Oregon Health Exchange

Affordable Care Act

In Oregon, the Health Insurance Exchange is called Cover Oregon. This online marketplace for Oregonians that qualify for tax creditsallows them to buy a private health insurance plan for themselves and their families. The plans which are sold in the Exchange, will also be available outside of the Exchange, without having to submit your information to the INS and IRS. You will also have more options outside of the Exchange. However, to receive a subsidy you will need to apply through Cover Oregon. Cover Oregon will help pay for premiums based on income. Below is the maximum monthly premium you would pay for a benchmark plan through Cover Oregon. Costs vary depending on the plan you choose and how many family members are on the plan. Families with income lower than these amounts will likely be eligible for no-cost coverage through Oregon Health Plan. There is no requirement that you must buy your insurance through Cover Oregon, just that you purchase a qualified health plan of some kind.

Most current individual plans (except for a few grandfathered plans) do not meet the requirements of the Affordable Care Act and will have to be replaced in 2014. Newly approved plans are currently scheduled to be available on 10/1/2013. Your current insurance company will transfer you to the closest new plan automatically. If you wish to apply for a subsidy, you will have to fill out a subsidy application and reapply for insurance.

If you apply for a subsidy, you will have to complete a Cover Oregon application annually. If your actual income exceeds your estimated income, you may receive a tax bill in April of the following year to recover any excess subsidy paid on your behalf. You are also signing the application under penalty of perjury and need to fill out the application accurately.

What You Pay
Individual (example costs)*		Family of 4 (example costs)*
Annual Income	Maximum amount you pay monthly	Annual Income	Maximum amount you pay monthly
$15,860-$17,253	$57	$32,499-$35,325	$118
$17,253-$22,980	$121	$35,325-$47,100	$247
$22,980-$28,725	$193	$47,100-$58,875	$395
$28,725-$34,470	$273	$58,875-$70,650	$559
$34,470-$45,960	$364	$70,650-$94,200	$746
*Depending on your age, premiums may be significantly lower		*Depending on your age, premiums may be significantly lower

Starting in 2014, all health plans will be required to cover essential health benefits

Prevention and wellness
Hospitalizations
Ambulatory services
Rehabilitative and habilitative services and devices
Emergency services
Prescription drugs
Laboratory services
Maternity and newborn care
Pediatric oral and vision care
Mental and behavioral health (substance use disorder services)

Cover Oregon / Silver Plan / Individual
Every carrier offering insurance plans through Cover Oregon must offer a standard silver plan. Individuals under certain income levels will be eligible for premium assistance; the amount of assistance will be based on the second-lowest cost silver plan. In addition, some individuals will receive help paying for co-pays and co-insurance if they buy a silver plan. Costs are estimated below.
Annual Income	$15,856-$17,234	$17,235- $22,979	$22,980- $28,724	$28,725- $45,960
Maximum Monthly Amount You Pay (Balance paid by federal tax credit; some plans may have lower premiums)	$40 – $57	$57 – $121	$121 – $193	$193 – $364
	Copays in grey sections are not subject to any deductible and count toward the annual out-of-pocket minimum		Benefits in blue are covered after the combined deductible is met
Combined Deductible (Applies to Medical and Drug)	$100	$750	$2,500	$2,500
Preventive Service	No Cost	No Cost	No Cost	No Cost
Primary Care Visit Copay (Applies to Physical, Speech & Occupational Therapy Visits and Pediatric Vision)	$10	$15	$35	$35
Specialty Care Visit Copay	$20	$30	$70	$70
Urgent Care Visit Copay	$30	$40	$90	$90
Inpatient/Outpatient Coinsurance	10%	10%	30%	30%
Emergency Room & Ambulance Coinsurance	10%	10%	30%	30%
Radiology (MRI, CT, Pet Scans) Coinsurance	10%	10%	30%	30%
Generic Drugs Copay	$5	$10	$15	$15
Preferred Brand Drugs Copay	$10	$25	$50	$50
Non-Preferred Brand and Specialty Drug Coinsurance	25%	50%	50%	50%
Maximum Out-of-Pocket	$750	$1,500	$4,250	$6,350

Cover Oregon / Silver Plan / Family of Four
Every carrier offering insurance plans through Cover Oregon must offer a standard silver plan. Families under certain income levels will be eligible for premium assistance; the amount of assistance will be based on the second-lowest cost silver plan. In addition, some families will receive help paying for co-pays and co-insurance if they buy a silver plan. Costs are estimated below, but they will vary depending on how many family members are enrolled in the plan.
Annual Income	$32,499- $35,324	$35,325- $47,099	$47,100- $58,874	$58,875- $94,200
Maximum Monthly Amount You Pay (Balance paid by federal tax credit; some plans may have lower premiums)	$81 – $118	$118 – $247	$247 – $395	$395 – $746
	Copays in grey sections are not subject to any deductible and count toward the annual out-of-pocket minimum		Benefits in blue are covered after the combined deductible is met
Combined Deductible (Applies to Medical and Drug)	$200	$1,500	$5,000	$5,000
Preventive Service	No Cost	No Cost	No Cost	No Cost
Primary Care Visit Copay (Applies to Physical, Speech & Occupational Therapy Visits and Pediatric Vision)	$10	$15	$35	$35
Specialty Care Visit Copay	$20	$30	$70	$70
Urgent Care Visit Copay	$30	$40	$90	$90
Inpatient/Outpatient Coinsurance	10%	10%	30%	30%
Emergency Room & Ambulance Coinsurance	10%	10%	30%	30%
Radiology (MRI, CT, Pet Scans) Coinsurance	10%	10%	30%	30%
Generic Drugs Copay	$5	$10	$15	$15
Preferred Brand Drugs Copay	$10	$25	$50	$50
Non-Preferred Brand and Specialty Drug Coinsurance	25%	50%	50%	50%
Maximum Out-of-Pocket	$1,500	$3,000	$8,500	$12,700