short, it is a safety net or last resort for people who cannot get individual health insurance coverage.
OMIP also provides health coverage in certain circumstances when an individual exhausts or is unable to obtain COBRA or portability coverage, and for individuals who are eligible for a health coverage tax credit through the federal government.
Is OMIP a subsidy program?
No. There are no tax dollars that go into funding this program. It is paid by a combination of monthly premiums and an assessment on all insurance companies who provide health insurance to Oregonians.
Is OMIP an insurance company?
No. OMIP is a state program that works like an insurance company, but is exempt from many of the provisions under the Oregon Insurance Code. OMIP currently contracts with Regence BlueCross BlueShield of Oregon (RBCBSO) to administer the program for the State of Oregon. The OMIP Board of Directors approves any rate and/or benefit changes.
Who is eligible for OMIP?
All individuals applying for OMIP coverage must first be a permanent resident of Oregon. They then must meet either the medical, portability (loss of group health insurance), or federal health coverage tax credit requirements as outlined below:
Medical eligibility requirements. Within the last six months one of the following has happened to you:
Federal Health Coverage tax credit requirements. You are eligible to receive a subsidy through the Federal Health Coverage Tax Credit (HCTC). To be eligible for Federal Health Coverage Tax Credit, you must have been certified by the US Department of Labor as being affected by competition from foreign trade, and are receiving a Federal Health Coverage Tax Credit under Section 35 of the Internal Revenue Code.
- You have one or more of the medical conditions listed in Section C of the application.
- You have been denied an individual health insurance policy or were offered coverage that excluded coverage for a specific medical condition.
- You were offered an individual health insurance policy but, the insurance carrier limited your choice of plans due to a specific medical condition.
- You are a permanent resident of Oregon and are transferring from another state's high-risk pool.
If you apply for OMIP coverage within 63 days after receiving your HCTC eligibility certificate, and you had the prior coverage in place for a period of not less than 90 days, OMIP will grant you credits toward the six-month wait period for pre-existing conditions.
Portability eligibility requirements. You may be eligible if you had at least 180 consecutive days of Oregon group coverage or at least 18 months of creditable coverage without a gap in coverage greater then 63 days, with the last month of the recent coverage being group insurance. Your application must also be received by OMIP within 63 days of the termination date of your prior coverage; and one of the following applies to you:
- Please provide a copy of your HCTC Eligibility Notice and a Certificate of Creditable Coverage from your prior health insurance carrier proving that you have 90 days of prior health insurance coverage.
What is portability?
- You have exhausted all COBRA or state continuation benefits available, and no Oregon portability options are available from your previous health insurance carrier.
- No COBRA, state continuation coverage, or portability coverage is available through your previous group plan.
- You are eligible for Oregon portability through your previous plan but you moved from the prior insurance carrier's service area or your insurance carrier no longer services the area where you live.
When an employee leaves employer-sponsored insurance, they are generally eligible for a portability policy in order to continue health coverage for themselves, spouses, and eligible dependents. Portability is an individual health insurance policy offered through the previous insurance company. Portability policies are not COBRA policies and are issued directly to the individual. Commercial portability policies usually have different benefits then the previous employer-sponsored health insurance.
I qualify for OMIP both medically and through portability - should I apply for both?
The portability route may be more advantageous to you because the monthly premiums generally are less expensive compared to the medical plans with the same deductible. However, if you do qualify through portability, you would have to pay the premium for the portability insurance coverage back to the date after your group insurance terminated. Also, there are only two deductible plans to choose from, the $750 and $1,500. If you want a plan with a lower deductible, you would need to apply for the $500 deductible medical plan.
How does someone prove they are an Oregon resident?
A person can provide any of the following: copy of their valid Oregon Driver License or Oregon Identification Card; Oregon income tax return; a dated rental agreement reflecting current Oregon address as listed on the application; a current utility bill with applicants name and Oregon address as listed on the application, or any other documentation that may be deemed appropriate by the administering insurer, RBCBSO.
If I'm a resident of Oregon, but not a US citizen can I still apply to OMIP?
Yes. You do not have to be a US citizen but you do have to permanently reside in Oregon and be an Oregon resident as defined by OMIP.
I live out-of-state but plan to move to Oregon, when will I be eligible for OMIP coverage?
You may apply to OMIP up to 90 days before the requested effective date. However, your application would not be processed until you are able to provide proof that you are an Oregon resident. Your effective date of OMIP coverage cannot be a date prior to you being an Oregon resident.
My spouse qualifies for OMIP; can I be on his/her OMIP plan?
Yes. However, you may want to look into individual (or group, if available) health coverage for yourself for a more favorable premium rate.
How much does an OMIP premium cost?
All of our plans are rated based on the age of the oldest insured, the number of people on the plan and the plan selected. Please click here to review the most current rates (.pdf).
How are premium rates determined?
OMIP premiums can be as much as 25 percent higher than the commercial rates for those members coming to OMIP because of a medical condition. This is because OMIP generally has higher expenses as a result of insuring individuals with greater health risks. OMIP portability premiums are set at an average of the commercial portability market.
What do the plans cover?
All the plans cover doctor visits, hospital, surgery, prescription drugs, ambulance and medical equipment. For more specific coverage, please click here to review the benefit summary (.pdf).
What's the difference among the four plans that OMIP offers?
They differ primarily by the medical deductible amount, the maximum out-of-pocket expenses, and the co-insurance amounts. The $1,500 deductible plans are the only plans that require a separate pharmacy deductible. Also, for all covered medical expenses, the $1,500 plans pay 70% if you use in-network providers and 50% for out-of-network providers versus 80% in-network and 60% out-of network for all the other OMIP deductible plans.
Are the plans available everywhere in the state?
Yes, all four plans are Preferred Provider Organization (PPO) Plans. You will pay less out-of-pocket if you seek services from a preferred provider or go to a preferred medical facility. Please click here to locate a preferred provider.
How does OMIP pay for health care services?
All the plans require enrollees to pay their calendar year deductible before OMIP pays for covered benefits. The plans have deductible options of $500, $750, $1,000 and $1,500. The lower the deductible, the higher the premium amount. OMIP reimburses for preventive benefits without requiring the enrollee to meet his/her deductible.
What is the maximum I will have to pay with OMIP each year?
If you choose Plan 500, your maximum out-of-pocket expense would be $1,500 per member, per calendar year, assuming you use in-network providers.
The out-of-pocket maximums include medical deductibles. They do not include any co-payments or monthly premiums. *Using an out-of-network provider will increase your out-of-pocket expenses substantially.
- If you choose Plan 750, your maximum out-of-pocket expense would be $3,750 per member, per calendar year, assuming you use in-network providers.
- If you choose Plan 1000, your maximum out-of-pocket expense would be $5,000 per member, per calendar year, assuming you use in-network providers.
- If you choose Plan 1500, your maximum out-of-pocket expense would be $7,500 per member, per calendar year, assuming you use in-network providers. In addition, there is a separate annual $1,000 prescription deductible.
Will OMIP pay for my prescription medications?
Most likely, yes. In general, generic drugs cost $5. Preferred-brand drugs cost $40. Non-preferred brand drugs cost $70. However, there are certain medications that are excluded such as; non-prescription medications, fertility medications, prescriptions for weight loss, prescriptions for cosmetic purposes and experimental or investigational medications. For a complete list of exclusions, please refer to the OMIP Plan Contract you select.
Also, if you enroll in Plan 1500 you will have a separate annual $1,000 prescription deductible. This means you will be responsible for paying for the first $1,000 in prescription expenses before OMIP begins paying.
I like the doctor I currently have. If I enroll with OMIP will I be able to keep this same doctor?
You may see any professional provider of your choice; however, if your provider is a preferred provider then you will pay less for covered services than if you see a doctor who is not a preferred provider. To verify if your doctor participates in the OMIP provider network, you may click here or contact customer service at 800-848-7280.
How does someone apply to OMIP?
Click here (.pdf) to obtain an application (Pages 21-31 in the OMIP/FMIP Member Handbook) or call Regence BlueCross BlueShield of Oregon (RBCBSO) to request an OMIP Packet 800-848-7280. You must complete the application (.pdf) in full and attach proof of Oregon residency. Also, send a declination letter if you have been turned down for health insurance because of a medical condition. If you are applying for portability coverage please submit the requested documentation as listed on the OMIP application.
If you need assistance filling out the application, you may want to seek the aid of a health insurance producer in your area.
If you need a Spanish interpreter, we do have one available when you call 800-848-7280.
How long does it take to process an application?
If the application is complete and all required documentation is attached, please allow up to 30-days. Your effective date for OMIP coverage will be the first of the month following the received date of your completed application. If you are applying for portability coverage your effective date begins the day after the last day of coverage under your previous health coverage.
What if I need medical care but I haven't received my OMIP insurance card?
Contact Regence BlueCross BlueShield of Oregon (RBCBSO) at 800-848-7280 to verify the status of your application and to obtain billing instructions for your provider. If you are applying for portability coverage and your application is complete your coverage will start the day after the last day of coverage under your previous insurance coverage. Please contact RBCBSO at 800-848-7280 for billing instructions.
What is a pre-existing condition?
Pre-existing conditions are those for which medical services, diagnosis, care or treatment were recommended or received in the six months before you obtained health insurance coverage through OMIP.
What is the six-month wait period for pre-existing conditions?
The OMIP benefit plans have a six-month wait period for pre-existing conditions, including pregnancy. This means OMIP will not pay benefits during the first six months you or your enrolled dependents are enrolled under an OMIP plan for coverage of expenses incurred for a pre-existing condition.
Note: There is no pre-existing waiting period if you are coming to OMIP via the portability route. We will also give month-to-month credit towards the pre-existing waiting period if the enrollee can provide a valid Certificate of Creditable Coverage showing the start and termination dates for the prior coverage. To receive credits, the OMIP application must be received within 63 days from the previous coverage end date.
So, how long is OMIP's pre-existing waiting period?
Six months unless you have credit for prior coverage.
I have not had insurance for years. I am pregnant and need insurance coverage. Can OMIP help me?
Maybe. Again, the OMIP benefit plans have a six-month limitation for pre-existing conditions (except HCTC), including pregnancy. Therefore, depending on when your baby is delivered (regardless of when the due date is), you may be covered. If the baby is delivered after you have had your policy in force for six months or more, you would be covered for that delivery. Having a policy in force means from the date you were enrolled and received an effective date, not the date you submitted your application.
Note: for those coming to OMIP via the portability route, there would be no limitation for pre-existing conditions provided the applicant had at least six months prior insurance and no lapse in coverage that exceeds 63 days.
What happens if I am enrolled in OMIP and then become eligible for Medicare due to turning 65?
You would become ineligible for OMIP effective the first of the month in which you turned 65. (We make the termination date the same as the Medicare effective date. You are eligible for Medicare on the 1st of the month in which you turn 65, not after).
What is FHIAP?
FHIAP is an acronym for Family Health Insurance Assistance Program. FHIAP offers subsidies for limited income Oregonians, below the 200 percent federal poverty level, which have been without health insurance for at least two months (except for people leaving OHP/Medicaid).
Can I have the FHIAP subsidy and OMIP coverage at the same time?
Yes, FHIAP is a subsidy program that helps those eligible pay for their OMIP premiums. The OMIP 500 and 750 plans are the only two plans which meet the FHIAP benchmark which means they are the only two plans you can have with OMIP that FHIAP will subsidize.
Can I have OMIP and Medicaid (OHP) coverage at the same time?
No. If it is discovered that you are receiving both, your OMIP coverage will be retroactively termed as far back as your original effective date and you will be responsible for any claim payments made on your behalf.
I cannot afford OMIP coverage, but I make too much for the Oregon Health Plan and the FHIAP subsidy. Can OMIP help me?
Unfortunately, OMIP depends upon premium payments for a large portion of their funding. OMIP is not a subsidy program. If you do not have a medical condition that you believe would disqualify you in the open market, you may want to apply directly to an insurance carrier in the State of Oregon as those rates most likely will be less than OMIP rates.
If you do have a medical condition that you know would disqualify you, you may apply to OMIP. However there are premium payments involved. You may want to contact Oregon SafeNet (800-SAFENET) for assistance.
Does OMIP recognize domestic partners?
Yes, as of January 1, 2008.
When am I no longer eligible for OMIP coverage?
You are no longer an Oregon resident as defined by OMIP if you:
Who would I contact to see if I might qualify for individual insurance in the open market?
- Become eligible or entitled to Medicare.
- Become enrolled in Medicaid (OHP).
- Are or become an inmate at a correctional facility or patient at a mental institution as defined under ORS 179.321.
- Fail to make your premium payment within the 31-day grace period.
- Are already enrolled in a substantially equivalent health benefit plan on the date your OMIP coverage becomes effective.
- Have OMIP premiums paid or reimbursed by a public entity or a health care provider for the purpose of reducing the payer's financial loss or obligation.
- Are employed by a business with two or more employees and you have applied to OMIP for coverage at the direction of an insurance producer, insurance company, or an employer to separate yourself from the rest of the employees being offered or provided heath benefit coverage in connection with your employment.
- Made any material misrepresentation or omission on the application; made any material misrepresentation to any providers; or you misrepresented that you met OMIP's residency requirements.
- Misuse the provider network by being disruptive, unruly or abusive.
You can apply directly to any health insurance carrier or you can utilize a health insurance producer. The Office of Private Health Partnerships provides a referral program to link individuals and small business owners with a health insurance agent (producer) who can help them navigate the insurance system. This service is free! Call 800-542-3104 for a producer referral or click here to fill out our producer referral form online. For a current listing of insurance companies that sell individual plans in Oregon, click here.