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OHP questions and answers for clients

Frequently Asked Questions about the Oregon Health Plan 

Please see below for frequently asked questions (FAQ) about the Oregon Health Plan. If you have a question that is not listed, you can  contact us.

Questions about Oregon Health Plan and other medical benefit packages

  
Answer
How can I get involved?
How do I get medical care?

If you are in an OHP coordinated care organization (CCOA or CCOB), call your CCO. If you are not in a CCOA or CCOB, call providers in your area and ask if they accept OHP (“open card”); or contact a local safety net clinic:

How do I get dental care?

If you are in an OHP dental care organization (DCO) or coordinated care organization (CCO - CCOA or CCOG), call your DCO/CCO. If you are not in a DCO/CCO, try these resources:

How do I get mental health care?
What plans work with OHP?

To find out about the plans in your area, go to the OHP Health and Dental Plans by County page.

How can OHP members find a health care provider?

Members in an OHP plan can call the plan to get a list of providers currently accepting new patients. Some plans have online provider directories.

Members not in a plan must call health care providers directly to find out if they accept OHP (Medicaid) patients.

 

Can members in an OHP plan seek services from a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?

Yes, but only when the FQHC or RHC is part of their plan’s provider panel.

For members, what are the advantages of managed or coordinated care?
  • Access to a network of health care providers. If you’re not in a plan, you must call health care providers yourself to find a provider taking new Medicaid patients. 
  • Access to preventive services. Plans offer prevention programs (e.g., tobacco cessation), which may be easier to access than if you are not in a plan.
  • Increased Quality of Care. Plans have systems for improving the quality of care for all of its members.
Is there other help?
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 a coordinated care organization for medical care (CCOA or CCOB), 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 (CAWEM - Citizen-Alien Emergency Waived Emergency 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.​

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.​

How do I send in a complaint about OHP or my plan?

Use the OHP Complaint Form (English) (Spanish) (Russian) (Vietnamese) to submit complaints to OHP Client Services or your plan.

If OHP or the plan denies coverage of a service that has already been delivered, can an OHP member appeal the denial?

All OHP members can file a request for hearing if they disagree with a payment decision. Members of OHP health or dental plans who disagree with the plan’s denial of payment can also appeal the decision with their plan.

The OHP member is only responsible for payment if he or she signed a waiver agreeing to be responsible for payment of the non-covered service.
How can OHP members request a hearing?

The OHP member must complete the Request for Administrative Hearing (MSC 443) or Appeal and Hearing Request for Medical Service Denials (OHP 3302) within 45 calendar days of date on the Notice of Action.​

Can a provider represent an OHP member in an appeal regarding the denial of payment for services?

The OHP member can designate anyone as his or her representative in an appeal or hearing. The member must provide written consent.​

Do OHP members have appeal rights when they are disenrolled from an OHP health or dental plan?

Yes. Our rules list the conditions for disenrollment. The plan must meet those conditions before we will approve the request for disenrollment. (See OAR 410-141-0080 and 410-141-3080).​

Who has to pay copayments?

Copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits who are not exempt from copayments. ​

Who does not have to pay copayments?
  • Children under age 19
  • Youths in foster care through age 20 
  • Young adults in the Former Foster Care Youth Medical program
  • Adults who receive OHP Plus (BMH, BMM or BMD) benefits who:
    • Are pregnant;
    • Receive services under a home- and community-based waiver: These services include most in-home services or services in an adult foster home or other home or facility paid by Aging and People with Disabilities;
    • Are inpatients in a hospital, nursing facility, or Intermediate Care Facility for the Mentally Retarded (ICF/MR); 
    • Are American Indian/Alaska Native members of a federally recognized Indian tribe or receive services through a tribal clinic;
    • Are receiving hospice care; or
    • Are eligible for the Breast and Cervical Cancer Program.
Do OHP members with other health care coverage have copayments?

Members with both Medicare and Medicaid coverage have copayments for the applicable Medicaid services. Providers cannot charge the member for their TPL copayments, coinsurance or deductibles if they are billing OHP for what TPL did not pay.

Providers should only collect the OHP copayment when the amount TPL paid for the service, plus the OHP copayment amount, is less than the amount OHP would normally pay for the service. This means the amount collected may be less than OHP's normal copayment, depending on how much TPL paid. ​

How much are copayments?

OHP charges a $3 copayment for certain types of outpatient services, and a $1 or $3 copayment for certain prescription drugs. The copayment amount depends on the type of prescription filled:

  • $1 for non-preferred Preferred Drug List (PDL) drugs and non-PDL generics costing more than $10; no copayment for preferred PDL generics, non-PDL generics costing less than $10, and preferred PDL brands; 
  • $3 for all other non-PDL brand-name drugs. ​
Which services have copayments?

Table 120-1230-1 in the General Rules administrative rulebook lists the provider types and services subject to OHP Plus copayments. These include: 

  • Some prescription drugs
  • Office visits 
  • Home visits 
  • Hospital emergency room services when there is not an emergency 
  • Outpatient hospital services 
  • Outpatient surgery 
  • Outpatient treatment for chemical dependency 
  • Outpatient treatment for mental health 
  • Occupational therapy 
  • Physical therapy 
  • Speech therapy 
  • Restorative dental work
  • Vision exams​
Which services do NOT have copayments?

Copayments are not charged for: 

  • Emergency services 
  • X-ray and lab services 
  • Durable medical equipment and supplies 
  • Routine immunizations 
  • Drugs ordered through our home-delivery pharmacy program  
  • Family planning services and supplies 
  • Diagnostic and preventive dental services – These include oral examinations to identify changes in your health or dental status. They also include routine cleanings, x-rays, lab work and tests needed to make a diagnosis or treatment decision. 
  • For members enrolled in an OHP health or dental plan, the services and drugs covered by that plan (copayments can apply to managed care plan services, but most plans have chosen not to charge copayments).
  • For members with Medicare and other health coverage resources (third-party liability, or TPL), any services and drugs paid by the TPL where the TPL's payment is as much or more than what OHA would normally pay for the service/drug.
  • Services to treat "health-care acquired conditions" (HCAC) and "other provider preventable conditions" (OPPC) services as defined in OAR 410-125-0450.
How do I know if someone should pay a copayment?

Look at the "Copays?" field on page 2 of your coverage letter. This field will contain a "Yes" for each member of your household who is responsible for copayment, and a “No” for members who are not responsible for copayments. ​

How do I know if a service requires a copayment?

Refer to the OHP Handbook for general descriptions of services requiring copayment. If you believe your health care provider is charging you a copayment in error, contact your OHP health plan or OHP Client Services.​

Are copayments charged per procedure, per visit, per day, etc.?

Providers may charge the applicable copayment per visit per day. Pharmacies may charge for each fill.​

Who collects the copayment, and when will it be collected?

The health care provider or pharmacy collects the copayment. They may collect it at the time of service or during the regular billing cycle.​

What happens if a member does not pay the copayment?

The member will still be able to receive the health care service or drug; however, the provider can choose whether to collect it at a later time.

OHP members who do not pay the copayment should see the provider's billing clerk to discuss the situation and options. Only the provider can waive the copayment. However, the provider may also turn the debt over to a collection agency.​

Can providers refuse to serve OHP members who do not pay a copayment?

No. This does not relieve the member of the responsibility to pay and it does not stop the provider from attempting to collect the copayments. The copayment is a legal debt, and is due and payable to the provider.​

Who can OHP members call with questions about their copayment requirements?

They can call the Client Services Unit, 1-800-273-0557. They can also call their caseworker.​

What can OHP members do if they feel they should not have to pay a copayment?

They may ask for a hearing if they think a provider made a mistake in the amount charged. They may also ask for a hearing if they think DHS made a mistake in their eligibility that has caused them to be subject to copayment requirements when they should not be subject.​

What can Client Services help me with?
  • Describe the types of medical and dental care OHP covers. 
  • Coach members on what to do when they have problems getting medical, dental or mental health care. 
  • Follow up on member complaints about services OHP has determined are not covered. 
  • Refer callers to the Governor's Advocacy Office for investigation when appropriate. 
  • Refer OHP health plan members to their plan's customer service when appropriate. 
  • Advise OHP members on the process for the review and resolution of health care bills. 
  • Answer basic questions about dates of OHP eligibility and other related issues. 
  • Issue Certificates of Creditable Coverage requested by members leaving OHP and moving to commercial health insurance. Requests are mailed directly to commercial health insurance providers OR the adult representative on the OHP record. 
  • Process requests from OHP members in the Pharmacy Management Program who want to change their assigned pharmacy. ​
What can Client Services NOT help me with?
  • Refer clients to specific doctors, dentists, clinics or other available providers. View our Access to Care questions to learn how to find an OHP health care provider. 
  • Determine what specific health care services are covered or not covered for any specific client. OHP coverage depends on the client's benefit package and the health care condition(s) the service is supposed to treat. Contact your health care provider. 
  • Answer questions about services provided by OHP medical and dental plans. Contact your plan
  • Send out OHP applications or help people complete the application. Contact an Application Assister in your county
  • Determine eligibility for any state programs. Contact your local DHS/AAA Office
  • Send out OHP client handbooks. Contact the OHP Customer Service or read the handbook online
  • Change a client's record (for example, add family members to cases, change address). Contact your caseworker.​
Where can I find the drugs covered by OHP health plans?

You will need to contact the plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card"). ​

Where can I find information about Medicare Part D coverage?

Visit the DHS Medicare Modernization Act website. This site provides a quick reference for clients, the general public, department staff, policymakers, stakeholders and providers looking for information on the Medicare prescription drug program.

What happens when a change occurs in an OHP member’s household (e.g., pregnancy, household members moving in or out, change in income)?

All OHP members must report household changes to their worker. 

  • The changes may make the member ineligible for medical assistance, or make the member eligible under a different benefit package.
  • If the reported changes affect medical eligibility, the member will receive a letter telling how eligibility has changed.
  • ​​
How do I get forms in alternate formats, such as Braille?

If you need a form or publication in a different format, such as (but not limited to) Braille, large print, audio tape, computer disk (in ASCII format) or oral presentation, contact your worker.​

I can’t find the form I need. What do I do?

If you cannot find the form you need on our Forms page, go to the DHS/OHA Forms Search Page for other DHS/OHA forms, and to find versions of DHS/OHA forms in Spanish and other languages.

How do I report fraud?

Use the DHS online reporting database or call 1-888-FRAUD01. Go to the DHS Fraud Reporting website to learn more.

What if I get a bill from my provider?

Do not pay it! If you get a bill that says you owe money, you should: 

  • Call your provider's office. Make sure they have billed OHP or your health plan using your Oregon Health (Medical Care) ID number. 
  • If you still get a bill, call your health plan or OHP Client Services.

If you don't take care of it right away, it may be sent to a collection agency.​

Why would I get a bill?

Health care providers generally cannot bill medical assistance clients for services that OHP covers. Your provider may not know you are on OHP.

  • Remember to take your Oregon Health ID (formerly Medical Care ID) with you to all health care appointments and show it to the office staff.
  • If you are in a health or dental plan, make sure your health care providers know what plan you are in. The provider should bill the plan in most circumstances.

Note: Copayments are not bills for health care services.​

Where do I send my bills?

If you still need help after contacting your plan and the provider who is billing you, send a copy of the bill to:

OHP Client Services
500 Summer St. NE, E44
Salem, OR 97301​

What is the Preferred Drug List (PDL)?
During the 2001 Oregon Legislative session, Senate Bill 819 created the Practitioner-Managed Prescription Drug Plan (PMPDP). The PMPDP requires the Oregon Health Plan (OHP) to maintain a list of the most cost-effective drugs to prescribe for fee-for-service members. This list is called the Preferred Drug List (PDL).
  • New prescriptions for non-preferred physical health drugs (not listed on the physical health PDL) require prior authorization (PA) Non-preferred mental health drugs do not require PA.
  • All non-preferred prescriptions are subject to OHP Plus (BMM, BMH, BMD) copayments when applicable.
Who created the PDL?

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL. ​

Why do we have a PDL?

The PDL identifies the most effective and safe drugs for the majority of patients, based on the information available. Oregon researchers and experts have carefully considered the comparative safety and effectiveness of the drugs recommended for inclusion on this list. Of the drugs recommended, only those representing the best value to the OHP are included. ​

How do I use the PDL?

The PDL is a tool to identify the most cost-effective drugs for open-card OHP patients. OHA asks that when practitioners start a new drug, to consider the drugs on the PDL first. ​

Where can I find the Preferred Drug List (PDL)?

You can view the current PDL or download Epocrates Rx to view the PDL on your smartphone or tablet.​

How does the Prioritized List work?
The Oregon Health Evidence Review Commission (HERC) ranks health care condition and treatment pairs in order of clinical effectiveness and cost-effectiveness.
 
The Prioritized List emphasizes prevention and patient education. In general:
  • Treatments that help prevent illness are ranked higher than services that treat illness after it occurs.
  • OHP covers treatments that are ranked on a covered Prioritized List line for the client's reported medical condition.
What lines are currently covered on the Prioritized List of Health Services?

Effective Jan. 1, 2016, OHP covers Prioritized List lines 1 through 475.

How do you notify the public of upcoming changes to OHP?
Services covered by OHP benefit plans, prior authorization criteria, and billing requirements are outlined in the division's Oregon Administrative Rules.
Any time we want to change what OHP covers or whom OHP serves, OHA must ask the federal Centers for Medicare and Medicaid Services (CMS) to approve the change. Sign up for OHP Public Notices and Meetings to find out when we have sent such a request to CMS.
 
We send OHP provider announcements to inform affected providers about changes to our fee-for-service payment rates. Sign up for OHP Provider Announcements to get these notifications.
What are public meetings?
According to Oregon law, any meeting related to medical assistance is a public meeting. The division holds the following meetings and posts them on the OHP Public Meetings Calendar:
  • Rule Advisory Committees for Oregon Administrative Rules
  • OHP Contractor Workgroups
  • Pharmacy and Therapeutics Committee
  • Other policy or stakeholder workgroups, listed on the Public Meetings page
What is a transportation brokerage?
A transportation brokerage is a local government entity that contracts with the Oregon Health Authority to provide non-emergent transportation services to Oregon Health Plan (OHP) clients who receive OHP Plus (BMM, BMH, BMD, CWX) benefits.
Can you arrange transportation outside the brokerage (i.e., directly with a preferred transportation provider)?

No. All medical ride requests must go through the brokerage.

  • The rides must be authorized and assigned to a brokerage sub-contracted provider that meet the client’s needs most appropriately and are the lowest cost. 
  • If a facility or branch arranges transportation without the broker's authorization, the transportation provider will not be paid through Medicaid. 
  • When the brokerage is closed, clients should call the brokerage’s after-hours number if a ride is needed for an urgent medical issue.
Does the brokerage call center offer any choices when it sets up rides?
The brokerage or call center staff must meet two main criteria:
  1. Find the most appropriate ride for the client based on actual need, not want.
  2. Find the ride that is the lowest cost. 

Oregon's federal waiver and current federal law allow the state to limit a client's freedom of choice with NEMT. Freedom of choice, in this context, refers to the general right a Medicaid participant has to choose service providers.

What questions do brokerages ask when an OHP member calls for a ride?
The brokerage will check the eligibility of the person, verify if the ride is to a Medicaid-covered service, and assess the client’s ability and needs. These questions are requirements brokerages ask to meet Medicaid standards: 
  • Where do you want to go? 
  • Are you going to an OHP-covered health care service? (If a client is unsure whether the service is covered, and it is unclear whether the service is a covered service, the brokerage will follow up with the provider.)
  • Do you have any other means of transportation? 
  • Do you have any special needs?​
OHP members at residential facilities expect to be helped (from their room, into the van, into the doctor’s office, etc.). Who provides this level of service?

The drivers are there to drive. If a client needs a care attendant, it is the facility's or the client's responsibility to provide one. 

The brokerage contract does not allow drivers to enter clients' rooms or escort clients to their appointments. Clients will need to be ready at the front door of the pick-up address. ​

Some OHP clients have limited mobility; will the driver assist them with getting onto the van?

Yes, ride requests should identify their special needs, so the drivers will know to provide assistance boarding and de-boarding the vehicle.

Will the brokerages transport children less than 12 years old unescorted?

No, the brokerage will not transport children less than 12 years old unescorted. 

The exception is when a Department of Human Services (DHS) volunteer is available to drive the child, primarily because of  protocols established by the DHS Child Welfare program and because of liability issues.

What would happen if the hospital needs to discharge a patient at 9:30 p.m.?

Brokerages have their own processes and protocols for after-hours transportation that allow for the transport to take place with authorization to follow. 

Hospitals should follow the after hours procedure for the brokerage and contact the appropriate after hours providers. Ambulance providers should not be used unless an ambulance is the appropriate mode for the client.

Can anyone ride with the client to their appointment?

If the client has a medical need to have an attendant travel with them, or the client is less than 12 years old, one attendant is allowed to accompany the client on the transport.  

Otherwise, whether or not an extra person can ride along on the transport depends on whether the transportation provider agrees to allow the extra person at no additional cost. 

In addition, this must be negotiated with the brokerage call center, and is subject to available space.

What would happen if all of the transportation providers refused to give an OHP member a ride due to scheduling conflicts?
The brokerage would ask the provider whether the appointment could be re-scheduled or delayed without doing harm to the client. If not, the brokerage would secure a provider from a different service level or from outside of the region. The client would be given options.

If a provider gets a call after hours directly from a client asking for a ride, how does the provider know they'll get paid if they provide the ride?

Providers take a risk when they accept this type of ride. They can ask to see the client’s medical card or call the toll-free number for the Automated Voice Response​ (AVR) to see if the person is eligible for services. 

What is a client "no-show"?

If a client has a scheduled ride and is not at the pick-up location as arranged, the driver will report a "no-show" to the brokerage.

Clients cannot be billed, and the brokerage cannot pay providers for these trips.

If a client needs to cancel a ride, the client should call the brokerage.

Repeated “no-shows” may result in requiring the client to phone in to confirm rides before pick up, schedule no more than one ride at a time, travel with a specific provider, or travel with an escort.

The “no-show” policy holds clients accountable for using their ride benefits appropriately.

Do the brokerages fulfill same-day ride requests?

The broker will try to arrange for same-day rides; however, it will depend on whether there is a provider available and whether prior authorization can be completed.

Transportation providers may already be booked with other clients’ appointments. Brokerages make urgent-care needs their highest priority. Clients should, whenever possible, schedule rides in advance.

What if clients have complaints about a certain driver or transportation service?

The most direct way to process concerns and complaints is to share them with the brokerage. 

After the complaint is researched, the brokerage may sanction or terminate a provider which is unable to provide on-time, safe services.​

What is home-delivery pharmacy?

Home-delivery pharmacy allows you to order a three-month supply of covered drugs or diabetic supplies and have it mailed to you each month, either to a residential address, PO Box or clinic.

If you have OHP benefits, you pay nothing for your home-delivered prescriptions. There are no copayments and no shipping fees.​

Who can use home-delivery pharmacy?
Clients with ongoing prescriptions for drugs that OHP covers on a fee-for-service basis. These include:
  • Clients not enrolled in an OHP medical plan;
  • OHP medical plan members (CCOA and CCOB) with ongoing prescriptions for drugs not covered by the plan, such as most mental health drugs;
  • Clients with OHP with Limited Drug benefits with ongoing prescriptions for drugs covered by OHP, but not Medicare, such as certain decongestants.
Home delivery isn't for everyone. You may prefer to talk to a pharmacist in person about new medications.
How long does home-delivery pharmacy take to fill prescriptions?

If you need the medicine right away, you should visit a local pharmacy.

It takes up to 10 days for your prescriptions to be delivered by mail. If you and your doctor are trying out different drugs, you should wait until you find the ones you will take long-term before you use home-delivery. ​

What prescriptions can the home-delivery pharmacy fill?
This service is for ongoing monthly prescriptions for drugs and diabetic supplies covered by OHP on a fee-for-service (“open card”) basis. Such prescriptions include:
  • Prescriptions for clients not enrolled in an OHP medical plan
  • Prescriptions for mental health drugs (which are generally paid by OHA, not the OHP medical plan)
  • Prescriptions for certain drugs covered by OHP, but not covered by Medicare (such as certain decongestants). 
How do I get started using home-delivery pharmacy?
You or your prescribing provider can start the process. Be sure to have the prescription number and your Oregon Health ID number handy.
  • Allow 8-10 days between ordering and delivery of your medications.
  • When it's time for a refill, you will get a reminder in the mail. Make sure to place refill orders about 14 days before your current supply runs out. 
Call 1-877-935-5797 (Monday through Friday, from 8 a.m. to 5 p.m.)
 
You can also call to transfer existing prescriptions from a local pharmacy or another home-delivery pharmacy.​
How do I mail or fax a home-delivery prescription order?
Fill out the order form (English or Spanish) and send with the prescription to:
 
Wellpartner Inc.
PO Box 5909
Portland, OR 97228-5909 
Fax 1-866-624-5797

Missing or incomplete information on your order will delay processing.
Where can I learn more about home-delivery pharmacy?
If you are not in an OHP coordinated care organziation (CCOA or CCOB), see the Wellpartner website.
 
If you are in a CCOA or CCOB, ask your CCO if they provide home-delivery pharmacy service.
What does the brokerage do?
Each brokerage has a call center that arranges rides for clients going to Medicaid-covered health care services. Call center duties include:
  • Verifying that the client is eligible to receive a ride,
  • Verifying that the appointment is for a Medicaid-covered service,
  • Verifying that the client does not have other means to get to the appointment, and
  • Authorizing the most appropriate type of transportation service based on the client’s needs.
Who provides the actual rides for the clients?

The brokerage sub-contracts with drivers and transportation providers to provide rides they have arranged.​

What type of authorization is necessary for NEMT?

Requests for NEMT must be prior authorized.  This includes requests for rides or reimbursement of transportation expenses such as mileage, meals and lodging.  ​

When lodging and meal expenses arise from an emergency situation, are lodging and meals considered NEMT expenses or something else? Who is responsible for authorizing and reimbursing them?

In this kind of situation (for example, when an emergency ambulance takes a child and parent to Doernbecher Children’s Hospital, and the parent qualifies as a medically necessary attendant whose expenses are allowable under the NEMT program), only the ride is considered an emergency expense.

Any other allowable travel expenses would be considered NEMT expenses, and the client or their representative must contact the brokerage as soon as possible within 30 days of the transport for authorizing and reimbursement of these expenses.​

Can a transportation brokerage reimburse overnight lodging and meals for an attendant who stays with the client when the client is admitted as in inpatient to a hospital?

No. Once a client is admitted as an inpatient, NEMT benefits can no longer pay for an attendant because the medical facility provides all of the client’s care. There are some exceptions:

  • If the doctor says in writing that the attendant is medically necessary, or
  • If it is less expensive to pay for the attendant’s meals and lodging than to return the attendant home and bring the attendant back again when the client is released.​
Who authorizes reimbursement for medical-related lodging and meals?

Brokerages now authorize and reimburse clients for medical-related lodging and meals in all counties.

Rules allow reimbursements to clients for expenses less than $10 to be held until they reach the $10 amount, but may reimbursements be processed for less than$10?

Yes. The $10 threshold exists to avoid writing checks for very small amounts, but reimbursements can be processed for less than $10 if the brokerage allows. 

Can clients get rides to any provider they want to go to for Medicaid-covered services?

​No, rides are only covered to the providers in the client’s local area, unless there is no provider available in the local area. 

Brokerages will seek guidance from the client’s primary care or referring provider. 

Although clients may choose to go out of their local area to any provider that will accept Medicaid, the transportation may not be covered if there is an appropriate local area provider available.​

Is there a time limit on how long a client must wait if they are in a grouped ride?

​Wait times on shared rides are reviewed individually and factor in client needs​.

Can NEMT be used to shop for a new care facility, or relocate to another care facility or out of state?

​NEMT can only cover moves to a new care facility for clients who have had a change in condition, noted in their DHS care plan, resulting in a need for a new service setting with a higher or lower level of care.  

NEMT cannot cover shopping for another facility, moving to another facility of the same level of care or moving out of state. 

DHS has some non-medical funds that may be available for some of these moves. Clients should talk with their local case workers to find out what may be available to them.

How should an ambulance company bill ambulance services when medical personnel determine it was not an emergency?

​It should be billed as a non-emergent ambulance service if the ride was provided or as an aid call if the ambulance personnel do not transport the client. This is an exception to the guidance that brokerages authorize non-emergent ambulance trips.​

What is the brokerage’s responsibility regarding non-emergent ambulance trips?

​Brokerages authorize non-emergent ambulance trips. The ambulance companies will bill OHA directly for reimbursement.​

How long will OHP coverage last before clients need to reapply? 

Clients must reapply after 12 months. An OHP application will be mailed at the end of the tenth month of coverage. ​


Questions about copayments

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Answer
Who has to pay copayments?

Copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits who are not exempt from copayments. ​

Who does not have to pay copayments?
  • Children under age 19
  • Youths in foster care through age 20 
  • Young adults in the Former Foster Care Youth Medical program
  • Adults who receive OHP Plus (BMH, BMM or BMD) benefits who:
    • Are pregnant;
    • Receive services under a home- and community-based waiver: These services include most in-home services or services in an adult foster home or other home or facility paid by Aging and People with Disabilities;
    • Are inpatients in a hospital, nursing facility, or Intermediate Care Facility for the Mentally Retarded (ICF/MR); 
    • Are American Indian/Alaska Native members of a federally recognized Indian tribe or receive services through a tribal clinic;
    • Are receiving hospice care; or
    • Are eligible for the Breast and Cervical Cancer Program.
Do OHP members with other health care coverage have copayments?

Members with both Medicare and Medicaid coverage have copayments for the applicable Medicaid services. Providers cannot charge the member for their TPL copayments, coinsurance or deductibles if they are billing OHP for what TPL did not pay.

Providers should only collect the OHP copayment when the amount TPL paid for the service, plus the OHP copayment amount, is less than the amount OHP would normally pay for the service. This means the amount collected may be less than OHP's normal copayment, depending on how much TPL paid. ​

How much are copayments?

OHP charges a $3 copayment for certain types of outpatient services, and a $1 or $3 copayment for certain prescription drugs. The copayment amount depends on the type of prescription filled:

  • $1 for non-preferred Preferred Drug List (PDL) drugs and non-PDL generics costing more than $10; no copayment for preferred PDL generics, non-PDL generics costing less than $10, and preferred PDL brands; 
  • $3 for all other non-PDL brand-name drugs. ​
Which services have copayments?

Table 120-1230-1 in the General Rules administrative rulebook lists the provider types and services subject to OHP Plus copayments. These include: 

  • Some prescription drugs
  • Office visits 
  • Home visits 
  • Hospital emergency room services when there is not an emergency 
  • Outpatient hospital services 
  • Outpatient surgery 
  • Outpatient treatment for chemical dependency 
  • Outpatient treatment for mental health 
  • Occupational therapy 
  • Physical therapy 
  • Speech therapy 
  • Restorative dental work
  • Vision exams​
Which services do NOT have copayments?

Copayments are not charged for: 

  • Emergency services 
  • X-ray and lab services 
  • Durable medical equipment and supplies 
  • Routine immunizations 
  • Drugs ordered through our home-delivery pharmacy program  
  • Family planning services and supplies 
  • Diagnostic and preventive dental services – These include oral examinations to identify changes in your health or dental status. They also include routine cleanings, x-rays, lab work and tests needed to make a diagnosis or treatment decision. 
  • For members enrolled in an OHP health or dental plan, the services and drugs covered by that plan (copayments can apply to managed care plan services, but most plans have chosen not to charge copayments).
  • For members with Medicare and other health coverage resources (third-party liability, or TPL), any services and drugs paid by the TPL where the TPL's payment is as much or more than what OHA would normally pay for the service/drug.
  • Services to treat "health-care acquired conditions" (HCAC) and "other provider preventable conditions" (OPPC) services as defined in OAR 410-125-0450.
How do I know if someone should pay a copayment?

The Provider Web Portal eligibility verification request and Automated Voice Response (AVR) Recipient Eligibility response provide copayment amounts for OHP Plus (BMM, BMD, BMH, BMP) services.

Copayment amounts ($1 or $3) will only display for members responsible for copayment. If an OHP member is exempt from copayment, the copayment will read $0.00 for all services.  ​

How do I know if someone should pay a copayment?

Look at the "Copays?" field on page 2 of your coverage letter. This field will contain a "Yes" for each member of your household who is responsible for copayment, and a “No” for members who are not responsible for copayments. ​

How do I know if a service requires a copayment?

The Provider Web Portal eligibility verification request and Automated Voice Response (AVR) Recipient Eligibility inquiry provide copayment amounts for OHP Plus (BMM, BMD, BMH, BMP) services.

If a service requires copayment, the service will list the amount to pay ($1, or $3). Services that do not require copayment will list $0. Table 120-1230-1 in the General Rules also lists the services that require copayment and the amounts that apply.  ​

How do I know if a service requires a copayment?

Refer to the OHP Handbook for general descriptions of services requiring copayment. If you believe your health care provider is charging you a copayment in error, contact your OHP health plan or OHP Client Services.​

Are copayments charged per procedure, per visit, per day, etc.?

Providers may charge the applicable copayment per visit per day. Pharmacies may charge for each fill.​

Who collects the copayment, and when will it be collected?

The health care provider or pharmacy collects the copayment. They may collect it at the time of service or during the regular billing cycle.​

What happens if a member does not pay the copayment?

The member will still be able to receive the health care service or drug; however, the provider can choose whether to collect it at a later time.

OHP members who do not pay the copayment should see the provider's billing clerk to discuss the situation and options. Only the provider can waive the copayment. However, the provider may also turn the debt over to a collection agency.​

Can providers refuse to serve OHP members who do not pay a copayment?

No. This does not relieve the member of the responsibility to pay and it does not stop the provider from attempting to collect the copayments. The copayment is a legal debt, and is due and payable to the provider.​

Who can OHP members call with questions about their copayment requirements?

They can call the Client Services Unit, 1-800-273-0557. They can also call their caseworker.​

How does OHA account for OHP copayments?

We compute the total OHP copayment due for services billed. We pay the total allowable amount, minus the correct copayments and any third-party payments. Our explanation of benefits (EOB) identifies copayment deductions. ​

What can OHP members do if they feel they should not have to pay a copayment?

They may ask for a hearing if they think a provider made a mistake in the amount charged. They may also ask for a hearing if they think DHS made a mistake in their eligibility that has caused them to be subject to copayment requirements when they should not be subject.​

Are FQHCs and RHCs required to charge copayments to OHP health plan members?

Yes. See OAR 410 Division 147 for useful information on this topic.

What do CCOs/plans need to know about copayments?

The questions and answers about client co-payments provide information specific to CCOs and plans.​


Questions about prescription drug coverage

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Answer
Which rules tell me about the drugs that OHP covers?
If a drug is administered by a physician, identified by HCPCS code, coverage is dictated by the Medical Surgical Rules.
 
If a drug in dispensed by pharmacies using an NDC, it is covered by Pharmaceutical Rules. ​
How does OHA reimburse for compound drugs?

Each component of a compound prescription, as defined in OAR 410-121-0146 (7) and 410-121-0160 (3) must be billed separately and is paid as above, but with a single dispensing fee.

Any reimbursement received from a third party for compounded prescriptions must be split and applied equally to each component.​

How does OHA reimburse for drugs dispensed to patients in a long-term care facility or community-based waiver facility?

Certain drugs are part of the facility capitation payments and not reimbursed via drug claim. See DHS/OHA's list of Drugs included in the bundled rate for long-term care nursing facilities.​

How does OHA reimburse for mental health drugs?
For all OHP members, OHA pays for covered mental health drugs on a fee-for-service basis.
  • For the purposes of the above payment policy, "mental health drugs" are defined as those drugs classified by First DataBank in the Standard Therapeutic Class equal to Class 07 (Ataractics, Tranquilizers), Class 11 (Psychostimulants, Antidepressants).
  • In addition, lamotrigine and divalproate are also considered mental health drugs.
  • These drugs are listed in the 7-11 Drug Carveout lists.
Who can OHA reimburse for drugs?
OHA only reimburses enrolled pharmacy providers (type 48) for drugs billed by NDC.
 
Other provider types are reimbursed for physician-administered drugs and home enteral nutrition using the professional claim format (CMS-1500 or 837P). ​
How does OHA reimburse pharmacies for EPIV services?

Pharmacies can bill OHA for oral nutritional supplements using the pharmacy claim format (Point of Sale or UCF 5.1) only when the supplement has a valid NDC.

How does OHP determine drug coverage?
To be considered for OHP coverage, drugs must:

What drugs does OHP never cover?

OHP does not cover drugs on the DESI List, and does not cover drugs that are used exclusively for not covered diagnoses (e.g., acne drugs).​

How do pharmacies request prior authorization for drugs or oral nutritional supplements?
To request PA, complete the Pharmacy and Oral Nutritional Supplements Prior Authorization form and fax to the Oregon Pharmacy Call Center at 888-346-0178. 
 
Or call the Oregon Pharmacy Call Center at 888-202-2126 with the diagnosis code and your NPI.

Where can I find the drugs covered by OHP health plans?

You will need to contact the plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card"). ​

Where can I find information about Medicare Part D coverage?

Visit the DHS Medicare Modernization Act website. This site provides a quick reference for clients, the general public, department staff, policymakers, stakeholders and providers looking for information on the Medicare prescription drug program.

What is the Preferred Drug List (PDL)?
During the 2001 Oregon Legislative session, Senate Bill 819 created the Practitioner-Managed Prescription Drug Plan (PMPDP). The PMPDP requires the Oregon Health Plan (OHP) to maintain a list of the most cost-effective drugs to prescribe for fee-for-service members. This list is called the Preferred Drug List (PDL).
  • New prescriptions for non-preferred physical health drugs (not listed on the physical health PDL) require prior authorization (PA) Non-preferred mental health drugs do not require PA.
  • All non-preferred prescriptions are subject to OHP Plus (BMM, BMH, BMD) copayments when applicable.
Who created the PDL?

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL. ​

Why do we have a PDL?

The PDL identifies the most effective and safe drugs for the majority of patients, based on the information available. Oregon researchers and experts have carefully considered the comparative safety and effectiveness of the drugs recommended for inclusion on this list. Of the drugs recommended, only those representing the best value to the OHP are included. ​

How do I use the PDL?

The PDL is a tool to identify the most cost-effective drugs for open-card OHP patients. OHA asks that when practitioners start a new drug, to consider the drugs on the PDL first. ​

Where can I find the Preferred Drug List (PDL)?

You can view the current PDL or download Epocrates Rx to view the PDL on your smartphone or tablet.​

How do drugs get added to the PDL?

The list is updated periodically. Drug manufacturers who want to propose drugs for PDL consideration can register on the Sovereign States Drug Consortium (SSDC) website to submit offers (see OAR 410-121-0030).​

When is the next Pharmacy & Therapeutics Committee meeting? How can I get notified of future meetings?
What is home-delivery pharmacy?

Home-delivery pharmacy allows you to order a three-month supply of covered drugs or diabetic supplies and have it mailed to you each month, either to a residential address, PO Box or clinic.

If you have OHP benefits, you pay nothing for your home-delivered prescriptions. There are no copayments and no shipping fees.​

Who can use home-delivery pharmacy?
Clients with ongoing prescriptions for drugs that OHP covers on a fee-for-service basis. These include:
  • Clients not enrolled in an OHP medical plan;
  • OHP medical plan members (CCOA and CCOB) with ongoing prescriptions for drugs not covered by the plan, such as most mental health drugs;
  • Clients with OHP with Limited Drug benefits with ongoing prescriptions for drugs covered by OHP, but not Medicare, such as certain decongestants.
Home delivery isn't for everyone. You may prefer to talk to a pharmacist in person about new medications.
How long does home-delivery pharmacy take to fill prescriptions?

If you need the medicine right away, you should visit a local pharmacy.

It takes up to 10 days for your prescriptions to be delivered by mail. If you and your doctor are trying out different drugs, you should wait until you find the ones you will take long-term before you use home-delivery. ​

What prescriptions can the home-delivery pharmacy fill?
This service is for ongoing monthly prescriptions for drugs and diabetic supplies covered by OHP on a fee-for-service (“open card”) basis. Such prescriptions include:
  • Prescriptions for clients not enrolled in an OHP medical plan
  • Prescriptions for mental health drugs (which are generally paid by OHA, not the OHP medical plan)
  • Prescriptions for certain drugs covered by OHP, but not covered by Medicare (such as certain decongestants). 
How do I get started using home-delivery pharmacy?
You or your prescribing provider can start the process. Be sure to have the prescription number and your Oregon Health ID number handy.
  • Allow 8-10 days between ordering and delivery of your medications.
  • When it's time for a refill, you will get a reminder in the mail. Make sure to place refill orders about 14 days before your current supply runs out. 
Call 1-877-935-5797 (Monday through Friday, from 8 a.m. to 5 p.m.)
 
You can also call to transfer existing prescriptions from a local pharmacy or another home-delivery pharmacy.​
How do I mail or fax a home-delivery prescription order?
Fill out the order form (English or Spanish) and send with the prescription to:
 
Wellpartner Inc.
PO Box 5909
Portland, OR 97228-5909 
Fax 1-866-624-5797

Missing or incomplete information on your order will delay processing.
Where can I learn more about home-delivery pharmacy?
If you are not in an OHP coordinated care organziation (CCOA or CCOB), see the Wellpartner website.
 
If you are in a CCOA or CCOB, ask your CCO if they provide home-delivery pharmacy service.

Questions about benefit coverage

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Answer
Is there a nurse advice line?

Oregon Health Plan Care Coordination - If you are not enrolled in a coordinated care organization for medical care (CCOA or CCOB), 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 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:

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 an Agreement to Pay form that contains all the elements of the OHP 3165 form, as required by OAR 410-120-1280. This form shows that the OHP member understands the service is not covered and agrees to pay for the service.

Without this form, 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 OHA's fee-for-service coverage.
Mental health drugs​ are always billed to OHA. All other prescriptions are billed to physical health plans (CCOA, CCOB).
Who created the PDL?

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL. ​

Where can I find the Preferred Drug List (PDL)?

You can view the current PDL or download Epocrates Rx to view the PDL on your smartphone or tablet.​

How do drugs get added to the PDL?

The list is updated periodically. Drug manufacturers who want to propose drugs for PDL consideration can register on the Sovereign States Drug Consortium (SSDC) website to submit offers (see OAR 410-121-0030).​

Where do I find past, current and proposed Prioritized Lists of Health Services?
Use the following links on the HERC website. You can also eSubscribe to receive e-mail updates from HERC whenever Prioritized List information changes or view all recent HERC updates.
What are OHP’s maximum allowable fee-for-service rates?

View the fee-for-service fee schedule for an overview of OHP's maximum allowable rates.

How can I view a copy of the model contracts for OHP health plans?

To view a copy of the model contracts, contact Kellie Skenandore. ​


Questions about coordinated care and health plans

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Answer
What plans work with OHP?

To find out about the plans in your area, go to the OHP Health and Dental Plans by County page.

For members, what are the advantages of managed or coordinated care?
  • Access to a network of health care providers. If you’re not in a plan, you must call health care providers yourself to find a provider taking new Medicaid patients. 
  • Access to preventive services. Plans offer prevention programs (e.g., tobacco cessation), which may be easier to access than if you are not in a plan.
  • Increased Quality of Care. Plans have systems for improving the quality of care for all of its members.

Questions about complaints and appeals

  
Answer
How do I send in a complaint about OHP or my plan?

Use the OHP Complaint Form (English) (Spanish) (Russian) (Vietnamese) to submit complaints to OHP Client Services or your plan.

If OHP or the plan denies coverage of a service that has already been delivered, can an OHP member appeal the denial?

All OHP members can file a request for hearing if they disagree with a payment decision. Members of OHP health or dental plans who disagree with the plan’s denial of payment can also appeal the decision with their plan.

The OHP member is only responsible for payment if he or she signed a waiver agreeing to be responsible for payment of the non-covered service.
How can OHP members request a hearing?

The OHP member must complete the Request for Administrative Hearing (MSC 443) or Appeal and Hearing Request for Medical Service Denials (OHP 3302) within 45 calendar days of date on the Notice of Action.​

Can a provider appeal a decision regarding the denial of payment for services?

Yes. A provider can appeal the decision through the coordinated care organization or managed care plan and then, if not resolved through this process, may ask OHA for a provider appeal in accordance with OAR 410-120-1560 through 410-120-1720. ​

Can a provider represent an OHP member in an appeal regarding the denial of payment for services?

The OHP member can designate anyone as his or her representative in an appeal or hearing. The member must provide written consent.​

Are there federal rules about a Medicaid client's right to a hearing?

Yes. The Code of Federal Regulations (CFR) governs hearing rights. 42 CFR 431.220(b) says we need not grant a hearing when the only issue is a federal or state law that requires an automatic change that adversely affects some or all recipients.​

Do OHP members have appeal rights when they are disenrolled from an OHP health or dental plan?

Yes. Our rules list the conditions for disenrollment. The plan must meet those conditions before we will approve the request for disenrollment. (See OAR 410-141-0080 and 410-141-3080).​

I disagree with a payment decision made by OHA or an OHP health plan. What can I do?

You can request a provider appeal. The General Rules outline your options and how to use them.

  • Claim re-determination – Request to OHA to review your claim due to a technical error.
  • Administrative review – Request to OHA to review policy or legal decisions not related to re-determination, contested case hearing, or client appeals.
Use the OHP 3085 form to submit your request for provider appeal.

Questions about bills

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Answer
What if I get a bill from my provider?

Do not pay it! If you get a bill that says you owe money, you should: 

  • Call your provider's office. Make sure they have billed OHP or your health plan using your Oregon Health (Medical Care) ID number. 
  • If you still get a bill, call your health plan or OHP Client Services.

If you don't take care of it right away, it may be sent to a collection agency.​

Why would I get a bill?

Health care providers generally cannot bill medical assistance clients for services that OHP covers. Your provider may not know you are on OHP.

  • Remember to take your Oregon Health ID (formerly Medical Care ID) with you to all health care appointments and show it to the office staff.
  • If you are in a health or dental plan, make sure your health care providers know what plan you are in. The provider should bill the plan in most circumstances.

Note: Copayments are not bills for health care services.​

Where do I send my bills?

If you still need help after contacting your plan and the provider who is billing you, send a copy of the bill to:

OHP Client Services
500 Summer St. NE, E44
Salem, OR 97301​