Text Size:   A+ A- A   •   Text Only
Find     
Site Image

OHP Plus Copayment Questions and Answers
  • For detailed information about copayment requirements, see the General Rules administrative rulebook (410-120-1230, Client Co-payment). 
  • For information about copayment requirements of OHP health plans, contact the plan.

If you have questions not answered in these questions, go to the Contact Us page and send your question to the appropriate DMAP contact.​ 

  
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.

​​

​​​​​