You asked for information on O-EPIC, the Oklahoma Employer and Employee Partnership for Insurance Coverage.

SUMMARY

The Oklahoma Employer and Employee Partnership for Insurance Coverage (O-EPIC) is a program that provides access to affordable health care coverage to low-income working adults and their spouses. The Oklahoma Health Care Authority contracts with a third-party administrator for O-EPIC administration.

O-EPIC is a health plan purchasing mechanism in which Oklahoma uses public funds to pay for a portion of health plan coverage costs for eligible adults (age 19 to 64) with household incomes equal to or less than 185% of the federal poverty level (FPL). Individuals can participate in this program through either employer-sponsored insurance (O-EPIC ESI) or a state-sponsored individual plan (O-EPIC IP). Eligibility has to be renewed annually.

O-EPIC ESI is a premium assistance program that pays part of the health plan premiums for eligible employees working for qualified Oklahoma small businesses (50 or fewer employees). To be eligible, an employer must pay a minimum of 25% of an eligible employee's health care premiums. An employer is not required to contribute toward spouse coverage. An eligible employee must pay up to 15% of the premiums, not to exceed 3% of monthly household income. The state pays the remaining premium. As of May 10, 2007, there were 946 small businesses participating in O-EPIC ESI, which had total enrollment of 2,228 employees and spouses. The average state subsidy per person in April 2007 was $ 234. 39.

O-EPIC IP is operated through the state Medicaid program and is available to adult Oklahomans not otherwise eligible to participate in an O-EPIC ESI qualified health plan. To be eligible, a person must be (1) working for an Oklahoma small business with 50 or fewer employees, (2) temporarily unemployed and eligible to receive unemployment benefits, or (3) disabled and working for any size employer. An enrolled person must pay monthly premiums up to 4% of gross monthly household income. Premium varies based on income and family size (individual or couple). As of May 10, 2007, O-EPIC IP covered 238 people at an average monthly premium of $ 28. 98 per person.

O-EPIC members are responsible for all out-of-pocket expenses (e. g. , copayments, coinsurance, deductibles). However, out-of-pocket expenses for services covered by the health plan that exceed 5% of the person's gross annual household income may be reimbursable, subject to a fixed cap that is established annually.

More information on O-EPIC is available at http: //www. oepic. ok. gov/.

O-EPIC EMPLOYER-SPONSORED INSURANCE

Employer Eligibility

In order to participate in the O-EPIC program for small employers, the business must:

1. be located in Oklahoma,

2. have 50 or fewer full time employees,

3. offer an O-EPIC qualified health care plans, and

4. contribute a minimum of 25% of eligible employees' monthly health plan premiums.

Employee Eligibility

In order to participate in the O-EPIC ESI program for small employers, an employee must be:

1. an Oklahoma resident;

2. a U. S. Citizen or qualified alien;

3. age 19-64;

4. within income guidelines (i. e. , at or below 185% FPL);

5. ineligible for Medicaid or Medicare;

6. contributing up to 15% of premium costs for employee and spouse coverage, if any, not to exceed 3% of monthly household income; and

7. enrolled in an O-EPIC qualified health plan that the employer offers.

Spouse Eligibility

An employee's spouse may participate in O-EPIC if:

1. the employer's health plan includes coverage for spouses;

2. the employee is eligible for O-EPIC;

3. the spouse's employer, if any, employs no more than 50 employees and is physically located in Oklahoma; and

4. the spouse is enrolled in the same health plan as the employee.

Qualified Health Plan

A qualified health plan is a health plan that the Oklahoma Health Care Authority has approved for participation in O-EPIC ESI. A qualified health plan must offer, at a minimum, benefits that include the following services: (1) hospital, (2) physician, (3) clinical laboratory and radiology, (4) pharmacy, and (5) office visits.

A plan may require copayments and deductibles, subject to the following restrictions:

1. An annual out-of-pocket maximum cannot exceed $ 3,000 per person covered. This amount includes any individual, annual deductible amount, except for pharmacy.

2. An office visit copayment cannot exceed $ 50 per visit.

3. Annual pharmacy deductibles cannot exceed $ 500 per person covered.

Example of O-EPIC ESI

Assuming a family of four (employee, spouse, and two children) with an annual household income of $ 34,000 or 170% FPL and monthly premiums of $ 300 for employee coverage and $ 600 for employee and spouse coverage, the premium payments under O-EPIC are as follows:

Source: http: //www. oepic. ok. gov/employer/employer. aspx?x=1#top

O-EPIC INDIVIDUAL PLAN

O-EPIC IP is available to the following people:

1. working adults who are not eligible for an employer-sponsored qualified health plan, and who work for an Oklahoma business with 50 or fewer employees;

2. temporarily unemployed adults who are eligible to receive unemployment benefits through the Oklahoma Employment Security Commission; and

3. working adults with a disability who work for any size employer.

In order to participate in the O-EPIC Individual Plan, a person must:

1. be an Oklahoma Resident;

2. be an U. S. Citizen (or qualified alien);

3. be between the ages of 19 and 64;

4. be ineligible for Medicaid or Medicare;

5. be ineligible for enrollment in the O-EPIC ESI program;

6. provide Social Security Numbers for all household members; and

7. have annual gross household income within eligibility guidelines.

2007 O-EPIC IP Income Eligibility Guidelines

For families larger than eight, add $ 6,438 to the maximum income for each additional family member.

Spouse Eligibility

If a spouse is eligible for O-EPIC ESI, he or she is not eligible for O-EPIC IP. Otherwise, a spouse of a non-disabled O-EPIC IP approved person is eligible for O-EPIC IP. A spouse of a disabled O-EPIC IP approved person is not automatically eligible, but may choose to apply separately.

Monthly Premiums

Monthly premiums are based on annual household income and family size. They range from $ 0 to $ 49. 33 for an individual and $ 0 to $ 66. 44 for an individual and spouse. Non-payment of premiums results in loss of coverage.

Benefit Package

The O-EPIC IP benefit package includes, but is not limited to, office visits, emergency care, inpatient and outpatient hospital benefits, pharmacy, X-rays, maternity care, and durable medical equipment. The plan includes a maximum lifetime benefit of $ 1 million. A member handbook is enclosed for your reference and is available at http: //www. oepic. ok. gov/pdflib/handbook. pdf.

O-EPIC IP covered members must pay copayments for some services, including those shown here:

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