2013 MEMBER HANDBOOK

Transcription

1 InterCommunity Health Network Coordinated Care Organization (IHN-CCO) 2013 MEMBER HANDBOOK Your medical and mental health benefits as a member of The Oregon Health Plan IHN-CCO_1005_2013A OHA approved

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3 Alternate format information English If you need this document in another language, large print, Braille, on tape, or another format, please call or TTY If you want a Member Handbook, you can see it at If you want us to send you a Member Handbook, please call Customer Service. You can have a voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider s office that you need an interpreter and in which language. Information on Health Care Interpreters is at Spanish Si necesita otro idioma, letra grande, Braille, CD, cinta de audio u otro formato, llame al Departamento de Atención al Cliente al o TTY Si desea ver el Manual para los Miembros, puede hacerlo en Si desea que le enviemos un ejemplar del Manual, llame al Departamento de Atención al Cliente. Si desea, puede haber un intérprete presente durante sus citas. Cuando llame para solicitar una cita, informe al consultorio médico que necesita un intérprete que hab le español. En hallará información sobre intérpretes que se especializan en el campo médico. iii

4 T A B L E O F C O N T E N T S Alternate format information... iii Welcome to InterCommunity Health Network Coordinated Care Organization (IHN-CCO), your community health care plan... 1 What is the Oregon Health Plan (OHP)?... 1 What is a Coordinated Care Organization (CCO)?... 2 What are managed care and fee-for-service?. 4 Who to call... 4 Questions or need help?... 4 Getting started.5 Your Oregon Health Identification (ID)..5 Benefit packages.6 Becoming an IHN-CCO member...6 Involvement in CCO activities..6 How to change CCO's 6 Disenrollment 6 Member rights and responsibilities.7 Primary Care Provider (PCP)...8 Members with Medicare or other Insurance.8 What is a Patient-Centered Primary Care Home (PCPCH)?...9 Second Opinion 9 Native Rights 9 Appointments 9 Interpreter Services..11 Co-payments.11 Getting a ride.11 Non-covered services...12 Payment for non-covered services and other insurance Medical health benefits...12 Referrals to other providers Preventive care Laboratory tests, x-rays, and other procedures Quitting tobacco Chemical dependency (drug and alcohol) treatment Intensive case management services (Exceptional Needs Care Coordination) Case management services Skilled nursing facility care Vision care Hearing services Family planning and related services If you are pregnant Newborn enrollment Mental health benefits...19 Mental health assessment and evaluation Routine mental health services Mental health treatment agencies How to obtain a referral to a non-county or out-of-panel provider Crisis and urgent mental health services Statewide peer-run warm line Intensive Children s Treatment Services (ICTS) AMHI program ( Aim High ) Prescription medications...25 Dental services...26 Urgent Care services...26 iv

5 Emergency and crises 26 Hospitals near you 277 Out-of-town emergencies 28 Care after and emergency..28 Grievance system information and appeal rights How to make a complaint or grievance 28 How to appeal a decision 29 If you need a fast appeal.29 How to get an Administrative Hearing.30 Fast (expedited) Hearing.30 Declaration for mental health treatment...30 End-of-life decisions and Advance Directives (Living Wills)...31 Physician incentives...32 A copy of your records...32 Your records are private 32 v

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7 Welcome to InterCommunity Health Network Coordinated Care Organization (IHN-CCO), your community health care plan IHN-CCO is a managed care plan that works with the Division of Medical Assistance Programs (DMAP) to provide health services to people enrolled in the Oregon Health Plan (OHP). IHN-CCO manages the Medical and Mental health care for eligible OHP members living in Linn, Benton, and Lincoln Counties. If you would like more information about the structure and operations of IHN-CCO as a managed care plan, please call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY This member handbook tells you what services are available to you and how to get those services. It also tells you what to do in an emergency and explains your rights and responsibilities. Federal and state laws related to information in this handbook may change from time to time. We will update this handbook within 90 days from when a major change takes effect. Read this member handbook thoroughly. Keep it as a guide for future reference. Your IHN-CCO handbook is not complete without the Oregon Health Plan Client Handbook. The Division of Medical Assistance Programs (DMAP) sends you this handbook and it is located at Your Client Handbook also gives you important information about your OHP benefit package, covered and non-covered services, and dental plan information. 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. It covers different groups of services, called benefit packages: OHP Plus is for pregnant women, children 18 years old and under, and people with disabilities of any age. It covers doctor visits, prescriptions, hospital stays, dental care, mental health services, and help with addiction to cigarettes, alcohol and drugs. OHP Plus can provide glasses, hearing aids, medical equipment, home health care, and transportation to health care appointments. OHP Standard is for Oregon residents who are older than 18. It covers doctor visits, prescriptions, emergencies, mental health services, and help with addiction to cigarettes, alcohol and drugs. Some people who have OHP Standard pay a monthly charge, called a premium, for it. There are other benefit packages. An OHA or DHS case worker can tell you which benefits you have. 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 1

8 could be covered if the patient has an above-the-line condition that could get better if their below-theline condition gets treated. What is a Coordinated Care Organization (CCO)? IHN-CCO 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: Benton County Health Department Children and adults can come into these community centers for physical and mental health care, and addiction and pharmacy services: Benton Health Center, Corvallis Lincoln Health Center, Corvallis Monroe Health Center, Monroe Lincoln County Health Department Lincoln Community Health Centers are clinics operated by Lincoln Cou nty Health and Human Services. The clinics provide primary care services, as well as mental health and addictions services at eight sites in Lincoln County. They include clinics in Lincoln City, Newport, South Beach and each of the four public high schools. Mental Health and Addictions Sites Newport, 36 SW Nye Street Lincoln City, 4422 NE Devils Lake Blvd. South Beach South Coast Highway, Suite 1 Primary Care Sites Newport, 1010 SW Coast Hwy. Suite 203 Lincoln City, 4422 NE Devils Lake Blvd. School-Based Health Center Sites Newport High School, 322 NE Eads Street Taft High School, 3780 SE Spyglass Ridge Toledo High School, 1800 NE Sturdevant Road Waldport High School, 320 Lower Crestline Drive Linn County Health Department Children and adults can come into these community centers for physical and mental health care, and addiction and pharmacy services. Primary Care Sites Lebanon, 100 Mullins Drive, Suite A-1 (formerly 55 Twin Oaks) 2

9 Mental Health and Addiction Sites Albany, 425 Second Avenue SW and 445 Third Avenue SW Lebanon, 1600 S. Main Sweet Home, 799 E. Long Street Local health care providers See the IHN-CCO Provider Directory for a complete listing of providers. Accountable Behavioral Health Alliance Accountable Behavioral Health Alliance (ABHA) manages mental health services through one of the County Mental Health Clinics. You will get services from the County staff or from one of our community providers. You and your County Mental Health Clinic will work to find the best provider for your needs. The Corvallis Clinic The Corvallis Clinic provides physical health care for children and adults. They have 80 providers in 26 different specialties. Mid-Valley Behavioral Care Network Mid-Valley Behavioral Care offers a range of mental h ealth and chemical dependency services in Linn County. Oregon Cascades West Council of Governments Senior and Disability Services ensure access and coordination of social and health care resources. Programs include: In-home services Relative foster care Adult foster care homes Assisted living facilities Residential care facilities Nursing home facilities Samaritan Health Plans Samaritan Health Plans manages the health insurance functions of IHN -CCO. Samaritan Health Services Samaritan Health Services provides physical and mental health care, along with hospital care. See your IHN-CCO Provider Directory for a complete listing of providers. Samaritan Mental Health Samaritan Mental Health provides inpatient mental health care along with mental health care services. IHN-CCO coordinates the care they provide: You have one number to call for customer service. All your service information is now in one place. 3

10 You have one IHN-CCO member ID card to receive your physical and mental health care services. You have one IHN-CCO member handbook to explain your benefits. Your care is managed by one group to make sure that all your providers are working together. What are managed care and fee-for-service? CCOs (Coordinated Care Organizations) are a type of managed care. Another type is Dental Care Organizations (DCOs). The Oregon Health Authority (OHA) wants OHP members to have their health care managed by private companies set up to do just that. OHA pays managed care companies a set amount each month to provide their members the health care services they need. In some parts of Oregon, most OHP members must receive 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. Who to call Questions or need help? IHN-CCO Customer Service Department is available to help you with your questions in person or over the phone: IHN-CCO Customer Service Department 815 NW Ninth Street, Suite 101 Corvallis, OR Phone: (541) ; toll-free ; or TTY Fax: (541) Office Hours: Monday Friday 8:30 a.m. to 5 p.m. Our offices are wheelchair accessible. Phone Hours: Monday Friday 8 a.m. to 8 p.m. For help with a Mental Health Crisis between 5 p.m. to 8 a.m., call You may also visit us on the Web at IHN-CCO. The IHN-CCO Customer Service Department can help you to choose a Primary Care Provider (PCP) for you and each covered member of your family. Let us know if you are unable to see your PCP during the first month of enrollment and you need services such as prescriptions, supplies, or other necessary items. Let us know if you lose your IHN-CCO member identification (ID) card. We can answer any questions you have after reading the materials in your member packet. 4

11 Let us know if you need a foreign language interpreter to be with you at a medical appointment or on a telephone call with the IHN-CCO Customer Service Department. We will help you with complex medical problems and special needs through our Exceptional Needs Care Coordinators (ENCC). We will help you with chronic medical conditions through our case management staff. Please call us if you have any complaints or concerns. Call your caseworker or the OHP Central Branch Office at or TTY for the following: If you have questions about your eligibility. If your address changes. If your living situation has changed since you filled out your enrollment form. If you have not received or you have lost your DMAP medical care identification (ID) card. If you get pregnant. If you have a new baby. If you have no transportation for health care appointments. If you have questions about your premiums. Getting started Your Oregon Health Identification (ID) When you become an Oregon Health Plan (OHP) member, the Division of Medical Assistance Programs (DMAP) will mail you your Oregon Health ID and your OHP coverage letter. Your Oregon Health ID used to be called your DHS Medical Care ID. If you still have you r DHS Medical Care ID, you can still use it. Your Oregon Health ID is a card the size of a business card that lists your name, your Medicaid ID number and the date it was issued. Every person in your household who is eligible receives their own Oregon Health ID. Take your Oregon Health ID to all health care appointments. Providers use the information on the card to check your eligibility. Coverage letter The coverage letter is for your information only. You do not need to take it to your health care appointments. The coverage letter shows your branch office name, phone number, your worker s code, and the benefit package, copayment and plan information for everyone in your household. You will get a letter when: You are new to the Oregon Health Plan You have a new managed care plan, Primary Care Manager or Third Party Resource You get a new ID Card Your benefits, address, or household members have changed 5

12 Benefit packages The health care services you may receive are based on the benefit packet you have been assigned. As an IHN-CCO member you have one of two benefit packages: OHP Plus or OHP Standard. As an IHN-CCO member with the OHP Plus package you have all the benefits covered under the Oregon Health Plan. As a member with the OHP Standard package your coverage is limited. Your Oregon Health ID (DHS Medical Care ID) and coverage letter will tell you what benefit package you have. IHN-CCO provides mental health services for you as part of your OHP benefit package. Becoming an IHN-CCO member When you become a member of IHN-CCO you receive a New Member Packet. The following materials are found in your packet. Please keep these materials for future reference: Member Handbook, including you member rights and responsibilities and our Notice of Privacy Practices Welcome letter A Provider Directory is available upon request. If you are missing any of these materials please call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY Involvement in CCO activities IHN-CCO has a Community Advisory Council. We invite you to apply to serve on the Council. Most of the Council members are Oregon Health Plan members. Other members are from government agencies and groups that provide OHP services. If you are interested in being a member of the Community Advisory Council, please call Customer Service for an application. We have several healthy living programs and activities for you to use. For more information about these services, please call IHN-CCO Customer Service Department at (541) , toll-free , or TTY How to change CCO s If you want to change to a different CCO, call your DHS case worker. There are several chances for you to change as long as another CCO is open for enrollment: If you, or a family member, do not want the CCO you ve been assigned to, you can change during the first 30 days after you enroll. Everyone in your family who is on OHP must change to the same CCO. If you are new to OHP, you can change CCOs during the fir st 90 days after you enroll. 6

13 If you move to a place that your CCO doesn t serve, you can change CCOs as soon as you tell your case worker about the move. You can change CCOs each time your case worker finds that you meet the requirements for OHP. This is called recertification and usually happens about the same time once each year. If you are also on Medicare, you can change or leave your CCO anytime. Disenrollment When you have a problem getting the right care, please let us try to help you before changing CCOs. Just call our Customer Service at IHN-CCO Customer Service Department at (541) , tollfree , or TTY If you still want to leave or change your CCO, call your DHS case worker. A CCO may ask the Division of Medical Assistance Programs (DMAP) to remove you from it if you: are abusive to CCO staff or your providers commit fraud, such as letting someone else use your health car e benefits If you want fee-for-service OHP instead of managed care OHP wants you to get managed health care from a CCO like IHN -CCO. CCOs can provide some services that OHP can t. But you can change to fee -for-service OHP at any time if: you are an American Indian or Alaska Native you are also on Medicare in addition to OHP Member rights and responsibilities Your rights are the things that you can count on getting from IHN -CCO. Your responsibilities are the things we need from you. As a person with OHP insurance, you have many rights and responsibilities. As an OHP client, you will be: Treated with respect and dignity, the same as other patients; Free to choose your provider; Urged to tell your provider about all your health concerns; Able to have a friend or helper come to your appointments, and an interpreter if you want one; Told about all of your OHP-covered and non-covered treatment options; Allowed to help make decisions about your health care, including refusing treatment, without being held down, put in a room away from other people, or forced to do something you don t want to do; Given a referral or second opinion, if you need it; Given care when you need it, 24 hours a day and 7 days a week; 7

14 Free to get mental health and family planning services without a referral; Free to get help with addiction to cigarettes, alcohol and drugs without a referral; Given handbooks and letters that you can understand; Able to see and get a copy of your health records; Able to limit who can see your health records; Sent a Notice of Action letter if you are denied a service or there is a change in service level; Given information and help to appeal denials and ask for a hearing; Allowed to make complaints and get a response without a bad reaction from your plan or provider; and Free to ask the Oregon Health Authority Ombudsperson for help with problems at or toll free at , TTY 711. As an OHP client, you agree to: Find a doctor or other provider you can work with and tell them all abo ut your health; Treat providers and their staff with the same respect you want; Bring your medical ID cards to appointments, tell the receptionist that you have OHP and any other health insurance, and let them know if you were hurt in an accident; Be on time for appointments; Call your provider at least one day before if you can t make it to an appointment; Have yearly check-ups, wellness visits and other services to prevent illness and keep you healthy; Follow your providers and pharmacists directions, o r ask for another choice; Be honest with your providers to get the best service possible; and Call your case worker when you move, are pregnant or no longer pregnant. Members with Medicare or other insurance If you have both Medicare and the Oregon Health Plan (Medicaid), you are a dual eligible member. IHN-CCO will coordinate your Medicaid benefits with your Medicare benefits if you have both. If you have other insurance coverage and are on IHN-CCO, call your caseworker or the IHN-CCO Customer Service Department. Primary Care Provider (PCP) When you need medical care, begin by calling your PCP. Your PCP will oversee your medical care and treatment and make sure that you see specialists when needed. You can call your PCP s office 24 hours a day, seven (7) days a week. Even if the office is closed, there is still someone available to help you. Please ask your provider s office about their ADA accessibility and non -English languages spoken if you have special needs for your appointment. 8

15 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 Patient -Centered 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. Second opinion We cover second opinions. If you want a second opinion about your treat ment options, ask your provider to refer you for another opinion. If you want to see a provider outside our network, you or your provider will need to get approval first. Care Helpers There may be times when you need help getting the right care. Your prima ry care team may have people specially trained to do this. These people are called Care Coordinators, Community Health Workers, Peer Wellness Specialists, and Personal Health Navigators. Please call IHN -CCO Customer Service Department at (541) , toll-free , or TTY for more information. Native Rights American Indians and Alaska natives can receive their care from an Indian Health Service (IHS) clinic or tribal wellness center. This is true whether you are in a CCO, prepa id health plan or OHP fee-forservice (open card). Appointments Making the most of your health care visit It is important to meet with a health care provider to prevent illnesses, as well as when you are sick. When you meet with doctors, counselors, nurse practitioners, or pharmacists, it is important to be prepared. When you are prepared for your appointment, your health care provider can help you better. This way, both you and your health care provider can make the most of your time together! Ask your provider s office about their ADA accessibility and non -English languages spoken if you have special needs for your appointment. Review these tips before your visit and take some extra time to prepare. How to make an appointment 1. Call your Primary Care Provider (PCP) or mental health provider. 2. Write down the date and the time of your appointment. 9

16 3. If you need an interpreter for the appointment, call IHN -CCO at least 3 days before the appointment at (541) , toll-free , or TTY Before your appointment What to take with you: Your medical identification (ID) cards: IHN-CCO medical ID card and DMAP medical care ID card A friend or family member: another person can help listen for important details A list with: o Questions you have about your health or treatment. o A list of medicines you are taking at this time. If you are not able to be at your appointment for any reason, call your provider s office as soon as you can to cancel or change the appointment. At your appointment Be on time. Relax: do not be nervous. Ask your health care provider the following questions: o What is my main problem? o What do I need to do? o Why is it important for me to do this? Get all of the answers you need. If you do not understand something, ask to have it repeated or explained. Write down information that will help you remember details of the visit. Before you leave your appointment Be clear on what you need to do next: Know where to go for any follow up visits. Special treatment? Tests? Fill a prescription? Understand why it is important to follow your provider s instructions. Ask when you should visit a doctor or another health care provider again. Cancelling Appointments If you are not able to be at your appointment for any reason, call your doctor s office as soon as you can to cancel or change the appointment. Your provider s office will schedule another appointment for you and make the time available for another patient. Each office has its own policies about appointments. They will tell you about its policy at your first visit. The policy says what to do if you will be late for an appointment or if you need to cancel an appointment. The policy also says what can happen if a person misses or comes late to too many appointments. Be sure to ask questions if you do not understand the office s policy. 10

17 Interpreter services You can have a voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider s office that you need an interpreter and in which language. Information on Health Care Interpreters is at To make sure that an interpreter will be at your appointment, please have this information ready when you call: The name of the person or persons the appointment is for The member s ID number A home phone number The date and the time of the appointment The name of the health care provider The full address of the appointment The phone number of the provider s office The reason for the appointment Please call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY , with your appointment information at least 3 days before your appointment. If you cannot keep the appointment, call our Customer Service Department right away. Getting a ride If you need help getting to your appointments, please call: Cascades West Ride Line, at or TTY at Some people on OHP Plus may be able to get help paying for rides. Child care If you need child care so you can go to your appointment, please call your case worker. They may be able to help you get money to pay a babysitter. Co-payments As an IHN-CCO member, you do not owe co-payments to your providers for health care visits or services. As an OHP member you could owe co-payments for other OHP benefits and services. Contact your caseworker if you have questions about your bene fit package, co-payments, or premiums. 11

18 OHP members do not pay bills for covered services If your health care provider sends you a bill, don t pay it. Please call our IHN-CCO Customer Service Department at (541) , toll-free , or TTY right away. Prioritized list of health services Oregon Health Plan members benefits and treatments are based on a list of health services ranked by the Health Evidence Review Commission (HERC), called the Prioritized List of Health Services. OHP members covered benefits are based on where their conditions and treatments are on the list. Not all medical services are covered. OHP covers services for finding out what s wrong and those services that are the most effective. This includes diagnosi ng a condition that is not on the covered list. Non-covered services Not all medical services are covered by the Oregon Health Plan (OHP) or IHN -CCO. OHP covers the health care services most likely to help you get better. Some of the health care services not covered by OHP include: Services not included in the person s OHP benefit package Services for conditions not funded on the Prioritized List Services for a person who is in law enforcement custody Services requested solely for legal reasons Services requested for reasons other than diagnosis or treatment Services provided in another country Services provided in an emergency room if the problem or concern is not an emergency OHP places limits on or restricts coverage for certain kinds of services. For e xample: OHP limits services that are more than what is needed to diagnosis or treat a health condition OHP limits services that cost more if a less expensive service is likely to be helpful OHP limits services that are for the convenience of the consumer but doesn t help diagnose or treat a health condition If you receive non-emergency or non-urgent care services from providers who are not part of your plan, you may be responsible for charges, including Medicare deductibles and coinsurances. If you think you need treatment, call your PCP or mental health provider. If you have questions about what is a covered or non-covered service, please call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY Please call IHN-CCO before you agree to pay a provider. 12

19 Payment for non-covered services and other insurance You can choose to get not covered medical or mental health treatment and services. The provider s office should tell you up-front if a service or treatment is not covered. They will tell you how much it costs. You must sign a form to say you will pay the bill for the non -covered service or treatment. Tell the provider s office and your DHS or OHA caseworker right away if you have other insur ance, such as Medicare or private insurance. Bring the ID card for your other insurance to each appointment with your provider. Your provider must bill any other insurance before they can bill us for your services. We will only pay the provider after the other insurance has paid, except in some special cases. We will only pay for medical and mental health services covered by OHP. Medical health benefits OHP covers medical health services for children, teenagers, and adults. Not all medical services are covered. OHP covers services for finding out what s wrong and those services that are the most effective. This includes diagnosing a condition that is not on the Prioritized List of Health Services. Here are some examples of services your plan may cover: Preventive care (like shots) Diagnostic services such as x-ray or laboratory work (services to find out what is wrong) Emergency care Medical examinations by your PCP or specialist Check-ups Immunizations Family-planning services Pregnancy and newborn care Prescription drugs Alcohol/drug treatment Exceptional Needs Care Coordination (ENCC) Here are some services your plan does not cover: Treatment for conditions that get better on their own without going to the doctor, like colds Treatment for conditions that can be treated at home, such as corns, calluses and some skin conditions Cosmetic surgeries or treatments that only improve appearance, not function Services to help you get pregnant Please call the IHN-CCO Customer Service Department for questions about what benefit package you have, your coverage, any limits, non-covered services, or services that may require IHN-CCO s approval first. 13

20 Referrals to other providers If you think you need to see a specialist or other provider, make an appointment with your PCP. Your PCP will decide which services and tests you may need and may refer you to a specialist. Some services must be requested by your PCP and approved by IHN-CCO. If you go to another provider and have certain services without getting approval, you might have to pay for those services. For a complete list of services that require approval, or prior authorization, call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY , or visit our website at Family planning services, emergency services, mental health services, or chemical dependency services do not require a referral from your PCP. For a list of contracted providers, see IHN-CCO s full provider directory on our website or call the IHN-CCO Customer Service Department for a copy. The provider directory includes the provider s name, location, phone number, and non -English speaking capabilities. IHN-CCO s provider directories are updated each week. For information about your mental health agencies go to the Mental health benefits section of this handbook. Preventive care Preventive care is a very important part of the care you rec eive from your PCP. This includes regular check-ups and immunizations (shots). It also includes any exams to make sure there is nothing wrong. Some examples of preventive care are pap smears, mammograms (breast x -ray) and special tests for diabetics. These services are needed to keep you healthy. By getting regular check-ups, your doctor will be able to find and treat problems before they become serious. Be sure to talk to your PCP about the recommended schedule for check-ups and immunizations. As an IHN-CCO member, you will receive a newsletter with information about staying healthy. You can also get materials from your PCP s office, local health departments, or the area hospitals about how to stay healthy. Your PCP will discuss the preventive care you need and when you need it. For some specialized services, you may need to have a referral. To get a referral, talk to your PCP. Laboratory tests, x-rays, and other procedures These services are covered if they are medically necessary and if your PCP orders them. Some services may require approval, or prior authorization, from IHN -CCO. For a complete list of services that require approval call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY , or visit our website at Quitting tobacco Quitting tobacco classes are a covered benefit for IHN-CCO members. Once every 12 months IHN- CCO will pay class enrollment fees for quitting tobacco. 14

21 IHN-CCO also offers other ways to help you stop using tobacco, including telephone -based programs. You can call the Oregon Tobacco Quit Line at: Quit-Now ( ) for English speaking members for Spanish speaking members for TTY users For more information about class options, call IHN-CCO Customer Service Department at (541) , toll-free , or TTY If your doctor feels that you need a prescription to help you quit tobacco, IHN-CCO will pay for sixteen (16) weeks of medication every 365 days. Chemical dependency (drug and alcohol) treatment If you think you need to see someone for an alcohol or drug problem, talk to your PCP or call a provider directly. Drug and alcohol providers have extra training and experience to help people who also get mental health services. You do not need a referral from your PCP for these services. For a list of contracted providers, see IHN-CCO s full provider directory on our website at You can also call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY for questions. Intensive care management services (Exceptional Needs Care Coordination) IHN-CCO has registered nurses who work as Intensive Care Managers (ICM), formerly Exceptional Needs Care Coordinators (ENCC). These nurses focus on helping members who are older, disabled, or have other special needs. However, any IHN-CCO member may request ENCC services. Intensive care coordination services include: Helping members understand their benefits and the process for getting services or supplies. Coordinating health care with doctors, other providers, and community agencies. Working with members who are having problems getting care. Identifying other resources for members. If you have questions or want to get in touch with an ICM, please call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY Case management services In addition to Exceptional Needs Care Coordination, IHN-CCO has case management services to help members who have chronic medical conditions (such as diabetes, asthma, or heart disease). Nurses 15

22 and other care management staff can work with members, health care providers, or state caseworkers to help find ways to meet health care needs. If you have questions or want to know more about case management services, please call the IHN- CCO Customer Service Department at (541) , toll-free , or TTY Health Education We respect the diversity of our members and the communities where they live. We want to make sure our services address the needs of people of all cultures, language s, races, ethnic backgrounds, abilities, religions, genders, and sexual orientations. We want everyone to feel welcome and wellserved in our plan. Your county clinic has written information about many topics. These include parenting and dealing with loss and sadness. Others include managing anger, stress, mental health problems, self-care, prevention, and disease self-management. They also give or sponsor classes about these things. Call our customer service department for further information on offe red classes and help. Skilled nursing facility care Skilled nursing facility (SNF) care is covered for up to 20 days following hospitalization when medically necessary. Vision care Call your Primary Care Provider (PCP) about any eye problems, such as an injury or infection. Your PCP will refer you to a specialist if needed. OHP Plus plan members: Benefits for Plus plan members who are Pregnant or age 20 or younger: Emergency treatment Medical eye exams Routine eye exams and glasses Benefits for Plus plan members who are not pregnant or age 21 or older: Emergency treatment Medical eye exams such as diabetic eye exams, and other vision services to treat certain medical conditions. 16

23 OHP Standard plan members: Treatment for eye diseases is covered for members with the Standard plan. Routine eye exams, frames, contacts, or exams for the purpose of fitting glasses or contacts are not covered. If you have questions about your vision benefits or which services require IHN-CCO s approval, please call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY Hearing services If you need hearing services, your PCP will make a referral. IHN-CCO covers hearing exams when needed. Hearing aids For Plus plan members, hearing aids are covered if criteria are met. For Standard plan members, hearing aids and exams for the purpose of fitting hearing aids are not covered. For more information about your hearing aid benefit call our Exceptional Needs Care Coordinator s (ENCC) at: (541) , toll-free , or TTY Family planning and related services The following family planning and related services are available to women, men, and teens: Family planning visits (physical exam and contraceptive education) Contraceptive supplies, such as birth control and condoms Sterilization services (tubal ligations and vasectomies) Related services include the following: Pap smear Pregnancy test Screenings for sexually transmitted diseases (STDs) Testing and counseling for AIDS and HIV You can go to any of the following places to receive family planning services: Your PCP s office A county health department A family planning clinic Any provider who will take your OHP Medical Care ID or IHN -CCO ID card 17

24 If you are pregnant If you are pregnant, it is very important to make an appointment with your PCP or obstetrician as soon as possible. It is always best to begin receiving prenatal care in the first 3 months of your pregnancy. You then need to receive regular prenatal care throughout your pregnancy until delivery. Preparing for childbirth IHN-CCO covers childbirth education classes such as Childbirth Preparation, Lamaze, and Breast - feeding classes in your local area. If you would like to attend childbirth education classes during your pregnancy, call the hospital where you are planning to deliver. Tell them you are an IHN -CCO member and are interested in their classes. Please bring your IHN-CCO Member ID card to your first class, or when you register. ALBANY Samaritan Albany General Hospital (SAGH): (541) or TTY: CORVALLIS Good Samaritan Regional Medical Center (GSRMC): (541) or TTY LEBANON Samaritan Lebanon Community Hospital (SLCH): (541) or TTY: LINCOLN CITY Samaritan North Lincoln Hospital (SNLH): (541) or TTY: NEWPORT Samaritan Pacific Community Hospital (SPCH): (541) or TTY: Newborn enrollment Contact your caseworker as soon as you know you are pregnant. It is also very important that you notify your caseworker again as soon as your baby is born. IHN -CCO will not cover the medical expenses of your newborn child until you have notified your caseworker of your child s birth. You also need to tell IHN-CCO the name of your newborn child s PCP. Changes in your family size If your family size changes, you must report this information to your caseworker. 18

25 Mental health benefits IHN-CCO covers mental health services for children, teenagers, and adults. Not all services are covered. Some of the mental health services covered are: Assessment/evaluation Counseling Case management Individual, group and family therapy Medication management Crisis services Emergency services Hospital services Programs to help with daily and community living Some services may be more helpful than others. It depends on your needs and concerns. Decisions about which services may be helpful are made together by you and your provider. Mental health assessment and evaluation As a member, you can have an assessment of your mental health needs. Call your county mental health agency and tell them you want to make an appointment with a counselor. See pages of this handbook for agency information. You do not have to be sure you have a mental health problem to make an appointment. If you think you might, that is enough. A counselor will be happy to talk with you. At your first appointment with them you will decide if you should get mental h ealth treatment. You will also decide if other services might help you. Routine mental health services Our mental health treatment agencies are listed in the next section of this handbook. They are arranged by county and then by city. You can call any of t hese agencies to make an appointment for routine services. You do not need a referral from a doctor or anyone else to do this. If you need help choosing an agency or want a list of providers at each agency: you can call our IHN- CCO Customer Service Department at (541) , toll-free , or TTY Please have your IHN-CCO Member ID card with you when you call. The treatment agency will use the information on your ID card to check your eligibility. You will also be asked for the name of the city or county where you live. This is so we can find an agency whose office is close to you. We may also ask for basic information about your needs and concerns. We may ask your age or whether you speak a language other than English. We may ask if you have been to any of our agencies in the past. This information will help us decide which agency may best meet your needs. Always bring your IHN-CCO Member ID card with you to each appointment. 19

26 Mental health treatment agencies ALBANY Linn County Linn County Mental Health Services Adult Outpatient Program Office location: 425 Second Ave. SW Phone: (541) Suites 200 and 203 Toll-free: Send mail to: P.O. Box 100 Oregon Relay TTY or Voice: 711 Albany, OR VCO: Services are for adults 18 years and older Services are available in English and Spanish; services in other languages are available with an interpreter Office hours: 8:30 a.m. 5 p.m. on Monday, Wednesday, Thursday & Friday 8:30 a.m. 6:15 p.m. on Tuesday Closed from Noon 1 p.m. on Monday through Friday Website: Linn County Mental Health Services Children s Outpatient Program Office location: 425 Second Ave. SW Phone: (541) Suite 101 Toll-free: Send mail to: P.O. Box 100 Oregon Relay TTY or Voice: 711 Albany, OR VCO: Services are for children and youth up to 18 years old Services are available in English and Spanish; services in other languages are available with an interpreter Office hours: 8:30 a.m. 5 p.m. on Monday, Wednesday, Thursday & Friday 8:30 a.m. 6:15 p.m. on Tuesday Closed from Noon 1 p.m. on Monday through Friday Website: 20

27 Linn County Mental Health Services Community Support Services & Crisis Team Office location: 445 Third Ave. SW Phone: (541) Send mail to: P.O. Box 100 Toll-free: Albany, OR Oregon Relay TTY or Voice: 711 VCO: Community Support Services are for adults 18 years and older with serious mental illness Crisis Team walk-in services are for children, youth and adults Services are available in English and Spanish; services in other languages are available with an interpreter Office hours: Community Support Services 8:30 a.m. 5 p.m. on Monday through Friday Closed from Noon 1 p.m. on Monday through Friday Crisis Team walk-in services 8:30 a.m. 5 p.m. on Monday through Friday Website: LEBANON Linn County Mental Health Services Office location: 1600 S. Main Phone: (541) Send mail to: 1600 S. Main Toll-free: Lebanon, OR Oregon Relay TTY or Voice: 711 VCO: Services are for children, youth and adults Services are available in English and Spanish; services in other languages are available with an interpreter Office hours: 8:30 a.m. 5 p.m. on Monday, Tuesday, Wednesday & Friday 8:30 a.m. 6:15 p.m. on Thursday Closed from Noon 1 p.m. on Monday through Friday Website: 21

28 SWEET HOME Linn County Mental Health Services Office location: 799 E. Long St. Phone: (541) Send mail to: 799 E. Long St. Toll-free: Sweet Home, OR Oregon Relay TTY or Voice: 711 VCO: Services are for children, youth and adults Services are available in English and Spanish; services in other languages are available with an interpreter Office hours: 8:30 a.m. 5 p.m. on Monday, Tuesday & Thursday 1 p.m. 5 p.m. on Wednesday Closed on Friday s; Call Lebanon office above Closed from Noon 1 p.m. on Monday through Thursday CORVALLIS Website: Benton County Benton County Mental Health Office location: 530 NW 27 th Street Phone: (541) Send mail to: P.O. Box 579 Toll-free: Corvallis, OR Oregon Relay TTY: (541) Services are for children, youth and adults Services are available in English and Spanish; services in other languages are available with an interpreter upon request. Some limited evening times for specific non -routine family meetings. Office hours: 8 a.m. 5 p.m. on Monday through Friday NEWPORT Website: Lincoln County Lincoln County Mental Health Office location: 36 SW Nye Street Phone: (541) Newport, OR Toll-free: Oregon Relay TTY: (541) Services are for children, youth and adults Services are available in English and Spanish; services in other languages are available with an interpreter upon request. Some limited evening times for specific non -routine family meetings. Office hours: 8 a.m. 5 p.m. on Monday through Friday Website: 22

29 LINCOLN CITY Lincoln County Mental Health Office location: 4466 NE Devils Lake Phone: (541) Blvd., Suite B Lincoln City, OR Oregon Relay TTY: (541) Services are for children, youth and adults Services are available in English and Spanish; services in other languages are available with an interpreter upon request. Some limited evening times for specific non -routine family meetings. Office hours: 8 a.m. 5 p.m. on Monday through Friday Website: How to obtain a referral to a non-county or out-of-panel provider You must have approval, or authorization, ahead of time to receive services from any non-county agency or out-of-panel provider for services that are not an emergency. If the same services are available at one of the county agency clinics, you may be required to go to the county agency. If not, your county mental health program will do an evaluation to find out if this other person should provide services to you. If approved, an appointment will be set up for you. If you choose to see a non-county or out-of-panel provider, you may be required to pay for these services if you don t have prior approval. To find out more about this, call the IHN-CCO Customer Service Department at (541) , toll-free , or TTY For our members who are Native American or Alaska Native: We do not have any Indian Health Care Provider in our network of mental health treatment agencies. You must follow the process for out -ofpanel authorizations if we are to pay for mental health services from an Indian Health Care Provider. Crisis and urgent mental health services Crisis services are available 24 hours per day, 7 days per week. A mental health crisis can be such things as feeling out of control, feeling the potential for harming yourself or others, or anything that you believe needs immediate attention. A mental health crisis is when a person needs help quickly so their mental health problem or concern does not become an emergency. If you already have a provider: Your provider will tell you how to reach them during a mental health crisis. If you are having a crisis, follow the plan you made with your provider. If you do not have a provider or cannot reach your provider: Call the number below for your county or call IHN-CCO Customer Service Department at (541) , toll-free , or TTY Tell the person who answers that you are having a mental health crisis. You will be connected to a local crisis service worker as soon as possible. The crisis worker will talk with you to help decide the best way to handle the crisis. Tell them about your OHP insurance as soon as you can. 23