Member Handbook 2013

Transcription

1 Member Handbook 2013

2 Cover photo: Lithia Park, Ashland, Oregon Left to right: At LaClinica Women s Health Center, Medford, certified midwife Loretta Sandoval examines Nancy. Jennifer helps her community by crocheting newborn caps for the local hospital. At LaClinica West Medford Health Center, Megan Orr, FNP, examines Jessica.

3 Welcome to Jackson Care Connect Toll Free TTY/TDD Mailing Address P.O. Box 1430 Medford, OR To submit an appeal in person, visit: 315 SW Fifth Avenue, Suite 900 Portland, OR Office hours: 8 a.m. to 5 p.m., Monday through Friday Behavioral health services provided by: Jackson County Mental Health Toll Free TTY/TDD E. Main St. Medford, OR Office hours: 8 a.m. to 12 p.m. and 1 p.m. to 5 p.m., Monday through Friday i

4 This handbook is available in different formats, including languages, large print, computer disk, audio tape, oral presentation or Braille. If you would like a different format, please call Jackson Care Connect toll free at Our TTY/TDD number is Este manual se encuentra disponible en diferentes formatos, incluyendo otros idiomas, letra grande, disco computacional, cinta de audio, presentación oral y Braille. Si le gustaría obtener un formato diferente, sírvase llamar al Servicio de Atencion al Cliente de Jackson Care Connect (Jackson Care Connect Customer Service) al El número para personas con dificultades auditivas (TTY/TDD) es ii

5 Contents Thank You for Choosing Jackson Care Connect... 1 Getting Plan Information... 1 What is the Oregon Health Plan?... 2 OHP Plus... 2 OHP Standard... 3 OHP Members Don t Pay Bills For Covered Services... 3 DMAP Coverage Letter... 3 Your Oregon Health ID Card... 4 Your Jackson Care Connect ID Card... 4 What is a Patient-Centered Primary Care Home?... 5 What is a Coordinated Care Organization?... 5 What are Managed Care and Fee-For-Service?... 5 If you want Fee-for-Service OHP instead of Managed Care... 6 Members with Both Medicaid and Medicare... 6 Your Rights and Responsibilities... 6 About Your Primary Care Provider (PCP)... 7 Your Primary Care Provider (PCP) Assignment... 7 Getting to Know Your PCP... 7 Changing your PCP... 8 Changing CCOs... 8 Getting Care When You Need It... 9 New Members Who Need Service Immediately... 9 Making Appointments to See your PCP... 9 Making Appointments to See a Mental Health Provider...10 Your Right to Have an Interpreter at Appointments...10 If You Must Miss a PCP Appointment...10 Mental Health Services...10 Direct Access to Specialists...11 Referrals to Other Providers...11 If You Need Care Out of Town...12 Urgent Care...12 After-Hours Care (Evenings, Weekends and Holidays)...12 Second Opinions...12 Emergencies and Crises...13 Mental Health Crisis...13 Suicide Prevention...14 What Are The Most Common Warning Signs?...14 Out of Town Emergencies...14 Health and Wellness...15 Baby, Child and Teen Health...15 Adult Immunization Schedule...15 Benefits and Services...16 Prioritized List of Health Services...16 Primary Care...16 Prescriptions...17 Prescription Coverage Limitations...17 Pharmacy...17 iii

6 How to team with your pharmacist...17 What to Ask your Provider about Prescriptions...18 How to Fill your Prescriptions...18 Mental Health Prescriptions...19 Specialty Care...19 Lab Tests, X-Rays and Other Procedures...19 Hospital Care...19 Family Planning...19 Hearing Services...20 Skilled Nursing Facility Care...20 Chemical Dependency (Drug and Alcohol) Treatment...20 Dental Services...20 Vision Care...20 Getting a Ride to Appointments...21 Medical Transportation...21 Child Care...22 Exceptional Needs Care Coordination...22 Care Management Teams...22 Non-covered Services...22 Will I Ever Have to Pay a Provider?...23 Native Rights...23 Outside the United States...24 Even More Support...24 If You Are Pregnant...24 Important To Know...25 Information for Birth Parents...25 Other Things You Should Know...26 End of Life and Advance Directives (Living Wills)...26 Declaration for Mental Health Treatment...26 Provider Incentives and Reimbursement...27 If you Change your Address or Phone Number...27 Disenrollment...27 Complaints and Appeals...28 Complaints (Grievances)...28 Appeals...28 Expedited Hearings for Urgent Medical Problems...29 A Copy of Your Records...30 Notice of Privacy Practices...30 Our Promise To You Regarding Your Health Information...30 How Jackson Care Connect Follows This Notice...30 Your Records are Private...31 How We May Use and Give Out Your Health Information...31 Health-Related Benefits and Services...32 Special Situations...33 Your Rights Regarding Medical Information About You...34 Meet Our Community Advisory Council...38 Frequently Asked Questions...38 iv

7 Thank You for Choosing Jackson Care Connect Jackson Care Connect works with the state of Oregon to provide services to Oregon Health Plan (OHP) members. With the help of members like you, providers, and hospitals and communities, Oregon has created a new type of health plan called a Coordinated Care Organization (CCO). With a CCO, you can get all of your health care services from the same plan. In your area, CareOregon and Jackson County Mental Health (JCMH) have partnered to serve you as Jackson Care Connect. This means that you will receive both physical and mental health services from Jackson Care Connect. By 2014, we ll also provide your dental care. You should also review your OHP Client Handbook. It has OHP information that isn t in this handbook. If you don t have a copy, you can read or download it online at apps.state.or.us/ Forms/Served/he9035.pdf. Getting Plan Information Jackson Care Connect sends you information about: Covered benefits and services How to find a provider How to get care for covered services when you are outside the Jackson Care Connect service area How Jackson Care Connect decides if new medical equipment should be a covered benefit Any law changes that affect your plan. We do this at least 90 days before the changes take place. Call Customer Service if you have questions about: Benefits Choosing or changing your primary care provider (PCP) Using your PCP s services Authorization for medical services and supplies Prescription drugs Participating vendors of medical supplies or equipment Prenatal (before birth) care, and participating prenatal care providers A bill you received from your provider when you were covered by Jackson Care Connect 1

8 Call your DHS caseworker if you have questions about: Changing your address, telephone number or name Other primary insurance coverage Giving birth or adopting a child Moving outside our service area (Jackson County) How to contact your dental care organization (DCO) Call your dental care organization (DCO) about your dental benefits. Your DCO is listed on your enrollment letter that you receive from DMAP. What is the Oregon Health Plan? The Oregon Health Plan (OHP) is a program that pays for the health care of low-income Oregonians. The state of Oregon and the U.S. government s Medicaid program pay for it. OHP provides different groups of services, called benefit packages: OHP Plus OHP Plus is for: pregnant women children 18 and under people with disabilities of any age. OHP Plus covers: doctor visits prescriptions hospital stays dental care mental health services help with addiction to tobacco products, alcohol and drugs. Toll Free TTY/TDD Office hours: 8 a.m. to 5 p.m., Monday through Friday OHP Plus can also provide glasses, hearing aids, medical equipment, home health care and transportation to health care appointments. 2

9 OHP Standard OHP Standard is for: Oregon residents who are older than 18. OHP Standard covers: doctor visits prescriptions emergencies mental health services help with addiction to tobacco products, alcohol and drugs. Some people who have OHP Standard pay a monthly charge for it, called a premium. There are other benefit packages. An Oregon Health Authority (OHA) or Department of Human Services (DHS) caseworker can tell you which benefits you have. Right now, OHP covers a list of 498 diseases and conditions, called the Prioritized List of Health Services. This list is on the web at herc/current-prioritized-list.aspx. Diseases and conditions not on the list are usually not covered by OHP, but there may be exceptions. For example, if a patient has an uncovered condition that could improve with treatment of a covered condition, the uncovered condition could be covered. OHP Members Don t Pay Bills For Covered Services If your health care provider sends you a bill, don t pay it. Instead, call Customer Service right away at or toll-free at TTY/TDD users can call DMAP Coverage Letter The Division of Medical Assistance Program (DMAP) sends you a coverage letter that contains your: DHS caseworker s ID and phone number. benefit package. copayment requirements. managed care enrollment information. This letter shows information for everyone in your household who has an Oregon Health ID card. You do not need to take this letter to your health care appointments or to pharmacies. DMAP will send you a new coverage letter if you ask for one or if your coverage changes. For OHP PLUS Members: Your Oregon Health Plan (OHP) coverage letter says that clients in OHP Plus medical, dental and mental health plans are subject to copayments ( copays ). However, health plans may choose not to collect these copayments. 3

10 As your OHP Plus medical plan, Jackson Care Connect has decided not to charge copays at this time. Instead, we will cover this cost for you. We know that everyone worries about getting quality health care at an affordable price. For that reason, we re asking our clinics and medical providers not to collect copays for members who are on the OHP Plus plan. If your provider asks you to pay a copay based on this DMAP standard, please do not pay it. Instead, ask the clinic staff to call our Customer Service department. If you have any questions about copays, please call Customer Service. Your Oregon Health ID Card The DMAP sends you one Oregon Health ID card. All eligible members in your household receive their own cards. Take your Oregon Health ID card to all health care appointments and pharmacies when you fill a prescription. Keep your Oregon Health ID card in a safe place. DMAP only sends a new card if your name changes or you ask for a new card. Your Jackson Care Connect ID Card If you or a family member changes PCPs, you will get a new Jackson Care Connect ID card. If you lose your ID card, please call Customer Service and we will send you another one. If you need care before you receive your Jackson Care Connect ID card, please call us. We will help you get the services you need. Toll Free TTY/TDD Office hours: 8 a.m. to 5 p.m., Monday through Friday IMPORTANT: Take your Oregon Health ID card and your Jackson Care Connect ID card to all your health care appointments and to the pharmacy when you fill a prescription. Providers use the information on ID cards to check your eligibility. Having your ID cards with you makes it easier to check in for appointments and get medicine at a pharmacy. 4

11 What is a Patient-Centered Primary Care Home? We want you to get the best care possible. One way we try to do that is by asking 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 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 a Coordinated Care Organization? Jackson Care Connect is a Coordinated Care Organization (CCO). We are a group of all types of health care providers, working together for people on OHP in your community. To ensure you get the best care, we ll coordinate your care with all of the providers or facilities you use. You ll have access to the same providers, but they ll work more closely together to serve you. Jackson Care Connect coordinates your care by: Connecting you with a primary care provider (PCP) to make sure you have the tools and support you need to stay healthy Providing care and advice that is easy to understand and follow Ensuring you have the right resources to overcome any barriers to good health Providing you with information and access to prevention services Keeping you closely connected to your PCP, so you can avoid trips to the emergency room or hospital Making sure your PCP and your other providers talk to each other about your health care needs Working with local resource providers to improve your health and health care Working closely with you, your providers and your community to make sure you feel comfortable, safe and cared for Our goal: better health care Our goal is to help you receive the best health care and services possible within your community, when you need them. We work closely with community and social agencies. If you face challenges like homelessness or hunger, or have multiple health conditions, we can connect you with people who can help. What are Managed Care and Fee-For-Service? CCOs like Jackson Care Connect are a type of managed care. Dental Care Organizations (DCOs) are another type. The OHA wants OHP members like you to have your health care managed by private companies set up to do just that. OHA pays managed care companies a set amount each 5

12 month to provide their members the health care services they need. Most OHP members must receive managed medical and dental care. Health services for OHP members not in managed care are paid by OHA, and are called Fee-for-Service (FFS). Native Americans and Alaska natives on OHP can choose to receive managed care or FFS. Any OHP member who has a good reason to receive FFS medical care can ask to leave managed care. Talk to your DHS caseworker about the best way to receive your medical care. If you want Fee-for-Service OHP instead of Managed Care OHP wants you to get your health care from a managed care plan like Jackson Care Connect. Jackson Care Connect can provide some services that OHP can t. But, you can change to Fee-for-Service OHP at any time if: you are an American Indian or Alaska Native. you are also on Medicare in addition to OHP. If you want to change plans, call your DHS caseworker. Members with Both Medicaid and Medicare Some people are eligible for both Medicaid (OHP) and Medicare. They are called dual eligible members. For more information, call Customer Service. Your Rights and Responsibilities As an OHP client, you will be: Treated with respect, the same as other patients Free to choose your provider Urged to tell your provider about all your health concerns Able to have a friend or helper come to your appointments, and an interpreter if you want one Told about all of your OHP-covered and non-covered treatment options Allowed to help make decisions about your health care, including refusing treatment, without being forced to do something you don t want to do Given a referral or second opinion, if you need it Given care when you need it, 24 hours a day and 7 days a week Free to get mental health and family planning services without a referral Free to get help with addiction to tobacco products, alcohol and drugs without a referral Given handbooks and letters that you can understand Able to see and get a copy of your health records Able to limit who can see your health records 6

13 Sent a Notice of Action letter if you are denied a service or there is a change in service level Given information and help to appeal denials and ask for a hearing Allowed to make complaints and get a response without a bad reaction from your plan or provider Free to ask the Oregon Health Authority Ombudsperson for help with problems at or toll free , TTY/TDD As an OHP client, you agree to: Find a doctor or other provider you can work with and tell them all about your health Treat providers and their staff with the same respect you want Bring your medical ID cards to appointments, tell the receptionist that you have OHP and any other health insurance, and let them know if you were hurt in an accident Be on time for appointments Call your provider at least one day before if you can t make it to an appointment Have yearly checkups, wellness visits and other services to prevent illness and keep you healthy Follow your providers and pharmacists directions, or ask for another choice Be honest with your providers to get the best service possible Call your DHS caseworker when you move, are pregnant or no longer pregnant About Your Primary Care Provider (PCP) Your Primary Care Provider (PCP) Assignment All Jackson Care Connect members have a PCP. When you become a Jackson Care Connect member, you can choose a primary care provider (PCP) or we can assign you one. This could be a doctor, a nurse practitioner or a physician s assistant. Start with your PCP for all of your health care needs. Some providers do not accept new patients. If you need help finding a provider in your area, call Customer Service. IMPORTANT: If you are pregnant or have a baby less than one year old, see your PCP as soon as possible. Getting to Know Your PCP Your PCP keeps track of all your basic and specialty care. Make an appointment to see your PCP as soon as possible. This way, your PCP can learn about you and your medical history before you have a medical problem. This will help you avoid delays the first time you need to use your benefits. When you don t feel well or need a checkup, call your PCP to make an appointment and get help deciding what care you need. 7

14 Before your appointment, write down any questions you may have so you remember to ask them. Also, write down any history of family health problems and make a list of any prescriptions, over-the-counter medications and vitamins you take. To learn more about a provider, including qualifications, specialty and board certification, visit our online provider directory at Changing your PCP After your first 30 days as a Jackson Care Connect member, you may change your PCP no more than twice in a six-month period. You may change your PCP more often if you move or are discharged from your PCP clinic. We can help you find a PCP whose office is convenient for you and who accepts new patients. You may also look in the Primary Care Clinics section of our provider directory, available online at To change your PCP, call Customer Service. After you choose a PCP, we will mail you a new Jackson Care Connect ID card that shows the name of the PCP you chose. When you choose a new PCP, the change is effective right away, but it might take a few days for your new PCP to get your information. If you or your PCP has questions about your PCP assignment or plan benefits, please call Customer Service. Toll Free TTY/TDD Office hours: 8 a.m. to 5 p.m., Monday through Friday Changing CCOs If you want to change to a different plan, call your caseworker. There are several chances for you to change as long as another plan is open for enrollment: If you move to a place that your CCO doesn t serve, you can change plans as soon as you tell your caseworker about the move. 8

15 You can change plans each time your caseworker finds that you meet the requirements for OHP. This is called recertification and usually happens about the same time once each year. If you are on Medicare, you can change plans anytime. Reasons why you might choose to leave Jackson Care Connect on your own include: If Jackson Care Connect does not, because of moral or religious objections, cover a service that you seek. If you need related services (for example a cesarean section and a tubal ligation) to be performed at the same time, not all related services are available within the network, and your PCP determines that receiving the services separately would subject you to unnecessary risk. If you have other reasons, including poor quality of care, lack of access to services covered under the contract, or lack of access to participating providers who know how to deal with your health care needs. Jackson Care Connect may ask the Division of Medical Assistance Programs (DMAP) to remove you from our plan if you: are abusive to our staff or providers commit fraud, such as letting someone else use your health care benefits move out of our service area lose OHP eligibility Getting Care When You Need It New Members Who Need Service Immediately If you are new to Jackson Care Connect and you need medical care or prescriptions immediately, please call Customer Service. Also, make an appointment with your PCP as soon as possible to be sure you receive any necessary ongoing care. Making Appointments to See your PCP If you need a medical appointment, call your PCP s office. Have your Medical ID number ready, and tell them that you are a Jackson Care Connect member. Call in advance for routine, non-emergency appointments. If you are sick and need a same-day appointment, tell the clinic staff when you call. In most cases, you can get a routine or follow-up appointment within four weeks of the request, or within 48 hours for urgent issues. If you need language interpretation, tell the clinic staff the language you speak. The PCP will arrange to have an interpreter at your appointment at no cost to you. 9

16 If you need sign language interpretation, tell the clinic staff or call Customer Service at TTY/TDD We will arrange to have a sign language interpreter at your appointment at no cost to you. Making Appointments to See a Mental Health Provider You do not need a referral from your PCP to get mental health services. Call Jackson County Mental Health at Mental illness may include: Depression Anxiety Schizophrenia Problems that result from physical or sexual abuse Bi-polar disorder Attention Deficit Hyperactivity Disorder (ADHD) Problems resulting from drug or alcohol use Feelings of hopelessness Thoughts of hurting yourself or others Mental Health treatment services may include: Assessment or evaluation to help decide what services you need Counseling or programs that help manage mental health conditions Programs to help with daily and community living Hospital care for mental illness Emergency services Medications needed to help manage mental health conditions Programs that teach life and social skills Skills training for parents and children Your Right to Have an Interpreter at Appointments If you do not speak English or you need sign language interpretation, it is your legal right to have an interpreter at your medical appointment at no cost to you. If you need help getting an interpreter for a medical appointment, please call your PCP. If You Must Miss a PCP Appointment Call your PCP and cancel the appointment as soon as possible. Each clinic has its own policies about missed appointments. Ask your clinic about its policy. Mental Health Services Important: You do not need a referral to get mental health services from a provider. Mental health services are available to all OHP members. These services include a mental health assessment, case management, and therapy and inpatient psychiatric care. We cover mental health assessment to find out what kind of help you need, case management, therapy, and care in a psychiatric hospital if you need it. 10

17 We offer: Outpatient therapy Case management Care coordination Medication management Children s services Intensive outpatient adult service Inpatient care when required You and your mental health professional may decide you need specialty mental health services. These services may require preauthorization and may include: Consultation with a mental health specialist Special testing or evaluation A referral to a special treatment program or community-based service Intensive Community Based Services for children Case Management services for adults Residential care Sub-acute residential care for children Crisis respite Transitional services for youth Psychiatry Direct Access to Specialists In most cases, your PCP will refer you to a specialist in the Jackson Care Connect network. However, you can see specialists for some kinds of care without seeing your PCP first. This is called direct access. You can make your own appointment for the following services from a specialist who is a Jackson Care Connect provider: Routine women s health care and preventive women s health care services, which includes, but is not limited to, prenatal care, breast exams, mammograms and Pap tests Emergency services, whether you get these services from plan providers or non-plan providers Urgently needed care that you get from non-plan providers when you are temporarily outside the plan s service area Renal (kidney) dialysis services you get when you are temporarily outside the plan s service area Family planning Immunizations (shots) Mental or behavioral health services Outpatient treatment for chemical dependency/drug and alcohol problems. A list of providers for these services is in Jackson Care Connect s online provider directory. Referrals to Other Providers For services not listed in the section above, make an appointment with your PCP first. Your PCP will decide which services and tests you may need. 11

18 If you need to see a specialist or other provider, your PCP will refer you. In most cases, you must see a Jackson Care Connect specialist or other provider. If a Jackson Care Connect specialist or provider is not available, your PCP will ask Jackson Care Connect if you can see an outof-network provider. Jackson Care Connect will work with your PCP in determining how soon you need to be seen and the specialist you need to see to address your medical needs. If you have already seen a specialist and have questions or concerns, make an appointment with your PCP to discuss them. If you or your PCP want a second opinion from another specialist, your PCP will refer you. If a Jackson Care Connect specialist or provider is not available, your PCP will ask us if you can see an out-of-network provider. Jackson Care Connect will work with your PCP to determine how urgently you need to be seen. They will also discuss which provider specialty meets your needs. If You Need Care Out of Town If you get sick when you are away from home, call your PCP. If you need urgent care, find a local doctor who will see you right away. Ask that doctor to call your PCP to coordinate your care. Urgent Care Always call your PCP s office first about any health problem. Someone will be able to help you day and night, even on weekends and holidays. Urgent problems are things like severe infections, sprains, and strong pain. If you don t know how urgent the problem is, call your PCP. When you have an urgent problem, do the following: 1. Call your clinic or provider s office. You can call anytime day or night, 24 hours a day, seven days a week. 2. Ask to speak to the clinic nurse or on-call provider. 3. A health care professional will tell you what to do. You may be scheduled for an appointment. After-Hours Care (Evenings, Weekends and Holidays) Your Jackson Care Connect PCP looks after your care 24 hours a day, seven days a week. Even if the PCP s office is closed, call the clinic s phone number. You will speak with someone who will contact your PCP, or give you advice on what to do. When your PCP is out of town or on vacation, they will arrange for another provider to be available to give you care and/or advice. Second Opinions We cover second opinions. If you want a second opinion about your treatment options, ask your PCP to refer you for another opinion. If you want to see a provider outside our network, you or your provider will need to get our approval first. 12

19 Emergencies and Crises If you think that you have a real emergency, call 911 or go to the nearest hospital. You don t need permission to get care in an emergency. An emergency can be chest pain, trouble breathing, bleeding that won t stop, broken bones or a mental health emergency. Do not go to a hospital emergency room for routine care that can be provided by your PCP. For example, the following conditions are not emergencies: common cold constipation diaper rash back pain toothache Emergency rooms will care for you until you are stable. If you need more care, you may be admitted to the hospital or emergency staff will tell you where to go for follow-up care. If you do not receive this information, contact your PCP on the next business day after your emergency treatment. Post-stabilization care means covered services provided after an emergency and after your condition is stabilized to maintain or improve your condition. Jackson Care Connect will pay for post-stabilization care provided by a hospital (whether or not the hospital is a plan provider). Mental Health Crisis You do not need approval to call the crisis line or get emergency services. You can use those services whenever you feel you are having an emergency. A mental health crisis means a person needs help quickly so the situation does not become an emergency. A mental health emergency is a situation where your health or safety, or the safety of others, would be in serious danger if you did not get help immediately. If you already have a provider, your provider s office will tell you how to reach them during a mental health crisis. If you are having a crisis, follow the plan made with your mental health professional. If you feel you need services immediately, call your provider s office and ask for an urgent appointment, or call 911. Things to look for if you or someone you know is having a mental health crisis: You or a member of your family are considering suicide You or a member of your family are hearing voices to hurt yourself or another person You or a member of your family hurts other people, animals or property You or a member of your family has dangerous or highly disruptive behaviors in school, work, or with friends or with family, and the behaviors are new or not being addressed by a mental health provider. 13

20 How to Get Help for a Mental Health Crisis Call , or toll free at You can also call 911 if you are in crisis. Suicide Prevention One concern that may come with untreated mental illness is a risk of suicide. With appropriate treatment, your life can improve dramatically. What are the most common warning signs? As many as 80 percent of those thinking about suicide want others to be aware of their emotional pain and stop them from dying. A warning sign does not mean a person is going to attempt suicide, but it should be taken seriously. Suicide warning signs include: Acting anxious or agitated; behaving recklessly Displaying extreme mood swings Giving away prized possessions Increasing the use of alcohol or drugs Planning a way to kill oneself, such as buying a gun Preoccupation with death Talking about wanting to die or wanting to kill oneself Talking about feeling hopeless or having no reason to live Talking about feeling trapped or in unbearable pain Talking about being a burden to others Withdrawing or feeling isolated Never keep talk of suicide a secret! For more information, the Oregon Youth Suicide Prevention website is: publichealth/ipe/suicide.cfm. If you want to talk with someone outside your mental health plan, call any of the following: SUICIDE ( ) Suicide Prevention Lifeline TALK (8255), online at suicidepreventionlifeline.org The David Romprey Memorial Warmline at: Out of Town Emergencies If you have a real emergency when you are away from home, call 911 or go to the nearest emergency room. Your care will be covered until you are stable. OHP covers emergency and urgent care anywhere in the United States, but not in Mexico, Canada, or anywhere else outside the United States. 14

21 Health and Wellness Jackson Care Connect is committed to helping you and your family stay well and live a healthy life. You can help prevent many serious illnesses and health conditions by making small, healthy lifestyle changes, using preventive health and wellness services, and working with your primary care provider. Our members come from many different backgrounds and cultures and speak many different languages. Your provider or clinic can make arrangements for you based on language, religion, gender, or other concerns you might have. If you have any questions, call Customer Service. Jackson Care Connect s health and wellness services include: Health checkups Help to quit using tobacco Immunizations (shots) Prenatal care for pregnant women Mammograms (for women) Pap smears (women) and prostate exams (men) Baby, Child and Teen Health Your children s health is important to Jackson Care Connect. To keep your children healthy, be sure they have immunizations and regular checkups even when they are not sick. Your child should have a health check-up with their PCP within three months of becoming a Jackson Care Connect member. It is important for your children to get all recommended vaccinations (shots). If your child has missed any vaccinations, make an appointment to get them as soon as possible. It s never too late to be vaccinated. Adult Immunization Schedule Getting regular health exams, tests and immunizations (shots) is important to staying healthy. Chronic illness or other conditions may put some people at high risk. Depending on your level of risk, your PCP may want you to have certain shots more often. Talk to your PCP about which shots you should have and when you should have them. The single most important thing you can do to improve your health and your family s health is to stop using tobacco. Jackson Care Connect pays for medications and telephone counseling with a trained coach to help you stop using tobacco. If you use tobacco, call Quit for Life toll-free at

22 Benefits and Services Prioritized List of Health Services OHP does not cover everything. A list of covered diseases and conditions, called the Prioritized List of Health Services, is available online at pages/herc/current-prioritized-list.aspx. The diseases and conditions below line 498 (called below the line ) usually are not covered by OHP, but there may be exceptions. For example, something below the line could be covered if you have a covered condition (line 498 or above) that could improve if the noncovered condition is treated. The prioritized list of health services was developed by the Oregon Health Evidence Review Commission (HERC). The HERC is a group of doctors, nurses and others concerned about health care issues. HERC members are appointed by the governor. To create the first prioritized list of health services, the HERC held public meetings around Oregon to find out which health issues were important to Oregonians. The HERC used that information to rank all health care procedures in order of effectiveness. The HERC meets regularly to update the list. OHP covers reasonable services for finding out what s wrong. That includes diagnosing a condition that is not currently funded. If a health care provider decides on a diagnosis or treatment that s not funded, OHP will not pay for any more services for that condition. Toll Free TTY/TDD Office hours: 8 a.m. to 5 p.m., Monday through Friday Primary Care Primary care is general medical care and treatment provided by your PCP. It includes: Preventive health care services that catch a health problem early or prevent it from happening (e.g., mammograms (breast X-rays), Pap smears, immunizations (shots)) Care for on-going, chronic conditions, like diabetes or asthma Prescriptions Referrals for specialty care Admission to the hospital, if needed 16

23 Prescriptions Jackson Care Connect has a formulary. The formulary is a list of drugs that we cover. Pharmacists and doctors decide which drugs should be in the formulary. Some drugs on the formulary have additional requirements or limits on coverage. The formulary and coverage limits/requirements are on our website at If you have questions about the formulary or want us to mail a copy to you, call Customer Service. Prescription Coverage Limitations These drugs are not covered: Drugs not listed in the formulary or drugs removed from the formulary Drugs used to treat conditions that are not covered by the Oregon Health Plan (examples are fibromyalgia, allergic rhinitis and acne) Drugs used for cosmetic purposes Drugs that are not approved by the U.S. Food and Drug Administration (FDA) and/ or drugs that have little or poor scientific evidence to support their use Drugs that are being studied and are not approved for your disease or condition. A drug may be approved by the FDA for use with one or more diseases or conditions, but not approved for other diseases or conditions. Pharmacy Jackson Care Connect s pharmacy network includes most drug chains. If you need a prescription outside Oregon, call Customer Service to find out if there is a contracted pharmacy near you. If you pay out-of-pocket for prescriptions, you may be reimbursed by Jackson Care Connect based on your benefit coverage and the limitations and exclusions of your plan. You will need to fill out a reimbursement request form and submit it to us. This form can be found on our website at or, you may call Customer Service for help. How to team with your pharmacist Some drugs on the formulary have additional requirements or limits on coverage that may include: The use of generic drugs when available Prior authorization Step therapy Age restrictions Quantity limits Jackson Care Connect covers some over-the-counter (OTC) drugs such as aspirin. They are listed on the formulary. You must get a prescription from your provider and give it to a pharmacist before Jackson Care Connect can pay for an OTC drug. 17

24 Drugs used to treat mental health conditions such as depression, anxiety and psychosis are covered directly by the Division of Medical Assistance Programs (DMAP). They are not listed on our formulary. Your pharmacist sends your prescription claim directly to DMAP. DMAP may require you to pay a copayment for these drugs. What to Ask your Provider about Prescriptions Jackson Care Connect providers are encouraged to prescribe medications that are on our formulary. Drugs that are not listed in the Jackson Care Connect formulary are called non-formulary and are not covered unless an exception is granted. IMPORTANT: Each time you receive a new prescription, ask your provider if it is covered by Jackson Care Connect and if it requires prior authorization or step therapy. If we don t cover the specific drug, ask your provider if another drug on our formulary would work for you. If your provider decides that the Jackson Care Connect formulary does not have an acceptable alternative or if the alternative drug requires prior authorization or step therapy, ask your provider to contact us and fax a formulary exception or prior authorization request. Generally, Jackson Care Connect only approves exception requests if either of these statements is true: 1. Alternative drugs or a restricted supply of the drug would work as well in treating your condition. 2. The alternative drug or restricted supply would cause bad medical effects for you. Our decisions for prior authorization and formulary exception requests are based only on appropriate care and coverage limitations. We may approve a 60-day transition supply of a non-formulary or restricted drug for a chronic medical condition for members who were taking the drug before they became a Jackson Care Connect member or after their discharge from a hospital or nursing facility. You or your provider may call Customer Service to ask for a transition supply. Talk to your provider as soon as possible about drugs that we cover or ask us for an exception. How to Fill your Prescriptions Fill your prescriptions at any Jackson Care Connect network pharmacy. Show your Jackson Care Connect ID card and your Oregon Health ID card when you fill a prescription. You can find our network pharmacies in our online provider directory at 18

25 Most prescriptions are limited to a supply of 31 days or less. The earliest date you can get a refill is 23 days after you last filled your prescription. We may approve an additional refill in the following situations: Your medication was lost or stolen You need extra medication because you are traveling You need extra medication because your dosage was changed You need an extra supply to keep at work or school EXCEPTIONS: You may get up to a 90-day supply of the following drugs: Generic oral contraceptives (birth control pills) Children s multivitamins with fluoride and prenatal vitamins, folic acid, sodium fluoride Digoxin, furosemide, hydrochlorothiazide, atenolol, metoprolol, captopril, enalapril, lisinopril Levothyroxine Albuterol HFA inhalers and nebulizer solutions If you have an urgent need for a drug that is not on the formulary or that has additional restrictions, we may approve up to a five-day emergency supply. You, your provider or your pharmacist can call Customer Service to request an emergency supply. Mental Health Prescriptions We don t cover all prescriptions. Please show your pharmacist your Oregon Health ID and your Jackson Care Connect ID cards. The pharmacy will know where to send the bill. Specialty Care Specialty care is care by a specialist provider, such as a cardiologist, orthopedist or endocrinologist. If you and your PCP decide that you should see a specialist, your PCP will give you a referral. Lab Tests, X-Rays and Other Procedures Jackson Care Connect pays for these services if your provider orders them. Hospital Care If you need care at a hospital, your PCP or specialist will arrange for your care. Family Planning A number of family planning services are covered by Jackson Care Connect: Physical exams and contraceptive education Contraceptive supplies such as condoms, birth control pills and intrauterine devices (IUDs) Emergency contraception (the morning after pill) Sterilization (tubal ligations and vasectomies) 19

26 Related services that are also covered include: Pap smears Pregnancy tests Screening and counseling for sexually transmitted diseases (STDs), including AIDS and HIV Hearing Services If you need hearing services, your PCP will make a referral. Jackson Care Connect pays for hearing tests, hearing aids and batteries. Skilled Nursing Facility Care Jackson Care Connect will pay for care in a skilled nursing facility for up to 20 days after you have been in the hospital. Additional skilled care may be covered by OHP. Chemical Dependency (Drug and Alcohol) Treatment If you think you need treatment for a drug or alcohol problem, talk to your PCP or contact adrug and alcohol dependency provider directly. Chemical dependency (CD) providers are listed in our online provider directory. For chemical dependency treatment, we pay for CD counseling office visits, acupuncture, methadone treatment, opioid substitution and detoxification services. We also cover CD treatment at a residential facility. Contact your CD provider for additional information. Important to Know The Jackson Care Connect Medical Benefits Assurance Unit (MBA) and Pharmacy units make authorization (payment) decisions about medical/surgical services, home health services, pharmacy and other benefits. Decisions are based only on appropriate care and coverage guidelines and rules. Jackson Care Connect does not reward staff for denying prior authorization requests and does not use financial incentives that reward using less services. Dental Services Dental services are not covered by Jackson Care Connect. They are available from the Oregon Health Plan through a dental care organization (DCO). Look on page 2 of your coverage letter for the name and phone number of your DMAP dental plan. Vision Care For basic vision care, call VSP at You do not need a PCP referral. If you have an eye injury or infection, call your PCP. Your PCP may refer you to a specialist. Eye exams for the purpose of checking on your medical condition (for example, people with diabetes) are covered. In this case, your PCP will tell you how often you should have a medical eye exam. 20

27 Benefits for members who are age 20 or younger: Eye exams and new glasses are covered with no limit only if they are medically necessary (for example, if you experience a change in your vision that requires new glasses). Medical necessity is decided by your PCP or other health care provider. Oregon Health Plan covers contact lenses only for a few conditions. Benefits for members who are over 20 and pregnant: Eye exams and new glasses are covered every 24 months. Glasses are also covered within 120 days after cataract surgery or up to one year after corneal transplant. Oregon Health Plan covers contact lenses only for a few conditions. Benefits for members who are 21 or older and not pregnant: Eye exams for prescribing glasses or contact lenses are ONLY covered when needed to treat medical conditions, such as an absent natural eye lens, synthetic eye lens replacement, thinning or coning of the eye lens, cataracts, and congenital cataracts. Glasses are covered within 120 days after cataract surgery or up to one year after corneal transplant. To receive full dental and vision coverage, call your caseworker if you become pregnant or are now pregnant but haven t notified your caseworker. To find your caseworker, please call the Oregon Health Plan at , TTY/TDD Getting a Ride to Appointments NOTE: Some people on OHP Plus may be able to get help paying for rides. If you re on OHP Plus, contact your DHS caseworker for more information. If you re not on the OHP Plus plan, you will need to pay for your own transportation. If you need help getting to your appointments, please call Translink at any of the following numbers: Toll free: You can find more information at Medical Transportation Jackson Care Connect pays for ambulance transportation in emergencies for OHP Plus members. 21

28 Child Care If you need child care so you can go to your appointment, please call your DHS caseworker. They may be able to help you get money to pay a babysitter. Exceptional Needs Care Coordination Exceptional Needs Care Coordination (ENCC) is available if you are disabled or have multiple chronic conditions, high health care needs or special health care needs. These services are provided by trained staff that can help you overcome barriers that may keep you from being healthy. They can also help you: Find a provider who can help you with your special health care needs, including help with mental health and substance use issues Get an appointment with your PCP, specialist or other health care or behavioral health provider Obtain needed equipment, supplies or services. Coordinate care among your doctors, other providers, home and community support agencies and social service organizations. To use these services, please call Customer Service. Care Management Teams We have a team of nurses, behavioral health specialists and health care coordinators that are ready to help you. If you have a serious or chronic health condition such as diabetes, heart failure, asthma, depression or substance use, or have been in the hospital, our Care Management Teams can talk with you about how to live well and feel better. We can help you make the most of your provider visits and connect you with helpful community resources. We also can help you understand your PCP s treatment plan. To talk with a Care Management Team member, call Customer Service. Non-covered Services Not all medical treatments are covered by the OHP or Jackson Care Connect. The following are not covered under the OHP Standard plan: Acupuncture (except for treatment of chemical dependency) Chiropractic and osteopathic manipulation services Hearing services hearing aids or exams for the purpose of fitting hearing aids Home health care (except enteral, parenteral, intravenous [EPIV] therapy) Non-emergency transportation Occupational therapy, physical therapy and speech therapy 22

29 Vision care frames, contacts or exams for the purpose of fitting glasses or contacts Treatment for eye disease is covered for members who have the Standard benefit. There is limited coverage for durable medical equipment (DME). If you have questions about covered or noncovered services, call our Customer Service Department. You can read or print the Oregon Health Plan Client Handbook online at: or.us/forms/served/he9035.pdf. Will I Ever Have to Pay a Provider? OHP members don t pay bills for covered services. If your health care provider sends you a bill, don t pay it. Instead, please call our Customer Service right away. Generally, you will not have to pay any medical bills, with a few exceptions. Services Covered by Jackson Care Connect When you schedule your first appointment with a provider, tell the scheduler that you have Jackson Care Connect or other medical insurance. If you don t tell them, you have to pay the provider out of your own pocket. You ll have to pay the provider if a third-party payer sent checks to you for services performed by your provider. Services Not Covered by Jackson Care Connect You have to pay the provider if you: Receive services outside Oregon that are not emergencies or urgent care Choose to have services that the provider tells you are not covered by Jackson Care Connect. In this case, the provider must tell you the cost of each service, and that you are responsible for paying for the service. The provider must also ask you to sign a written form stating that you were told this information, and that you knowingly and voluntarily agreed to pay for non-covered services. Please call Customer Service before you agree to pay a provider. Native Rights American Indians and Alaska natives can receive their care from an Indian Health Service (IHS) clinic or tribal wellness center. This is true whether you are in a CCO, prepaid health plan or OHP Fee-For-Service (open card). If you are a member of Native American or Alaskan Native descent, you can access Native American providers in our network for your health care needs. These providers can be found in our online provider directory. You can also see Native American providers that are not in our network. However, Native American providers who are not part of our network must follow the same rules as network 23

30 providers. Only covered benefits will be paid for. If a service requires a pre-authorization, they must request it before providing the service. A list of services that need pre-authorization are posted on our website. If you have questions about your benefits under the American Recovery and Restoration Act, or if you need help understanding our pre-authorization rules, please feel free to contact your caseworker or Customer Service for help. Outside the United States Jackson Care Connect will not cover any health services you get outside the United States, including Canada and Mexico. New Technology The OHP decides if new technologies and new uses of current technologies are included in your benefit package. If you have questions about whether or not a service is covered, please call Customer Service. Even More Support If you have severe health issues that meet specific requirements, our Care Management workers can work one-on-one with you. These workers might visit you at home, go with you to appointments, talk with your community support groups or help you in other ways. If You Are Pregnant It is very important for your health and your baby s health to get prenatal care while you are pregnant. Jackson Care Connect covers: Prenatal care (care for you before your baby is born) Labor and delivery Postpartum care (care for you after your baby is born) Care for your newborn baby As soon as you know you are pregnant, do the following: 1. Call your DHS caseworker. Your worker will make sure you don t lose OHP benefits while you are pregnant. Your worker can also help you get additional services that you may need. 2. Call your PCP and make an appointment for prenatal care. If you prefer, you can pick your own obstetrician/ prenatal care provider. A list of providers who can deliver your baby is included in the online provider directory. 24

31 Important To Know As soon as possible after your baby is born: Call your DHS caseworker to enroll your baby in the OHP. This is not done automatically. If you received all your medical care from an obstetrician or prenatal care provider during your pregnancy, you need to choose a primary care provider (PCP) now. Call Jackson Care Connect s Customer Service to help you find a PCP near you. Information for Birth Parents Oregon s A Safe Place for Newborns Law allows a birth parent (mother or father) to leave a newborn infant at an authorized facility, such as a hospital, doctor s office during business hours, birthing clinic, police or fire station or sheriff s office. There are no legal penalties for making this choice if the baby is 30 days old or younger, is given to a staff person and shows no signs of abuse. information and phone numbers for county child welfare offices. You will be asked to fill out a voluntary health questionnaire about the infant. You may leave at any time. Babies receive medical attention if they need it. The staff person who accepts the baby contacts DHS, and the baby is placed in a temporary home. If you change your mind, you can seek custody of the baby. A court hearing will be held on the first business day after the day the baby is left. There will be several court hearings after that date. Your ability to seek custody of the baby will depend on how quickly the court moves to end the parents rights. Online resources: Parent resources: ph/asafeplace/resources.shtml Brochure: ph/asafeplace/brochure.shtml If you need support, want to talk to someone about this decision, or need information on adoption, counseling or other social services, call SAFENET ( ). If you decide to take your baby to a safe place for newborns authorized facility, you will not have to answer questions. You will be offered 25

32 Other Things You Should Know End of Life and Advance Directives (Living Wills) Adults 18 years and older can make decisions about their own care, including refusing treatment. It s possible that someday you could become so sick or injured that you can t tell your providers whether you want a certain treatment or not. If you have written an Advance Directive, also called a Living Will, your providers may follow your instructions. If you don t have an Advance Directive, your providers may ask your family what to do. If your family can t or won t decide, your providers will take the usual steps in treating your conditions. If you don t want certain kinds of treatment, like a breathing machine or feeding tube, you can write that down in an Advance Directive. It lets you decide your care before you need that kind of care - in case you are unable to direct it yourself, such as if you are in a coma. If you are awake and alert your providers will always listen to what you want. You can get an Advance Directive form at most hospitals and from many providers. You also can find one online at dcbs/shiba/docs/advance_directive_form. pdf. If you write an Advance Directive, be sure to talk to your providers and your family about it and give them copies. They can only follow your instructions if they have them. Some providers and hospitals will not follow Advance Directives for religious or moral reasons. You should ask them about this. If you change your mind, you can cancel your Advance Directive anytime. To cancel your Advance Directive, ask for the copies back and tear them up, or write CANCELED in large letters, sign and date them. For questions or more information contact Oregon Health Decisions at or , TTY/TDD Declaration for Mental Health Treatment Oregon has a form called a Declaration for Mental Health Treatment. This form is a legal document. It allows you to make decisions now about future mental health care in case you are unable to make your own care decisions. If you do not have this form in place, and you are not able to make your own decisions, then only a court or two doctors can decide that you cannot make your own care decisions. You may also use this form to name an adult who can make mental health decisions for you when you cannot make them for yourself. This person must agree in writing to represent you. The person you name must follow your wishes. If your wishes are unknown, the person you name must make decisions that are in your best interest. 26

33 A Declaration for Mental Health Treatment is effective for three years. If you become unable to make decisions, this document will remain in effect until you are capable of making decisions. You may change or cancel your declaration at any time as long as you are capable of making decisions for yourself. It is important to give this form to your health care provider and to give a copy to the person you name to represent you. You may request this form three ways: Call the state of Oregon at Request a copy from your current provider Online go to oha/amh/pages/tools-providers.aspx (under Forms ) For more information on the Declaration for Mental Health Treatment go to the state of Oregon s website at: oha/amh/forms/declaration.pdf. You can talk directly with your mental health provider, if you have one. To find out, call our Customer Service Department and ask for information about our physician payment arrangements If you Change your Address or Phone Number If you move or change your phone number, tell your DHS caseworker as soon as possible. They depend on you for this information. Your worker s phone number is on page 2 of your coverage letter. Also, tell your PCP clinic your new information. If you need a new PCP clinic after you move, please let us know. Our Customer Service staff will help you choose a new PCP. Disenrollment When you have a problem getting the right care, please let us try to help you before changing plans. Just call Customer Service at or toll-free at (TTY/TDD ) and ask for our Care Coordinator. Provider Incentives and Reimbursement We do not pay or reward our providers for limiting services and referrals. You have the right to ask if Jackson Care Connect has special financial arrangements with our providers that can affect the use of referrals and other services. 27

34 Complaints and Appeals Complaints (Grievances) Jackson Care Connect providers want to give you the best possible medical care. However, if you have a complaint with any part of your care, contact a Customer Service representative in person, by phone or in writing. Our staff will address your concerns. If your complaint needs additional follow up, you will receive a follow up call or letter within five business days. We will provide a final response to you within 30 calendar days. You may also contact your provider directly to discuss your concerns. Appeals If you have been denied a service by Jackson Care Connect, you may request an appeal. Follow the instructions on the Notice of Action (initial decision notice) to begin the appeal process through Jackson Care Connect and request an administrative hearing through DMAP. You must file the appeal within 45 days from the date of the decision notice. If you choose to file an appeal, we will review it and mail you a Notice of Appeal Resolution within 16 days after the date of your request. If you also appeal to DMAP, they will schedule a hearing within 45 days of your request. If you are not satisfied with the decision, follow the instructions on the Notice of Appeal Resolution to request an administrative hearing with DMAP within 45 days from the date of the decision notice. Your Notice of Action denial letter will have a Hearing Request form that you can send in to ask the state for a hearing. You can also ask us to send you a Hearing Request form, or call OHP Client Services at , TTY/TDD , to ask for a form. At the hearing, which will be held over the phone, you can explain why you do not agree with the our 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, including your provider. Make sure that the representative you name is willing and able to speak on your behalf at the hearing. You can also have witnesses testify. Neither DMAP nor Jackson Care Connect 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) at for advice and possible representation. TTY/TDD users can dial Legal aid information can also be found at 28

35 PLEASE NOTE: If your provider is contracted with Jackson Care Connect, he/she can also file an appeal to have services covered for you. Your provider can also support your appeal by sending us your medical records when we ask for them, or by including them with their appeal. If the provider files the appeal, and if the decision is still to deny coverage, he/she will not have rights to ask for 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. If your problem is not solved at any step in this process, contact the Jackson Care Connect Appeals Coordinator or the DMAP Hearings Representative. Expedited Hearings for Urgent Medical Problems If you believe your medical problem cannot wait for a review, you can ask us or DMAP for an expedited (fast) appeal or hearing. Our mailing address is: Jackson Care Connect Attn: Appeals and Grievances P.O. Box 1430 Medford, OR Or, you may fax your appeal form to , Attention: Jackson Care Connect Appeals Coordinator. Also, you may mail a request for an expedited (fast) hearing to DMAP at the following address: Oregon Dept. of Human Services Division of Medical Assistance Program Hearings Unit 500 Summer St., NE, E49 Salem, OR or TTY/TDD: Fax: The DMAP Medical Director will review your medical records and decide if your medical problem cannot wait for the regular hearing process. You should get a decision within three workdays. Important To Know Our Customer Service staff can help you file a complaint. If you need help, please call us at or and ask to speak to a Customer Service representative. TTY/TDD users should call You also can ask your DHS caseworker for help, or call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at , TTY/TDD , for advice and possible representation. Legal Aid information can also be found at Appealing a decision will not affect continuation of service with Jackson Care Connect. However, you could be liable for payment of services delivered during the appeal process if the decision to deny or limit the service is upheld. 29

36 A Copy of Your Records You can have a copy of your medical records, unless the provider feels that this creates a safety risk. Your PCP has most of your records, so you can ask them for a copy. They may charge a reasonable fee for copies. You can ask us for a copy of the records we have. We may charge you a reasonable fee for the copies, limited to the actual cost of making the copies. You can have a copy of your mental health records unless your provider thinks this could cause serious problems. Notice of Privacy Practices This section describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you need help understanding our privacy practices, please call Customer Service. Our Promise To You Regarding Your Health Information Our staff understands that your health information is personal. We protect your health information. We keep records about Jackson Care Connect members to be sure we have accurate information about how we give you services. Toll Free TTY/TDD Office hours: 8 a.m. to 5 p.m., Monday through Friday How Jackson Care Connect Follows This Notice This notice describes how Jackson Care Connect uses and gives out your health information. We are required by law to maintain the privacy of your health information and to provide you with this notice. This notice tells you about our legal duties, and about how we protect your privacy. We are required to comply with the rules shown here. 30

37 Your Records Are Private We only share your records with people who need to see them for treatment and payment reasons. You can limit who sees your records. If there is someone you don t want to see your records, please tell us in writing. You can ask us for a list of everyone we have shared your records with. A law called the Health Insurance Portability and Accountability Act (HIPAA) protects your medical records and keeps them private. This is also called confidentiality. How We May Use and Give Out Your Health Information Jackson Care Connect informs members of its policies and procedures about the collection, use and disclosure of members protected health information (PHI) including: The organization s routine use and disclosure of PHI Use of authorizations Access to PHI Internal protection of oral, written and electronic PHI across the organization Protection of information disclosed to plan sponsors or employees For health care operations We may use medical information about you for health care operations. That means we will use information about you so we can operate the business of being a health plan and provide services to you. Some of those ways are listed below. For coordination of your care We use your information to manage your health care. This means that we may talk with your provider, pharmacist, or some other clinics, agencies or facilities about providing services to you. We might also send your provider or pharmacist a report with your name on it that shows him or her certain information about his or her patients. For example, we might send a provider a report that lists all of the provider s patients who were seen in a hospital emergency room during the past month. We may use your health information to make sure that you are seeing the correct provider for your health issues and that you are receiving appropriate care and treatment. After-hours help for unassigned members may be provided by another agency that we contract with to provide those services. When they provide services to our members, information may be shared for coordination of care. 31

38 Protection of your Personal Health Information Jackson Care Connect protects your personal health information (PHI) as required by all HIPAA privacy and security laws and Oregon privacy laws. Any oral, written, and electronic use, or access and storage of member information are restricted to those Jackson Care Connect staff members whose job duties require access to it. We use physical restrictions (such as locks) and electronic restrictions (such as passwords, encryption and firewalls) to protect your information in all forms. Hard copy media (such as paper and film) is shredded or destroyed in such a way that your information cannot be read or reconstructed. Electronic media is cleared, purged or destroyed so that information cannot be retrieved, consistent with the National Institute of Standards and Technology (NIST) SP Health-Related Benefits and Services For payment We may use medical information about you so that the treatment, equipment or medications that you were given at your provider s office, a clinic, the hospital, pharmacy or another facility can be paid for. For example, your provider may send us information about a simple surgery that you had at a clinic, so that he or she can be paid for taking care of you. We would look at that information so we can pay the provider correctly. Quality Improvement We use health information for quality improvement reasons, too. That means that health information is used to make sure that all Jackson Care Connect members get highquality health care. For example, we might give information about you to a company so they can mail you a survey about the health care you received. We would use the information you give us to help your providers with any changes they need to make to improve quality of care. Planning We use health information to make sure we are offering the right kinds of health services. For example, we may look at your information and information about other Jackson Care Connect members to see if we should offer different or better services to our members. Treatment alternatives We may use your medical information to tell you about other services in which you might be interested. You may ask us not to give you this kind of information by sending a written notice telling us not to send you that type of information. We might also give information to your provider or pharmacist about using other treatments or medications for you than those you are receiving now. 32

39 Division of Medical Assistance Programs (DMAP) Because we are funded by DMAP, we are required to provide the state with certain information about Jackson Care Connect members. For example, DMAP may want to know how many services were provided to newborns during the past year. Research Sometimes we will allow your health information to be used as part of a health research project. Except as allowed by law, we will not share your name or other personal information that might identify you. An outside review board has to approve research projects when they use records with your name or other private information on them. For example, a research project might compare the health of all patients who took one kind of medicine with the health of patients who took another kind of medicine to see which group of patients got better sooner. After we look at all the information, we might send out a report saying that a certain drug appears to treat a medical problem better than another drug does. Before we can do a study like that, the project has to be approved by the review board. Special Situations Public health risks We may give information out for public health reasons. For example: To notify the police or other state or local authorities if we believe that a member has been the victim of abuse, neglect or domestic violence. We only do this if the member agrees or if we are required to do that by law. To notify people about recalls for medicines or medical equipment they may be using Health oversight activities We may give out medical information to agencies that monitor the health care system and government health programs, so the agency can make sure civil rights or privacy laws are being followed. For example, we might give out information to report fraud and abuse to appropriate authorities. Law enforcement We may be required to give medical information to law enforcement officials. For example, a judge may require us to: Obey a court order, subpoena, warrant or summons that asks for medical information Respond to emergencies 33

40 As required by law We give out your health information if we are required to do so by state, federal, county or city laws. National security and intelligence activities We may give out health information about you if the law requires us to do so for intelligence or other national security activities. Inmates If you are an inmate of a jail or prison or are under the custody of a police officer, we can give medical information about you to that jail or officer. This information would be needed so they can give you health care, or protect your health or the health of someone else, or for the safety of the jail. Your Rights Regarding Medical Information About You Right to inspect and copy your records You and your legal representatives have the right to review and obtain a copy of your Jackson Care Connect medical information and health plan records, unless your provider feels that this poses a safety risk to you. The health plan records consist of information related to eligibility, enrollment, payment, benefits and services, and case management records that are used by Jackson Care Connect to make decisions about an individual regarding their eligibility or benefits. Usually, this information is billing records and some medical information that we get from your provider, clinic or hospital when they request payment. To see your records and get a photocopy of your information, you need to ask us in a letter, and also submit a Member Request to Review and Receive a Copy of Designated Record Set form. You can ask someone else to write the letter for you, but you must sign it. To request a copy of your records, send your letter and form to Customer Service. If you don t have the form, send your letter and we will send you the form. Right to change your records If you think that medical information that we have about you is wrong or something is missing, you may ask us to make changes in your information. To do that, send us a letter telling us what you would like to have changed and why you want the change to be made. We may tell you that we won t make the change if you don t give us your request in writing, or if the information was not created by us, or if we believe that the information is accurate and complete. If we do not make the change, we tell you how to ask us to review that decision. Right to an accounting of disclosures You have the right to ask us for a list of people to whom we have given your health information. This does not include information we use to make sure you get treatment, or that your treatment is paid for or that we need to help 34

41 us serve you better. You would need to write a letter asking us to give you that list. You can ask someone else to write the letter for you, but you must sign it. Right to request restrictions You have the right to ask for a restriction on how the medical information that we have about you is given out. You have a right to restrict information provided to a health plan for purposes of payment or health care operations and the personal health information related to a health care item or service for which the health care provider has been paid out of pocket in full. You also have the right to set a limit on how your information is used. For example, you would need to complete these steps to ask us not to use or give out your medical information about a surgery you had: 1. Send us a letter that asks us (Jackson Care Connect) to restrict how your medical information is used. 2. Tell us which information you want to restrict and if you want to limit how we use or disclose it. 3. Tell us to whom the limits should apply. For example, you may want information released only to your spouse, child or parent. However, we are not required to do what you ask us to do. If we don t agree, we would send you a letter telling you that. If that happens, you can send us a letter and ask that the Medical Director consider your request again. You have the right to request that releases of your PHI be restricted to a limited data set. A limited data set is protected health information that does not include information that could identify you, such as your name and the names of your relatives, employers or household members. Other information that you could ask us to remove from releases of your PHI includes postal address information, other than town or city, state and ZIP code; telephone numbers; Fax numbers; electronic mail ( ) addresses; Social Security Numbers; medical record numbers; health plan beneficiary numbers; account numbers; certificate/ license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers; Web Universal Resource Locators (URLs); Internet Protocol (IP) address numbers; biometric identifiers, including finger and voice prints; and/or full-face photographic images and any comparable images. If we agree with your request, we would restrict the information. Disclosure of PHI to family and friends We may disclose PHI to a family member, relative or friend or anyone else you designate as long as you are present prior to the use or disclosure and you agree or do not object. If you are not present (or you are incapacitated or in an emergency situation), we may determine that the disclosure of your PHI to a family member, relative or friend is in your 35

42 best interests using our professional judgment and our experience with common practice. In these cases we will only disclose the PHI that is directly relevant to the person s involvement in your health care or payment related to your health care. Right to request confidential communications You have the right to make reasonable requests that we contact you about medical issues in a certain way or at a certain place. For example, you can ask us to contact you only at work or only by mail. If you want to do that, you must send us a letter asking us to contact you in that way. Also, we may leave messages for you at your home, requesting that you call us back, reminding you about appointments or providing information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you are away, we may leave a message letting you know we called. We may either leave a number for you to call us back, or let you know that we will call you again. If you do not want us to leave phone messages on your voice mail or with anyone who answers the phone when you are away, you must tell us either orally or in writing. You can send us your written request, or call Customer Service. Right to a paper copy of this notice You have the right to have a copy of this notice. You can ask us to give you a copy of this notice at any time. You can also ask us to send you a copy of the notice in an . To request a copy, call or toll-free and ask to speak to a Customer Service representative. TTY/TDD users can call Changes to this notice We reserve the right to change this notice of privacy practices. If we change the notice, the changes would apply to information we already have about you. The changes would also apply to information we receive in the future. If we make a major change to this notice, we will make it available to you. How to file a privacy complaint or report a privacy problem If you think your privacy rights are not being maintained, you can send us a letter of complaint to the address listed at the front of this handbook. You may contact any agency listed below to file a privacy complaint. You may also contact them to report a problem with how Jackson Care Connect has used or disclosed your health information. IMPORTANT: Your benefits will not be affected by any complaints you make. Jackson Care Connect cannot treat you differently if you file a complaint. 36

43 Oregon Department of Human Services Privacy Officer 500 Summer St NE, E24 Salem, OR Phone: (Salem) or toll-free Fax: (Salem) TTY/TDD: Oregon Department of Human Services Governor s Advocacy Office 500 Summer St NE, E17 Salem, OR Phone: Fax: (Salem) TTY/TDD: [email protected] Office for Civil Rights Medical Privacy Complaint Division US Dept. of Health and Human Services 200 Independence Avenue SW HHH Building, Room 509 H Washington DC Phone: TTY/TDD: [email protected] Centers for Medicare and Medicaid Services (CMS) CMS Region Sixth Avenue, MS-40 Seattle, WA Phone: Fax: Contact the Jackson Care Connect Compliance Officer if you have any questions about this notice or if you want more information on privacy. Other uses of medical information: There may be other uses of your medical information that are not shown on this notice. If we want to use your information for those things, we would ask you to give us your written permission to do that. If you give us permission to use or give out your health information, you can change your mind at any time, and ask Jackson Care Connect to stop using or giving out your health information. If you do that, you understand that we are not able to take back any information that we already gave out. We are required to keep copies of our records that we have about you. If you give us written authorization to use or disclose specific information about vocational rehabilitation, HIV/AIDS, mental health, developmental disability, genetic testing or alcohol/drug abuse treatment, the authorization must clearly describe the information that may be disclosed and the purpose. We must obtain your specific written authorization each time we disclose information about vocational rehabilitation, HIV/AIDS, most uses and disclosures of psychotherapy notes, developmental disability, genetic testing or alcohol/drug abuse treatment. If you have any questions or concerns about this notice, please contact Customer Service. 37

44 Meet Our Community Advisory Council Jackson Care Connect s Community Advisory Council (CAC) is here to improve the service Jackson Care and its providers offer members. Many CAC members are patients. They find ways to suggest and improve JCC programs. They also organize activities and projects for fellow members and the community on health care issues. To get involved, find out more about the CAC, or share an idea, please call us at , or send an to [email protected]. Frequently Asked Questions Q. How do I change my primary care provider (PCP) or my mental health provider? A. Call Customer Service. We are happy to help you find a new PCP or mental health provider. Q. I want to see a specialist. What should I do? A. If you and your PCP decide that you should see a specialist, your PCP will give you a referral. Q. I want to see a mental health specialist. What should I do? A. You do not need a referral from your PCP. You may contact a mental health provider listed in the Jackson Care Connect provider directory or call Customer Service. Q. Why was I assigned to a provider when I already have a doctor? A. Our system matches new members with PCPs given the area they live in. If you already see a PCP in our network, just give us a call. We re more than happy to update our records. 38

45 Q. Does Jackson Care Connect collect OHP Standard premiums? A. Jackson Care Connect does not collect OHP standard premiums. Continue to send your monthly premiums to: OHP Premium Billing Office: PO Box 1120, Baker City, Oregon If you have questions about your premiums, please contact the Premium Billing Office at Q. I m a new member. I need to refill a prescription for medication from my last insurance and get diabetic supplies. What should I do? A. Call Customer Service. You may be eligible for a transitional supply. Talk to your Jackson Care Connect provider as soon as possible about medical supplies and/or drugs that Jackson Care Connect covers. Q. Does my plan cover dental services? A. The OHP does provide a limited dental benefit. Please contact your dental plan, which was assigned to you by the OHP. Your dental plan contact information can be found on your OHP coverage letter. Q. Does my plan cover vision services? A. Due to limited funding, the OHP does not cover routine vision services (other than medical eye exams) except for those under age 21 and pregnant women. Q. My doctor sent me a bill. What should I do? A. Don t pay the bill. Call Customer Service immediately. Q. I am pregnant and would like to begin my prenatal care right away. How can I find an OB/GYN that will deliver my baby at the hospital of my choice? A. Contracted providers can be found using our online provider search on our website. You can call and ask which hospitals your OB/GYN works with. If you do not have internet access, or just prefer to call us for the information, we would be glad to help you. Q. I just moved. I have a new baby. I changed my name. Who do I tell? A. Tell your DHS caseworker as soon as possible. Q. I m a new member and would like to know if my medications are covered. A. Jackson Care Connect maintains a list of covered drugs called a formulary. Please talk with your doctor about the medications you need. Your doctor may need to submit a prior authorization or may need to make a change to a covered drug. (Jackson Care Connect does not cover Mental Health drugs. Mental Health drugs are covered by the OHP. Your pharmacy will bill these medications to the OHP.) If you are a new member and are unable to fill a medication prescription, you may qualify for a transition supply. Please call us to find out if you qualify. 39

46 Q. If you or family member is considering suicide, what should you do? A. See How to Get Help for a Mental Health Crisis/Suicide Prevention on page 14 of this handbook. Q. How can you be sure that you ll be able to see who you want under the OHP and Jackson Care Connect? A. Jackson Care Connect has a vast provider network of hospitals, as well as hundreds of providers and pharmacies in Jackson County. We work with you to build a team your providers, behavioral health specialists, pharmacists and everyone at Jackson Care Connect and to get you high quality care to meet your needs. Q. Where does the money come from to pay for our members benefits? A. OHP is paid for by federal and state taxes with the amount decided by the Oregon legislature. In turn, funding is passed on to Jackson Care Connect by the OHP, so that we may provide you with the care you need to stay healthy. Toll Free TTY/TDD Office hours: 8 a.m. to 5 p.m., Monday through Friday 40

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48 Jackson Care Connect PO Box 1430 Medford, OR Telephone: TTY: JCC-HBK-EN