Oregon Medical Insurance > Oregon Medical Insurance Pool ( OMIP) / Federal Medical Insurance Pool (FMIP) > Plan Eligibility

Oregon Medical Insurance Pool (OMIP) and the Federal Medical Insurance Pool (FMIP) both offer health insurance benefits for those who qualify.

To determine which high risk pool you are eligible for, please review the following questions:

1. Are you an Oregon resident? Oregon residency means you must be a permanent resident of Oregon to be eligible for OMIP/FMIP. A resident is a person who maintains a residence in Oregon, lives there at least 180 days per benefit enrollment year.
   1. If yes, then please continue onto question number 2.
   2. If no, STOP you are not eligible for benefits through either high risk pool.
2. Have you been uninsured for the past six months and are you a U.S. citizen or non-citizen U.S. national, or a non-citizen who is lawfully present in the U.S.? (See page 4.)
   1. a. If yes, you are eligible for health care benefits through FMIP. Please read the eligibility requirements for FMIP to see if you qualify on page 3.
   2. b. If no, then you are not eligible for health care benefits through FMIP. Please read the eligibility requirements for OMIP to see if you qualify on page 7.

FMIP Eligibility

Who Is Eligible For FMIP?
If you are an Oregon resident, you may be eligible to enroll under a Federal Medical Insurance Pool (FMIP) contract. You must be a U.S. citizen or non-citizen U.S. national, or a non-citizen who is lawfully present in the U.S. and have been uninsured for the past six months to qualify for FMIP.

Once you enroll, your FMIP health insurance contract will provide additional information pertinent to your specific plan.

What Are The Requirements To Enroll In FMIP?

Residency Requirement To apply for FMIP coverage you must be a resident of Oregon.
A resident is someone who is legally domiciled in Oregon. Once enrolled in FMIP you must maintain a principal place of residence in Oregon and physically reside in this state, at least 180 days each benefit enrollment year.

If FMIP discovers you have made any fraudulent misrepresentation, FMIP may terminate your policy back to the effective date of FMIP coverage. In addition, FMIP may retain your premiums as liquidated damages and reserve the right to recover from you the benefits paid.

If FMIP discovers you have made any material misrepresentations or omissions, FMIP may terminate your policy back to the effective date of FMIP coverage. In addition, FMIP may retain your premiums to cover any claims and administration costs FMIP paid retroactive to the date FMIP terminates your policy and recover from you any amounts FMIP paid in excess of your premiums.

Eligibility Requirements

To apply for FMIP coverage you must meet the medical eligibility requirements.

Medical Eligibility
If any of the following statements fit your situation, you are eligible to apply for FMIP coverage under a FMIP medical plan.

• Within the last five years you have had professional medical treatment and or were diagnosed by a professional medical provider for any of the medical conditions listed in Section C of the FMIP application.
• Within the last six months, you were issued a declination letter from an insurance carrier refusing to sell you an individual comprehensive medical insurance policy, due to your health status.
• Within the last six months, you were offered an individual health insurance policy that excluded coverage for a specific medical condition that you currently have or had in the past.
• Within the last six months, you were offered an individual health insurance policy but were limited by the choice of particular plans the carrier was willing to offer you due to a specific medical condition that you currently have or had in the past.

If any of these Medical situations apply to you, please refer to Rate Schedule B, FMIP Eligibility, in the FMIP Health Rate Brochure

Persons Not Eligible

Note that the following circumstances will make you ineligible for FMIP coverage regardless of whether or not you meet Residency or Medical Requirements:

• Are NOT a U.S. citizen or non-citizen U.S. national or a non-citizen who is lawfully present in the U.S.
• Are eligible for, entitled to, or enrolled in Medicare.
• Are eligible and enrolled in health care benefits under Medicaid/Oregon Health Plan (OHP).
• Are or become an inmate of a correctional institution or a patient at a mental institution as defined by ORS 179.321.
• Have terminated FMIP coverage within the last 12 months for a reason other than becoming eligible for Medicaid/OHP health care benefits. This includes non-payment of FMIP premiums.
• OMIP/FMIP has paid up to $2 million in health care benefits for you.
• Have been enrolled in creditable health insurance coverage at any time in the last six months.
• Have FMIP premiums paid or reimbursed by a public entity, employer, or a health care provider for the purpose of reducing the payer’s financial loss or obligation.
• Are employed by a business with two or more employees and you have applied to FMIP at the direction of an insurance agent, insurance company, or an employer to separate yourself from the group health care benefit coverage offered or provided to the rest of the employees at your place of employment.
• Fail to pay your premium payments in the time-frame required.
• Dependents, except for newborns, where specified in the FMIP contract.

OMIP Eligibility

Who Is Eligible For OMIP?

If you are an Oregon resident, you and your dependents (legal spouse, domestic partner, or *child) may be eligible to enroll under an Oregon Medical Insurance Pool (OMIP) contract.

Once you enroll, your OMIP health insurance contract will provide additional information regarding eligibility and other information pertinent to your specific contract.

*Child/children means your unmarried children, under 26 years of age that are dependent on you for full or partial support, living with you, and you are an Oregon resident; or your unmarried child, under 26 years of age that is dependent on you for full or partial support, is a full-time student at an accredited institution for higher learning, and you are an Oregon resident; or a child who is unmarried and incapable of self-support because of physical, mental, or developmental disability and the child is principally dependent on you for support. The disability must have occurred before the child’s 26th birthday.

What Are The Requirements To Enroll In OMIP?

Residency Requirement

To apply for OMIP coverage you must be a resident of Oregon. A resident is someone who is legally domiciled in Oregon. Once you enroll in OMIP you must maintain a principal place of residence in Oregon and physically reside in this state at least 180 days each benefit enrollment year and file personal resident income taxes in Oregon.

If OMIP discovers you have made any fraudulent misrepresentation, OMIP may terminate your policy back to the effective date of OMIP coverage. In addition, OMIP may retain your premiums as liquidated damages and reserve the right to recover from you or your enrolled dependent the benefits paid.

If OMIP discovers you have made any material misrepresentations or omissions, OMIP may terminate your policy back to the effective date of OMIP coverage. In addition, OMIP may retain your premiums to cover any claims and administration costs OMIP paid retroactive to the date OMIP terminates your policy and recover from you any amounts OMIP paid in excess of your premiums.

Eligibility Requirements

To apply for OMIP coverage you must meet either the medical eligibility requirements, portability (loss of group health benefit coverage) requirements, or be eligible for a Federal Health Coverage Tax Credit (HCTC) under the Federal Trade Adjustment Assistance Program or under the Pension Benefit Guarantee Corporation. The following information will help you decide the category for which you may be eligible:

Medical Eligibility

If any of the following statements fit your situation, you are eligible to apply for OMIP coverage under a OMIP medical plan.

• Within the last five years you have had professional medical treatment and or were diagnosed by a professional medical provider for any of the medical conditions listed in Section C of the OMIP application.
• Within the last six months, you were issued a declination letter from an insurance carrier refusing to sell you an individual comprehensive medical insurance policy, due to your health status.
• Within the last six months, you were offered an individual health insurance policy that excluded coverage for a specific medical condition that you currently have or had in the past.
• Within the last six months, you were offered an individual health insurance policy but were limited by the choice of particular plans the carrier was willing to offer you due to a specific medical condition that you currently have or had in the past.
• You have permanently moved to Oregon and are transferring your coverage from another state’s high risk pool.

If any of these Medical situations apply to you, please refer to Rate Schedule A, Medical Eligibility, in the OMIP Health Rate Brochure (included in this handbook.)

Portability Eligibility

You may be eligible for OMIP portability coverage under certain circumstances when you lose group health benefit coverage as outlined below.

• You had at least 180 consecutive days of group coverage or at least 18 months of creditable coverage without a gap in coverage greater than 63 days, with the most recent coverage ending in group insurance and no COBRA or Oregon Portability benefits are available through your health plan.
• You had at least 180 consecutive days of group coverage or at least 18 months of creditable coverage without a gap in coverage greater than 63 days, with the most recent coverage ending in group insurance and you have exhausted your COBRA benefits and there are no Oregon Portability benefits available through your health plan.
• You were currently enrolled or eligible for Oregon Portability coverage through your previous health plan but you have moved our of the service area or the carrier no longer services the area where you live.

If you are eligible for Portability coverage your application must be received by OMIP within 63 days from your previous employers health coverage’s termination date.

If you are applying for portability coverage please refer to the OMIP Rate Schedule C, Portability Eligibility.

Note: Your OMIP coverage starts the date your former coverage ends meaning you will owe premiums from that date which may include more than one month of premium.

Federal Health Coverage Tax Credit Eligibility

If you are eligible to receive a Federal Health Coverage Tax Credit (HCTC) under Section 35 of the Internal Revenue Code, then you are automatically eligible to receive health coverage through one of the four OMIP medical plan options. There is not a six-month waiting period for qualified Federal HCTC enrollees who have had 90 days of prior creditable coverage without any breaks in coverage greater than 63 days and whose application was received by OMIP within 70 days from the date on the HCTC eligibility certificate.

Persons Not Eligible

Note that the following circumstances will make you or your dependent(s) ineligible for OMIP coverage regardless of whether or not you meet Residency, Medical, Portability, or Federal Health Coverage Tax Credit Eligibility Requirements:

• Are eligible for, entitled to, or enrolled in Medicare.
• Are eligible and enrolled in health care benefits under Medicaid/Oregon Health Plan (OHP).
• Are or become an inmate of a correctional institution or a patient at a mental institution as defined by ORS 179.321.
• Have terminated OMIP coverage within the last 12 months for a reason other than becoming eligible for Medicaid/OHP health care benefits. This includes non-payment of OMIP premiums.
• OMIP has paid up to $2 million in health care benefits for you.
• Are actively enrolled in a substantially equivalent health insurance policy.
• Have OMIP premiums paid or reimbursed by a public entity, employer, or a health care provider for the purpose of reducing the payer’s financial loss or obligation.
• Are employed by a business with two or more employees and you have applied to OMIP at the direction of an insurance agent, insurance company, or an employer to separate yourself from the group health care benefit coverage offered or provided to the rest of the employees at your place of employment.
• Fail to pay your premium payments in the time-frame required.

Pre-existing Conditions

Pre-existing Condition — Six-Month Waiting Period

The OMIP contracts have a six-month waiting period for coverage for pre-existing conditions, including pregnancy, unless you are covered under OMIP Portability.

We will not pay benefits during the first six months of enrollment for coverage of expenses incurred for a pre-existing condition unless we grant you credit for prior health coverage.

A pre-existing condition is one for which professional medical advice, diagnosis, care, or treatment was recommended or received or a treatment plan was prescribed in the six-months prior to your OMIP effective date.

For purposes of the six-month waiting period, the term “pregnancy” includes, pre and postnatal care, miscarriage, abortion, delivery (vaginal or surgical), and complication of pregnancy, including, but not limited to:

• Intra-abdominal surgical procedures;
• Placenta abruptio and placenta previa;
• Acute exacerbations or heart conditions and/or diabetes;
• Toxemias. Ectopic pregnancy is not considered a pre-existing medical condition and is not subject to this six-month waiting period for pregnancy.

Ectopic pregnancy is not considered a pre-existing medical condition and is not subject to this six-month waiting period for pregnancy.

Credit For Prior Coverage

We will grant credits toward the six-month pre-existing condition waiting period for each month of prior health coverage, if you or your enrolled dependents had prior continuous creditable coverage, and your application was received within 63 days of your prior health coverage’s termination date.

Each month of prior creditable coverage will reduce the six-month waiting period under the contract by one month.

There is not a six-month waiting period for qualified Federal HCTC enrollees who have had 90 days of prior creditable coverage without any breaks in coverage greater than 63 days and whose application was received by OMIP within 70 days from the date on the HCTC eligibility certificate.

Creditable coverage means prior substantially equivalent health insurance coverage that reimburses for medical and hospital expenses without regards to a specific medical condition or disease and has comparable, similar benefits and payout amounts to OMIP’s health benefit plan.