Member Handbook. January 5, APPROVED BY DMAP on 01/05/2011

Transcription

1 Handbook For members living in the following counties in Oregon: Grant, Harney, Hood River, Lake (excluding zip codes 97620, 97630, 97635, 97636, and 97637), Sherman, Wasco, and Wheeler January 5, 2011 APPROVED BY DMAP on 01/05/2011 Este manual está disponible en español a petición del interesado al o gratis al

2 IMPORTANT TELEPHONE NUMBERS AND CONTACT INFORMATION PacificSource Community Solutions Office Location 2965 NE Conners Avenue Bend, OR am 5pm, Monday - Friday (our office is compliant with the Americans with Disabilities Act) Mailing Address PacificSource Community Solutions PO Box 5729 Bend, OR Customer Service Department (541) (800) Toll-free (800) TTY PacificSource Community Solutions Tobacco Cessation Assistance (541) (800) Toll-free 8am 5pm, Monday Friday Oregon Tobacco Quit Hotline* (for use after normal business hours only) (877) 270-STOP Tollfree *A Quit Line specialist will provide PacificSource Community Solutions members with a one-time counseling session and refer you to the PacificSource Community Solutions Tobacco Cessation Assistance Line Oregon Health Plans Premium Billing Office (888) Toll-free (800) TTY Apply for the Oregon Health Plan (800) Toll-free (800) TTY Check Status of Your Oregon Health Plan Application (800) Toll-free (800) TTY Client Services Unit (800) Toll-free Dial 711 TTY 2

3 TABLE OF CONTENTS IMPORTANT TELEPHONE NUMBERS AND CONTACT INFORMATION... 2 PacificSource Community Solutions... 2 Oregon Health Plans... 2 WELCOME TO PACIFICSOURCE COMMUNITY SOLUTIONS... 5 Alternate Format... 5 Your Identification (ID) Cards... 5 When Do I Call Customer Service?... 5 When Do I Call PacificSource Community Solutions?... 5 When Do I Call My Caseworker?... 6 What if I have Other Questions?... 6 Disenrollment... 6 Exceptional Needs Care Coordination (ENCC)... 6 If You Need Services Now... 6 YOUR PRIMARY CARE PROVIDER... 7 Changing your Primary Care Provider... 7 GETTING CARE... 7 Prior Authorization... 8 Women s Health Specialist Care and Referrals... 8 Specialist Care and Referrals... 8 Emergency Services... 8 Urgent Care Services... 9 PacificSource Community Solutions Provider Payments and Incentives PacificSource Community Solutions Business Structure and Operations How To Cancel Appointments YOUR BENEFITS Contracted vs. Non-Contracted Providers Benefit Chart EXCLUSIONS MEMBERS WITH BOTH MEDICARE AND MEDICAID COVERAGE GRIEVANCES AND APPEALS Complaints Appeals Administrative Hearings Continuation of Benefits Medicare Appeals COORDINATION OF BENEFITS THIRD PARTY LIABILITY YOUR RIGHTS

4 YOUR RESPONSIBILITIES ADVANCE DIRECTIVES NOTICE OF PRIVACY PRACTICES GLOSSARY

5 WELCOME TO PACIFICSOURCE COMMUNITY SOLUTIONS This handbook gives you important information about the two (2) Health Plans available through the Oregon Health Plan: Plus and Standard. To find out which plan you have, please see box 9a and 9b on your OHP coverage letter. This handbook will help you use your PacificSource Community Solutions coverage. Covered services include medical and behavioral health (mental health, and drug and alcohol abuse) services offered to members who live in the following Oregon counties: Grant, Harney, Hood River, Lake (excluding zip codes 97620, 97630, 97635, 97636, and only), Sherman, Wasco, and Wheeler. Alternate Format If you need this Handbook or other informational materials in another form, such as: Other Languages Large Print Computer Disk Audio Tape Oral Presentation Braille Please call our Customer Service at (541) or Toll Free (800) to request the format you need. The TTY line for members with hearing impairments is (800) Your Identification (ID) Cards You will get a PacificSource Community Solutions Identification card and member materials within 14 days after enrolling. You may also get a PacificSource Community Solutions card when you change your Primary Care Provider (PCP). Keep your ID card with you at all times. Please show your PacificSource Community Solutions ID card to your provider at each visit. When Do I Call Customer Service? PacificSource Community Solutions wants to make sure you get the services you need. Our office is open Monday through Friday from 8AM to 5PM. Customer Service is available anytime during normal office hours. You can reach our Customer Service department at: (541) Bend (800) Toll-free (800) TTY Line for people with hearing impairments When Do I Call PacificSource Community Solutions? Call Customer Service if you: Need help picking a Primary Care Provider (PCP) Need to change your PCP selection Are in the first month of enrollment (are unable to see your PCP) and need a prescription, supplies, or other necessary items and/or services Have questions about the Plan Have questions about a medical bill Have questions about a claim Have questions about your benefits Need a new PacificSource Community Solutions ID card Have a complaint about your coverage 5

6 When Do I Call My Caseworker? Call your caseworker for help with these questions or problems: If you recently moved If you recently changed your name If you recently had a baby and want to add him/her to the Oregon Health Plan If you need to find out if you are still eligible or will be eligible next month If you need transportation to or from a medical appointment If you need to change your managed care plan If you have questions about the benefit plan you were assigned to What if I have Other Questions? If you have questions about your premium bill, call the OHP Premium Billing Office at (888) or TTY (800) If you want to apply for the Oregon Health Plan, call (800) or TTY (800) If you are checking the status of your Oregon Health Plan application, call (800) or TTY (800) Disenrollment Your enrollment with PacificSource Community Solutions could end for several reasons. For example: If you lose your Oregon Health Plan eligibility; If you move outside of the Plan s service area; If you miss too many appointments with your providers; If you commit illegal acts, such as letting someone else use your ID card or changing a prescription; If you are disruptive or abusive toward Plan or provider staff or property; If you commit or threaten physical violence toward your provider or staff. You also have the right to ask to be disenrolled from the Plan. PacificSource Community Solutions does not process these requests. Please talk with your caseworker if you wish to make such a request and they will let you know of the process. You will be notified whether it is approved or denied. Exceptional Needs Care Coordination (ENCC) We have Registered Nurses who assist members who are aged, blind, or disabled and have complex medical or special needs. ENCC nurses help arrange your health care services, including services after you leave the hospital, and community and social services. You may request ENCC help by calling PacificSource Community Solutions at: (541) Bend (800) Toll-free (800) TTY Line for people with hearing impairments If You Need Services Now In the first month of enrollment, if you are unable to see a Primary Care Provider (PCP) and you need: Prescriptions Supplies Other necessary items Services 6

7 Call Customer Service at: (541) Bend (800) Toll-free (800) TTY Line for people with hearing impairments YOUR PRIMARY CARE PROVIDER When you signed up for PacificSource Community Solutions you had to give us the name of your Primary Care Provider (PCP). If you did not give us the name of your PCP, PacificSource Community Solutions will choose a PCP for you. When you get your PacificSource Community Solutions ID card, please look at the name of your PCP. If you would like a different PCP than the one on your card, please call Customer Service. You may change your PCP up to two times per year. Your PCP will oversee all of your medical care.* This includes specialty care and hospital care, if necessary. Do not go to any provider other than your PCP unless he or she tells you to. If you go to a provider who is not your PCP or a provider your PCP has not referred you to, you may have to pay for the care yourself. In a true emergency, get medical help even if you can t contact your PCP. * The exceptions to this rule are listed under Specialist Care and Referrals. Changing your Primary Care Provider If you want to change your PCP, call Customer Service. You will be able to change your PCP up to twice a year. This limit may be extended if you are moving to an area where you will not be able to reach your current PCP. We may also make an exception if our Medical Director approves it. Important! You must call PacificSource Community Solutions before you see a new PCP. Your new choice will be effective on the first of the month following your request. If you call within the first week of the month the change will be effective right away. A new ID card will be sent to you with the name of your new PCP on it. You will need to talk to your new PCP about any new referrals and authorizations. GETTING CARE To see your PacificSource Community Solutions provider for routine checkups or when you get sick: 1. Call your PCP to make an appointment. 2. Schedule regular checkups with your PCP to learn more about your health care needs and to prevent major illness. Important! Remember: You must contact your PCP for all your health care, except for an emergency, mental health, chemical (drugs and alcohol) dependency, family planning services, or for care not covered by PacificSource A separate Provider Directory listing contracted providers and hospitals will be sent to you. It will include any languages those providers speak other than English. 7

8 Prior Authorization Some services need to be approved before you get them (pre-authorized) by PacificSource Community Solutions. Call Customer Service to see if a service needs to be pre-authorized and whether it has been approved. Generally, you must see a PacificSource Community Solutions contracted provider for pre-authorized services. Women s Health Specialist Care and Referrals Female members can go to a women s healthcare specialist that is a contracted provider. You do not need your PCP to refer you for covered women s routine and preventive health care services. This is in addition to your PCP if your PCP is not a women s health specialist. Specialist Care and Referrals If it is necessary for you to get specialty care, for most services your PCP must refer you. He or she will need to contact PacificSource Community Solutions for approval for that referral (pre-authorization). IMPORTANT! If you see a specialist without a referral from your PCP, PacificSource Community Solutions will not pay for your care. You may be billed for those services. The following is a list of services that do not need a referral from your PCP. Unless noted, you must use a PacificSource Community Solutions participating provider. Annual women s exam Immunizations (shots) (may be received from any provider) Maternity care (a referral from your PCP is needed to see a specialist other than your maternity doctor) Mental health services Chemical (drugs and alcohol) Dependency services Routine vision exams Most family planning services (may be given by any provider) Emergency Services Emergency services are covered 24 hours a day, 7 days a week. Emergency services do not require preauthorization. If you believe you have an emergency medical condition call 911 or go to the emergency room. If you are not sure your condition is an emergency, call your PCP s office, they will help direct your care. Call Customer Service at (541) or toll-free (800) and tell us about your emergency within 72 hours. Important! Do not go to the emergency room for care that should take place in your provider s office. Take care of problems before they become serious. Call your PCP when you are sick. Please do not wait until after office hours to get care for you or your family. Routine care for sore throats, colds, flu, back pain, and tension headaches, for example, is not considered an emergency. Remember, whenever you need advice, call your PCP s office. Someone will be able to help day and night, 24 hours a day, 7 days a week. If your PCP cannot talk with you, speak to the on-call provider. They will be able to direct your care. 8

9 Follow up care is not an emergency. You should call your PCP s office to make arrangements for follow up care. Important! If you are treated in the emergency room for something that is not an emergency, you may be responsible for payment. AWAY FROM HOME Emergency Care When You Are Away From Home If you are traveling and have an emergency, go to the nearest emergency room or call 911. Emergency services are only covered as long as the emergency exists. Please call our office to arrange for further care if it is needed while you are out of the service area. Also, call for follow-up care or to get care from another provider. My PCP s number is: ( ) - What is an Emergency Medical Condition? An emergency medical condition means you have symptoms that are severe including severe pain. You believe your health will be in serious danger if you don t get help right away. The serious harm can be to the person s physical or mental health, or in the case of a pregnant woman, the health of your unborn child. An emergency medical condition can also be a serious problem with a bodily function or with a part of your body, such as your heart. Some examples of emergency situations are: Broken bones Bleeding that does not stop Suspected heart attacks Major burns Loss of consciousness What are Emergency Services? Emergency services are covered services that are needed to evaluate or stabilize an emergency medical condition. Emergency services include all inpatient and outpatient treatment that may be needed to make sure within reasonable medical likelihood, that the patient s condition will get much worse if discharged or moved to another facility. What are Post Stabilization Services? Post stabilization services for an emergency medical condition to help a member stay stable and improve or resolve the stabilized condition. Do I Need to Contact My PCP for Follow-Up Care? Call your PCP s office to make arrangements for follow up care. Your PCP will schedule another appointment and coordinate your services if follow-up care is needed. Urgent Care Services Urgent care services are covered 24 hours a day, 7 days a week whether you are at home or are traveling outside the service area. Urgent care services do not require pre-authorization. If you believe you have an urgent care condition, call your PCP, who will direct your care, or go to an urgent care office nearby. 9

10 What are Urgent Care Services? Urgent care services are covered services that are medically appropriate and needed right away in order to prevent a person from getting much worse. This could be caused by a sudden physical or mental illness or an injury. Services that can be planned ahead of time by the person are not considered urgent services. Take care of problems before they become serious. Call your PCP when you are sick. Please do not wait until after office hours to get care for you or your family. Routine care for sore throats, colds, flu, back pain, and tension headaches, for example, is not an urgent care condition. Important! Do not go to urgent care office for care that should take place in your provider s office. Remember, whenever you need advice, call your PCP s office. Someone will be available to help day and night 24 hours a day, 7 days a week. If your PCP cannot talk with you, speak to the on-call provider. They will be able to direct your care. Do I Need to Contact My PCP for Follow-Up Care? Yes, call your PCP s office to make arrangements for follow up care. Your PCP will schedule another appointment and coordinate your services if follow-up care is needed. PacificSource Community Solutions Provider Payments and Incentives You are entitled to ask if PacificSource Community Solutions has special financial arrangements with our providers. Special financial arrangements are payments to reduce the use of referrals and or other services that you might need. To get this information, call our Customer Service Department at (541) , or Toll Free , or TTY and request information about our provider payment arrangements. PacificSource Community Solutions Business Structure and Operations You are entitled to ask about the structure of PacificSource Community Solutions and how it operates. This information tells you who we are, how the company is set up, and who is in charge. To get this information, call our Customer Service Department at (541) , or Toll Free (800) , or TTY (800) and request information about our company structure. How To Cancel Appointments If you cannot make it to a scheduled appointment, call your PCP or the specialist as soon as possible. If you miss appointments and do not call your PCP or referral specialist you may prevent another patient from receiving a needed appointment. Your health is important, be sure to follow-up with your doctor when he or she says they need to see you. If you miss too many appointments your doctor can decide not to be your PCP. If you miss too many appointments without canceling first, PacificSource Community Solutions may ask that you be disenrolled from the plan. YOUR BENEFITS The Oregon Health Services Commission (HSC) has a list of all medical conditions and treatments, called the Prioritized List of Health Services. The conditions and treatments are listed in order of effectiveness. As an Oregon Health Plan member, you are eligible for benefits based on where your conditions and treatments are on this list. 10

11 The HSC holds regular meetings to review and update the list as needed. Because the state of Oregon does not have enough money to pay for treatment of every condition on the list, the HSC has to draw a line and will only pay for the conditions and treatments that are listed as most effective. Conditions that are covered for treatment by the OHP are Above the Line, and conditions that are not covered are Below the Line. PacificSource Community Solutions must use this list when deciding whether a service can be covered by the Plan. If you have been diagnosed with a condition that falls Below the Line then payment for treatment, prescriptions and specialist office visits may be denied by PacificSource Community Solutions. For some services that are Above the Line (for example: surgeries and some medical equipment), certain requirements created by the OHP or PacificSource Community Solutions will also need to be met to be covered. Reasonable services to help diagnose your condition (find out what s wrong and whether it s Above or Below the Line), may be covered by PacificSource Contracted vs. Non-Contracted Providers Unless otherwise noted in the benefits chart below, the services you request or receive must be from a contracted provider. A contracted provider is someone who has agreed to work with PacificSource Community Solutions in providing services to our members, and accepts our payment in full for those services. PacificSource Community Solutions has a list of contracted providers that was sent to you when you joined the Plan. If you need another list or just want to check if a provider you want to see is contracted, call Customer Service and they will give you that information. If you are referred to a non-contracted provider, PacificSource Community Solutions must approve the service in advance; otherwise the Plan will not pay for it. There are a few exceptions where you can see a non-contracted provider without a referral from your PCP and without getting an approval in advance. These are: Ambulance and Emergency Room Services (for emergencies) Family Planning Immunizations There are also some services that you can get without a referral from your PCP, but they will only be covered when provided by a contracted provider: Colon Cancer Screening Mammograms Maternity Services Pap Tests/Pelvic Exams/Clinical Breast Exams Prostate Cancer Screening Routine Vision Exams, Fitting and Glasses/Contact Lenses (for members in plans that have this benefit) Benefit Chart The benefits chart on the following page lists the services PacificSource Community Solutions covers, subject to your eligibility for OHP, pre-authorization requirements, and where your condition ranks on the Prioritized List of Health Services (see above section). Call Customer Service if you need more information about which services are covered and if they need to be approved in advance (preauthorized) by PacificSource 11

12 OHP members are eligible for different benefit packages. If you are a Standard member, some of your benefits are either limited or not covered at all. Please check your Oregon Health Plan coverage letter. It will tell you which benefit package you have. You pay $0 copay for covered services as a PacificSource Community Solutions member. Although PacificSource Community Solutions contracted providers will not collect copays for covered services, you could be required to pay a copay for services with other providers outside of the PacificSource Community Solutions network. 12

13 Services Acupuncture If you are an OHP Plus These services may be covered for treatment of a covered illness or injury. If you are an OHP Standard Not covered by PacificSource Please check your Oregon Health Plan coverage letter. If you have drug and alcohol abuse coverage, it will give the name of the agency that administers these benefits. Ambulance Services Ambulance services are covered for emergencies only, if transportation in another vehicle could put your health in danger. If you have an emergency and need an ambulance, call 911. Chiropractic Services Colon Cancer Screening Includes: Once every 12 months for members age 50 and older. Additional screening as recommended by your provider. Death with Dignity The following services are covered when performed by a licensed physician or psychologist: Community Solutions for emergency transportation only. These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource You can see any contracted provider for this service, and do not need to be referred by your PCP. Covered by the Oregon Health Plan. Services should be billed directly to the Division of Medical Assistance Programs, not to PacificSource For Standard members, these services may be covered only for drug and alcohol abuse treatment. Community Solutions for emergency transportation only. Not covered by the Oregon Health Plan or PacificSource Community Solutions. You can see any contracted provider for this service, and do not need to be referred by your PCP. Covered by the Oregon Health Plan. Services should be billed directly to the Division of Medical Assistance Programs, not to PacificSource Community Solutions. The medical confirmation Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 13

14 Services of the terminal condition The two visits in which the member makes the oral request The visit in which the written request is made The visit in which the prescription is written Counseling consultations Medication/ dispensing Dental Services Diagnostic Services Examples are: CT Scans Labs MRIs PET Scans X-rays These are tests to determine your condition and how to treat it. Some diagnostic exams, such as MRIs and PET scans, need to be approved in advance by PacificSource Community Solutions. Drug and Alcohol Abuse Treatment Services If you are an OHP Plus Not covered by PacificSource Please check your Oregon Health Plan coverage letter. If you have Dental coverage, it will give the name of the Dental Care Plan that administers these benefits. PacificSource Community Solutions covers lab and x-ray services when your PCP or treating specialist orders them. You may get these services in your provider s office or in a hospital outpatient department. Some diagnostic services, such as MRIs, PET scans and nuclear cardiac testing, need to be approved in advance by PacificSource Please call Customer Service to find out which services need an approval in advance. If you are an OHP Standard Not Please check your Oregon Health Plan coverage letter. If you have Dental coverage, it will give the name of the Dental Care Plan that administers these benefits. Dental coverage is limited for Standard members. PacificSource Community Solutions covers lab and x-ray services when your PCP or treating specialist orders them. You may get these services in your provider s office or in a hospital outpatient department. Some diagnostic services, such as MRIs, PET scans and nuclear cardiac testing, need to be approved in advance by PacificSource Community Solutions. Please call Customer Service to find out which services need an approval in advance. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 14

15 Services If you need help for drug or alcohol treatment, talk to your PCP or call the county health clinic. The county health clinics are listed in your Provider Directory. Or you can call Customer Service. PacificSource Community Solutions pays for office visits and treatment. The plan also covers inpatient services for medical detoxification, when provided in an acute care hospital, and when it is considered medically appropriate. Residential services are not covered. If you are an OHP Plus You do not need to be referred by your PCP for this service. If you are an OHP Standard You do not need to be referred by your PCP for this service. The Addictions and Mental Health Division (AMH) covers non-hospital residential or outpatient drug and alcohol services. For information on how to access these services, contact customer Service, the Community Mental Health Program (CMHP), and outpatient drug/alcohol service provider, the residential treatment program, or the Office of Mental Health and Addiction Services (OMHAS). Durable Medical Equipment (DME) and Supplies Durable Medical Equipment and Supplies include items such as: crutches, diabetic supplies, hospital beds, These items may be covered for treatment of a covered illness or injury. The following are covered without approval in advance from PacificSource Coverage is limited. See Exclusions Section for a list of items that may be covered for treatment of a covered illness or injury. Only the following are covered: Continuous airway pressure Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 15

16 Services ostomy supplies, nebulizers, oxygen equipment, walkers, and wheelchairs. See Exclusions Section for a list of items that are NOT covered. Emergency Room (see page 8 for more information) Please don t go to the ER for a problem that is not an emergency and can be treated at your provider s office or even at an urgent care center during regular office hours. If you don t know if your condition is an emergency, call your PCP s office at any time. Either your If you are an OHP Plus Oxygen and oxygen equipment/supplies Glucose monitors Diabetic supplies, such as glucose test strips (subject to quantity limits) with provider prescription Some equipment and supplies need to be approved in advance by PacificSource Please call Customer Service to find out which items need an approval in advance. Community Solutions for emergencies only, within the United States. Emergency care is covered 24 hours a day, 7 days a week. Treatment for a condition that is not an emergency is not covered. If you have an illness or injury while traveling outside of the United States (including Canada and Mexico), you are not covered by the If you are an OHP Standard device (CPAP) and supplies Diabetic supplies, such as glucose test strips (subject to quantity limits) with provider prescription (no approval in advance is needed) Ostomy supplies Repairs, service and replacement of medically appropriate, covered durable medical equipment, prosthetics and orthotics, as long as it is reasonable and necessary Respiratory supplies Suction pumps Tracheostomy care supplies Urological supplies, such as catheters Ventilator Some equipment and supplies need to be approved in advance by PacificSource Community Solutions. Please call Customer Service to find out which items need an approval in advance. Community Solutions for emergencies only, within the United States. Emergency care is covered 24 hours a day, 7 days a week. Treatment for a condition that is not an emergency is not covered. If you have an illness or injury while traveling outside of the United States (including Canada and Mexico), you are not covered Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 16

17 Services PCP or another provider can help you make that decision. Exceptional Needs Care Coordinator Services (see page 6 for more information) If you feel you need these services, call PacificSource Community Solutions and ask for an ENCC nurse. They will help you coordinate health care services or obtain care. Family Planning With the exception of medical and surgical procedures, you may see a Plan provider, any provider that takes your DMAP ID card, County Health Department, or family planning clinics. Medical and Surgical procedures, as listed below, may only be covered when performed by a PacificSource Community Solutions contracted provider. These services include: Annual exam Contraceptive education and counseling Laboratory tests (such as pregnancy tests and screenings for sexually transmitted diseases) Radiology services Medical and surgical If you are an OHP Plus Plan. Community Solutions for members who are aged, blind, or disabled, and have complex medical and/or special needs. You do not need to be referred by your PCP for this service. If you are an OHP Standard by the Plan. Community Solutions for members who are aged, blind, or disabled, and have complex medical and/or special needs. You do not need to be referred by your PCP for this service. Medical and surgical procedures in a hospital setting may need to be approved in advance by PacificSource Community Solutions. Please call customer service to find out which services need an approval in advance. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 17

18 Services procedures, abortions, tubal ligations and vasectomies Prescriptions and supplies (such as birth control pills and condoms) Hysterectomies are not covered as part of family planning. Hearing Exams and Hearing Aids Home Health Services may include: Skilled nursing Home Health aide services Occupational Therapy Physical Therapy If you are an OHP Plus Community Solutions when referred by your PCP to a contracted provider. Hearing aids need to be approved in advance by PacificSource One or two hearing aids may be covered every five years for adults who meet coverage criteria. Two hearing aids may be covered every three years for children 19 years of age and under who meet coverage criteria. PacificSource Community Solutions covers up to 60 batteries every 12 months. In order to be covered, you must also meet the coverage criteria for hearing aids. Community Solutions for covered illnesses or injuries when the member is homebound. Services need to be approved in advance by PacificSource If you are an OHP Standard Not covered by the Oregon Health Plan or PacificSource Community Solutions. Not covered by the Oregon Health Plan or PacificSource Community Solutions. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 18

19 Services Speech Therapy Related medical supplies Hospice Services In order to cover these services, the following requirements must be met: Services must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions; The member must elect hospice care; A plan of care must be established before services are provided; The services must be consistent with the plan of care; A certification that the member is terminally ill must be completed. Services may include: Nursing services Medical social services Physician services Hospital Services (Inpatient and Outpatient) If you are an OHP Plus Covered by the Oregon Health Plan. Services should be billed directly to the Division of Medical Assistance Programs, not to PacificSource These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource If you are an OHP Standard Covered by the Oregon Health Plan. Services should be billed directly to the Division of Medical Assistance Programs, not to PacificSource Neither the Oregon Health Plan nor PacificSource Community Solutions cover services provided in a hospital for diagnosis or treatment of some conditions. Coverage is determined by the diagnosis (it must be included in the hospital benefit list for Standard members), whether it is Above the Line and if the treatment pairs with the diagnosis. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 19

20 Services Immunizations Immunizations are covered for children and adults. They are not covered for foreign travel or employment purposes. Check with your provider to see which immunizations are right for you or your child. Interpreter Services (including sign language) If you are an OHP Plus You can see any provider that accepts your DMAP card for this service, and do not need to be referred by your PCP. If you are an OHP Standard Services need to be approved in advance by PacificSource You can see any provider that accepts your DMAP card for this service, and do not need to be referred by your PCP. These services are available by phone or in person. If you need these services in person, in most cases you will need to call Customer Service at least five (5) days before you come in. Mammograms Includes: One baseline mammogram for women between ages 35 and 39. One screening mammogram every 12 months for women age 40 and older. Maternity Services Please see a PacificSource Community Solutions contracted provider right away if you become These services are covered for doctor visits for members who do not speak English or have a hearing impairment. You can see any contracted provider for this service, and do not need to be referred by your PCP. Services include: Prenatal visits Labor and delivery These services are covered for doctor visits for members who do not speak English or have a hearing impairment. You can see any contracted provider for this service, and do not need to be referred by your PCP. Services include: Prenatal visits Labor and delivery pregnant. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 20

21 Services Please also contact your caseworker as soon as possible. He or she will make sure you do not lose medical coverage before your baby is born. It is important to begin prenatal care early in your pregnancy and continue with regular medical care. You also need to tell your caseworker if your pregnancy ends. Try to stay within the Plan s area if you are close to delivery. If you are outside of the service area at that time, PacificSource Community Solutions will only cover the delivery, the baby s newborn check-up in the hospital, and emergency care. The Plan will not pay for prenatal care outside of the area. Mental Health Services If you are an OHP Plus Postpartum care (care for you after your baby is born) You do not need to be referred by your PCP to an obstetrician for this service. Not covered by PacificSource If you are an OHP Standard Postpartum care (care for you after your baby is born) You do not need to be referred by your PCP to an obstetrician for this service. Not covered by PacificSource Naturopath Newborn Coverage Please call your caseworker as soon as your baby is born. Your baby has medical Please check your Oregon Health Plan coverage letter. If you have Mental Health coverage it will include the name of the agency that administers these benefits. These services may be covered for treatment of a covered illness or injury. Please check your Oregon Health Plan coverage letter. If you have Mental Health coverage it will include the name of the agency that administers these benefits. Not covered by the Oregon Health Plan or PacificSource Community Solutions. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 21

22 Services coverage until his or her first birthday, even if you are no longer eligible for Oregon Health Plan benefits. When you call your caseworker, have the following information ready: Date of Birth Baby s Name Baby s Social Security Number (or call again as soon as you have one) Gender Parent s Names Once you have enrolled your newborn, check your next coverage letter to make sure he or she is listed. If not, call your caseworker again. Occupational Therapy Help developing small muscles. Office Procedures For example: steroid injections, laparoscopies, varicose vein treatments, and other. Pap Tests, Pelvic Exams, and Clinical Breast Exam One exam every 12 months for women up to age 65. If you are an OHP Plus These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource These services may be covered for treatment of a covered illness or injury. Some services need to be approved in advance by PacificSource You can see any contracted provider for this service, and do not need to be referred by your PCP. If you are an OHP Standard Not covered by the Oregon Health Plan or PacificSource Community Solutions. These services may be covered for treatment of a covered illness or injury. Some services need to be approved in advance by PacificSource Community Solutions. You can see any contracted provider for this service, and do not need to be referred by your PCP. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 22

23 Services Physical Exams Includes: One exam every 48 months for members ages 19 to 34. One exam every 24 months for members age 35 and older. Physical Therapy Help developing large muscles. Prescription Drugs (see page 28 for more information) Coverage is based on a list of covered drugs (formulary) and whether you have a condition that is covered by the Oregon Health Plan. Generic drugs must be used when they are available. Primary Care Provider Office Visits (see page 7 for more information) With the exception of emergency room services, family planning, maternity, and some preventative services noted in this benefits chart, your PCP should be your first contact when you need medical care. If you are an OHP Plus These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource Community Solutions for a covered illness or injury. Some prescription drugs need to be approved in advance by PacificSource Some treatments at your PCP s office need to be approved in advance by PacificSource If you are an OHP Standard Not covered by the Oregon Health Plan or PacificSource Community Solutions. Community Solutions for a covered illness or injury. Some prescription drugs need to be approved in advance by PacificSource Community Solutions. Some treatments at your PCP s office need to be approved in advance by PacificSource Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 23

24 Services Prostate Cancer Screening Includes: One rectal exam every 12 months for men age 50 or older. Prostate testing as recommended by your provider. Skilled Nursing Facility If you are eligible and it is medically necessary, skilled nursing is covered for up to 20 days following a covered hospitalization. If you are eligible for Medicare, they may cover additional Skilled Nursing Facility care. Specialist Office Visits You must be referred by your PCP to see a specialist, unless it is for women s routine/preventative healthcare and maternity services. Some treatments at specialist offices also need to be approved in advance by PacificSource Community Solutions. Speech Therapy Help developing the voice. If you are an OHP Plus These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource These services may be covered for diagnosis and/or treatment of a covered illness or injury. Services need to be approved in advance by PacificSource These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource If you are an OHP Standard These services may be covered for treatment of a covered illness or injury. Services need to be approved in advance by PacificSource These services may be covered for diagnosis and/or treatment of a covered illness or injury. Services need to be approved in advance by PacificSource Not covered by the Oregon Health Plan or PacificSource Community Solutions. Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 24

25 Services Substance Abuse Help to stop using drugs and alcohol. Surgeries If you are an OHP Plus See Drug and Alcohol Abuse. These services may be covered for treatment of a covered illness or injury. Inpatient surgeries and some outpatient surgeries need to be approved in advance by PacificSource Please call Customer Service to find out which services need an approval in advance. If you are an OHP Standard See Drug and Alcohol Abuse. Surgeon fees for these services may be covered for treatment of a covered illness or injury. However, the hospital fees for some procedures are not covered by the Oregon Health Plan or PacificSource Community Solutions. Hospital coverage is determined by the diagnosis (it must be included in the hospital benefit list for Standard members), whether it is Above the Line and if the treatment pairs with the diagnosis. Tobacco Cessation Services These include: Provider office visits to help you quit smoking Nicotine patches, gum, and lozenges Chantix, Buproban, bupropion Classes or phone counseling Transportation to Healthcare Appointments If getting to your appointments is a problem, Call PacificSource Community Solutions Tobacco Cessation Assistance at (541) to find out about this benefit and how it works. These are covered by the Oregon Health Plan directly; not covered by PacificSource Outpatient and inpatient services need to be approved in advance. Please call Customer Service to find out which services need an approval in advance. Call PacificSource Community Solutions Tobacco Cessation Assistance at (541) to find out about this benefit and how it works. Not covered by the Oregon Health Plan or PacificSource Community Solutions. you may take the bus, have a Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 25

26 Services friend or relative drive you, or find a volunteer from a community agency. If none of those options are available, then you can call one of the following agencies that provide transportation to OHP members free of charge. If you are an OHP Plus If you are an OHP Standard Cascades East Ride Center (for Crook, Deschutes, Grant, Harney and Jefferson counties) , or TTY 711. TransLink (for Klamath and Lake counties) , or TTY 711. Transportation Network (for Hood River, Sherman, Wasco and Wheeler counties) , or TTY 711. If you have arranged transportation with one of these centers, and you cancel or change your appointment, let them know. If your county is not listed, call your caseworker to find out about transportation in your area. Urgent Care Services If you have a medical condition that is not an Some services need to be approved in advance (pre-authorized) by PacificSource Call Customer Service to see if a service needs to be approved in advance, and/or whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions contracted provider for these services and they must be medically necessary. The condition(s) and treatment must be on the OHP Prioritized List, which can be found at 26