OHP is Medicaid, not Medicare

Oregon Health Plan (OHP) is a Medicaid program run by the state of Oregon. It is not Medicare. The two programs are completely separate — Medicare is federal and based on age or disability status, while OHP is a state Medicaid program based on income and other factors.

If you live in Oregon and have a low income, you may be able to join OHP. If you are 65 or older or have certain disabilities, you may be able to join Medicare instead, or possibly both at the same time. The program you may have access to for depends on your age, income, disability status, and citizenship.

OHP covers doctor visits, hospital care, prescription drugs, mental health services, and other medical expenses. The coverage and cost depend on which OHP category you fall into — there are several, and they have different rules and copayments.

Key Takeaways

  • OHP is Oregon's Medicaid program for people with low income, not a Medicare program for older adults.
  • You can have both OHP and Medicare at the same time if you meet the requirements for each.
  • OHP has multiple categories with different income limits, so your income determines which one you may join.
  • OHP covers preventive care, hospital stays, prescription drugs, and mental health services with little or no copay depending on your category.

How OHP and Medicare are different

Medicare is a federal program that covers people who are 65 or older, people under 65 with certain disabilities, and people with end-stage renal disease. You pay into Medicare through payroll taxes during your working years, and then you become may be able to access at a certain age or when you meet disability criteria. Medicare has the same rules in every state.

OHP is a state program that covers people with low income, regardless of age. Oregon sets its own income limits and rules. You do not need to have worked or paid taxes to join OHP — you only need to live in Oregon, have a low enough income, and meet other requirements like citizenship status.

If you are 65 or older and have a low income, you may join both Medicare and OHP at the same time. When you have both, Medicare is your primary insurance and OHP helps pay costs that Medicare does not cover. This combination is sometimes called "dual coverage."

OHP income limits and categories

OHP has several categories, and each one has its own income limit. The income limits change each year based on the federal poverty level. As of 2024, some OHP categories cover people with income up to 138% of the federal poverty level, while others cover people with higher incomes.

The main OHP categories are Standard OHP (for adults with low income), OHP Plus (for people who are pregnant, children, or in certain other groups), and OHP for Seniors and People with Disabilities (for people 65 or older or with disabilities). Each category has different copayments and covered services.

To find out which category you might join and what the current income limit is, you can contact the Oregon Department of Human Services or visit the OHP website. Income limits vary by family size, so a family of three has a higher limit than a single person.

What OHP covers

OHP covers preventive care like doctor visits and screenings with no copay. It covers hospital stays, emergency room visits, and urgent care. OHP covers prescription drugs, mental health and substance use treatment, dental care (in some categories), vision care, and hearing aids.

Some services may have a small copay — usually $1 to $3 per visit or prescription — depending on which OHP category you are in. Preventive services like vaccines and cancer screenings have no copay in all categories. If you cannot afford the copay, you can ask the provider to waive it.

OHP does not cover everything. Cosmetic surgery, some experimental treatments, and some over-the-counter drugs are not covered. Your OHP plan will send you a handbook that lists what is and is not covered.

How to join OHP

To join OHP, you must live in Oregon, have a low enough income, be a U.S. citizen or may have access to immigrant, and meet other requirements. You can start the process online through the Oregon Department of Human Services website, by phone, by mail, or in person at a local office.

You will need to provide proof of income (like recent pay stubs or tax returns), proof of citizenship or immigration status, and proof of Oregon residency. The process usually takes 30 to 45 days. If you are in an emergency situation, you may be able to join faster.

Once you are approved, OHP coverage usually starts on the first day of the month after you are approved. You will receive a member card in the mail. You can use it at any doctor, hospital, or pharmacy that accepts OHP.

OHP and Medicare together

If you are 65 or older or have a disability and also have a low income, you may join both Medicare and OHP. When you have both, Medicare pays first, and OHP pays some of the costs that Medicare does not cover — like copayments, coinsurance, and deductibles.

Having both programs can save you money because OHP covers many costs that Medicare leaves you responsible for. However, you must meet the income and other requirements for both programs. Some people with Medicare have too much income to join OHP, even though they have low income by other standards.

If you think you might join both programs, contact the Oregon Department of Human Services to learn about you meet the income limit for OHP. They can also tell you whether you should join Medicare first or OHP first.

Common mistakes to avoid

Do not assume you cannot join OHP because you have Medicare. Many people have both at the same time. Do not wait to explore if you think you might be may be able to access — the sooner you explore, the sooner coverage can start.

Do not forget to report changes in your income, family size, or address. OHP requires you to report changes within 30 days. If you do not report a change and your income goes up, OHP may ask you to pay back benefits you received.

Do not assume that all doctors and hospitals accept OHP. Some do not. When you join, ask your doctor whether they accept OHP before you schedule an appointment. Your OHP plan can give you a list of doctors and hospitals in your area that accept OHP.

Frequently Asked Questions

Can I have OHP and Medicare at the same time?

Yes. If you are 65 or older or have a disability and also have a low income, you may join both programs. Medicare is your primary insurance, and OHP helps pay costs that Medicare does not cover. You must meet the income and other requirements for both programs.

What is the income limit for OHP?

The income limit depends on which OHP category you are in and your family size. Most OHP categories cover people with income up to 138% of the federal poverty level, but some categories have higher limits. Income limits change each year. Contact the Oregon Department of Human Services to find out the current limit for your family size.

How long does it take to get OHP coverage?

The process usually takes 30 to 45 days from the time you submit your process. If you are in an emergency situation or have a medical condition that needs urgent treatment, you may be able to join faster. Coverage usually starts on the first day of the month after you are approved.

Do I have to pay a premium for OHP?

Most OHP members do not pay a monthly premium. Some members in certain categories may have a small premium, but it is usually very low or waived if you cannot afford it. You may have small copayments when you use services, but preventive care has no copay.

What happens if my income goes up after I join OHP?

You must report income changes to OHP within 30 days. If your income goes above the limit for your category, you may no longer be may be able to access for OHP. OHP may ask you to pay back benefits if you did not report the change. If your income goes up slightly, you may move to a different OHP category instead of losing coverage.