The 10 most asked questions about how Oregon's new healthcare exchange, CoverOregon.com

1. 2014 Health Reform
Oregon’s Insurance
Exchange

2. 10 MOST-ASKED QUESTIONS
 What is health care reform?
 What do I need to do now?
 What are the Health Insurance Marketplaces?
 Do I have to buy from the Exchange?
 Who has to buy health insurance?
 What if I can‘t afford to buy health care coverage?
 What if I don‘t buy health care coverage?
 Can anyone get health care coverage?
 What services will be covered?
 What does a ―grandfathered‖ plan mean?

3. What is health care reform?
 The term ―health care reform‖ refers to the
Affordable Care Act — the federal law that was
passed in March 2010 —as well as any state
laws passed to implement. These laws are
intended to give more people access to
affordable health care coverage and receive
better medical care.
 Some changes include preventive care without
any out of pocket cost, such as annual routine
physical exams and immunizations, the removal
of pre-existing waiting periods, and no longer
denying coverage based on health conditions.

4. What do I need to do now?
 If you have individual medical coverage or no medical
coverage, you need to take action this fall. The Open
Enrollment Period for the Health Insurance
Marketplaces, or Exchanges, starts October 1st for
coverage beginning January 1st. You will want to learn
what options you will have through the Exchange, and
how any current health coverage you may have will be
affected. You will have many decisions to make.
Keep in mind as you explore your options we are here
to help you!
 Businesses employing > 50 full time employees are
mandated to offer health coverage beginning in 2014,
however penalties for not doing so have been delayed
until 2015.

5. What is the Health Insurance Marketplace?
Marketplaces, aka ―Exchanges‖, will be a state or
federally run website where many people can secure
health care coverage. The Exchange will be available to
people who are uninsured or acquire insurance on their
own. You will be able to compare and choose health
plans offered by private companies and find out if you
are eligible for financial assistance or the Oregon Health
Plan (Medicaid). The Exchange will also operate a Small
Business Health Options Program (SHOP) for employers
with 50 or fewer employees to provide a variety of group
plans. Employees may be able to choose from plans the
employer selects or from all plans available. The
Exchange Open Enrollment begins October 1, 2013, and
coverage effective dates will be January 1, 2014.

6. Oregon’s Insurance Exchange
WWW.COVEROREGON.COM
 Cover Oregon will be the health insurance
marketplace for individuals, families, and small
businesses located in Oregon.
 It will allow Oregonians to compare health plans,
find out if they are eligible for financial assistance,
and enroll in a health plan.
 Initially Cover Oregon will only be open to
individuals, families and small businesses with 50 or
fewer full-time employees. It will expand to
companies with up to 100 employees in 2017.

7. APPROVED COVER OREGON CARRIERS
Individual Medical Companies:
Atrio Health Plans
BridgeSpan Health Company
HealthNet of Oregon
Health Republic
Kaiser Permanente
Lifewise Health Plan
Moda Health (ODS Companies)
Oregon’s Health CO-OP
PacificSource Health Plans
Providence Health Plans
Trillium Community Health Plan
Individual Dental Companies:
Best Life
Dental Health Services
Dentegra Insurance Company
Kaiser Permanente
Moda Health (ODS Companies)
PacificSource Health Plans
Trillium Community Health Plan
Willamette Dental Insurance
No Stand Alone Dental Offered
SHOP/GROUP Medical & Dental Companies:
Atrio Health Plans, Health Republic, Kaiser Permanente, Moda Health,
Oregon‘s Health CO-OP, PacificSource, Providence, Trillium, Best Life, Dental
Health, Dentegra, Guardian Life, Willamette Dental

8. SOMETHING NEW!
Coordinated Care Organizations (CCO’s)
 Coordinated Care Organizations (CCO‘s) are local health care
entities that bring together all aspects of care: doctors, hospitals,
dental care, mental health care and public health. The goal of
CCO‘s is to work for better health care and lower costs by focusing
on prevention, chronic disease management, earlier interventions
and reduction of waste and inefficiency in the health system.
 Coordinated Care Organizations (CCO‘s) are a new health care
delivery model being used by the Oregon Health Plan. They are the
umbrella organizations that govern and administer care for OHP
members in their local communities. CCO‘s must be accountable for
health outcomes of the population they serve. They will have one
budget that grows at a fixed rate for mental, physical and ultimately
dental care. CCO‘s will bring forward new models of care that are
patient-centered and team-focused. They will have flexibility within
the budget to deliver defined outcomes. They will be governed by a
partnership among health care providers, community members, and
stakeholders in the health systems that have financial responsibility
and risk.

9.  www.familycareinc.org &
www.healthshareoregon.org
These are two CCO‘s that will serve
members on the Oregon Health Plan, that
live in Multnomah County.
Coordinated Care Organizations
(CCO’s) continued

10. Do I have to buy from the Exchange?
No. The Exchange is just one of the ways people can
shop for health coverage. People can still get coverage
through their employer or directly from an insurance
company. If currently covered by an individual health
plan, your insurance company will be making changes to
your plan as of January 1st to comply with the new laws &
will update you later this fall on those changes.
To qualify for individual & family premium tax credits &
cost sharing, however, you are required to enroll through
Cover Oregon. Also, to receive the Small Business Tax
credit, small employers are also required to enroll through
Cover Oregon.

11. Who has to buy health insurance?
The Affordable Care Act requires most U.S.
citizens and legal immigrants to have a basic
level of health coverage starting January 1,
2014.
Some people are excluded from this mandate.
 People with certain religious beliefs,
 Members of Native American tribes,
 Undocumented immigrants,
 Inmates,
 People with income below a certain level

12. What if I can’t afford to buy health care coverage?
The government will provide financial assistance
through premium tax credits & cost sharing to help
some people pay for health coverage. This is
determined by a person‘s income level and family
size. You will be able to find out if you qualify for
financial assistance when Cover Oregon launches
in October.
If your spouse has group health coverage through
their employer, and you are eligible to enroll, you
are not eligible to receive a subsidy or tax credit.
However, dependent children whose Household
income is up to 250% of the FPL will qualify for
coverage through the Exchange even if they have
the option to enroll through their parent‘s group
health plan.

13. Income Ranges that Qualify for Assistance
 If you’re single, the range of income
qualifying for assistance is between $11,490
and $45,960.
 For couples, the range of combined income
qualifying for assistance is between $15,510
and $62,040.
 For a family of four, the range of combined
income qualifying for assistance is between
$23,550 and $94,200.

14. Health Insurance Assistance Chart
Federal Poverty Level 2013
Family
Size
100%* 138%** 150% 200% 250% 300% 400%
1 $11,490 $15,856 $17,235 $22,980 $28,725 $34,470 $45,960
2 $15,510 $21,404 $23,265 $31,020 $38,775 $46,530 $62,040
3 $19,530 $26,951 $29,295 $39,060 $48,825 $58,590 $78,120
4 $23,550 $32,499 $35,325 $47,100 $58,875 $70,650 $94,200
* Medicaid Eligible Currently
** Medicaid Eligible Effective January 1, 2014 due to ACA Medicaid Expansion

15. Single Person with $40,000 annual income

16. Family of 4 with $45,000 annual income

17. Family of 4 with $90,000 annual income

18. What if I don’t buy health care coverage?
 If you don‘t buy coverage and go without it for
three months or longer, you‘ll be charged a
tax penalty by the government.
 Penalty is $95 per adult and $47.50 per child
(up to $285 for a family) or 1.0% of family
income, whichever is greater, for 2014.

19. 2015 & 2016 tax penalties
(Individuals & Families)
 2015: Penalty is $325 per adult and $162.50
per child (up to $975 for a family) or 2.0% of
family income, whichever is greater.
 2016: Penalty is $695 per adult and $347.50
per child (up to $2,085 for a family) or 2.5%
of family income, whichever is greater.

20. Can anyone get health care coverage?
Yes, anyone can get coverage.
As of January 1st 2014, insurance companies
can no longer deny coverage to anyone who
has a medical condition, and you don‘t have to
pass a medical exam to qualify for coverage.
Pre-existing conditions will be a thing of the
past.

21. What services will be covered?
EHB’s (Essential Health Benefits)
 Ambulatory patient services, which includes doctor office visits
and other same-day outpatient care
 Emergency services
 Hospitalizations
 Maternity and newborn care
 Mental health and substance use disorder services, including
behavioral health treatment
 Prescription drugs
 Rehabilitative and habilitative services and devices
 Laboratory services
 Preventive and wellness services and chronic disease
management
 Pediatric services, including oral and vision care

22. What does a “grandfathered” plan mean?
Health plans that were in effect on or before March
23, 2010, are exempt from many changes required
under the Affordable Care Act. You can find out if
your insurance is grandfathered by reviewing your
health plan documents. However, if you are
covered on an individual health plan chances are it
is not a grandfathered plan. Also, the majority of
group medical plans are no longer grandfathered
due to changes made by employers since March
23, 2010. Therefore, the vast majority of all plans
currently in force are no longer grandfathered.

23. Moving on..
 Who
 What
 Where
 When
 Why
 How

24. Who is affected by Health Reform?
 Individuals & Families with private, individual
health insurance
 Individuals & Families with NO health insurance
 Individuals on Portability, COBRA and OMIP
 Children covered by Healthy Kids
 Individuals covered by Oregon Health Plan

25. Who is affected, cont’d.
 Small Business Owners offering group health
coverage. They can keep existing coverage,
outside of the Exchange.
 Small Businesses can shop through Cover
Oregon, and possibly receive a tax credit.
 Or they cancel their group plan & have
employees go to Cover Oregon directly to see if
they qualify for premium tax credits & cost
sharing.

26. What decisions do you need to make?
 If you qualify for a tax credit and/or cost sharing, to
assist you in paying for insurance and with reduced
copayments, you‘ll want to sign up through Cover
Oregon‘s Exchange.
 If not, you can either secure coverage inside or
outside of the Exchange. Outside of the Exchange
there will be a wide range of health plan options to
choose from, which will also be subject to all of the
ACA requirements, i.e. no medical underwriting, no
waits on pre-existing conditions.
 Talk with us about your situation. We will help guide
you and narrow down the best options for you.
Remember, there is no cost to work with an agent!

27. Remember, incomes that qualify for assistance:
Federal Poverty Level 2013
Family
Size
100%* 138%** 150% 200% 250% 300% 400%
1 $11,490 $15,856 $17,235 $22,980 $28,725 $34,470 $45,960
2 $15,510 $21,404 $23,265 $31,020 $38,775 $46,530 $62,040
3 $19,530 $26,951 $29,295 $39,060 $48,825 $58,590 $78,120
4 $23,550 $32,499 $35,325 $47,100 $58,875 $70,650 $94,200
* Medicaid Eligible Currently
** Medicaid Eligible Effective January 1, 2014 due to ACA Medicaid Expansion
Eligible for OHP / Healthy Kids

28. What do the plans in Cover Oregon look like?
Plan Type Plan Covers Member‘s
Responsibility
Bronze 60% 40%
Silver 70% 30%
Gold 80% 20%
Platinum 90% 10%

29. What rates may look like for metal plans
Catastrophic Plan 21-year-old, single, non-tobacco user $120
Standard Bronze Plan
 21-year-old, single, non-tobacco user $130
 40-year-old, single, non-tobacco user $166
 60-year-old, single, non-tobacco user $352
Standard Silver Plan
 21-year-old, single, non-tobacco user $173
 40-year-old, single, non-tobacco user $221
 60-year-old, single, non-tobacco user $469
Standard Gold Plan
 21-year-old, single, non-tobacco user $212
 40-year-old, single, non-tobacco user $271
 60-year-old, single, non-tobacco user $575

30. For the young invincibles…
 There will be a ‗catastrophic‘ plan available to
people up to age 30, through the Cover
Oregon Exchange.
 No subsidies are offered for this plan, but it
satisfies the Individual Mandate to obtain
health insurance.

31. Annual Income $15,856 - $17,234 $17,235 - $22,979 $22,980 - $28,724 $28,725 - $45,960
Maximum Monthly
Amount you Pay
$40 - $57 $57 - $121 $121 - $193 $193 - $364
Combined Deductible
(Medical and Drug)
$100 $750 $2,500 $2,500
Preventive Service No Cost No Cost No Cost No Cost
Primary Care Visit
Copayment
$10 $15 $35 $35
Specialty Care Visit
Copayment
$20 $30 $70 $70
Urgent Care Visit
Copayment
$30 $40 $90 $90
Inpatient
Coinsurance
10% 10% 30% 30%
Generic/Preferred/
Specialty Drug
Copay
$5 / $10 / 25% $10 / $25 / 50% $15 / $50 / 50% $15 / $50 / 50%
Maximum Out-of-
Pocket
$750 $1,500 $4,250 $6,350
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.

32. Where to go for information?
 www.greenberg-insurance.com Our website will help
you enroll directly on a Cover Oregon plan when the time
comes. In the meantime, our website offers a wealth of
information and resources for you to learn more.
 www.coveroregon.com Cover Oregon‘s website is
currently providing information on health reform, subsidy
calculators and what you can expect.
 Take a step by step guide on your way out. Call or email
us for help! We work one on one with individuals,
families & small businesses with no cost to you.

33. Cover Oregon Open Enrollment dates
For 2013 Initial Enrollment:
You can enroll from
October 1st 2013 – March 31st 2014.
For 2014 and beyond,
Open Enrollment runs from:
October 15th 2014 through December 7th 2014.
If you miss your opportunity to enroll, you will
have to wait until the following year‘s open
enrollment, unless you have a ‗Qualifying
Event‘ (birth of child, change in family status).

34. When do you need to take action
For those with no current coverage:
October 1, 2013: Open enrollment in Cover
Oregon begins. Coverage starts January 1, 2014.
For those with existing health insurance:
October 1, 2013 is when your insurance company
will be sending you information on their upcoming
plan and rate changes affecting you. Decide
whether to keep the new coverage, or enroll with
Cover Oregon through the March 31st 2014 initial
open enrollment period.

35. Why does this matter to you?
 Health Insurance Companies have specific
rules as to when you can sign up for
coverage and make changes. You want to
make the right decision up front.
 The only way to obtain premium assistance is
to enroll in Cover Oregon.
 You need to compare and contrast your
options before the end of this year, so you
are not stuck in a health plan you don‘t like
for an entire year.

36. How will enrollment take place?
 After October first, you‘ll go to
www.CoverOregon.com
 You‘ll have the option to elect an Insurance Agent from the drop
down box.
 Greenberg & Associates Insurance
 Sharon Greenberg, License #676714
 Adrienne Hutchins, License # 7373957
 Ethel Sly, License #16382850
 Describe your household; you‘ll need to have:
Birthdates, Social Security Numbers, Family Income, All
Household members & relationships, Home
address/Oregon residency information, tobacco use,
whether anyone is currently pregnant, your tax filing
information (who is a dependent on your tax return)

37. Enrollment, continued.
 When applying for financial subsidies or tax
credits:
 Enter Household Income. Have last year‘s tax
return handy, your recent paystubs and who has
income in your household. You‘ll enter your gross
estimated income for 2014.
 You‘ll be asked if any family members are blind,
disabled or have special needs.
 You‘ll be asked if you have current medical & dental
coverage.
 Review your application and confirm your identity.
Move on to the Final Steps.

38. Finding a Medical & Dental plan
 1) Household plan for all family members
 2) One plan per person
 3) Defined groups
 Set your Preferences, like what benefits you want and
which doctors you‘d like to see.
 Choose a Plan and then review your plan selections.
 Tax Credit Allocations. Choose up front monthly
subsidy, or a tax credit at the end of the year.
 E sign and submit for enrollment.
 You can make a plan change before January 1st if
you‘ve not paid your first premium.

39. Financial Assistance Notice
 If your financial situation changes during
the year, contact Cover Oregon right away
for a redetermination of your subsidy, so
you will not be asked to refund any portion
of your subsidy at the end of the year if
your income increased.

40. In conclusion ….
 Decide whether to stay with your current
insurance company, or enroll through the
Cover Oregon Exchange.
 Use the step by step guide to enroll in Cover
Oregon online.
 Majority of enrollments will be online and web
based, but paper applications are still
available.
 We will be able to assist you with enrollment
and coverage questions.

41. ~The Benefits of Working with an Agent~
 They‘re free!! There is no charge for working with an
agent. Premiums will be the same on all plans in or outside
the Exchange whether you work with an agent or not.
 We‘re able to show you health plans from many insurance
carriers, both in and out of the Exchange.
 We share our knowledge and experience with you.
 We help you understand your benefits.
 We help you enroll and obtain coverage from start to finish.
 We are your advocate! We help with claims, benefits issues
and questions all year long.

42. We at Greenberg & Associates are part of the Cover
Oregon team and are available to answer questions and
assist you with enrollment.
If you are a current client, please contact us this fall for
help with your options for January.
If you aren‘t working with us, but would like us to
help with your situation, be sure to write down your name,
phone # & email address on our contact sheet as you
leave. Be sure to take a step by step guide on enrolling in
Cover Oregon.

43. Thank you for coming!
Call or email us if you have questions or would
like to discuss your situation in greater detail.
Adrienne Hutchins
Greenberg & Associates Insurance, LLC.
adrienne@greenberg-insurance.com
503-297-8078
3439 NE Sandy Blvd., #378
Portland, OR 97232