Previous Rules

461-155-0360    Temporary Effective 07/01/16 through 08/31/16
Pursuit of Cost-Effective Employer Sponsored Health Insurance

  1. This rule applies to the OSIPM program and is for the purpose of applying OAR 461-120-0345.

  2. The Health Insurance Group (HIG) determines if employer sponsored health insurance meets the criteria as cost effective for the purpose of OAR 410-120-1960.

  3. If the insurance is determined to be cost effective and the client or eligible applicant pursues the insurance, HIG will authorize reimbursement of the client or eligible applicant's portion of the premium per OAR 410-120-1960.

  4. If the insurance is determined to be cost effective and the client or eligible applicant fails to pursue cost effective employer sponsored insurance, the Department will apply a penalty per OAR 461-120-0345.

Stat. Auth.: ORS 411.060, 411.404
Stats. Implemented: ORS 411.060, 411.404

461-155-0360    Effective 07/01/14
Pursuit of Cost-Effective Employer Sponsored Health Insurance

  1. This rule applies to the following medical assistance programs: CEM, EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), and OSIPM and is for the purpose of applying OAR 461-120-0345.

  2. The Health Insurance Group (HIG) determines if employer sponsored health insurance meets the criteria as cost effective for the purpose of OAR 410-120-1960.

  3. If the insurance is determined to be cost effective and the client or eligible applicant pursues the insurance, HIG will authorize reimbursement of the client or eligible applicant's portion of the premium per OAR 410-120-1960.

  4. If the insurance is determined to be cost effective and the client or eligible applicant fails to pursue cost effective employer sponsored insurance, the Department will apply a penalty per OAR 461-120-0345.

Stat. Auth.: ORS 411.060, 411.404
Stats. Implemented: ORS 411.060, 411.404

461-155-0360    Effective 01/01/12
Pursuit of Cost-Effective Employer Sponsored Health Insurance

  1. This rule applies to the following medical assistance programs: CEM, EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), OSIPM, and SAC and is for the purpose of applying OAR 461-120-0345.

  2. The Health Insurance Group (HIG) determines if employer sponsored health insurance meets the criteria as cost effective for the purpose of OAR 410-120-1960.

  3. If the insurance is determined to be cost effective and the client or eligible applicant pursues the insurance, HIG will authorize reimbursement of the client or eligible applicant's portion of the premium per OAR 410-120-1960.

  4. If the insurance is determined to be cost effective and the client or eligible applicant fails to pursue cost effective employer sponsored insurance, the Department will apply a penalty per OAR 461-120-0345.

Stat. Auth.: ORS 411.060, 411.404
Stats. Implemented: ORS 411.060, 411.404

461-155-0360    Effective 01/01/10
Cost-Effective Health Insurance

  1. This rule applies to the following medical assistance programs: CEM, EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), OSIPM, and SAC. This rule explains how to determine whether an employer-sponsored health insurance plan is cost effective for the purpose of applying OAR 461-120-0345.

  2. The first step in making the determination of cost effectiveness is to determine the number of people in the household group who are in a benefit group of any of the programs listed in section (1) of this rule.

  3. Based on the number determined in section (2) of this rule, the maximum cost-effective premium is determined from the following tables:

    CEM/EXT/GAM/MAA/MAF/OHP-OPC,
    OHP-OP6, OHP-OPP/SAC
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $ 82
    2 $164
    3 $246
    4 $328
    5 $410
    6 $492
    7 $574
    8 $656
    9+ $738

    OSIPM-AB
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $145
    2 $289

    OSIPM-AD
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $167
    2 $334

    OSIPM-OAA
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $147
    2 $294

  4. The insurance is cost effective if the employee's share of the premium is equal to or less than the amount determined in section (3) of this rule.

  5. If the health-insurance plan is cost effective, the Department will reimburse the actual amount of the premium, not to exceed the amount determined in section (3) of this rule.

Stat. Auth.: ORS 411.060, 414.042
Stats. Implemented: ORS 411.060, 414.042

461-155-0360    Temporary Effective 10/01/09 through 12/31/09
Cost-Effective Health Insurance

  1. This rule applies to the following medical assistance programs: CEM, EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), OSIPM, and SAC. This rule explains how to determine whether an employer-sponsored health insurance plan is cost effective for the purpose of applying OAR 461-120-0345.

  2. The first step in making the determination of cost effectiveness is to determine the number of people in the household group who are in a benefit group of any of the programs listed in section (1) of this rule.

  3. Based on the number determined in section (2) of this rule, the maximum cost-effective premium is determined from the following tables:

    CEM/EXT/GAM/MAA/MAF/OHP-OPC,
    OHP-OP6, OHP-OPP/SAC
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $ 82
    2 $164
    3 $246
    4 $328
    5 $410
    6 $492
    7 $574
    8 $656
    9+ $738

    OSIPM-AB
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $145
    2 $289

    OSIPM-AD
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $167
    2 $334

    OSIPM-OAA
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $147
    2 $294

  4. The insurance is cost effective if the employee's share of the premium is equal to or less than the amount determined in section (3) of this rule.

  5. If the health-insurance plan is cost effective, the Department will reimburse the actual amount of the premium, not to exceed the amount determined in section (3) of this rule.

Stat. Auth.: ORS 411.060
Stats. Implemented: ORS 411.060

461-155-0360    Effective 10/01/08
Cost-Effective Health Insurance

  1. This rule applies to the following medical assistance programs: EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), OSIPM, and SAC. This rule explains how to determine whether an employer-sponsored health insurance plan is cost effective for the purpose of applying OAR 461-120-0345.

  2. The first step in making the determination of cost effectiveness is to determine the number of people in the household group who are in a benefit group of any of the programs listed in section (1) of this rule.

  3. Based on the number determined in section (2) of this rule, the maximum cost-effective premium is determined from the following tables:

    EXT/GAM/MAA/MAF/OHP-OPC,
    OHP-OP6, OHP-OPP/SAC
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $ 82
    2 $164
    3 $246
    4 $328
    5 $410
    6 $492
    7 $574
    8 $656
    9+ $738

    OSIPM-AB
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $145
    2 $289

    OSIPM-AD
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $167
    2 $334

    OSIPM-OAA
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $147
    2 $294

  4. The insurance is cost effective if the employee's share of the premium is equal to or less than the amount determined in section (3) of this rule.

  5. If the health-insurance plan is cost effective, the Department will reimburse the actual amount of the premium, not to exceed the amount determined in section (3) of this rule.

Stat. Auth.: ORS 411.060
Stats. Implemented: ORS 411.060

461-155-0360   Effective 10/01/04
Cost-Effective Health Insurance

  1. This rule applies to the following medical assistance programs--EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), OSIPM, REFM, and SAC. It explains how to determine whether an employer-sponsored health insurance plan is cost effective for the purpose of applying OAR 461-120-0345.

  2. The first step in making the determination of cost effectiveness is to determine the number of people in the household group who are in a benefit group of any of the programs listed in section (1).

  3. Based on the number determined in section (2) of this rule, the maximum cost-effective premium is determined from the following tables:

    EXT/GAM/MAA/MAF/OHP-OPC,
    OHP-OP6, OHP-OPP/REFM/SAC
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $ 82
    2 $164
    3 $246
    4 $328
    5 $410
    6 $492
    7 $574
    8 $656
    9+ $738

    OSIPM-AB
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $145
    2 $289

    OSIPM-AD
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $167
    2 $334

    OSIPM-OAA
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $147
    2 $294

  4. The insurance is cost effective if the employee's share of the premium is equal to or less than the amount determined in section (3) of this rule.

  5. If the health-insurance plan is cost effective, the Department will reimburse the actual amount of the premium, not to exceed the amount determined in section (3) of this rule.

Stat. Auth.: ORS 411.060
Stats. Implemented: ORS 411.060

461-155-0360 Effective 2/01/03
Cost-Effective Health Insurance

  1. This rule applies to the following medical assistance programs--EXT, GAM, MAA, MAF, OHP (except OHP-CHP and OHP-OPU), OSIPM (except OSIPM-MN with a spend-down), REFM and SAC. It explains how to determine whether an employer-sponsored health insurance plan is cost effective for the purpose of applying OAR 461-120-0345.

  2. The first step in making the determination of cost effectiveness is to determine the number of people in the household group who are in a benefit group of any of the programs listed in section (1).

  3. Based on the number determined in section (2) of this rule, the maximum cost-effective premium is determined from the following tables:

    EXT/GAM/MAA/MAF/OHP-OPC,
    OHP-OP6, OHP-OPP/REFM/SAC
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $ 82
    2 $164
    3 $246
    4 $328
    5 $410
    6 $492
    7 $574
    8 $656
    9+ $738

    OSIPM-AB
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $145
    2 $289

    OSIPM-AD
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $167
    2 $334

    OSIPM-OAA
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $147
    2 $294

  4. The insurance is cost effective if the employee's share of the premium is equal to or less than the amount determined in section (3) of this rule.

  5. If the health-insurance plan is cost effective, the Department will reimburse the actual amount of the premium, not to exceed the amount determined in section (3) of this rule.

Stat. Auth.: ORS 411.060
Stats. Implemented: ORS 411.060

461-155-0360
Cost-Effective Health Insurance Premiums

For ADCM (except ADCM-EA) , GAM, OHP (except OHP-HPC) , OSIPM (except OSIPM-MN with a spend-down) and REFM, use the following to determine if an employer-sponsored health plan is cost-effective:

  1. Determine the premium amount for employer-sponsored health insurance paid by a member of the household group.

  2. Determine the maximum cost-effective premium amount for members of the benefit group from the following tables:

    EXT/GAM/MAA/MAF/OHP-OPC,
    OHP-OP6, OHP-OPP/REFM/SAC
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $ 82
    2 $164
    3 $246
    4 $328
    5 $410
    6 $492
    7 $574
    8 $656
    9+ $738

    OSIPM-AB
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $145
    2 $289

    OSIPM-AD
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $167
    2 $334

    OSIPM-OAA
    # in Benefit
    Group covered
    by insurance    		 Cost-effective
    premium amount
    (Employee cost)
    1 $147
    2 $294

  3. The insurance is cost effective if the employee's share of the premium is equal to or less than the amount in section (2) of this rule.

  4. If the health-insurance premium is cost effective, the Division will reimburse the actual amount of the premium, not to exceed the cost-effective amount for the number of persons in the benefit group who are covered by the insurance.