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Oregon Health Plan Benefits Frequently Asked Questions

Learn more about the benefits OHP covers. 

  • For detailed information about covered benefits, see the General Rules administrative rulebook (410-120-1160, Medical Assistance Benefits and Provider Rules).
  • Also see this overview of benefit package coverage (PDF).
  • Clients can find more information about benefits in the OHP Client Handbook (PDF).
  • Providers can use the Benefits and HSC Inquiry on the Provider Web Portal to find out whether a specific benefit is covered by a client's benefit package. 
If you have questions not answered on this page, go to the Contact Us page and send your question to the appropriate DMAP contact.
  
Answer
Who gets which OHP benefit package?

The main benefit packages are:

  • OHP Plus (BMH): For people eligible for Medicaid or the Children's Health Insurance Program (CHIP), such as children, pregnant women, seniors and people with disabilities.
  • OHP with Limited Drug (BMD, BMM): For people who are eligible for both Medicaid and Medicare Part D.​
Is there a nurse advice line?

Oregon Health Plan Care Coordination - If you are not enrolled in an OHP Fully Capitated Health Plan, Physician Care Organization or Coordinated Care Organization, you can call 1-800-562-4620 anytime you are sick, hurt or want to talk to a nurse. Additional programs are available for OHP members with more complex conditions.

What are OHP pharmacy benefits?

Your doctor will know what prescriptions are covered, and your pharmacy will know whether you will need to pay a copayment.​

What are OHP dental benefits?

Read our brochure in English or Spanish.

What are the OHP benefit packages?

This chart lists the benefits covered for each OHP benefit package:

  • OHP with Limited Drug: BMD and BMM
  • OHP Plus: BMH
  • OHP Plus Supplemental: BMP
  • CAWEM Plus: CWX (OHP Plus benefits for CAWEM-eligible pregnant women)
The following benefits are non-OHP medical assistance:
  • CWM (Citizen - Alien Emergency Waived Medical)
  • MED (Qualified Medicare Beneficiary)
What does OHP Plus cover?

OHP Plus (BMH) is the most comprehensive benefit. It covers most health care services. Services to improve vision (e.g., glasses) are covered for children under age 19 and pregnant adults; for non-pregnant adults, vision services are covered only for specific medical conditions.

OHP with Limited Drug (BMD or BMM) covers the same benefits as OHP Plus, except it does not cover drugs that Medicare Part D should cover.
 

This chart lists the benefits covered for each OHP benefit package.

What does OHP Plus Supplemental cover?

OHP Plus Supplemental covers the following services for pregnant women age 21 and over: 

  • Glasses 
  • Contact lenses 
  • Fittings for glasses or contacts 
  • Eye exams for prescribing glasses or contacts 
  • Dental crowns 
  • Dental visits for observation 
  • Replacement of full dentures 
  • Root canals on molars and some other tooth root procedures 
  • Some gum or oral surgery 
  • Some types of dentures and partials

This chart lists the benefits covered for each OHP benefit package.

Are eye exams covered?

For non-pregnant adults age 21 or older, OHP Plus (BMM, BMH and BMD) covers medical eye exams for any eye condition except for "disorders of refraction and accommodation" (e.g., nearsightedness, farsightedness, astigmatism). Diagnostic services are still covered.

Eye exams for “disorders of refraction and accommodation” are covered for OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage.​

Are glasses or contact lenses covered?

For non-pregnant adults age 21 or older, OHP Plus (BMM, BMH and BMD) only covers glasses or contact lenses to treat the following medical diagnoses:

  • Pseudoaphakia 
  • Aphakia 
  • Congenital aphakia 
  • Keratoconus

For OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage, only glasses (not contact lenses) are covered for “disorders of refraction and accommodation.”

Will OHP pay for treatment when there is an accident or injury to the eye(s)?

Yes. Urgent/emergent treatment is a covered service for all benefit packages.​

Does OHP cover preventive services?

Yes. The OHP Plus, CAWEM Plus, and OHP with Limited Drug benefit packages cover preventive services, which include immunizations, check-ups, and screening tests (such as mammograms and PAP tests). ​

Does OHP cover help to stop smoking (tobacco cessation services)?

The following services are available:

How do I know which benefit package applies?

Look on page 2 of your OHP coverage letter. It lists the benefit package(s) for each person in your household.

How do I know which benefit package applies?

Use Automated Voice Response, the Provider Web Portal, or the 270/271 eligibility inquiry and response. Learn more on the Eligibility Verification page.​

What if someone wants treatments not included their benefit package?

If an OHP member wants a service that is not covered by their benefit package or is not covered for the condition being treated, the member must sign a waiver, as required by OAR 410-120-1280. The waiver shows that the OHP member understands the service is not covered and agrees to pay for the service.

Without this waiver, providers may be responsible for costs related to providing excluded and limited services.​

How do OHP members know if a health care service isn't covered?

OHP health plans are required to send out a Notice of Action to their members, as defined in OAR 410-141-0260 and 410-141-3263, which includes the denial of payment for services.

All providers should let their patients know whether or not the service is covered before delivering the service, including when services will exceed benefit limits (e.g., more frequent dental care).​

How does the Prioritized List of Health Services determine what OHP covers?

It ranks pairs of health conditions and treatments according to effectiveness. The higher a condition and treatment pair is ranked, the more likely OHP will cover it. To learn more visit our Prioritized List page.​

What services are plans required to cover?
The OHP Rules explain plan coverage. Generally, plan coverage must be comparable to DMAP's fee-for-service coverage.
Mental health drugs​ are always billed to DMAP. All other prescriptions are billed to OHP health plans (CCO, FCHP, PCO).