Medicaid, SCHIP, and Federal Authority²

Section 1115 Waiver - Oregon initially received approval from CMS to implement a waiver demonstration for the Oregon Health Plan (OHP) in 1993. At that time, the state expanded coverage to most Oregonians below 100 percent FPL and to children and pregnant women up to 170 percent FPL.

Among other things, the waiver allowed Oregon to implement a prioritized list of conditions and treatments for Medicaid benefits under the OHP that ranks health services based on the "comparative benefit to the population to be served."

HIFA Waiver - In 2002, the state applied for both an 1115 and a HIFA waiver to amend and expand the OHP (the state's existing 1115 waiver) to create the second iteration of the Oregon Health Plan or OHP2. OHP2 sought to expand coverage to individuals with incomes below 185 percent FPL. The effort separated the Medicaid program into two benefit packages-OHP Plus and OHP Standard.

• The OHP Plus benefit package and cost-sharing structure is similar to the original OHP and serves low-income seniors, people with disabilities, families meeting the eligibility criteria for Temporary Aid to Needy Families (TANF), and children and pregnant women.
• The OHP Standard benefit package, designed for Oregon's expansion population (who are adults, 19 to 64 years of age up to 100 percent FPL), implemented in February 2003, is leaner in benefits and includes significant co-pays. Premiums were increased for those enrolled in OHP Standard and administrative rules were tightened, including a six-month lockout for nonpayment of premiums.

The OHP2 waiver changes also resulted in including the state's premium subsidy program, the Family Health Insurance Assistance Program (FHIAP), under Medicaid so it could receive federal match for what had been previously funded with only state dollars.

In July 2004, the state received approval for a further modification. The amendment allowed the state to retain the eligibility level for OHP Standard at 100 percent FPL and allowed for a redefined OHP Standard benefit package that will include a core set of services and, depending upon available state funds, a limited inpatient hospital benefit and a hospice benefit. Included with this approval is the flexibility for the state to reduce and/or add services as long as the core set of services continues to be offered. Further, the amendment allowed the state to expand health care to uninsured children with family income from 185 percent FPL to 200 percent FPL under Title XXI and expand coverage to FHIAP participants with income from 185 percent to 200 percent FPL under both Title XIX and Title XXI. As of October 2006, the expansion for children and families to 200 percent FPL has not been implemented.

In April 2006, the Oregon received approval for two more demonstration amendments. The state was allowed to extend the eligibility period for SCHIP from six months to 12 months. In addition, the state was allowed to amend the premium policy for individuals enrolled in OHP Standard by exempting from the premium requirement those with incomes at or below 10% FPL and by eliminating the six-month lock-out for nonpayment of premiums for those with incomes above 10% FPL. Individuals above 10% of the federal poverty level must pay all past due premiums before they can qualify for a new eligibility period. These demonstration amendments went into effect in June 2006.

High-Risk Pool  

The Oregon Medical Insurance Pool became operational in 1990 and is financed by premiums and assessments on insurers and reinsurers. The premium cap is set at 125 percent of average rates for individual coverage but portability premiums cannot be more than 100 percent of average portability rate charged by insurers. As of June 2006, approximately 15,000 were enrolled in the pool.

Other

Family Health Insurance Assistance Program (FHIAP) - The FHIAP program was created in 1997 with state-only dollars to address the needs of families who do not qualify for Medicaid or Medicare. In 2002, the program was included in the Oregon Health Plan 2 Waiver and began to receive federal matching funds. FHIAP provides a premium subsidy on a sliding scale to individuals (families and adults without children) with income below 185 percent FPL. Members enroll in their employer's group insurance if one is available; otherwise they enroll in an individual plan in the private market.

	Notes and Sources

Information presented in the profile was summarized in December 2006 from a review of state Web sites and reports, and through contacts with state officials. In most cases the profiles were reviewed by state officials; however, it is possible that states have implemented strategies that are not reflected in this profile.

² The profile only includes Medicaid and SCHIP waivers intended to make comprehensive expansions to the uninsured. At this time, the profiles do not include Family Planning, Pharmacy Plus waivers, or long-term care waivers.

³ Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2005 and 2006 Current Population Survey.