Oregon Medicaid, SCHIP, & Federal Authority

Section 1115 Waiver – Oregon initially received approval from the Centers for Medicare and Medicaid Services (CMS) to implement a waiver demonstration for the Oregon Health Plan (OHP) in 1993. This waiver was amended and expanded under Health Insurance Flexibility and Accountability (HIFA) authority in 2002, creating the OHP2. The OHP2 has undergone several amendments and was renewed for an additional three years in November 2007. A key feature of the direct coverage program is that benefits are structured using a prioritized list of conditions and treatments, which ranks health services based on the “comparative benefit to the population to be served.” The waiver also expands Medicaid coverage to most individuals with family incomes up to 185 percent of the federal poverty level (FPL) through three benefit packages or programs: OHP Plus, OHP Standard, and the Family Health Insurance Assistance Program (FHIAP).

• The OHP Plus benefit package provides a comprehensive array of services to Medicaid state plan and optional populations, including low-income older adults, individuals with disabilities, families meeting the eligibility criteria for Temporary Aid to Needy Families (TANF), children, and pregnant women.

• The OHP Standard program has a more limited benefit package and includes premiums for individuals with household income exceeding 10 percent of the FPL. The state may require enrollees to be current on their premium payment before they may apply for another six-month eligibility period.  This program serves the expansion population of uninsured, non-pregnant adults with incomes below 100 percent of the FPL, but has been closed to new applicants since August 2004. In 2008, the State reopened enrollment to a limited number of individuals randomly selected from the OHP Standard Reservation List who meet all financial and non-financial eligibility requirements.  The OHP Standard reservation list was open for one month and received 92,000 unduplicated names; approximately 10,000 people are expected to be enrolled through this process.

• FHIAP is a voluntary premium assistance program for individuals with incomes up to 185 percent of the FPL. Premium subsidies, which vary according to income, may be used for individual or employer-sponsored private health insurance. 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 OHP2 Waiver and began to receive federal matching funds.  Members enroll in their employer’s group insurance if one is available; otherwise they enroll in an individual plan in the private market.  FHIAP provides a premium subsidy on a sliding scale to individuals (families and adults without children) with income below 185 percent of the FPL.  When employer-sponsored coverage is offered, the state pays a portion of the individual share of the premium.  For both individual and employer-based plans, the state pays between 50 and 95 percent of premiums. With the renewal of the waiver in November 2007, FHIAP was no longer allowed to use Title XXI matching funds for adults, but could use Title XIX funds instead. The use of Title XXI funds had been allowed under the prior waiver. This created a state General Fund shortfall which caused the program to close to new enrollments, starting in November 2007, and to provide 4,300 adults under 85% of the FPL an opportunity to transfer to OHP Standard or be terminated from the program, beginning June 1, 2008.