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Oregon Medical Insurance > Oregon Medical Insurance Pool - OMIP > Plan 1000 Benefits


 
Medical Plan 1000 Benefit Summary
Lifetime Maximum Benefit
$2,000,000
Pre-existing Waiting Period, Including Pregnancy
6 months
There is no pre-existing wait period for children under the age of 19.
 
In Network you pay
Out of Network you pay
Annual Medical Deductible
$1,000
Maximum Annual Medical Out of Pocket, excluding medical deductible, per individual1
$4,000
$8,000
Doctor Visits
20%
40%
Hospital
20%
40%
Outpatient Surgery
20%
40%
Skilled Nursing Care - limited to 60 days
20%
40%
Home Health Care - limited to 130 visits
20%
40%
Emergency Room2
20% + $200 copay
20% + $200 copay
Ambulance
20%
Maternity
20%
40%
Diagnostic X-Ray/Lab
20%
40%
Transplant2
0%
40%
Hospice
20%
40%
Rehabilitation Inpatient/Outpatient - limited to 60 days
20%
40%
Durable Medical Equipment
20%
Mental Health/Chemical Dependency
20%
40%
Womens Health Care Services3
20%
40%
Mens Health Care Services3
20%
Not Covered
Immunizations3
20%
Not Covered
Well-Baby Care/Well-Child Care 3
20%
Not Covered
Preventive Care under the PPACA3
0%
Not Covered
Prescription Drugs:  No out of pocket maximum on prescription drugs2 & $0 Rx deductible
Generic Co-Insurance4
Up to $5
Preferred Brand Co-Insurance4
Up to $40
Non-Prefered Brand Co-Insurance
Up to $70
  1. This is the maximum amount you will pay for covered medical services per individual, per calendar year, excluding the deductibles, before OMIP will begin paying 100% for covered services.
  2. The emergency room co-pay, out-of-pocket prescription drug payments, transplants performed at noncontracting facilities, and disallowed charges do not apply to the medical deductible or out-of-pocket maximum.
  3. These services do NOT accumulate towards the maximum annual out-of-pocket expense. Also, you do not have to meet the annual medical deductible before OMIP pays for these services. Coverage is provided only for those preventative care services designated by: The United States Preventive Services Task Force (USPSTF) for services with an A or B rating in the current recommendations; by the Health Resources and Services Administration (HRSA); or by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
  4. $0 co-payment for fluoride, regular aspirin, and iron as specified by the Patient Protection Affordable Care Act and specific diabetic supplies, insulin (excluding pumps), and evidence-based generic maintenance medications as determined by OMIP. A list of these medications can be found on our website at www.omip.state.or.us. This list is subject to change.

This Health Benefit Plan Summary is intended only as a brief summary of our benefit plans. Please refer to the contract for specific details. Exact terms, conditions, provisions, exclusions, and limitations are defined in the contract.

 

 

 
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