Asking for Fee-for-Service Oregon Health Plan (OHP) Coverage

When Can You Ask for Fee-for-Service OHP?

We want your coordinated care organization (CCO) to coordinate your medical, dental and behavioral health care. But you can ask for fee-for-service OHP if you have a serious medical reason to see a provider outside your CCO's network.

Questions to Ask Before You Ask for Fee-for-Service OHP:

If not, please talk to them about your health care needs.

Your CCO is your first contact whenever you need help getting care.
OHP wants your CCO to coordinate your medical, dental and behavioral health care.
Your CCO has care coordinators who can help you get the care you need.
Your CCO must help you find ways to get the care you need within your CCO.

If you don't know, ask.

If they only work with local CCOs, getting fee-for-service OHP will not help you get the care you need.

If you only want fee-for-service OHP so that you can keep seeing a behavioral health provider:

If approved, you will no longer be enrolled in a CCO for any of your care.
This means you can see your fee-for-service behavioral health provider. But you will need to find new medical, dental and pharmacy providers who accept fee-for-service OHP.

Your CCO can cover some or none your care, depending on the type of provider you need for fee-for-service coverage.

If you need a fee-for-service dental provider, your CCO can still cover medical and behavioral health care.
If you need a fee-for-service medical provider, your CCO can still cover behavioral health and dental care.
If you need a fee-for-service behavioral health provider, you will no longer be in your CCO. You will need to get all care (medical, behavioral health and dental) from fee-for-service providers.

If You Have a Serious Medical Reason to Not Be in a CCO:

You will need to get proof from your provider that you are:

Getting care from a provider who is not in your local CCO, and
Changing to a CCO provider would negatively affect your health.

That provider needs to ask OHP for approval. Your provider will need to send OHA forms and proof that you need temporary fee-for-service coverage to stay healthy. This includes:

A completed OHP 416 (Request for Temporary Fee-for-Service Coverage) form. Give the completed form to your provider.
A written request stating the medical reasons you need fee-for-service OHP.
Chart notes that talk about the specific needs your CCO can't meet.

Your provider will talk to OHP about the request.

If you want updates about the request, you will need to ask your provider.
If your provider wants updates, they will need to ask OHP Provider Services (800-336-6016).

You will get a letter.

The letter will say when this coverage starts and ends.

The coverage will last from six to 12 months.

If you still need temporary fee-for-service coverage after your 6 to 12 month approval period ends:

Your provider will need to send a new request to OHA to extend the coverage.
Your provider needs to do this at least 30 days before your approval period ends.
Otherwise, OHP will enroll you in your local CCO the day after your temporary fee-for-service coverage ends.