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