This division oversees the Oregon Health Plan, which is a public and private partnership that ensures universal access to a basic level of health care for Oregonians. The division also includes provisions for oversight, research and analysis to achieve the best use of health-care funding.
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The Oregon Health Plan – The Oregon Health Plan (OHP) is a public/private partnership that ensures universal access to a basic level of health care for Oregonians. The major components of the OHP are Medicaid reform, insurance for small business and high-risk medical insurance pool. In addition, the OHP includes provisions for oversight, research and analysis to achieve the best use of health-care funding.
The OHP was formed in response to the rising costs of medical care and the growing number of people unable to afford such care. The Plan’s initial objectives included providing a basic health-care package for low-income persons, health insurance for individuals who have been denied coverage for medical reasons, voluntary group insurance plans for small employers, and reforms to make insurance more available and affordable.
The OHP also seeks to lower costs by reducing cost shifts; emphasizing managed care, preventive care, early intervention and primary care; and not covering ineffective care.
The OHP covers Oregonians who qualify for Medicaid and since 1994 has made Medicaid available to thousands of people who previously did not qualify.
One of the defining differences of the OHP is how it determines the benefit available to OHP clients. Instead of covering all medical services for a limited Medicaid population, the OHP covers both the traditional Medicaid population and the expanded OHP population using a limited list of medical services. This list is called the Prioritized List of Health Services.
The prioritized list emphasizes prevention and patient education. In general, services that help prevent illness are higher on the list than services that treat illness after it occurs.
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Children’s Health Insurance Program (CHIP) – This program created by Congress in 1997 increases funding to states for coverage of low-income children. Oregon used the money to extend the basic OHP benefit package to low-income pregnant women and later to uninsured low-income children up to age 19.
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OHP Plus and Standard Benefit Packages – Changes made in 1991 introduced client co-payments for most adults, and replaced the basic benefit package with two new ones: HP Plus and OHP Standard. The basic benefit package was renamed OHP Plus. OHP Standard was a new package whose clients would receive a reduced set of benefits, pay premiums for OHP coverage and higher co-payments.
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Health Services Commission – The HSC devised a list of health services ranked by clinical effectiveness and value to society. Actuaries determined how much it would cost to provide the services on the list. Combined, these pieces of information indicate the value of the health service relative to the cost of providing the service. The HSC reviews the prioritized list at least every two years. The Legislature then decides how much of the list to include in the health care budget. The Legislature can fund services only in numerical order, and it cannot rearrange the order of the list. The state must have federal approval from CMS to move the funding line.
As of January 1, 2006, OHP covers services up through line 530 of the 710 condition/treatment pairs on the list. Covered services include preventive services to promote health and reduce risk of illness, comfort care or hospice treatment for terminal illnesses, regardless of where the conditions are on the list. OHP benefits generally do not cover conditions that get better on their own, for which home treatment works, cosmetic procedures and conditions for which treatment is generally ineffective.
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Managed Care Organizations - Most OHP Medicaid clients receive their care through managed care organizations and a primary care practitioner who is a member of the plan. Other clients have a primary care manager receive care on a fee-for-service basis. Managed care organizations contract with DHS to provide physical, dental, mental health, and/or chemical dependency services for OHP clients. DMAP pays these plans a monthly fee for each enrolled person for the services they provide.
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OregonMedical Insurance Pool - OMIP provides medical insurance coverage for all Oregonians who are unable to obtain medical insurance because of health conditions. It also provides health insurance portability coverage to Oregonians who have exhausted COBRA benefits and have no other portability options available to them. OMIP also offers coverage for individuals who have been affected by competition from foreign trade, and are eligible to receive a federal tax credit under Section 35 of the Internal Revenue Code. As of 2003, OMIP has insured more than 30,000 Oregonians who otherwise would have had no health care coverage.
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Small employer health insurance – The Legislature established the Small Employer Health Insurance (SEHI) Reform law to address the problems small employers had obtaining group health policies. Under the reforms, basic coverage is accessible to all companies employing two to 50 people. Any insurance company in Oregon’s small business market must offer this “basic” plan, and no employer in that category may be refused. The plan’s benefits are similar to the original OHP Basic Health Care Package, and include mental health and alcohol and chemical dependency benefits.
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Office of Private Health Partnerships – Originally called the Insurance Pool Governing Board, the OPHP certifies low-cost health insurance plans for uninsured small businesses and the self-employed. OPHP also administers the Family Health Insurance Assistance Program (FHIAP), which subsidizes the purchase of health insurance for uninsured Oregonians in certain income ranges by paying a large part of their health insurance premiums.
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Health Services Commission - The HSC is responsible for creating and maintaining the Prioritized List of Health Services, ranking services available under the Oregon Health Plan from the most important to the least important. The list is accompanied by a report of an independent actuary retained for the commission to determine rates necessary to cover the costs of the services. The Commission is composed of eleven members, including five physicians, four consumer representatives, a public health nurse, and a social worker.
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OregonHealth Policy Commission - The commission serves as the
policy-making body responsible for health policy and planning for the state. It is directed to, among other things, develop a plan for and monitor the implementation of state health policy, act as the policy-making body for a statewide clearinghouse for information, provide a forum for discussion of health care issues facing the citizens of the state and act as primary advisory committee to the Governor, and the Legislative Assembly.
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Health Resources Commission - The goal of HRC is to ensure that all Oregonians have access to high-quality, effective health care at an affordable cost, whether that care is purchased by the state or by the private sector. The Commission’s role is to encourage the rational and appropriate allocation and use of medical technology in Oregon. It does this by informing and influencing health care decision makers through its analysis and dissemination of information concerning the effectiveness and cost of medical technologies and their impact on the health and health care of Oregonians.
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Medicaid Advisory Committee – The MAC is a federally-mandated body that advises the Oregon Health Policy Commission, the Office for Oregon Health Policy and Research, and the Departmentof Human Services on the operation of the Oregon Health Plan. It develops policy recommendations at the request of the Governor and the Legislature.
