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Frequently Asked Questions: Benefit Packages
Learn more about the benefits OHP covers.
If you have questions not answered on this page, go to the Contact Us page and send your question to the appropriate DMAP contact.
Q. Do all the OHP benefit packages cover the same services?
A. No. OHP Plus (BMH) is the most comprehensive benefit. OHP with Limited Drug (BMD or BMM) covers the same benefits as OHP Plus, except for drugs that Medicare Part D should cover.
OHP Standard (KIT) only covers:
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A limited hospital benefit
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Physician services
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Emergency transportation by ambulance
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Prescription drugs
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Lab and x-ray services
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Some medical equipment and supplies
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Outpatient chemical dependency services
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Outpatient mental health
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Emergency dental
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Hospice
OHP coverage is based on two things: The client's benefit package and whether the service is covered according to the Prioritized List of Health Services. Our provider rules also give details on services not covered by the OHP benefit packages.
Q. How do I know which benefit package applies?
A. For clients, page 2 of your OHP coverage letter will show this information for each eligible household member.
Providers can use Automated Voice Response or the Provider Web Portal to find out a client's benefit package information (displayed using 3-digit benefit plan codes). The eight codes that indicate medical eligibility are:
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BMD (OHP with Limited Drug)
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BMH (OHP Plus)
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BMM (Qualified Medicare Beneficiary and OHP with Limited Drug)
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BMP (OHP Plus Supplemental Benefit)
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CWM (Citizen - Alien Emergency Waived Medical)
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CWX (CAWEM Plus - OHP Plus benefits for pregnant CAWEM-eligible women)
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KIT (OHP Standard)
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MED (Qualified Medicare Beneficiary)
Q. What benefit packages cover preventive services, including help to stop smoking?
A. The OHP Plus, CAWEM Plus, OHP with Limited Drug and OHP Standard benefit packages cover preventive services, which include immunizations, check-ups, and screening tests (such as mammograms and PAP tests).
Services to help you stop smoking are also available. You can call the Oregon Quit Line at toll-free at 1-877-270-7867 or talk to your health care provider. Our Spanish Quit Line number is 1-877-2NO-FUME (1-877-266-3863, TTY 711).
Q. Who gets which OHP benefit package?
A. This overview explains what each of the eight benefit packages offer. The three main benefit packages are:
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OHP Standard (KIT): For a limited number of uninsured adults (ages 19 to 64) who are not eligible for traditional Medicaid (OHP Plus). Most people with OHP Standard benefits must pay monthly premiums. OHP Standard does not have copayments.
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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. People with OHP Plus benefits do not pay premiums, but some adults with OHP Plus pay small copayments. See the Copayment FAQ to learn more about copayments.
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OHP with Limited Drug (BMD, BMM): For clients who are eligible for both Medicaid and Medicare Part D. It covers the same services as OHP Plus, except for prescription drugs covered by Medicare Part D.
Q. What if someone wants treatments not included their benefit package?
A. If a client wants a health care service that OHP does not cover according to the client's benefit package or the Prioritized List of Health Services, the client must cover the cost of excluded services. Clients may also pay for services that exceed benefit limits (e.g., more frequent dental care).
The General Rules describe the health care provider's roles and responsibilities in this area. If providers do not follow our rules, they may be responsible for costs related to excluded and limited services.
Q. What happens when a change occurs that affect a client's eligibility for benefits? How do unpaid premiums affect eligibility?
A. All clients must report changes to his or her worker that may affect eligibility.
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If a client's situation changes, he or she may become ineligible for medical assistance or become eligible under a different benefit package (e.g., move from Standard to OHP Plus coverage or vice versa).
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When this occurs, the client will receive a letter telling how eligibility has changed.
If DHS is evaluating a client's eligibility for OHP Standard and there are outstanding premiums, the client must pay those premiums to remain eligible for OHP Standard benefits.
Q. What is the BMP (OHP Plus Supplemental Benefit) package?
A. BMP is a supplemental plan to the OHP Plus plans (BMM, BMH and BMD) for pregnant clients age 21 and over. It includes the following services:
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Certain dental services |
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Glasses
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Contact lenses
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Fittings for glasses or contacts
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Eye exams for prescribing glasses or contacts
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Crowns
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Office visits for observation
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Replacement of full dentures
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Root canals on molars and some other tooth root procedures
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Some gum or oral surgery
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Some types of dentures and partials
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Q. Do clients under age 21 with BMM, BMH or BMD have these supplemental benefits?
A. Yes, clients with BMM, BMH or BMD have these benefits as part of their coverage, but you will not see "BMP" displayed for these clients.
Q. If a client with BMM, BMH or BMD who is age 21 and over doesn't have the BMP package, is an eye exam covered if diabetes is affecting a client's vision?
A. Yes. OHP clients age 21 and over with BMM, BMH and BMD can see a provider for a medical eye exam for any eye condition except for "disorders of refraction and accommodation" (e.g., nearsightedness, farsightedness, astigmatism). Diagnostic services are still covered.
Eye exams for the purpose of prescribing glasses or contact lenses are limited to OHP clients age 21 and over with the BMM, BMH or BMD benefit who have one of the following medical diagnoses:
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Pseudoaphakia
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Aphakia
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Congenital aphakia
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Keratoconus
Q. Will OHP pay for treatment when there is an accident or injury to the eye(s)?
A. Yes. Urgent/emergent treatment is a covered service.
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