Do you have a disability that makes it hard for you to read printed material? Do you speak a language other than English? We can give you information in one of several ways: Large print Audio tape Braille Electronic format Oral presentation (face-to-face or on the phone) Sign language interpreter Translations in other languages Let us know what you need. Call OHP Customer Service at 1-800-699-9075, TTY 711. Do barriers in buildings or transportation make it hard for you to attend meetings? To get state services? We can move our services to a more accessible place. We can provide the type of transportation that works for you. The Governor's Advocacy Office 500 Summer St NE, E17 Salem, OR 97301 1-800-442-5238 1-800-945-6214 TTY 503-378-6532 Fax
or send to US Dept of Health & Human Services Office for Civil Rights 2201 Sixth Avenue, Mail Stop RX-11 Seattle, WA 98121 1-800-362-1710 1-206-615-2296 TTY 1-206-615-2297 Fax OCRComplaint@hhs.gov
Accessible services... 4 Is access a problem?... 4 Contents... 1 Welcome to the Oregon Health Plan... 1 What is the Oregon Health Plan?... 1 Benefit packages... 3 1. OHP Plus benefit package... 3 Co-payments... 3 2. OHP Plus Supplemental benefit package... 4 3. OHP with Limited Drug benefit package... 5 Co-payments... 5 4. Qualified Medicare Beneficiary (QMB) benefit package.. 6 5. Citizen Alien-Waived Emergency Medical Assistance (CAWEM) benefit package... 7 6. CAWEM Plus benefit package... 7 Health care services... 8 Preventive services... 11 Medical services... 11 Second opinions... 12 Not covered and limited services... 13 Dental services include the following:... 14 Mental health services include the following:... 15
Chemical dependency or substance use disorder treatment... 15 Outpatient treatment and medication treatment services.. 16 Residential treatment services... 16 Stop smoking programs... 17 Pregnancy care coverage... 17 Pregnant clients:... 18 Remember!... 18 Newborn care coverage... 19 Family planning and related services... 19 Patient-Centered Primary Care Homes (PCPCHs)... 20 Medical transportation services... 21 Transportation brokerages... 23 Oregon Health ID card... 26 Coverage Letter... 27 How to read the sample Coverage Letter... 29 Service delivery... 31 Fee-for-service... 33 Native rights... 33 24-hour health care advice... 34 Emergency medical care... 34 Take your ID... 35 Emergency care when you re away from home... 35 If it's not really an emergency... 35 Urgent care... 35
Follow-up to emergency or urgent care... 36 Dental emergency and urgent care... 36 Oregon Health Plan Care Coordination services... 37 Care away from home... 38 Travel outside of the United States... 39 Pharmacy Management Program... 39 Exceptions allowed... 39 You may change your pharmacy enrollment:... 39 OHP home-delivery pharmacy services... 40 Problems with health care services... 40 OHP client rights... 42 OHP client responsibilities... 45 Managed care member rights and responsibilities... 48 Managed care member rights... 48 Managed care member responsibilities... 48 Managed care... 51 What are the benefits of managed care?... 51 Types of managed care enrollment... 51 Coordinated care organizations (CCOs)... 52 Primary care provider in a CCO, medical or dental plan... 53 To coordinate your medical and dental care, your PCP and PCD will:... 53 Interpreter services... 54 Identification cards... 54 Special services... 55
Intensive Care Coordination Services (ICCS) and Exceptional Needs Care Coordinators (ENCC)... 55 Urgent care... 56 Emergencies and crises... 56 Follow-up to emergency or urgent care... 57 Out-of-town emergencies... 57 If you need care out-of-town... 57 Labor and delivery... 58 Newborn enrollment... 58 Getting a ride... 58 Child care... 59 Physician incentives... 59 Mental health services... 59 Mental health prescriptions... 60 ISA services for children s mental health treatment... 60 Services on this page are offered only by CCOs... 61 Care helpers... 61 Involvement in CCO activities... 61 AMHI services for mental health treatment... 61 Culturally-sensitive health education... 62 Problems with your health care services... 63 How to change CCOs... 63 Disenrollment... 64 If you want to receive services as a fee-for-service client. 64 When to call your CCO or plan... 65 Requesting a copy of your records... 65 Your records are private... 66
Billing information... 67 If you get a bill... 68 If you were in the hospital and get bills from other providers 69 Paying for medical services on OHP... 70 Co-payments... 70 More information... 70 Grievance, appeal and hearing rights... 71 How to make a complaint or grievance... 71 Notice of action... 71 How to appeal a decision... 71 If you need a fast appeal... 72 Provider appeals... 73 How to get an administrative hearing... 73 Fast (expedited) hearings... 74 End-of-life decisions and advance directives (living wills) 75 Declaration for Mental Health Treatment... 77 Health care professionals... 78 Who to call for help and other resources... 80 When to call:... 80 Who to call:... 81 OHP Client Services 1-800-273-0557... 82 OHA Ombudsperson 1-877-642-0450... 83 Division of Child Support 1-800-850-0228... 83 Assignment of rights... 83
Personal injury or accident liens... 84 Personal Injury Liens Unit... 84 Domestic violence... 85 Notice of Privacy Practices... 86 Estate recovery... 86 How the program works... 87 For care provided before October 1, 2013... 88 Medicare Part D prescription drug coverage... 88 Surviving spouses and children... 88 My OHP phone list... 90
Info for ALL OHP clients The Oregon Health Plan (OHP) is a state program that provides health care coverage to low-income Oregonians. This booklet will help you understand: The different ways people receive care under OHP managed. care and fee-for-service. How to read your Oregon Health Identification Card and Coverage Letter. Health care coverage under OHP. The benefit packages under OHP. How to use the health services that are covered under OHP. What you need to know about managed care, including coordinated care organizations (CCOs), under OHP. Keep this booklet, and the information you received from your CCO or managed care plan for answers to your questions about your health care coverage. What is the Oregon Health Plan? In Oregon, the Medicaid program is called the Oregon Health Plan (OHP). Medicaid is a health care program for low-income families that is paid for by both federal and state dollars. Helpful phone numbers Page 1
Info for ALL OHP clients OHP covers doctor visits, prescriptions, hospital stays, dental care, mental health services, and help with addiction to tobacco, alcohol and drugs. OHP can provide hearing aids, medical equipment, home health care, and transportation to health care appointments. OHP does not cover all health care services. Oregon Health Plan clients receive services based on where health care conditions and treatments are placed on the Prioritized List of Health Services. The Prioritized List of Health Services is a list of health care conditions and their treatments, which are ranked in order of effectiveness. Diseases and conditions that are below the current line of coverage are usually not covered by OHP. However, something that is below the line may be covered if the patient also has an above the line condition that could get better if their belowthe-line condition is also treated. The Prioritized List of Health Services is online at www.oregon.gov/oha/ohpr/herc OHP covers reasonable services for finding out what's wrong. That includes diagnosing a condition that is below the coverage line. However, in most cases, once it s determined that a diagnosis or treatment is below the coverage line, OHP will not pay for any more services for that condition. Helpful phone numbers Page 2
Info for ALL OHP clients The medical, dental or mental health services OHP covers for each client is called a "benefit package." Each client receives a benefit package based on certain things, such as age or healthcare condition. Members of your household may receive different benefit packages. Benefit package information for each household member is found on page 2 of the Coverage Letter (see example on page 28). An explanation of each benefit package appears below. A quick reference chart on pages 9 and 10 lists the benefits for each benefit package at a glance. 1. OHP Plus benefit package This is a comprehensive package of medical, dental, mental health and chemical dependency services. Services covered by OHP Plus are listed on the Benefit Packages chart on pages 9 and 10. Co-payments Some OHP Plus adult clients are required to make copayments for outpatient services and prescription drugs. If you are enrolled in a CCO or managed care plan, you may not have to pay a co-payment. Amounts of OHP Plus co-payments are: $0 - $3 for prescription drugs (for each filled prescription). Helpful phone numbers Page 3
Info for ALL OHP clients $3 for outpatient services (such as office visits to see a doctor, dentist or other health care provider). You do not have to make co-payments for treatments such as shots, lab tests or x-rays. You do not have to pay for emergency services. The co-payment is only for the visit to the provider. You do not have to pay a co-payment for: Family planning services and supplies, such as birth control pills. Prescription drugs ordered through the OHP Home- Delivery Pharmacy Program. See page 40 for more information about this program. Emergency services. Lab tests, shots, durable medical equipment or x-rays. Services received from most CCOs or managed care plans. If you cannot pay If you cannot make a required co-payment, you will still receive the drug product or health care service; however, you will still owe a debt to the pharmacy or health care provider for the co-payment. 2. OHP Plus Supplemental benefit package This benefit package provides additional coverage to pregnant women. It expands vision and dental coverage to the same level that children and adults under the age Helpful phone numbers Page 4
Info for ALL OHP clients of 21 receive. If you become pregnant, call OHP Customer Service at 1-800-699-9075, TTY 711. 3. OHP with Limited Drug benefit package OHP Plus with Limited Drug is a comprehensive package of services that focuses on preventive care (page 11). Only the prescription drug coverage is limited. You receive this benefit package if you are eligible for both Medicaid and Medicare Part D. The OHP with Limited Drug package covers all the same medical, dental and mental health benefits as the OHP Plus package. However, this package does not cover prescription drugs that Medicare Part D pays for. OHP does pay for some other drugs that Medicare does not cover. Note: OHP will not pay for types of drugs that Medicare Part D would cover, even if you choose not to enroll in a Medicare drug plan. You will have to pay for them yourself. Co-payments You may have to make a co-payment for the outpatient services and prescription drugs. Co-payments are: $3 for outpatient services, such as office visits to see a doctor or other health care provider. You do not have to Helpful phone numbers Page 5
Info for ALL OHP clients make co-payments for treatments such as shots, lab tests or x-rays. You do not have to pay for emergency services. The co-payment is only for the visit to the provider. $0 -- $3 prescription drugs, for each filled OHP prescription. If you are enrolled in a CCO or medical plan, you may not have to pay a co-payment. Different, mandatory co-payments of $1 to $6.50 apply to your Medicare Part D drugs. OHP does not pay Medicare premiums, deductibles or co-payments for Medicare Part D drug plans or services. 4. Qualified Medicare Beneficiary (QMB) benefit package This program helps you if you are eligible to receive hospital benefits through Medicare. QMB clients have limited income but are not eligible for Medicaid. The state helps by paying for QMB clients' Medicare premiums, deductibles and coinsurance. However, OHP does not pay for premiums or co-payments for Medicare Part D drug plans or services. If you have only QMB, your health care costs are paid for by Medicare, not by OHP. Helpful phone numbers Page 6
Info for ALL OHP clients Clients may be eligible for more than one benefit package at once. For example, a person with QMB benefits may also be eligible for OHP with Limited Drug benefits. 5. Citizen Alien-Waived Emergency Medical Assistance (CAWEM) benefit package These clients are not citizens of the United States and do not have an immigration status that meets Medicaid requirements. Coverage is limited to emergency services. 6. CAWEM Plus benefit package This program helps pregnant women receiving CAWEM benefits by providing all OHP Plus benefits except sterilizations, therapeutic abortions, hospice services, and Death with Dignity services. Helpful phone numbers Page 7
Info for ALL OHP clients The health services you may receive are based on your assigned benefit package. See page 2 on your Coverage Letter to find out what type of coverage you have. Benefit packages are defined on pages 3 through 7. The following chart shows what services are covered by benefit package. Helpful phone numbers Page 8
Helpful phone numbers Page 9 Info for ALL OHP clients
Helpful phone numbers Page 10 Info for ALL OHP clients
Info for ALL OHP clients Preventive services Preventing health problems before they happen is an important part of your care. Under OHP, you can get preventive services to help you stay healthy. Preventive services include check-ups and tests to find out what is wrong. You should talk with your provider about how often you should get check-ups. Other preventive services include the following: Immunizations (shots) for children and adults (not for foreign travel or employment purposes) Dental check-ups, exams and preventive dental care for children and adults Mammograms (breast x-rays) for women Maternity and newborn care Maternity management (special services to help you have a safe pregnancy) Pap smears Prostate screenings for men Routine physicals Well-child exams Medical services Services covered by OHP Plus, CAWEM Plus, and OHP with Limited Drug all include the following: Helpful phone numbers Page 11
Info for ALL OHP clients 24-hour emergency care, x-ray, and lab services An exam or test (laboratory or x-ray) to find out what is wrong, whether the treatment for the condition is covered or not Chemical dependency (alcohol and drug) treatment Diabetic supplies and education Emergency ambulance Eye health care Family planning Hospice Labor, delivery and newborn care Medical equipment and supplies Mental health services Most prescription drugs Preventive services Treatment for most major diseases Some surgeries Specialist care and referrals Stop-smoking programs If you are in a CCO or managed care plan, you will need to get a referral from your provider to see a specialist. Second opinions Second opinions are a covered service. If you want a second opinion about your treatment options, ask your PCP to refer you for another opinion. If you are enrolled in managed care and want to see a provider outside of your Helpful phone numbers Page 12
Info for ALL OHP clients CCO or plan s network, you or your provider will need to get your CCO s or plan s approval first. Not covered and limited services OHP covers reasonable services for diagnosing conditions, including the office visit to find out what is wrong. However, once they know what is wrong, OHP may not cover followup visits if the condition or treatment is not funded on the Prioritized List of Health Services (see page 2). There are some services that are not covered even if treatment may be important. If you get a health care service that is not covered, you may have to pay the bill. Your provider will tell you if a service is not covered and what choices you have. For example, OHP does not pay for the following services: Treatment for conditions that get better on their own (such as colds or flu) Treatment for conditions for which home treatment works (such as sprains, allergies, corns, calluses or some skin conditions) Cosmetic surgeries or treatments Treatments that are not generally effective Services to help you get pregnant Weight loss programs Helpful phone numbers Page 13
Info for ALL OHP clients Buy-ups. To "buy up" means you get an item that is not covered by OHP by paying the difference between the item OHP covers and a more expensive, non-covered item. For example, OHP may cover a basic pair of eyeglasses but the client may want a more expensive pair that is not covered by OHP. The client cannot "buy up" by paying the difference between the two. Some services have limits. Your provider can help answer your questions about limited services. Dental services include the following: Preventive services (cleanings, fluoride treatments, sealants for children) Routine services (fillings, x-rays) Dental check-ups Tooth removal Dentures 24-hour emergency care Specialist care and referrals Helpful phone numbers Page 14
Info for ALL OHP clients Mental health services include the following: Evaluations and consultations Therapy Case management Medication management Hospitalization Emergency services Programs to help with daily and community living Chemical dependency or substance use disorder treatment The services you may receive are based on the benefit package you have been assigned to. Problems with alcohol or other drugs affect the whole family. You may need treatment if drinking alcohol or using other drugs causes problems such as these in your life: Fighting with your loved ones Missing work Getting sick Having trouble with the law Identifying problems before they become worse will increase your chance of recovery. You do not need a referral to get help for problems with alcohol or drugs. You can go to: Any provider who will take your Oregon Health ID Your primary care provider. Helpful phone numbers Page 15
Info for ALL OHP clients Outpatient treatment and medication treatment services OHP covers outpatient treatment and medication treatment, such as: Methadone Suboxone Buprenorphine Vivitrol Other medication services that help a person reduce the use of or abstain from alcohol or other drugs Some of the outpatient and residential treatment services are: Screening and assessment Acupuncture Detoxification Individual and group counseling Medication Family/couple counseling Physical examination Urine Analysis (UAs) Residential treatment services OHP covers residential treatment services including treatments provided in a 24-hour care facility, for both adults and youth. There are residential treatment facilities that allow parents to bring their young children to treatment with them. Helpful phone numbers Page 16
Info for ALL OHP clients For more information on residential services, call the Oregon Partnership Alcohol and Drug HelpLine at: 1-800-923-HELP (4357) or 1-877-553-TEEN (8336) youth line 1-877-515-7848 for Spanish-speaking clients 503-945-5962 The Addictions and Mental Health Medicaid Policy Unit can also answer your questions about these types of services. Stop smoking programs OHP pays for services to help you stop smoking. Talk to your primary care provider for more information. Oregon Quit Line: English 1-800-QUIT NOW (1-800-784-8669) Español: 1-855-DEJELO-YA TTY 1-877-777-6534 Online www.quitnow.net/oregon Pregnancy care coverage Pregnancy care is covered by OHP. If you become pregnant, call OHP Customer Service at 1-800-699-9075, TTY 711, right away. They will make sure you do not lose medical coverage before your baby is born. You also need to call OHP Customer Service if a pregnancy ends. Helpful phone numbers Page 17
Info for ALL OHP clients Pregnant clients: Receive services under OHP Plus or OHP with Limited Drug and the OHP Plus Supplemental benefit package. Are not charged co-payments. If you are pregnant, or think you might be, it is important that you see a health care provider right away. Remember! Regular check-ups are important to have a healthy baby. Keep your appointments and follow your provider s advice. Alcohol and drugs taken before or during pregnancy can harm your unborn baby. If you need help for alcohol and drug use, talk to your provider. Now is a good time to stop smoking cigarettes. Smoking during pregnancy can harm your baby. Talk to your provider to find out ways he or she can help you quit. If you need a specialist for your pregnancy care, your provider can refer you to one. Your provider can give you vitamins that will keep your baby healthy during your pregnancy and help prevent birth defects. Helpful phone numbers Page 18
Info for ALL OHP clients Newborn care coverage Call OHP Customer Service at 1-800- 699-9075, TTY 711 as soon as you can after your baby is born within two weeks is good. Your baby has medical coverage until his or her first birthday, even if you are no longer eligible for OHP. You will receive a new OHP Coverage Letter listing your baby and an OHP Health ID card for your baby. Call OHP Customer Service if you do not receive these. When you call OHP Customer Service, give the following information about your baby, and your baby s parents: Date of birth Name Sex Social Security number (or call again as soon as your baby gets one) Your primary care provider Family planning and related services The following family planning and related services are available to women, men and teens: Family planning visits (physical exam and contraceptive education) Helpful phone numbers Page 19
Info for ALL OHP clients Contraceptive supplies, such as oral contraceptives and condoms Sterilization services (tubal ligations and vasectomies) "Related services" include the following: Pap smear Pregnancy test Screenings for sexually transmitted diseases (STDs) Abortions Testing and counseling for AIDS and HIV Even if you re in a CCO or managed care plan, you can go to any one of the following places to receive family planning services: A county health department; A family planning clinic; Any provider who will take your Oregon Health ID. There is no co-payment for any of the family planning and related services or supplies. Patient-Centered Primary Care Homes (PCPCHs) We want you to get the best care possible. One way we try to do that is ask our providers to be recognized by OHA as a patient-centered primary care home (PCPCH). PCPCHs receive extra funds to follow their patients closely and make Helpful phone numbers Page 20
Info for ALL OHP clients sure all their medical and mental health needs are met. You can ask at your clinic or provider s office if it is a PCPCH. Medical transportation services Keeping your health care appointments is important. If you do not have your own transportation, you might: Take the bus Ask a friend or relative to drive you Find a volunteer from a community service agency Call the transportation brokerage call center that serves OHP clients free of charge in your county. Transportation brokerages are listed on page 23. In some cases, you may be reimbursed for medical transportation expenses including gas, meals and lodging. You need to get approval for transportation reimbursement before you go to your health care appointment. To get approval: Contact your DHS branch office if you live in one of the following counties: Baker Clackamas Crook Deschutes Grant Harney Jefferson Helpful phone numbers Page 21
Info for ALL OHP clients Malheur Marion Multnomah Polk Union Wallowa Washington Yamhill For all other counties, contact the transportation brokerage listed on the chart on the following pages. Helpful phone numbers Page 22
Info for ALL OHP clients Transportation brokerages Use the brokerage in your county to ask for approval and receive reimbursement for your medical transportation costs. *Note: The brokerages in these counties do not provide client reimbursement at this time. Contact your local DHS branch office for reimbursement if you live in one of these counties. ** Note: The brokerage in these counties will provide client reimbursement starting April 1, 2014. For TTY/Relay Service, dial 711. Counties served Brokerage Benton Linn Lincoln Baker* Crook** Deschutes** Grant* Harney* Jefferson** Malheur* Union* Wallowa* Cascades West Ride Line Cascades West Council of Governments Phone: 541-924-8738 Toll-free: 1-866-724-2975 Cascades East Ride Center Central Oregon Intergovernmental Council Phone: 541-385-8680 Toll-free: 1-866-385-8680 Helpful phone numbers Page 23
Info for ALL OHP clients *Note: The brokerages in these counties do not provide client reimbursement at this time. Contact your local DHS branch office for reimbursement if you live in one of these counties. ** Note: The brokerage in these counties will provide client reimbursement starting April 1, 2014. For TTY/Relay Service, dial 711. Counties served Brokerage RideSource Call Center Lane Transit District Lane Phone: 541-682-5566 Toll-free: 1-877-800-9899 Gilliam Hood River Morrow Sherman Umatilla Wasco Wheeler Coos Curry Douglas Jackson Josephine Klamath Lake Transportation Network Mid-Columbia Council of Governments Phone: 541-298-5345 Toll-free: 1-877-875-4657 TransLink Rogue Valley Transit District Phone: 541-842-2060 Toll-free: 1-888-518-8160 Helpful phone numbers Page 24
Info for ALL OHP clients *Note: The brokerages in these counties do not provide client reimbursement at this time. Contact your local DHS branch office for reimbursement if you live in one of these counties. ** Note: The brokerage in these counties will provide client reimbursement starting April 1, 2014. For TTY/Relay Service, dial 711. Counties served Brokerage Marion* Polk* Yamhill* Clatsop Columbia Tillamook Clackamas* Multnomah* Washington* TripLink Salem Area Mass Transit District Phone: 503-315-5544 Toll-free: 1-888-315-5544 Northwest Ride Center Sunset Empire Transit District Toll-free: 1-888-793-0439 Transportation Services Tri-Met Phone: 503-802-8700 Toll-free: 1-800-889-8726 Helpful phone numbers Page 25
Info for ALL OHP clients When you are enrolled in the Oregon Health Plan you will receive an Oregon Health ID card. The state issues the ID only when: You are new to OHP Your name changes Your ID number changes, or You ask for a replacement ID card. New clients also receive a Coverage Letter that shows the branch office name, phone number, worker s code, benefit package, co-payment and CCO/plan information for everyone in the household (see page 27). Take your Oregon Health ID to all health care appointments. Providers use the information on the card to check your eligibility. It is illegal to use an Oregon Health ID for health services for anyone not listed on the ID. Helpful phone numbers Page 26
Info for ALL OHP clients The Coverage Letter is for your information only. You do not need to take it to your health care appointments. You will get a new letter when: You are new to the Oregon Health Plan You have a new CCO You get a new Oregon Health ID, or Your benefits, address or household members have changed. Helpful phone numbers Page 27
Helpful phone numbers Page 28 Info for ALL OHP clients
Info for ALL OHP clients How to read the sample Coverage Letter Page 1 (sample on previous page) This page shows your worker s ID and phone number, and, under Reason for letter an explanation of why you got the letter. Page 2 Lists the benefit package, co-payment requirements and managed care or TPR enrollment for everyone in your household who is eligible for benefits. TPR is other health coverage, such as private insurance or Medicare. Name Date of birth Client ID# Co pay? Benefit Package John Doe 01/01/1968 XXXXXXXX Yes OHP Plus A, B Jane Doe 02/01/1969 XXXXXXXX No OHP with Limited B, C, E drug Timmy Doe 03/01/2006 XXXXXXXX No OHP Plus D Managed Care/ TPR enrollments A CCOB Mental and Physical PACIFIC TRAILS 800-555-1212 D Private Maj Med/Rx/Den BLUE CROSS OF OREGON B Dental Care Organization MILES OF SMILES 866-555-1212 E Medicare Part A MEDICARE NW Part A C Mental Health Organization HEALTHY MIND CARE 888-555-1234 F Page 3 Lists the names and phone numbers of you CCO, managed care plans or TPR. The example below shows the following coverage information: Helpful phone numbers Page 29
Info for ALL OHP clients John Has co-payments, OHP Plus benefits and is enrolled in: A Coordinated Care Organization: Pacific Trails, for physical, hospital and mental health care B Dental Care Organization: Miles of Smiles, for dental care Jane Does not pay co-payments, has OHP with Limited Drug benefits, receives her physical and mental health care as a fee-for-service client and is enrolled in: B Dental Care Organization: Miles of Smiles, for dental care E Medicare Part A: Medicare NW, for hospital care Timmy Does not pay co-payments, has OHP Plus benefits and is not enrolled in any OHP CCOs or managed care plans because he has private health insurance: D Private Health Insurance: Blue Cross of Oregon, for physical health care, dental health care and prescription coverage. Helpful phone numbers Page 30
Info for ALL OHP clients There are two ways to receive health care through the Oregon Health Plan. They are fee-for-service (FFS) and managed care. Be sure to look at your Coverage Letter to see if you are enrolled in a coordinated care organization (CCO) or managed care medical, dental or mental health plan. Depending on where you live and other factors, you may be enrolled in a CCO or managed care plan for some kinds of health care and receive health care from any provider who will take your Oregon Health ID for other services. For instance, you may receive your medical and mental health services through your CCO, but not be enrolled in a dental plan. For information about managed care services, please turn to page 51. Health services for OHP members who are not enrolled in a CCO or medical plan are called fee-for-service or open card clients. Their providers are paid by DMAP. Your managed care enrollment information is listed on page 2 of your OHP Coverage Letter. Reasons why clients may not be enrolled in managed care include: Helpful phone numbers Page 31
Info for ALL OHP clients There are no CCOs/plans available in the area in which they live. Clients who are American Indian, Alaska Natives or are eligible for services through an Indian Health Services program are not required to enroll in a CCO or plan. These clients can choose to receive health care from any provider who will take their Oregon Health ID. New clients with the following conditions may delay enrollment in a CCO/plan if they: Are scheduled for surgery. Enrollment in a CCO/plan may be delayed until after surgery. Are in the last three months of a pregnancy. If not already enrolled in a CCO or plan, enrollment may be delayed until after the birth of the baby. Clients who have End Stage Renal Disease or receive routine dialysis treatment, or have received a kidney transplant within the last 36 months are not required to enroll in a CCO. Clients who have both Medicare and OHP benefits may choose when they enroll in a CCO or medical plan. Helpful phone numbers Page 32
Infor for All OHP Clients Info for fee-for-service clients Fee-for-service means that you are not enrolled in a CCO or managed care plan. If you are not enrolled in managed care, you can receive health care from any provider who will take your Oregon Health ID. You may need to call doctors' offices to find out if they accept OHP fee-forservice clients. That provider will bill DMAP directly for any services provided and will receive a "fee" for his or her "service." Some people call this an "open card." If you are a fee-for-service client, the "Managed Care/TPR" Field on page 2 of your Coverage Letter will not show a CCO or managed care plan. However, if you have private insurance, that insurance will be listed in this column. (TPR stands for Third Party Resource.) Native rights Native Americans and Alaska natives on OHP can choose to receive managed care or receive services as fee-forservice clients. Native Americans and Alaska natives can receive their care from an Indian Health Service (IHS) clinic or tribal wellness center. This is true whether they are in a CCO or a plan, or receive services on a fee-for-service basis. Helpful phone numbers Page 33
Infor for All OHP Clients Info for fee-for-service clients 24-hour health care advice Sometimes when you or your child gets sick or hurt, you can't tell if you need to see a doctor or not. Other times, you know you need medical care, but you don't know if you should wait to see your regular provider or go to an urgent care center or hospital emergency room. If you receive care on a fee-for-service basis, you can call the nurse advice line at 1-800-562-4620. The nurse will ask some questions, then help you decide where to get treatment. Maybe you do not need a trip to the hospital. The nurse may even call back later to see how you are. You can get information about community resources, other medical assistance, and a personal Health Coach by calling 1-800-562-4620. The nurses are available 24 hours a day, seven days a week. This service is free. Emergency medical care An emergency is a serious injury or sudden illness, including severe pain, that you believe might cause death or serious bodily harm if left untreated. If you are pregnant, emergency services also include your unborn baby s health. If you believe you have an emergency, call 9-1-1 or go to the nearest emergency room. Emergency care is covered 24 hours a day, seven days a week. Helpful phone numbers Page 34
Infor for All OHP Clients Info for fee-for-service clients Take your ID At the emergency room, show your Oregon Health ID. The emergency room staff will call your provider if they need to know more about you. Emergency care when you re away from home If you are traveling and have an emergency, go to the nearest emergency room or call 9-1-1. Emergency services are authorized only for as long as the emergency exists. Call your primary care provider to arrange for further care if it is needed while you are gone. Also, call for follow-up or transfer of your care. If it's not really an emergency If you use an ambulance or the emergency room for something that DMAP does not consider an emergency, you may have to pay the bill. Emergency room care is very expensive. Do not go to the emergency room for care that should take place in your provider s office. Care for sore throats, colds, flu, back pain or tension headaches is not considered an emergency. Call your provider or the 24-hour nurse advice line instead. Urgent care An urgent medical condition is serious enough to be treated right away, but does not require emergency room care. For urgent care, call your provider. They will give you advice on what to do. If you cannot reach your provider, call the 24- Helpful phone numbers Page 35
Infor for All OHP Clients Info for fee-for-service clients hour nurse advice line 1-800-562-4620, or go to an urgent care center. Follow-up to emergency or urgent care After you are released from the emergency room or from an urgent care clinic, call your primary care provider (PCP) as soon as possible. Tell your provider where you were treated and why. Your PCP will handle all of your follow-up care and schedule another appointment if it is needed. Dental emergency and urgent care A dental "emergency" is dental care requiring immediate treatment. Examples of dental emergencies include: Severe tooth pain A tooth knocked out Serious infection "Urgent" dental care is dental care requiring prompt but not immediate treatment. Examples of urgent conditions include: A toothache Swollen gums A lost filling If you have a dental emergency or urgent care need, call your regular dentist. Helpful phone numbers Page 36
Infor for All OHP Clients Info for fee-for-service clients Oregon Health Plan Care Coordination services (OHPCC) You may be placed in, or referred by your doctor to the OHPCC if you are a fee-for-service client. These services are provided by a company known as APS Healthcare. The program helps you with your care needs. This may include assistance finding a doctor, food or shelter. The program also may help with hospital discharge planning, managing medications, or how to self-manage chronic conditions, obtain the proper equipment, or remain living in your own home longer. A few examples of chronic conditions that could put you at risk and may result in you being enrolled in the OHPCC for FFS are: Diabetes Asthma Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Coronary artery disease (CAD) Depression Chronic pain You also may be placed in a case management program if you have multiple medical or acute needs that require more frequent or complex coordination. The goal of the OHPCC program is to keep you healthier with a focus on supporting your choice to remain Helpful phone numbers Page 37
Infor for All OHP Clients Info for fee-for-service clients independent in your community with the coordination of needed services. The program also helps reduce the use of emergency rooms when other resources can be used, or the need to be hospitalized or re-admitted to the hospital. If you are in the program you are encouraged to participate with the program health coach. You will learn how to better work with your doctors and how to obtain needed services. Being a part of this program does NOT reduce, change or eliminate any of your OHP benefits. You also have the right to request to be enrolled in a CCO or managed care plan in your area at any time. You may call the 24-hour nurse advice line at 1-800-562-4620 any time you have questions about your health and health care needs. Care away from home If you travel outside of Oregon, OHP covers only emergency services. You may be billed for out-of-state emergent care if the provider does not enroll as a DMAP provider. After you receive emergency treatment, call your primary care provider to arrange for further care if it is needed while you are gone. Also, call for follow-up or transfer of your care. Helpful phone numbers Page 38
Infor for All OHP Clients Info for fee-for-service clients Travel outside of the United States If you travel outside the United States (including Canada and Mexico), OHP will not cover any health care services you get in another country. Pharmacy Management Program If you are in the Pharmacy Management Program, you must go to one pharmacy for your prescription drugs. You will have 30 days to change pharmacies if you do not want to be enrolled in the pharmacy listed on your Coverage Letter. To change pharmacies, call OHP Client Services. Exceptions allowed You may receive drugs from a different pharmacy if: You have an urgent need to fill a prescription and your enrolled pharmacy is not available (for example, it is closed or you are out of the area); Your pharmacy does not have the prescribed drug in stock. You may change your pharmacy enrollment: If you move; When your eligibility for OHP is re-determined, usually once a year; If you are denied services by your enrolled pharmacy. Helpful phone numbers Page 39
Infor for All OHP Clients Info for fee-for-service clients OHP home-delivery pharmacy services This program lets fee-for-service clients order and receive medications in the mail at home or at your clinic. You do not have to make copayments for drugs provided through the DMAP Home-Delivery Pharmacy. You can: Order ongoing prescriptions for the entire family; Order refills by mail or phone; Be guaranteed quality and safety; Have delivery within eight to 10 days; Order up to a three-month supply at one time. You can use these services even if you are restricted to one walk-in pharmacy through the Pharmacy Management Program. Your doctor can send your prescription to the home-delivery service or you can enroll yourself by calling 1-877-935-5797 toll-free. Customer service representatives are available Monday through Friday from 7:30 a.m. to 5:30 p.m. Problems with health care services If you have a complaint about the way you were treated at a health care appointment (such as staff rudeness or unresolved billing): Call OHP Client Services at 1-800-273-0557 (TTY 1-800-375-2863). Helpful phone numbers Page 40
Infor for All OHP Clients Info for fee-for-service clients Fill out an OHP complaint form (OHP 3001). You can get this form from OHP Customer Service at 1-800- 699-9075, TTY 711, from a local DHS office or on the OHA website at: www.oregon.gov/oha/healthplan/pages/forms.aspx If you disagree with a decision about your health care made by DMAP, complete an Administrative Hearing Request form (MSC 443). See page 71 for more information about your rights to a hearing. Helpful phone numbers Page 41
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members To be treated with dignity and respect To be treated by providers the same as other people seeking health care benefits to which you are entitled To obtain covered substance abuse treatment, family planning, or related services without a referral To have a friend, family member, or advocate present during appointments and at other times as needed within clinical guidelines To be actively involved in the development of your treatment plan To receive information about your condition and covered and non-covered services, to allow an informed decision about proposed treatment(s) To consent to treatment or refuse services and be told the consequences of that decision, except for courtordered services To receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency To receive written materials explained in a manner that is understandable to you To receive necessary and reasonable services to diagnose the presenting condition Helpful phone numbers Page 42
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members To receive covered services under the OHP which meet generally accepted standards of practice and are medically appropriate To obtain covered preventive services To receive a referral to specialty providers for medically appropriate, covered services To have a clinical record maintained which documents conditions, services received and referrals made. To have access to your own clinical record, unless restricted by statute To have your medical records corrected To transfer a copy of your clinical record to another provider To make a statement of wishes for treatment (Advance Directive) and obtain a power of attorney for health care To receive written notice before a denial of, or change in, a service level or benefit is made, unless such notice is not required by federal or state regulations To know how to make a complaint, grievance or appeal and receive a response To request an administrative hearing with the Department of Human Services or Oregon Health Authority Helpful phone numbers Page 43
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members To receive a notice of an appointment cancellation in a timely manner. To receive adequate notice of DHS/OHA privacy practices Additional rights for managed care members are shown on page 48 Helpful phone numbers Page 44
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members To treat all providers and personnel with respect To be on time for appointments made with providers To call in advance if you are going to be late or have to cancel your appointment To seek periodic health exams, check-ups, and preventive services from your medical, dental or mental health providers To use your PCP or clinic for diagnostic and other care, except in an emergency To obtain a referral to a specialist from the PCP or clinic before seeking care from a specialist, unless selfreferral is allowed To use emergency and urgent care services appropriately To give accurate information for inclusion in the clinical record To help the provider or clinic obtain clinical records from other providers. This may include signing a release of information form To ask questions about conditions, treatments and other issues related to your care that you don't understand To use information to make informed decisions about treatment before it is given Helpful phone numbers Page 45
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members To help in the creation of a treatment plan with your provider To follow prescribed, agreed-upon treatment plans To tell your provider you have OHP coverage and to show your Oregon Health ID when asked. To call OHP Customer Service at 1-800-699-9075, TTY 711 and tell them: If you have a change of address or telephone number If someone in the family becomes pregnant Of the birth of a child If any family members move in or out of the household If there is any other insurance available and to report any changes in insurance in timely manner To pay for non-covered services you receive To assist DMAP to find any other insurance to which you are entitled and to pay DMAP the amount of benefits you received as a result of an accident or injury To notify DMAP of issues, complaints or grievances To sign a release so that DHS/OHA and your CCO/plan can get information they need to respond to an administrative hearing request in an effective and efficient manner Helpful phone numbers Page 46
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Additional rights and responsibilities for managed care members are shown on page 48 Helpful phone numbers Page 47
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Managed care member rights In addition to the rights shown on page 42, as a member of a CCO or managed care plan, you also have the right to: Select or change your provider Have the CCO s/plan's written materials explained in a manner that is understandable; Know how to make a complaint with the CCO/plan and receive a response from them; Make complaints and get a response without a bad reaction from your CCO, plan or provider; Receive care when you need it, 24 hours a day, seven days a week; Be able to limit who can see your health records; Help make decisions about your health care, including refusing treatment, without being held down, kept away from other people or forced to do something you don t want to do. Managed care member responsibilities In addition to the rights shown on page 42, as a member of a CCO or managed care plan, you also have the responsibility to: Choose your provider or clinic, once enrolled. Helpful phone numbers Page 48
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Obtain services only from your PCP (except in an emergency) or through CCO/plan providers upon referral from your PCP. Obtain a referral to a specialist from your PCP or clinic before seeking care from a specialist, unless referral to the specialist is allowed. Notify the CCO/plan or PCP within 72 hours of an emergency. Assist the CCO/plan in pursuing any third party resources available and to pay the CCO/plan the amount of benefits it paid for an injury from any recovery received from the injury. Bring issues or complaints to the attention of the CCO/plan. Helpful phone numbers Page 49
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members THIS PAGE INTENTIONALLY LEFT BLANK Helpful phone numbers Page 50
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Coordinated care organizations and managed medical and dental care plans coordinate your health care needs. OHA pays CCOs and managed care plans a set amount each month to provide their members the health care services they need. Most OHP members must receive managed medical, mental health and dental care. Managed care enrollment information is listed on page 2 of your OHP Coverage Letter. What are the benefits of managed care? You may not have to pay co-payments. You and your family will have guaranteed access to physical and dental health care 24 hours a day, seven days a week. Types of managed care enrollment If you are in managed care, you may be enrolled in one or more of the following: Coordinated care organization (CCO-A), for coordinated physical, dental and mental health care Coordinated care organization (CCO-B), for coordinated physical and mental health care Fully capitated health plan, physician care organization (PCO) for physical health care Dental care organization, for dental care Helpful phone numbers Page 51
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Coordinated care organization (CCO-E), for mental health care Coordinated care organization (CCO-G), for dental and mental health care Managed care enrollment is listed on page 2 of your OHP Coverage Letter. Coordinated care organizations (CCOs) Most OHP members are moving into coordinated care organizations (CCOs). CCOs are set up so that anyone who provides your care doctors, nurses, counselors can focus on prevention and improving care. They are a group of all types of health care providers who work together for people on OHP in their communities. Instead of just treating you when you get sick, CCOs work with you to keep you healthy and help you manage existing health conditions. For example, there may be added services for OHP clients who have chronic conditions like diabetes, asthma or other health needs. CCOs can also help prevent unnecessary trips to the hospital or emergency room. CCOs offer more team-based care. They can better share information to avoid repeat or unnecessary testing. You will get the tools and support you need to stay healthy. Helpful phone numbers Page 52
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Your care and the advice you get will be easy to understand and follow. CCOs will help all of your providers work together to improve your health and health care. Primary care provider in a CCO, medical or dental plan When you enroll in a CCO, medical or dental plan they will ask you to choose a primary care provider (PCP) or primary care dentist (PCD). Each family member may choose a different PCP or PCD. Your PCP and PCD will provide or coordinate your medical and dental services and treatments. Your CCO, medical or dental plan will give you 30 days to choose a PCP or PCD. After 30 days, they may choose one for you. Ask your CCO, medical or dental plan for a list of providers if you don't have one. To coordinate your medical and dental care, your PCP and PCD will: Keep your medical and dental records in one place to give you better service. Provide access for you to medical and dental care 24 hours a day, seven days a week. Be your first contact when you need medical or dental care, unless it's an emergency. Arrange for your specialty or hospital care when needed. Helpful phone numbers Page 53
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Interpreter services You have the right to request a qualified or certified medical interpreter or a sign language interpreter to assist you with your language needs at your appointments. If you need an interpreter, let your provider know which is your preferred language and they will schedule an interpreter for you at no cost to you. When possible, feel free to let your provider know in advance about your language needs Identification cards Your CCO or managed care plans will send you identification cards. They tell you what to do in an emergency. It is important to show both your Oregon Health ID and your CCO/plan ID when you seek health care. Call your CCO s/plan's member services department to replace lost IDs. The CCO or managed care plans you are enrolled with are listed on your Coverage Letter. If you receive non-emergency or non-urgent care services from providers who are not part of your CCO or plan, you may have to pay for them, including Medicare deductibles and coinsurances. Helpful phone numbers Page 54
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Special services You must have a referral from your PCP before you see a specialist. If you do not have a referral, OHP may not pay for the care you receive. You may have to pay the specialist's bill. You do not need a referral to get family planning and related services. You may seek this type of help from anyone who will take your Oregon Health ID. You will get your prescription drugs at the pharmacies your CCO or plan contracts with. Ask your CCO/plan for a list. Intensive Care Coordination Services (ICCS) and Exceptional Needs Care Coordinators (ENCC) CCOs and medical plans have special staff to assist members who have complex medical or special needs. CCOs have intensive care managers, while medical plans have exceptional needs care coordinators. These staff help coordinate health care services for members age 65 or older and members with disabilities, complex medical issues or special needs. Members who have special medical supply or equipment needs, or who will require support services in obtaining care, may ask for help from an ICCM or ENCC by calling their CCO or medical plan. Helpful phone numbers Page 55
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Urgent care Always call your PCP s office first about any health problem. Someone will be able to help you day and night, even on weekends and holidays. If you can t reach your PCP s office about an urgent problem or they can t see you soon enough, you can go to the nearest urgent care clinic without an appointment. Urgent problems are things like severe infections, sprains, and strong pain. If you don t know how urgent the problem is, call your PCP. Emergencies and crises If you think that you have a real emergency, call 911 or go to the emergency room (ER) at the nearest hospital. You don t need permission to get care in an emergency. An emergency might be chest pain, trouble breathing, bleeding that won t stop, broken bones, or a mental health emergency. Please don t use the ER for things that can be treated in your doctor s office. Sometimes ERs have a long, uncomfortable wait and take hours to see a doctor, so you should only go there when you have to. If you go to an emergency room or urgent care clinic, show both your Oregon Health ID and your medical plan card. The emergency room staff will call your provider if they need to know more about you. A mental health emergency is feeling or acting out of control, or a situation that might harm you or someone else. Get help right away do not wait until there is real danger. Call your CCO or plan s crisis hotline, 911, or go to the ER. Helpful phone numbers Page 56
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Follow-up to emergency or urgent care After you are released from the emergency room or from an urgent care clinic, call your primary care or mental health provider as soon as possible. Tell your provider where you were treated and why. Your PCP or mental health provider will handle all of your follow-up care and schedule another appointment if it is needed. Emergency care is covered until you are stable. Follow-up care once you are stable is covered but not considered an emergency. Out-of-town emergencies If you have a real emergency when you are away from home, call 911 or go to the nearest emergency room. Your care will be covered until you are stable. For follow-up care after the emergency, call your PCP. OHP covers emergency and urgent care anywhere in the United States, but not in Mexico, Canada, or anywhere outside the U.S.A. If you need care out-of-town If you get sick when you are away from home, call your PCP. If you need urgent care, find a local doctor who will see you right away. Ask that doctor to call your PCP to coordinate your care. Helpful phone numbers Page 57
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Labor and delivery If at all possible, try to stay within your CCO or medical plan s service area during the last 30 days of your pregnancy. However, if you must leave your CCO or medical plan s service area, they are responsible only for emergency care that you receive while outside their service area. Your CCO or plan will cover the delivery and the baby s newborn checkup in the hospital but not the prenatal care. They will also pay for any other emergency care involving you or your baby. Newborn enrollment Your CCO or medical plan will cover your newborn child at the time of birth. However, you will still need to call OHP Customer Service at 1-800-699-9075, TTY 711, to enroll your baby as soon as possible (within two weeks is best). You should receive a new Coverage Letter with your baby listed. If not, call OHP Customer Service. Getting a ride If you need help getting to your appointments, please call the brokerage listed on page 21. Some people may be able to get help paying for rides. Helpful phone numbers Page 58
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Child care If you need child care so you can go to your appointment, please call OHP Customer Service at 1-800-699-9075, TTY 711. They may be able to help you get money to pay a babysitter. Physician incentives Neither CCOs nor plans pay or reward their providers for limiting services and referrals. Contact your CCO or plan if you are interested in any physician incentives they provide. Mental health services Mental health services are available to all OHP members. You can get help with depression, anxiety, family problems, and difficult behaviors, to name a few. Your CCO or medical plan covers mental health assessment to find out what kind of help you need, case management, therapy, and care in a psychiatric hospital if you need it. Important: You do not need a referral to get mental health services from a network provider. Please see your CCO s or Plan s Provider Directory for a list of network providers. Helpful phone numbers Page 59
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Mental health prescriptions CCOs and plans do not cover all prescriptions. Most medications that people take for mental illness are paid by OHP on a fee-for-service basis. Be sure to show your pharmacist your Oregon Health ID and your CCO or plan ID cards. With this information, your pharmacist will know who to bill. ISA services for children s mental health treatment Integrated Services Array (ISA) is a program of intensive services for children with mental illness, to keep them safe at home, in school and in their community. Most participants are 10 to 15 years old. Helpful phone numbers Page 60
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Care helpers There may be times when you need help getting the right care. Your primary care team may have people specially trained to do this. These people are called care coordinators, community health workers, peer wellness specialists, and personal health navigators. Please ask your CCO s customer service for more information. Involvement in CCO activities Your CCO has a community advisory council. Most of the council members are Oregon Health Plan members. Other members are from government agencies and groups that provide OHP services. If you are interested in being a member of the community advisory council, please call your CCO s customer service for an application. AMHI services for mental health treatment Aim High (AMHI) is a program to help adults in residential settings get better mental health care. It also helps adults with mental illness get more and better services in the community. The goal is to keep people healthy outside of the State Hospital. Your CCO/Plan has several healthy living programs and activities for you to use. They are listed in your CCO/Plan member handbook. For more information about these services, please call your CCO/Plan s Customer Service. Helpful phone numbers Page 61
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Culturally-sensitive health education CCOs respect the dignity and the diversity of our members and the communities where they live. They want to make sure their services address the needs of people of all cultures, languages, races, ethnic backgrounds, abilities, religions, genders, sexual orientations, and other special needs of our members. They want everyone to feel welcome and well-served in their CCO. Health education programs include self-care, prevention, and disease self-management. Please call your CCO s customer service for more information Helpful phone numbers Page 62
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Problems with your health care services If you have a complaint about the way you were treated at a health care appointment (such as staff rudeness or unresolved billing), choose one of the following: Call your CCO or managed care plan at the number shown on your Coverage Letter. Call OHP Client Services to discuss your problem. Fill out an OHP complaint form (OHP 3001). You can get this form from OHP Client Services, from any DHS office or on the DHS/OHA website at https:/apps.state.or.us/forms/served/he3001.pdf. Your CCO/plans also have complaint forms. See also your hearing rights on page 71. How to change CCOs If you want to change to a different CCO, call OHP Customer Service at 1-800-699-9075, TTY 711. There are several chances for you to change as long as another CCO is open for enrollment: If you or a family member do not want the CCO you ve been assigned to, you can change during the first 90 days after you enroll. If you are new to OHP, you can change CCOs during the first 90 days after you enroll. If you move to a place that your CCO doesn t serve, you can change CCOs as soon as you tell OHP Customer Service about the move. Helpful phone numbers Page 63
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members You can change CCOs each time we find that you meet the requirements for OHP. This is called recertification and usually happens about the same time once each year. If you are also on Medicare, you can change or leave your CCO anytime. If you have an important reason that is approved by DMAP. Once during each enrollment period. Disenrollment When you have a problem getting the right care, please let your CCO/plan try to help you before you change CCOs or plans. Just call your CCO or plan s customer service and ask for a Care Coordinator. If you still want to leave or change your CCO/plan, call OHP Customer Service at 1-800-699-9075, TTY 711. Your CCO or plan may ask DMAP to remove you if you: Are abusive to CCO/plan staff or your providers Commit fraud, such as letting someone else use your health care benefits. If you want to receive services as a fee-for-service client OHP wants you to get managed health care from a CCO. CCOs can provide some services that OHP can t. But you can change to fee-for-service OHP at any time if: You are an American Indian or Alaska Native Helpful phone numbers Page 64
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members You are also on Medicare in addition to OHP You have an important reason that is approved by DMAP. When to call your CCO or plan If you are in a CCO or managed care plan, call them: To change your PCP; To ask which providers are taking new patients; If you have a problem with your CCO s/plan's services; If you get or lose other health insurance; If you need urgent care; If you get emergency care; To ask what services are covered and not covered; To find out which hospital, pharmacy, or vision provider to use; To get special help for a disability. Requesting a copy of your records Your PCP has most of your records, so you can ask them for a copy. They may charge a reasonable fee for copies. You can ask your CCO/Plan for a copy of the records they have. They may charge you a reasonable fee for copies. You can have a copy of your mental health records, unless your provider thinks this could cause serious problems. Helpful phone numbers Page 65
Infor for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Your records are private Your records are shared only with people who need to see them for treatment and payment reasons. You can limit who sees your records. If there is someone you don t want to see your records, please tell your CCO/Plan in writing. You can also ask for a list of everyone who has seen your records. Helpful phone numbers Page 66
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members OHP clients don t pay bills for covered services. Your healthcare provider can send you a bill only if all of the following are true: 1. The service is something that your OHP, CCO or plan does not cover, and; 2. Before you received the service, you signed a valid agreement to pay form (also called a waiver), and; 3. The form showed the estimated cost of the service, and; 4. The form said that OHP does not cover the service, and; 5. The form said you agree to pay the bill yourself. These protections usually apply only if the healthcare provider knew or should have known you had OHP. Also, they only apply to providers who participate in the OHP program (most providers do). Your provider will not be paid if they don t bill DMAP or your CCO/Plan correctly. That doesn t mean you have to pay. If you already received the service and DMAP or your CCO/Plan do not pay your medical provider, your provider can t bill you. You may receive a notice saying that the service will not be paid. That notice does not mean you have to pay. Also, you should not have to help your provider s office correct billing problems if they occur. If you are asked by your provider to help them get paid, contact OHP Client Services. Helpful phone numbers Page 67
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members If you are told that the service isn t covered by OHP, you still have the right to challenge that decision by filing an appeal and/or asking for a hearing. If you get a bill Even if you don t have to pay, do not ignore health care bills. As soon as you get a bill for a service that you received while you were on OHP, you should: 1. Call the provider, tell them that you were on OHP, and ask them to bill your CCO. 2. Call OHP Client Services, or if you are in managed care, your CCO or Plan s customer service right away and say that a provider is billing you for an OHP service. They will help you get the bill cleared up. Do not wait until you get more bills. 3. You can appeal by sending a letter to your provider, DMAP, and your CCO or plan saying that you disagree with the bill because you were on OHP at the time of the service. Keep a copy of the letter for your records. 4. Follow up to make sure the bill is paid. 5. If you receive court papers, call DMAP, your CCO or plan right away. You also may call a lawyer or the Public Benefits Hotline at 1-800-520-5292 for legal advice and help. There are consumer laws that can help you when you are wrongfully billed while on OHP. Helpful phone numbers Page 68
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members If your CCO or plan does not resolve the billing problem, call OHP Client Services for help. If you pay a health care bill yourself, DMAP, your CCO, or your plan will not pay you back. Many providers send unpaid bills to collection agencies and even sue in court to get paid. It is much more difficult to fix the problem once that happens. Be sure to act as soon as you receive a bill from your provider or a notice from a collection agency. If you were in the hospital and get bills from other providers When you go to the hospital or the emergency room, you may be treated by a provider who doesn t work for the hospital. For example, the emergency room doctors may have their own practice and provide services in the emergency room. They may send you a separate bill. If you have surgery in a hospital, there will be a separate bill for the hospital, the surgeon, and maybe even the lab, the radiologist, and the anesthesiologist. Just because the hospital has been paid by OHP, it doesn t mean that the other providers were paid by OHP. Do not ignore bills from people who treated you in the hospital. If you get other bills, call each provider and ask them to bill DMAP, your CCO or plan. You should follow steps 1-5 from the previous page for each bill you get. Helpful phone numbers Page 69
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Paying for medical services on OHP You may have to pay for services that are covered by OHP if you see a provider that does not take OHP or is not part of our provider network. Before you get medical care or go to a pharmacy, make sure that they are in our network. You will have to pay for services if you weren t eligible for OHP when you received the service. You will have to pay for services not covered by OHP if you sign a detailed agreement to pay form for that specific service before you receive it. Even if your service is covered by OHP, you may have to pay a co-payment. You can t be denied services if you can t make your co-payment, but you will still owe the money to your provider. Co-payments Co-payments are your responsibility. Providers may bill you for unpaid co-payments. More information Find more information about billing, paying for services and Appeals and Hearings at the Clients section of the OHP website at: www.oregon.gov/oha/healthplan/pages/index.aspx You can also request a copy of the Client Billing Toolkit from OHP Client Services. Helpful phone numbers Page 70
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members How to make a complaint or grievance If you are unhappy with your CCO or plan, health care services or your provider, you can complain or file a grievance. They will try to make things better. Just call their customer service or send them a letter. They will call or write back in a week to let you know that they are working on it. Your CCO or plan will send you a letter in 30 days explaining how they will address your complaint. They will not tell anyone about your complaint unless you ask them to. Notice of action If DMAP, your CCO or plan denies, stops or reduces a medical service your provider has ordered, they will mail you a Notice of Action letter explaining why they made that decision. The letter will explain how to appeal (through your CCO or plan) or request a hearing (through DMAP) to ask to have the decision changed. You have a right to ask to change it through an appeal, a contested case hearing, or both, at the same time. You must ask no more than 45 days from the date on the Notice of Action letter. How to appeal a decision In an appeal, a different health care professional from your CCO or plan will review your case. Ask for an appeal by: Calling your CCO or plan s customer service, or Helpful phone numbers Page 71
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Writing them a letter. If you want help with this, call your CCO or plan; they can fill out an appeal form for you to sign. You will get a Notice of Appeal Resolution within 16 days letting you know if the reviewer agrees or disagrees with your CCO or plan s decision. You can keep getting a service that already started before the decision to stop it. You must ask your CCO or plan to continue the service within 10 days of getting the Notice of Action letter that stopped it or by the effective date listed on the notice of action, whichever date is later. If you continue the service and the reviewer agrees with the original decision, you may have to pay the cost of the services that you received after the effective date on the Notice of Action letter. If you need a fast appeal If you and your provider believe that you have an urgent medical problem that cannot wait for a regular appeal, tell your CCO or plan that you need a fast (expedited) appeal. Include a statement from your provider or ask them to call and explain why it is urgent. If your CCO or plan agree that it is urgent they will call you with a decision in three workdays. Helpful phone numbers Page 72
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Provider appeals Your provider has a right to appeal for you when their physician s orders are denied by a CCO or plan. How to get an administrative hearing You can have a contested case hearing with an Oregon administrative law judge. You will have 45 days from the date on your Notice of Action or Notice of Appeal Resolution to ask the state for a hearing. You may ask for a hearing by completing the Administrative Hearings Request Form (MSC 443). You can get an MSC 443 and help filling it out from any DHS office or by calling OHP Customer Service at 1-800-699-9075, (TTY 711). If you are in a CCO or managed care plan, your Notice of Action letter will have a hearing request form that you can send in. You can also ask your CCO or managed care plan to send you a hearing request form, or call OHP Client Services and ask for a hearing request form. If you are enrolled in a CCO or managed care plan, you can request an appeal through them and a hearing at the same time. At the hearing you can tell the judge why you do not agree with our decision and why the services should be covered. You do not need a lawyer, but you can have one or Helpful phone numbers Page 73
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members someone else, like your doctor, with you. If you hire a lawyer you must pay the lawyer s fees. You can ask the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 1-800-520-5292, TTY 711, for advice and possible representation. Information on free legal aid can also be found at www.oregonlawhelp.org. A hearing often takes more than 30 days to prepare. While you wait for your hearing, you can keep on getting a service that already started before our original decision to stop it. You must ask to continue the service within 10 days of getting the Notice of Action that stopped it, or 10 days from the effective date shown on the Notice of Action, whichever is later. If you continue the service and the judge agrees with the original decision, you may have to pay the cost of the services that you received after the effective date on the original Notice of Action. Fast (expedited) hearings If you and your provider believe that you have an urgent medical problem that cannot wait for a regular hearing process, say that you need a fast (expedited) hearing and fax the hearing request form to the OHP Hearings Unit. Include a statement from your provider explaining why it is urgent. You should get a decision in three workdays. The Hearings Unit s fax number is 503-945-6035. Helpful phone numbers Page 74
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Adults 18 years and older can make decisions about their own care, including refusing treatment. It s possible that someday you could become so sick or injured that you can t tell your providers whether you want a certain treatment or not. If you have written an advance directive, also called a living will, your providers may follow your instructions. if you don t have an advance directive, your providers may ask your family what to do. If your family can t or won t decide, your providers will take the usual steps in treating your conditions. If you don t want certain kinds of treatment, such as a breathing machine or feeding tube that will keep you alive, you can write that down in an advance directive. It lets you decide your care before you need that kind of care, in case you are unable to direct it yourself, such as if you are in a coma. If you are awake and alert your providers will always listen to what you want. You can get a free advance directive form at most hospitals and from many providers. You also can find one online at Helpful phone numbers Page 75
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members www.oregon.gov/dcbs/shiba/docs/advance_directive_form.p df. If you write an advance directive, be sure to talk to your providers and your family about it and give them copies. They can only follow your instructions if they have them. Some providers and hospitals will not follow advance directives for religious or moral reasons. You should ask them about this. The advance directive also lets you name a person to direct your health care when you cannot do so. This person is called your health care representative. Your health care representative does not need to be a lawyer or health care professional. It should be someone with whom you have discussed your wishes in detail. Your health care representative must agree in writing to represent you. If you change your mind, you can cancel your advance directive anytime. To cancel your advance directive, ask for the copies back and tear them up, or write CANCELED in large letters, sign and date them. For questions or more information contact Oregon Health Decisions at 1-800-422-4805 or 503-241-0744, TTY 711. Note: For religious reasons some CCOs do not allow their providers to follow advance directives. Helpful phone numbers Page 76
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Oregon has a form for stating your wishes for mental health care if you have a mental health crisis, or if for some reason you can t make decisions about your mental health treatment. The form is called the Declaration for Mental Health Treatment. You can complete it while you can understand and make decisions about your care. The Declaration for Mental Health treatment tells what kind of care you want if you ever need that kind of care but are unable to make your wishes known. Only a court and two doctors can decide if you are not able to make decisions about your mental health treatment. This form allows you to make choices about the kinds of care you want and do not want. It can be used to name an adult to make decisions about your care. The person you name must agree to speak for you and to follow your wishes. If your wishes are not known, this person will decide what you would want. A declaration form is good for only three years. If you become unable to decide during those three years, your declaration will remain good until you can make decisions again. You may change or cancel your declaration when you can understand and make choices about your care. You must give your form to your primary care provider and the person you name to make decisions for you. Helpful phone numbers Page 77
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members For more information on the Declaration for Mental Health Treatment go to the state s website at www.oregon.gov/oha/amh/forms/declaration.pdf. The following is a list of types of identified health care professionals licensed in Oregon. Not all CCOs or managed care plans cover the services of all healing arts professionals. You may need a referral from your primary care provider (PCP) to see a healing arts professional. If you do not have a referral, you may have to pay the bill. No referral is needed for covered chemical dependency (alcohol and drug) treatment, family planning or related services. Helpful phone numbers Page 78
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Acupuncturists Audiologists Chiropractic physicians Clinical social workers Counselors, professional Dental hygienists Dental specialists Dentists, general Denturists Dieticians Hearing aid dealers Marriage and family therapists Massage technicians Midwives, licensed direct entry (LDEM) Naturopathic physicians Nurses, licensed practical Nurse practitioners Nurses, registered Occupational therapists Occupational therapy assistants Optometrists Osteopathic physicians Physical therapist assistants Physicians, M.D. Physician assistants Podiatrists Pharmacists Physical therapists Psychiatric social workers* Psychologists Psychologist associates Radiologic technologists (full license) Radiologic technologists (limited permit) Respiratory therapists School counselors School psychologists Speech pathologists * Not all psychiatric social workers are licensed. Helpful phone numbers Page 79
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members If you have a question or problem with your health care coverage or provider, there are ways to resolve it. The following pages show different offices that may be able to answer your questions. Please read carefully how each office can help you. These phone lines are very busy, so you may have to re-dial several times before you get through. When to call: If you: Get pregnant or a pregnancy ends Have a baby Move Have questions about your eligibility Get or lose other health insurance Want to change your CCO/plans or Want to ask for a hearing Have not received your Oregon Health ID and Coverage Letter, or if they are wrong Have family members move in or out of your home Helpful phone numbers Page 80
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Need this booklet in another language, large print, Braille, on tape, computer disk, or in an oral presentation Become eligible for health insurance through an employer Become disabled or determined eligible for SSI Do not have transportation to or from a health care appointment. Who to call: Medicare recipients who receive benefits from Area Agency on Aging or Aging and People with Disabilities call your local office. Foster parents call your local Child Welfare office. All other clients call OHP Customer Service at 1-800- 699-9075 TTY services -- 711. Your contact number is also listed on your Coverage Letter. If you are unsure who to call, you can call OHP Customer Service for help. Helpful phone numbers Page 81
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members OHP Client Services 1-800-273-0557 500 Summer St NE, E44 TTY 711 Salem, Oregon 97301 FAX 503-373-7866 Like any insurance company, the Oregon Health Plan has a group of customer service representatives to help you understand and use your coverage. Call CSU if you need a client advisor to: Provide you general information about your medical and dental coverage. Coach you on how to resolve problems involving access or quality of care. Help you resolve what you consider to be an inappropriate denial of covered benefits. Explain the OHP managed care system and help you navigate through that system. Research and resolve medical billings from your health care providers. Send you another client handbook or other written materials you need. Take your request for changing an assigned pharmacy. Advise you about OHP co-payments. Note: CSU advisors cannot send you a list of health care providers or refer you to any specific doctor. Helpful phone numbers Page 82
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members OHA Ombudsperson 1-877-642-0450 500 Summer St NE, TTY 711 Salem, Oregon 97301 FAX 503-947-2341 For help with problems that have not been resolved through other means. Division of Child Support 1-800-850-0228 Visit www.oregonchildsupport.gov TTY 1-800-735-2900 to find your local Child Support office The Division of Child Support (DCS) will set up and enforce child support orders or medical support orders for families who receive public assistance. These support payments: Help children in need Encourage family self-sufficiency Return money to the state treasury Reduce the state's costs in providing public assistance Assignment of rights When you applied for OHP services, you gave the state permission to establish paternity and pursue health care coverage from parent(s) not living in your household. The state is now paying for your child's health care, so the department will keep any money it collects for health care from the absent parent(s) or other insurance companies. Helpful phone numbers Page 83
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Personal injury or accident liens If you, as a Medicaid client, have an accident or injury, you need to tell us. Someone else might be responsible to pay for the medical bills that result. When you applied for OHP, you agreed to let us have any medical payments you receive, or have the right to receive, from private health insurance or other sources to repay us for assistance paid due to the accident or injury. This applies from the date of your injury to the date of a settlement. If you do not notify us of your accident, the department, or your CCO or managed care plan, can take legal action (pursue a lien) against you to collect the cost of medical services you received as a result. Personal Injury Liens Unit P O Box 14512 Salem, OR 97309 Toll Free 1-800-377-3841 503-378-4514 (Salem) Helpful phone numbers Page 84
Info for All OHP Clients Info for Fee-for-Service clients Info for CCO/Plan Members Domestic violence This is a list of some of the warning signs of an abusive relationship. You may be in an abusive relationship, if your current or past partner or spouse: Puts you down Stops you from getting or keeping a job Makes threats against you or your children Makes you afraid for your safety Keeps you from seeing your friends or family Shoves, grabs, slaps, punches, pinches, strangles, kicks, hits or chokes you Tries to hurt you in any other way Call one of these phone numbers for confidential help in creating a safety plan and to get support and information: Portland Women s Crisis Hotline 1-888-235-5333 503-235-5333 (Portland) 503-419-4357 (TTY) National Domestic Violence 1-800-799-SAFE (7233) 1-800-787-3224 (TTY) (Serves both men and women) Helpful phone numbers Page 85