State Marketplace Profiles: Oregon
Updated as of October 10, 2013
Establishing the Marketplace
On June 17, 2011, Governor John Kitzhaber (D) signed SB 99 into law establishing the Oregon Health Insurance Exchange Corporation.1 That same month, the Governor signed SB 91, which specified requirements of health insurance carriers offering coverage in the state.2 On March 6, 2012, the legislature passed HB 4164 to approve the final version of the Marketplace’s business plan.3 On October 1, 2012, the Marketplace announced that its new name would be Cover Oregon.
Structure: The legislation defines Oregon’s Marketplace as a quasi-governmental organization, specifically a “public corporation performing governmental functions and exercising governmental powers.”
Governance: Cover Oregon is governed by a nine-member board, including two ex officio members (or their designees): the Director of the Oregon Health Authority and the Director of the Department of Consumer and Business Services. The Governor appoints seven members who are subject to confirmation by the Senate, with expertise or experience in individual insurance purchasing, business, finance, sales, health benefits administration, individual and small group health insurance, or the use of a health insurance marketplace. Also, at least two appointed members must be individual or small business consumers of the Marketplace. No more than two appointed members can be employed by, consultant to, or members of a board of directors of the following organizations: an insurer or third-party administrator; an insurance producer; a health care provider, facility, or clinic; or a trade association for these parties. Board members must declare any conflicts of interest and abstain from voting on related issues.
The Oregon Senate confirmed the Governor’s nominees to the Health Insurance Marketplace Board on September 23, 2011.4 They are:
- Liz Baxter (Chair), Oregon Public Health Institute
- Teri Andrews (Vice-Chair), CG Industries
- Ken Allen, Oregon American Federation of State and County Municipal Employees (AFSCME) Council 75
- Aelea Christofferson, ATL Communications
- Dr. George Brown, Legacy Health Systems
- Jose Gonzales, Tu Casa Real Estate Corporation
- Gretchen Peterson, Hanna Anderson
The Board appointed an Executive Director on October 6, 2011.5 Cover Oregon also has four advisory committees that meet regularly and report to the Board of Directors: the Consumer Advisory Committee, Board Development Committee, Finance and Audit Committee, and Personnel and Compensation Committee.
Contracting with Plans: Cover Oregon is authorized to act as an active purchaser when contracting with plans, specifically to “limit the number of qualified health plans (QHP) that may be offered through the Marketplace as long as the same limit applies to all insurers.” While Cover Oregon will not negotiate rates, it will set requirements for QHPs that are stronger than the outside market in several areas. These standards will be the same for all carriers, and carriers’ plans must meet these elevated standards to participate. Carriers may choose to participate in either or both the Individual Marketplace and the SHOP, and are not required to participate in the same markets inside and outside the Marketplace. Carriers participating in Cover Oregon are required to offer a standard bronze, silver-, and gold-level plan in each service area of each market – individual and small employer – in which they participate. Carriers offering plans at any metal level must also offer a child-only plan at that level. In addition to the standard plans, carriers have the option to offer the following plans: two non-standard plans; two additional plans that demonstrate innovation in the use of networks, wellness programs or other options not related to premiums or benefits; three platinum plans; and/or one catastrophic plan. However, each carrier may only offer up to three plans in each metal tier, including the standard plans at the bronze, silver, and gold levels.6 Catastrophic plans may only be sold in Cover Oregon’s individual market to specific populations stipulated in the ACA: individuals under age 30, individuals for whom coverage is unaffordable, and individuals with a hardship.7 Cover Oregon will allow rating factors of age, geography, and tobacco use.
The Department of Consumer and Business Services created an Advisory Committee to develop standards for bronze- and silver-level plans to help the state monitor and compare plans.8 In addition, information on carrier and plan quality ratings will be available to consumers on Cover Oregon’s website. The website will display quality information about the participating carriers, including an aggregated experience score based on CAHPS data (Consumer Assessment of Healthcare Providers and Systems) that plans already collect and two encounter-based utilization scores.9 Cover Oregon anticipates that displayed quality information will change in later years to include measures of patient experience or the impact on disparities in access to care. Cover Oregon has also developed a quality rating system for health plans that will start during October 2013 open enrollment. The Marketplace will use 13 measures that fall into three categories (preventive care, patient experience, and complex care) to help users shop for plans based on quality and value.10
In October 2012, Cover Oregon released a Request for Applications to health insurance carriers interested in offering benefit plans through the individual and/or small group Marketplace.11 The state later adopted regulations related to certification of QHPs.12 The Oregon Insurance Division approved all of the medical and dental plans filed by carriers. There are currently 11 carriers participating in the individual market, 8 carriers in the small group market, and 9 carriers offering dental plans.13 These carriers submitted QHPs and proposed rates for 2014 to the Insurance Division,14 which held two weeks of public hearings on the proposed rates and conducted analysis of the carrier’s rate justifications. On July 10, 2013 the Insurance Division released the plans’ approved rates.15 The Insurance Division lowered rates for individual plans from a few percentage points to 30 percentage points. For small employers, the Insurance Division reduced rates from requested amounts up to 12 percentage points.16 Plans are required to offer the same rates inside and outside of the Marketplace.17 In the rating area of Oregon’s largest city, Portland, 32 silver plans will be offered and 27 bronze plans will be offered.18
Carrier certification occurs once every two years, and carriers that did not apply initially must wait until 2015 to apply (for the 2016 plan year). Changes to existing QHPs can be made annually, and the plan and rates must be approved by the Insurance Division and certified by Cover Oregon. Carriers may add plans mid-year, but cannot exceed three plans in each metal tier in a service area.
Dental and Vision Benefits: QHPs with embedded dental benefits, QHPs without dental benefits, and stand-alone dental plans may be sold on the Marketplace. Medical carriers offering plans through Cover Oregon may decide whether to include pediatric dental benefits in a medical offering, and plans that include pediatric dental will be displayed alongside plans that do not. The inclusion or exclusion of pediatric dental benefits will be indicated in the plan details, in the same way as other non-mandatory benefits. Cover Oregon will offer stand-alone dental plans as a separate offer after a medical selection is made. All standalone dental plans must cover the pediatric dental essential health benefit at the high (85%) or low (70%) actuarial value.
Within the individual Marketplace, all consumers will be given the option to shop for a dental plan, but will not be required to purchase. Within SHOP, an employee will be given the option to shop for a dental plan only if the employer has agreed to sponsor a dental option. The effective date for the dental plan must align with medical coverage and carriers are limited to offering three standalone dental plans in each of the individual and small group markets. There is a separate out of pocket maximum for standalone dental issuers, and the “reasonable out of pocket limit” for Pediatric Dental EHB through Cover Oregon will be $1,000 per member.19
Risk Adjustment, Reinsurance, and Risk Corridors: On July 29, 2013, legislation was signed into law that established the Oregon Reinsurance Program, which will be administered by the Oregon Medical Insurance Pool Board. The program is temporary and is set to run through December 31, 2016.20
Consumer Assistance and Outreach: Oregon identified a subcontractor to create a brand identity for the Marketplace and develop a multi-phased communications plan based on market research and the results of focus groups. Cover Oregon’s logo and website were unveiled in October 2012, along with an online calculator for individuals to find out how much financial assistance they might be eligible for when purchasing coverage in 2014. The website offers information and resources in Spanish, Russian, Vietnamese, Korean, and Chinese. In March 2013, Cover Oregon identified a contractor to implement the marketing and communications plan.21 The contract will run through December 2014, and may be extended for a maximum of five years.22
In April 2013, Cover Oregon finalized an intergovernmental agreement with the Oregon Health Authority (OHA) to expand OHA’s existing outreach and application assistance program, which utilizes a network of providers who offer enrollment assistance in public programs.23 The state will use community partners, which are local organizations that are cultural experts on their community. Staff at these organizations will be known as “application assisters,” a term which encompasses Navigators, In-Person Assisters, and application counselors. Application assisters will conduct eligibility and enrollment for public and private health coverage. Training and certification is required for all application assisters, including paid staff and volunteers, and must be renewed annually. In-person and web-based training will be provided free of charge. Application assisters must pass a background check and will receive an identification number.
Community partners will be eligible to receive performance-based grants, though funding will not be available to support all community partners. Funding opportunities are available through OHA and posted on the state’s procurement website, the Oregon Procurement Information Network (ORPIN). Additionally, the U.S. Department of Health and Human Services (HHS) announced in May 2013 that 29 federally qualified health centers in Oregon would be eligible for an additional $2.8 million in outreach and enrollment grants.24 Community partners not receiving a grant will be permitted to provide application assistance as long as they sign an agreement with OHA.
Cover Oregon announced the first round of Community Partner grantees on September 13th. Thirty community-based organizations from around the state received $3.16 million to help individuals and families enroll in health insurance. The grantees include groups that serve diverse populations, remote communities, people living with mental illness and a wide range of social service agencies. Community Partners will be available to help individuals enroll in health insurance starting Oct. 1. Later in October, individuals will be able to enroll online as well. Cover Oregon has trained more than 1,200 employees at community-based organizations to be application assisters and nearly 1,600 insurance agents. Three additional grant opportunities for small business outreach, provider outreach, and general outreach, funded by Cover Oregon, will be announced in the coming weeks. Obtaining assistance from Community Partners is free for Oregonians, and consumers can be connected to certified Community Partners through Cover Oregon’s website.25
Application assisters may help consumers with enrolling in a QHP; however, if consumers need information on QHPs beyond what is available through the website, assisters must refer the consumers to an agent.26 Agents and brokers will not participate as Navigators, but will be involved in a separate Agent Management program, which utilizes a network of licensed health insurance producers to improve outreach to all geographic areas of the state and to hard-to-reach populations.27 Insurance producers will be trained annually, be affiliated with the Cover Oregon as certified agents and, when appropriate, coordinate and collaborate with the Navigators. Cover Oregon will collect and pass through any carriers’ commissions or bonus payments to the agents.
Cover Oregon is also operating a Customer Service Center (call center) to offer assistance to individuals wishing to speak with representatives over the phone. The call center went live in June, and was averaging 40 calls a day, with call volume increasing. The Service Center has over 50 full-time employees and plans to hire approximately 100 supplemental staff who speak a variety of languages to meet the anticipated call volume of the initial open enrollment period.28
On July 8, Cover Oregon launched a $20 million statewide marketing and outreach campaign (“Long Live Oregonians!”) that features TV, radio and online ads created by local Oregon musicians and artists, and an on-the-ground outreach effort in partnership with agents, community organizations, Tribes, providers, business associations, state agencies and other key partners.29 Cover Oregon plans to use an integrated marketing campaign that includes marketing materials, community meetings, research, paid media, earned media, online outreach, and statewide and grassroots partners over a phased marketing process (Awareness and Education, Enrollment, Retention/Awareness, and Enrollment). The campaign will gear advertisements to specific audience segments, persona types, and influencers/supporters.30 Cover Oregon is also using social media to advertise the Marketplace, through Facebook, Twitter, You Tube, Linked In, and Google+.
Small Business Health Options Program (SHOP) Marketplace: Oregon has decided to restrict the SHOP Marketplace to businesses with 50 or fewer employees in 2014 and 2015, and to 100 of fewer employees beginning in 2016. Oregon has previously required that small group premiums be determined on a tiered-composite rating basis. The state will incorporate federally-required per-member rating methodology, but maintain its tiered-composite rating requirement, both inside and outside of the Marketplace starting in 2014.31 Cover Oregon has developed four options for small employers to offer their employees through SHOP:
- Traditional: The employer chooses one insurance company and plan in which their employees must enroll.
- Plan Bundling: The employer chooses one insurance company but allows their employees to select from all plans offered by that company.
- Multiple Companies/One Plan: The employer selects a benefit plan level and the employees can select a plan from all companies.
- Broad Choice: Employees can select from several companies and plans.32
Financing: Cover Oregon conducted a significant amount of budgeting and forecasting work in the first quarter of 2013 to set an administrative fee on Qualified Health Plans (QHPs) for 2014. Cover Oregon underwent a public rule-making process to establish the fee, and also provided for public input at both Finance and Audit Committee meetings and Board meetings. At its March 2013 meeting, the Board of Directors adopted an administrative fee on health insurers offering QHPs through the Marketplace of 2.68% of premium, or $9.38 per member per month (PMPM), for 2014. The fee, along with a $15 million charge on public programs, will generate $32 million in reserves in 2014 (half of Cover Oregon’s 2015 budget of $64 million).33 Cover Oregon also established a monthly administrative fee of $0.93 PMPM on insurers offering standalone dental plans through the Marketplace in 2014.
Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through a Marketplace, cover certain defined health benefits. Governor Kitzhaber created an EHB workgroup to recommend a benchmark plan for the individual and small group market. The workgroup, jointly chartered by the Oregon Health Policy Board and Cover Oregon presented the final recommendation of Small Group PacificSource Preferred CoDeduct plan to the Marketplace Board and the Oregon Health Policy Board in mid-2012.34 In addition, the federal BlueVision “High Plan” package was defined as the pediatric vision benefit and the state’s CHIP plan as the pediatric dental benefit.
Evaluation Plan: Cover Oregon has developed a draft evaluation plan to measure how well Cover Oregon is achieving its goals and identify operational adjustments that will help to achieve its goals more effectively. Cover Oregon has identified 12 key goals that fall into three categories: (1) Engaging partners and raising consumer awareness, (2) A seamless eligibility and enrollment process and excellent customer service, and (3) Improving accessibility and affordability of coverage and care and the health of Oregonians. For each of these three categories, Cover Oregon’s Evaluation Team will collect and analyze data in program design, implementation, and outcomes. Data will be collected through an Evaluation Database that will store enrollment data from Cover Oregon’s IT system and data from consumer surveys, and join these data for analysis. The Evaluation Team will also conduct focus groups with individual market consumers, employers, Service Center staff, agents, and community partners. Evaluation findings will be disseminated within Cover Oregon and to the public through annual reports, briefs, online data exploration tools, and ad hoc reports.35
Oregon has received multiple federal grants: the Exchange Planning grant of $1 million, the Early Innovator grant of $48.1 million and a supplement of $11.8 million to build a modular and reusable IT system, a Level One Establishment grant of $9 million to support the final design and implementation of the Marketplace’s business and operations plans through August 2012, a second Level One Establishment grant of $6.7 million to continue to support the planning process through May 2013, and a Level Two Establishment grant of $226.4 million to cover costs associated with testing and implementation of the IT user interface, staffing the call center, and developing multi-media marketing materials.36 Cover Oregon estimates annual start-up costs between 2011 and 2013 to total approximately $27 million, excluding the development of the IT infrastructure and website which will be funded with the Early Innovator Grant.
In addition, Oregon, along with nine other states, is receiving technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance Marketplaces, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.37
On December 7, 2012, Oregon received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based Marketplace.38 The Cover Oregon Marketplace began accepting paper applications on October 1st. The online portal is expected to be operational by mid-October and will begin enrolling qualified individuals, families, and small businesses into coverage at that point. Customers can currently contact community partners for help enrolling in coverage.
SB 99 (Chapter 415), Oregon’s 2011 Health Insurance Exchange Act.
SB 91 (Chapter 322), Oregon’s 2011 Act Related to Health Benefits Plans.
HB 4164. Oregon’s 2012 legislation related to the Oregon Health Insurance Exchange.
Oregon Health insurance Exchange Board of Directors: Meetings and Members.
Waldroupe A. “Rocky King Named Permanent Director of Oregon’s Health Insurance Exchange.” The Lund Report. October 6, 2011.
Cover Oregon. May 2013 Compliance Report.
Cover Oregon. Request for Applications: Qualified Health Plans.
Oregon Department of Consumer and Business Services. “Message from the Oregon Insurance Divisions Commissioner Lou Savage.” July 2012.
Cover Oregon. Application for Carriers: Questions. December 21, 2012.
Oregon Health Insurance Exchange. Request for Application: Qualified Health Plans. Revised November 30, 2012.
Oregon Health Insurance Exchange. Certification of Plans as Qualified Health Plans.
Oregon Insurance Division. New Rate Requests. Samples of Proposed Rates for 2014 by Age and Region.
Oregon Health Insurance Rate Review. Approved Rates for 2014 Health Plans.
Oregon Department of Consumer and Business Services. News Release: July 10, 2013.
Cover Oregon Dental Requirements, updated March 4, 2013. Cover Oregon Dental Guidelines, updated May 22, 2013. Cover Oregon Application for Carriers: Dental Questions, answered March 8, 2013.
Oregon State Legislature. HB 3458.
Cover Oregon. Board Meeting Minutes, March 14, 2013.
Cover Oregon. Request for Proposals. Marketing and Communication Services. Released December 14, 2012.
Cover Oregon. May 2013 Compliance Report.
Health Resources and Services Administration. Health Center Outreach and Enrollment Assistance.
Cover Oregon Press Release Sept. 13, 2013. Cover Oregon Announces First Round of Recipients for Outreach and Enrollment Grants.
Cover Oregon. Community Partners Frequently Asked Questions.
Oregon Health Insurance Exchange Corporation. Draft Agent Management Program. Revised September 2012.
Cover Oregon Press Release July 8, 2013. Cover Oregon Launches Statewide Outreach and Marketing Campaign and “Oregon Exchange Puts Folk Singers on TV.” LifeHealthPro. July 25, 2013.
Cover Oregon. Cover Oregon’s Outreach and Marketing Campaign: July 8, 2013.
Cover Oregon Board Meeting Minutes. August 8, 2013.
Cover Oregon. 2012 Annual Report.
Memo from the Essential Health Benefits Workgroup to the Oregon Health Insurance Exchange Corporation and Oregon health Policy Board. July 3, 2012.
Cover Oregon. Draft Cover Oregon Evaluation Plan. April 1, 2013.
Oregon Affordable Insurance Exchange Grants Awards List.
The Robert Wood Johnson Foundation. ‘RWJF Seeks Coverage of 95 Percent of All Americans by 2020.’ May 6, 2011.
Letter from Acting Administrator Tavenner to Exchange Director King. December 7, 2012.