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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
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.​
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)
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.​


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 DMAP for what TPL did not pay.

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

How much are copayments?

DMAP 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 DMAP's 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 DMAP 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 DMAP's 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 Client 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 DMAP 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 covered by DMAP?
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 DMAP 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 DMAP 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 DMAP reimburse for mental health drugs?
For all OHP members, DMAP 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.
Who can DMAP reimburse for drugs?
DMAP 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 DMAP reimburse pharmacies for EPIV services?

Pharmacies can bill DMAP 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 DMAP/OHP determine drug coverage?
To be considered for OHP coverage, drugs must:

What drugs does DMAP/OHP never cover?

DMAP 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 DMAP 3978 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 DMAP for pricing and DMAP 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. DMAP 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 in January and July. Drug manufacturers who want to propose drugs for PDL consideration can register on the Sovereign States Drug Consortium (SSDC) Web site 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 who take the same prescription drugs month after month for ongoing health conditions will benefit the most from this service.
  • Clients not enrolled in an OHP medical plan can sign up to get most prescriptions filled.
  • Clients in OHP medical plans can sign up to get prescriptions covered by DMAP (not the medical plan) filled, such as most mental health drugs.
  • Clients with OHP with Limited Drug benefits can sign up to get prescriptions covered by DMAP (not Medicare) filled, 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 DMAP 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 DMAP, not the OHP medical plan)
  • Prescriptions for certain drugs 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 Medical Care 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 medical plan or coordinated care organziation (CCO), see the Wellpartner website.
 
If you are in an​ OHP medical plan or CCO, ask your plan or 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 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 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 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).
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 DMAP for pricing and DMAP 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 in January and July. Drug manufacturers who want to propose drugs for PDL consideration can register on the Sovereign States Drug Consortium (SSDC) Web site 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 DMAP’s fee-for-service fee schedule for an overview of DMAP rates.

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

To view a copy of the model contracts, contact Katrina Smith​ or Kellie Skenandore of DMAP. ​


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?

OHP Complaint Form - Use this form to submit complaints to OHP Client Services or your plan.

If DMAP 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) 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 managed care plan and then, if not resolved through this process, may ask for an administrative review by DMAP 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 DMAP or an OHP health plan. What can I do?

DMAP’s General Rules outline your options and how to use them.

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

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​