2013 MEMBER HANDBOOK

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IHN-CCO_1005_2013A OHA approved 09.2013

InterCommunity Health Network

Coordinated Care Organization (IHN-CCO)

2013 MEMBER HANDBOOK

Your medical and mental health benefits as a member of

The Oregon Health Plan

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Alternate format information

English

If you need this document in another language, large print, Braille, on tape, or another format, please call 1-800-832-4580 or TTY 1-800-735-2900. If you want a Member Handbook, you can see it at www.samhealth.org/IHN-CCOmembers. If you want us to send you a Member Handbook, please call Customer Service.

You can have a voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider’s office that you need an interpreter and in which language. Information on Health Care Interpreters is at www.Oregon.gov/oha/oei

Spanish

Si necesita otro idioma, letra grande, Braille, CD, cinta de audio u otro formato, llame al

Departamento de Atención al Cliente al 1-800-832-4580 o TTY 1-800-735-2900. Si desea ver el Manual para los Miembros, puede hacerlo en www.samhealth.org/IHN-CCOmembers. Si desea que le enviemos un ejemplar del Manual, llame al Departamento de Atención al Cliente.

Si desea, puede haber un intérprete presente durante sus citas. Cuando llame para solicitar una cita, informe al consultorio médico que necesita un intérprete que hable español. En

www.Oregon.gov/oha/oei hallará información sobre intérpretes que se especializan en el campo médico.

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Welcome to InterCommunity Health Network

Coordinated Care Organization (IHN-CCO),

your community health care plan

IHN-CCO is a managed care plan that works with the Division of Medical Assistance Programs (DMAP) to provide health services to people enrolled in the Oregon Health Plan (OHP). IHN-CCO manages the Medical and Mental health care for eligible OHP members living in Linn, Benton, and Lincoln Counties. If you would like more information about the structure and operations of IHN-CCO as a managed care plan, please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

This member handbook tells you what services are available to you and how to get those services. It also tells you what to do in an emergency and explains your rights and responsibilities.

Federal and state laws related to information in this handbook may change from time to time. We will update this handbook within 90 days from when a major change takes effect.

Read this member handbook thoroughly. Keep it as a guide for future reference. Your IHN-CCO handbook is not complete without the Oregon Health Plan Client Handbook. The Division of Medical Assistance Programs (DMAP) sends you this handbook and it is located at

www.oregon.gov/OHA/healthplan. Your Client Handbook also gives you important information about your OHP benefit package, covered and non-covered services, and dental plan information.

What is the Oregon Health Plan (OHP)?

The Oregon Health Plan (OHP) is a program that pays for low-income Oregonians’ health care. The State of Oregon and the US Government’s Medicaid program pay for it. It covers different groups of services, called benefit packages:

OHP Plus is for pregnant women, children 18 years old and under, and people with disabilities of any age. It covers doctor visits, prescriptions, hospital stays, dental care, mental health services, and help with addiction to cigarettes, alcohol and drugs. OHP Plus can provide glasses, hearing aids, medical equipment, home health care, and transportation to health care appointments.

OHP Standard is for Oregon residents who are older than 18. It covers doctor visits, prescriptions, emergencies, mental health services, and help with addiction to cigarettes, alcohol and drugs. Some people who have OHP Standard pay a monthly charge, called a premium, for it.

There are other benefit packages. An OHA or DHS case worker can tell you which benefits you have. OHP does not cover everything. A list of the 498 diseases and conditions that are covered, called the Prioritized List of Health Services, is on the web at www.oregon.gov/OHA/OHPR/HERC. The diseases and conditions below line 498 usually are not covered by OHP. Something that is “below the line”

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could be covered if the patient has an above-the-line condition that could get better if their below-the-line condition gets treated.

What is a Coordinated Care Organization (CCO)?

IHN-CCO is a Coordinated Care Organization (CCO). We are a group of all types of health care providers who work together for people on OHP in our community. The providers in our CCO are:

Benton County Health Department

Children and adults can come into these community centers for physical and mental health care, and addiction and pharmacy services:

 Benton Health Center, Corvallis

 Lincoln Health Center, Corvallis

 Monroe Health Center, Monroe Lincoln County Health Department

Lincoln Community Health Centers are clinics operated by Lincoln Cou nty Health and Human Services. The clinics provide primary care services, as well as mental health and addictions services at eight sites in Lincoln County. They include clinics in Lincoln City, Newport, South Beach and each of the four public high schools.

Mental Health and Addictions Sites

 Newport, 36 SW Nye Street

 Lincoln City, 4422 NE Devils Lake Blvd.

 South Beach. 4909 South Coast Highway, Suite 1 Primary Care Sites

 Newport, 1010 SW Coast Hwy. Suite 203

 Lincoln City, 4422 NE Devils Lake Blvd. School-Based Health Center Sites

 Newport High School, 322 NE Eads Street

 Taft High School, 3780 SE Spyglass Ridge

 Toledo High School, 1800 NE Sturdevant Road

 Waldport High School, 320 Lower Crestline Drive Linn County Health Department

Children and adults can come into these community centers for physical and mental health care, and addiction and pharmacy services.

Primary Care Sites

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 Albany, 425 Second Avenue SW and 445 Third Avenue SW

 Lebanon, 1600 S. Main

 Sweet Home, 799 E. Long Street Local health care providers

See the IHN-CCO Provider Directory for a complete listing of providers. Accountable Behavioral Health Alliance

Accountable Behavioral Health Alliance (ABHA) manages mental health services through one of the County Mental Health Clinics. You will get services from the County staff or from one of our community providers. You and your County Mental Health Clinic will work to find the best provider for your needs.

The Corvallis Clinic

The Corvallis Clinic provides physical health care for children and adults. They have 80 providers in 26 different specialties.

Mid-Valley Behavioral Care Network

Mid-Valley Behavioral Care offers a range of mental health and chemical dependency services in Linn County.

Oregon Cascades West Council of Governments

Senior and Disability Services ensure access and coordination of social and health care resources. Programs include:

 In-home services

 Relative foster care

 Adult foster care homes

 Assisted living facilities

 Residential care facilities

 Nursing home facilities Samaritan Health Plans

Samaritan Health Plans manages the health insurance functions of IHN-CCO. Samaritan Health Services

Samaritan Health Services provides physical and mental health care, along with hospital care. See your IHN-CCO Provider Directory for a complete listing of providers.

Samaritan Mental Health

Samaritan Mental Health provides inpatient mental health care along with mental health care services.

IHN-CCO coordinates the care they provide:

 You have one number to call for customer service. All your service information is now in one place.

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 You have one IHN-CCO member ID card to receive your physical and mental health care services.

 You have one IHN-CCO member handbook to explain your benefits.

 Your care is managed by one group to make sure that all your providers are working together.

What are managed care and fee-for-service?

CCOs (Coordinated Care Organizations) are a type of managed care. Another type is Dental Care Organizations (DCOs). The Oregon Health Authority (OHA) wants OHP members to have their health care managed by private companies set up to do just that. OHA pays managed care companies a set amount each month to provide their members the health care services they need. In some parts of Oregon, most OHP members must receive managed medical and dental care.

Health services for OHP members not in managed care are paid by OHA, called fee -for-service (FFS). Native Americans and Alaska natives on OHP can choose to receive managed care or FFS. Any OHP member who has a good reason to receive FFS medical care can ask to leave managed care. Talk to your case worker about the best way to receive your medical care.

Who to call

Questions or need help?

IHN-CCO Customer Service Department is available to help you with your questions in person or over the phone:

IHN-CCO Customer Service Department 815 NW Ninth Street, Suite 101

Corvallis, OR 97339

Phone: (541) 768-4550; toll-free 1-800-832-4580; or TTY 1-800-735-2900 Fax: (541) 768-6701

Office Hours: Monday–Friday 8:30 a.m. to 5 p.m. Our offices are wheelchair accessible. Phone Hours: Monday–Friday 8 a.m. to 8 p.m.

For help with a Mental Health Crisis between 5 p.m. to 8 a.m., call 1-855-571-3894. You may also visit us on the Web at www.samhealth.org/IHN-CCO.

 The IHN-CCO Customer Service Department can help you to choose a Primary Care Provider (PCP) for you and each covered member of your family.

 Let us know if you are unable to see your PCP during the first month of enrollment and you need services such as prescriptions, supplies, or other necessary items .

 Let us know if you lose your IHN-CCO member identification (ID) card.

 We can answer any questions you have after reading the materials in your member packet.

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 Let us know if you need a foreign language interpreter to be with you at a medical appointment or on a telephone call with the IHN-CCO Customer Service Department.

 We will help you with complex medical problems and special needs through our Exceptional Needs Care Coordinators (ENCC).

 We will help you with chronic medical conditions through our case management staff.

 Please call us if you have any complaints or concerns.

Call your caseworker or the OHP Central Branch Office at 1-800-699-9075 or TTY 1-800-735-2900 for the following:

 If you have questions about your eligibility.

 If your address changes.

 If your living situation has changed since you filled out your enrollment form.

 If you have not received or you have lost your DMAP medical care identification (ID) card.

 If you get pregnant.

 If you have a new baby.

 If you have no transportation for health care appointments.

 If you have questions about your premiums.

Getting started

Your Oregon Health Identification (ID)

When you become an Oregon Health Plan (OHP) member, the Division of Medical Assistance Programs (DMAP) will mail you your Oregon Health ID and your OHP coverage letter. Your Oregon Health ID used to be called your DHS Medical Care ID. If you still have you r DHS Medical Care ID, you can still use it. Your Oregon Health ID is a card the size of a business card that lists your name, your Medicaid ID number and the date it was issued. Every person in your household who is eligible receives their own Oregon Health ID. Take your Oregon Health ID to all health care appointments. Providers use the information on the card to check your eligibility.

Coverage letter

The coverage letter is for your information only. You do not need to take it to your health care appointments. The coverage letter shows your branch office name, phone number, your worker’s code, and the benefit package, copayment and plan information for everyone in your household. You will get a letter when:

 You are new to the Oregon Health Plan

 You have a new managed care plan, Primary Care Manager or Third Party Resource

 You get a new ID Card

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Benefit packages

The health care services you may receive are based on the benefit packet you have been assigned. As an IHN-CCO member you have one of two benefit packages: OHP Plus or OHP Standard. As an IHN-CCO member with the OHP Plus package you have all the benefits covered under the Oregon Health Plan. As a member with the OHP Standard package your coverage is limited. Your Oregon Health ID (DHS Medical Care ID) and coverage letter will tell you what benefit package you have. IHN-CCO provides mental health services for you as part of your OHP benefit package.

Becoming an IHN-CCO member

When you become a member of IHN-CCO you receive a New Member Packet. The following materials are found in your packet.

Please keep these materials for future reference:

 Member Handbook, including you member rights and responsibilities and our Notice of Privacy Practices

 Welcome letter

A Provider Directory is available upon request. If you are missing any of these materials please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

Involvement in CCO activities

IHN-CCO has a Community Advisory Council. We invite you to apply to serve on the Council. Most of the Council members are Oregon Health Plan members. Other members are from government

agencies and groups that provide OHP services. If you are interested in being a member of the Community Advisory Council, please call Customer Service for an application.

We have several healthy living programs and activities for you to use. For more information about these services, please call IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900

How to change CCO’s

If you want to change to a different CCO, call your DHS case worker. There are several chances for you to change as long as another CCO is open for enrollment:

 If you, or a family member, do not want the CCO you’ve been assigned to, you can change during the first 30 days after you enroll. Everyone in your family who is on OHP must change to the same CCO.

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 If you move to a place that your CCO doesn’t serve, you can change CCOs as soon as you tell your case worker about the move.

 You can change CCOs each time your case worker finds that you meet the requirements for OHP. This is called recertification and usually happens about the same time once each year.

 If you are also on Medicare, you can change or leave your CCO anytime.

Disenrollment

When you have a problem getting the right care, please let us try to help you before changing CCOs. Just call our Customer Service at IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900. If you still want to leave or change your CCO, call your DHS case worker.

A CCO may ask the Division of Medical Assistance Programs (DMAP) to remove you from it if you:

 are abusive to CCO staff or your providers

 commit fraud, such as letting someone else use your health care benefits

If you want fee-for-service OHP instead of managed care

OHP wants you to get managed health care from a CCO like IHN-CCO. CCOs can provide some services that OHP can’t. But you can change to fee-for-service OHP at any time if:

 you are an American Indian or Alaska Native

 you are also on Medicare in addition to OHP

Member rights and responsibilities

Your “rights” are the things that you can count on getting from IHN-CCO. Your “responsibilities” are the things we need from you. As a person with OHP insurance, you have many rights and

responsibilities.

As an OHP client, you will be:

 Treated with respect and dignity, the same as other patients;

 Free to choose your provider;

 Urged to tell your provider about all your health concerns;

 Able to have a friend or helper come to your appointments, and an interpreter if you want one;

 Told about all of your OHP-covered and non-covered treatment options;

 Allowed to help make decisions about your health care, including refusing treatment, without being held down, put in a room away from other people, or forced to do something you don’t want to do;

 Given a referral or second opinion, if you need it;

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 Free to get mental health and family planning services without a referral;

 Free to get help with addiction to cigarettes, alcohol and drugs without a referral;

 Given handbooks and letters that you can understand;

 Able to see and get a copy of your health records;

 Able to limit who can see your health records;

 Sent a Notice of Action letter if you are denied a service or there is a change in service level;

 Given information and help to appeal denials and ask for a hearing;

 Allowed to make complaints and get a response without a bad reaction from your plan or provider; and

 Free to ask the Oregon Health Authority Ombudsperson for help with problems at 1-503-947-2346 or toll free at 1-877-642-0450, TTY 711.

As an OHP client, you agree to:

 Find a doctor or other provider you can work with and tell them all abo ut your health;

 Treat providers and their staff with the same respect you want;

 Bring your medical ID cards to appointments, tell the receptionist that you have OHP and any other health insurance, and let them know if you were hurt in an accident;

 Be on time for appointments;

 Call your provider at least one day before if you can’t make it to an appointment;

 Have yearly check-ups, wellness visits and other services to prevent illness and keep you healthy;

 Follow your providers’ and pharmacists’ directions, or ask for another choice;

 Be honest with your providers to get the best service possible; and

 Call your case worker when you move, are pregnant or no longer pregnant.

Members with Medicare or other insurance

If you have both Medicare and the Oregon Health Plan (Medicaid), you are a “dual eligible” member. IHN-CCO will coordinate your Medicaid benefits with your Medicare benefits if you have both. If you have other insurance coverage and are on IHN-CCO, call your caseworker or the IHN-CCO Customer Service Department.

Primary Care Provider (PCP)

When you need medical care, begin by calling your PCP. Your PCP will oversee your medical care and treatment and make sure that you see specialists when needed. You can call your PCP’s office 24 hours a day, seven (7) days a week. Even if the office is closed, there is still someone available to help you. Please ask your provider’s office about their ADA accessibility and non -English languages spoken if you have special needs for your appointment.

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What is a Patient-Centered Primary Care Home (PCPCH)?

We want you to get the best care possible. One way we try to do that is ask our providers to be recognized by the Oregon Health Authority as a Patient-Centered Primary Care Home (PCPCH). That means they can receive extra funds to follow their patients closely, and make sure all their medical and mental health needs are met. You can ask at your clinic or provider’s office if it is a PCPCH.

Second opinion

We cover second opinions. If you want a second opinion about your treat ment options, ask your provider to refer you for another opinion. If you want to see a provider outside our network, you or your provider will need to get approval first.

Care Helpers

There may be times when you need help getting the right care. Your prima ry care team may have people specially trained to do this. These people are called Care Coordinators, Community Health Workers, Peer Wellness Specialists, and Personal Health Navigators. Please call IHN -CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900 for more information.

Native Rights

American Indians and Alaska natives can receive their care from an Indian Health Service (IHS) clinic or tribal wellness center. This is true whether you are in a CCO, prepa id health plan or OHP fee-for-service (open card).

Appointments

Making the most of your health care visit

It is important to meet with a health care provider to prevent illnesses, as well as when you are sick. When you meet with doctors, counselors, nurse practitioners, or pharmacists, it is important to be prepared. When you are prepared for your appointment, your health care provider can help you better. This way, both you and your health care provider can make the most of your time together! Ask your provider’s office about their ADA accessibility and non-English languages spoken if you have special needs for your appointment.

Review these tips before your visit and take some extra time to prepare.

How to make an appointment

1. Call your Primary Care Provider (PCP) or mental health provider. 2. Write down the date and the time of your appointment.

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3. If you need an interpreter for the appointment, call IHN-CCO at least 3 days before the appointment at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

Before your appointment

What to take with you:

 Your medical identification (ID) cards: IHN-CCO medical ID card and DMAP medical care ID card

 A friend or family member: another person can help listen for important details

 A list with:

o Questions you have about your health or treatment.

o A list of medicines you are taking at this time.

If you are not able to be at your appointment for any reason, call your provider’s office as soon as you can to cancel or change the appointment.

At your appointment

 Be on time.

 Relax: do not be nervous.

 Ask your health care provider the following questions:

o What is my main problem?

o What do I need to do?

o Why is it important for me to do this?

 Get all of the answers you need. If you do not understand something, ask to have it repeated or explained.

 Write down information that will help you remember details of the visit.

Before you leave your appointment

Be clear on what you need to do next:

 Know where to go for any follow up visits. Special treatment? Tests? Fill a prescription?

 Understand why it is important to follow your provider’s instructions.

 Ask when you should visit a doctor or another health care provider again.

Cancelling Appointments

If you are not able to be at your appointment for any reason, call your doctor’s office as soon as you can to cancel or change the appointment. Your provider’s office will schedule another appointment for you and make the time available for another patient. Each office has its own policies about

appointments. They will tell you about its policy at your first visit. The policy says what to do if you will be late for an appointment or if you need to cancel an appointment. The policy also says what can happen if a person misses or comes late to too many appointments. Be sure to ask questions if you do not understand the office’s policy.

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Interpreter services

You can have a voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider’s office that you need an interpreter and in which language. Information on Health Care Interpreters is at www.Oregon.gov/oha/oei

To make sure that an interpreter will be at your appointment, please have this information ready when you call:

 The name of the person or persons the appointment is for

 The member’s ID number

 A home phone number

 The date and the time of the appointment

 The name of the health care provider

 The full address of the appointment

 The phone number of the provider’s office

 The reason for the appointment

Please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900, with your appointment information at least 3 days before your appointment. If you cannot keep the appointment, call our Customer Service Department right away.

Getting a ride

If you need help getting to your appointments, please call:

 Cascades West Ride Line, at 1-866-724-2975 or TTY at 1-800-735-2900 Some people on OHP Plus may be able to get help paying for rides.

Child care

If you need child care so you can go to your appointment, please call your case worker. They may be able to help you get money to pay a babysitter.

Co-payments

As an IHN-CCO member, you do not owe co-payments to your providers for health care visits or services. As an OHP member you could owe co-payments for other OHP benefits and services. Contact your caseworker if you have questions about your benefit package, co-payments, or premiums.

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OHP members do not pay bills for covered services

If your health care provider sends you a bill, don’t pay it. Please call our IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900 right away.

Prioritized list of health services

Oregon Health Plan members’ benefits and treatments are based on a list of health services ranked by the Health Evidence Review Commission (HERC), called the Prioritized List of Health Services. OHP members’ covered benefits are based on where their conditions and treatments are on the list. Not all medical services are covered. OHP covers services for finding out what’s wrong and those services that are the most effective. This includes diagnosing a condition that is not on the covered list.

Non-covered services

Not all medical services are covered by the Oregon Health Plan (OHP) or IHN -CCO. OHP covers the health care services most likely to help you get better.

Some of the health care services not covered by OHP include:

 Services not included in the person’s OHP benefit package

 Services for conditions not funded on the Prioritized List

 Services for a person who is in law enforcement custody

 Services requested solely for legal reasons

 Services requested for reasons other than diagnosis or treatment

 Services provided in another country

 Services provided in an emergency room if the problem or concern is not an emergency OHP places limits on or restricts coverage for certain kinds of services. For e xample:

 OHP limits services that are more than what is needed to diagnosis or treat a health condition

 OHP limits services that cost more if a less expensive service is likely to be helpful

 OHP limits services that are for the convenience of the consumer but doesn’t help diagnose or treat a health condition

If you receive non-emergency or non-urgent care services from providers who are not part of your plan, you may be responsible for charges, including Medicare deductibles and coinsurances.

If you think you need treatment, call your PCP or mental health provider. If you have questions about what is a covered or non-covered service, please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900. Please call IHN-CCO before you agree to pay a provider.

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Payment for non-covered services and other insurance

You can choose to get not covered medical or mental health treatment and services. The provider’s office should tell you up-front if a service or treatment is not covered. They will tell you how much it costs. You must sign a form to say you will pay the bill for the non -covered service or treatment. Tell the provider’s office and your DHS or OHA caseworker right away if you have other insur ance, such as Medicare or private insurance. Bring the ID card for your other insurance to each

appointment with your provider. Your provider must bill any other insurance before they can bill us for your services. We will only pay the provider after the other insurance has paid, except in some special cases. We will only pay for medical and mental health services covered by OHP.

Medical health benefits

OHP covers medical health services for children, teenagers, and adults. Not all medical services are covered. OHP covers services for finding out what’s wrong and those services that are the most effective. This includes diagnosing a condition that is not on the Prioritized List of Health Services. Here are some examples of services your plan may cover:

 Preventive care (like shots)

 Diagnostic services such as x-ray or laboratory work (services to find out what is wrong)

 Emergency care

 Medical examinations by your PCP or specialist

 Check-ups

 Immunizations

 Family-planning services

 Pregnancy and newborn care

 Prescription drugs

 Alcohol/drug treatment

 Exceptional Needs Care Coordination (ENCC) Here are some services your plan does not cover:

 Treatment for conditions that get better on their own without going to the doctor, like colds

 Treatment for conditions that can be treated at home, such as corns, calluses and some skin conditions

 Cosmetic surgeries or treatments that only improve appearance, not function

 Services to help you get pregnant

Please call the IHN-CCO Customer Service Department for questions about what benefit package you have, your coverage, any limits, non-covered services, or services that may require IHN-CCO’s approval first.

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Referrals to other providers

If you think you need to see a specialist or other provider, make an appointment with your PCP. Your PCP will decide which services and tests you may need and may refer you to a specialist. Some services must be requested by your PCP and approved by IHN-CCO. If you go to another provider and have certain services without getting approval, you might have to pay for those services. For a complete list of services that require approval, or prior authorization, call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900, or visit our website at www.samhealth.org/IHN-CCOmembers.

Family planning services, emergency services, mental health services, or chemical dependency services do not require a referral from your PCP. For a list of contracted providers, see IHN-CCO’s full provider directory on our website or call the IHN-CCO Customer Service Department for a copy. The provider directory includes the provider’s name, location, phone number, and non -English speaking capabilities. IHN-CCO’s provider directories are updated each week. For information about your mental health agencies go to the Mental health benefits section of this handbook.

Preventive care

Preventive care is a very important part of the care you receive from your PCP. This includes regular check-ups and immunizations (shots). It also includes any exams to make sure there is nothing wrong. Some examples of preventive care are pap smears, mammograms (breast x -ray) and special tests for diabetics. These services are needed to keep you healthy. By getting regular check-ups, your doctor will be able to find and treat problems before they become serious. Be sure to talk to your PCP about the recommended schedule for check-ups and immunizations.

As an IHN-CCO member, you will receive a newsletter with information about staying healthy. You can also get materials from your PCP’s office, local health departments, or the area hospitals about how to stay healthy.

Your PCP will discuss the preventive care you need and when you need it. For some specialized services, you may need to have a referral. To get a referral, talk to your PCP.

Laboratory tests, x-rays, and other procedures

These services are covered if they are medically necessary and if your PCP orders them. Some services may require approval, or prior authorization, from IHN-CCO. For a complete list of services that require approval call the IHN-CCO Customer Service Department at

(541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900, or visit our website at www.samhealth.org/IHN-CCOmembers.

Quitting tobacco

Quitting tobacco classes are a covered benefit for CCO members. Once every 12 months IHN-CCO will pay class enrollment fees for quitting tobacco.

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IHN-CCO also offers other ways to help you stop using tobacco, including telephone -based programs. You can call the Oregon Tobacco Quit Line at:

 1-800-Quit-Now (1-800-784-8669) for English speaking members

 1-877-266-3863 for Spanish speaking members

 1-877-777-6534 for TTY users

For more information about class options, call IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

If your doctor feels that you need a prescription to help you quit tobacco, IHN-CCO will pay for sixteen (16) weeks of medication every 365 days.

Chemical dependency (drug and alcohol) treatment

If you think you need to see someone for an alcohol or drug problem, talk to your PCP or call a provider directly. Drug and alcohol providers have extra training and experience to help people who also get mental health services. You do not need a referral from your PCP for these services. For a list of contracted providers, see IHN-CCO’s full provider directory on our website at

www.samhealth.org/IHN-CCO. You can also call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900 for questions.

Intensive care management services

(Exceptional Needs Care Coordination)

IHN-CCO has registered nurses who work as Intensive Care Managers (ICM), formerly Exceptional Needs Care Coordinators (ENCC). These nurses focus on helping members who are older, disabled, or have other special needs. However, any IHN-CCO member may request ENCC services.

Intensive care coordination services include:

 Helping members understand their benefits and the process for getting services or supplies.

 Coordinating health care with doctors, other providers, and community agencies .

 Working with members who are having problems getting care.

 Identifying other resources for members.

If you have questions or want to get in touch with an ICM, please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

Case management services

In addition to Exceptional Needs Care Coordination, IHN-CCO has case management services to help members who have chronic medical conditions (such as diabetes, asthma, or heart disease) . Nurses

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and other care management staff can work with members, health care providers, or state caseworkers to help find ways to meet health care needs.

If you have questions or want to know more about case management services, please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or

TTY 1-800-735-2900.

Health Education

We respect the diversity of our members and the communities where they live. We want to make sure our services address the needs of people of all cultures, languages, races, ethnic backgrounds, abilities, religions, genders, and sexual orientations. We want everyone to feel welcome and well-served in our plan.

Your county clinic has written information about many topics. These include parenting and dealing with loss and sadness. Others include managing anger, stress, mental health problems, self-care, prevention, and disease self-management. They also give or sponsor classes about these things. Call our customer service department for further information on offered classes and help.

Skilled nursing facility care

Skilled nursing facility (SNF) care is covered for up to 20 days following hospitalization when medically necessary.

Vision care

Call your Primary Care Provider (PCP) about any eye problems, such as an injury or infection. Your PCP will refer you to a specialist if needed.

OHP Plus plan members:

Benefits for Plus plan members who are Pregnant or age 20 or younger:

 Emergency treatment

 Medical eye exams

 Routine eye exams and glasses

Benefits for Plus plan members who are not pregnant or age 21 or older:

 Emergency treatment

 Medical eye exams such as diabetic eye exams, and other vision services to treat certain medical conditions.

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OHP Standard plan members:

 Treatment for eye diseases is covered for members with the Standard plan.

 Routine eye exams, frames, contacts, or exams for the purpose of fitting glasses or contacts are not covered.

If you have questions about your vision benefits or which services require IHN-CCO’s approval, please call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free

1-800-832-4580, or TTY 1-800-735-2900.

Hearing services

If you need hearing services, your PCP will make a referral. IHN-CCO covers hearing exams when needed.

Hearing aids

For Plus plan members, hearing aids are covered if criteria are met. For Standard plan members, hearing aids and exams for the purpose of fitting hearing aids are not covered.

For more information about your hearing aid benefit call our Exceptional Needs Care Coordinators (ENCC) at: (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

Family planning and related services

The following family planning and related services are available to women, men, and teens:

 Family planning visits (physical exam and contraceptive education)

 Contraceptive supplies, such as birth control and condoms

 Sterilization services (tubal ligations and vasectomies) “Related services” include the following:

 Pap smear

 Pregnancy test

 Screenings for sexually transmitted diseases (STDs)

 Testing and counseling for AIDS and HIV

You can go to any of the following places to receive family planning services:

 Your PCP’s office

 A county health department

 A family planning clinic

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If you are pregnant

If you are pregnant, it is very important to make an appointment with your PCP or obstetrician as soon as possible. It is always best to begin receiving prenatal care in the first 3 months of your pregnancy. You then need to receive regular prenatal care throughout your pregnancy until delivery.

Preparing for childbirth

IHNCCO covers childbirth education classes such as Childbirth Preparation, Lamaze, and Breast -feeding classes in your local area. If you would like to attend childbirth education classes during your pregnancy, call the hospital where you are planning to deliver. Tell them you are an IHN -CCO

member and are interested in their classes. Please bring your IHN-CCO Member ID card to your first class, or when you register.

ALBANY

Samaritan Albany General Hospital (SAGH): (541) 812-4301 or TTY: 1-800-735-2900 CORVALLIS

Good Samaritan Regional Medical Center (GSRMC): (541) 768-5090 or TTY 1-800-735-2900

LEBANON

Samaritan Lebanon Community Hospital (SLCH): (541) 451-7177 or TTY: 1-800-735-2900

LINCOLN CITY

Samaritan North Lincoln Hospital (SNLH): (541) 994-3661 or TTY: 1-800-735-2900 NEWPORT

Samaritan Pacific Community Hospital (SPCH): (541) 265-2244 or TTY: 1-800-735-2900

Newborn enrollment

Contact your caseworker as soon as you know you are pregnant. It is also very important that you notify your caseworker again as soon as your baby is born. IHN-CCO will not cover the medical expenses of your newborn child until you have notified your caseworker of your child’s birth. You also need to tell IHN-CCO the name of your newborn child’s PCP.

Changes in your family size

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Mental health benefits

IHN-CCO covers mental health services for children, teenagers, and adults. Not all services are covered. Some of the mental health services covered are:

 Assessment/evaluation

 Counseling

 Case management

 Individual, group and family therapy

 Medication management

 Crisis services

 Emergency services

 Hospital services

 Programs to help with daily and community living

Some services may be more helpful than others. It depends on your needs and concerns. Decisions about which services may be helpful are made together by you and your provider.

Mental health assessment and evaluation

As a member, you can have an assessment of your mental health needs. Call your county mental health agency and tell them you want to make an appointment with a counselor. See pages 19-23 of this handbook for agency information. You do not have to be sure you have a mental health problem to make an appointment. If you think you might, that is enough. A counselor will be happy to talk with you. At your first appointment with them you will decide if you should get mental h ealth treatment. You will also decide if other services might help you.

Routine mental health services

Our mental health treatment agencies are listed in the next section of this handbook. They are arranged by county and then by city. You can call any of these agencies to make an appointment for routine services. You do not need a referral from a doctor or anyone else to do this.

If you need help choosing an agency or want a list of providers at each agency: you can call our IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or

TTY 1-800-735-2900.

Please have your IHN-CCO Member ID card with you when you call. The treatment agency will use the information on your ID card to check your eligibility. You will also be asked for the name of the city or county where you live. This is so we can find an agency whose office is close to you. We may also ask for basic information about your needs and concerns. We may ask your age or whether you speak a language other than English. We may ask if you have been to any of our agencies in the past. This information will help us decide which agency may best meet your needs.

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Mental health treatment agencies

Linn County

ALBANY

Linn County Mental Health Services – Adult Outpatient Program

Office location: 425 Second Ave. SW Suites 200 and 203

Phone: (541) 967-3866 Toll-free: 1-800-304-7468 Send mail to: P.O. Box 100 Oregon Relay TTY or Voice: 711

Albany, OR 97321 VCO: 1-800-735-3260

Services are for adults 18 years and older

Services are available in English and Spanish; services in other languages are available with an interpreter

Office hours: 8:30 a.m. – 5 p.m. on Monday, Wednesday, Thursday & Friday 8:30 a.m. – 6:15 p.m. on Tuesday

Closed from Noon – 1 p.m. on Monday through Friday

Website: www.co.linn.or.us/Health/mental_health/mh.htm

Linn County Mental Health Services – Children’s Outpatient Program

Office location: 425 Second Ave. SW Suite 101

Phone: (541) 967-3866 Toll-free: 1-800-304-7468 Send mail to: P.O. Box 100 Oregon Relay TTY or Voice: 711

Albany, OR 97321 VCO: 1-800-735-3260

Services are for children and youth up to 18 years old

Office hours: 8:30 a.m. – 5 p.m. on Monday, Wednesday, Thursday & Friday 8:30 a.m. – 6:15 p.m. on Tuesday

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Linn County Mental Health Services – Community Support Services & Crisis

Team

Office location: 445 Third Ave. SW Phone: (541) 967-3866 Send mail to: P.O. Box 100 Toll-free: 1-800-304-7468

Albany, OR 97321 Oregon Relay TTY or Voice: 711 VCO: 1-800-735-3260

Community Support Services are for adults 18 years and older with serious mental illness Crisis Team walk-in services are for children, youth and adults

Office hours: Community Support Services

8:30 a.m. – 5 p.m. on Monday through Friday

Crisis Team walk-in services

8:30 a.m. – 5 p.m. on Monday through Friday Website: www.co.linn.or.us/Health/mental_health/mh.htm

LEBANON

Linn County Mental Health Services

Office location: 1600 S. Main Phone: (541) 451-5932 Send mail to: 1600 S. Main Toll-free: 1-888-451-2631

Lebanon, OR 97355 Oregon Relay TTY or Voice: 711 VCO: 1-800-735-3260

Services are for children, youth and adults

Office hours: 8:30 a.m. – 5 p.m. on Monday, Tuesday, Wednesday & Friday 8:30 a.m. – 6:15 p.m. on Thursday

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SWEET HOME

Linn County Mental Health Services

Office location: 799 E. Long St. Phone: (541) 367-3888 Send mail to: 799 E. Long St. Toll-free: 1-800-920-7571

Sweet Home, OR 97386 Oregon Relay TTY or Voice: 711 VCO: 1-800-735-3260

Office hours: 8:30 a.m. – 5 p.m. on Monday, Tuesday & Thursday 1 p.m. – 5 p.m. on Wednesday

Closed on Friday’s; Call Lebanon office above

Closed from Noon – 1 p.m. on Monday through Thursday

Website: www.co.linn.or.us/Health/mental_health/mh.htm

Benton County

CORVALLIS

Benton County Mental Health

Office location: 530 NW 27th Street Phone: (541) 766-6835 Send mail to: P.O. Box 579 Toll-free: 1-800-757-6844

Corvallis, OR 97339 Oregon Relay TTY: (541) 766-6759

Services are available in English and Spanish; services in other languages are available with an interpreter upon request. Some limited evening times for specific non -routine family meetings.

Office hours: 8 a.m. – 5 p.m. on Monday through Friday Website: www.co.benton.or.us/health

Lincoln County

NEWPORT

Lincoln County Mental Health

Office location: 36 SW Nye Street Phone: (541) 265-4179 Newport, OR 97365 Toll-free: 1-888-232-7192

Oregon Relay TTY: (541) 265-6915

Office hours: 8 a.m. – 5 p.m. on Monday through Friday

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LINCOLN CITY

Lincoln County Mental Health

Office location: 4466 NE Devils Lake Blvd., Suite B

Phone: (541) 994-1741

Lincoln City, OR 97367 Oregon Relay TTY: (541) 265-6915

Office hours: 8 a.m. – 5 p.m. on Monday through Friday

Website: www.lincolncountyhealth.com/BH/MentalHealthPAGE.htm

How to obtain a referral to a non-county or out-of-panel provider

You must have approval, or authorization, ahead of time to receive services from any non-county agency or out-of-panel provider for services that are not an emergency. If the same services are available at one of the county agency clinics, you may be required to go to the county agency. If not, your county mental health program will do an evaluation to find out if this other person should provide services to you. If approved, an appointment will be set up for you. If you choose to see a non-county or out-of-panel provider, you may be required to pay for these services if you don’t have prior

approval. To find out more about this, call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

For our members who are Native American or Alaska Native: We do not have any Indian Health Care Provider in our network of mental health treatment agencies. You must follow the process for out-of-panel authorizations if we are to pay for mental health services from an Indian Health Care Provider.

Crisis and urgent mental health services

Crisis services are available 24 hours per day, 7 days per week. A mental health crisis can be such things as feeling out of control, feeling the potential for harming yourself or others, or anything that you believe needs immediate attention. A mental health crisis is when a person needs help quickly so their mental health problem or concern does not become an emergency.

If you already have a provider:

Your provider will tell you how to reach them during a mental health crisis. If you are having a crisis, follow the plan you made with your provider.

If you do not have a provider or cannot reach your provider:

Call the number below for your county or call IHN-CCO Customer Service Department at

(541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900. Tell the person who answers that you are having a mental health crisis. You will be connected to a local crisis service worker as soon as possible. The crisis worker will talk with you to help decide the best way to handle the crisis. Tell them about your OHP insurance as soon as you can.

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LINN COUNTY

During business hours:

8 a.m. – 5 p.m., Monday through Friday (541) 967-3866 Or call toll-free: 1-800-304-7468

Outside of business hours:

After 5 p.m. and on weekends

1-855-571-3894 BENTON COUNTY (541) 766-6620

24 hours a day, 7 days a week 1-888-232-7192 LINCOLN COUNTY

24 hours a day, 7 days a week 1-855-571-3894

Don’t know who to call?

Call IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900, 24 hours a day, 7 days a week. Tell the person who answers that you are having a mental health crisis. You will be connected to a crisis services worker right away. The crisis worker will talk with you to help decide the best way to handle the crisis. Tell them about your OHP insurance as soon as you can.

Plan ahead for a mental health crisis

It can be very helpful for you and your provider to create a crisis plan ahead of time. A crisis plan lists steps and options for how to help you in a crisis. A crisis plan lets you say what does and does not help when you’re in a crisis.

Statewide peer-run warm line

This Warm Line is a telephone support service designed and provided by people who have or had challenges in mental health. They are able to support their peers who are struggling with a variety of mental health issues, who are experiencing huge and painful feelings. Sometimes people just need a friendly person to listen and care about what they are going through. Peer counselors are available free to all Oregon residents. Call 1-800-698-2392 to talk to a peer counselor.

For more information about the Warm Line and when you can call them, visit their website at www.communitycounselingsolutions.org/warmline.html or call the IHN-CCO Customer Service at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900.

Intensive Children’s Treatment Services (ICTS)

ICTS services are for children who are having major problems at home and school. These services help children stay in their communities. A team will work with you and your child to understand you family’s strengths and needs.

If you think your family could gain from these services, please call your county mental health program. They will determine if your child is eligible.

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AMHI and ISA Services for Mental Health Treatment

Aim High (AMHI), Adult Mental Health Initiative, is a program to help adults in res idential settings get better mental health care. It also helps adults with mental illness get more and better services in the community. The goal is to keep people healthy outside of the State Hospital.

Integrated Service Array (ISA) is a program for children with mental illness.

Prescription medications

IHN-CCO will pay for most prescriptions if you have a prescription from your PCP or mental health provider. Most mental health medications are paid for directly by OHP. You may fill prescriptions at almost any pharmacy in Linn, Benton, and Lincoln County. Just ask your pharmacy if they accept IHN-CCO. If there are problems with the pharmacy filling your prescription, your provider can call the IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or

TTY 1-800-735-2900.

IHN-CCO uses a “formulary” for prescription drugs. A formulary is a list of covered prescription drugs. All IHN-CCO providers have a copy of the formulary in their office. When you need a prescription, your doctor will choose a drug from the formulary. Drugs that are not on the formulary are called non-formulary.

If for some reason you should need a drug that is not on the IHN-CCO formulary, your doctor can ask for an exception. Our Pharmacy Director will decide if it is medically necessary for you to have a drug that is nonformulary. If there is a high medical need for the prescription, we will pay for the non -formulary drug.

Be sure to talk to your PCP or mental health provider who provides the medications before you go out of town. They can help you get medication refills before you leave or tell you what to do if you run out of medication.

This information is for any member of your household who has Medicare and Medicaid (Oregon Health Plan) coverage: On January 1, 2006, OHP stopped paying for your prescription drugs.

Instead, a federal program called the Medicare Prescription Drug Program will pay for your drugs. This drug benefit will be Part D of your Medicare coverage. Medicare requires co -payments for Part D drug coverage. Most of the plans that provide a drug benefit will charge a co-payment from $1 to $5. OHP will continue to pay for all other covered health services.

Mental Health Prescriptions

We don’t cover all prescriptions. Most medications that people take for mental illness are paid for by OHP “fee-for-service.” Please show your pharmacist your Oregon Health ID. The pharmacy will know where to send the bill

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Dental services

Dental services are covered. If you need dental services or have not chosen a primary care dentist, please call one of our dental network organizations listed below. If you need help choosing, please call our Customer Service Department at 1-800-832-4580.

Member Services for Dental Information: Advantage Dental: 1-866-268-9631

Capital Dental: 1-800-525-6800

ODS (also known as ModaHealth Dental): 1-866-923-0410 Willamette Dental: 1-855-433-6825

Urgent care

Always call your PCP’s office first about any health problem. Someone will be able to help you day and night, even on weekends and holidays. If you can’t reach your PCP’s off ice about an urgent problem or they can’t see you soon enough, you can go to the following urgent care or walk -in clinics without an appointment. Urgent problems are things like severe infections, sprains, and strong pain. If you don’t know how urgent the problem is, call your PCP.

Albany

Geary Street Urgent Care 1700 Geary Street SE

(541) 812-5500, TTY 1-800-735-2900 Monday-Friday: 8 a.m. to 9 p.m. Saturday: 9 a.m. to 6 p.m. Sunday: 10 a.m. to 6 p.m.

Samaritan North Albany Urgent Care 400 NW Hickory Avenue, Suite 303 (541) 812-5275, TTY 1-800-735-2900 Monday-Friday: 9 a.m. to 8 p.m. Saturday: 9 a.m. to 6 p.m. Sunday: 10 a.m. to 6 p.m.

Corvallis

Samaritan Urgent Care

5234 SW Philomath Boulevard (541) 768-4970, TTY 1-800-735-2900 Monday-Friday: 8 a.m. to 9 p.m. Saturday: 9 a.m. to 6 p.m. Sunday: 10 a.m. to 6 p.m.

The Corvallis Clinic Immediate Care 3680 NW Samaritan Drive

(541) 754-1282, TTY 1-800-735-2900 Monday-Friday: 8 a.m. to 8 p.m. Saturday-Sunday: 10 a.m. to 5 p.m.

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Lebanon

Lebanon Urgent Care Clinic 525 N. Santiam Highway

(541) 451-7915, TTY 1-800-735-2900 Monday-Friday: 8 a.m. to 9 p.m. Saturday: 9 a.m. to 6 p.m. Sunday: 10 a.m. to 6 p.m.

Newport

Samaritan Pacific Walk-In Clinic 930 SW Abbey Street, Suite F (541) 574-4860, TTY 1-800-735-2900 Monday-Friday: 9 a.m. to 6:30 p.m. Saturday: 10 a.m. to 4 p.m.

Closed for lunch: 12 p.m. to 1

Emergencies and crises

If you think that you have a real emergency, call 911 or go to the Emergency Room (ER) at the nearest hospital. You don’t need permission to get care in an emergency. An emergency might be chest pain, trouble breathing, bleeding that won’t stop broken bones, or a me ntal health emergency. Please don’t use the ER for things that can be treated in your doctor’s office. Sometimes ERs 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 in the table below, call 911, or go to the ER.

LINN COUNTY

During business hours:

8 a.m. – 5 p.m., Monday through Friday (541) 967-3866 Or call toll-free: 1-800-304-7468

Outside of business hours:

After 5 p.m. and on weekends

1-855-571-3894 BENTON COUNTY (541) 766-6620

24 hours a day, 7 days a week 1-888-232-7192 LINCOLN COUNTY

24 hours a day, 7 days a week 1-855-571-3894

Hospitals near you

Hospital care and emergency care is provided at the local locations listed below. All of the hospitals listed have language interpreter services available.

ALBANY

Samaritan Albany General Hospital (SAGH) 1046 6th Ave SW, Albany, OR 97321

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Good Samaritan Regional Medical Center (GSRMC) 3600 NW Samaritan Drive, Corvallis, OR 97330 (541) 768-5111 or TTY 1-800-735-2900

LEBANON

Samaritan Lebanon Community Hospital (SLCH) 525 North Santiam Highway, Lebanon, OR 97355 (541) 258-2101 or TTY 1-800-735-2900

LINCOLN CITY

Samaritan North Lincoln Hospital (SNLH) 3043 NE 28th Street, Lincoln City, OR 97367 (541) 994-3661 or TTY 1-800-735-2900 NEWPORT

Samaritan Pacific Community Hospital (SPCH) 930 SW Abbey Street, Newport, OR 97365 (541) 265-2244 or TTY 1-800-735-2900

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 Emergency Room. 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 in Mexico, Canada, or anywhere outside the US.

Care after an emergency

Emergency care is covered until you are stable. Call your PCP or mental health provider for follow-up care. Follow-up care once you are stable is covered but not considered an emergency.

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Grievance system information and appeal rights

How to make a complaint or grievance

If you are very unhappy with IHN-CCO, your health care services or your provider, you can complain or file a grievance. We will try to make things better. Just call IHN-CCO Customer Service

Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900, or send us a letter to the address on page 4. We will call or write back in a week to let you know that we are working on it.

We will send you a letter in 30 days explaining how we will address your complaint. We will not tell anyone about your complaint unless you ask us to.

Appeals and hearings

If we deny, stop or reduce a medical service your provider has ordered, we will mail you a Notice of Action letter explaining why we made that decision. The letter will explain how to appeal (ask us to change our decision). You have a right to ask to change it through an a ppeal, a state fair hearing, or both. You must ask no more than 45 days from the date on the Notice of Action letter.

How to appeal a decision

In an appeal, a different health care professional at IHN-CCO will review your case. Ask us for an appeal by:

 Calling IHN-CCO Customer Service Department at (541) 768-4550, toll-free 1-800-832-4580, or TTY 1-800-735-2900, or

 Writing us a letter

If you want help with this, call and we can fill out an appeal form for you to sign. If you have a case worker you can ask them for help. 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.

You can keep on getting a service that already started before our decision to stop it. You must ask us to continue the service within 10 days of getting the Notice of Action 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 Action letter.

If you need a fast appeal

If you and your provider believe that you have an urgent medical problem that cannot wait for a

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or ask them to call us and explain why it is urgent. If we agree that it is urgent we will call you with a decision in 3 workdays.

Provider appeals

Your provider has a right to appeal for you when their physician’s orders are denied by a CCO. Your provider must have your written permission in order to appeal for you.

How to get an Administrative Hearing

You can have a state fair hearing with an Oregon Administrative Law Judge. You will have 45 days from the date on your Notice of Action or Notice of Appeal Resolution to ask the state for a

hearing. Your Notice of Action letter will have a Hearing Request form that you can send in. You can also ask us to send you a Hearing Request form, or call OHP Client Services at 800 -273-0777, TTY 711, and ask for a form.

At the hearing, which will be held over the phone, 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 www.oregonlawhelp.org.

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 decision to s top it. You must ask us to

continue the service within 10 days of getting the Notice of Action that stopped it. 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 Effective Date on the original Notice of Action.

Fast (expedited) Hearing

If you and 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 th e Hearing Request form to the OHP Hearings Unit. Include a statement from your provider explaining why it is urgent. You should get a decision in 3 workdays. The Hearings Unit’s fax number is 503 -945-6035.

Declaration for mental health treatment

Oregon has a form for stating 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 can complete it while you can understand and make decisions about your care. The Declaration for Mental Health treatment tells what kind of care you

2013 MEMBER HANDBOOK

InterCommunity Health Network

Coordinated Care Organization (IHN-CCO)

2013 MEMBER HANDBOOK

Your medical and mental health benefits as a member of

The Oregon Health Plan

Alternate format information

TABLE OF CONTENTS

Welcome to InterCommunity Health Network

Coordinated Care Organization (IHN-CCO),

your community health care plan

What is the Oregon Health Plan (OHP)?

What is a Coordinated Care Organization (CCO)?

What are managed care and fee-for-service?

Who to call

Questions or need help?

Getting started

Your Oregon Health Identification (ID)

Coverage letter

Benefit packages

Becoming an IHN-CCO member

Involvement in CCO activities

How to change CCO’s

Disenrollment

If you want fee-for-service OHP instead of managed care

Member rights and responsibilities

As an OHP client, you will be:

As an OHP client, you agree to:

Members with Medicare or other insurance

Primary Care Provider (PCP)

What is a Patient-Centered Primary Care Home (PCPCH)?

Second opinion

Care Helpers

Native Rights

Appointments

Making the most of your health care visit

How to make an appointment

Before your appointment

At your appointment

Before you leave your appointment

Cancelling Appointments

Interpreter services

Getting a ride

Child care

Co-payments

OHP members do not pay bills for covered services

Prioritized list of health services

Non-covered services

Payment for non-covered services and other insurance

Medical health benefits

Referrals to other providers

Preventive care

Laboratory tests, x-rays, and other procedures

Quitting tobacco

Chemical dependency (drug and alcohol) treatment

Intensive care management services

(Exceptional Needs Care Coordination)

Case management services

Health Education

Skilled nursing facility care

Vision care

OHP Plus plan members:

OHP Standard plan members:

Hearing services

Hearing aids

Family planning and related services

If you are pregnant

Preparing for childbirth

Newborn enrollment

Changes in your family size

Mental health benefits

Mental health assessment and evaluation

Routine mental health services

Mental health treatment agencies

Linn County

ALBANY

LEBANON

SWEET HOME

Benton County

CORVALLIS