Coordinated Care Organization Member Handbook

Transcription

1 Coordinated Care Organization Member Handbook Central Oregon Region For members living in the following counties in Oregon: Crook, Deschutes, Jefferson, and Klamath (only zip codes 97731, 97733, 97737, and 97739) Si necesita servicios de intérprete, llame al (541) o (800) Este manual está disponible en español a petición del interesado al (541) o gratis al (800) Revised OHP-PS MM2361_DMAP Approved

2 Important Telephone Numbers and Contact Information PacificSource Community Solutions Office Location 2965 NE Conners Avenue Bend, OR (our office is accessible to people with disabilities) Mailing Address PacificSource Community Solutions PO Box 5729 Bend, OR Customer Service Department (541) Local (800) Toll-free (800) TTY 8:00 a.m. - 5:00 p.m. Monday - Friday Mental Health Crisis Line (available after hours) (866) Toll-free (866) TTY Quit for Life Program (Tobacco Cessation Assistance) (866) Toll-free (877) TTY Para inscribirse en Español, llame al (866) y oprima 2. Available 24 hours a day, 7 days a week* *Closed on some holidays Dental Plans Advantage Dental Services (866) Toll-free TTY users call Capitol Dental Care (800) Toll-free TTY users call ODS Community Health (800) Toll-free TTY users call Willamette Dental Group (855) Toll-free TTY users call Oregon Health Plan Apply for the Oregon Health Plan or Check the Status of your Application (800) Toll-free TTY users call Client Services (800) Toll-free TTY users call County Health Departments Lutheran Community Services NW (Crook County) 365 NE Court Street Prineville, OR (541) (800) TTY 8:30 a.m. 5:00 p.m., Monday Friday Deschutes County Health Services 2577 NE Courtney Drive Bend, OR (541) TTY users call :00 a.m. 6:00 p.m., Monday Friday BestCare Treatment Services (Jefferson County) 125 SW C Street Madras, OR (541) TTY users call :00 a.m. 5:00 p.m., Monday Friday 1

3 Table of Contents Important Telephone Numbers and Contact Information... 1 Welcome to PacificSource Community Solutions... 4 Alternate Format... 4 Your Identification (ID) Cards... 4 What is the Oregon Health Plan (OHP)?... 4 What is a Coordinated Care Organization (CCO)?... 5 What are Dental Providers?... 5 Involvement in CCO Activities... 5 What is a Patient-Centered Primary Care Home (PCPCH)?... 6 What is Managed Care and Fee-for-Service?... 6 Care Helpers... 6 BILLING INFORMATION... 6 What should I do if I get a bill?... 7 When will I have to pay for medical services on OHP?... 7 Second Opinion... 8 How Do I Call Customer Service?... 8 When Do I Call Customer Service?... 8 When Do I Call My Case worker or OHP?... 8 When Do I Call the County Health Department?... 9 Culturally Sensitive Health Education... 9 Changing CCOs... 9 Disenrollment... 9 Changing Your Dental Plan Getting a Ride Intensive Care Coordination Services (ICCS) If You Need Services Now YOUR PRIMARY CARE PROVIDER Changing Your Primary Care Provider YOUR BEHAVIORAL HEALTH PROVIDER Changing Your Behavioral Health Provider YOUR DENTAL PROVIDER Changing Your Dental Provider GETTING CARE Pre-Approval Women s Health Specialist Care and Referrals Specialist Care and Referrals Emergency Services Emergency Care Away From Home Physical Health Emergencies Behavioral Health Emergencies Urgent Care Services What are Urgent Care Services? How to Make Appointments

4 Primary Care and Specialist Appointments How to Cancel Appointments YOUR BENEFITS Contracted (Network) vs. Non-Contracted Providers BENEFITS CHART PRESCRIPTION DRUGS EXCLUSIONS MEMBERS WITH BOTH MEDICARE AND MEDICAID COVERAGE GRIEVANCES AND APPEALS Grievance (Complaints) Appeals Administrative Hearings Continuation of Benefits Appeal rights available to providers to challenge the failure of the CCO to cover a service Medicare Appeals COORDINATION OF BENEFITS YOUR RIGHTS Member Rights PacificSource Community Solutions Provider Payments and Incentives PacificSource Community Solutions Business Structure and Operations Residential Services Rights YOUR RESPONSIBILITIES MEMBER PARTICIPATION WITH PACIFICSOURCE COMMUNITY SOLUTIONS DECLARATION FOR MENTAL HEALTH TREATMENT ADVANCE DIRECTIVES NOTICE OF PRIVACY PRACTICES Using Your Rights and Complaints GLOSSARY

5 Welcome to PacificSource Community Solutions This handbook gives you important information about the Oregon Health Plan (OHP). This handbook will help you use your PacificSource Community Solutions coverage. Covered services include medical, dental, and behavioral health services. Behavioral health includes mental health, drug and alcohol treatment. We serve members who live in the following Oregon counties: Jefferson, Deschutes, Crook, and Klamath (zip codes 97731, 97733, 97737, and only). This Coordinated Care Organization (CCO) plan is offered by PacificSource Community Solutions, Inc. When this handbook says PacificSource, we, us, our, the plan, or our plan it means PacificSource Community Solutions, Inc. Alternate Format Si necesita servicios de intérprete, llame al (541) o (800) Este manual está disponible en español a petición del interesado al (541) o gratis al (800) If you need this Member Handbook or other informational materials in another format, such as: Other Languages Large Print Computer Disk Audio Tape Oral Presentation Braille Please call our Customer Service Department at (541) or toll-free (800) to request the format you need. The TTY line for members with hearing impairments is (800) If you want a Member Handbook, you can see it at If you would like 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 certified healthcare interpreters is at Your Identification (ID) Cards You will get a plan Identification card and member materials within 14 days after enrolling. You may also get a new plan 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. What is the Oregon Health Plan (OHP)? The Oregon Health Plan (OHP) is a program that pays for low-income Oregonians healthcare. The State of Oregon and the US Government s Medicaid program pay for it. OHP covers doctor visits, prescriptions, hospital stays, dental care, mental health services, and help with addiction to cigarettes, alcohol, and drugs. OHP can provide glasses, hearing aids, medical equipment, home healthcare, and transportation to healthcare appointments. 4

6 CAWEM (Citizen Alien Waived Emergency Medical) covers emergency services for non-us citizens. CAWEM Plus also covers childbirth. To find out which benefits you qualify for, please call OHP at (800) 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 are not usually covered by OHP. Something that is Below-the-Line, could be covered if the patient has an above-the-line condition that could get better if their below-the-line condition is treated. PacificSource Community Solutions must use the Prioritized List when deciding whether a service can be covered by our plan. If you have been diagnosed with a condition that falls Below-the-Line, payment for treatment, prescriptions, and specialist office visits may be denied by PacificSource Community Solutions. Some services (like surgeries and some medical equipment) that are Above-the-Line must meet certain OHP or Plan requirements to be covered. Reasonable services to help diagnose your condition (find out what is wrong and whether it is Above or Below-the-Line ), are covered by PacificSource Community Solutions. What is a Coordinated Care Organization (CCO)? PacificSource Community Solutions is a Coordinated Care Organization (CCO). We are a group of all types of healthcare and dental providers who work together for people on OHP in our community. PacificSource coordinates the care you receive from providers. We do this by working with your providers. We want you to receive all the services you need in a way that fits your personal and cultural needs. We will talk to the nurses, pharmacists, and doctors who work with you. We also work with your provider to help you receive the preventive services, tests, follow-up care, and medications that are important to maintaining your health. Additional ways we help coordinate your care: Helping you understand your healthcare plan limits, benefits, and guidelines. Connecting you with your primary care provider (PCP). Coordinating your community support and social services. What are Dental Providers? Dental providers are Dentists and other specialists that provide dental services to our members. Certain dental plans have agreed to be contracted with us. Their customer service numbers are located in the front of the handbook under Important Phone Numbers. Involvement in CCO Activities PacificSource Community Solutions 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. 5

7 We have several healthy living programs and activities for you to use. They are listed on page 1. For more information about these services, please call Customer Service toll-free at (800) or TTY at (800) 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. What is Managed Care and Fee-for-Service? CCOs (Coordinated Care Organizations) are a type of managed care. The Oregon Health Authority (OHA) wants OHP members to have their healthcare 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 healthcare services they need. Most OHP members must receive managed medical, behavioral health and dental care. Health services for OHP members not in managed care are paid by OHA, called open card, or fee-for service (FFS) OHP. Native Americans, Alaska natives and Medicare members on OHP can choose to receive managed care or have an open card. Any CCO member who has a good reason to have an open card can ask to leave managed care. Talk to your provider or case worker about the best way to receive your medical care. You also can call OHP at (800) Care Helpers There may be times when you need help getting the right care. Your primary 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. For more information, please call Customer Service at: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments BILLING INFORMATION OHP Members Do Not Pay Bills for Covered Services. Your medical provider can send you a bill you only if all of the following are true: 1. The medical service is something that PacificSource Community Solutions does not cover. 2. Before you received the service, you signed a valid Agreement to Pay form (also called a waiver). 3. The form showed the estimated cost of the service. 4. The form said that OHP does not cover the service. 5. The form said you agree to pay the bill yourself. These protections usually only apply if the medical provider knew or should have known you had OHP. Also, they only apply to providers who participate in the OHP program (but most providers do). 6

8 Sometimes, your medical provider doesn t do the paperwork correctly and won t be paid for that reason. That doesn t mean you have to pay. If you already received the service and we refuse to pay your medical provider, your provider still can t bill you. You may receive a notice from us saying that we will not pay for the service. That notice does not mean you have to pay. The provider will write-off the charges. If we or your provider tell you that the service isn t covered by OHP, you still have the right to challenge that decision by filing an appeal and asking for a hearing. What should I do if I get a bill? Even if you don t have to pay, DO NOT IGNORE MEDICAL BILLS - call us right away. Many providers send unpaid bills to collection agencies and even sue in court to be paid. It is much more difficult to fix the problem once that happens. As soon as you get a bill for a service that you received while you were on OHP, you should: 1. Call the provider, tell them that you were on PacificSource Community Solutions, and ask them to bill us. 2. Call our Customer Service at (541) , toll-free at (800) , or TTY at (800) right away and say that a provider is billing you for an OHP service. We will help you get the bill cleared up. Do not wait until you get more bills. 3. You can appeal by sending your provider and us a letter saying that you disagree with the bill because you were on PacificSource Community Solutions at the time of the service. Keep a copy of the letter for your records. 4. Follow up to make sure we paid the bill. 5. If you receive court papers, call us right away. You may also call an attorney or the Public Benefits Hotline at (800) for legal advice and help. There are consumer laws that can help you when you are wrongfully billed while on PacificSource Community Solutions. I was in the hospital, and PacificSource Community Solutions paid for that, but now I am getting bills from other providers. What can I do? When you go to the hospital or the emergency room, you may be treated by a provider who doesn t work for the hospital. For example, the emergency room doctors may have their own practice and provide services in the emergency room. They may send you a separate bill. If you have surgery in a hospital, there will be a separate bill for the hospital, the surgeon, and maybe even the lab, the radiologist, and the anesthesiologist. Just because the hospital has been paid by us, it doesn t mean that the other providers were paid. Do not ignore bills from people who treated you in the hospital. If you get other bills, call each provider and ask them to bill us. You should follow steps 1-5 above for each bill you get. When will I have to pay for medical services on OHP? You may have to pay for services that are covered by us if you see a provider that does not take OHP or is not part of our provider network. Before you get medical care or go to a pharmacy, make sure that they are in our network. You can look them up in the Provider Directory that came with this handbook, and online at You will have to pay for services if you weren t eligible for OHP when you received the service. The date you became eligible for OHP is on your OHP coverage letter from DMAP. 7

9 You will have to pay for services not covered by OHP if you sign a detailed Agreement to Pay (a waiver) for that specific service before you receive it. Even if your service is covered by OHP, you may have to pay a copay. You can t be denied services if you can t make your copay, but you will still owe the money to your provider. Second Opinion We cover second opinions. If you want a second opinion about your treatment options, ask your PCP to refer you for another opinion. Your provider will need to contact the plan to get approval of the referral (pre-approval).if you want to see a non-contracted provider; you or your PCP will need to get our approval first. How Do I Call Customer Service? We want to make sure you get the services you need. Our office is open Monday through Friday from 8:00 a.m. to 5:00 p.m. Customer Service is available anytime during normal office hours. You can reach our Customer Service Department at: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments When Do I Call Customer Service? 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 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 plan ID card; or Have a complaint about your coverage or services received. If you need transportation to or from a medical, dental or mental health appointment. When Do I Call My Case worker or OHP? Call your case worker for help with these questions or problems. If you don t have a caseworker, call OHP at (800) : If you want to apply for the Oregon Health Plan; If you are checking the status of your Oregon Health Plan application; If you recently moved; If you recently changed your name; If you recently had a baby and want to add him or 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; or If you have questions about the benefit plan you were assigned to. 8

10 When Do I Call the County Health Department? If you need help choosing a counselor or behavioral health provider. If you need to see a counselor or behavioral health provider. If you want to get an assessment of your behavioral needs. If you have questions about behavioral health treatments. If you think you may need behavioral health services. Culturally Sensitive Health Education We respect the dignity and 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, languages, races, ethnic backgrounds, abilities, religions, genders, sexual orientations, and other special needs of our members. We want everyone to feel welcome and well-served in our plan. An interpreter is available in Spanish and other languages. Interpreter services are free of charge. Please call our Customer Service Department at (541) or toll-free (800) to ask for an interpreter. El intérprete está disponible en español y otros idiomas. Los servicios de interpretación son gratuitos. Por favor llame a nuestro Departamento de Servicio al Cliente al (541) o al número gratuito (800) para solicitar un intérprete. Changing CCOs If another CCO is available, you may change at certain times: If you didn t choose the CCO you are in, you may change within 30 days of enrolling. You may change when your eligibility for OHP is determined, usually once a year. Within the first 90 days of entering OHP. Once during each enrollment period. If you are also on Medicare, you can change or leave your CCO anytime. Disenrollment If you have a problem getting the right care, please let us try to help you. Call our Customer Service at: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments Your enrollment with the plan 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 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; or If you commit or threaten physical violence toward your provider or staff. If another CCO is available in your area, you have the right to ask to change CCOs. PacificSource Community Solutions does not process these requests. Please talk with your case worker if you wish to 9

11 make such a request and they will let you know of the process. If you don t have a caseworker, call OHP at (800) You will be notified whether a change is possible. American Indians and Alaska natives can choose to be enrolled in a CCO like PacificSource. They may also choose to get their healthcare services from a tribal clinic and have OHP fee-for-service pay the bills, without enrolling in a CCO. Please talk to your case worker about the best way to receive your healthcare. Changing Your Dental Plan If you didn t choose the dental plan you are in, you may change within 30 days of enrolling. You may change your dental plan once per enrollment period. Call customer service is you want to change your dental plan: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments Getting a Ride If you need help getting to your appointments, please call Cascade East Ride Center toll-free at (866) TTY users call (800) Rides to medical, dental and behavioral health care appointments are covered by OHP. Intensive Care Coordination Services (ICCS) Intensive Care Coordination Services (ICCS), formerly Exceptional Needs Care Coordination (ENCC), is for people with complex medical or special needs. It helps members who are aged, blind or have disabilities, and children with special needs. If you have complex medical needs, please request ICCS information by calling the plan at: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments If You Need Services Now Call customer service, if in the first month of enrollment, you are unable to see a primary care provider (PCP) and you need: Prescriptions Supplies Other necessary items Services YOUR PRIMARY CARE PROVIDER When you signed up for PacificSource Community Solutions, you were assigned a primary care provider (PCP) in your community. If you have been on our plan before, and had a PCP, you were re-assigned to your previous PCP. When you get your plan 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. If you request a PCP change by the 7 th day of the current month, your change will be effective right away. If you have recently received services from your current PCP, your requested 10

12 changes will not go in effect until the 1 st day of the following month. If you request a PCP change after the 7 th day of the current month, your change will be effective the 1 st day of the following month. 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 cannot 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 the plan before you see a new PCP. If you request a PCP change by the 7 th day of the current month, your change will be effective right away. If you have recently received services from your current PCP, your requested changes will not go in effect until the 1 st day of the following month. If you request a PCP change after the 7 th day of the current month, your change will be effective the 1 st day of the following month. A new ID card with the name of your PCP will be sent to you. You will need to talk to your new PCP about any new referrals and authorizations. YOUR BEHAVIORAL HEALTH PROVIDER Behavioral health services include mental health and drug and alcohol treatment services for children, youth, and adults. The county health department in your area oversees behavioral health services. County health departments are contracted with the plan. They are listed in your Provider Directory and at the front of this handbook. The behavioral health providers at the county health department will work with you to find the best provider for your needs. The behavioral health providers at the county health department will oversee all your behavioral healthcare. You may go to any mental or behavioral health provider in our network without a referral. In a true emergency, get help even if you cannot contact your behavioral health provider. An evaluation or review will be done at the county health department to help you choose a behavioral health provider that best meets your needs. You can also call our Customer Service Department to get help with choosing a behavioral health provider. An interpreter is available in Spanish and other languages. Interpreter services are free of charge. Please call our Customer Service Department at (541) or toll-free (800) to ask for an interpreter. El intérprete está disponible en español y otros idiomas. Los servicios de interpretación son gratuitos. Por favor llame a nuestro Departamento de Servicio al Cliente al (541) o al número gratuito (800) para solicitar un intérprete. 11

13 Changing Your Behavioral Health Provider You can see any behavioral health provider in our network without a referral. If you want to change your behavioral health or drug and alcohol treatment provider, we encourage you to talk to your current provider first. They will work with you to resolve your concerns or find the best provider for your needs. If you do not want to talk to your current counselor or case manager, you can talk to a supervisor at that agency. If you need help changing your current behavioral health provider, please call your local county behavioral health provider. They will help you select another case manager or other behavioral health provider. You can also call PacificSource Community Solutions Customer Service and we will help you change your behavioral health provider. YOUR DENTAL PROVIDER Your dental plan will assign you a primary care dental provider who will oversee your dental care. This includes specialty care, if necessary. If you already have a dentist, tell your dental plan who it is and they will try to assign you to that one. Do not go to any provider other than your assigned dental provider unless he or she tells you to. If you go to a provider who is not your dental provider or a provider your dental provider has not referred you to, you may have to pay for the care yourself. In a true emergency, get help even if you cannot contact your dental provider. Changing Your Dental Provider If you want to change your dental provider, we encourage you to talk to your dental plan. It is printed on your ID card. They will work with you to resolve your concerns or find the best provider for your needs. GETTING CARE To see your plan provider for routine checkups or when you get sick: 1. Call your primary care provider (PCP) or primary care dentist (PCD) to make an appointment. 2. Schedule regular checkups with your PCP and PCD to learn more about your healthcare needs and to prevent major illness. Important! Remember: You must contact your PCP for all your medical care, except for an emergency, behavioral health, chemical dependency (drug and alcohol treatment), annual women s care, family planning services, prenatal care, or for care not covered by PacificSource Community Solutions. 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. 12

14 Pre-Approval Some services need to be approved before you get them (pre-approved) by the plan. Call Customer Service to see if a service needs to be pre-approved and whether it has been approved. Generally, you must see a provider contracted with the plan for pre-approved services. Women s Health Specialist Care and Referrals For covered women s routine and preventive services, members can go to any women s healthcare specialist that is in the PacificSource network. You do not need your primary care provider (PCP) to refer you for covered women s routine and preventive healthcare services. Intensive Community-Based Treatment and Support Services (ICTS) ICTS services are special behavioral health services for children. Services include a trained team of behavioral health providers and case managers. They help families with children deal with trauma, substance abuse, depression, anxiety, juvenile justice, parent/child relationships, or have other behavioral health needs. The county health department manages ICTS services. These county departments are in the PacificSource network. They are listed in your Provider Directory and at the front of this book. The behavioral health providers at the county health department will work with you to see if your child is eligible. They will assist you in finding the best services for your family s needs. AMHI and ISA Services for Mental Health Treatment Aim High (AMHI) is a program to help adults in residential settings get better mental health care. It also helps adults with mental illness get more and better services in the community. The goal is to keep people healthy outside of the State Hospital. Integrated Services Array (ISA) is a program of intensive services for children with mental illness, to keep them safe at home, in school and in their community. Most participants are 10 to 15 years old. If you want more information about these programs, please call Customer Service. Specialist Care and Referrals If it is necessary for you to get specialty care, your primary care provider (PCP) must refer you for most services. Your provider will need to contact the plan to get approval of the referral (pre-approval). IMPORTANT! If you see a specialist without a referral from your PCP, the plan will not pay for your care. You may be billed for those services. If you get a bill, please call PacificSource Customer Service right away. The following is a list of services that do not need a referral from your PCP. Unless noted, you must use a provider that is in the PacificSource network for these services. Annual women s exam; Anticoagulation office visits; Drug and alcohol treatment services; Emergency care; Intensive Care Coordination Services(ICCS) members; Family planning services (may be given by any provider); 13

15 Health department services; Members with special needs rate group A (example: HIV) Certain immunizations (shots) (these may be received from any provider); Lactation services (help with breastfeeding your baby); Maternity care (a referral from your PCP is needed to see a specialist other than your maternity doctor); Mental healthcare; Routine vision exams (only available to children and pregnant women) School-based health center services; and Urgent care. Emergency Services Emergency services are covered 24 hours a day, 7 days a week. Emergency services do not require preapproval. 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 primary care provider s (PCP) office, they will help direct your care. 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, are not considered emergencies. 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. 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 you do not think is a real emergency, you may be responsible for payment. Emergency Care 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 Customer Service Department to arrange for further care if it is needed while you are out of the service area. Also, call to arrange for follow-up care or to get care from another provider. My Primary Care Provider s (PCP s) number is: ( ) - Physical Health Emergencies 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 your physical or mental health. In the case of a pregnant woman, serious harm can be to the health of the unborn child. 14

16 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; Loss of consciousness; Major burns; or Suspected heart attacks. 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, the patient s condition will get much worse if discharged or moved to another facility. What are Post-Stabilization Services? Post-stabilization services are covered services for an emergency medical condition. They help a member stay stable and improve or resolve the condition. Do I Need to Contact My Primary Care Provider (PCP) for Follow-Up Care? Call your PCP s office to make arrangements for follow-up care. Your PCP will schedule an appointment and coordinate your services if follow-up care is needed. Behavioral Health Emergencies What is a Behavioral Health Crisis? A behavioral health crisis includes feelings of being out of control, feeling like you may harm yourself or others, or anything you believe needs immediate attention. Behavioral health crisis services are covered services that are needed right away to prevent a serious worsening of a person s mental health. A behavioral health crisis or emergency behavioral health services are covered 24 hours a day, 7 days a week. Help in a behavioral health crisis does not require pre-approval from the plan. Ask your doctor, counselor, therapist, or behavioral health provider to create a crisis plan for urgent and emergent situations. A crisis plan will give you instructions to get the best care for your needs in a crisis. Call Customer Service and tell us about your emergency within 3 days after your crisis. Important! If you do not have a primary care provider or behavioral health provider or cannot reach them, call our Mental Health Crisis line at (866) or TTY (866) , 24 hours a day, 7 days a week. Important! If you believe you are having a behavioral health crisis, call 911, or call our Mental Health Crisis line at (866) or TTY (866) , 24 hours a day, 7 days a week. What are Post- Stabilization Services? Post -stabilization services are covered services for an emergency. They help a member stay stable and improve or resolve the condition. 15

17 Urgent Care Services What are Urgent Care Services? Urgent care services are covered services that are needed right away 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. 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-approval. If you believe you have an urgent care condition, call your behavioral or primary care provider (PCP) who will direct your care. You may also go to an urgent care office nearby. Take care of problems before they become serious. Call your behavioral or primary care provider (PCP) when you need care. 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, tension headaches, and routine counseling appointments, for example, are not urgent care conditions. Important! Do not go to an 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. How to Make Appointments Behavioral Health Appointments Call the county health department to make an appointment. The county health departments are contracted behavioral health providers listed in your Provider Directory and at the front of this handbook. The county health department will help you make your first appointment. Important! You do not need to get a referral from the county health department for drug and alcohol treatment services. You can see any of the contracted drug and alcohol treatment providers included in your Provider Directory. Primary Care and Specialist Appointments If you need to see your PCP, call their office to make an appointment. If your PCP wants you to see a specialist, check with your PCP to see if they are making the appointment for you. Also, check to see if you need a referral or a pre-approval to see the specialist. If you have questions about what services need a referral or pre-approval you may call our Customer Service Department. 16

18 How to Cancel Appointments If you cannot make it to a scheduled appointment, call your provider as soon as possible. If you miss appointments and do not call your provider, you may prevent another patient from receiving a needed appointment. Your health is important. Be sure to follow up with your provider when he or she says they need to see you. If you miss too many appointments your provider can decide not to be your PCP. YOUR BENEFITS Contracted (Network) 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. They accept our payment as payment in full for those services. The plan has a list of contracted providers including hospitals and other facilities. The list was sent to you when you joined the plan. If you need another list or want to check if a provider is contracted, and accepting new members, call our Customer Service Department. You can also go to to search for contracted providers. A non-contracted provider is a provider who has not agreed to enter into a contract with us. They generally do not accept our payment as payment in full. If you are referred to a non-contracted provider, the plan must approve the service in advance. If the service is not approved, the plan will not pay for it. There are a few exceptions in which you can see a non-contracted provider without getting an approval in advance. These are: Ambulance and Emergency Room Services (for emergencies); Family Planning; and Some Immunizations (shots). There are some additional services that you can get without getting a referral in advance. However, these services 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; and Routine Vision Exams, Fitting and Glasses/Contact Lenses (only available to children and pregnant women). You may also call our Customer Service Department if you want information on provider office hours, providers address, access for members with disabilities, ADA compliance, and providers that speak languages other than English. 17

19 BENEFITS CHART The benefits chart lists the services our plan covers. These services are subject to your eligibility for OHP, pre-approval 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 (pre-approved) by the plan. Some services need to be approved in advance (pre-approved) by PacificSource Community Solutions. Call Customer Service to see if a service needs to be approved in advance, and whether it has been approved. Unless otherwise noted, you must see a PacificSource Community Solutions network 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 Acupuncture Benefits Ambulance Services Ambulance services are covered one way 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. Behavioral Health Services (see page 12 for more information) The county health department will coordinate your care. The county departments are listed in your Provider Directory and in the front of this handbook What is Covered Services must be approved in advance by PacificSource. These services may be covered if approved for treatment of a covered illness or injury. Covered for emergency transportation only. Covered by PacificSource Community Solutions. You can see any contracted county behavioral health department for this service and do not need to be referred by your primary care provider (PCP). Services include: Case management; Consultations; Emergency services; Evaluations/Assessments; Hospitalization; Intensive Community-Based Treatment and Support Services (ICTS); Medication management; Programs to help with daily and community living, Psychiatric residential and day treatment for children, Therapy. 18

20 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: The medical confirmation 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; and Medication/ Dispensing. Dental Services *Some of these services are limited to people who are under 21 or pregnant. For more detailed information on your dental benefits, call your dental plan. Services must be approved in advance by PacificSource. These services may be covered if approved for treatment of a covered illness or injury. Covered by PacificSource Community Solutions. You can see any contracted provider for this service. You do not need to be referred by your primary care provider (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 following is a partial list of coverage benefits. Some services may need to be approved in advance. Dental services need to be dentally necessary to be covered. Be sure to talk to your dentist about your schedule for checkups. *What is Covered? Exams X-rays Cleanings Fluoride Sealant (age and teeth limitations) Fillings Crowns (age, pregnancy or teeth limitations) Root Canals (age, pregnancy or teeth limitations) Dentures (age, pregnancy or teeth limitations) *Some of these services are limited to people who are under 21 or pregnant. For more detailed information on your dental benefits, call your dental plan. Prescription medications Your OHP plan covers required prescription medications ordered by your dental provider. 19

21 Diagnostic Services Examples are: Bone density (DEXA) scans; CT Scans; Labs; MRIs; PET Scans; and 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 Treatment Services The plan 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. 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, your county health department, the outpatient drug/alcohol service provider, the residential treatment program, or the AMH division. Durable Medical Equipment (DME) and Supplies Durable Medical Equipment and Supplies include items such as: BIPAP CPAP Crutches Diabetic supplies Hospital beds, The plan 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 the plan. Please call Customer Service to find out which services need an approval in advance. Covered by PacificSource Community Solutions. These services are managed by the county health departments. The county health departments are listed in your Provider Directory and in the front of this handbook. If you need help for drug or alcohol treatment, talk to your primary care provider (PCP) or call the county health department. You may also call our Customer Service Department. You may see any contracted drug and alcohol treatment provider in our network without a referral. These items may be covered for treatment of a covered illness or injury. The following are covered without PacificSource s approval in advance: BIPAP CPAP Oxygen and oxygen equipment/supplies; Glucose monitors; and Diabetic supplies, such as glucose test strips (subject 20

22 Ostomy supplies Nebulizers Oxygen equipment Walkers and wheelchairs See Exclusions Section for a list of items that are NOT covered. Emergency Room (ER) (see page 15 for more information) to quantity limits) with 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. Covered by PacificSource 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 you do not think is a real emergency is not covered. Please do not go to the ER for a problem that is not an emergency. This is a problem that can be treated at your provider s office during regular office hours or at an urgent care center. If you do not know if your condition is an emergency, call your primary care provider s (PCP) office at any time. Either your PCP or another provider can help you make that decision. If you have an illness or injury while traveling outside of the United States (including Canada and Mexico), you are not covered by the Plan. Eye Health (also see Vision Care Medical Conditions) Family Planning With the exception of medical and surgical procedures, you may see a Plan provider, any provider that takes your PacificSource Community Solutions ID card, a 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. Eye diseases and injuries to the eye are covered. Covered by PacificSource Community Solutions. You do not need to be referred by your primary care provider (PCP) for this service. 21

23 These services include: Annual exam; Birth control education and counseling; Laboratory tests (such as pregnancy tests and screenings for sexually transmitted diseases); Medical and surgical procedures, tubal ligations and vasectomies; Prescriptions and supplies (such as birth control pills and condoms); and Radiology (imaging) services. Hysterectomies are not covered as part of family planning. Hearing Exams and Hearing Aids Includes: One basic hearing test in a 12- month period; One comprehensive hearing test in a 12-month period; One hearing aid or set of hearing aids evaluation/tests in a 12- month period; One electroacoustic evaluation for hearing aid monaural in a 12- month period; One electroacoustic evaluation for hearing aid binaural in a 12- month period. One pure tone hearing (threshold) test; air and bone in a 12-month period. Home Health Services may include: Home Health aide services; Occupational therapy; Physical therapy; Related medical supplies; Skilled nursing; and Speech therapy. Hospice Services Covered by PacificSource Community Solutions when referred by your PCP to a contracted provider. Hearing aids need to be approved in advance by PacificSource. Up to one hearing aid for each ear may be covered every five years for adults who meet coverage criteria. Up to two hearing aids for safety purposes for adults who meet coverage criteria due to vision limitations, Up to one hearing aid for each ear may be covered every three years for children 20 years of age and under who meet coverage criteria. The plan covers up to 60 batteries every 12 months. In order to be covered, you must also meet the coverage criteria for hearing aids. Services need to be approved in advance by the plan. These services may be covered if approved for treatment of a covered illness or injury. Covered by the Oregon Health Plan. 22

24 In order to cover these services, the following requirements must be met: Services must be reasonable and necessary for managing pain and discomfort caused by the terminal illness as well as related conditions; The member must choose hospice care; A plan of care must be established before services are provided; The services must be part of the Plan of care; and The member s doctor must sign a statement that the member is terminally ill. Services may include: Nursing services; Medical social services; or Physician services. Hospital Services (Inpatient and Outpatient) Intensive Care Coordination Services (ICCS) (see page 10 or more information) (formerly called Exceptional Needs Care Coordinator Services (ENCC)) If you have complex medical needs, or need help getting the right care, call our Customer Service Department and ask for an ICCS coordinator. They will help you coordinate healthcare services or get the right care. Care Coordinator services are covered free of charge. Immunizations Certain immunizations, or shots, 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. Intensive Community-Based Hospice Services should be billed to PacificSource Community Solutions. If the member is a resident of a Nursing Facility, the Nursing Facility should bill the Division of Medical Assistance Programs. These services may be covered for treatment of a covered illness or injury. Services must be approved in advance by PacificSource. Covered by PacificSource Community Solutions for members who are aged, blind, or disabled, and have complex medical needs. Covered by PacificSource Community Solutions. You can see any provider that accepts your ID card for this service. You do not need to be referred by your primary care provider (PCP). Some immunizations need to be approved in advance by the plan. Covered by PacificSource Community Solutions. 23

25 Treatment and Support Services (ICTS) ICTS services are coordinated through the county health department. These county departments are contracted with the plan. They are listed in your Provider Directory and at the front of this book. Interpreter Services (including sign language) ICTS services are special behavioral health services for children. Services include a trained team of providers and case managers. They assist families with children dealing with trauma, substance use, depression, anxiety, juvenile justice, parent/child relationships, or have other behavioral (mental) health needs. Covered by PacificSource Community Solutions. These services are covered for members who do not speak English or have a hearing impairment. They are available by phone or in person. If you need these services in person, in most cases you will need to call your provider at least five (5) days before your appointment, if possible. Interpreter services are covered free of charge. If you need help with this process, contact our Customer Service Department. 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 contracted provider right away if you become pregnant. Please also contact your case worker as soon as possible. He or she will make sure you do not lose medical coverage before your baby is born. If you don t have a caseworker, call OHP at (800) Covered by PacificSource Community Solutions. You can see any provider in our network for this service. You do not need to be referred by your primary care provider (PCP). Covered by PacificSource Community Solutions. Services include: Prenatal visits; Labor and delivery; and Postpartum care (care for you after your baby is born). You do not need to be referred by your primary care provider (PCP) if you choose to see an obstetrician in our network for this service. The plan will not pay for routine pre-natal care that is done by a non-contracted provider. It is important to begin prenatal care early in your pregnancy and continue with regular medical care. You also 24

26 need to tell OHP or your case worker at DHS 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 the time of delivery, the plan 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. Naturopathy Includes services provided by a licensed naturopathic doctor (N.D.). Naturopathic doctors are trained in alternative healthcare. Newborn Coverage These services may be covered for treatment of a covered illness or injury. You must get a referral from your PCP for these services. Services must be approved in advance by PacificSource. Covered by PacificSource Community Solutions Please call your case worker or OHP as soon as your baby is born. Your baby has medical coverage until his or her first birthday, even if you are no longer eligible for Oregon Health Plan benefits. When you call your case worker, have the following information ready: Baby s name; Baby s Social Security number (or call again as soon as you have one); Date of birth; Parents names; and Sex of baby. Once you have enrolled your newborn, check your next coverage letter to make sure he or she is listed. If not, call OHP or your case worker again. Please call our Customer Service Department to tell us who your baby s PCP is, or if you need help finding one. Occupational Therapy Services that help develop small muscles. These services may be covered for treatment of a covered illness or injury. Services must be approved in advance by the plan. (See exceptions and limitations below.) Initial evaluations and re-evaluations do not require pre- 25

27 Office Procedures For example: steroid injections, laparoscopies, varicose vein treatments, and other services. Pap Tests, Pelvic Exams, and Clinical Breast Exam One exam every 12 months for women. Physical Exams Includes: One exam every calendar year for members ages One exam every 4 years for members ages One exam every 2 years for members age 35 and older. Physical Therapy Services that help develop large muscles. Prescription Drugs (see page 31 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 (PCP) Office Visits (see page 10 for more information) approval, but are limited to: Up to two initial evaluations in any 12-month period; and Up to four re-evaluation services in any 12-month period. These services may be covered for treatment of a covered illness or injury. Some services must be approved in advance by PacificSource. Covered by PacificSource Community Solutions. You can see any contracted provider and do not need to be referred by your primary care provider (PCP). Covered by PacificSource Community Solutions when done by your primary care provider (PCP). These services may be covered for treatment of a covered illness or injury. Services must be approved in advance by PacificSource. (See exceptions and limitations below.) Initial evaluations and re-evaluations do not require preapproval, but are limited to: Up to two initial evaluations in any 12-month period; and Up to four re-evaluation services in any 12-month period. Covered by PacificSource Community Solutions for a covered illness or injury. Some drugs must be approved in advance by PacificSource. Most drugs to treat mental health or drug and alcohol conditions are covered by the Oregon Health Authority and not PacificSource Community Solutions. Covered by PacificSource Community Solutions. Some treatments at your PCP s office must be approved 26

28 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. Prostate Cancer Screening Includes: One rectal exam every 12 months for men age 50 or older. Prostate testing as recommended by your provider. Rides to Healthcare Appointments If getting to your appointments is a problem, you may take the bus, have a friend or relative drive you, or find a volunteer from a community agency. in advance by PacificSource. Covered by PacificSource Community Solutions. These are covered by the Oregon Health Plan directly; not covered by PacificSource Community Solutions. 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: Cascades East Ride Center (Baker, Crook, Deschutes, Grant, Harney, Jefferson, Malheur, Union and Wallowa Counties) (541) (866) Toll-free (800) TTY If your county is not listed, call your case worker at DHS or your local DHS office to find out about transportation in your area. If you have arranged transportation with one of these centers and you cancel or change your appointment, let them know. 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 These services may be covered for treatment of a covered illness or injury. Services must be approved in advance by PacificSource. 27

29 Skilled Nursing Facility care. Specialist Office Visits You must be referred by your primary care provider (PCP) to see a specialist, unless it is for women s routine, preventative healthcare or maternity services. (See page 13 for exceptions to the referral requirement.) Some treatments at specialist offices must be approved in advance by PacificSource. Speech Therapy Services that help develop the voice. Substance Use Help to stop using drugs and alcohol. Surgeries Stop Smoking/Tobacco Cessation Services These include: Acupuncture; Classes or phone counseling; Nicotine patches, gum, and lozenges; Provider office visits to help you quit These services may be covered for diagnosis and treatment of a covered illness or injury. Services must be approved in advance by PacificSource. If you are an ICCS (Intensive Care Coordination Services) member, you do not need a referral from your PCP for an initial specialist visit. Additional visits require approval in advance from the plan. These services may be covered for treatment of a covered illness or injury. Services must be approved in advance by PacificSource. (See exceptions and limitations below.) The following services do not require approval in advance: Up to two evaluations of speech/language in a 12- month period; Up to two evaluations for dysphagia (difficulty swallowing) in a 12-month period; Up to four re-evaluations in a 12-month period; One evaluation for speech-generating/augmentative communication system or device in a 12-month period. Covered by PacificSource Community Solutions. See Drug and Alcohol Treatment. These services may be covered for treatment of a covered illness or injury. Inpatient surgeries and some outpatient surgeries must be approved in advance by PacificSource, except in the case of an emergency. Please see Emergency Services section on page 14. Please call Customer Service to find out which services need an approval in advance. Covered by PacificSource Community Solutions. Call Quit for Life Program at (866) Toll-free, (877) TTY for more information about this program and how it works. Para inscribirse en Español, llame al (866) y oprima 2. 28

30 smoking; and Some medications used for the treatment of tobacco. Urgent Care Services If you are unable to contact your primary care provider s office, and you have a medical condition that is not an emergency but cannot wait for a doctor s appointment or is outside of your primary care provider s office hours, consider going to an Urgent Care center. Vision Care (Medical Conditions) (also see Eye Health) These are services for medical eye conditions, such as glaucoma and diabetes and eye injuries. Vision Care (Routine Exams, Fitting and Glasses/Contact Lenses) for Children up to Age 20 and Pregnant Women For members who meet criteria for coverage of routine vision care: You do not need a referral from your primary care provider (PCP). You must see a PacificSource Community Solutions contracted provider. Basic glasses are covered in full, but if you want to buy more expensive (deluxe) glasses, you will need to pay the full price. Under OHP policies, the plan cannot pay the difference between the amount covered and the cost of more expensive glasses. Covered by PacificSource Community Solutions. You must be referred by your primary care provider (PCP) to see a specialist for covered medical conditions of the eye. Services and treatment may need to be approved in advance by PacificSource Community Solutions. Covered by PacificSource Community Solutions for member: Ages birth to 20. May be covered more than once a year as long as the records support the medical need. Contact Lenses are only covered when glasses cannot be worn for medical reasons. Coverage must be approved in advance by PacificSource. Not covered for members over 21 years, unless you are pregnant. If so, then: Covered once every 24 months. Glasses with a prescription equal to or less than +/-.25 diopters in both eyes are not covered. For members over 21 and not pregnant, these are only covered for the following diagnoses: Eye Injury Aphakia Pseudoaphakia Congenital Aphakia Keratoconus Cataracts Congenital cataracts If you have been diagnosed with these conditions, it is covered every 24 months. 29

31 Well-Child Care Well-child care is covered for children and young people to help them stay healthy. Even if your child is not sick, he or she needs to see their primary care provider (PCP) for regular checkups. Visits for illness or injury are covered separately. Covered by PacificSource Community Solutions. See your child s primary care provider (PCP) for this Service. Services include: Dental referrals; Exams; Health Education; Hearing and vision tests; Immunizations; Lead testing; and Nutrition information. These health exams follow a schedule: Birth to 24 months 7 visits. Ages 2 to 18 one exam every calendar year. Some services need to be approved in advance (pre-approved) by PacificSource Community Solutions. 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 network 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 30

32 PRESCRIPTION DRUGS PacificSource Community Solutions covers prescription drugs for conditions paid for by the Oregon Health Plan. Family planning drugs, some over-the-counter products, and some devices are also covered. Drugs used to treat behavioral health and chemical dependency (drug and alcohol addiction) conditions are covered by the Oregon Health Authority (OHA). Please have your pharmacy bill OHA directly and not PacificSource Community Solutions for these types of prescriptions. For more detailed information about your prescription drug benefit, please refer to the Formulary (Drug List) on our website. Important! All items for covered conditions require a prescription from your primary care provider (PCP), behavioral health provider, or specialist. PacificSource will pay for your covered medications and covered over-the-counter products. However, you must present a valid prescription and your plan ID card to a participating pharmacy. Most pharmacies are participating with our plan. If you have specific questions about a pharmacy provider near you please call our Customer Service Department. PacificSource Community Solutions has developed a list of prescription drugs and some over-the-counter drugs that are available to you. This list is also called a drug formulary. It includes both brand name and generic medications that are safe and effective. It is required that you use generic drugs when they are available. To determine if a drug you take is covered on the list or has special coverage restrictions, please call our Customer Service Department. If your provider feels you should get a drug that is not on the list, he or she may ask for a Pre-Approval. The request must tell us why other medications are not a good choice for you. Once we review the request, we will tell you and your provider in writing of our decision. If it is approved, you will then be able to fill the prescription or get a similar drug that is on the drug formulary. If it is denied, you can appeal the denial and ask us to change our decision. If you are a new member with PacificSource Community Solutions, please call our Customer Service Department to find out if the drugs you take are on the list of covered medications or have special coverage restrictions. If a drug you take is not covered or it has special restrictions, please ask your provider to send a request with your medical records to the plan s Pharmacy Services Department. If you are unable to see your provider before you run out of a medication you are currently taking, you can ask for a temporary exception. Please have your provider call or fax our Pharmacy Services Department at (541) or toll-free at (888) The plan s Pharmacy Services fax number is (541)

33 EXCLUSIONS Exclusions are services are not covered for any member under the Oregon Health Plan. You may be able to pay for some of these services yourself. Please contact Customer Service if you want to receive a complete list of these services. Buy-ups (To buy-up means you get an item that is not covered by OHP or the plan by paying the difference between the item the plan covers and a more expensive, noncovered model). Circumcisions. Cosmetic services. Determined not medically or dentally appropriate. Determined not to significantly improve the basic health of the member. Immunizations (shots) for foreign travel. Incontinence items, including creams, salves, lotions, barriers (liquid, spray, wipes, powder, paste), devices, or other skin care products. Lifts (barrier-free ceiling track, chair, mechanism, stairs, or van). Personal comfort or convenience items such as hot tubs, treadmills, whirlpools, Band- Aids and bandages, tape, chairs, humidifiers, exercise equipment, cleansers, medical alert bracelets, thermometers, etc. Self-help programs (like Alcoholics Anonymous). Services received outside the United States including Mexico and Canada. Services that are considered experimental or investigational. Services that need to be approved in advance by PacificSource Community Solutions, and were not pre-approved. Services to help you get pregnant or for treatment of sexual dysfunction, including impotence. Services covered by other responsible parties (like workers compensation, car insurance, and other coverage). Treatment for conditions that are not covered by OHP ( Below the Line. ) Weight loss programs (like Nutrisystem, Weight Watchers, and other similar programs). You may choose to receive non-covered services. However, you will have to pay for these services. Before receiving any non-covered service, you and your provider must agree in writing that you will pay for the service. 32

34 MEMBERS WITH BOTH MEDICARE AND MEDICAID COVERAGE The following information is for any member of your household who has both Medicare and Medicaid (OHP) coverage: We call them dual eligibles or duals. Medicare is health insurance that you pay for when you are working. It is run by the federal Centers for Medicare and Medicaid Services (CMS). When you become eligible for Medicare, the Oregon Health Plan (OHP) will stop paying for your prescription drugs. Instead, the Medicare Prescription Drug program will pay for your drugs. This drug benefit will be Part D of your Medicare coverage as soon as you are enrolled with Medicare. Medicare may require copays for Part D drug coverage. Some duals have their copays covered by Medicaid. OHP will continue to pay for all other covered health services. GRIEVANCES AND APPEALS Grievance (Complaints) Your providers want to give you the best care possible. There may be times when you are not satisfied with a service you received. If you have a grievance (also called a complaint) about a provider s services or treatment please talk about it with your provider. If you do not want to talk about it with your provider, or if you feel that the complaint is about a problem that we should look into (for example, if you feel you are treated differently than other patients,) please do the following: Call our Customer Service Department for help in resolving it. You can do this in person, over the phone at (541) , toll-free at (800) , TTY at (800) , or in writing. We will also look into problems with the services you received from PacificSource or our staff. Complaints can be submitted by you or your representative. You also have the right to have a qualified community health worker, qualified peer specialist, or a personal health navigator help you do this. A provider cannot act as your authorized representative for filing a grievance. For more information, please call Customer Service at: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments For written complaints, please send them to: PacificSource Community Solutions Attn: Grievance/Appeals PO Box 5729 Bend, OR

35 You can also fax them to (541) A letter will be mailed to you within five (5) calendar days of receipt of your complaint. It will tell you how the complaint was resolved or whether we need more time to gather more information to resolve it. If we do request more time, your complaint will be resolved within 30 calendar days. You need to give us permission to investigate and help you resolve the issue. Please note that we will not tell anyone anything about your complaint unless you ask us to. If you are not happy with our answer, you can also file the complaint with the Oregon Health Authority (OHA) Governor s Advocacy Office. You can call them at (503) , or toll- free at (800) The TTY number is 711. Their fax number is (503) Appeals The plan also has an appeals process if you disagree with a decision to deny coverage of medical or behavioral health services. The deadline to file an appeal is 45 calendar days from the date in the denial letter you receive from us. The denial letter is called a Notice of Action. In order to process your appeal, we must have it in writing. Your denial letter will include an appeal form. You or your authorized representative can fill it out. Your provider can file it for you with your written permission. You can call Customer Service and we will fill it out for you, and send it to you to sign. You may also write a letter to us with your concerns. If you need another form or want help, call Customer Service at (541) , toll-free at (800) , or TTY at (800) We will send you another form, help you in filling it out or guide you through the appeals process. You also have the right to have a qualified community health worker, qualified peer specialist, or a personal health navigator help you in sending us an appeal. For more information, please call Customer Service at: (541) Local (800) Toll-free (800) TTY line for people with hearing impairments The written appeal should be sent to: PacificSource Community Solutions Attn: Grievance/Appeals PO Box 5729 Bend, OR You can also fax it to (541) It is helpful to include any supporting documents you feel will help us in making a decision. You have 45 calendar days to submit your request. You do not have to wait until you have gathered all your information to send us the appeal. You can give us additional information during the appeals process. You can also tell us who to call and we can get it ourselves. 34

36 We will send you a letter within five (5) calendar days of having received your appeal. This is to let you know we are looking into your issue. All issues are reviewed carefully. It may take up to 16 calendar days to give you a written decision. You need to give us permission to look into and help you resolve the issue. Please note that all information gathered during this process is kept private. You may qualify for a fast (or expedited) appeal if you have not received the services and the 16 calendar day timeframe of a regular appeal could put your health or life in danger. If you feel this is your situation, you can ask for a fast appeal. A qualified healthcare reviewer will look at your healthcare records and decide if we should make a fast decision. We will get back to you with a decision by phone (if possible) within 3 days of the time we received the request. If the healthcare reviewer decides that you do not qualify for a fast appeal, your appeal will be processed under the 16 calendar day timeframe. If your provider supports your request for a fast appeal, we will automatically process it in 3 days. Your provider must contact us by phone or in writing to tell us of this need. For both standard and fast appeals, we can extend the review timeframe up to 14 calendar days. We would do this if either you or the plan need more time to get information that would benefit your appeal. Your provider can support your appeal by sending us your medical records when we ask for them. If your provider is in the PacificSource network, he or she can also file an appeal to have services covered for you. Your provider should include your medical records with their appeal. Please note: If your provider files the appeal and if the decision is still to deny coverage, he or she will not have the right to act as your authorized representative for an Administrative Hearing (see next section). Having a provider file an appeal on your behalf does not mean that your 45 calendar day timeframe to file an appeal will be extended. Administrative Hearings When you receive a denial letter from us, you or your representative also have the option to ask for an Administrative Hearing through the State. If you file an appeal and are still not satisfied with the results, you or your representative may ask for an Administrative Hearing. Your provider cannot act as your authorized representative in a hearing, but they can be with you and help you. You do not have to file an appeal first to ask for a hearing. Denial letters sent to you by PacificSource Community Solutions will have an Administrative Hearing Request form (DHS 443) included. To ask for a hearing, fill out the DHS 443 form and turn it in to any local Department of Human Services (DHS) branch office, your DHS case worker, or send it to: Division of Medical Assistance Programs Attn: Hearings Unit 500 Summer St NE, E49 Salem, OR Fax: (503)

37 If you are filing the hearing request after an initial denial letter from PacificSource Community Solutions, the DHS 443 must be received within 45 calendar days from the date of the denial letter. If you are filing the hearing request after we have processed an appeal for you, the DHS 443 must be received within 45 calendar days from the date of the Notice of Appeal Resolution. Make sure you include a copy of the Notice of Action denial letter or Notice of Appeal Resolution with your hearing form. Hearings are held before a neutral person called an Administrative Law Judge. They are usually held over the phone, but you can request one in person. Representatives from the Division of Medical Assistance Programs (DMAP) and PacificSource Community Solutions will be at the hearing. If you need an interpreter, your Hearings Representative will arrange for one. At the hearing, you can explain why you do not agree with the plan s decision, and why the services requested should be covered. You do not need to hire a lawyer, but you can have one or someone else help you with the hearing. You can fill out the section in the hearing request form to name a representative who will speak for you at the hearing. The representative can be anyone you choose, but it cannot be your provider. Make sure that the representative you name is willing and able to speak for you at the hearing. You can also have witnesses speak (for example: your child, friend, caregiver, or provider). Neither DMAP nor PacificSource Community Solutions will pay for the cost of a lawyer. However, you may try the following options: Call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) toll-free at (800) , TTY 711 for advice and possible representation. Legal Aid information can also be found at You also may be able to get free or reduced-cost legal services through the Oregon State Bar Association at (800) If your problem is resolved after you have requested an Administrative Hearing, please let the DMAP or AMH Hearings representative handling your case know about it. Continuation of Benefits The plan may continue to cover the service requested while waiting for an appeal or hearing decision. In order to do this, you must ask for the continuation of benefits within 10 calendar days of the date on the denial letter. You must also ask for the appeal or State Fair Hearing within 45 calendar days of the denial letter. The request must deal with a termination, suspension, or reduction of a service that had already been approved for coverage. (For example, PacificSource Community Solutions approved 20 physical therapy visits. After you had been to 10 visits, the Plan decided not to cover the other 10.) The services must have been ordered by an authorized provider. The original period covered by the original approval must not have expired. If we continue to cover the services requested under the above circumstances, we will cover them while waiting for the decision, until one of the following occurs: 1. You cancel the appeal or hearing; 36

38 2. The appeal decision or final order on the hearing is not to your benefit; or 3. The effective dates for the previously approved service have expired, or you have used up the number of approved services. If the decision on the appeal or hearing is not to your benefit, the plan will ask for the money back on any services that were covered after you received the denial letter. Appeal rights available to providers to challenge the failure of the CCO to cover a service If services have been denied to you, your providers are allowed to file an appeal on your behalf. They need to have your written permission to do so. There is a form they can use located on our website, at Your provider should include your medical records with their appeal, and a reason why the plan should cover the service. Please note: If your provider files the appeal and if the decision is still to deny coverage, he or she will not have the right to act as your authorized representative in an Administrative Hearing. Having a provider file an appeal on your behalf does not mean that your 45 calendar day timeframe to file an appeal will be extended. Medicare Appeals If you also have Medicare benefits, you may have additional appeal rights. Please call our Customer Service Department for more information about this. COORDINATION OF BENEFITS Please notify Customer Service if you or someone in your family has other insurance with any other companies (besides Medicare). We need to make sure the correct insurance pays for any claims. Third Party Liability Please let us know if you are injured in an automobile, at work, or if someone else is responsible to pay for your injury. We need to make sure the correct insurance is billed. Full use must be made of other possible resources to pay for any injuries. We will generally make payment on claims only when other means are not available for your medical needs. 37

39 YOUR RIGHTS Member Rights As an OHP member, you have the following rights: To be treated with dignity and respect To be treated by providers the same as other people seeking health care benefits to which you are entitled To get covered mental health, substance abuse treatment, family planning, or related services without a referral To have a friend, family member, or advocate with you during appointments and at other times as needed within clinical guidelines To be actively involved in making a treatment plan To get information about your condition and covered and non-covered services, to allow an informed decision about proposed services(s) To agree to or refuse services except for court-ordered services To be told the results of agreeing or refusing services To get written materials describing rights, responsibilities, benefits available How to get services, and what to do in an emergency To get written materials explained in a manner that can be understood To get necessary and reasonable services to diagnose the presenting condition To get covered services under the OHP which meet generally accepted standards of practice and are needed To get covered preventive services To get a referral to a specialist for needed, covered services To have a clinical record maintained which documents conditions, services received and referrals made. To have access to your own clinical record, unless restricted by law or OARs To have your medical records corrected To transfer a copy of your clinical record to another provider To make a statement of wishes for services (Advance Directive) and get a power of attorney for health care To get written notice before a denial of, or change in, a service level or benefit is made unless such notice is not required by federal or state OARs To know how to make a complaint, grievance or appeal and get a response To request an administrative hearing with the DHS or OHA To get a notice of an appointment being cancelled in a timely manner To get adequate notice of DHS/OHA privacy practices Select or change your provider Have the plan's written materials explained so you can understand it Make complaints and not be treated bad by the plan or provider Get care when you need it, 24 hours a day, seven days a week Be able to limit who can see your health records Help make decisions about your health care, about: 38

40 o refusing services, without being held down, o being kept away from other people, o being forced to do something you don t want to do To exercise all rights if the member is a child, as defined by OARs PacificSource Community Solutions Provider Payments and Incentives You have the right to ask if the plan gives our providers special payments. Special payments 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, 8:00 a.m. to 5:00 p.m., Monday through Friday at (541) , or toll-free (800) TTY users should call (800) Ask for information about our provider payment arrangements. PacificSource Community Solutions Business Structure and Operations You have the right 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 8:00 a.m. to 5:00 p.m., Monday through Friday at (541) , or toll-free (800) TTY users should call (800) Ask for information about our company structure. Residential Services Rights In addition to the rights listed above, every individual receiving residential services has the following rights: To a safe, secure and clean living environment To a humane service environment that has: o reasonable protection from harm o reasonable privacy o daily access to fresh air and the outdoors To keep and use personal clothing and belongings To have enough private, secure storage space To express sexual orientation gender identity and gender presentation To get to and participate in social, religious and community activities To private and uncensored communications by mail, telephone and visitation, subject to the following restrictions: o This right may be restricted only if the provider documents in the individual s record that there is a court order that says something else, or o that in the absence of this restriction, significant physical or clinical harm will result to the individual or others. (The nature of the harm must be specified in reasonable detail. Any restriction of the right to communicate must be no broader than necessary to prevent this harm) and o the individual and his or her guardian, if applicable, must be given specific written notice of each restriction of the individual s right to private and uncensored communication. o The provider must make sure that correspondence: o can be conveniently received and mailed, o that telephones are reasonably able to use and allow for confidential 39

41 communication, (Reasonable times for the use of telephones and visits may be established in writing by the provider) o that space is available for visits. To have access to and get available and applicable educational services in the most integrated setting in the community To communicate privately with public or private rights protection programs or rights advocates, clergy, and legal or medical professionals; To participate regularly in indoor and outdoor recreation To not be required to perform labor To have enough food and shelter To a reasonable accommodation if, due to a disability, the housing and services are not sufficiently accessible YOUR RESPONSIBILITIES Member Responsibilities As an OHP member, you have the following responsibilities: To choose, or help with assignment to, a managed care plan (such as PacificSource Community Solutions) To choose a primary care provider (PCP) To choose or help us assign you to a behavioral health provider To take your PacificSource Community Solutions Identification (ID) card with you whenever you need care To treat PacificSource Community Solutions staff and health provider staff with respect To be on time for appointments or call in advance to cancel if you are not able to make it or if you are running late To tell your provider of your behavioral health problems To decide about care before it is given To get behavioral health services from contracted providers. You may get services from non-contracted providers only in an emergency To call PacificSource Community Solutions Customer Service to tell us of an emergency within 3 days To use only your assigned behavioral health provider for your behavioral health needs To seek periodic health exams and preventive services from your providers To have yearly check-ups, wellness visits and other services to prevent illness and keep you healthy To use your PCP or clinic for diagnostic and other care except in an emergency To get a referral from your PCP before seeking care from a specialist To use urgent and emergency services appropriately To give accurate information that is included in your medical records To help your providers obtain your medical records from other providers, which may include signing an authorization for release of information To ask questions about conditions, treatments, and other issues related to your care that you don t understand 40

42 To use information to make informed decisions before receiving treatment To be honest with your providers to get the best service possible To help create treatment plans with your provider or behavioral health provider To follow prescribed treatment plans to which you have agreed To tell the provider that you have OHP coverage before receiving services and to show your plan ID card upon request To tell your case worker if you change your address or phone number; To tell your case worker if you become pregnant, let him or her know when you are no longer pregnant, and/or when your baby is born To tell your case worker if any family members move in or out of your house To tell your case worker and providers if you have any other insurance available To pay for services that are not covered by your plan To help the plan in pursuing any third party resources available (such as Workers Compensation or auto insurance) To pay the plan the amount of benefits it paid for an injury from any recovery received from that injury To let the plan know of any issues, complaints, or grievances To sign an authorization for release of healthcare information so that OHP and the plan can get information needed to respond to an Administrative Hearing request MEMBER PARTICIPATION WITH PACIFICSOURCE COMMUNITY SOLUTIONS You have the opportunity to participate with the plan in a number of ways including: 1. Completing and returning the Wellness Surveys. 2. ICCS (Intensive Care Coordination Services) Members, by requesting and participating in ICCS services. 3. Participating in Case Management and Care Coordination. 4. Following up on recommendations PacificSource Community Solutions suggests in letters, such as updating immunizations. 5. Participating in Disease Management programs. 6. Participating in Behavioral Health activities. DECLARATION FOR MENTAL HEALTH TREATMENT In a crisis or emergency, a person may be unable to make decisions about their mental health treatment. There is a form to say ahead of time what services the person does and does not want. This form is called a Declaration for Mental Health Treatment. The Declaration lets the person give the name of an adult who will make decisions for them. It lets the person say what hospital or other facility they prefer. It lets the person say what 41

43 medications are okay to use. It also lets the person say what they do not want. The Declaration is only valid in Oregon since other states have different rules. Your provider can tell you about the Declaration. They can give you a copy and even help you to fill it out. You can also get a copy of the Declaration at no cost to you by calling our Customer Service Department toll-free at (800) or the OHA Addictions and Mental Health Division at (503) If you are hearing impaired, use TTY (503) Your provider or PacificSource Community Solutions must provide you with a copy of your Declaration if you ask for it. If you are not given a written copy, you can file a complaint with the OHA (Oregon Health Authority) by calling toll-free (800) For more information on the Declaration for Mental Health Treatment go to the State of Oregon s website at: If your provider does not follow your wishes as stated in your Declaration for Mental Health Treatment, you can call (503) or (503) , or write a complaint to: State Survey and Certification Agency Office of Licensing and Quality Care 500 Summer Street NE, E-13 Salem, OR ADVANCE DIRECTIVES If you are an adult, you have the right to know about any medical treatment your provider recommends, and to refuse it if you choose. However, a serious illness or injury could mean you are unable to make decisions or let someone know what you want. Oregon has a law that allows you to say ahead of time, in writing, how you want to be treated if you were seriously ill or injured and unable to make these decisions for yourself. This is done through a legal form called an Advance Directive. The Advance Directive lets you name a person to make healthcare decisions for you if you are not able to do so. This person is called your healthcare representative. They must agree to represent you by signing the form. Your healthcare representative does not need to be a lawyer or healthcare professional. It should be someone with whom you have discussed your wishes in detail. The Advance Directive also lets you give instructions in advance for health providers to follow if you become unable to say what you want (for example, if you are in a coma). It lets you tell your provider to either continue or stop life-sustaining help if you are near death. It also tells your provider if you do not want to have your life prolonged if you have an injury or disease that two doctors agree you will not recover from. You will get care for pain and comfort no matter what choices you make. 42

44 As long as you are able, you have the right to decide your own healthcare, even if you have completed an Advance Directive. Completing this form is your choice. The plan will not interfere with the instructions provided in your advance directive. If you choose not to complete the form, it will not affect your health plan coverage or your ability to access services. We are required to update this handbook within 90 days from the date of any change in state law that affects the information in this handbook about Advance Directives. You can get a copy of the Advance Directive at no cost to you by calling our Customer Service Department or your local hospital. You can also obtain it from other sources, such as Oregon Health Decisions, by calling (503) , toll-free (800) , or online at The Advance Directive is only valid if you voluntarily sign it when you are of sound mind. Unless you limit the duration, it does not have an expiration date. However, you can cancel it at any time. Your provider or our plan must provide you with a copy of your Advanced Directive upon request. If you do not receive a written copy, you can file a written complaint with the DHS Division of Medical Assistance Programs (DMAP). Call (800) to file a complaint. For questions or more information, contact Oregon Health Decisions at (800) or (503) , TTY 711. If your provider does not follow your wishes as stated in your Advance Directive, you can call (503) or (503) , or write a complaint to: State Survey and Certification Agency Office of Licensing and Quality Care 500 Summer Street NE, E-13 Salem, OR NOTICE OF PRIVACY PRACTICES The Notice of Privacy Practices will tell you how PacificSource Community Solutions may use or disclose health information about you. This information is called Protected Health Information (PHI). Not all situations will be described. We are required to protect health information by federal and state law. We are required to follow the terms of the notice currently in effect. When this notice says we, it means PacificSource Community Solutions. You have the right to ask for a copy of this notice at any time. You may view this notice on line at We may use and disclose health information without your approval: 43

45 For Treatment. We may use or disclose PHI with healthcare providers who are involved in your healthcare. For example, information may be shared to create and carry out a plan for your treatment. For Healthcare Operations. We may use or disclose PHI in order to manage programs and activities. For example, we may use PHI to review the quality of services you receive. We may use or disclose health information without your approval for the following purposes under limited circumstances: Appointments and Other Health Information. We may send you reminders for medical care or checkups. We may send you information about health services that may be of interest to you. For Health Oversight. We may use or disclose PHI for government healthcare oversight activities. Examples are audits, investigations, inspections, and licenses. For Law Enforcement and As Required by Law. We will disclose PHI for law enforcement and other purposes as required or allowed by federal or state law. For Disputes and Lawsuits. We will disclose PHI in response to a court order. We will disclose PHI in response to an administrative order. If you are involved in a lawsuit or dispute, we may share your information in response to legal requirements. Worker s Compensation. We may disclose PHI as allowed by law to worker s compensation or like programs. To Avoid Harm. We may disclose PHI in order to avoid a serious threat to your health and safety or to the health and safety of a person or the public. For Research. We use PHI for studies and to develop reports. These reports do not identify specific people. Disclosures to Family, Friends, and Others. We may disclose PHI to your family or other persons who are involved in your healthcare. You have the right to object to the sharing of this information. Other Uses and Disclosures Require Your Written Permission For other purposes, we will ask for your written permission before using or disclosing PHI. You may cancel this permission at any time in writing. We cannot take back any uses or disclosures already made with your permission. Other Laws Protect PHI. Many programs have other laws for the use and disclosure of health information about you. For example, usually you must give your written permission for us to use and disclose your mental health and chemical dependency treatment records. Your PHI Privacy Rights Right to See and Get Copies of Your Records. In most cases, you have the right to look at or get copies of your health records. You may be charged a fee for the cost of copying your records. You must make the request in writing. Please send it to PacificSource Community Solutions, PO Box 5729, Bend, OR We will answer your request within 30 days. If for any reason this information is not in our office, we will answer within 60 days. 44

46 Right to Request a Correction or Update of Your Records. You may ask to change or add missing information to health records we created about you, if you think there is a mistake. You must make the request in writing, and provide a reason for your request. We may deny your request in certain circumstances. Right to Get a List of Disclosures. You have the right to ask us for a list of your PHI disclosures made after April 14, You must make the request in writing. This list will not include the times that information was disclosed for treatment, payment, or healthcare operations. The list will not include information provided directly to you or your family, or information that was sent with your authorization. If you request a list more than once during a 12-month period, you may be charged a fee. Right to Request Limits on Uses or Disclosures of PHI. You have the right to ask that we limit how your health information is used or disclosed. You must make the request in writing and tell us what information you want to limit and to whom you want the limits to apply. We are not required to agree to the restriction. You can request in writing or verbally that the restrictions be ended. Right to Revoke Permission. If you are asked to sign an authorization to use or disclose PHI, you can cancel that authorization at any time. You must make the request in writing. This will not affect information that has already been shared. Right to Choose How We Communicate with You. You have the right to ask that we share PHI with you in a certain way or in a certain place. For example, you may ask us to send information to your work address instead of your home address. You must make this request in writing. You do not have to explain the reason for your request. Right to File a Complaint. You have the right to file a complaint if you do not agree with how we have used or disclosed health information about you. Your benefits will not be affected by any complaints you make. We cannot hold it against you if you file a complaint. We cannot hold it against you if you cooperate in an investigation. We cannot hold it against you if you refuse to agree to something that you believe to be unlawful. Right to Get a Copy of this Notice. You have the right to ask for a copy of this notice at any time. Using Your Rights and Complaints If you think your privacy has been shared when it should not have been, you may send a written complaint to our Privacy Contact. Privacy rules are overseen by the Compliance Officer, who also acts as the Privacy Officer. This privacy notice is effective April 14, We will not treat you badly because of your complaint. Please send your complaint to: PacificSource Community Solutions: Attn: Grievance/Appeals PO Box 5729 Bend, OR You may also send your complaints to: 45

47 Oregon Health Authority Ombudsperson 500 Summer Street NE, E-17 Salem, OR Fax (503) Phone (800) Toll-free 711 TTY U.S. Department of Health and Human Services 200 Independence Ave. SW Room 509F, HHH Building Washington D.C (866) Toll-free (886) TTY If you have any questions please call Customer Service at: (541) Local (800) Toll-free (800) TTY 46

48 GLOSSARY Action, in the case of the plan, means the denial or limiting of a requested service, including the type or level of service; 1. The limiting or stopping of a previously approved service; 2. The denial, in whole or in part, of payment for a service; 3. The failure to provide services in a timely manner as defined by the State; 4. The denial of a Medicaid enrollee s request to get services outside the network. Addictions & Mental Health Division (AMH) of the OHA provides access to mental health and addiction services and supports meeting the needs of adults and children. Administrative Hearing means a hearing before an Administrative Law Judge about an action by PacificSource Community Solutions (such as a denial, limiting or stopping of benefits) that is held upon your request. A hearing may also be held if you believe a claim for services was not acted upon promptly or PacificSource Community Solutions took the wrong action with it. Advance Directive is a legal form that lets you name a person to make healthcare decisions for you if you are not able to do so. Oregon has a law that allows you to say ahead of time, in writing, how you want to be treated if you were seriously ill or injured and unable to make these decisions for yourself. Aim High (AMHI) is a program to help adults in residential settings get better mental health care. It also helps adults with mental illness get more and better services in the community. The goal is to keep people healthy outside of the State Hospital. Appeal is a request for review of an action as action is defined in 42 CFR (and in this glossary). Complaint is an expression of concern or dissatisfaction that you or your authorized representative want addressed, about any aspect of service, such as access to care, quality of service, quality of clinical care, interaction with providers and staff or PacificSource Community Solutions, or concerns about your rights as consumer. A complaint is also called a grievance. Coordinated Care Organization (CCO) is a health plan that includes all types of healthcare providers who have agreed to work together in their local communities for people who receive healthcare coverage under the Oregon Health Plan. Consultation is advice given from one provider to another about your care. Contracted Provider is someone in the PacificSource network of providers who has agreed to work with PacificSource Community Solutions in providing services to our members. They accept our payment in full for covered services. 47

49 Copay is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit or a prescription drug. Crisis Services are services for things such as feeling out of control, feeling the potential for harming yourself or others, or anything that you believe needs immediate attention. Declaration of Mental Health Treatment is a legal form that lets you name a person to make behavioral healthcare decisions for you if you are not able to do so. Oregon has a law that allows you to say ahead of time, in writing, how you want to be treated if you were in a crisis and are unable to make these decisions for yourself. Department of Human Services (DHS) is Oregon s agency responsible for social programs. DHS Worker is a staff person with DHS who is assigned to help you with questions. Division of Medical Assistance Programs (DMAP) is the OHA office that runs the Oregon Health Plan. Emergency Medical Condition is a medical condition with acute symptoms of such severity (including severe pain) that a careful person with an average understanding of health and medicine, could reasonably expect that no immediate medical attention would result in the following: 1. Placing the health of a person (including a pregnant woman s unborn child) in serious danger. 2. Serious injury to bodily functions. 3. Stop the functioning of any bodily organ or part. Emergency Services are covered inpatient and outpatient services that are: 1. Given by a provider that is qualified to provide the services. 2. Needed to evaluate or stabilize an emergency medical condition. Evaluation is a way to decide what healthcare services you may need. Excluded Services are certain services or items are not covered under any program or for any group of eligible Clients. If the Client accepts financial responsibility for a Non-Covered Service, payment is a matter between the Provider and the Client. (See the requirements of OAR ) Grievance is a statement of dissatisfaction about any matter other than an action, as defined in CFR. See Complaint. Intensive Care Coordination Services (ICCS), formerly Exceptional Needs Care Coordination (ENCC), services to assist members who are aged 65 or older, blind, or disabled and have complex medical needs. ICCS care coordinators help arrange healthcare services. This includes services after leaving the hospital, and community and social services. Members who have special medical supply or equipment needs, or who need help getting the right care, may ask for help from an ICCS coordinator. 48

50 Intensive Community Treatment and Support Services (ICTS) are special behavioral health services provided to children. Services occur through a team decision process that includes the child and family or guardian. Interpreter Services are services for members who do not speak the same language as the provider or are hearing impaired or deaf. Limited Services are behavioral health services that are only partly covered. You may have to pay for these services. You will have to pay if you know they are limited and choose to accept the care. This includes services that go beyond an evaluation. Medication Management is when someone besides your provider orders and monitors your medicines. This does not include paying for your medicines. Non-Contracted or Non-network Provider is a provider who has not agreed to enter into a contract with us. They generally do not accept our payment, as payment in full. Non-Covered or Excluded Services are services not covered by the Oregon Health Plan (OHP). Notice of Action is a notice sent to you when PacificSource Community Solutions denies either fully or in part, a requested service, including the type or level of service. This can also be a reduction temporary or permanent stopping, of a previously approved service. Oregon Health Authority (OHA) is the state agency that is responsible for most of Oregon s healthcare programs, including the Oregon Health Plan. Oregon Health ID is a card with your OHP insurance information on it. Keep this with you and show it at every health care visit. 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. Personal Health Navigator is a person in the community who helps patients find resources for medical and other needs. This can include help in making provider appointments, arranging rides, going to an appointment with the patient, following up after an appointment, helping the patient understand their health condition and ways to improve it, providing support, making home visits, applying for medical and other help (such as food stamps or housing), and helping with insurance forms. Post Stabilization Services are covered services related to an emergency medical condition and are provided after an enrollee is stabilized in order to keep them stable. Also, under the circumstances described in CFR (a)(e) to improve or resolve the enrollee s condition. Primary Care Provider (PCP) is a provider who has responsibility for coordinating your initial and primary care. PCPs give referrals for care outside their scope of practice as well as 49

51 consultations, and specialist care. They also assure the continuity of the right care. Provider is a qualified person, facility, or other health organization that provides medical, dental, or mental health services or items. Psychiatric Residential Treatment Services are services provided in a structured treatment environment with daily 24-hour supervision and active psychiatric treatment. Qualified Community Health Worker is another word for Personal Health Navigator (see definition above). Qualified Peer Specialist is a person in the community who helps members find resources related to their mental health needs. This person has similar life experience, provides social and emotional support, and is familiar with mental health, insurance processes, and other community resources. Service Area is the part of the state where the plan provides services under the OHP. Urgent Care consists of services that are medically appropriate and needed right away to prevent a person s physical or mental illness or injury from getting much worse. 50