Eastern Oregon Coordinated Care Organization Member Handbook

Transcription

1 Eastern Oregon Coordinated Care Organization Member Handbook January

2 WELCOME Eastern Oregon Coordinated Care Organization (EOCCO) is happy to help with your healthcare. EOCCO and our providers want to give you the best care we can. It is important you know how to use your medical plan. This handbook talks about our program, tells you how to get medical care and gives you tips on getting the most out of your medical plan. You can request a copy of this handbook at any time by calling Moda Health customer service at , TTY 711. You may request the Oregon Health Plan Client Handbook from the State of Oregon by calling , TTY 711. It gives you important information about: Covered and non-covered medical services Mental Health Plan information Your rights and responsibilities And other important information EOCCO is administered by GOBHI and Moda Health (formally ODS). GOBHI administers your mental health benefits. Moda Health administers your medical, pharmacy and chemical dependency and substance use disorder benefits. If you have questions about your mental health benefits, call GOBHI: (toll-free) 711 (TDD/TTY for hearing- and speech-impaired) GOBHI is in The Dalles at 309 E Second St. It is open 8 a.m. to 5 p.m., Monday through Friday. Access is available for those with disabilities. You can also visit If you have questions about your medical benefits, call Moda Health Customer Service:

3 (toll-free) TTY: 711(For hearing- and speech-impaired) If you have questions about your pharmacy benefits, please contact Moda Health Pharmacy Customer Service: (toll-free) TTY: 711(For hearing- and speech- impaired) If you need help getting chemical dependency (drug or alcohol) or substance use disorder treatment, call Moda Health Behavioral Health: (toll-free) TTY: 711(For hearing- and speech-impaired) EOCCO is located in downtown Portland at 601 S.W. Second Ave., Suite 700, and is open from 7:30 a.m. to 5:30 p.m. Pacific Time, Monday through Friday. Physical access is available for members with disabilities. You also can visit our website at or us at Alternative Formats You can receive this Handbook and any information in other formats. You can ask for another language, large print, computer disk, audio tape, spoken presentation or Braille. Please call our Customer Service Department at (TTY 711) and ask for the format you need or visit our website at Otros formatos Que pueden recibir este manual del miembro Oregon salud Plan o imprime material informativo en otras formas, tales como otro idioma, grande, disco, cinta de audio. presentación oral o Braille. Por favor llame a nuestro departamento de servicio al cliente al (TTY 711) para solicitar el formato necesita. 2

4 Table of Contents INTRODUCTION AND FREQUENTLY ASKED QUESTIONS... 5 New members... 7 HOW YOUR PLAN WORKS... 7 Care Teams. 8 Oregon Health ID card... 8 EOCCO medical ID card... 9 Your PCP assignment... 9 Changing your PCP GETTING CARE How to make a doctor s appointment How to make an appointment to see a Mental Health Provider.. 10 If you cannot keep your appointment Interpreter services Seeing a specialist or other provider Services that do not require a referral Services that require prior approval How to get a second opinion. 12 After-hours medical care Emergency care Emergency care when you are away from home.. 13 Mental Health crisis.. 13 Suicide Prevention How to get help for a Mental Health Crisis Urgent medical care Health and Prevention education.. 15 PLAN BENEFITS AND SERVICES Oregon Health Plan coverage Preventive care Specialty care Lab tests, X-rays and other procedures Prescription medications Prescription coverage for members on Medicare Prescription coverage for Mental Health Family planning

5 Hospital care Chemical dependency treatment Smoking and Tobacco cessation services Oregon Tobacco Quit Line Mental health AMHI and ISA Services for Mental Health Treatment...19 Dental services Vision services Hearing services Skilled nursing facility care Transportation Services covered by DMAP NONCOVERED SERVICES Indian Health Services. 21 IF YOU ARE PREGNANT Maternity services outside the service area OTHER IMPORTANT INFORMATION Changes to your address or phone number Information and Privacy Member disenrollment request Plan disenrollment request Advance directives Declaration for Mental Health Treatment Clinical records MEMBER RIGHTS AND RESPONSIBILITIES INFORMATION AVAILABLE UPON REQUEST PROVIDER PAYMENTS PROVIDER APPEAL RIGHTS COMPLAINTS AND APPEALS PROVIDER DIRECTORY

6 INTRODUCTION AND FREQUENTLY ASKED QUESTIONS: What is the Oregon Health Plan (OHP)? The Oregon Health Plan (OHP) is a program that pays for low-income Oregonians health care. The State of Oregon and the US Government s Medicaid program pay for it. OHP does not cover everything. A list of the 498 diseases and conditions that are covered, called the Prioritized List of Health Services, is on the web at The diseases and conditions below line 498 usually are not covered by OHP. Something that is below the line could be covered if the patient has an above-the-line condition that could get better if their below-the-line condition gets treated. What is a Coordinated Care Organization (CCO)? Eastern Oregon Coordinated Care Organization (EOCCO) is a Coordinated Care Organization (CCO). We are a group of all types of health care providers who work together for people on OHP in our community. The providers in our CCO are: Greater Oregon Behavioral Health, Inc.: GOBHI will help provide your mental healthcare and services. Moda Health.: Moda Health will help provide your medical, pharmacy, substance use disorder and chemical addiction treatment, care and services. GOBHI and Moda Health work with clinics, doctors, nurses and hospitals to supply your care. EOCCO offers care in these counties: Baker Malheur Union Sherman Wallowa Gilliam Grant Harney 5

7 Lake Morrow Umatilla Wheeler EOCCO works with providers to arrange your care. We work to give you the best care we can. Our staff may contact you to help set up your care. We may contact you after an appointment to help you understand your care plan. We may call to remind you about appointments. We may ask how we can help you get healthier. When you see more than one provider, we will help set up your care. We will suggest you see your provider for routine care. Intensive Care Coordination Services Intensive Care Coordination Services (ICCS), formerly Exceptional Needs Care Coordination (ENCC), is for people with complex medical or special needs. It helps members who are aged, blind or have disabilities, and children with special needs. Members who need special medical supplies or equipment or who will need support in getting care may ask for help from our ICCS team. Please call our Customer Service Department for help from the EOCCO ICCS team. What is a Patient-centered Primary Care Home (PCPCH)? We want you to get the best care possible. One way we try to do that is ask our providers to be recognized by the Oregon Health Authority as a Patientcentered Primary Care Home (PCPCH). That means they can receive extra funds to follow their patients closely, and make sure all their medical and mental health needs are met. You can ask at your clinic or provider s office if it is a PCPCH. What is the Community Advisory Council (CAC)? EOCCO Community Advisory Councils work to get member ideas about how to improve the service EOCCO and its provider organizations offer members. They identify improvement opportunities and provide suggestions about EOCCO programs. They also organize activities and projects that engage fellow EOCCO members and the community on health issues. To get involved, find out more about the CAC, or share an idea, please call GOBHI at

8 What are managed care and fee-for-service? CCOs are a type of managed care. Another type is Dental Care Organizations (DCOs). The Oregon Health Authority (OHA) wants OHP members to have their care managed by private companies. OHA pays managed care companies a set amount each month to provide this care. In some parts of Oregon, most OHP members must get managed medical and dental care. Health services for OHP members not in managed care are paid by OHA, called fee-for-service (FFS). Native Americans and Alaska natives on OHP can choose to receive managed care or FFS. Any OHP member who has a good reason to receive FFS medical care can ask to leave managed care. Talk to your case worker about the best way to receive your medical care. What if I receive a bill for covered services? If your health care provider sends you a bill, don t pay it. Please call Customer Service at (TTY: 711) right away. Do I have a Co-Pay? No, EOCCO will not collect co-pays. If your health care provider asks you for a co-payment, don t pay it. Please call Customer Service at (TTY: 711) right away. New members If you need medical care before you receive your ID card, your covered services will be paid. These services may include prescriptions, supplies and other items you need. Please call Customer Service at (TTY 711) and we will help you find a provider and get the care you need. HOW YOUR PLAN WORKS EOCCO is a managed care plan. As a member of EOCCO, you choose or are assigned a clinic or doctor s office as your primary care provider (PCP). Your PCP will work with you as a partner to take care of your medical needs. Your PCP will provide access for you to medical care 24 hours a day, seven days a week. Call your PCP before you get medical care. See the Provider Directory for your PCP s telephone number or call our Customer Service Department. 7

9 Your PCP will: Provide all of your routine care and look after all your healthcare needs Arrange for specialty or hospital care when needed Write prescriptions Keep your medical records in one place to give you better service Do not wait until you are sick to call your PCP. Call your PCP s office and let them know you are an EOCCO member and have selected or been assigned to them as your PCP. Ask about office hours and how to get help after hours or when you have an emergency. Care Teams EOCCO also has a team of nurses, behavioral health specialists and health care coordinators that are ready to help you with your specific health care needs. Working with you, your providers, and community resources we make sure you feel comfortable, safe and cared for. Our care program helps you to manage your chronic health condition such as diabetes, heart failure, asthma, depression or substance use. If you have been in the hospital, our Care Teams can talk with you about how to live well and feel better. We can help you make the most of your provider visits and connect you with helpful community resources. We also can help you understand your PCP s treatment plan. We work closely with your health care providers to make sure you have the help you need because we want to help you reach your health goals. To talk with a Care Team member, call Healthcare Services at (TDD/TTY users dial 711). Oregon Health ID card The Division of Medical Assistance Programs (DMAP) will send you an Oregon Health Identification (ID) card when you first enroll into OHP. Each OHP member in your household will receive their own ID card. Take your Oregon Health ID card with you when you go for medical care and to the pharmacy. If you lose your Oregon Health ID card, contact your DHS worker or Client Services at to get a new one. DMAP also sends you an important coverage letter. It has your case worker s ID and phone number, your OHP benefit package, your copays (if 8

10 any) and which managed care plans you have. The coverage letter shows information for everyone in your household who has an Oregon Health ID card. EOCCO medical ID card Each member of EOCCO also gets an EOCCO medical ID card. This card is very important because it identifies you as an EOCCO member and has other important information. It tells you what to do in an emergency and lists the Customer Service phone numbers. Be sure to show your EOCCO medical ID card and Oregon Health ID card each time you go to the doctor or pharmacy. Your PCP assignment Members living in North Lake, Morrow and Umatilla counties will be assigned a primary care provider (PCP). If you wish to choose a different PCP, you have 30 days to choose one from the Provider Directory located in the back of this book. Call our Customer Service Department and let us know you want to choose a different PCP. If approved, your new PCP selection will be effective the first day of the month or the first day of enrollment in which your PCP change was made. Members living in all other service areas will have the option to choose their own PCP. You will have 30 days to choose one from the Provider Directory located in the back of this book. Call our Customer Service Department and let us know the PCP you have chosen. If approved, your new PCP selection will be effective the first day of the month or the first day of enrollment in which your PCP change was made. If you do not choose a PCP within your first 30 days of enrollment, we will choose one for you. Call our Customer Service Department if you need assistance choosing a provider. 9

11 Changing your PCP If you would like to change your PCP, you may do so during the first 30 days of your enrollment. You also can change your PCP up to two times every six months. To choose a new PCP, use the Provider Directory located in the back of this book. Once you have chosen your PCP, call our Customer Service Department and tell us your selection. If approved, your new PCP selection will be effective the first day of the month or the first day of enrollment in which your selection was made. Be sure to have each eligible member of your family choose a PCP. Each person can have a different PCP. GETTING CARE How to make a doctor s appointment Call your PCP s office during office hours (normally 9 a.m. to 5 p.m.). If you need your PCP s phone number, check the Provider Directory or call our Customer Service Department. Tell the office you are an EOCCO member, and tell them why you would like to see a provider. If possible, give the PCP office a telephone number where you can be reached. Remember to take your Oregon Health ID card and EOCCO medical ID card with you when you go to your appointment. If you need language or sign language interpretation, tell the clinic staff. They can arrange to have an interpreter at your appointment. If you need help getting to your appointment, call your DHS worker in advance. Your DHS worker may be able to help you get transportation to your appointment. How to make an appointment to see a Mental Health Provider You do not need a referral from your PCP to get mental health services. You may call a mental health provider listed in your EOCCO Provider Directory. 10

12 If you cannot keep your appointment Call the provider s office as soon as you can and let them know you cannot keep your appointment. The office will reschedule your appointment and make the cancelled time available for someone else. If you miss too many appointments, your provider may dismiss you as a patient or ask why this is happening. Your provider may work with you to find out what can be done to meet your need for services. Your DHS worker may be able to help you get money for child care so you can go to your appointment. Interpreter services If you are hearing or sight impaired or need help understanding or speaking English, your provider will arrange for an interpreter for you. You may also call our Customer Service Department to get a translation or an interpreter. Your PCP s office can get an interpreter after business hours if you need one for an urgent or emergency call. Seeing a specialist or other provider If you need to see a specialist or provider other than your PCP, you must see your PCP first for most services. Your PCP will decide whether you should see another provider. If you need to see another provider, your PCP will write a referral. EOCCO must approve the referral before you can go to your appointment. Services that do not require a referral Some services do not require a referral, and you can see any contracted provider. Below are examples of services that do not require a referral: Urgent and emergency care Family planning and birth control Routine vision exam Prenatal care Immunizations (shots) Outpatient services for drug or alcohol problems Women s annual gynecological exams Routine laboratory and radiology services Mental Health 11

13 Services that require prior approval Your PCP will contact EOCCO to request a prior authorization. Below are examples of services that require prior authorization. In-patient hospital stays Surgeries Medical equipment Most specialist services How to Get a Second Opinion If your provider gives you a diagnosis or gives you a plan to treat a medical condition and you want to get a different opinion from another provider you can request a second opinion. To request a second opinion call Customer Service and ask for one. After-hours medical care If you need medical attention or advice when your PCP s office is closed, call the PCP clinic s regular phone number. An answering service may answer. Say that you are an EOCCO member. You will get advice or a referral for care. After-hours calls to your PCP should be for urgent medical conditions only. For routine advice and appointments, call your PCP s office during business hours. Emergency care An emergency is an injury or sudden illness that you believe may put your life in serious danger or cause bodily harm if left untreated. If you are pregnant, emergency services also include your unborn baby s health. Below are examples of emergencies: Broken bones Bleeding that does not stop Suspected heart attack Loss of consciousness Seizure Severe pain If you have an emergency, call or go to the emergency room. 12

14 Emergency care is covered 24 hours a day, seven days a week. You have the right to get services at any hospital for emergency care. Emergency care includes services needed to maintain and stabilize your condition. No referral or authorization is required for emergency care. Please call your PCP or our Customer Service Department within 3 days of receiving emergency care. After your emergency condition is stabilized, you may need follow-up care. Follow-up care includes services needed after you are discharged from the emergency room. Follow-up care is not an emergency. You should call your PCP s office to make arrangements if follow-up care is needed. Do not go to the emergency room for care that should take place in your PCP s office. Below are examples of nonemergency routine care: Sore throat Cold Flu Back pain Tension headache If you are not sure if your condition is serious enough to go to an emergency room, call your PCP s office. Someone is available to give you advice 24 hours a day, seven days a week. Speak to the provider on call, even if he or she is not your usual provider. Emergency care when you are away from home If you travel outside the EOCCO service area and have an emergency, go to the nearest emergency room or call Emergency services are only covered as long as the emergency exists. Please call your PCP to arrange for further care if it is needed while you are out of the area. OHP does not cover services outside the US, including Canada and Mexico. Mental Health Crisis A mental health emergency is a situation where your health or safety, or the safety of others, would be in serious danger if you did not get help right 13

15 away. A crisis means a person needs help quickly so the situation does not become an emergency. If you already have a provider: Your provider s office will tell you how to reach them during a mental health crisis. If you are having a crisis, follow the plan made with your mental health professional. If you feel you need services immediately, call your provider s office and ask for an urgent appointment or call 911. Things to look for if you or someone you know is having a mental health crisis: You, or a member of your family, are considering suicide You, or a member of your family, are hearing voices to hurt yourself or another person Hurts other people, animals or property You, or a member of your family, has dangerous or highly disruptive behaviors at school, work, with friends or with family Suicide Prevention One concern that may come with untreated mental illness is a risk of suicide. With appropriate treatment, your life can improve dramatically. What are the most common warning signs? Some estimate as many as 80% of those thinking about suicide want others to be aware of their emotional pain and stop them from dying. A warning sign does not automatically mean a person is going to attempt suicide, but it should be taken seriously. Suicide Warning Signs: Talking about wanting to die or to kill oneself Planning a way to kill oneself, such as buying a gun Talking about feeling hopeless or having no reason to live Talking about feeling trapped or in unbearable pain Talking about being a burden to others Giving away prized possessions Thinking and talking a lot about death Increasing the use of alcohol or drugs 14

16 Acting anxious or agitated; behaving recklessly Withdrawing or feeling isolated Displaying extreme mood swings Never keep talk of suicide a secret! For more information, the Oregon Youth Suicide Prevention website is: If you want to talk with someone outside your mental health plan, call any of the following: SUICIDE ( ) Suicide Prevention Lifeline TALK (8255), online at suicidepreventionlifeline.org The David Romprey Memorial Warmline at: How to Get Help for a Mental Health Crisis: See the provider directory at the end of this handbook for the emergency phone number for the Mental Health Provider in your county. Urgent medical care An urgent medical condition is serious enough to be treated right away but does not require emergency room care. If you have an urgent medical problem, call your PCP s office. You can call anytime, day or night. Identify yourself as an EOCCO member. You will be given advice or a referral for care. Health and prevention education EOCCO will pay up to $50 for you to attend a childbirth preparation class at your local hospital. Contact Customer Service for more information. PLAN BENEFITS AND SERVICES Please see the Oregon Health Plan Client Handbook for more information on the Oregon Health Plan that may not be included in this handbook. Some services may be covered by DMAP that are not covered by EOCCO. 15

17 Oregon Health Plan (OHP) coverage The OHP covers a full range of services, including preventive and routine care, chemical dependency and much more. The following services are covered under the Plan. Preventive care Your PCP will provide general medical care and preventive care. Preventive care includes checkups and any tests to find out what is wrong. Be sure to discuss the recommended schedule for checkups with your provider. Other preventive services include: Well-child exams Immunizations (shots) for children and adults (not for foreign travel or employment purposes) Routine physicals Pap smears Mammograms (breast X-rays) for women Prostate screenings for men Maternity and newborn care Specialty care If you need specialty care, your PCP will refer you to a specialist. Before you see a specialist, you must see your PCP for a referral. Lab tests, X-rays and other procedures Labs, X-rays and other tests are covered when ordered by your PCP or an authorized specialist. Prescription medications Prescriptions can be filled at any Moda Health Network pharmacy. Information on participating pharmacies is in the Provider Directory. Be sure to show both your EOCCO medical ID card and Oregon Health ID card when filling a prescription. Some medications require both cards in order to process the prescription. You may not be able to get a prescription filled without them. Some medications are only covered with prior approval. Your provider will contact Moda Health to get prior approval if it is needed. Some over-thecounter items are covered with a written prescription from your provider. 16

18 Please call the Moda Health Pharmacy Department at if you have any questions about your pharmacy benefits. Prescription coverage for members on Medicare OHP is not the primary plan for prescription drug coverage for members also enrolled in Medicare. Instead, a federal program called Medicare prescription drug coverage will cover most of your prescription drugs. This drug benefit is Part D of your Medicare coverage. Medicare requires copayments for Part D drug coverage. Most Part D plans will charge you a copayment for your prescription drugs. These copayments can range from $0 to $6.35 per prescription. EOCCO will not pay for any portion of your Part D copayments. If you have Medicare Part D, show the ID card provided by your Part D plan to the pharmacy and your EOCCO medical ID card. The pharmacy is required to bill your Part D plan first; EOCCO will not pay for drugs covered by your Part D plan. If your medication is not covered by your Part D plan, EOCCO can then be billed to determine if the medication is covered under the OHP program. EOCCO will continue to pay for all other covered health services. Prescription coverage for Mental Health We do not cover all prescriptions. Most medications that people take for mental illness are paid for by OHP fee-for-service. Please show your pharmacist your Oregon Health ID card and your EOCCO ID cards. The pharmacy will know where to send the bill. Family planning For family planning services, you may see your PCP, any EOCCO provider, the county health department, a family planning clinic or any provider who will take your EOCCO ID card. You do not need a referral from your PCP for family planning services. Covered family planning services include: Physical exams Lab and X-ray services Birth control education Birth control supplies Sterilization services 17

19 Hospital care If you need hospital care, your PCP will get approval for a hospital stay. Except in emergencies, call your PCP before you go to the hospital. Chemical dependency treatment You may receive chemical dependency and substance use disorder treatment without a referral from your PCP. See the Provider Directory for a list of chemical dependency and substance use disorder providers. If you need help finding a provider, call your PCP or our Customer Service Department. Chemical dependency and substance use disorder treatment includes: Counseling office visits Synthetic opiate treatment and methadone treatment Detoxification services Smoking and Tobacco cessation services Help to stop smoking and using tobacco (tobacco cessation) is covered for EOCCO members. Coverage includes counseling, nicotine patches and prescriptions commonly used for tobacco cessation. EOCCO will pay for 10 sessions every three months for intensive tobacco cessation treatment and counseling. You do not need a referral for tobacco cessation treatment and counseling. Oregon Tobacco Quit Line The Oregon Tobacco Quit Line is a free telephone service available to all Oregon residents who want to stop using tobacco. The Quit Line offers free quitting information, one-on-one telephone counseling and referrals. For more information about the Oregon Tobacco Quit line, visit or call: (Spanish) 711 (TTY) Mental health Mental health services are available to all OHP members. You can get help with depression, anxiety, family problems, and difficult behaviors, to name a 18

20 few. We cover mental health assessment to find out what kind of help you need, case management, therapy, and care in a psychiatric hospital if you need it. Important: You do not need a referral to get mental health services from a network provider. Please see our Provider Directory for a list of network providers. AMHI and ISA Services for Mental Health Treatment Aim High (AMHI) is a program to help adults in one of the state hospitals get out and those in residential settings get better mental health care. It also helps adults with mental health challenges get more and better services in the community. The goal is to keep people healthy outside of the State Hospital. Intensive Service Array (ISA) is a program to help children with severe mental health conditions receive the appropriate level of care. For more information about these services please call Dental services Dental health services are provided by a dental care organization (DCO) in your area. To find out the name and phone number of your DCO, look on page 2 of your coverage letter or call your DHS worker. Vision services Routine vision screenings and glasses are only covered for clients who are pregnant or younger than 21 years of age. For routine vision care, you can go directly to any vision provider listed in the Provider Directory located in the back of this handbook. If you have an eye injury or infection, call your PCP for care or a referral. Pregnant women (21 or older) can have an eye exam and new glasses (lenses and frames) every 24 months. Children and pregnant women (20 and younger) can have an eye exam and new glasses (lenses and frames) every 12 months. Additional exams and glasses may be covered more often when recommended by your physician or optometrist. Hearing services Hearing aids, hearing tests and batteries are covered. If you need hearing services, your PCP will make a referral. 19

21 Skilled nursing facility care Skilled nursing facility (nursing home) care is covered for up to 20 days after you have been in the hospital. Your provider will get approval from Moda Health. Additional skilled care may be covered by Medicaid or Medicare if you have Medicare benefits. Transportation Ambulance transportation is covered in emergencies or when your PCP has approved it in advance. Nonemergency transportation may be provided if you have no other way to get to a medical appointment. Call your DHS worker in advance to arrange for transportation. Services covered by DMAP Some services are only covered by DMAP, even if you are a member of EOCCO. These services include: Elective abortion and related services Residential chemical dependency and substance use disorder treatment Transportation to medical appointments Secure transport if you might be a harm to yourself or others Prescription drugs for mental health conditions Contact your DHS worker for information about how to access these services. NONCOVERED SERVICES Not all medical care is covered. When you need medical care, contact your PCP. If you have questions about covered or non-covered services, call our Customer Service Department. If you receive a service that is not covered, you may have to pay the bill. You only have to pay if you signed a form before you got the service saying you agree to pay for it. It must show the name of the service and the approximate cost. If you get non-emergency or non-urgent care services from a provider who is not an EOCCO provider, you may be billed for charges, including 20

22 Medicare deductibles and coinsurances. You only have to pay if you signed a form before you got the service saying you agree to pay for it. It must show the name of the service and the approximate cost. The following are examples of non-covered services: Treatment for conditions that get better on their own, such as colds Treatment for conditions for which home treatment works, such as sprains Cosmetic surgeries or treatments Treatments that are not generally effective Services to help you get pregnant Weight-loss programs Buy-ups* *A buy-up is when a member pays the difference between an item OHP covers and a more expensive, non-covered model. For example, OHP may cover a basic pair of eyeglasses, but the client may want a more expensive pair that is not covered by OHP. The member tries to buy up by paying the difference between the two. This is not allowed. Indian Health Services If you are a member of Native American or Alaskan Native descent you can see Native American providers that are NOT in our network. However, Native American providers who are not part of our network must follow the same rules as network providers. Only covered benefits will be paid for. If a service requires a pre-authorization, they must request it before providing the service. If you want to know what services require pre-authorization call Customer Service. If you have questions about your benefits under the American Recovery and Restoration Act, or if you need help understanding our pre-authorization rules, please feel free to call Customer Service for help. IF YOU ARE PREGNANT If you become pregnant, call your DHS worker right away. Your DHS worker will make sure you do not lose medical coverage. If you are pregnant, or think you might be, it is important that you see a healthcare 21

23 provider right away. Regular check-ups are important to have a healthy baby. Call your DHS worker as soon as your baby is born. Your DHS worker will enroll your baby in the Oregon Health Plan. Maternity services outside the service area If at all possible, try to stay within the EOCCO service area during the last 30 days of your pregnancy. Only emergency care outside the service area is covered, which includes the delivery and the baby s newborn checkup in the hospital. Any emergency care involving your baby is also covered. Prenatal care is not covered outside the service area. OTHER IMPORTANT INFORMATION Changes to your address or phone number If you move or change your phone number, contact your DHS worker to ensure that you continue to receive important information from EOCCO. Also, give your PCP s office your new address or phone number. Information and Privacy This notice describes how medical information about you may be used and disclosed and how you can get access to this information. A law called the Health Insurance Portability and Accountability Act (HIPAA) protects your medical records and keeps them private. This is also called confidentiality. We have a paper called Notice of Privacy Policies that explains in detail how we use our members personal information which is included in the member welcome packet mailed to you when you are enrolled into EOCCO. You may request a copy at any time by calling customer service and ask for our Notice of Privacy Policies All information in your medical records and anything you discuss with your providers, their staff, EOCCO, GOBHI or Moda Health is confidential, or private. Information in these records will not be released without your prior consent, except as requested by DMAP. The Notice of Privacy Practices will tell you how we may use or disclose information about you. Not all situations will be described. 22

24 We may use and Disclose Information without your authorization: For Treatment. We may use or disclose information with health care providers who are involved in your health care. For Payment. We may use or disclose information to get payment or to pay for the health care services you received. For Health Care Operations. We may use or disclose information in order to manage our programs and activities. For Health Oversight Activities. We may use or disclose information during inspections or investigations of our services. As Required by Law and For Law Enforcement we will use and disclose information when required or permitted by federal or state law or by court order. For Abuse Reports and Investigation we are required by law to receive and investigate reports of abuse. To Avoid Harm. We may disclose information to law enforcement in order to avoid a serious threat to the health and safety of a person or the public. You have the right to ask for a restriction on how the medical information that we have about you is given out. Member disenrollment request OHP members may ask to leave a managed care plan without cause in the first 30 days of enrollment as long as another plan is available. The head of household may ask for disenrollment by phone or in writing. Disenrollment will take effect on the first of the month following DMAP approval. A member may also choose to disenroll from the managed care plan whenever the member's eligibility is redetermined by DHS. If you are new to OHP, you may ask to change plans in the first 90 days of enrollment. American Indians, Alaska natives and people who have Medicare too can change plans or go on OHP fee-for-service (open card) anytime. Talk to your provider or caseworker about the best choice for you. Plan disenrollment request EOCCO could ask OHA to take you from our plan for these reasons: Losing your eligibility through the Oregon Health Plan Moving out of the EOCCO service area 23

25 Committing fraudulent or illegal acts Being abusive to staff or property Advance directives Every Oregon adult has the right to make decisions about his or her medical treatment. This includes the right to accept and refuse medical treatment. An illness or injury may keep you from telling your doctor and family members what your wishes are about the medical care you want to receive. Oregon law allows you to say your wishes in advance while you are able to do so. The form used to write down your wishes is called an advance directive. Every Oregon adult has the right to fill out an advance directive form. You can make a complaint if your provider does not do what you ask in your Advance Directive. Send it to: Oregon Health Authority Ombudsman 500 Summer St. N.E., E17 Salem, OR Telephone: TTY: An advance directive booklet, Making Health Care Decisions, is available at no cost from EOCCO. Please call our Customer Service Department to request information on advance directives. You may find out more about advance directives by calling Oregon Health Decisions at or , TTY 711. Declaration for Mental Health Treatment Oregon has a form called a Declaration for Mental Health Treatment. This form is a legal document. It allows you to make decisions now about future mental health care in case you are unable to make your own care decisions. If you do not have this form in place, and you are not able to make your own decisions, your family or providers will decide your treatment. Only a court or two doctors can decide that you cannot make your own care decisions. You may also use this form to name an adult who can make mental health decisions for you when you cannot make them for yourself. This person must agree in writing to represent you. The person you name must follow your wishes. If your wishes are unknown, the person you name must make decisions that are in your best interest. 24

26 A Declaration of Mental Health Care is effective for three years. If you become unable to make decisions, this document will remain in effect until you are capable of making decisions. You may change or cancel your declaration at any time as long as you are capable of making decisions for yourself. It is important to give this form to your doctor and to give a copy to the person you name to represent you. For a copy and more information on the Declaration for Mental Health Treatment go to the State of Oregon s website at: Clinical records Each provider will keep a clinical record that documents conditions, services provided and referrals made. EOCCO members have the right to ask for and receive copies of their clinical records. The provider may charge a reasonable copying fee. You also have the right to ask that the record be changed or corrected. MEMBER RIGHTS AND RESPONSIBILITIES As a member of EOCCO, you have the right to: Be treated with dignity and respect. Be treated by providers the same as other people seeking healthcare benefits to which they are entitled. Select or change your PCP. Be involved in creating your treatment plan. Receive information about your condition as well as covered and noncovered services so that you can make an informed decision about proposed care. Agree to care or turn down care and be told what will happen if you decide to turn down care, except for court-ordered services. Receive covered care under the OHP. Allowed to help make decisions about your health care, including refusing treatment, without being held down, kept from other people, or forced to do something you don t want to do out of fear that someone might do something to you. Receive covered preventive care. 25

27 Receive interpreter services. Have access to urgent and emergency care 24 hours a day, seven days a week. Be referred to specialty providers for medically appropriate, covered services. Refer yourself directly to mental health, chemical dependency or family planning without getting a referral from a PCP or other provider. Have a clinical record maintained that documents conditions, services received and referrals made. Have a friend, family member or support person with you during office visits and at other times as needed within clinical guidelines. Have access to your own medical record, unless restricted by law; request and receive a copy of your medical records, and request that they be amended or corrected. Transfer a copy of your medical record to another provider. Make a statement of wishes for treatment (advance directive), including the right to accept or refuse medical, surgical, chemical dependency or mental health treatment, and the right to obtain a power of attorney for healthcare. Receive written notice before a denial of, or change in, a benefit or service level is made, unless such notice is not required by federal or state regulations. Know how to make a complaint or appeal about any aspect of your care or the plan. Request an administrative hearing with the Division of Medical Assistance Programs. Receive written materials describing rights, responsibilities, benefits available, how to access care and what to do in an emergency. Have written materials explained in a manner that is understandable to you. Receive necessary and reasonable services to diagnose your presenting condition. Receive a notice of an appointment cancellation in a timely manner. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation and to report any violations to EOCCO or to the Oregon Health Plan. 26

28 As a member of EOCCO, you must: Choose your primary care provider or clinic, once enrolled. Be on time for appointments made with providers and call in advance if you are going to be late, or cancel if you are unable to keep the appointment. Tell providers your healthcare is covered under the Oregon Health Plan before services are received and, if requested, show the provider your Oregon Health ID. Treat all providers and their staff with respect. Seek periodic health exams, checkups and preventive care from your PCP. Use urgent and emergency care appropriately, and notify the plan or your PCP within 72 hours of an emergency. Obtain a referral to a specialist from your PCP before seeking care from a specialist, unless self-referral is allowed. Use your PCP for diagnostic and other care, except in an emergency. Give accurate information for the clinical record. Help the provider obtain clinical records from other providers. This may include signing a release of information form. Ask questions about conditions, treatments and other issues related to your care that you do not understand. Use information to decide about treatment before it is given. Help to create a care plan with the provider. Follow prescribed, agreed-upon treatment plans. Tell your DHS worker if you change your address or phone number. Tell your DHS worker if you become pregnant and when your baby is born. Tell your DHS worker if any family members move in or out of the household. Tell your DHS worker if you have any other insurance. Pay the monthly OHP premium on time, if required. Assist in getting any other resources available to pay for your health care. If you receive money for an injury, you must pay the plan the amount of benefits they paid to care for that injury. Bring problems, complaints and grievances to the attention of EOCCO. Sign an authorization for release of medical information so that EOCCO and the Division of Medical Assistance Programs (DMAP) 27

29 can get information that is needed to respond to an administrative hearing request in an effective and efficient manner. Pay for non-covered services that you agree to pay for before you receive them. INFORMATION AVAILABLE UPON REQUEST EOCCO If you would like information about EOCCO s structure and operation, call Moda Health Customer Service at (TTY: 711). PROVIDER PAYMENTS You may ask if EOCCO pays our physicians bonuses for limiting their use of referrals and other services. To get this information, please call our Customer Service Department and ask for information about our physician payment arrangements. PROVIDER APPEAL RIGHTS Your provider may appeal a decision by EOCCO to deny a service that was requested for you. Providers can call GOBHI at or Moda Health Customer Service at to request the appeal. Providers may also help you to submit appeals to EOCCO. If you would like help from your provider please contact their office. COMPLAINTS AND APPEALS If you are not happy with the care from your medical provider or service from EOCCO, you can file a complaint. If you receive a denial and you do not agree with the decision, you can file an appeal or request an administrative hearing. A denial is a decision to not pay, stop paying for or providing less service. If you need help with a complaint, an appeal or an administrative hearing request, EOCCO or your caseworker can help you. You can call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at , TTY 711, for advice and possible representation. Legal Aid information can also be found at 28

30 Follow these steps to file a complaint or appeal, or to request an administrative hearing: Complaint 1. To file a complaint, call EOCCO Medical Customer Service or write: EOCCO Telephone: Attn: Appeal Unit 601 S.W. Second Ave. TDD/TTY: 711 Portland, OR EOCCO will get back to you in five working days to let you know that we have received your complaint, provide our decision or explain the delay. 3. EOCCO will respond to your complaint within 30 calendar days of receiving it. You may need to give EOCCO permission to request your medical records. All information about your complaint is handled confidentially. If you are not satisfied with the response to your complaint, you can file a complaint with the state of Oregon by writing to: Oregon Health Authority Ombudsman 500 Summer St. N.E., E17 Salem, OR Telephone: TTY: Appeal 1. To file an appeal, call EOCCO Customer Service within 45 days of the date of the denial. To file your appeal in writing, request an EOCCO appeal form. You should receive this form with your denial. Call or write: EOCCO Telephone: Attn: Appeal Unit 601 S.W. Second Ave. TDD/TTY:

31 Portland, OR If you call in an appeal, you must follow up with a written, signed appeal. Use the EOCCO appeal form that you received with a copy of your denial. EOCCO can help you write your appeal. 2. EOCCO will get back to you in five calendar days to let you know that we received your appeal and provide our decision. If we need more than 5 days we will explain why. 3. EOCCO will complete the review and respond to your appeal within 16 calendar days. If EOCCO cannot resolve your complaint within 16 calendar days, you will receive another letter explaining the delay. Your complaint will be resolved within 14 calendar days from the date the original 16 calendar days ended. 4. If you believe your problem is an emergency and cannot wait for a review, ask EOCCO for an expedited or rush appeal. If EOCCO agrees that your appeal is an emergency, EOCCO will respond to your request within three working days. 5. You may need to give EOCCO your consent to investigate the appeal and to request your medical records. All information about your appeal is handled confidentially. 6. You can ask for an administrative hearing while your appeal is in progress, or if you do not agree with the response to your appeal. Like an appeal, you must ask for it within 45 days of receiving our denial. 7. You have the right to continue services during the appeal process, but you will be responsible for payment of those services if the denial is upheld. 8. You have the right to have someone file an appeal and speak for you. Please give us in writing the name of the person who will represent you. 30

32 Administrative hearing To request an administrative hearing, call EOCCO or your DHS worker within 45 days of the date of the denial. 1. To contact EOCCO, call , TDD/TTY: 711 and request a Notice of Hearing Rights instruction form (DMAP 3030) and an Administrative Hearing Request form (DHS 443). You should receive these forms with your denial letter. 2. Read the Notice of Hearing Rights instruction form (DMAP 3030) completely. The instructions provide important information such as how to request an expedited or rush hearing and how to continue services during the hearing process. 3. Complete the Administrative Hearing Request form (DHS 443) and return it to DMAP, your DHS worker or the nearest Department of Human Services office within 45 days from the date of the denial. 4. You have the right to continue services during the administrative hearing process, but you will be responsible for payment of those services if the appeal denial is upheld. PROVIDER DIRECTORY The following pages contain a listing of EOCCO providers by City. The list gives you the name, address and phone number of providers. The list also indicates if the provider or office staff speaks a language other than English. If you are hearing or speech impaired and would like to contact your provider please call 711. To get the most up to date information on EOCCO providers please visit our website at or call GOBHI at or Moda Health Customer Service at (TTY: 711). 31

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36 P.O. Box Portland, Oregon Member Inquiries Medical: Pharmacy: Insurance products provided by ODS Community Health, Inc (08/12)