Key Takeaways
- Oregon uses the federal HealthCare.gov platform as a State-Based Exchange on Federal Platform (SBE-FP)
- The Oregon Division of Financial Regulation (DFR) regulates health insurance
- Pre-existing condition exclusions are prohibited under ACA-compliant plans
- Oregon is transitioning to a fully state-based exchange under SB 972
- Oregon has expanded Medicaid under the ACA (Oregon Health Plan)
Oregon Health Insurance Policy Requirements
Oregon has health insurance regulations that work alongside federal requirements under ORS Chapter 743B (Health Benefit Plans) and related statutes.
Regulatory Structure
Oregon health coverage is regulated by multiple agencies:
| Agency | Role |
|---|---|
| Oregon Division of Financial Regulation (DFR) | Regulates health insurance, licenses agents/brokers, handles complaints |
| Oregon Health Authority (OHA) | Administers Oregon's Health Insurance Marketplace |
| Federal CMS | Operates the HealthCare.gov platform for Oregon |
Health Insurance Marketplace
Oregon's marketplace history and current status:
Current Status: State-Based Exchange on Federal Platform (SBE-FP)
- Oregon uses HealthCare.gov for enrollment
- State maintains marketplace administration
- The Oregon Health Insurance Marketplace office (part of OHA) administers the exchange
- Open enrollment: November 1 through January 15
Cover Oregon History
Oregon originally operated its own marketplace (Cover Oregon):
- Established by Senate Bill 99 (2011)
- Technology platform had significant problems
- In March 2015, Cover Oregon was abolished
- Functions folded into existing state agency and HealthCare.gov
Transition to State-Based Exchange
Governor Tina Kotek signed Senate Bill 972 enabling Oregon to transition back to a fully state-based exchange:
- Enables local control and customization
- Could lead to wider health insurance coverage
- May help contain premium growth
- Allows for more robust regulation and oversight
Metal Tier Plans
| Tier | Actuarial Value | Cost Sharing |
|---|---|---|
| Bronze | 60% | Higher out-of-pocket costs |
| Silver | 70% | Moderate cost sharing |
| Gold | 80% | Lower out-of-pocket costs |
| Platinum | 90% | Lowest out-of-pocket costs |
Marketplace Assessment
Under ORS 741.105 and Senate Bill 65 (2021):
- Assessment rates established for qualified health plans
- $5.50 per member per month (PMPM) for qualified health plans (2025)
- $0.36 PMPM for stand-alone dental plans (2025)
- Funds marketplace operations and enrollment support
Medicaid Expansion
Oregon has expanded Medicaid under the ACA:
- Oregon Health Plan (OHP) provides coverage
- Covers adults up to 138% of federal poverty level
- Administered by Oregon Health Authority
Pre-Existing Condition Protections
Oregon prohibits pre-existing condition exclusions in ACA-compliant plans:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited by federal law |
Guaranteed Issue and Renewal
Oregon requires:
Guaranteed Issue
- Insurers must accept all applicants for ACA-compliant plans
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with proper notice)
Mental Health Parity
Oregon requires mental health parity:
Coverage Requirements
Oregon law requires health plans to cover:
- Mental health conditions
- Substance use disorders
- Behavioral health services
Federal MHPAEA Compliance
Oregon requires compliance with the federal Mental Health Parity and Addiction Equity Act (MHPAEA):
- Financial requirements must be comparable to medical/surgical
- Treatment limitations must be comparable
- Prior authorization requirements must be comparable
- Out-of-pocket costs must be comparable
Exam Tip: Oregon is a State-Based Exchange on Federal Platform (SBE-FP), meaning it uses HealthCare.gov for enrollment but maintains its own marketplace administration.
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Short-Term Health Insurance
Oregon has specific guidance for short-term health insurance:
- Must comply with state regulations
- DFR provides guidance on sales and disclosures
- Not ACA-compliant coverage
- Limited duration and benefits
External Review
Oregon provides external review rights:
- Consumers can appeal denied claims
- Independent external review available
- Binding decision on insurer
Consumer Resources
Oregon provides consumer assistance:
- Oregon Consumer Assistance Program (Oregon Health Connect) - Part of DFR
- Can answer questions about health insurance regulations
- Help file complaints or appeal health plan decisions
- Phone and website assistance available
What type of health insurance exchange does Oregon currently operate?
What legislation enables Oregon to transition to a fully state-based health insurance exchange?
Which agency regulates health insurance in Oregon?
What is the per-member per-month assessment rate for qualified health plans on Oregon's marketplace in 2025?
What is Oregon's Medicaid program called?