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Health Insurance

This electronic form is intended to be used to ADD, CHANGE or REMOVE employer-sponsored or private health insurance.

This form is also used to apply for Health Insurance Premium Reimbursement (HIPP).

Note: Insurance that will be starting or ending in the future should not be reported on this form until after the change happens.

Notice: You will need a current internet browser - such as Chrome, Mozilla Firefox, or Internet Explorer 8 or higher.

Documents that may be helpful to complete this form

  • Insurance cards for all policies reported
  • Digital copy of last two pay stubs or last billing statement if applying for Premium Reimbursement (HIPP) program
  • Oregon Medical Care Identification - card issued to individuals receiving Oregon Medical Program health benefits

Step 1: Enter Your Contact Information

Contact Information

Step 2: Enter your policy information



Saved Policies
Insurance Company Policy ID Number Group Number Type of Policy
There are no policies to display.

Policy Information
Please enter the full policy number (include letters and numbers). If Kaiser Permanente, enter the Health Record number.
Please enter all letters and numbers shown on the card.
What is the source of the insurance?
What is the status of the insurance policy?
Check all policy types that apply
Policyholder and Dependants
The policyholder is the owner of the insurance.
To view the text, click inside the box.
To view the text, click inside the box.
Please list all people covered by this policy who are applying for or receiving Oregon Medical benefits. If the policyholder and person covered by TPL are the same person, you will need to add the policy holder here as well.

Warning - Potential Duplicate: Based on what you've entered so far, you have already submitted the same information.

If this is a duplicate, you do not need to submit this information again. Continue if you want to add new information.

First Name Last Name Date of Birth Oregon Health ID#
This dependent has already been reported.
To view the text, click inside the box.
There are no dependents to display.

Additional Questions

Are there any safety concerns for anyone who is covered by this insurance that prevents you/them from using it?
Are there any other reasons other than safety concerns that would prevent you from using this insurance?
Insurance Card (optional)

Accepted file formats include: .jpg, .pdf. Maximum upload size for each is 5MB.

Please provide a digital copy of the front and back of your insurance card for each policy reported. If you are unable to provide at this time, select "Save and Continue".

Supporting Documentation

Please upload your supporting documentation in the form of .JPG, .JPEG, .PNG, .GIF, .PDF, .DOC, or .DOCX. Max file size is 100 MB

Upload your files

Choose files to upload. You can select more than one file at a time. You can also drag and drop files anywhere in this block to start uploading.


My Uploads

Name Size Status Remove
100% Complete
General Comments


Step 3: Premium Reimbursement (HIPP)

Applying for HIPP

If you reported active insurance in Step 2, the Health Insurance Premium Payment (HIPP) program may be able to reimburse the policyholder for the premiums they pay. Premium reimbursement is not available for policies that have already ended.

Important information to know before you apply for HIPP

  • Medicaid eligible clients covered by Medicare Part A, Part B, and Part C are not eligible for HIPP
  • Insurance policies that have been court ordered are not eligible for HIPP
  • HIPP is only available for active policies. HIPP is not approved for terminated policies
  • Dental, vision, cancer, accident and other non-major medical policies are not eligible for HIPP
  • At least one person covered by the insurance must also be covered by Medicaid (OHP)
  • If the policyholder is receiving federal tax credits for the insurance, they are not eligible for HIPP
  • The insurance premiums must be determined cost-effective for the state pursuant to OAR 410-120-1960

Would you like to apply for HIPP?

Tell us about the insurance

Please provide the information requested below. A Premium Reimbursement Coordinator (PRC) will review the information you’ve provided and will contact you if they need additional information. You will be notified by mail if you qualify. Please allow up to 90 days for processing before contacting us.


If the insurance is purchased directly from the insurance company, does the policyholder receive federal tax credits to help pay the premiums?
Is the insurance reported in Step 2 court ordered?
Is anyone covered by the insurance pregnant or do they have a serious health condition?


Please provide the information below about the person(s) with the health condition(s) or pregnancy:
First Name Last Name Description
There are no records to display.
Coverage Details

If you know your annual in-network deductible and in-network out of pocket maximum, please enter them here.

$
$
$
$
Is the insurance reported in Step 2 provided from an employer or does the policyholder purchase it directly from an insurance company?
Employer Information

Enter the contact information of the Human Resources/Benefits Coordinator for the employer that can answer general questions about the insurance carrier and policy costs.

How often does the employer deduct premiums from the paycheck?
How much does the employer deduct from each check for health insurance premiums?
$
What is the monthly premium amount that is billed?
$
Upload Proof of Insurance Payment (optional)

Accepted file formats include: .jpg, .pdf. Maximum upload size for each is 5MB.

To complete the application for HIPP, please provide the following:

  • A copy of the last two check stubs showing the insurance deduction
  • A copy of your most recent billing statement

If you are unable to upload your proof of payment you can email the required proof to reimbursements.hipp@state.or.us. In your email you must include the confirmation number given at the end of this submission so we are able to match your documents correctly. If we do not receive copies of your check stubs within 30 days of submitting this form, we will assume you no longer want to apply for HIPP and your HIPP application will be denied.

Note: if you are unable to upload or email your check stubs, you can also mail copies to: PO Box 14023, Salem, Oregon 97309, Attn: HIPP. You must include your confirmation number with your documents.

Supporting Documentation

Please upload your supporting documentation in the form of .JPG, .JPEG, .PNG, .GIF, .PDF, .DOC, or .DOCX. Max file size is 100 MB

Upload your files

Choose files to upload. You can select more than one file at a time. You can also drag and drop files anywhere in this block to start uploading.


My Uploads

Name Size Status Remove
100% Complete
Comments

Step 4: Review


Insurance Information


Policy Information



Policy Holder Information

Other People Covered
!! BROKEN RECORD - NO DEPENDENTS !!
Are there any safety concerns for anyone who is covered by this insurance that prevents you/them from using it?
Are there any other reasons other than safety concerns that would prevent you from using this insurance?
General Comments None
Insurance Card Attachments
None
!! BROKEN RECORD - NO POLICIES !!

Premium Payment Assistance


Would you like to apply for HIPP?
If the insurance is purchased directly from the insurance company, does the policyholder receive federal tax credits to help pay the premiums?
Is the insurance reported in Step 2 court ordered?
Is anyone covered by the insurance pregnant or do they have a serious health condition?
Persons with Conditions
Coverage Details
Insurance Provided By
Employer Name
HR/Benefits Coordinator
How often does the employer deduct premiums from the paycheck?
Amount Deducted Each Check $
Monthly Premium Amount $
General Comments None
Proof of Insurance Payments Provided Separately
Proof of Insurance Payments
None

Premium Payment Assistance (Legacy Record Format)

Does the policyholder pay for all or part of your private or employer-sponsered medical health insurance premium?
How much do you pay monthly for your insurance?
How often is the payment made?
Is anyone covered by the insurance pregnant or have a serious medical condition? If yes, what is the condition?
Is the insurance court ordered?
Employer Name
Employer Phone
Pay Stub Upload
None

Step 5: Confirmation

Confirmation

Thank you, your Notification of Other Health Insurance has been successfully submitted.

  • Your confirmation number is:
  • An email receipt has been sent to the email address provided.
  • You can also print or save this receipt for your records. To save, change the Printer "Name" in the drop down menu of the print window to "Adobe PDF" or PDF Creator". Click OK and then save the record to the file of your choice.
  • Form submitted on .

Once you have clicked the Done button you will not be able to retrieve this form. If you would like to print or save your submission, click the "Print or Save this page" button before you click "Done"

Done

Review


Insurance Information


Policy Information



Policy Holder Information

Other People Covered
!! BROKEN RECORD - NO DEPENDENTS !!
Are there any safety concerns for anyone who is covered by this insurance that prevents you/them from using it?
Are there any other reasons other than safety concerns that would prevent you from using this insurance?
General Comments None
Insurance Card Attachments
None
!! BROKEN RECORD - NO POLICIES !!

Premium Payment Assistance


Would you like to apply for HIPP?
If the insurance is purchased directly from the insurance company, does the policyholder receive federal tax credits to help pay the premiums?
Is the insurance reported in Step 2 court ordered?
Is anyone covered by the insurance pregnant or do they have a serious health condition?
Persons with Conditions
Coverage Details
Insurance Provided By
Employer Name
HR/Benefits Coordinator
How often does the employer deduct premiums from the paycheck?
Amount Deducted Each Check $
Monthly Premium Amount $
General Comments None
Proof of Insurance Payments Provided Separately
Proof of Insurance Payments
None

Premium Payment Assistance (Legacy Record Format)

Does the policyholder pay for all or part of your private or employer-sponsered medical health insurance premium?
How much do you pay monthly for your insurance?
How often is the payment made?
Is anyone covered by the insurance pregnant or have a serious medical condition? If yes, what is the condition?
Is the insurance court ordered?
Employer Name
Employer Phone
Pay Stub Upload
None