Navigating Health Insurance and Medicaid

Section Summary 

Navigating health insurance can be incredibly complex. It's important that individuals of all ages are educated on the process of acquiring and utilizing health insurance in Oregon to ensure their health needs are met. This section discusses: 

• What is Medicaid and the Oregon Health Plan?
• How can I apply and maintain eligibility for the Oregon Health Plan?
• What is private insurance? 
• Common terms in health insurance

Medicaid and the Oregon Health Plan

The most common types of health insurance used by youth and young adults include Medicaid, employer-sponsored health insurance, and private health insurance. Determining which type of health insurance one is eligible for and how one’s insurance plan can be put to use are critical to maintain and enhance the health and well-being of Oregonians. 

Medicaid is a federal program that operates across the United States to ensure individuals of all ages who are experiencing financial constraints and struggling with limited resources are provided with free or low-cost health care. In 2024 in the United States, nearly 80 million people were covered by Medicaid. Each state implements its own Medicaid program via state and federal funding. 

The Oregon Health Plan (OHP) is Oregon’s Medicaid program that offers free health coverage for people who live in Oregon and meet the program’s eligibility requirements. For instance, OHP may cover services such as dental and hospital care, doctor visits, and mental health support. Luckily, through OHP, a handful of healthcare programs exist to meet the needs of low-income Oregonians.

• OHP Plus addresses the needs of children who are between the ages of 0 to 18 and adults who are between the ages of 19 to 64.
• OHP Plus Supplemental addresses the needs of pregnant adults who are age 21 or older. 

Eligibility

In order to qualify for OHP, individuals or families must meet certain residency and income requirements.  

• Residency requirements 
• Income requirements and income limits (subject to change annually)

Not sure if OHP is the right fit for you? Use this tool to help guide your decision. 

Applying for OHP

An individual can apply for OHP at any time since enrollment in the program is always open year round. There are several different routes one can take to apply for OHP which include applying online, in-person, or by the phone. 

To apply for OHP online, an individual must first create a ONE account by going to one.oregon.gov and then follow this step-by-step guide to assist them in setting up their account. Following the creation of their account, an individual must go to one.oregon.gov and click “Apply Now”. Refer to this step-by-step guide on how to complete the application.

Alternatively, to apply for OHP in person, individuals can find a local Oregon Department of Human Services (ODHS) office near them or to apply over the phone call ONE Customer Service at 1-800-699-9075. 

Recertification & Reporting Changes 

Participating in the recertification process and reporting changes to OHP is an important step to ensure individuals still qualify for health care coverage. To ensure that OHP is able to easily contact you, regularly check that personal information is up-to-date (including address, phone number, and email). This step is essential in breaking down barriers to effectively communicate with OHP personnel and preventing a delay in receiving healthcare coverage.

Personal information can be viewed and/or edited online through one’s Oregon Eligibility (ONE) account by following this step-by-step guide (see page 8) or by calling the ONE Customer Service Center at 800-699-9075. Offices are open Monday-Friday from 7:00 a.m. to 6:00 p.m. Individuals can also contact their Coordinated Care Organization (CCO) to update their contact information.

Every two years, OHP sends members a notice regarding whether more information is needed to determine renewal eligibility, a renewal packet is required to be filled out, or one still qualifies or does not qualify for coverage.

These notices are received by members in the mail and/or can be viewed online through one’s Oregon Eligibility (ONE) account; click here to access a step-by-step guide to assist you in setting up an account.

More information about the renewal process can be found here and a step-by-step guide of how to renew your OHP coverage online can be found here. 

Alternatively, you can watch the video below to gain further insight into the renewal process. 

Employer Sponsored Health Insurance

Employer-sponsored health insurance may be an option for individuals seeking coverage through their workplace, often providing a more affordable alternative to private insurance. These plans may be offered by employers to their employees, and sometimes their families, as part of a benefits package. Similar to private health insurance, employer-sponsored plans require enrollees to pay a monthly portion, or premium, though employers typically cover part of this cost to reduce the financial burden on employees. Coverage options, costs, and benefits vary depending on the employer and the specific plan selected, and enrollment usually occurs during an annual open enrollment period or after a qualifying life event.

Private Health Insurance

In cases where individuals do not qualify for OHP and/or do not recieve coverage through their employer, private health coverage is an alternative option individuals can pursue to attain coverage that best suits their individualized needs and/or the needs of their family. Private health insurance may include individual plans and group plans. This type of insurance requires an individual to select a plan and commit to paying a premium in order to receive coverage. Individual or group plans can be bought by one individual or a family either directly through a private health insurance company or the Health Insurance Marketplace. 

Eligibility - Health Insurance Marketplace 

To be deemed eligible for private health insurance through the Marketplace a person must meet the following criteria: 

• Is a U.S. citizen or national (or be lawfully present) 
• Resides in the United States 
• Unable to acquire insurance through employer 
• Not currently incarcerated

Common Terms in Health Insurance

When it comes to navigating insurance, it is vital that we familiarize ourselves with commonly used terms and their definitions. This is particularly crucial in not only strengthening one's ability to understand the components of their insurance plan but to also ensure they have a transparent understanding of what is covered or not covered so there are no expenses that come as a surprise later.

• Balance bill: Also known as "suprise billing," balance billing occurs when one's insurance plan does not completely cover the cost of the service and their provider bills them for the remaining amount.
• Benefits: The services paid for by your health care plan.
• Care coordination: Service that provides support, education, and community resources to help one meet their health needs and navigate their way through the health care system. 
• Coordinated care organization (CCO): A CCO is a network composed of various different healthcare providers who work alongside each other in their local communities to assist people who receive health coverage under OHP with using their benefits and getting connected to care. 
• Copay: A portion of money one must pay for services such as doctor visits or prescriptions. 
• Deductible: The amount of money you pay (usually per year) for health care services that are covered before your insurance pays for the remaining amount. 
• Explanation of benefits (EOB): A statement provided by one’s insurance company that outlines the services utilized and the amount that was charged to one’s insurance plan by a provider, organization, or supplier. 
• ObamaCare: Also known as the Affordable Care Act (ACA), this is a health care reform law that was established in March 2010 aiming to increase the accessibility and affordability of healthcare coverage, expand Medicaid to cover all adults below a certain income level, and support alternative delivery methods of medical care to alleviate costs associated with health care in general. 
• Out of pocket maximum: The highest amount of money you will be required for to pay for covered services within a plan year, (including deductibles and copays) after which the insurance provider will pay 100% the cost of covered services. 
• Premium: A monthly payment made to health insurance company for coverage. Premium amounts vary depending on factors like number of individuals covered by the plan, age, health status, location, and health insurance company.