Provider FAQs: OHP benefit packages

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• Do all the OHP benefit packages cover the same services?
• How do I know which benefit package applies to my patient?
• Who gets which OHP benefit package?
• What if my patient who is covered by OHP Standard wants treatments that are excluded under the OHP Standard benefit package?
• Are my patients who are enrolled in the OHP Standard benefit package eligible for Project Prevention and the Quit Line?
• What happens when a change occurs that affects my patient's eligibility for benefits? How do unpaid premiums affect eligibility? 

Q. Do all the OHP benefit packages cover the same services?
 

A. No. All OHP benefit packages are based on the Prioritized List of Health Services. (The Health Services Commission creates the list. The Oregon Legislature adopts the list.) OHP Standard excludes some services covered by the OHP Plus. OHP with Limited Drug only covers prescriptions not covered by Medicare Part D. Our provider rules give details on services not covered by the OHP benefit packages.

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Q. How do I know which benefit package applies to my patient?

Automated Voice Response and the Provider Web Portal indicate DHS medical eligibility by reading 3-digit benefit plan codes. The codes that indicate DHS medical eligibility are:

• BMD (OHP with Limited Drug)
• BMH (OHP Plus)
• BMM (Qualified Medicare Beneficiary and OHP with Limited Drug)
• CWM (Citizen - Alien Emergency Waived Medical)
• CWX (CAWEM Plus - OHP Plus benefits for pregnant CAWEM-eligible women)
• KIT (OHP Standard)
• MED (Qualified Medicare Beneficiary)

If your patient is enrolled with any OHP managed care plans or private insurance ("third party resources"), AVR and Web portal will list those as 4-digit codes. You can find the carrier name and phone number to match these codes at this link.

Q. Who gets which OHP benefit package?

OHP Plus covers Medicaid, CHIP or waivered clients such as children, pregnant women, seniors and people with disabilities. OHP Plus clients do not pay premiums. Some adults with OHP Plus pay small copayments; others are exempt. See the provider rules for specific guidelines.

OHP with Limited Drug is for clients who are eligible for both Medicaid and Medicare Part D. It covers all the same services that OHP Plus covers, with the exclusion of prescription drugs that Medicare Part D covers.

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Q. What if my patient who is covered by OHP Standard wants treatments that are excluded under the OHP Standard benefit package?

A. Patients who get OHP Standard must cover the cost of excluded services. They also pay for services that exceed benefit limits. Our rules describe your role and responsibilities in this area. If you do not follow our rules, you may be responsible for costs related to excluded and limited services.

The General Rules provide useful information on this topic.

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Q. Are my patients who are enrolled in the OHP Standard benefit package eligible for Project Prevention and the Quit Line?

Q. What happens when a change occurs that affect my patient's eligibility for benefits? How do unpaid premiums affect eligibility?

A. Your patient must report changes to his or her worker that affect eligibility.

If you patient's situation changes, his or her eligibility for medical assistance may change. As a result, your patient may become ineligible for medical assistance or may become eligible for a different program with a different benefit package. When this occurs, the worker will send a notice to your patient telling how eligibility has changed.

Eligibility may change from the program that provides the OHP Standard benefit package to a program that provides the OHP Plus or OHP with Limited Drug benefit package. Medical programs that provide OHP Plus or OHP with Limited Drug do not require premiums. Unpaid premiums do not affect eligibility for programs that provide OHP Plus or OHP with Limited Drug.

If the worker is evaluating your patient's eligibility for OHP Standard and he or she has outstanding premiums, your patient will have to pay those premiums before qualifying again for OHP Standard.

Unpaid premiums for other household members do not affect a child's eligibility for medical assistance.

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