Consumer Guide to Health Insurance

How to get health insurance

Most people get health insurance through group plans offered by their employers; such plans are usually paid for by the employer and by the employee through payroll deductions.

At work

Despite what some people think, employers are not required to provide health insurance for employees. However, if an employer chooses to offer health coverage, the policy must be available to all eligible employees, usually during an annual insurance sign-up period called open enrollment. Many employers offer health insurance only to full-time employees.

If, as an employee whose company offers health-insurance benefits, you do not enroll in the employer's insurance plan within 30 days of initial eligibility, the insurance company can require you to complete a questionnaire called the Oregon Standard Health Statement. The health statement can be used only to determine pre-existing medical conditions, not to refuse you group health insurance.

Special regulations apply to health insurance offered by employers with 50 or fewer employees. You can find information about insurance companies that offer small-employer health insurance (SEHI), their service areas, and their premiums.

Self-insured health plans

Some employers choose to pay employees' health costs instead of offering a plan from an insurance company. These plans, self-funded by employers, are called self-insured plans.

Some employers hire an insurance company, a managed-care organization (MCO), or a third-party administrator (TPA) to handle their claims under a self-insured health plan. The self-insured health plan must be available to all eligible employees, and the employer is responsible for ensuring that it is.

Self-insured health plans are federally regulated by the U.S. Department of Labor under the Employee Retirement Income Security Act (ERISA). State governments do not regulate self-insured plans; however, the Oregon Insurance Division may be able to provide consumer assistance if you have questions or complaints about such a plan.

For additional information or to file a complaint about a self-insured plan, contact the U.S. Department of Labor, Employee Benefits Security Administration, 1111 Third Avenue, Suite 860, Seattle WA 98101-3212. You may call the Department of Labor's office in Seattle, (206) 553-4244.

Club and association group plans

Some fraternal and professional organizations, associations, and clubs offer group health insurance to members. Like insurance offered by employers, this health insurance must be offered at some time to all eligible members. This is called "guaranteed issue." To find out whether an organization offers health insurance to its members, contact the organization's member services representative.

Individual insurance plans

If you do not have access to group coverage, you can often buy a policy for yourself and your family on the individual market. Premiums (the amount you pay each month for your health-insurance policy) vary, based on your age, family size, what the policy covers, and the area in which you live.

Purchasing an individual policy requires careful shopping because costs, benefits, and underwriting standards (the guidelines and procedures used by insurance companies to decide whether to insure you) vary.

If you apply for an individual insurance plan, you will be asked to complete a questionnaire about your health called the Oregon Standard Health Statement. The health statement requests medical information from the past five years.

Be sure to fill out the health statement and application completely and accurately. You should disclose all health conditions that you have had during the past five years, including any condition for which you take medication. Be sure to explain on the form if you no longer have a medical problem.

If you make an error on the application, cross it out and initial the changes.

If the insurance company sells you a policy, your application becomes part of the policy and is considered a legal document. Your insurance company can investigate and rescind, or take back, your policy for up to two years after you apply if you provide inaccurate information on your application or fail to disclose a condition occurring within the past five years.

Should you answer "yes" to any question on the health statement, an insurance company has the right to request your medical records and use that information and any other information from your application to decide whether or not to offer you health insurance, even if the information is about a condition that you had more than five years ago.

Companies generally refuse to insure people with chronic illnesses. If you have a chronic illness, you may be able to get insurance through a government insurance program.

Government programs

Oregon Medical Insurance Pool (OMIP)

OMIP offers individual health plans to those who have been refused individual health insurance because of their medical conditions. There is a 25-percent surcharge added to regular insurance rates for this coverage. 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 may have to wait up to six months for insurance coverage of pre-existing conditions. For more information, call (800) 848-7280, toll-free.

Family Health Insurance Assistance Program (FHIAP)

This program helps uninsured Oregon families and individuals obtain health insurance by paying part of their premiums, including premiums for employer-sponsored insurance. For information about eligibility, call FHIAP toll-free, (800) 542-3104.

Oregon Health Plan (OHP)/Medicaid Program

The Oregon Health Plan is Oregon's version of Medicaid, the comprehensive federal health-insurance program for people with disabilities and those with very low incomes. For information, call the Oregon Health Plan, (800) 359-9517, toll-free, or call the Seniors and People with Disabilities office nearest you. To find the nearest Seniors and People with Disabilities office, call the Department of Human Services, Seniors and People with Disabilities, (800) 282-8096.

Medicare

Medicare is a federal program providing medical insurance for people 65 or older, those who draw Social Security disability payments, and those who have kidney disease. More information about Medicare is available from the Oregon's Senior Health Insurance Benefits Assistance Program (SHIBA). SHIBA has volunteers throughout Oregon who provide one-on-one counseling about Medicare, Medicare-supplement insurance, Medicare health-maintenance organizations, and long-term-care insurance. Call (800) 722-4134 (toll-free in Oregon) to request a copy of Free Help with Medicare and Other Health Insurance. It includes a list of phone numbers for contacting a SHIBA volunteer. The Social Security Administration (telephone: (800) 877-1213, toll-free) or local Social Security branch office can help you find out if you are eligible for Medicare and, if so, can enroll you and tell you what your monthly premium will be.

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