Insurance Reporting Application
Office of Payment Accuracy and Recovery

Step 1: Enter Your Contact Information

Step 2: Enter your policy information

Policy Information

Insurance Company Name Select One Aetna Blue Cross Blue Shield of Oregon Cigna Health Net Kaiser Permanente Lifewise MODA/ODS Pacific Source Providence UHC - United Health Care Other

Other Insurance Company

Insurance Company Phone

Insurance Company Address

City

State

Zip

Policy ID Number Please enter the full policy number (include letters and numbers). If Kaiser Permanente, enter the Health Record number.

Group Number Please enter all letters and numbers shown on the card.

What is the source of the insurance?

Insurance is from an employer

Insurance is paid for privately

Insurance is provided by an absent parent

Other

Explanation for 'Other'

What is the status of the insurance policy?

Active

Terminated

Policy Expiration Date

Check all policy types that apply

Medical

Dental

Pharmacy

Medicare supplement

Other

Vision

Cobra

Accident Only

Student Policy

Long Term Care

Other Policy Type

Policyholder and Dependants

Policyholder's First Name The policyholder is the owner of the insurance.

Policyholder's Last Name

Social Security Number

To view the text, click inside the box. Why do we need this?

Date of Birth

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.		Remove

There are no dependents to display. Add another person

Additional Questions

Are there any safety concerns for anyone who is covered by this insurance that prevents you/them from using it?

Yes

No

Don't Know

If yes, please describe in 50 words or less.

Are there any other reasons other than safety concerns that would prevent you from using this insurance?

Yes

No

Don't Know

If yes, please describe in 50 words or less.

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.

Choose files

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My Uploads

Name	Size	Status
		100% Complete

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?

Yes

No, I am not interested

No, based on the information above I am not eligible

Don't know. I'm not the client or policyholder

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?

Yes

No

If the policyholder is receiving federal tax credits they are not eligible for HIPP. By selecting yes you acknowledge that the insurance is not eligible for HIPP. You are still required to report the health insurance you entered in Step 2 so please click "Continue" to move to Step 4.

Is the insurance reported in Step 2 court ordered?

Yes

No

Other

Insurance that has been court ordered is not eligible for HIPP. By selecting yes you acknowledge that the insurance is not eligible for HIPP. You are still required to report the health insurance you entered in Step 2 so please click "Continue" to move to Step 4.

Please describe in 50 words or less.

Is anyone covered by the insurance pregnant or do they have a serious health condition?

No

Yes

Add Person

Please provide the information below about the person(s) with the health condition(s) or pregnancy:

First Name	Last Name	Description
			Remove

There are no records to display.

Coverage Details

Enter the date your Yearly Open Enrollment ends

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

Individual In-Network Deductible

$

Individual In-Network Out-of-Pocket

$

Family In-Network Deductible

$

Family In-Network Out-of-Pocket

$

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

Employer insurance - Insurance provided as a benefit of employment and insurance premiums are being withheld from a paycheck

Insurance privately purchased - Insurance purchased directly from an insurance company. This includes Retiree and COBRA policies

Employer Information

Employer Name

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.

First Name

Last Name

Phone Number

Email Address

How often does the employer deduct premiums from the paycheck?

Weekly

Twice a month

Every other week

Monthly

Other

Please Describe How Often:

How much does the employer deduct from each check for health insurance premiums?

Amount deducted from each check

$

What is the monthly premium amount that is billed?

Monthly premium amount

$

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.

Check this box if you are going to send your proof separately.

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.

Choose files

---

My Uploads

Name	Size	Status
		100% Complete

Comments

Please use this area for any other comments you'd like to make.