JANUARY
2020
Oregon Health Plan
Member Handbook
500 SE Cass Ave I Suite 101 I Roseburg OR 97470 Member Services: 541-229-4UHA or 541-229-4842 Toll– free 1-866-672-1551 I TTY 541-440-6304
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OHP-UHA-19-074
If you need another language, large print, Braille, CD, tape or
another format, call Member Services at
541-229-4842 ï TTY 541-440-6304.
You can have a voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider’s office that you need an interpreter and in which language. Information on Health Care Interpreters is at www.Oregon.gov/oha/oei.
Si necesita la información en otro idioma, letra grande, Braille, CD, cinta de audio u otro formato, llame al departamento de Atención al Cliente al 541-229-4842 and TTY 541-440-6304. Si desea ver el Manual para Miembros, lo hallará en http://
Si desea que le enviemos un ejemplar del Manual para Miembros, llame al departamento de Atención al Cliente.
Si desea, puede tener presente durante sus citas a un intérprete de idiomas o para sordomudos. Cuando llame para concertar una cita, indíquele al consultorio del proveedor que necesita un intérprete y para qué idioma. Hallara información sobre intérpretes especializados en el campo sanitario en
Welcome to Umpqua Health Alliance
Umpqua Health Alliance (UHA) wants to take good care of you and your family. Your health plan is not here to just take care of you when you are sick. Our goal is to help you and your family get well and stay well. You will have an active role in staying healthy.
Please take a few minutes to read this handbook carefully. It will answer many of the questions you may have about how to use your Oregon Health Plan (OHP) coverage, will tell you what services are available, and how to get those services. It also tells you what to do in an emergency and explains your rights and responsibilities. UHA also wants to protect the privacy of your Personal Health Information (PHI). If you wish for someone to speak to Member Services about your health, please make sure to let us know. If you have any questions about your physical or mental health care benefits, please call Member Services at the phone numbers listed below. You can also find the UHA handbook online at
http://www.umpquahealth.com/ohp/ or request that a copy be sent to you free of charge at any time.
You may see the Oregon Health Plan Handbook at
https://aix-xweb1p.state.or.us/es_xweb/DHSforms/Served/he9035.pdf or ask for one by calling 800-273-0557.
UHA will assign you to or you may choose a Primary Care Provider (PCP). A Dental Care Organization (DCO) will be assigned to you. They will look after your health care needs, write prescriptions, refer you to specialty care, and admit you to the hospital if needed. Start your medical care by calling your PCP first and your dental care by calling your DCO or Primary Care Dentist (PCD).
Member Services Location and Hours of Operation
Umpqua Health Alliance Member Services office is located at:
500 SE Cass Ave Suite 101, Roseburg, OR 97470
Hours of operation are:
Monday through Friday
8:00 am to 5:00 pm
Members may reach a person 24 hours a day, seven days a week by calling:
541-229-4UHA (541-229-4842) | Toll Free: 866-672-1551
TTY 541-440-6304 or 711
Fax: 541-677-6038
OHA Language Access Statement
Umpqua Health Alliance
541-229-4842
UHAMemberServices@umpquahealth.com
OHA Language Access Statement
Words to know…………………………………………………………………………………………..
What is the Oregon Health Plan (OHP)?....................................................................................
OHP Now Covers Me! / Managed Care and Fee-For-Service / What is a (CCO)?....................
Where is my Coverage? ……....................................................................................................
How We Coordinate your Care / Dual Eligible - Members with Medicaid & Medicare………….
How to Change CCOs ...……………………………………………………………………………....
Enrollment / Member Communication .………………………………………………………………
Native Rights………….…………………………………………………….……...…………………...
Communication and Language Assistance….………………………………………………………
Getting Started with OHP / Copays / Your Opinion Matters……………………………………….
Unfair Treatment .......................................................................................................................
Compliance/Fraud, Waste, and Abuse .…………………………………………….…….…………
Provider Availability, Time and Distance Standards ……………………………………………….
OHP Member Rights and Responsibilities.……………………………………….…………………
Confidentiality / Care Helpers ………………………………………………………………………...
Intensive Care Manager / Case Manager …………………………………………………………..
Nurse Advice Line ……………………………………………………………………………………..
Culturally Sensitive Health Education ..….…………………..………………………………………
New Day Program ……………………………………………………………………………………..
After Hours / Urgent Care / Emergency Care / Crises.
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Table of Contents
Tobacco Use…………………………………………………………………………………...
Primary Care Provider (PCP) ..……………………………………………………………………..
Specialists / Things to Remember at your Appointment .…………..…………………………….
Covered Medical Services…………………………………………………………………………..
Services Covered by the Oregon Health Plan / Services That are Not Covered…………….
Billing Information.…………………………………………………………………………………….
Pharmacy and Medication Coverage/ UHA Medication Formulary.…….……………………..
Vision Services.........................................................................................................................
Dental Services…………………….…….……………………………………………………………
Chemical Dependency and Substance Use………………………………………………………..
Mental Health Services…………………………………………………………………..…………...
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39-40
41-42
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47-49
Hospital Services / Ambulance Services / Care After Emergency / Post-Stabilization Ser-
vices / Care Transitions ……………………………………………………………………………...
Second Opinions / Preventative Services ………………………………………………..………..
Out-of-Town Care and Moving / Missed Appointments / Updating Contact Information.…...
Other Things You Need to Know .……………...…………………………………………………..
Getting A Ride.………………………………………………………………………………………...
Complaints and Grievances / Appeals and Hearings……………………………………………..
Declaration for Mental Health Treatment..………………………………………………………….
End of Life Decisions and Advance Directives (Living Wills) .……………………………………
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57-59
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Action — A termination, suspension of, or reduction in covered benefits, services, eligibility or an increase in beneficiary liability.
Acute Inpatient Psychiatric Care — Care you receive in a hospital. We must approve this type of care.
Administrative Hearing — A telephone conference with an Administrative Law Judge to review a decision called a Notice of Adverse Benefit Determination with which you disagree.
Advance Directive — A form that allows you to have another person make health care decisions when you cannot. It also tells a doctor or medical personnel if you do not want any life saving help if you are near death.
Appeal — When you ask your plan to review a decision the plan made about covering a health care service. If you do not agree with a decision the plan made, you can appeal it and ask to have the decision reviewed.
Case Management — Services to help you get care from other agencies.
Complaint — A Member or their representative’s expression of dissatisfaction about any matter
other than an “Action.”
Consultation — Advice given from one professional to another involved in your care.
Copay or Copayment — Medicare and other plans may pay for services but also charge the member a small fee. This fee is called a copay. OHP and UHA do not have copays.
Daily Structure and Support — Programs to help you with daily tasks or to live in the community. They also help you get along with other people.
Dental Care Organization (DCO) — The organization that helps you obtain dental care and assigns you to a dentist in your area.
Department of Human Services (DHS) — State agency in charge of programs such as Supplemental Nutrition Assistance Program (SNAP) and Medicare. DHS and OHA work together to make sure you have the care you need.
Durable Medical Equipment (DME) — Medical equipment such as wheelchairs and hospital beds. They are durable because they last. They do not get used up like medical supplies.
Emergency Medical Condition — An illness or injury that needs care right now. A physical health example is bleeding that won’t stop or a broken bone. A mental health example is feeling out of control or feeling like hurting yourself.
Emergency Medical Transportation — Using an ambulance to get care. Emergency medical technicians (EMT) give you care during the ride or flight. This happens when you call 911.
Emergency Room Care — Care you get when you have a serious medical issue and it is not safe to wait. This care happens in an Emergency Room (ER).
Emergency Services — Care you get during a medical crisis. These services help make you
stable when you have a serious condition.
ER and ED — Emergency Room and Emergency Department, the place in a hospital where you can get care right now.
Evaluation — A way to decide your need for mental health services.
Excluded Services — Things that a health plan doesn’t pay for. Services to improve your looks, like cosmetic surgery, and for things that get better on their own, like colds, are usually excluded.
Family Partner — Also known as Family Support Specialist means an individual who is responsible for assessing mental health and substance use disorder service and support needs of a member of a Coordinated Care Organization (CCO) through community outreach. Also assisting members with access to available services and resources, addressing barriers to services and providing education and information about available resources for individuals with mental health or substance use disorders in order to reduce stigma and discrimination toward consumers of mental health and substance use disorder services and to assist the member in creating and maintaining recovery, health and wellness.
Grievance — A complaint about a plan, provider, or clinic. The law says CCO’s must respond to each complaint.
Habilitation Services and Devices — Services and devices that
teach daily living skills. An example is speech therapy for a child who has not started to speak.
Health Insurance — A plan or program that pays for some or all of its members’ health care costs. A company or government agency makes the rules for when and how much to pay.
Home Health Care — Services you get at home to help you live better. For example, you may get help after surgery, an illness or injury. Some of these services help with medicine, meals and bathing.
Hospice Services — Services to comfort a person during end-of-life care.
Hospital Inpatient and Outpatient Care — Inpatient care is when you get care and stay at a hospital for at last three nights. Outpatient care is when you get care at a hospital but do not need to stay overnight.
Hospitalization — When someone is checked into a hospital for care.
Interpreter Services — Language or sign interpreters for persons who do not speak the same
language as the provider or for persons who are hearing impaired.
Job Opportunities and Basic Skills (JOBS) Treatment — Programs that help you function better in employment settings.
Limited Services — Physical and mental health services that are only partly covered. You may have to pay for these services. You will have to pay if you know the services are limited and you agree to get and pay for the care anyway. This includes services that go beyond those needed to find out what is wrong.
Medically Necessary — Services and supplies that your doctor says you need. You need them to prevent, diagnose or treat a condition or its symptoms. It can mean services that a provider accepts as standard treatment.
Medication Management — The ordering and monitoring of your medications. This does not
include covering the cost of your medications.
Network — The group of providers that a CCO contracts with to provide services. They are the doctors, dentists, therapists, and other providers that work together to keep you healthy.
Network Provider — A provider the CCO contracts with for services. If you see network providers, the CCO pays. Also called a “Participating Provider”.
Non-Network Provider — A provider that does not have a contract with the CCO. These providers
may not accept the CCO payment for their services. You might have to pay if you see a non-network provider. Also called a “Non- Participating Provider”.
Notice of Adverse Benefit Determination — A letter that tells you when a decision is made about your health care.
Personal Care Services — Services that must be prescribed by a physician or licensed practitioner of the healing arts in accordance with a plan of treatment or authorized for the individual in accordance with a service plan approved by the State or designee. The services are provided by an individual who is qualified to provide such services and who is not a legally responsible relative of the individual. The services may be furnished in a home or other allowable location.
Physician Services — Services that you get from a doctor.
Plan — A company that arranges and pays for health care services. Most plans have physical, dental and mental health care.
Post-Stabilization Care — This is care you get after you have received emergency medical services. It helps to improve or clear up your health issues, or stop it from getting worse. It does not matter whether you get the emergency care in or outside of our network. We will cover services medically necessary after an emergency. You should get care until your condition is stable.
Preapproval (Preauthorization, or PA) — Permission for a service. This is usually a document that says your plan will pay for a services. Some plans and services require this before you get care.
Premium — What a person pays for insurance.
Prescription Drug Coverage — Health insurance or plan that helps pay for medications.
Prescription Drugs — Medications that your doctor tells you to take.
Prevention — What you do to help keep you healthy and stop you from getting sick such as checkups and flu shots.
Primary Care Provider or Primary Care Physician — The medical professional who takes care of your health. This is usually the first person you call when you have health issues or need care. Your PCP can be a doctor, nurse practitioner, physician's assistant, osteopath or sometimes a
naturopath.
Primary Care Dentist (PCD) — The main dentist who takes care of your teeth and gums.
Provider — A licensed person or group that offers a health care service. Examples are a doctor, dentist or therapist.
Residential Care Program — A facility providing room, board and mental health services. The program helps you function at home, school, and in the community.
Rehabilitation Services and Devices — Special services and devices to help you get back to full health. These help usually after surgery, injury or substance abuse.
Second Opinion — An opinion from a doctor/healthcare provider other than a member’s regular doctor/healthcare provider who gives the member his or her view about the member’s health issue and how to treat it.
Skilled Nursing Care — Help from a nurse with wound care,
therapy, or taking your medicine. You can get skilled nursing care in a hospital, nursing home or in your home.
Skills Training — A program to help you function socially. It helps you manage money. It also helps you eat right and teaches you how to cook.
Special Health Care Needs — Individuals who have high health care needs, multiple chronic conditions, mental illness or substance use disorders and either
have functional disabilities,
live with health or social conditions that place them at risk of developing functional disabilities (for example, serious chronic illnesses, or certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care), or
are a member that is identified by OHA who needs priority care.
Specialist — A provider trained to care for a certain part of the body or type of illness.
State Fair Hearing — A Department Hearing related to an action, including a denial, reduction or termination of benefits that is held when requested by a UHA member. A hearing may also be held when requested by a UHA member who believes a claim for services was not acted upon within a reasonable timeframe or believes the payer took an action improperly.
Subcontractor — Means any individual, entity, facility, or organization, other than a participating provider, that has entered into a subcontract with UHA or with any subcontractor for any portion of the work under UHA.
Therapeutic Group Home — A care setting that helps you develop home skills.
Therapy — Care that meets the goals of your treatment plan.
Treatment Foster Care — A program that helps you develop skills allowing you to live alone.
Urgent Care — Care that you need the same day. It could be for serious pain, to keep you from feeling much worse, or to avoid losing function in part of your body.
Youth Partner — An individual providing services to another individual who shares a similar life experience with the peer support specialist (addiction to addiction, mental health condition to mental health condition).
What is the Oregon Health Plan (OHP)?
The Oregon Health Plan (OHP) is a program that pays for the healthcare of low-income Oregonians. The State of Oregon and the US Government’s Medicaid program pay for it. The OHP program covers doctor’s visits, prescriptions, hospital stays, dental care, mental health services, help with addiction to cigarettes, alcohol and drugs, and free rides to covered health care services. OHP can provide hearing aids, medical equipment and home health care if you qualify.
OHP Supplemental is a benefit for children through age 20, and pregnant women. It covers
glasses and additional dental care.
The Triple Aim
Improve the lifelong health of all Oregonians
Increase the quality, reliability, and availability of care for all Oregonians
Lower or contain the cost of care so it is affordable for everyone
OHP does not cover everything. A list of the diseases and conditions that are covered, called the Prioritized List of Health Services, is online at http://www.oregon.gov/oha/HPA/CSI-HERC/Pages/
Prioritized-List.aspx. Some diseases and conditions usually are not covered by OHP. Those conditions could be covered if treating them will help a patient’s covered condition.
Umpqua Health Alliance (UHA) is a Coordinated Care Organization (CCO). CCOs are a type of managed care. The Oregon Health Authority (OHA) wants people on OHP to have their health care managed by local healthcare networks consisting of all types of providers working together to deliver patient centered care. OHA pays managed care companies a set amount each month to provide
their members the health care services they need.
Health services for OHP members not in managed care are paid directly by OHA. This is called fee- for-service (FFS) because OHA pays providers a fee for services they provide. It is also called an
Open Card. Native Americans, Alaska Natives, people on both Medicare and OHP can be in a CCO, or can ask to change to fee-for-service anytime. Any CCO member who has a medical reason to have FFS can ask to leave managed care. OHP member Services at 800-273-0557 can help you understand and choose the best way to receive your health care.
If you have questions about coverage for you or your family, please call Member Services at the number listed above.
Starting Jan. 1, 2018, the Oregon Health Plan (OHP) is became available to more children and
teens younger than 19, regardless of immigration status. This includes youth with Deferred Action for Childhood Arrivals (DACA) status and those previously only eligible for Citizen Alien Waived
Emergent Medical (CAWEM or CAWEM Plus). All other OHP requirements for those under 19, such as household income, remain the same.
What are Managed Care and Fee-For-Service?
The Oregon Health Plan (OHP) is a program that pays for low-income Oregonians’ health care. The State of Oregon and the US Government’s Medicaid program pay for it. OHP covers doctor’s visits, prescriptions, hospital stays, dental care, mental health services, help with addiction to cigarettes, alcohol and drugs, and free rides to covered health care services. OHP can provide hearing aids, medical equipment and home health care if you qualify.
OHP Supplemental benefits are for children through age 20, and pregnant women. It covers glasses and additional dental care.
What is a Coordinated Care Organization (CCO)?
UHA is a group of all types of health care providers who work together for people on OHP in our community.
Some groups in our CCO are:
Adapt, a provider of alcohol and drug treatment, primary care services, and mental health services;
Advantage Dental Services, a dental care provider, 866-268-9631;
ATRIO Health Plans, a provider of Medicare Advantage insurance, 877- 672-8620;
Aviva Health, a Federally Qualified Health Center (FQHC);
Cow Creek Health & Wellness Center, a rural health center providing medical care for tribal members as well as the general public, 800-929-8229;
Mercy Medical Center, the Roseburg area’s community hospital;
Umpqua Health Newton Creek,
LLC, a Rural Health Clinic (RHC) providing medical care;
Umpqua Health-Transitional Care Clinic, a health center that provides care after being discharged from the hospital until you can get an appointment with your assigned PCP.
Umpqua Health Alliance’s network covers most of Douglas County with the exception of some areas in Reedsport , Gardiner, Winchester Bay, and Scottsburg.
How We Coordinate Your Care
Umpqua Health Alliance coordinates the care you receive. Instead of just treating you when you get sick, we work with you to help keep you healthy.
We can work with you to prevent unnecessary trips to the hospital or ER.
You will get the tools and support you need to help you stay healthy.
We offer advice about your care that will be easy to understand and follow.
We will coordinate the care we provide by making it easy for all of your providers to share
information that will help to get you healthy and help keep you healthy.
All of your providers will work together, and with you, to improve your health and make sure all of your medical, dental, and mental health needs are met.
We will offer prevention programs to help keep you and your family from getting sick.
We want you to get the best care possible. Sometimes we provide health-related services (formerly called flexible services) that OHP doesn’t cover. These are non-medical services that CCO’s may pay for in special situations. Health-related services can be for one person, or for a community, to benefit the broader population. Call Member Services for more information.
Another way we coordinate your care is ask our providers to be recognized by the Oregon Health Authority (OHA) as a Patient Centered Primary Care Home (PCPCH), or other primary care team. That means they can receive extra funds to follow their patients closely, and make sure all their medical, dental, and mental health needs are met. You can ask at your clinic or provider’s office if it is a PCPCH.
If you are a Full Benefit Dual Eligible (FBDE) member, and have questions or need help with navigating the coordinated health care system, please contact Member Services at the number listed above, or toll free at 866-672-1551 and someone at UHA will help you.
Dual Eligible Members with Medicaid & Medicare
Some people are eligible for both Medicaid and Medicare benefits. They are called Dual Eligible. If you are Dual Eligible, make sure your provider knows. Medicare should be billed first. You will then receive a Medicare Explanation of Benefits (EOB) in the mail. If your Medicare EOB denies any of your covered services, don’t be alarmed. Contact UHA Member Services at 541-229-4842 and tell us that you received a bill. You are not responsible for paying the co-insurance, co-pay, or deductible for covered services. UHA will pay the rest of the charges for covered services. Your provider will take care of sending UHA all of the information.
If you get care from a provider that is not listed in Umpqua Health Alliance’s Provider Directory you may have to pay the bill. Only emergency care by an out-of-network provider would be covered. If you want to see a provider that is not in the Provider Directory, ask your PCP for a referral.
For more information on getting help with coordinated care, please see the Intensive Care section on page 27 in this handbook.
How to Change CCOs
If you want to change to a different CCO, call OHP Customer Service at 503-378-2666 or 800-699-9075.
If another CCO is open for enrollment, there are several chances for you to change:
If you do not want the CCO you’ve been assigned to,
you can change during the first 90 days after you enroll.
If you move to a place that your CCO doesn’t serve, you can change CCO’s as soon as you tell OHP Member Services about your move. You can change CCO’s once each year.
If you are a Native American or Alaska Native, or are also on Medicare, you can ask to change or leave your CCO anytime.
Disenrollment — When you have a problem getting the right care, please let us try to help you before changing CCO’s.
Call Member Services at the number listed above and ask for a Care Coordinator. If you still want to leave or change your CCO, contact OHP Client Services at the numbers listed at
the top of this section.
A CCO may ask the Oregon Health Authority (OHA) to remove you from the plan if you:
Are abusive to CCO staff, property or your providers
Commit fraud, such as letting someone else use your health care benefits
Move outside of the service area of your plan
Lose OHP eligibility
UHA does not determine disenrollment. OHA will review the plan’s request for disenrollment for the above reasons.
Other reasons you might choose to leave UHA’s CCO on your own include:
When we do not cover a service that you want.
You need “related” services to be performed at the same time (for example, a cesarean section and a tubal ligation). Not all related services are available within the network and your PCP determines that receiving the services separately would cause you unnecessary risk.
Page 17
Enrollment / Member Communication
When you enroll with the Oregon Health Plan (OHP), you will receive letters in the mail explaining how the coverage works. You will receive the following letters in the mail:
OHP Coverage Letter — OHP sends you a coverage letter with your benefit package and managed care enrollment information. The coverage letter shows information for everyone in your household who has a OHP Medical Care ID card. You do not need to take the coverage letter to your health care appointments or pharmacies.
OHP Medical ID Card — OHP also sends you one Oregon Health ID card that has your name, client number and the date the card was issued. All eligible members in your household receive their own Oregon Health ID cards. You must keep it with you and show it to your PCP, pharmacy, hospital, and all medical providers.
If you lose your Oregon Health ID card, call
OHP Client Services at 800-699-9075 for help.
OHP will send you a new coverage letter if you ask for one or if your coverage changes.
UHA Medical ID Card — Each member of UHA will also receive a UHA Medical ID Card. The UHA Medical ID card is sent out attached to a welcome letter within a week of your UHA enrollment.
Please punch out the ID Card that is attached to the welcome letter and keep it with you at all times. Show the card where ever you receive medical services.
Front
Back
Enrollment / Member Communication (Continued)
Member Handbooks — If you would like another copy of this Member Handbook, please give us a call at the number listed above. You can request a new one at any time, free of charge.
You can also find the online edition of the UHA Member Handbook on our website at
https://www.umpquahealth.com/ohp/#ohp-services
Once you have been transferred onto UHA, what do you do next?
When you receive your UHA Member ID Card, it will list who your assigned PCP is and their contact phone number. Call your PCP to set up an appointment. Even if you do not feel ill, it’s always a good idea to get to know your provider so that they can have all of your medical history already on hand in case you do get sick.
Newborn Coverage — If you are covered by UHA, your newborn baby will also be covered. However, please enroll your baby with UHA as soon as possible (preferably within two weeks). You must tell OHP Client Services about your baby’s birth. Call them at 800-699-9075. When your baby becomes eligible, OHP will send you a coverage letter. Even when you may no longer be eligible for coverage, your child may continue to be eligible.
Coordinated Care Organization (CCO) Enrollment— Most people with OHP Benefits are enrolled in a CCO. Your CCO pays for your health care. For most people, the
CCO pays for medical, dental, and behavioral health (mental health and substance use disorder
treatment) services. Your OHP coverage letter and UHA Medical ID Card lists the type of care your CCO covers:
CCOA: Medical, dental, and behavioral.
CCOB: Medical and behavioral health care. OHA pays for dental care. CCOG: Dental and behavioral health care. OHA pays for medical care. CCOE: Behavioral health care only. OHA pays for medical and dental care.
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 or have FFS (fee-for-service) OHP. The clinic must bill the same as network providers.
UHA is contracted with Cow Creek Tribe of Indians. They are located at 2371 NE Stephens St Suite 200 Roseburg, OR 97470. Their phone number is 541-672-8533, Toll Free 800-929-8229.
Communication and Language Assistance
All members have a right to know about Umpqua Health Alliance’s programs and services.
Members or potential members who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English are called Limited English Proficient or LEP. Anyone who is LEP may be entitled to language assistance for healthcare services/encounters or benefits.
We provide the following at no cost to you:
Sign language interpreters
Spoken language interpreters for other languages
Written materials in other languages
Braille
Large print
Audio
Auxiliary Aids and other formats
If you need help or have questions, please call Member Services at the number listed above.
If you feel more comfortable speaking a
different language, please tell your doctor’s office or call our Member Services. We can have an interpreter available to you for your doctor visit. We also have many doctors in our network who speak or sign other languages. You may also ask for our documents in your preferred written language by calling our Member Services team.
Getting Started with OHP
As a member of OHP, you will receive several letters in the mail. Some of the letters you will receive are:
When you are first approved for OHP, this will include your OHP ID card.
When OHP transfers your coverage to a CCO.
If your benefit package changes in other ways.
Once you are enrolled in a CCO, you will receive your Member ID card as well as a Member Handbook.
Your CCO will send out a letter for any benefit changes within 30 days of the change.
OHP will send out multiple letters when it is time to re-enroll. They space them out as reminders to re-enroll.
If OHP requires any more information from you. This could be regarding proof of income, or proof of residency. The letter will list the items they need.
Copays
Do I have a copay? No, UHA does not have copays. If your provider asks for a copay, don’t pay it. Please call Member Services at the number at the top of the page. Tell the provider’s office and call OHP Client Services at 800-699-9075 right away if you have other insurance, such as Medicare or private insurance. Be sure to bring the ID Card for your other insurance to each appointment with your provider. Your provider must bill any other insurance before they can bill UHA for your services. We will only pay the provider after the other insurances have paid, except in some special cases.
Some people who also have Medicare coverage may have a small copay for prescriptions.
Your Opinion Matters
Umpqua Health Alliance strives to better serve our community through meeting the health care needs of our members. In order for UHA to better understand how to help you as our member, we send out a Health Risk Assessment Survey (HRA) to all new members. Randomly selected members who have received care from our in-network providers may also receive a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. If you received either one of
these surveys, please fill it out and mail it back. This information can help us recognize your health care concerns or needs, so that we may better serve you as our member.
Do you think Umpqua Health Alliance or a provider treated you unfairly? We must follow state and federal civil rights laws. We cannot treat people unfairly in any program or activity because of a person’s:
Age
Color
Disability
Gender identity
Marital status
National origin
Race
Religion
Sex
Sexual orientation
Everyone has a right to enter, exit and use buildings and services. They also have the right to get information in a way they understand. We will make reasonable changes to policies, practices and procedures by talking with you about your needs.
Compliance/ Fraud, Waste, and Abuse
Umpqua Health Alliance is committed to doing the right thing.
We have a Fraud, Waste, and Abuse (FWA) Plan that we follow to ensure that we are complying with State and Federal laws and regulations.
Examples of Fraud:
Billing for services that were not done
Providing inaccurate diagnosis to justify doing tests and surgeries that aren't medically necessary
Examples of Waste:
A doctor ordering tests that are not necessary
Mail order pharmacy sending medications to a member without confirming they are still needed
Examples of Abuse:
When a doctor provides treatment that does not match up with the original diagnosis (the reason you went to the doctor in the first place)
Billing for an office visit that was 45 minutes long when they only saw the patient for 15 minutes
Please help us stop health care fraud by reporting suspicious activity. The right to report Fraud, Waste, and Abuse anonymously is protected under the Whistleblower Laws.
Compliance/ Fraud, Waste, and Abuse (Continued)
To report your concerns or get more information please contact our diversity, inclusion and civil rights executive manager:
Web: www.umpquahealth.ethicspoint.com Email: compliance@umpquahealth.com Phone: 844-348-4702, TTY 711
By Mail: Umpqua Health Alliance
Attention: Chief Compliance Officer 3031 NE Stephens St.
Roseburg, OR 97470
You also have a right to file a Civil Rights Complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR). Contact that office one of these ways:
Web: www.hhs.gov/
Email: OCRComplaint@hhs.gov
Phone: 800-868-1019, 800-537-7697 (TDD)
By Mail: U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue SW
Room 509F HHH Bldg.
Washington, DC 20201
Where to report a case of Fraud, Waste, or Abuse by a Provider:
Medicaid Fraud Control Unit (MFCU)
Oregon Department of Justice
100 SW Market St OR
Portland, OR 97201
Phone: 971-673-1880
Fax: 971-673-1890
OHA Program Integrity Audit Unit (PIAU)
3406 Cherry Ave. NE Salem, OR 97303-4924
Fax: 503-378-2577
Hotline: 1-888-FRAUDO01 (888-372-8301)
Where to report a case of Fraud, Waste, or Abuse by a Member:
DHS/OHA Fraud Investigation
PO Box 14150
Salem, OR 97309
COMPLIANCE, FRAUD, WASTE, ABUSE & PRIVACY
ARE EVERYONE'S RESPONSIBILITY
Hotline: 1-888-FRAUD01 (888-372-8301)
Fax: 503-373-1525 Attn: Hotline
Provider Availability, Time, and Distance Standards
Umpqua Health Alliance (UHA) makes sure we have enough providers. We review grievances and appeals from members, member complaints received by Members Services, how services are used, requests for out-of-network services, requests for special accommodations, requests for sec- ond opinions, community health assessments, and member satisfaction survey results.
UHA’s providers are required to meet the following availability standards for appointment wait times.
Primary Care Providers (PCPs) or PCPCH
Specialists
Dental Care Pro- viders (DCPs)
Behavioral Health Providers
Availability Standards:
Routine Apt: Within 4 weeks
Urgent Apt: Within 72 hours
Follow-up ER Visit: Within 72 hours
Availability Standards:
Routine Apt: Within 4 weeks
Urgent Apt: Within 72 hours
Availability Standards:
Routine Care: Within 8 weeks
Urgent Care: Within 1-2 weeks
Emergent Care: Within 24 hours
Availability Standards:
Non-urgent Behavioral Health: Within 7 days from the date of the request
Urgent: immediately
Time and Distance Standards
UHA makes sure that its provider network is meeting the following time and distance access standards. For all providers: Acceptable travel times and distances may not exceed the following:
In urban areas, 30 miles, 30 minutes
In rural areas, 60 miles, 60 minutes
Standards:
Travel time for member to PCP: 30 min urban/60 min rural
Distance for member to PCP: 30 miles urban/60 miles rural
Standards:
Dental: Within 60 min/60 miles or member
Endocrinology: Within 60 min/60 miles of member
Gynecology (OB/GYN): Within 60 min/60 miles of member
Infectious Diseases: Within 60 min/60 miles of member
Oncology (Medical/Surgical): Within 60 min/60 miles of member
Oncology (Radiation/Radiology): Within 60 min/60 miles of member
Behavioral Health: Within 60 min/60 miles
Pediatrics: Within 60 min/60 miles of member
Cardiology: Within 60 min/60 miles of member
Rheumatology: Within 60 min/60 miles of member
Hospitals: Within 60 min/60 miles of member
Outpatient Dialysis: Within 60 min/60 miles of member
Inpatient Psychiatric Facility Services: Within 60 min/60 miles of member
Pharmacy: Within 60 min/60 miles or member
Primary Care Providers (PCPs) or PCPCH
Specialists
Including, but not limited to the following. For more information, please contact Member Services at the number listed above.
OHP Member Rights and Responsibilities
[OAR 410-141-3590, OAR 410-141-3585, and 42 CFR 438.100]
As an OHP member, you will —
Be treated with respect and dignity, the same as other patients
Choose your provider
Get services and supports that fit your culture and language needs
Tell your provider about all your health
concerns
Have a friend or helper come to your appointments, and an interpreter if you want one
Actively help develop your treatment plan
Get information about all of your OHP- covered and non-covered treatment options
Help make decisions about your health care, including refusing treatment, except for court- ordered services
Get written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency and receive information in accordance with information requirements (42CFR438.10)
Be furnished health care services in accordance with requirements for access, coverage, and coordination of medically necessary services (42CFR438.206 through 42CFR438.210)
Be free from any form of restraint or seclusion
Freely exercise his or her rights, and the exercising of those rights will not adversely
affect the way the CCO, its network providers, or the State Medicaid agency treats the member.
Complain about different treatment and discrimination
Get a referral to a specialist or second opinion if you need it,
Get care when you need it, any time of day or night, including weekends and holidays
Get mental health and family planning services without a referral
Get help with addiction to cigarettes, alcohol and drugs without a referral
To receive necessary and reasonable services to diagnose the presenting condition
To receive a notice of an appointment cancellations in a timely manner
See and get a copy of your health records, unless your doctor thinks it would be bad for you
Limit who can see your health records
Get a Notice of Adverse Benefit Determination letter if you are denied a service or there is a change in service level
Get information and help to appeal denials and ask for a hearing
Make complaints and get a response without a bad reaction from your plan or provider
Ask the Oregon Health Authority Ombudsman for help if a complaint or grievance was not resolved in your favor at 503-947-2346 or toll- free 877-642-0450, TTY 711
Execute a Declaration of Mental Health Treatment in accordance with ORS 127.703, and file a complaint for failure to follow a Declaration of Mental Health Treatment.
As an OHP member, 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 UHA and any other health insurance, and tell them if you were hurt in an accident
Be on time for appointments
Call your provider at least one day before if you can’t make it to an appointment
Have yearly check-ups, wellness visits and
other services to prevent illness and keep you healthy
Follow your providers and pharmacists directions, or ask for another choice
Be honest with your providers to get the best service possible
Call OHP Client Services at 800-699-9075 if you move, are pregnant or no longer pregnant
Tell the receptionist if you have OHP and any other health insurance.
Confidentiality Your Records are Private
We only share your records with people who need to see them for treatment and payment reasons. You can request a limit on who can see your records. Please contact us for more information.
A law called the Health Insurance Portability and Accountability Act (HIPAA) protects your medical records and keeps them private. This is also called confidentiality. UHA has a confidentiality policy called Notice of Privacy Practices that explains in detail how we use our Member’s personal information. We will send you the complete UHA confidentiality policy if you ask. Call Member Services at the number listed at the top of the page to request a copy of the Notice of Privacy Practices.
Privacy is important to your health plan. All patient information is private. This includes anything in
your medical record, and anything you give to us. It also includes anything you tell your provider and clinical staff. If you need to have your medical records sent to another provider, you will need to sign a Records Release form. Chemical dependency and HIV information will not be released unless you give permission on the signed release form.
There are state and federal laws that protect Member’s privacy. Health care information will not be released by UHA or our providers without your approval, except in an emergency or when required by state and federal regulations. However, your clinical records may be reviewed by the state or federal government to see if we gave you the best possible care.
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 Traditional Health Workers (THW). THW is a blanket term for public health workers who work in the community under the direction of a licensed medical provider. They are known as Care Coordinators.
Examples of these helpers are:
Community Health Workers: Someone who assists people and their community to achieve positive health outcomes
Peer Wellness Specialists: These are people who focus on the recovery from addition, mental health, and physical health
Personal Health Navigators: They provide information, assistance, tools, and support to enable a patient to make the best healthcare decisions.
Our THW Liaison (care helper) can be reached by calling 541-673-1462.
Intensive Care Manager
UHA has an Intensive Care Manager (ICM) that is available Monday through Friday, 8:00 am to 5:00 pm, to assist members who have complex medical needs or special healthcare needs. This program is designed for individuals who have high health care needs, multiple chronic conditions, mental illness or substance use disorders and either, have functional disabilities, live with health or social conditions that place them at risk of developing functional disabilities (for example, serious chronic illnesses, or certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care), or are a member that is identified by OHA who needs priority care.
Members who need assistance with medical supplies, equipment, scheduling appointments, or other health care needs can contact UHA’s ICM. Providers, caseworkers, care providers, or family members can also let us know if someone is in need of assistance.
ICM’s also can help if you are new to Medicare and need help getting prescriptions, supplies, other necessary items, and services within the 1st month of your enrollment.
To receive help from an Intensive Care Manager, please contact UHA’s Member Services at the number listed above, or at Toll Free 866-672-1551.
Case Manager
Case Managers are here to assist you with navigating the healthcare process. They are a good resource to help connect you with resources for housing, transportation, Temporary Assistance for Needy Families (TANF), Women, Infants and Children (WIC), in-home caregivers, United Community Action Network (UCAN), Uplift, interpreter/translation services, and much more.
What is Case Management?
Coordination/facilitation of care
Discharge planning
Transitional planning
What services can Case Management offer?
Free transportation to and from
appointments
Flexible spending (see page 16 for more information)
Review
Support
Assess Client Needs
Identify support needs
Coordination of services among providers
Resources for free services
Access to cell phones
To get connected, talk to your provider or call Member Services at 541-229- 4842 and ask for your Case Manager. We’re here to help you explore healthcare opportunities!
Implement support
Assemble support team
Nurse Advice Hotline
This service is for current Umpqua Health Alliance members only. This is not for emergencies. If you have an emergency, call 911.
What is the Nurse Advice Line?
It’s a benefit that UHA provides for our members. They can speak with trained nurses at any time. These nurses are here for you to speak with about symptoms you may be having. They will help you with your next steps in care. This service is available any time of day or night, 7 days a week.
What do they do?
Tell the nurse your problem or concerns. They will quickly help you decide on the best care.
What information do I need before I call?
Caller’s Name: Patient’s Name: Patient’s Date of Birth: Patient’s Gender: Callers Relationship to Patient: Return Phone Number: Member ID Number (Optional):
Call today at 888-516-6166
Culturally Sensitive Health Education
We respect the dignity and the diversity of our members and the communities where they live. We want to serve the needs of people of all cultures, languages, races, ethnic backgrounds, abilities, religions, genders, sexual orientation, gender identification, and other special needs of our members. We want everyone to feel welcome and well-served on our plan.
We have several healthy living programs and activities for you to use. Our health education programs include self-care, prevention, and disease self-management. For more information about these services, please call Member Services at the number listed above.
Early Childhood Cavities can be Prevented. Healthy baby teeth are important for good health and normal growth. Brush your baby’s teeth every day. Never put your baby to bed with a bottle. Lift your baby’s lip and check their front teeth regularly for white or brown spots. Be sure to bring any concerns to the attention of your Dental Care Provider or your PCP.
Child Immunizations (shots) are also covered by UHA. Umpqua Community Health Center (UCHC) abn Aviva Health has clinics that provide immunizations to children and adults available Monday
through Friday. Please call Aviva Health at 541-672-9596 for more information regarding immunization services and hours. You may also check with your pediatrician to see if they provide
immunizations. Immunizations may also be obtained at the “Shots for Tots” clinics held in Douglas County.
Asthma care and prevention is important. UHA has information that can be mailed to you. If you would like information sent to you, call Member Services and ask to speak to a nurse.
Women’s Annual Exams are covered. The exam includes a general physical exam, pelvic exam, review of health history, evaluation of health screen tests, mammogram (breast x-ray), Pap
smear, tests for sexually transmitted diseases, and discussion of any sexual concerns.
Support Groups for various disorders (health problems) are available in Douglas County. If you have a disorder and would like to find out more about joining a support group, call Member Services. You can also ask about other social services that are available in Douglas County. One of UHA’s nurse case managers will be available to answer your questions.
Culturally Sensitive Health Education (Continued)
Transgender Health — UHA respects the healthcare needs of all of our members. This includes members who are or identify as:
Trans Men
Trans Women
Two-Spirit
Non-binary
Gender Nonconforming
For more information on transition coverage, please contact Member Services at the number listed above.
Diabetes Empowerment Education Program (DEEP) — Umpqua Health Alliance is proud to offer the Diabetes Empowerment Education Program, or DEEP. The free six-week workshop helps people with diabetes live healthy lives. During weekly classes, participants will learn how to:
Manage blood sugar
Have a healthy diet
Work with your healthcare team
Set weekly goals
Find support and community resources
Participants will receive free tools and resources. Friends and family are welcome!
You will receive a $10.00 voucher to the Umpqua Valley Farmers Market for each weekly class you attend during the six week workshop (Max $60.00 total).
To sign up and get more information, please contact: Member Services at the number listed above.
New Day Program
About New Day — New Day is a service of Umpqua Health Alliance for moms in Douglas County on the Oregon Health Plan. We help pregnant women struggling with substance abuse or other challenges.
We work together with you and your OB doctor,
and other community providers and agencies to offer support and resources.
The New Day staff can help with:
Evaluating your needs
Emotional support
Counseling
Buprenorphine Medication Assisted Therapy (MAT)
Methadone/Suboxone plan
Drug treatment options
Stop smoking
Making and keeping your appointments
Finding resources
Are you Pregnant and Unsure What to do Next?
Most importantly, see a doctor. You can:
Call your OB/Gyn to make an appointment
Call your PCP and get a referral
Call UHA Member Services at the number listed above, or toll free at 866-672-1551 and ask for help
Ask your counselor, case manager, or any community partner for help
Call New Day to make a self-referral at
541-537-0402 or 541-229-7049
Arrangements can also be made for a meeting place in the community.
Visit us on the web at www.umpquahealth.com. Phone: 541-229-7049 │ Fax Line: 541-459-5741
Please like us on Facebook:
https://www.facebook.com/UmpquaHealth/
Substance Use During Pregnancy — Lots of things can cause problems for babies before and after they are born, and sometimes those problems last a lifetime. Things like smoking, alcohol, substance abuse, marijuana, unsafe housing, poor nutrition, domestic violence, and stress are harmful to pregnant women and their children. The New Day program can help you deal with these things. Even small changes can make a BIG difference. We can help.
If you are currently using opiates like heroin or pain pills, or in a methadone or suboxone program, we can work with a doctor who specializes in MAT to help you get through your pregnancy safely. You want a healthy baby and we want to help get you there.
Our Staff—The New Day program is led by Mandy Rigsby, BA, NCAC II, CADC II, CGAC I
Behavioral Support in Pregnancy.
Location
500 SE Cass St. Ste. 200
Roseburg, OR 97470
Referrals
To make a referral to New Day, contact your pro- vider and request they send it to Mandy Rigsby.
Referrals can also be sent by phone, email or fax.
Office: 541-229-7049
Cell: 541-537-0402
Email: mrigsby@umpquahealth.com Referral Fax: 541-229-8180
After Hours, Urgent, Emergency Care and Crises
After-hours, Weekends, Holidays — You have access to your PCP any time of day or night, every day of the year. When the PCP’s office is closed, you can call their office number. An answering service will contact your provider or
tell you what to do. If your PCP is not available, he or she will arrange for someone else to take care of your medical needs or give you advice.
Urgent Care — Always call your doctor’s, or primary care provider’s
(PCP) office, first about any health problem.
Someone will be able to help you day and night, even on weekends and holidays. If you can’t reach your PCP’s office about an urgent problem or they can’t see you soon enough, you can go to Evergreen Urgent Care or Umpqua Health Newton Creek without an appointment.
Evergreen Urgent Care is open Monday through Friday from 7:00 am to 7:00 pm, and Saturday and Sunday from 9:00 am to 5:00 pm. Their phone number is 541-677-7200.
Umpqua Health Newton Creek is open Monday through Friday 7:00 am to 6:00 pm. Their phone number is 541-229-7038.
Urgent problems are things like severe infections, sprains, and strong pain. If you don’t know how urgent the problem is, call your PCP.
Dental — Contact your Primary Care Dentist (PCD) for tooth pain. If you do not know who your PCD is, call the Dental Care Organization (DCO) listed on your UHA Member ID card.
Emergencies and Crises — If you think you
have a real emergency, call 911 or go to the ER at the nearest hospital. You don’t need prior approval to get care in an emergency. An emergency might be chest pain, trouble
breathing, bleeding that won’t stop, broken
bones, or a mental health emergency. Please
don’t use the ER for things that can be treated in your doctor’s office. Sometimes ER’s have a long, uncomfortable wait and take hours to see a doctor, so you should only go there when you
have to.
A mental health emergency is feeling or acting out of control, or a situation that might harm you or someone else. Get help right away, do not wait until there is real danger. Call the Crisis Hotline at 800-866-9780, or call 911, or go to the ER.
Do not use the ER for Routine Care — Examples of routine care are colds, back pain, constipation, toothache or diaper rash. You should not wait until after office hours to contact your PCP or PCD for routine care. If you use the ER for routine care, you may have to pay the bill.
Tobacco cessation products are covered by the UHA. The best thing you can do for your health and your family’s health is to stop using tobacco. If you are interested in quitting smoking or chewing tobacco, please call Member Services. We have resources to help you quit.
There are so many good reasons to quit.
WHAT’S YOURS?
Plan.
The Quit For Life ®
Program helps people learn to live without tobacco for all
kinds of reasons.
Here’s what you get when you join Quit for Life:
Quitting Aids — We'll help you decide what type, dose and duration of nicotine substitute or other medication that is right for you and teach you how to use it so it really works. You can receive FREE nicotine replacement
therapy products (patches or gum) if it's part of your personalized
Quitting Plan.
Quit Guide — We'll send you an easy-to-use workbook that you can reference in any situation to help you stick with your Quitting
Quit Coach® — You will have expert support and assistance whenever you need it, over the phone, from coaches who specialize in helping people quit tobacco.
Web Coach® — You'll get access to a private, online community where you can complete activities, watch videos, track your progress, and join in discussions with others in the program. There are over 25,000 active members.
Text2QuitSM — This text message feature allows you to connect with your Quit Coach®, interact with Web Coach®, use medications correctly, manage urges, and avoid relapse – all from your supported mobile phone.
For more information or to enroll in the program, please call 1-866-QUIT-4-LIFE (1-866-784-8454) or go to https://www.quitnow.net/ProgramLookup/
* This information is courtesy of www.quitnow.net
Tobacco Use (Continued)
Stop Smoking Programs
Oregon Quit Line:
English 1-800-QUIT-NOW (1-800-784-8669)
Español 1-855-DEJELO-YA
TTY 1-877-777-6534
Online www.quitnow.net/oregon
Other Sources to Consider to Help Stop Smoking:
Smoke Free: https://smokefree.gov
Teen: https://teen.smokefree.gov/
VA: https://smokefree.gov/tools-tips/smokefreevet-signup
American Cancer Society:
Online:
http://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking.html
Freedom From Smoking
Online: http://www.ffsonline.org/
Toll Free: 800-586-4872
Nicotine Anonymous:
Online:
http://nicotine-anonymous.org/
UHA assigns a primary care provider once we are told of your enrollment. You may want to choose a different provider. A current list of participating providers and hospitals can be found on our website at www.umpquahealth.com/. This online list of providers will allow you to search by provider or facility name, gender, and specialty. The provider list will also show which providers speak languages other than English. You may also call Member Services to check if your provider is a
participating provider.
If you already have a PCP, see if they are on the list. If you do not have a PCP or your PCP is not on the list, pick a PCP from the list that is taking new patients.
If you are a new member of Umpqua Health Alliance, please contact us if the assigned PCP on your Member ID Card is incorrect.
If at any time you want to change your PCP, call Member Services at the number listed above. If you have a hearing impairment, please use TTY numbers listed above. The change is
effective the same day.
If you would like a copy of our PCP Assignment
Policy, including information on changing PCP’s, please call Member Services at the number above.
We will mail you a copy free of charge.
If you can’t see a PCP in the first month of enrollment and need medication, supplies, or other services, contact Member Services at the number listed above. Make an appointment with your PCP as soon as possible to be sure that you receive any ongoing care that you need.
Referrals to other Providers — When you need a specialist or another provider, talk to your PCP first. If you need to see a specialist, the PCP will refer you and decide what services and tests you may need. If Umpqua Health Alliance does not have the specialist you need, your PCP will request approval for you to see an out-of-network provider. If you see an out-of-network provider and you don’t have a referral, you may have to pay for the services.
Services that do not Require a Referral — Services that do not require a referral include emergency and urgent care, family planning services and supplies, prenatal care, immunizations (shots), intensive care coordination services, mental health services, and outpatient treatment for chemical dependence (drug and alcohol problems). You may make your own appointments for the above services. UHA also has Traditional Health Workers (THW) that can help you get these services. You can self–refer for our THW’s services. Please refer to the THW section on page 26 of this handbook. Mental health services are available to all OHP Members. You do not need a referral to get mental health services from any provider. Prior Authorization is required for out-of-network services, and inpatient mental health services. Please call Member Services or go on-line at
www.umpquahealth.com/ to find a provider.
Umpqua Health Alliance’s service providers are listed on-line in the Provider Directory at
www.umpquahealth.com/ or you can request that a copy be mailed to you free of charge at any
time. If you need help navigating this section of our website, please refer to our Step-by-Step Guide To Finding a Provider. You can receive a copy of this by calling Member Services at the number above, or on our website.
For more information on what does and doesn’t require a PA/Referral, please visit
https://www.umpquahealth.com/ohp/. It is located in the Member Forms/Notices section under “Prior Approval Requirements”. If you would like a copy of our PA/Referral Policy, please contact Member Services at the number listed above to receive a copy at no cost to you.
Things to Remember at Your Appointment
At your doctors appointment:
Always be on time, if for some reason you are unable to make your appointment, call their office and let them know. Preferably within 24 hours of your scheduled appointment.
Relax, your doctor is here to help. Remember to breathe. Take slow, deep breaths.
Make sure to talk to your doctor about any medical needs or concerns you may have.
If you don’t understand what your doctor is telling you, don’t be afraid to ask them to repeat themselves or to have them explain it to you differently.
Before you leave your doctors appointment:
Make sure you know what the next treatment plan is. Do you need to follow up with your PCP or a specialist? Are there any tests that need to be ran? Do you have any prescriptions you need to pick up?
Make sure you understand why and how you are to follow your treatment plan?
Be sure you know when you are to follow up with your PCP or a specialist?
Covered Medical Services Include but are not limited to:
Preventive services
An exam or test (lab or x-ray) to find out what is wrong, whether the treatment or condition is covered or not
Treatment for most major diseases
24-hour emergency care, lab and x-ray services
Eye health care
Chemical dependency (alcohol and drug) treatment
Diabetic supplies and education
Family Planning Services:
Wigs for chemotherapy or radiation thera- py patients
Hospice
Stop smoking programs
Labor, child birth and newborn care
Some surgeries
Most prescription drugs
Specialist care and referrals
Emergency ambulance services
Hospital care for covered conditions
Medical equipment and supplies
Coordinated Care Services
You do not need a referral for family planning services and supplies. You can go to any OHP provider that is willing to provide these services.
Examples of family planning services and supplies are:
Appointments for birth control, including emergency contraception
Pregnancy testing and counseling
Testing and treatment for sexually transmitted diseases
Abortion
Tubal Ligation
Vasectomy
You can get more information about how to receive these services by calling Member Services or your primary care provider. You can also call the Oregon Reproductive Health Program at (971) 673- 0355. The Oregon Reproductive Health Program works with over 165 clinics throughout the state to offer free or low cost reproductive health services and birth control for women, men, and teens who need them. This program seeks to reduce unintended pregnancy in Oregon by providing access to
the information, services, and resources necessary to ensure that all pregnancies are healthy, well- timed and intended.
Members will be notified of changes in access to benefits 30 days before the effective date of the change or as soon as possible.
Services Covered by the Oregon Health Plan
Umpqua Health Alliance does not cover everything. Some services are only available through Oregon Health Authority (OHA).
Some examples of these services include, but are not limited to:
Therapeutic abortion and related services
Hospice services for members who live in a nursing facility
Long term care services—services which help to meet the needs of people with a chronic illness or disability who cannot care for themselves for a long period of time.
If you have any questions about these services and how to obtain them, please contact Member Services at the number located at the top of the page or call OHA at 800-699-9075.
Services That Are Not Covered
OHP covers reasonable services for diagnosing conditions, including the office visit to find out what is wrong. Once the problem is diagnosed, OHP may not cover follow-up visits if the condition or
treatment is not funded on the Prioritized List of Health Services.
The Oregon Health Evidence Review Commission (HERC) developed the Prioritized List of Health Services. The HERC held many public meetings throughout Oregon to find out what health issues were important to Oregonians. Not all medical treatments are covered. The Commission then used that information to list all health care procedures in order of effectiveness. The Oregon Legislature did not fund conditions that ranked lower on the priority list, which means not all medical treatments are covered.
OHP does not pay for the following services:
Treatment for conditions that get better on their own such as colds or flu
Treatment for conditions for which home
treatment works such as sprains, allergies,
corns, calluses or some skin conditions
Cosmetic surgeries or treatments
Treatments that are not generally effective
Services to help you get pregnant
Treatment rendered outside of Oregon that are not emergencies or urgent care
If you have any further questions about what is covered, please contact UHA Member Services at the top of this page.
Not Covered
Covered
OHP Members Do Not Pay Bills for Covered Services. Your medical or dental provider can send you a bill only if all of the following are true:
The medical service is something that UHA or OHP plans do not cover
Before you received the service, you signed a valid Agreement to Pay, OHP form number 3165
(also called a Waiver)
The form showed the estimated cost of the service
The form said that OHP does not cover the service
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. Always show your Umpqua Health Alliance ID card.
These protections apply if the provider participates in the OHP program (most providers do).
Sometimes your provider doesn’t do the paperwork correctly and won’t get 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 can 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 asking for an appeal and a hearing.
What Should I Do if I Get a Bill?
Even if you don’t have to pay, please do not ignore medical bills - call us right away. Many providers send unpaid bills to collection agencies and even sue in court to get 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:
Billing Information (Continued)
Call the provider, tell them that you were on OHP, and ask them to bill your CCO.
Call Member Services at the number listed above 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.
You can appeal by sending your provider and UHA a letter saying that you disagree with the bill because you were on OHP at the time of the service. Keep a copy of the letter for your records.
Follow up to make sure we paid the bill.
If you receive court papers, call us right away. You may also call an attorney or the Public Benefits Hotline at 800-520-5292 for legal advice and help. There are consumer laws that can help you when you are wrongly billed while on OHP.
I was in the Hospital and my Plan Paid for That, but Now I am Getting Bills From Other
Providers. What can I do?
When you go to the hospital or the ER, you may be treated by a provider who doesn’t work for the hospital. For example, the ER doctors may have their own practice and provide services in the ER. 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, maybe even the lab, the radiologist, and the anesthesiologist. Just because we paid the hospital bill, it doesn’t mean that we paid the other providers. 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 your CCO. 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 OHP if you choose to see a provider that does not take OHP. Before you get medical care or go to a pharmacy, make sure that they are in our provider network or a provider that accepts OHP. The provider's office should tell you up-front if a service or treatment is not covered and how much it costs. To be responsible to pay, you must first sign an Agreement to Pay form to say you will pay the bill for the non-covered service or
treatment. Tell the provider’s office and your caseworker right away if you have other insurance, such as Medicare or private insurance.
Bring the ID Card for your other insurance to each appointment with your provider. Your provider must bill any other insurance before they can bill us for your services. We will only pay the provider after the other insurance has paid, except in some special cases.
Pharmacy and Medication Coverage
Filling your Prescriptions. Your prescription medications should be filled by a pharmacy listed in the Provider Directory at www.umpquahealth.com. Take your prescription to the pharmacy, along with your Oregon Health ID card and your Umpqua Health Alliance Medical ID card.
Do not go to a pharmacy that is not listed in the Provider Directory or to an ER to get your prescriptions filled. UHA may only pay for medications from pharmacies/providers that are enrolled with the Oregon State Medicaid program (OHP). Many of these pharmacies have extended hours for you to have your prescriptions filled in the evenings or on the weekends.
UHA does not pay for medications without a prescription. We also do not cover over-the-counter drugs. Certain medications may require pre-approval for UHA coverage. If you have been prescribed a medication that is one of these or is not on our formulary, your doctor may submit a request for approval. This does not verify coverage. UHA will notify you, the pharmacy, and doctor if the request has been approved or denied. If the request is denied you may appeal the denial. Or you may choose to pay for this medicine out of pocket. The cost may not be repaid in this case.
To receive non-formulary drugs or over-the-counter drugs, you will need to pay out of pocket as UHA does not cover these.
If you have questions or need help getting a medication, please call Member Services.
For medication delivery, call the pharmacy and ask about delivery. Some pharmacies may deliver to your home. They will let you know what you need to do to set this up.
A copy of the Provider Directory can be requested by calling Member Services at any time, at no cost to you.
Mental Health Prescriptions. Most medications that people take for mental illness are paid directly by the Oregon Health Authority (OHA). Please show your pharmacist your Oregon Health ID and your Umpqua Health Alliance medical ID card. The pharmacy will know where to send the bill.
Pharmacy and Medication Coverage (Continued)
Which Medications are not Covered?
Medications not listed in the formulary or drugs removed from the formulary
Medications that do not have an FDA approved use
Medications used to treat conditions that are not covered by the Oregon Health Plan (examples are fibromyalgia, allergic rhinitis and acne)
Medications that are not medically necessary
Medications that are not approved by the FDA
Medications listed as less than effective by the FDA (DESI drugs)
Experimental or investigational medications
Medications to help you get pregnant
Medications used for sexual dysfunction (including impotence)
Medications used for weight loss
Cosmetic or hair-growth medications
Some medications you can buy without a prescription (sometimes called over-the-counter medications)
Medications covered by Medicare Part D for dual eligible members
Fluoride for members over 18 years old
UHA Medication Formulary
Formulary. UHA has a list of covered drugs called a formulary. Pharmacists and doctors
decide which drugs should be in the formulary. You can find the formulary on our website at
http://www.umpquahealth.com/ohp/. It is located in the Member Forms/Notices section. It is called “UHA Formulary”.
The drugs on the formulary can have additional requirements or limits on coverage that include:
The use of generic drugs when available
Prior authorization (pre-approval)
Step therapy (trying other drugs first)
Age restrictions
Quantity limits
UHA has limited vision services. Routine vision exams and glasses are covered for members who are pregnant or younger than 21. Members age 20
and younger can have an eye exam and new glasses (lenses and frames) every 12 months. Pregnant women (21 or older) can have an eye exam and new glasses (lenses and frames) every 24 months.
UHA has eye doctors (optometrists and ophthalmologists) available for vision care. Please call Member Services if you need help finding an eye doctor.
Eye exams for the purpose of checking on your medical condition (for example, diabetes, glaucoma,
or eye injuries and emergencies) are covered. If you think you need a medical eye exam, check with your PCP who may refer you to a specialist.
Dental Services
Dental services are part of your benefits. We will assign you to a Dental Care Organization (DCO). They will send you information to help you get dental care and tell you who your dentist is going to be.
Basic Dental Coverage Includes:
24-hour emergency care
Crowns: Stainless steel crowns on back teeth for adults age 21 and over, most other crowns for children, pregnant women and adults ages 18 to 20
Dentures: Full dentures every 10 years, partial dentures every 5 years
Preventive services including cleanings, fluoride, varnish, sealants for children
Root canals on back teeth for children, pregnant women and adults age 18 to 20
Routine services (check-ups, fillings, x-rays and tooth removal)
Specialist care
Advantage Dental
Phone number: 866-268-9631
Website: https://www.advantagedental.com/
Dental Services
How to Get Dental Care — When you and your family need dental services, please call your Primary Care Dentist (PCD). They are available 24 hours a day, seven days a week. PCDs will take care of most of your dental care. If you need to see a specialist, your PCD will refer you. If you need to see your dentist, please try calling during normal business hours. If you call after hours, there will be a message telling you where to call for urgent or emergency services. The on-call Customer
Service Representative will call your PCD and arrange a time for them to call you back. The on- call Dentist may be the one returning your call.
Even though they are not your PCD, let them guide you in taking care of your needs.
How do I Make an Appointment? — When you need to see your Dentist, call your Primary Care Dentist’s office to schedule an appointment.
When the receptionist answers, tell them who your PCD is, what your name is, and why you need to be seen. They will work with you to set up an appointment.
If you are Unable to Keep Your Appointment, make sure to call the dentists office at least one day before your appointment. If you need a ride, please call UHA Member Services at the number above, or call Bay Cities Brokerage at 877-324-8109.
If you miss three appointments without canceling, your PCD may no longer want to provide care for you or your family members.
Dental Prevention — Preventative care is very important to your wellbeing. You can receive this care from your dentist. This includes regular checkups and cleanings. You can discuss your care with your dentist and schedule the necessary appointment for your care. Having dental prevention will help avoid tooth problems in the future.
Care Away From Home — Umpqua Health Alliance and your Dental Care Organization (DCO) do not pay for routine or follow-up care if you are outside of the coverage area. If you decide to get routine dental care while you are away from home, you may have to pay the bill.
Dental Benefits and Services
Benefits | UHA (for pregnant women and members under 21) | UHA (for all other adults) |
Emergency Services | ||
Emergency Stabilization (in or out of the service area) Examples: |
|
|
Preventative Services | ||
Exams | ||
Cleaning | ||
Fluoride Treatment | ||
X-rays | ||
Sealants (Age 16 and Younger) | Not Covered | |
Restorative Services | ||
Fillings | ||
Partial Dentures | Limited | Limited |
Complete Dentures | Limited | Limited |
Crowns | Limited | Limited |
Oral Surgery and Endodontics | ||
Extractions | ||
Root Canal Therapy | Limited | |
Extreme pain or infection
Bleeding or swelling
Injuries to the teeth or gum
Please note that the above services are not covered for everyone. Covered services depends on the dentist’s diagnosis and treatment plan.
Dental Services
Interpreter Services — If you need an interpreter for your dental visit, please contact your DCO’s Member Services. Interpreter services are available either by phone or in person. They will also be able to provide informational materials in an alternate format when requested.
Intensive Care Coordination — The Intensive Care Coordination program helps members that are 65 and over or who have Special Health Care Needs. They help you get the dental care you need. If you have special supply or equipment needs, or need support services, please call your DCO and ask for an Intensive Care Manager.
What if I Have a Dental Emergency? — Emergency care is available 24 hours a day, seven days a week. Prior approval is not required for a dental emergency. Call your PCD, if you are unable to reach your PCD, call your DCO. They can help you find an available emergency dentist. If you are unable to reach your PCD or DCO, call 911 or go to the ER. Tell the ER personnel the name of your PCD.
Follow-up care is NOT an emergency. Call your PCD for follow-up care if needed.
How To Tell If You Have a Dental Emergency — An emergency is when a service is needed im- mediately because of an injury or sudden illness. Examples of emergencies are heavy bleeding that does not stop, a tooth that has been knocked out, or an infection that makes it hard to breathe.
Issues like cavities, broken teeth, and typical routine care are not considered emergencies.
Chemical Dependency and Substance Use
Outpatient services for alcohol and drug treatment are part of the basic benefit package for all Oregon Health Plan (OHP) Members. These services include outpatient treatment, intensive outpatient detoxification and methadone maintenance. You do not need a referral for outpatient chemical dependency services. Contact your PCP for treatment centers that are in-network.
Mental Health Services
Mental health services are available to all OHP Members. You can get help with depression, anxiety, family problems, and difficult behaviors, to name a few. 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.
Important: You do not need a referral to get mental health services from a network provider. Please go to our on-line Provider Directory at http://www.umpquahealth.com/ohp/.
Our mental health providers can help with lots of services including mental health assessments and evaluations, crisis intervention, and outpatient treatment for adults, youth and family. In addition, they provide services made to meet the
needs of certain people that have been found to need special services.
Other mental health services that are covered are:
Programs that teach you how to live on your own
Services to make sure you are taking your medications right
Services needed in an emergency or that are medically
necessary
Visits with a psychiatrist or other professional who can prescribe medication for mental illness
Programs that teach you how to get along with other people
Hospital care for a mental illness
Programs that teach you how to get and keep a job
Programs that teach you how to manage your mental condition
Programs that help promote and maintain an optimal mental status
If you are having a Crisis, please contact our 24 Hour Crisis Line at 800-866-9780
Mental Health Services (Continued)
UHA partners with ADAPT (Alcohol Drug Abuse Prevention Training) to provide our community access to primary care, addictions treatment, and behavior health services to promote health and restore lives.
ADAPT provides person-centered care including:
Patient Centered Primary Care Home (PCPCH)
Psychiatric and behavioral health services
Inpatient and outpatient specialty addiction care programs
School and Community Prevention & Education
For more information, please contact your PCP or ADAPT at 541-672-2691. You can also check out their website at http://www.adaptoregon.org/.
Adult Mental Health Services:
Choice Model Services coordinate care for adults with serious mental illness when they leave the Oregon State Hospital to live in the community. The Choice Model gets discharged clients the
community services they need. This could be outpatient or residential treatment, adult foster care, or living in a supported apartment. The goal is to avoid going back to the state hospital.
Children’s Mental Health Services:
Children with behavioral challenges are served through Wraparound or intensive care coordination. Intensive care coordination services meet the child and family’s needs. System of Care and Wrapa- round planning involves everyone in the child’s life - schools, community organizations, doctors, the criminal justice system, and others - in forming a team around the child and family to plan support services.
Mental Health Services (Continued)
What is Depression?
Depression is a serious mental health illness often marked as feeling anxious or sad. These feelings are common but are usually for a short time. Depression is when these feelings don’t go away and impede on your daily life.
What are some of the symptoms of Depression?
If you are depressed you may feel:
If I’m depressed, how do I help myself get better?
To help yourself feel better:
Spend time with family and friends
Sad
Empty
Anxious
Hopeless
Worthless
Restless
Helpless
Irritable
Engage in physical activities
Don’t take on everything all at once; break things down into smaller, manageable projects
For more information or if you need help, please don’t wait
Call or Text the info below
Teen Support OregonYouthLine.org Text: teen2teen to 839863
Suicide Prevention Lifeline
1-800-273-TALK (8255)
1-888-628-9454 (Spanish)
24 Hour Crisis Line
1-800-866-9780
Mercy Medical Center is your primary hospital. It is located at 2700 Stewart Parkway in Roseburg, Oregon. If you need a service which they are not able to provide, you will be referred to a different hospital.
UHA is also contracted with the following hospitals outside of Douglas County:
Sacred Heart University District Hospital Eugene
3377 Riverbend Drive, Suite 502
Springfield, OR 97477
Sacred Heart University District and Sacred Heart University District Rehab
1255 Hillyard St
Eugene, OR 97401
Sacred Heart Riverbend
3333 Riverbend Dr
Springfield, OR 97477
Ambulance Services
Please call your PCP to see if your medical condition requires emergency transport if you are not sure.
Ambulance services are only covered for emergencies. If you use the ambulance for something that is not a real emergency, you may have to pay the bill.
Call 9-1-1 for ambulance service.
Care After an Emergency
Emergency care is covered until you are stable. Call your PCP, PCD, or mental health provider for follow-up care. Follow-up care once you are stable is covered but not considered an
emergency. Please get follow-up care from your PCP or regular doctor.
Post–Stabilization Services
Care Transitions
We offer a program called Care Transitions to help you when you are being discharged from the hospital. We can:
Answer any questions you may have about getting out of the hospital
Answer questions about the drugs your doctor gives you
Help arrange your doctor visits
Help set up support for you or your family member if needed, when you get out of the hospital. Also, if you need help transitioning back to your home from other places where you were treated, please call and let us know. You can reach a member of the Care Transition team at 541-229-7051.
Post-Stabilization Services are services that are provided after a patient is stabilized in order to maintain a stabilized condition or to improve or resolve their condition. Post-Stabilization Services are available at any hospital. For more information about our hospitals, please see Hospital Services section above.
We cover second opinions. As a member of Umpqua Health Alliance (UHA) you are allowed to get a second opinion at no cost to you as the member per UHA’s Coordinated Care Organizations (CCO) contract with the Oregon Health Authority.
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 approval from UHA first.
UHA informs you of this right in the Member Handbook and via our website at
www.umpquahealth.com/ohp/ or by contacting your Primary Care Provider (PCP) or calling the UHA Member Service department at 541-229-4842 and they will be happy to assist you.
You can seek a second opinion from a participating provider and may contact and schedule the appointment without prior approval from UHA.
You may seek a second opinion from a non-participating provider. You can contact a non- participating provider and schedule a second opinion. You or the provider can contact UHA Member Services to receive further assistance.
Preventive Services
Preventing health problems before they happen is important. Umpqua Health Alliance’s OHP Members are covered for preventive services to help you stay healthy. They include check-ups and any tests to find out what is wrong. Your provider will recommend a schedule for check-ups and
other services.
Other Preventive Services Include:
Well-child exams
Immunizations (shots) for children and adults (not for foreign travel or employment purposes)
Routine physicals
Women’s exams and Pap tests
Mammograms (breast x-rays) for women
Prostate screenings for men
Maternity and newborn care
Colorectal screening
Teeth cleaning
Fluoride treatment
Sealants
X-rays of teeth
Out-of-Town Care and Moving Out of the County
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.
Out-of-Town Emergencies — If you have a real emergency when you are away from home, call 911 or go to the nearest ER. Your care will be covered until you are stable. For follow-up care after the emergency, call your PCP.
OHP covers emergency and urgent care anywhere in the United States, but not outside the US. For example, this means OHP will not pay for any care you get in Mexico or Canada. Immunizations (shots) required for foreign travel are also not covered.
Moving Out of the County — Call OHP Client Services at 800-699-9075 immediately if you are moving out of Douglas County. They will help you make the change to another plan. You can also notify OHP that you moved by sending an email to
OregonHealthPlan.Changes@dhsoha.state.or.us. If you do not tell OHP Client Services, you may not receive the care you need when you move.
Missed Appointments
Call your Provider’s office as soon as you know you can’t keep the appointment. This will allow your provider to schedule another appointment at that time. Ask your clinic or provider about their policy for missed appointments.
Updating Contact Information
If you change your address or phone number, please let OHP Client Services know. If they do not receive your updated contact information, it may result in you not receiving your re-enrollment packet, or other important information about your health care.
You can update your address and phone numbers by doing one of the following:
Call OHP Client Services at 800-699-9075
Send an email to: OregonHealthPlan.Changes@dhsoha.state.or.us
Log-in or create a profile on OregONEligiblity: https://one.oregon.gov/
Other Things You Need to Know
Copy of Your Records — You can have a copy of your medical records. Your doctor’s office 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. You can have a copy of your mental health records unless your provider thinks this could cause serious problems.
Right to Change Your Records — If you believe that medical information is missing from your records or is not accurate, you may ask your provider to make changes. To make changes to your records, you will need to send your provider a letter telling them what you would like to have changed and why you want the change.
They may deny your request to change your records due to the following reasons:
They believe that the information is accurate and/or complete.
You haven’t given them your request in writing.
The information was not created by your provider.
If your provider does not make the change, you have the right to appeal this decision. Please contact UHA Member Services to start that appeal.
Physician Incentives — We pay a bonus or reward our providers for keeping you healthy. We do
not pay or reward our providers for limiting services and referrals.
Involvement in CCO Activities — Umpqua Health Alliance has a Community Advisory Council (CAC). We invite you to apply to serve on the Council. Most of the Council includes members that 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 CAC, please call Member Services at the number above for an application.
Structure and Operation — At your request, UHA will provide information on the structure and operation of UHA’s organization.
Disease Management & Prevention Programs — UHA providers have access to health education programs, including self-care, prevention, and disease self-management materials, in easy-to-read
formats and in Spanish. You can always ask your provider to print these materials for you, to help you be more involved in your health care and give you ideas on things you can do that will make you healthier. More prevention ideas and resources are listed on our website www.umpquahealth.com/.
Fraud and Abuse — Misuse of UHA and/or OHP costs all of us. The following actions are forms of misuse:
A person makes false statements regarding resources or income to eligibility workers.
A provider bills Medicaid for services that the recipient never received.
A person uses doctors or hospitals for social purposes rather than for needed health care.
A person manipulates the program to acquire drugs or supplies for ineligible persons, or for personal gain.
A person abuses narcotics purchased through the program.
If you believe there is fraud or abuse happening, please contact Member Services or Compliance (their contact information is located on page 23 of this Handbook).
Other Things You Need to Know (Continued)
Third Party Recovery — If you have been in an accident (Motor Vehicle or Workman's Comp) please go to www.umpquahealth.com and fill out the Accident/Injury/Information form.
Please follow these simple steps:
Select OHP Members from the
top menu
Scroll down to MEMBER
FORMS/NOTICES and select Accident/Injury/Information
Form.
Other Insurance — If you get or lose other health insurance, call OHP Customer Service at 800-
699-9075, TTY 711 and tell them. You can also let Member Services know. You are also required to help find any other insurance to which you are entitled. If you receive payments as a result of an accident or an injury, you must return the amount of benefits received to UHA.
Hardship Waivers —
Any person receiving money or
valuables after a UHA member dies may ask OHA to waive Estate Recovery. The person must meet the requirements of a hardship waiver. There are important deadlines for hardship waivers. Please contact the Estate Administration Unit right away.
To learn more about Estate Recoveries:
Read the Estate Recovery Program brochure (MSC 9093) at https://apps.state.or.us/Forms/Served/me9093.pdf
Also see Oregon Administration Rules 461-135-0832 to 461-135-0847
If you still have questions, contact:
DHS Estate Administration Unit
PO BOX 14021, Salem, OR 97301
800-826-5675 (toll-free inside Oregon) 503-378-2884 / TTY: 711
Fax: 503-78-3137
If you need help getting to your appointments, please call Bay Cities Brokerage at 877-324-8109. We can pay for rides to OHP-covered services if you don’t have a way to get to your doctor, dentist, or counselor, and in some emergencies, to your pharmacy. We may give you a bus ticket or taxi fare. Or we may pay you, a family member or friend for gas to drive you. If you have to travel overnight for approved services, we can help pay for food and lodging.
These rides are also called Non-Emergency Medical Transportation (NEMT). Bay Cities will provide a ride to fill prescription medications if the member needs to stop on the way home from a doctor’s appointment.
Bay Cities Brokerage contracts with local companies to provide medical transportation rides. You may have rides from different companies depending on who is available.
In order to best ensure a ride is available to you, please call and schedule your ride as far in advance of your appointment as possible.
NEMT Complaints and Concerns —The NEMT program is committed to quality customer service.
If you have a complaint or concern, you should call Bay Cities Brokerage at 877-324-8109.
Types of Service Offered: Rides are scheduled with the most cost-effective type of service to meets your needs. Based on the situation, this could be:
Bus (ticket/pass) or Mass Transit
Wheelchair van
Car
Secure transport
Stretcher car
Mileage reimbursement
Bay Cities Brokerage is a shared ride program so other passengers may be picked up and dropped off along the way. When possible, you may also be asked to schedule multiple appointments on the
same day to avoid repeated trips. You may also be asked to have a friend or family member drive you to
the appointment. They would receive mileage payment. For more information, check out their website at:
Please make sure to call Bay Cities 24 hours before your doctors appointment. If you are
needing an Out-of-Town ride to an appointment, please call within (two) 2 business days. If you cancel or change your appointment, call right away to cancel or change your ride.
FOR ANY TRANSPORT REQUESTS TO THE ER CALL 911.
We only pay for emergency room care in true emergencies.
Getting a Ride (Continued)
Scheduling a ride: Call Bay Cities Brokerage at 877-324-8109 to schedule your ride. Their call center is open Monday through Friday from 8:00 am to 5:00 pm.
Rides should always be scheduled at least two (2) business days in advance and no less than 24 hours, if possible.
Any trip request that is received after 4:00 pm the day prior to the appointment will not be authorized
unless the doctors office scheduled it after 4:00 pm and they can verify it.
They will arrange the most cost effective transportation for your needs. This may be a volunteer who gives rides to your health care appointments.
Mileage reimbursement: You can contact Bay Cities Brokerage to request a copy of Rider ’s Guide and get reimbursement forms. The reimbursement amounts are as follows:
Mileage: $0.25/mile.
Meal Reimbursements - Travel must be a minimum of (4) four hours outside of your local area. Members do not need to submit receipts for meals.
Breakfast: $3.00 - Travel must begin before 6:00 am
Lunch: $3:50 - You must be gone the entire period from 11:30 am to 1:30 pm
Dinner: $5:50 - Travel ends after 6:00 pm
Lodging reimbursement is available if the travel begins before 5:00 am in order to reach a scheduled appointment or if travel from a scheduled appointment would end after 9:00 pm. Lodging is not reimbursed if the trip can be completed in one day or for multiple appointments on different days when they can be scheduled the same day.
Lodging Amount: $40.00 per night
Please allow up to 30 days for processing reimbursement verification forms. Proof of Appointment
Forms must be returned within 45 days following the appointment. All reimbursement requests must
have prior approval or they will not be processed.
The Riders Guide and Bay Cities Brokerage polices and procedures are available on their website at
http://www.bca-ride.com or you can request a copy be sent to you by calling 877-324-8109.
Contact Information:
Bay Cities Brokerage
Toll Free: 1-877-324-8109
Call Center: 541-672-5661
Mailing address: Bay Cities Brokerage 1290 NE Cedar St.
Roseburg, OR 97470
If you are very unhappy with Umpqua Health Alliance, your health care services, your provider (with your written consent), or authorized representative, you can complain or file a grievance at any time. We will try to make things better. Just call Member Services at the number above to have us file a grievance on your behalf or to request a complaint form be mailed to you, or send us a letter to the address on the front of the handbook.
If we can’t solve it in 5 workdays, we will send you a letter to explain why. If we need up to 30 days
to address your complaint, we will send you a letter within 5 workdays to explain why. We will not tell anyone about your complaint unless you ask us to. If we need even more time, we will send another letter within 5 days.
Appeals and Hearings
If we deny, stop or reduce a medical, dental, behavioral health, or transportation service your provider has requested us to cover, we will send you and the requesting provider a Notice of Action (NOA) letter explaining why we made that decision.
These notices are important because they allow you to ask us to review coverage decisions if you do not agree with them. To learn more about how to ask for this review, please continue reading this section, and refer to the Complaints or Grievances section above. These notices do not mean you have to pay.
You have a right to ask to change it through an appeal and a state fair hearing. You, your provider (with your written consent) or authorized representative must first ask for an appeal no more than 60 calendar days from the date on the Notice of Adverse Benefit Determination letter.
How to Appeal a Decision — In an Appeal, a different health care professional at Umpqua Health Alliance will review your request. Ask us for an Appeal by:
Calling Member Services at the number listed above.
Writing us a letter and sending it to the address on the front cover of this handbook.
Filling out an Appeal and Hearing Request, OHP form number 3302.
If you would like your provider to appeal this decision, have their office give us a call to set up a Peer to Peer. This is a phone meeting between your doctor and the UHA Medical Director.
If you want help with this, call and we can fill out an Appeal form for you to sign. You can ask someone like a friend or case manager to help you. You may also call the Public Benefits Hotline at 800-520-5292 for legal advice and help. An acknowledgement letter will be sent to inform you that we have received your appeal. You will get a Notice of Appeal Resolution from us in 16 days letting you know if the reviewer agrees or disagrees with our decision. If we need more time to do a good review, we will send you a letter saying why we need up to 14 more days.
You can keep on getting a service that already started before our decision to stop or reduce it. You must ask us to continue the service within 10 days of getting the Notice of Adverse Benefit Determination letter that stopped it. If you continue the service and the reviewer agrees with the original decision, you may have to pay the cost of the services that you received after the effective date on the Notice of Adverse Benefit Determination letter.
If You Need a Fast Appeal — If you, your authorized representative, or your provider believe that you have an urgent medical problem that cannot wait for a regular appeal, tell us that you need a
fast (expedited) appeal. We suggest that you include a statement from your provider or ask them to call us and explain why it is urgent. If following standard timeframes could jeopardize the Member’s life or health, it will be treated as urgent and we will make a decision within 72 hours.
How to Get an Administrative Hearing — After an appeal, you, your provider (with your written consent) or authorized representative can ask for a state fair hearing with an Oregon Administrative Law Judge. You can only request a hearing after UHA makes an adverse determination of your appeal. You will have 120 days from the date on your Notice of Appeal Resolution (NOAR) to ask
the state for a hearing. Your NOAR letter will have a form that you can send in. Once we receive your hearing request, UHA will date-stamp it with the date of receipt and then forward it to OHA within 2 business days. You can also ask us to send you an Appeal and Hearing Request form, or call OHP Client Services at 800-273-0557, TTY 711, and ask for form number 3302.
Notice of Hearing Rights (DMAP 3030) is available at
https://apps.state.or.us/Forms/Served/he3030.pdf and the Hearing Request Form (MSC 0443) or Appeal and Hearing Request (OHP 3302) is available on the OHA Website at:
MSC 0443 - https://apps.state.or.us/Forms/Served/me0443.pdf
OHP 3302 - https://apps.state.or.us/Forms/Served/he3302.pdf
At the hearing, you can tell the judge why you do not agree with our decision and why the services should be covered. You do not need a lawyer, but you can have one or someone else, like your doctor, with you. If you hire a lawyer you must pay their fees. You can ask the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 800-520-5292, TTY 711, for advice and possible representation. Information on free Legal Aid can also be found at
A hearing often takes more than 30 days to prepare. While you wait for your hearing, you can keep on getting a service that already started before our original Notice of Adverse Benefit Determination decision to stop it. You must ask the state to continue the service within 10 days of getting our Notice of Appeal Resolution that confirmed our denial. If you continue the service and the judge agrees with the original decision, you may have to pay the cost of the services that you received after the date on the original Notice of Adverse Benefit Determination.
Fast (expedited) Hearing — If you or your provider believe that you have an urgent medical problem that cannot wait for a regular hearing process, say that you need a fast (expedited) hearing and fax the Appeal and Hearing Request form to the OHP Hearings Unit. We suggest that you include a statement from your provider as to whether you are entitled to a fast hearing. You should get a decision from the State Hearings Unit in 2 workdays. The Hearing Unit’s fax number is 503-
945-6035. Members who are dissatisfied with the disposition of a Complaint or Appeal may present their complaints to the Oregon Health Authority (OHA) Ombudsman by calling toll-free at 877-642-
0450. You may also find a complaint form at https://apps.state.or.us/Forms/Served/he3001.pdf. UHA will fully cooperate with the investigation. UHA will follow any recommendation for resolution of the grievance given by the OHA Ombudsman.
If you would like more information about how Appeals and Grievances work, please call Member Services at the number listed above.
Flowchart for Appeals and Hearings
Provider asks for approval, or bills for a specific service
UHA denies the claim or approval request
UHA mails a Notice of Action/Benefit Denial to provider and member
Member asks UHA for an Appeal
Member asks UHA for a
Hearing
At the appeal, UHA
After the hearing, the administrative law judge
Agrees to pay for the service
Still denies the service
Agrees with UHA denial
Does not agree with UHA denial
Sends Notice of Appeal Resolution to member
Sends Notice of Appeal Resolution to member
Sends Proposed and Final Order to UHA and Member
Sends Proposed and Final Order to UHA and Member
Service is still denied
UHA pays for the service
Declaration for Mental Health Treatment
Oregon has a form for writing down your wishes for mental health care if you have a mental health crisis, or if for some reason you can’t make decisions about your mental health treatment. The form is called the Declaration for Mental Health Treatment. You should complete it while you can understand and make decisions about your care. The Declaration for Mental Health treatment tells what kind of care you want if you ever need that kind of care but are unable to make your wishes known. Only a court or two doctors can decide if you are not able to make decisions about your mental health treatment.
This form allows you to make choices about the kinds of care you want and do not want. It can be used to name an adult to make decisions about your care. The person you name must agree to speak for you and follow your wishes. If your wishes are not in writing, this person will decide what you would want.
A declaration form is only good for three (3) years. If you become unable to decide during those three (3) years, your declaration will remain good until you can make decisions again. You may change or cancel your declaration when you can understand and make choices about your care.
You must give your form to your Primary Care Physician (PCP) or Mental Health Provider and the person you name to make decisions for you.
For help with or for more information on the Declaration for Mental Health Treatment ,call Member
Services at the number at the top of the page, or go to the State of Oregon website at: https://aix-
xweb1p.state.or.us/es_xweb/DHSforms/Served/le9550.pdf .
If you don't think we followed requirements about sharing information with you on Declaration for Mental Health Treatment, you can complain. You can file a grievance through Umpqua Health Alliance (please see Grievance section of this handbook). You can also file a complaint with the Oregon Health Plan by calling their Member Services at 866-699-9075, or you can file through the Health Care Regulation and Quality Improvement office.
To find the complaint form for the Quality Improvement office, please follow this link: https://
www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/
HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/
ALLFACILITIESComplaintIntakeForm.pdf
You can send your complaint form to:
Health Care Regulation and Quality Improvement
800 NE Oregon St, #305
Portland, OR 97232
Email: Mailbox.hcls@state.or.us Fax: 971-673-0556
Phone: 971-673-0540; TTY: 971-673-0372
End-of-Life Decisions and Advance Directives (Living Wills)
Some providers may not follow Advance Directives. Ask your providers if they will follow yours.
Adults ages 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 https://www.oregon.gov/oha/PH/ABOUT/Documents/Advance-Directive.pdf . If you write an Advance Directive, be sure to talk to your Primary Care Provider, Mental Health Provider, 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 CANCELLED in large letters, sign and date them.
You will not be treated differently for not having an Advance Directive. UHA does not limit the implementation of Advance Directives as a matter of conscience. For questions or more information contact Oregon Health Decisions at 800-422-4805 or 503-692-0894, TTY 711.
If your provider does not follow your wishes in your Advance Directive, you can complain. You can file a grievance through Umpqua Health Alliance (please see Grievance section of this handbook, pages 57—59). You can also file a complaint with the Oregon Health Plan by calling their Member Services at 866-699-9075, or you can file through the Health Care Regulation and Quality Improvement office.
To find the complaint form, please follow this link: https://www.oregon.gov/oha/PH/
PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/
HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/
ALLFACILITIESComplaintIntakeForm.pdf
You can send your complaint form to:
Health Care Regulation and Quality Improvement
800 NE Oregon St, #305
Portland, OR 97232
Email: Mailbox.hcls@state.or.us Fax: 971-673-0556
Phone: 971-673-0540; TTY: 971-673-0372
GO TO
EMERGENCY
Where should I go?
Emergency rooms should be used for very serious or life-threatening problems, when you need medical care now and cannot wait.
Examples include:
ROOM OR
CALL 911
Chest Pain
Vomiting blood
Severe burns and cuts
High fevers
Seizures
Numbness in leg, arm
or face
GO TO
URGENT
CARE
Urgent care clinics should be used for common illnesses and minor injuries. This is for when you need care today but your illness or injury isn’t life- threatening. Check with your PCP first to see if they can see you.
Examples include:
Flu-like symptoms
Earaches
Sprains and minor broken bones
Minor cuts or burns
Back and body pain
Migraines
CALL OR SEE
YOUR
PRIMARY CARE
For most of your health problems, you should schedule an appointment with your Primary Care Provider (PCP).
They know your health history, and can
best care for most medical needs.
Examples include:
PROVIDER
Medication refills
Regular physicals
Vaccinations
Medical screenings
Advice on a new or worsening health problem
OHP-UHA-19-075
2570 NW Edenbower Blvd. Monday - Friday 7AM - 7PM Saturday- Sunday 9AM - 5PM (541) 957-1111
3031 NE Stephens St.
Daily 7AM - 7PM (541) 229-7038
