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Oregon Health Plan

Definition of "Oregon health plan"

Plan that provides a legal resident of the state of Oregon access to basic health care through three major components:

  1. Medicaid Reform (rationing) extends Medicaid eligibility to those individuals below the federal poverty level, and requires, if possible, that Medicaid benefits be provided through MANAGED CARE plans.
  2. Employer Mandate employers must provide health insurance for all permanent (working at least 17.5 hours per week) employees on a play or pay basis, where the employer plays by providing the employees with a health insurance plan or pays by paying a payroll tax that is passed through to the state's Insurance Pool Fund.
  3. Market Reform benefits available must be substantially similar to those provided by Medicaid.
The indemnity insurance plan and the Health Maintenance Organization (HMO) provide similar benefits, and both plans must be accessible to all businesses whose employment is in the range of 3 to 25 employees. The indemnity insurance plan has the following characteristics: (1) $15 co payment for preventive services (most other services require a 50% co payment); (2) no deductible; (3) out-of-pocket expenses to be limited to $3750 annually on an individual basis and $7500 annually on a family basis. After these annual limits have been reached, 100% of the expenses are paid by the insurance plan up to a $1,000,000 lifetime maximum; and (4) preventive services to include children's immunizations, dental examinations, basic medical examinations, vision examinations through age 18, basic blood pressure and cholesterol screening for adults every five years through age 39 and every two years beginning at age 40, maternity care, mental health benefits, alcohol and chemical dependence benefits. All insurance companies that sell and/or service insurance plans to employers who have 3 to 25 employees must offer at least those basic benefits and cannot refuse to sell this plan to any such employer. In addition, no employee or employee's dependent can be excluded from the plan; there must be portability from any previous individual or group health insurance plan; benefits cannot be denied because of preexisting conditions to include pregnancy; policies cannot be cancelled on a selective basis, even for those employees who develop high-risk health care problems; and premium rates cannot exceed the geographic premium rate maintained for a stipulated geographic area.

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