How To Qualify For Medicaid In Oregon


What Is Free Or Low

Oregon Medicaid Eligibility on the Provider Web Portal, updated May 15, 2014

Free or low-cost coverageMost individuals who qualify for Medicaid will have no monthly premium, no copay, and no out-of-pocket cost for most covered services. Depending on your income, a small monthly premium may apply.

Fill out your information below to find out if you may qualify for Medicaid. If you do, you may be eligible to get your Medicaid health care through Kaiser Permanente. If you dont qualify for Medicaid, you may qualify for federal financial assistance to help you afford your health care.

NOTE: The information provided is for reference only. Final eligibility is determined by the Oregon Health Plan for Medicaid and for federal financial assistance.

Oregon Long Term Care

Oregon is an income cap state, meaning that in order to be eligible for Medicaid long term care benefits there is a hard income limit. Non income cap states allow applicants to spend down money for their care, whereas income cap states require the amount to be no higher than their limit at time of application.

What Are The Requirements For Medicaid In Oregon

In Oregon, general requirements for Medicaid must be met once an applicant determines that he or she belongs to a qualifying patient group. General Medicaid eligibility requirements must be satisfied in order to receive full Medicaid benefits in the state.

What are the Medicaid application guidelines for general eligibility criteria? Medicaid requirements ask that candidates provide the following items in order to qualify for state-sponsored medical assistance:

In addition to requirements for Medicaid listed above, it is important to provide these items for any others living in the home. If a candidate for Medicaid benefits plans to add beneficiaries to his or her plan, identifying information for those family members must be available as well.

for more information on the different requirements for Medicaid.

In some cases, Medicaid requirements may differ for those with medical conditions. As an elderly patient, a blind or disabled candidate or a woman with cervical or breast cancer, the state may ask for medical documentation to confirm Medicaid eligibility.

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For persons with limited financial resources, Medicaid pays for nursing home care. For those who wish to live at home or in assisted living, sometimes Medicaid will pay for care in those locations if it can be obtained at a lower cost than in a nursing home. It does this through Medicaid Waivers, which are also called Home and Community Based Services Waivers or Waiver Funded Services.

View Or Download Our Free Guide

Free Oregon Medicaid Prior Authorization Form

While we are not affiliated with the government in any way, our private company engaged writers to research the Medicaid program and compiled a guide and the following answers to frequently asked questions. Our goal is to help you get the benefits that you need by providing useful information on the process.

Our free Medicaid Guide is filled with helpful information about how to apply, program eligibility and how to get in touch with local offices. You can view or download our free guide here.

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How To Apply For Ohp Plus

You can apply for OHP Plus at any Oregon Department of Human Services office in the state, by calling 800-359-9517, or by completing the online application at . The DHS must make a decision about your application within 45 days, or within 90 days when you are applying on the basis of a disability.

If you are denied OHP, you have the right to request a hearing. The best way to do that is to complete the hearing request form at and turn it in to a DHS office in person, where you can get a date-stamped copy as your receipt.

What Is Oregon Medicaid Called

In Oregon, the state Medicaid program is known as the Oregon Health Plan. The program is unique because it was developed with a Medicaid waiver that allows states to create pilot programs or experimental programs designed to explore new methods of paying for health care.

Oregon used its waiver to create a health plan that doesn’t cover some of the most expensive services, reducing government expenditures. Oregon was also one of the first states to incorporate managed care into its Medicaid program, further reducing the cost of providing health coverage to the state’s low-income residents.

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What Does Oregon Health Plan Cover

Oregon Health Plan pays for most if not all related healthcare costs such as:

  • Physical health: Doctor visits, preventive services to help you stay healthy, tests to find out about your health, treatment for most major diseases, emergency ambulance and 24-hour emergency care,family planning services, and pregnancy and newborn care.
  • Behavioral health: Mental health and counseling, and help with addiction to tobacco, alcohol and drugs.
  • Dental health: Cleanings and preventive treatments, dental check-ups and x-rays, fillings, tooth removal, 24-hour emergency care.
  • Prescriptions: OHP with Limited Drug only includes drugs not covered by Medicare Part D.
  • Eye care: Medical care glasses to treat a qualifying medical condition such as aphakia or keratoconus, or after cataract surgery.
  • Vision care: Exams and glasses .Other needs: OHP can pay for hearing aids, medical equipment, home health care, skilled therapy, hospital care, and rides to health care appointments.

How Much Does The Oregon Health Plan Cost

Increasing Medicaid-Public Health Collaboration in Oregon

Medicaid recipients in Oregon may need to pay a monthly premium, which is a monthly fee for enrollment in the program. Premium amounts are based on the recipients annual income.

Recipients may sometimes need to pay a small out-of-pocket cost for treatments, which are known as copayments. Copayment amounts depend on the recipients age, household income and what the state pays for the specific service.

Each Medicaid participant through the Oregon Department of Human Services has their own individual health care plan. Some participants may be required to pay fees, and some recipients may not be required to pay fees, i.e., are exempt.

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How To Appeal An Application Denial

Medicaid applications will be denied if applicants do not meet the eligibility requirements. Also, beneficiaries can have their benefits terminated or reduced if their eligibility status changes while they are enrolled.

Learn more about Oregon Medicaid eligibility requirements here.

If your Medicaid application is denied or your benefits amount is reduced, you have the right to file an appeal. You must send an appeal request within 90 days of when you receive notice of the denial or benefits reduction.

You can submit your appeal request by following the step by step instructions on your determination letter or by calling 1 699-9075.

The Oregon Department of Human Services will review your claim and may ask for additional information or evidence of your eligibility.

How Long Does The State Have To Make A Decision

If you are applying for OHP, DHS must decide if you qualify within 45 days. If your application for OHP is based on disability, the state has 90 days from the date of your OHP application to decide if you qualify. If more than 90 days go by, you have the right to request an administrative hearing. You will probably receive two different decision notices. The one you receive first will let you know if you are eligible for the OHP programs that are not based on disability. The second notice will tell you if you are eligible for OHP based on your disability. You have the right to a hearing if you don’t agree with either of those decisions.

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What Income Levels Are Included

This is based on the federal poverty level. Adults can earn up to 138 percent of that and be eligible, and kids are eligible if they live in families who earn up to 305% of this level.

As an example, adults would be eligible if they live in a family of four earning up to $3,013 each month, and kids would be eligible if they live in a family of four earning up to $6,660 each month.

Oregon Medicaid Income Limit Charts

Income Requirements For Medicaid Oregon

The Oregon Medicaid eligibility income limit charts are divided by groups.

For example, the first chart is focused on income limits for children who qualify for Medicaid.

Similarly, the second chart below focuses on the Medicaid income limits for adults in Oregon who qualify for Medicaid.

Oregon Medicaid Income Limit for Children

Below is the income limit for children by age category. Find the age category your child falls into and you will see the income limit by household size.

Oregon Medicaid Income Limit Children
Children Medicaid Ages 0-1

How to Read the Oregon Medicaid Income Limits Charts Above

You cannot have an income higher than the Federal Poverty Level percentage described for your group to be eligible for Medicaid.

Similarly, when you identify the income group that applies to you, the income limit you see refers to the maximum level of income you can earn to qualify for benefits.

For example, if you are pregnant, to qualify for Medicaid, you cannot have an income higher than 185% of the Federal Poverty Level which for a family of two is $32,227 as shown in the chart above.

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What Healthcare Does The Oregon Health Plan Cover

Through Medicaid, people gain access to health care services that may not be affordable without it. Additionally, some programs and benefits include special protectionssuch as provider network and payment methodsthat help ensure services are accessible. Medicaid also provides preventive care and other services help people stay healthy and avoid costlier care.

Medicaid covers medical and health care services such as:

  • Doctors visits

Medicaid does not cover the following types of medical services:

  • Cosmetic procedures or surgeries
  • Unnecessary hospital expenses, like TV rentals or meals for guests
  • Experimental treatments, supplies, equipment or drugs
  • Any services not covered under the State Plan for Medical Assistance

Learn more about medical and health care services that are covered by Medicaid in Oregon on the Health Authority page here.

How To Apply For The Oregon Health Plan In Oregon

To apply for Medicaid in Oregon, complete the following two steps:

  • Choose how you are going to apply, whether online, by mail, in person, by fax or by email.
  • To apply for Medicaid online, click here to access the Oregon ONE Portal.

    To apply for Medicaid , click here to access the application form, fill it out, and mail it with the necessary documents to:

    OHP Customer Service

    P.O. Box 14015Salem, OR 97309

    To apply for Medicaid in person, click here to find your nearest Self-Sufficiency Programs office.

    To apply for Medicaid , click here to access the application form, fill it out, and fax it with the necessary documents to 378-5628.

    To apply for Medicaid , complete the application form above and send it with scans of the necessary documents to .

  • Submit your application.
  • If you have questions about the application process or require assistance, call the Oregon OHP Customer Service Center at 1 699-9075.

    Or, contact your nearest local Oklahoma Self-Sufficiency Programs office. Find contact information for local offices in Oklahoma here.

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    What Is The Limit On Resources For Long Term Care Services

    The resource limit for a single person is $2,000 in 2018. The resource limit has not changed since 1988. The Medicaid program counts any resource that you could use to pay for care unless the rules make that resource exempt. Resources include cash, bank accounts, IRAs, investments, real property, vehicles, and the cash surrender value of life insurance policies. Resources in a revocable living trust are counted. Joint bank accounts and similar resources are counted as belonging to you unless the other joint owner has proof of the amount that he or she contributed to the joint account. There are special resource rules for married couples.

    State And Federal Spending

    Oregon Medicaid Waiver Program Application Guide – Children With ADHD, Autism, Down Syndrome
    See also: Medicaid spending and enrollment statistics

    During fiscal year 2016, Medicaid spending nationwide amounted to nearly $553.5 billion. Spending per enrollee amounted to $7,067 in fiscal year 2013, the most recent year for which per-enrollee figures were available as of June 2017. Total Medicaid spending grew by 33 percent between fiscal years 2012 and 2016. The Medicaid program is jointly funded by the federal and state governments, and at least 50 percent of each state’s Medicaid funding is matched by the federal government, although the exact percentage varies by state. Medicaid is the largest source of federal funding that states receive. Changes in Medicaid enrollment and the cost of healthcare can impact state budgets. For instance, in Oregon, the percentage of the state’s budget dedicated to Medicaid rose from 13.1 percent in 2010 to 23.4 percent in 2015. However, state cuts to Medicaid funding can also mean fewer federal dollars received by the state.

    During fiscal year 2016, combined federal and state spending for Medicaid in Oregon totaled about $8.4 billion. Spending on Oregon’s Medicaid program increased by about 83.1 percent between fiscal years 2012 and 2016. Hover over the points on the line graph below to view Medicaid spending figures for Oregon. Click on the red bar below the graph to view these figures as compared with three of Oregon’s neighboring states.

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    So How To Sign Up For Oregon Health Plan

    You have several options:

    • Apply Online Go to to login or create an account
    • Paper Applications You can download and print an application or have an application mailed to you. Request a paper application by calling OHP Customer Service at 800-699-9075. Paper applications are available in multiple languages.
    • Or Call and OHP Community partnerProject Access Now, to apply or renew call 345-6553.

    A word of caution: If you decide to call in by phone to enroll with the Oregon Health Plan, it may involve a long waiting period, so its highly recommended you either apply online or print the application, fill it out and mail or fax it in. Print the Oregon Health Plan application here:

    Oregon Medicaid Income Limit

    The Oregon Medicaid Income Limit is calculated as a percentage of the Federal Poverty Line.

    To qualify, you must meet the Oregon Medicaid Income limits listed below.

    Here is the Federal Poverty Level for 2021.

    2021 Federal Poverty Levels for the 48 Contiguous States & D.C.
    Household Size

    Additionally, to be eligible for Medicaid, you cannot make more than the income guidelines outlined below:

    • Children up to age 1 with family income up to 185 percent of FPL
    • Any child age 1-5 with a family income up to 133 percent of FPL
    • Children ages 6- 18 with family income up to 133 percent of FPL
    • CHIP for children with family income up to 300 percent of FPL
    • Pregnant women with family income up to 185 percent of FPL
    • Parents of minor children with family income up to 38 percent of FPL
    • Individuals who are elderly, blind, and disabled with family income up to 74% of the FPL
    • Adults without dependents under Medicaid expansion with income up to 133% of the FPL

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    What Happens If The Person Who Needs Medicaid Gives Something Away

    If you give money or property away, or if you transfer something for less than its fair market, the gift or transfer may make you ineligible for Medicaid assistance for a period of time. There are harsh penalties if you make gifts or transfers and apply for Medicaid for long term care within five years of making the gift or transfer.

    The period of ineligibility does not begin until you have spent down to the resource limit and you meet the other eligibility requirements for Medicaid for long term care. The amount that was given away is divided by the average private pay cost of care to determine the length of the period of ineligibility.

    There are some gifts and transfers for less than fair market value which do not result in a period of ineligibility. For example, there is no penalty if you transfer assets to your spouse. You should consult an experienced elder law attorney before making gifts or transfers if you or your spouse may need Medicaid assistance to help pay for long term care in the future.

    How To Qualify For Medicaid Because Of Disability

    Oregon Medicaid Eligibility on the Provider Web Portal ...

    If you are an Oregonian who receives SSI benefits, then you automatically qualify to receive OHP Plus. However, you do not need to apply for disability from Social Security to receive OHP Plus on the basis of your disability. Instead, you can indicate on your OHP application that you are disabled, and the state will review your medical records and determine whether you qualify.

    Oregon uses the same definition of disability as the Social Security Administration — that is, a disability is a condition that prevents you from working that has lasted, or will last, more than one year or will result in your death.

    When you apply for OHP on the basis of disability, your application is referred to a group called the Presumptive Medicaid Disability Determination Team . The PMDDT will need a release of information from you to get your medical records. If you don’t have enough information in your medical records to allow the PMDDT to decide if your condition meets a Social Security impairment listing, the PMDDT may arrange for you to see a particular doctor or have a certain test. The state pays for any medical exams and tests that the PMDDT orders.

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