Here are some general guidelines for how to use insurance. If you have questions about your policy, you may want to call the customer service number on your insurance card.
You go to a doctor or hospital for care
You give the doctor or hospital your insurance card or information.
You pay the doctor or hospital any co-payment required by the insurance
plan.
The doctor bills the insurance company. Note: You are responsible for
billing your insurance if the doctor doesn't do this for you.
The insurance company sends an explanation of benefits to you. It lists
what the doctor or hospital charged, what the insurance company's "allowed
expense" is for that procedure, what the insurance company paid, and
what you owe for co-insurance, co-payment, and your deductible.
Note: If you have more than one insurance plan, then the insurance companies
coordinate payment of benefits before sending you an explanation of benefits
and what you may owe.
The doctor or hospital may require you to pay the difference between
what they charge for the service and the amount the insurance company allows
for the service. (See "allowed expenses.")
You pay the balance of your share to the doctor or hospital. This usually
includes your coinsurance percentage, unmet annual deductible, and amounts
not covered by your policy.
Where to Get Health Insurance
Oregonians get health insurance through their employer, government programs, or directly from an insurance company. About 52 percent of Oregonians get health insurance through their employer. Another 26 percent of Oregonians get their health insurance through the government programs Medicare or Medicaid. Approximately 7 percent of Oregonians purchase their insurance directly from a health insurance company or the state high-risk insurance pool. The remaining 15 percent of Oregonians are uninsured.
At Work
Employers are not required to provide or pay for health insurance
for employees or their family members.
If an employer offers health insurance, it must be available to all eligible
employees. Many employers offer health insurance only to fulltime employees.
Employers decide how much of the insurance premium they will pay for employees
and family members, and the amount employees are required to pay.
Employers pick the insurance company and choose the benefits available
to employees. Employers can also require employees to take the
employer's health plan and to pay their share of the costs.
Many large employers self-insure their employee health plans. This means
they don't buy a policy from an insurance company, but instead, pay the
benefits directly from company funds. These plans are regulated by the U.S.
Department of Labor and not by your state insurance department. See: http://www.dol.gov/ebsa/
Employer health insurance can't reject coverage for employees or family
members because of their medical conditions. There may be a waiting period
for new employees before existing medical conditions will be covered. The
insurance company can ask for your health information to determine pre-existing
medical conditions. However, insurers can't use this information to refuse
coverage for you or your family members.
Employees are usually given 30 days from when they are hired to decide
whether to enroll themselves and their family members in the employer insurance.
After that, employees and family members generally must wait until the annual
open enrollment. However, special enrollments are allowed when there are
certain events such as marriage, births, loss of job, etc.
Government Health Insurance Programs
Medicare
Medicare is a federal program that provides medical insurance for
most people 65 or older and for people of all ages who meet disability eligibility
requirements.
For free, personalized help understanding Medicare choices, call the
Oregon Senior Health Insurance Benefits Assistance Program: 1-800- 722-4134.
Oregon Health Plan (OHP)/Medicaid Program
OHP is Oregon's version of Medicaid, the comprehensive federal health
insurance program for people with disabilities and those with very low incomes.
Call OHP at 1-800-359-9517 or the Oregon Seniors and People with Disabilities
office at 1-800-282-8096.
Children under the age of 19 may qualify for the State Children's
Health Insurance Program (SCHIP) even if adults in the household do not.
Oregon Medical Insurance Pool (OMIP)
OMIP offers health plans to people who are refused individual health
insurance because of their medical conditions.
OMIP is not an income-based program. Except for people who qualify
for state or federal premium subsidies through special programs, OMIP members
must pay the full premium.
There is no waiting period for treatment of pre-existing conditions
for those who had health insurance within 63 days of the start of the new
OMIP policy. This is called "creditable coverage." Without creditable
coverage, you must wait six months for insurance coverage of pre-existing
conditions.
Family Health Insurance Assistance Program (FHIAP)
FHIAP pays from 50 percent to 95 percent of the premium for Oregonians
who are uninsured and meet income and other guidelines. FHIAP subsidies can
pay for insurance at work or to buy individual health plans (including OMIP)
if insurance is not available through an employer.
You may want to put your name on a first-come, first-served waiting
list for this program. Because of limited funding, it could be up to two years
before you receive an application.
Federally funded health centers offer free care in both urban and rural areas. Put in your
address here and find one near you. http://www.findahealthcenter.hrsa.gov/
You will be asked to complete a detailed health application called
the "Oregon Standard Health Statement." All companies must use this
statement to decide if you and your family members qualify based on your health
condition. If one insurance company rejects coverage for you or a family member,
you can apply to another insurance company. If you are turned down by an insurance
company, you may apply to the Oregon Medical Insurance Pool.
Insurers can exclude payment for existing medical conditions for six
months. However, if you had health insurance within 63 days of the start of
the new policy, you get credit for this coverage and may have no wait or a
wait of less than six months for coverage of existing medical conditions.
The amount you pay for health insurance varies based on your plan
choices, your age, and family size.
Agent Help With Individual Health Insurance
If you are shopping for an individual plan, a licensed health insurance
agent can help. (If you get health insurance at work, the benefits administrator
can answer questions about your insurance choices.)
Agents, also called "producers," can help you compare plans,
fill out an insurance company application or assist with claims issues. If
you or someone in your family is turned down for insurance because of a health
condition, an agent can tell you what to do next.
How do agents operate?
Some agents work for a single insurance company, while independent
agents work for themselves and represent multiple companies. With a single
phone call to an independent agent, you can get information on more than one
company's plans. You may want to ask the agent what companies he or she represents.
All agents must be "appointed" by health insurance companies to
sell their products.
Some agents in Oregon also have Web sites that allow you to compare plans
from different companies. You can use search engines to find them, typing
in key words such as "health insurance in Oregon."
Agents get a commission from the insurance company if you buy a plan.
The commission is built into the cost of the premium, and does not affect
the cost to you.
Should I contact more than one agent?
One agent can't get a better price than another
for the same plan because rates are filed and approved by the Oregon
Insurance Division. In shopping for an agent, consider service. Will your
agent help you understand how your policy works and explain what's covered
and not covered and what your costs will be? Will they check to see whether
your needs change?
How do I choose an agent?
Ask friends or family for recommendations.
Contact the Insurance Division's Producer Licensing Unit (503-947-7981)
or visit www.insurance.oregon.gov.
to determine that the agent is licensed.
Ask insurance agents for client recommendations.
If you know what insurance company you want, the company can recommend
an agent.
This is a tax-sheltered savings account similar to an IRA but earmarked
for medical expenses. The money you deposit into the HSA is used to pay for
medical expenses including deductibles, co-payments and other expenses allowed
by IRS rules. Deposits are 100 percent tax-deductible for the self-employed
and can be easily withdrawn by check or debit card to pay routine medical
bills with tax-free dollars. Larger medical expenses are covered by a low-cost,
high-deductible health insurance policy. What is not used from the account
each year stays in the account and continues to grow interest on a tax-favored
basis to supplement retirement, just like an IRA. Learn more at: http://www.ustreas.gov/offices/public-affairs/hsa/
Club and association group plans
Individuals can also get insurance through clubs or associations. Fraternal
and professional organizations, associations, and clubs may offer the opportunity
for members to purchase group health insurance. This type of health insurance
must be offered to all members regardless of their medical conditions. Contact
the organization to find out whether it offers health insurance.
Adobe Reader is required to view PDF files. Click the "Get Adobe Reader" image to get a free download of the reader from Adobe. Available for Macintosh or Windows.
