your guide to benefits and services january 2020 allcare cco€¦ · if you get sick: call your...

allcare cco

Member HandbookYour guide to benefits and services January 2020

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Need help?Member Services: (541) 471-4106 Toll free: (888) 460-0185 TTY: 711 Language Access: (888) 260-4297

2020 AllCare CCO Member Handbook

Getting The Handbook in Another Format

You can get this document in other languages, large print, braille, or a format you prefer free of charge. Call AllCare Health Member Services at: (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, language access (888) 260-4297, or Fax at (541) 471-3784.

Everyone has a right to know about AllCare CCO’s programs and services. All members have a right to know about and use our programs and services. We give these kinds of free help:

• Sign language interpreters• Qualified and certified spoken language interpreters

for other languages• Written materials in other languages • Braille• Large print• Audio and other formats

If you need help or have questions, please call (888) 460-0185.

If You Need an Interpreter

If you need an interpreter at your appointments, tell your provider’s office that you need an interpreter

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and for which language. Information on certified Health Care Interpreters is at Oregon.gov/OHA/OEI.

Other Ways to Get The Handbook

You can find and download the member handbook on our website at: AllCareHealth.com/CCO/Member-Handbook

You can also ask for a handbook to be mailed to you by calling Member Services at: (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access (888) 260-4297.

Como obtener el manual en otro formato

Usted puede obtener este documento en otros idiomas, letra grande, braille, o en un formato que usted prefiera sin costo alguno. Llame al Servicios para Miembros de AllCare Health. Teléfono: (541) 471-4106, llame gratis al (888) 460-0185, para personas con discapacidad auditiva (TTY) 711, acceso lingüístico (888) 260-4297, o Fax at (541) 471-3784.

Toda persona tiene el derecho a saber sobre los programas y servicios de AllCare CCO. Todos los miembros tienen el derecho a saber sobre los programas

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y servicios y de usarlos. Damos este tipo de ayuda gratuita:

• Intérpretes de lenguaje de señas• Intérpretes calificados y certificados de idiomas

hablados para otros idiomas • Materiales escritos en otros idiomas• Braille• Letra grande• Audio y otros formatos

Si necesita ayuda o si tiene preguntas, por favor llame al (888) 460-0185.

Si necesita un Intérprete

Si necesita un intérprete en sus citas, dígale a la oficina de su médico que necesita un intérprete y para qué idioma. Información sobre Intérpretes Certificados de Atención Médica se encuentra en Oregon.gov/OHA/OEI.

Otras maneras de obtener el manual

Usted puede encontrar y descargar el manual para miembros en nuestra página web: AllCareHealth.com/CCO/Member-Handbook

También puede solicitar que se le envié un manual por correo por medio de llamar a Servicios para Miembros

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al: (541) 471-4106, llame gratis al (888) 460-0185, para personas con discapacidad auditiva (TTY) 711, o acceso lingüístico (888) 260-4297.

Changes to Benefits

If your benefits change, you will be notified in writing 30 days before the change takes place, or as soon as possible. For questions about benefit changes, contact Member Services at: (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access (888) 260-4297.

Handbook Updates

The handbook is current. We update our handbook yearly. It was last updated on November 22, 2019. Sometimes changes are made to state and federal laws that effect your benefits. If this happens, we will update the handbook within 90 days.

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Contact Us

All of our offices are open Monday through Friday, 8:00 a.m. to 5:00 p.m.

Our offices are located at:

Grants Pass: 1701 NE 7th Street, Grants Pass, OR 97526

Medford: 3629 Aviation Way, Medford, OR 97504

Brookings: 580 5th Street, #400, Brookings, OR 97415

You can reach us by phone at: (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access at (888) 260-4297. You can send us a fax at (541) 471-3784.

Our mailing address is: AllCare Health Attn: AllCare CCO 1701 NE 7th Street Grants Pass, OR 97526

You can find us on the web at: AllCareHealth.com/CCO

Medicare Counseling

The Senior Health Insurance Benefits Assistance (SHIBA) program can help you with your Medicare. It

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• Age

• Color

• Disability

• Gender Identity

• Marital Status

• National Origin

• Race

• Religion

• Sex

• Sexual orientation

is free and confidential. SHIBA counselors can help you select a Medicare Prescription Drug Coverage plan. They can help you compare Medicare Advantage plans and Medicare Supplement (Medigap) policies. They can help you apply for a Medicare Savings Program. SHIBA can also look over your Medicare bills, file appeals, and report complaints.

If you would like help from SHIBA, call: Oregon Senior Health Insurance Benefits Assistance (SHIBA) Toll free: (800) 722-4134

Visit SHIBA online at: OregonSHIBA.org MedicareStartsAt65.org

Unfair Treatment

If you think AllCare CCO or a provider gave you unfair treatment, please tell us.

We must follow state and federal civil rights laws. We cannot treat people unfairly because of:

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To report your concern or to get more information, please contact:

AllCare Health Attn. Member Services 1701 NE 7th Street Grants Pass, OR 97526

Or call (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access at (888) 260-4297.

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:

File online at: HHS.gov/

Email to: [email protected]

Phone: (800) 868-1019, TTY: (800) 537-7697

Mail to: U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F HHH Bldg. Washington, D.C. 20201

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ContentsGetting The Handbook in Another Format . . . . . . . . . . . . . . . . . . . . . 2If You Need an Interpreter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Other Ways to Get The Handbook . . . . . . . . . . . . . . . . . . . . . . . . . . 3Como obtener el manual en otro formato . . . . . . . . . . . . . . . . . . . . . 3Si necesita un Intérprete. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Otras maneras de obtener el manual . . . . . . . . . . . . . . . . . . . . . . . . 4Changes to Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Handbook Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Medicare Counseling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Unfair Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Important Things To Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Important Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Nondiscrimination Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Your Member Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Your Member Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .19How to get your New Member Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21What is the Oregon Health Plan (OHP)? . . . . . . . . . . . . . . . . . . . . . 23Fee-for-Service (FFS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23When to Call OHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24About AllCare CCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24AllCare CCO Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24How We Coordinate Your Care . . . . . . . . . . . . . . . . . . . . . . . . . . 25Culturally-sensitive Health Education . . . . . . . . . . . . . . . . . . . . . . . 26Native Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26AllCare CCO Will Help You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Involvement in CCO Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . 28What Your Member ID Card Does for You . . . . . . . . . . . . . . . . . . . . 29Change of Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30How to Change CCOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

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What OHP Covers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Prior Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36What AllCare CCO Does Not Cover . . . . . . . . . . . . . . . . . . . . . . . . 37Choosing Your Primary Care Provider . . . . . . . . . . . . . . . . . . . . . . . 39Using the Online “Find A Doctor” Search . . . . . . . . . . . . . . . . . . . . . 39Changing Your Primary Care Provider . . . . . . . . . . . . . . . . . . . . . . . 40Patient-Centered Primary Care Home . . . . . . . . . . . . . . . . . . . . . . . 40Meeting Your Primary Care Provider. . . . . . . . . . . . . . . . . . . . . . . . .41If You Need an Interpreter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41If You Cannot Keep an Appointment . . . . . . . . . . . . . . . . . . . . . . . .41Getting a Ride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Seeing A Specialist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Out-of-Network Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Second Opinion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Practice Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Copay or Bills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50If You Have Medicare or Other Insurance . . . . . . . . . . . . . . . . . . . . . 52When You Are Sick. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53If You Need Care Out-of-Town . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Nurse Help Line – (844) 747-5656 . . . . . . . . . . . . . . . . . . . . . . . . . 53Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Care After an Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56After You Leave the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Case and Disease Management Services . . . . . . . . . . . . . . . . . . . . . 58Primary Care Team Specialists, Care Helpers, or Traditional Health Workers. 58When You Have Special Medical Needs . . . . . . . . . . . . . . . . . . . . . . 59Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59In-Network Retail and Mail-Order Pharmacies . . . . . . . . . . . . . . . . . . 60Preventive Healthcare: Keeping You Healthy . . . . . . . . . . . . . . . . . . . 60Quitting Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61Healthy Living. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61More Member and Community Benefits. . . . . . . . . . . . . . . . . . . . . . 62

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Transgender Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Abortions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Women’s Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Pregnancy and Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66After the Baby is Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Immunizations, vaccines (shots) . . . . . . . . . . . . . . . . . . . . . . . . . . 68Health Services for Older Children and Teens . . . . . . . . . . . . . . . . . . 68Oral Health Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Choosing a Primary Care Dentist (PCD). . . . . . . . . . . . . . . . . . . . . . 69What Are My Oral Health (Dental) Benefits? . . . . . . . . . . . . . . . . . . . 70Dental Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71Urgent Dental Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71If You Need a Ride to Your Dental Visit . . . . . . . . . . . . . . . . . . . . . . .71Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Hearing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Medical Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Mental Health Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Mental Health Crisis Help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Declaration for Mental Health Treatment . . . . . . . . . . . . . . . . . . . . . 79Behavioral Health Provider Directory . . . . . . . . . . . . . . . . . . . . . . . 80Alcohol and Drug Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81Fraud, Waste, or Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84End-of-life Decisions and Advance Directives (Living Wills) . . . . . . . . . . 86Grievance System Information and Appeal Rights. . . . . . . . . . . . . . . . 88How to File an Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Get a Copy of Your Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91Your Records are Private . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91Words You Should Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

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Important Things To DoIf you get sick: Call your Primary Care Provider (PCP). Their name and phone number can be found on your member ID card.

If you get sick after normal office hours: Call your PCP. The answering service will give you the phone number of the doctor on call that day.

OR call the FREE 24-hour Nurse Help Line at (844) 747-5656 any time of day or night.

If you believe you have an emergency medical condition: Go to the nearest hospital emergency room.

OR Call 9-1-1

If you have questions about your AllCare CCO benefits: Please call Member Services between 8:00 a.m. and 5:00 p.m., Monday through Friday at (541) 471-4106 or toll free at (888) 460-0185. If you are hearing impaired, dial the TTY number 711. If you need an interpreter, call our language access number at (888) 260-4297.

You may also visit the AllCare CCO website at AllCareHealth.com/CCO

If you want to view, download, or print a copy of our member handbook, please go to AllCareHealth.com/CCO/Member-Handbook. The member handbook is available online in English, Spanish, and audio versions. To request a member handbook in print, a different language, or in another format at no cost to you, call Member Services between 8:00 a.m. and 5:00 p.m., Monday through Friday at (541) 471-4106, toll free at (888) 460-0185, TTY 711, or language access at (888) 260-4297.

Important Records

Family members on AllCare CCO:

Name ID number

______________________________________ ______________________________

______________________________________ ______________________________

______________________________________ ______________________________

Your family’s Primary Care Providers (doctor or nurse practitioner):

Name Phone number

______________________________________ ______________________________

______________________________________ ______________________________

______________________________________ ______________________________

allcare cco

OHA 2993A (02/2017)

Nondiscrimination Policy

Language Access Statement

ENGLISHYou can get this document in other languages, large print, braille or a format you prefer free of charge. Program/contact: Phone: Email: We accept all relay calls or you can dial 711.

ARABIC / اللغة العربيةيمكنكم الحصول على هذا المستند مجانا في لغات أخرى، أو بخط كبير، أو بلغة البريل أو

بصيغة تفضلونها. البرنامج/ االتصال:

هاتف: البريد اإللكتروني )اإليميل(:

نستقبل جميع المكالمات الهاتفية المعمولة بواسطة خدمات االتصال المكتوب )relay calls( أو يمكنكم االتصال بالرقم 711.

BOSNIAN / BOSANSKIMožete besplatno dobiti ovaj dokument na drugim jezicima, štampan velikim slovima, Brajevim pismom ili u formatu koji želite. Program/kontakt: Telefon: E-pošta: Primamo sve specijalne telefonske pozive od ljudi sa problemima sa sluhom ili govorom ili možete birati 711.

BURMESE / မနမာဤစာက အခားဘာသာစကားမား၊ ပႎႀပစာလးကးမား၊ မကမမငမားအတၾက ဘေရးလ သႚမဟတ သငပႎႀစသကသည ပစတႚဖင အခမရႎငပၝသည။အစအစဥ/အဆကအသၾယ - ဖနးနပၝတ - အးေမးလ - တဆငဆကသၾယသည ဖနးေခဆမႁမား အားလးက က႗ႎပတႚ လကခပၝသည။ သႚမဟတ 711 က သငဆကႎငပၝသည။

To report concerns or to get more information, please contact us in one of these ways:

• Web: Email:

• Phone: • Mail:

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. Contact that office one of these ways:

• Web: www.hhs.gov | Email: [email protected]• Phone: 1-800-368-1019, 1-800-537-7697 (TDD)• Mail: 200 Independence Ave., SW, Room 509F HHH Bldg.

Washington, D.C. 20201

We must follow state and federal civil rights laws. We cannot treat people unfairly in any of our programs or activities 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.

OHA 2993A (02/2017)











• Web: Email:










OHA 2993A (02/2017)











• Web: Email:










OHA 2993A (02/2017)











• Web: Email:










OHA 2993A (02/2017)











• Web: Email:










AllCare Health Member Services(888) 460-0185 5810-064 (888)

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AllCare Health Member Services(888) 460-0185



.117 (sllac yaler)

allcare cco


• Age • National origin• Color • Race• Disability • Religion• Gender identity • Sex• Marital status • Sexual orientation




• Web: AllCareHealth.com/CCO• Phone: (888) 460-0185• Mail: 1701 NE 7th Street Grants Pass, OR 97526


• Web: www.HHS.gov • Email: [email protected]• Phone: (800) 368-1019 (800) 537-7697 (TTY)• Mail: 200 Independence Ave., SW, Room 509F HHH Bldg. Washington, D.C. 20201


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2020 AllCare CCO Member Handbook 3OHA Language Access Statement

OHA 2993A (02/2017)

RUSSIAN / РУССКИВы можете бесплатно получить текст этого документа на другом языке, набранный крупным шрифтом или шрифтом Брайля либо в предпочитаемом вами формате. Название программы и контактное лицо: Телефон: Эл. почта: Мы отвечаем на любые вызовы по линии трансляционной связи; кроме того, вы можете набрать номер 711.

SIMPLIFIED CHINESE / 简体中文您可以免费获得本文件的其他语言版本，或者大号字体、盲文及您所喜欢格式的版本。计划/联系人：电话：电子邮箱：我们会接听所有转接电话，或者您可以拨打 711。

SOMALI / SOOMAALIWaxaad heli kartaa dokumentigan oo ku qoran luqaddo kale, far waaweyn, farta dadka indhaha aan qabin wax ku akhriyaan ee braille ama qaabka aaad doorbidayso oo lacag la’aan ah. Barnaamijka/halka la iskala soo xiriirayo: Telefoonka: Email-ka: Waa aqbalnaa wicitaanada gudbinta oo dhan ama waxaad wici kartaa 711.

SPANISH / ESPAÑOLPuede obtener este documento en otros idiomas, en letra grande, en braille o en un formato que usted prefiera sin cargo. Programa/contacto: Teléfono: Correo electrónico: Aceptamos llamadas de retransmisión o puede llamar al 711.

THAI / ไทยคณสามารถขอรบเอกสารนเปนภาษาอน เปนตวอกษรขนาดใหญ อกษรเบรลล หรอรปแบบทคณตองการโดยไมตองเสยคาใชจาย โปรแกรม/ผตดตอ: โทรศพท: อเมล: เรายอมรบสายโทรเขาแบบพมพเขาและพดตามทกสายหรอคณสามารถเลอกกดหมายเลข 711

TRADITIONAL CHINESE / 繁體中文您可以免費獲得本文件的其他語言版本，或者大號字體、盲人點字及您所喜歡格式的版本。計畫/連絡人：電話：電郵：我們會接聽所有傳譯電話，或者您可以撥打 711。

UKRAINIAN / УКРАЇНСЬКАВи можете отримати цей документ іншими мовами, великим шрифтом, шрифтом Брайля або в будь-якому форматі, якому ви надаєте перевагу. Програма/контактна особа: Телефон: електронна пошта: Ми приймаємо всі виклики через службу комутованих повідомлень або ви можете набрати 711.

VIETNAMESE / TIẾNG VIỆTQuý vị có thể có tài liệu này miễn phí bằng ngôn ngữ khác, bản in khổ lớn, chữ nổi hoặc một định dạng khác. Chương trình/liên lạc: Số điện thoại: Email: Chúng tôi chấp nhận tất cả các cuộc gọi chuyển tiếp hoặc quý vị có thể bấm số 711.

POHNPEIAN / LOKAIA EN POHNPEIKomwi kak alehda doaropwe wet ni lokaia tohrohr akan, ni nting laud, braille (preili: nting ohng me masukun), de ni ehu mwohmw tohrohr me komw kupwurki, ni soh pweipwei oh soh isipe.Pwurokirahm/koandak: Nempehn Delepwohn: E-mail: Se kin alehda koahl karos me lelohng reht de komw kak eker 711.

ROMANIAN / ROMÂNA Puteți obține acest document în alte limbi, într-un font mărit, în limbajul Braille sau într-un alt format preferat, în mod gratuit. Program/contact: Telefon: E-mail: Acceptăm toate apelurile prin serviciu de releu sau puteți suna la 711.

2OHA Language Access Statement

OHA 2993A (02/2017)

MARSHALLESE / KAJIN MAJEL.Kwomaroñ bok peba in ilo kajin ko jet, jeje kon leta ko rekil.ep, ilo braille ak ilo bar juon waween em. m. anl.o. k ippam. ejjel.o. k wo. naan. Kojel.a in program/kepaake: Telpon. : Email: Komij bok aolep kal.l.o.k in relay ak kwomaroñ jiburi 711.

OROMO [CUSHITE] / AFAAN OROMOOGalmee kana afaanoota biraatiin, barreefama qube gurguddaatiin, bireelii ykn barreefana warra qaroo dhabeeyyii ykn haala atii barbaadduun kanfaltii malee argachu ni dandeessa. Sagantaa/kontoraata: Bilbila: Imeelii: Waamicha bilbilaa hunda ni fudhanna ykn 711 irratti bilbilu ni dandeessa.

FARSI فارسی/شما می توانید این متن را به زبان های دیگر، با حروف درشت، خط بریل یا فرمتی که

می خواهید، به طور رایگان دریافت کنید. برنامه/تماس:

تلفن: ایمیل:

ما تمام تماس های دریافتی را می پذیریم یا می توانید با شماره 711 تماس بگیرید.

FRENCH / FRANÇAISVous pouvez obtenir ce document, sans frais, en d’autres langues, en gros caractères, en braille ou dans un format de votre choix. Programme/contact : Téléphone : Email : Nous acceptons tous les appels relais, ou bien vous pouvez composez le 711.

GERMAN / DEUTSCHSie können dieses Dokument kostenlos in verschiedenen Sprachen, extra großem Druck, Braille oder einem von Ihnen bevorzugten Format bekommen. Programm/Kontakt: Telefon: E-Mail: Wir akzeptieren alle Relais-Anrufe oder Sie können 711 wählen.

JAPANESE / 日本語この資料は、他の言語に翻訳されたもの、大型活字、点字、その他ご希望の様式で、無料で入手可能です。プログラム／連絡先電話番号：電子メール：全ての電話リレーサービスを受け付けていますが、711にお電話いただいても結構です。

KOREAN/한국어본 문서는 다른 언어로도 제공되며, 큰 활자, 점자 등 귀하가 선호하시는 형식의 문서를 무료로 받아보실 수 있습니다. 프로그램/연락처: 전화번호: 이메일: 청각/언어 장애인을 위한 통신중계 서비스 (relay calls)를 지원하고 있습니다. 또는 711 번으로 전화 주시기 바랍니다.

LAO / ລາວທານສາມາດໄດຮບເອກະສານນເປນພາສາອນ,ຕວພມຂະໜາດໃຫຍ,ໜງສໂພງສ�ລບຄນຕາບອດຫໃນຮບແບບທທານຕອງການໄດໂດຍບເສຽຄາ.ໂຄງການ/ຕດຕ:ໂທຣະສບ:ອເມວ:ພວກເຮາຍອມຮບການໂທສ�ລບຄນພການຫທານສາມາດໂທຫາ711ໄດ.

CAMBODIAN / PasaExµr

G ñ kGacTT Y l)anÉksarenHCaPasadéTeTot CaGkSrF M² GkSrs Mrab ;

CnB ikarEP ñ k b ¤ CaTRmg ;Nam Y y EdlG ñ kcg ;)an edaym inK itéf ø.

kmµviFI/Tak;TgeTA³ TUrs½BÞ³ GIuEm:l³ eyIgTTYlykral;karbBa¢ÚnTUrs½BÞbnþ b¤GñkGaccuceTAelx 711 .

CHUUKESE / CHUUKESEKe tongeni omw kopwe angei noum kapin ei taropwe, ese kamo, non fosun fonuom, ika non “large print” (weiweita ika mak mei kan mese watte), ika non “braille” (faniten ekewe mei chun), ika ren pwan ekoch sakkun pisekin ika angangen awewe. Meeni pirokram/io kopwe poporaus ngeni: Fon: Email: Aipwe etiwa “relay calls”, ika ke tongeni pwisin kori 7-1-1.






AllCare Health Member Services(888) 460-0185 AllCare Health Member Services

(888) 460-0185

AllCare Health Member Services(888) 460-0185 AllCare Health Member Services

(888) 460-0185

5810-064 (888)secivreS rebmeM HtlaeH eraCllA

15

2020 AllCare CCO Member Handbook 3OHA Language Access Statement

OHA 2993A (02/2017)

RUSSIAN / РУССКИВы можете бесплатно получить текст этого документа на другом языке, набранный крупным шрифтом или шрифтом Брайля либо в предпочитаемом вами формате. Название программы и контактное лицо: Телефон: Эл. почта: Мы отвечаем на любые вызовы по линии трансляционной связи; кроме того, вы можете набрать номер 711.

SIMPLIFIED CHINESE / 简体中文您可以免费获得本文件的其他语言版本，或者大号字体、盲文及您所喜欢格式的版本。计划/联系人：电话：电子邮箱：我们会接听所有转接电话，或者您可以拨打 711。

SOMALI / SOOMAALIWaxaad heli kartaa dokumentigan oo ku qoran luqaddo kale, far waaweyn, farta dadka indhaha aan qabin wax ku akhriyaan ee braille ama qaabka aaad doorbidayso oo lacag la’aan ah. Barnaamijka/halka la iskala soo xiriirayo: Telefoonka: Email-ka: Waa aqbalnaa wicitaanada gudbinta oo dhan ama waxaad wici kartaa 711.

SPANISH / ESPAÑOLPuede obtener este documento en otros idiomas, en letra grande, en braille o en un formato que usted prefiera sin cargo. Programa/contacto: Teléfono: Correo electrónico: Aceptamos llamadas de retransmisión o puede llamar al 711.

THAI / ไทยคณสามารถขอรบเอกสารนเปนภาษาอน เปนตวอกษรขนาดใหญ อกษรเบรลล หรอรปแบบทคณตองการโดยไมตองเสยคาใชจาย โปรแกรม/ผตดตอ: โทรศพท: อเมล: เรายอมรบสายโทรเขาแบบพมพเขาและพดตามทกสายหรอคณสามารถเลอกกดหมายเลข 711

TRADITIONAL CHINESE / 繁體中文您可以免費獲得本文件的其他語言版本，或者大號字體、盲人點字及您所喜歡格式的版本。計畫/連絡人：電話：電郵：我們會接聽所有傳譯電話，或者您可以撥打 711。

UKRAINIAN / УКРАЇНСЬКАВи можете отримати цей документ іншими мовами, великим шрифтом, шрифтом Брайля або в будь-якому форматі, якому ви надаєте перевагу. Програма/контактна особа: Телефон: електронна пошта: Ми приймаємо всі виклики через службу комутованих повідомлень або ви можете набрати 711.

VIETNAMESE / TIẾNG VIỆTQuý vị có thể có tài liệu này miễn phí bằng ngôn ngữ khác, bản in khổ lớn, chữ nổi hoặc một định dạng khác. Chương trình/liên lạc: Số điện thoại: Email: Chúng tôi chấp nhận tất cả các cuộc gọi chuyển tiếp hoặc quý vị có thể bấm số 711.

POHNPEIAN / LOKAIA EN POHNPEIKomwi kak alehda doaropwe wet ni lokaia tohrohr akan, ni nting laud, braille (preili: nting ohng me masukun), de ni ehu mwohmw tohrohr me komw kupwurki, ni soh pweipwei oh soh isipe.Pwurokirahm/koandak: Nempehn Delepwohn: E-mail: Se kin alehda koahl karos me lelohng reht de komw kak eker 711.

ROMANIAN / ROMÂNA Puteți obține acest document în alte limbi, într-un font mărit, în limbajul Braille sau într-un alt format preferat, în mod gratuit. Program/contact: Telefon: E-mail: Acceptăm toate apelurile prin serviciu de releu sau puteți suna la 711.



(888) 460-0185


(888) 460-0185






AllCare Health Member Services


2OHA Language Access Statement

OHA 2993A (02/2017)

MARSHALLESE / KAJIN MAJEL.Kwomaroñ bok peba in ilo kajin ko jet, jeje kon leta ko rekil.ep, ilo braille ak ilo bar juon waween em. m. anl.o. k ippam. ejjel.o. k wo. naan. Kojel.a in program/kepaake: Telpon. : Email: Komij bok aolep kal.l.o.k in relay ak kwomaroñ jiburi 711.

OROMO [CUSHITE] / AFAAN OROMOOGalmee kana afaanoota biraatiin, barreefama qube gurguddaatiin, bireelii ykn barreefana warra qaroo dhabeeyyii ykn haala atii barbaadduun kanfaltii malee argachu ni dandeessa. Sagantaa/kontoraata: Bilbila: Imeelii: Waamicha bilbilaa hunda ni fudhanna ykn 711 irratti bilbilu ni dandeessa.

FARSI فارسی/شما می توانید این متن را به زبان های دیگر، با حروف درشت، خط بریل یا فرمتی که

می خواهید، به طور رایگان دریافت کنید. برنامه/تماس:

تلفن: ایمیل:

ما تمام تماس های دریافتی را می پذیریم یا می توانید با شماره 711 تماس بگیرید.

FRENCH / FRANÇAISVous pouvez obtenir ce document, sans frais, en d’autres langues, en gros caractères, en braille ou dans un format de votre choix. Programme/contact : Téléphone : Email : Nous acceptons tous les appels relais, ou bien vous pouvez composez le 711.

GERMAN / DEUTSCHSie können dieses Dokument kostenlos in verschiedenen Sprachen, extra großem Druck, Braille oder einem von Ihnen bevorzugten Format bekommen. Programm/Kontakt: Telefon: E-Mail: Wir akzeptieren alle Relais-Anrufe oder Sie können 711 wählen.

JAPANESE / 日本語この資料は、他の言語に翻訳されたもの、大型活字、点字、その他ご希望の様式で、無料で入手可能です。プログラム／連絡先電話番号：電子メール：全ての電話リレーサービスを受け付けていますが、711にお電話いただいても結構です。

KOREAN/한국어본 문서는 다른 언어로도 제공되며, 큰 활자, 점자 등 귀하가 선호하시는 형식의 문서를 무료로 받아보실 수 있습니다. 프로그램/연락처: 전화번호: 이메일: 청각/언어 장애인을 위한 통신중계 서비스 (relay calls)를 지원하고 있습니다. 또는 711 번으로 전화 주시기 바랍니다.

LAO / ລາວທານສາມາດໄດຮບເອກະສານນເປນພາສາອນ,ຕວພມຂະໜາດໃຫຍ,ໜງສໂພງສ�ລບຄນຕາບອດຫໃນຮບແບບທທານຕອງການໄດໂດຍບເສຽຄາ.ໂຄງການ/ຕດຕ:ໂທຣະສບ:ອເມວ:ພວກເຮາຍອມຮບການໂທສ�ລບຄນພການຫທານສາມາດໂທຫາ711ໄດ.

CAMBODIAN / PasaExµr

G ñ kGacTT Y l)anÉksarenHCaPasadéTeTot CaGkSrF M² GkSrs Mrab ;

CnB ikarEP ñ k b ¤ CaTRmg ;Nam Y y EdlG ñ kcg ;)an edaym inK itéf ø.

kmµviFI/Tak;TgeTA³ TUrs½BÞ³ GIuEm:l³ eyIgTTYlykral;karbBa¢ÚnTUrs½BÞbnþ b¤GñkGaccuceTAelx 711 .

CHUUKESE / CHUUKESEKe tongeni omw kopwe angei noum kapin ei taropwe, ese kamo, non fosun fonuom, ika non “large print” (weiweita ika mak mei kan mese watte), ika non “braille” (faniten ekewe mei chun), ika ren pwan ekoch sakkun pisekin ika angangen awewe. Meeni pirokram/io kopwe poporaus ngeni: Fon: Email: Aipwe etiwa “relay calls”, ika ke tongeni pwisin kori 7-1-1.


Our offices are open 8:00 a.m. to 5:00 p.m. to serve you.


17


Your Member Rights

As an OHP member, you have the right to...• Be treated with dignity and respect.• Be treated by providers the same way as other people seeking healthcare.• Choose your provider or where you would like to get care. You can also

change those choices.• Refer yourself directly to behavioral health or family planning services without

getting a referral from a PCP or other provider.• Have a friend, family member, or other person with you during appointments.• Be involved in creating your treatment plan.• Get information about your condition, what is covered, and what is not

covered, so you can make a good decision about treatments.• Accept or refuse treatments and be told what might happen based on your

decision. Court ordered services cannot be refused.• Get a referral or second opinion if you need it.• Get written materials that tell you your rights, responsibilities, benefits, how to

get services, and what to do in an emergency.• Get written materials explained in a way you can understand them. • Learn about CCOs and how to use the healthcare system.• Get services that consider your culture and language and are in a place close

to where you live. If available, you can also get care in a non-traditional setting.• Get care coordination, management, and community-based care that works

well with your culture and language to reduce the need for visits to the hospital.

• Get the needed and proper services to diagnose your health condition.• Get person-centered care and services that give you choice, independence,

and dignity. This care will meet generally accepted standards of practice.• Have a steady and stable relationship with a care team that will look after your

overall care management.• Get help with using the healthcare delivery system to find out how to get

services like:1. Certified or qualified healthcare interpreters.2. Certified traditional health workers.

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2020 AllCare CCO Member HandbookYo

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3. Community health workers.4. Peer wellness specialists.5. Doulas.6. Personal health navigators.

• Get covered preventive services.• Get urgent and emergency services 24 hours a day, seven days a week without

prior authorization.• Get a referral to specialty providers for covered coordinated care services

when medically needed.• Get help with addiction to tobacco, alcohol, and drugs without a referral.• Have a clinical record kept that keeps track of conditions, services received,

and referrals made.• Have access to, and get a copy of, your clinical record. Your PCP may charge a

fee for the copy. AllCare CCO will not.• Ask to have your clinical record amended or corrected.• Transfer your clinical record to another provider.• Make a statement of your wishes for treatment. It can tell your wishes to

accept or refuse medical, surgical, or behavioral health treatment. It can give instructions and powers of attorney for your healthcare.

• Get written notices of a denial or change in benefits before they are made. If a notice is not required by federal or state regulations, you might not get a notice.

• Make a complaint or file an appeal with AllCare CCO.• Ask for a hearing if you disagree with a decision made by AllCare CCO or the

Oregon Health Plan.• Get certified or qualified healthcare interpreter services.• Get notice of an appointment cancellation in a timely manner.• Not have people hold you down or keep you away from others as a way to

make you do something you don’t want to do, to make caring for you easier for your providers, or to punish you for something you said or did.

• Report abuse to AllCare CCO and/or the Oregon Health Plan.• Get free help from the OHA ombudsperson.


19

2020 AllCare CCO Member Handbook Your M

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Your Member Responsibilities

As a CCO member, you agree to…• Choose (or help choose) a Primary Care Provider (PCP) and Primary Care

Dentist (PCD), or other service provider. • Treat the CCO staff, provider, and clinic staff members with respect.• Be on time for appointments.• Call in advance to cancel if you are unable to keep appointments. • Call in advance if you expect to be late.• Tell your provider what health insurance you have before your appointment.• Tell the staff if you were hurt in an accident.• Be honest with your providers to get the best service.• Have yearly check-ups, wellness visits, and preventative services to keep

you healthy.• Get a referral from your PCP to see a specialist if you need it. Please see page

page 48 on how to get a referral to see a specialist.• Use your PCP or clinic for all your healthcare needs except in an emergency.• Use urgent and emergency care appropriately. • Let your PCP know, within 72 hours, if you have used any emergency services.• Give accurate information to your healthcare providers. • Help your provider get your health records. This may include signing an

authorization to release your health record. • Participate in your own healthcare. • Ask questions if you are unclear. • Tell providers about all your health issues. • Use information from your CCO, providers, or care teams to make smart

decisions about treatments.• Help your provider in the creation of your treatment plan.• Follow directions from your provider and pharmacist or ask for another choice.• Always bring your medical ID cards to appointments.• Tell Oregon Health Plan (OHP) if:

1. You change your address.2. You change your phone number.3. You marry, divorce, become pregnant, or have a child.


20


4. Any family member has moved out of the household. 5. Your job income goes up or down $100 or more a month.6. Your other monthly income (such as child support, unemployment

benefits, etc.) goes up $50 or more.7. You get or lose other health insurance.8. You are injured by another person, business, governmental agency, or

have a claim for personal injury.9. Your immigration status changes.10. You get or lose Medicare coverage.

• Pay for non-covered services.• Bring issues, complaints, or grievances to the attention of AllCare CCO.• Read all letters that OHA and AllCare CCO send you. If you have problems

reading the information, call AllCare CCO or OHP Client Services and ask for help.

• Report Medicaid fraud. Please call, email, or write us if you think you see fraud. An example would be charging for a service you didn’t get, or someone using another person’s ID to get OHP benefits.

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21

How to get your New Member Materials allcare cco

Getting member materials in a form you can useEveryone has a right to know about AllCare CCO’s programs and services. All members have a right to know about and use our programs and services.

We give these kinds of free help:

• Sign language interpreters• Spoken language interpreters for

other languages• Written materials in other languages • Braille• Large print• Audio and other formats

If you need an interpreter at your appointments, tell your provider’s office that you need an interpreter and for which language. Information on certified Health Care Interpreters is at: Oregon.gov/OHA/OEI.

Getting member materials from our websiteBelow is a list of CCO member materials you can find and download on our website at: AllCareHealth.com/CCOMemberMaterials.

• Member Handbook• Provider Directories• Dental Brochure• Formularies (Drug Lists)• ReadyRide Rider’s Guide• Nurse Helpline Phone Number• Resources for New

& Expecting Moms• Lookup Tools• Important Forms

Getting printed versions of member materialsIf you need help, have questions, or want printed versions of the member materials, or to get them in another format (such as other languages, large print, or braille) at no cost, call Member Services at (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access at (888) 260-4297.

2019 Provider & Pharmacy DirectoryJackson County and surrounding areas

allcare cco

allcare cco

Member Handbook

Your guide to benefits and services

January 2020

Px

ReadyRide

Rider’s Guide

allcare cco

How AllCare CCO members can get a ride.

Call ReadyRide 8:00 a.m. to 6:00 p.m., Monday through Friday.

(800) 479-7920 | AllCareHealth.com/CCO

ReadyRide is AllCare CCO’s exclusive non-emergent medical transportation provider.

OHP-ALL-16-060

2019 Drug Coverage

allcare cco

AllCare CCO Member Dental Benefits

We’re here to helpIf you have questions about your member benefits, please call AllCare CCO at (541) 471-4106, toll free (888) 460-0185, or TTY 711. Language Access: (888) 260-4287

allcare cco1701 NE 7th Street, Grants Pass, OR 97526Tel (541) 471-4106 Toll free (888) 460-0185Fax (541) 471-3784

AllCareHealth.com/Medicaid

What are my benefits?Prevention• Exams (once per year for adults, twice a year for children 18 and under)• Cleanings (once a year for adults, twice a year for children 18 and under)• Fluoride treatments

• X-rays• Sealants are covered only for children under 16 years of age

RestorativeThese services are covered if your primary care dentist says they are dentally appropriate. Some of these services may need pre-approval from your dental plan.• Fillings• Partial dentures every 5 years• Complete dentures every 10 years• Stainless steel crowns

for premolars/molars (back teeth)Oral Surgery and Endodontics• Tooth removal• Root canals for clients through age 20, is covered only for first and second molars• Root canals for clients age 21 and older who are pregnant, is covered only for first molars

Emergency ServicesSee details inside.

OHP-ALL-16-083

AllCare Health is right here in Southern Oregon, to serve you, your friends, neighbors, and coworkers.


23


What is the Oregon Health Plan (OHP)?The Oregon Health Plan (OHP) is a program that pays healthcare costs for low-income Oregonians’. The State of Oregon and the US Government’s Medicaid program pay for it. OHP covers doctor visits, prescriptions, hospital stays, dental care, mental health services, help with addiction to tobacco, alcohol and drugs, and free rides to covered healthcare services. If you qualify, OHP can provide hearing aids, medical equipment, and home health care.

OHP Supplemental is for children through age 20 and pregnant women. It covers glasses and additional dental care.

CAWEM (Citizen Alien Waived Emergency Medical) covers emergency services for non-US citizens who are not on OHP. CAWEM Plus also covers childbirth. OHP Customer Service can tell you which benefits you qualify for.

OHP does not cover everything. A list of the sicknesses and conditions that are covered, called the Prioritized List of Health Services, is online at Oregon.gov/OHA/HSD/OHP/Pages/Prioritized-List.aspx. Other sicknesses and conditions not on that list are usually not covered by OHP. Those conditions could be covered if treating them will help a patient’s covered condition.

CCOs (Coordinated Care Organizations) are a type of managed care organization that contracts with the Oregon Health Authority (OHA). OHA pays CCOs a set amount of money each month to give members the healthcare services they need.

Fee-for-Service (FFS)Health services for OHP members who are not in managed care, are paid directly by OHA. This is called fee-for-service (FFS) because OHA pays providers a fee for the services they provide. It is also called an “Open Card”.

Native Americans, Alaska natives, and people who are on both Medicare and OHP can be in a CCO, but can ask to change to FFS anytime. Any CCO member who has a medical reason to have FFS can ask to leave managed care.

Call OHP Client Services at (800) 273-0557 for help understanding and choosing the best way to receive your healthcare.

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When to Call OHP

Call OHP if you:• Need to change your address, phone number, or name.• Become pregnant or have a baby.• Have other health insurance coverage.• Want to change your CCO.• Move outside of AllCare CCO’s service area.

You can call OHP Customer Service Monday through Friday, 8:00 a.m. to 5:00 p.m. at (503) 378-2666 or (800) 699-9075. Call wait times vary. When call volume is high, you may experience longer wait times.

About AllCare CCOAllCare CCO is a privately-owned Oregon Benefit Company, certified by the B Lab as a Certified B Corporation. AllCare CCO is owned by local, southern Oregon healthcare providers and is part of the AllCare Health family of companies. You can find out more about AllCare Health, its commitment to local communities, and its status as a Certified B Corp by visiting: AllCareHealth.com/BCorp, or by calling Member Services at (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) at 711, or language access at (888) 260-4297.

AllCare CCO Service AreaAllCare CCO is a Coordinated Care Organization (CCO). We are a group of all types of healthcare providers who work together for people on the Oregon Health Plan (OHP) in Jackson, Josephine, and Curry counties and Glendale and Azalea in Douglas County. Some providers in our CCO are:

For mental health needs:• Options for Southern Oregon • Curry Community Health

Toll free (877) 457-1320 Toll free (877) 519-9322

For alcohol and drug treatment:• Allied Health Services Medford • Curry Community Health Toll free (888) 654-1831 Toll free (877) 519-9322

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• Addictions Recovery Center (541) 779-1282

For dental needs:• Advantage Dental • ODS Community Health Toll free (866) 268-9631 Toll free (800) 342-0526• Capitol Dental Care • Willamette Dental Group Toll free (800) 525-6800 Toll free (855) 433-6825

For transportation needs:• ReadyRide Toll free (800) 479-7920

We also work with many local partners to offer other healthcare services, such as: Living Well with Chronic Conditions classes, tobacco cessation support, and YMCA Fitness Program memberships. These are only a few examples of wellness programs we can provide. For a full list of the organizations that help AllCare CCO bring these programs to you, call Member Services at: (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) at 711, or language access at (888) 260-4297.

How We Coordinate Your Care AllCare CCO coordinates the care you receive by bringing together many types of care into one group. We also help to make sure that anyone who gives you care — such as doctors, counselors, dentists, and nurses — can focus on prevention and improving your overall health.

This means your providers won’t only treat you when you get sick. They will also help you find ways to stay healthy and manage your existing health conditions.

To help us serve you better, please let us know if you were enrolled in a different CCO before you became an AllCare CCO member.

AllCare CCO will:

• Give you the tools and support you need to stay healthy.• Give care and advice that is easy to understand and follow.• Work with local resources to improve your health and the healthcare you get.

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• Focus on prevention to help you avoid trips to the hospital or emergency room that are not needed.

• Make sure that all members are treated fairly.

Culturally-sensitive Health EducationWe respect the dignity and 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. We want everyone to feel welcome and well-served in 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. They are listed on page 61. For more information about these services, please call Member Services at: (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access at (888) 260-4297.

Native RightsIf you are a Native American or Alaska native, you can get your healthcare from a tribal clinic. If your provider is not in our network, they must follow the same rules as network providers. Only covered benefits will be paid for. If a service requires AllCare CCO’s pre-approval, the provider must request it before providing the service.

AllCare CCO Will Help You Member Services is happy to help you with your questions about AllCare CCO. Please call us if you have questions about:

• Services that are covered by AllCare CCO.• How to use preventive healthcare services.• How to choose a Primary Care Provider (PCP) or where to get services.• How to see a specialist.• How to make an appointment with a PCP.• Complaints, concerns, or suggestions.

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When calling Member Services, please have the following items in front of you:

• AllCare CCO Member ID card for the person you are calling about.• Oregon Health Plan Member ID card.• Any other information that might help us answer your questions.

When you have this information ready, we can look up your file and answer your questions faster.

Telephone: (541) 471-4106, toll free (888) 460-0185

Hearing impaired (TTY): 711

Language Access: (888) 260-4297

Office Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. Our offices are wheelchair accessible.

Office Locations: Grants Pass Medford Brookings 1701 NE 7th Street 3629 Aviation Way 580 5th Street, #400 Grants Pass, OR 97526 Medford, OR 97504 Brookings, OR 97415

Mailing Address:AllCare Health Attn: AllCare CCO 1701 NE 7th Street Grants Pass, OR 97526

If you can’t get in to see your PCP during your first monthIf you need prescriptions, medical supplies, or medical services right away, please call Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY 711, or language access at (888) 260-4297.

For those members new to AllCare CCO or CCO members newly enrolled with Medicare, Care Coordination is available to help with the process of getting your prescriptions, medical supplies, treatments and medications approved by current or previous CCO, or other necessary items. This would include help if you can’t get in

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to see your PCP or Primary Care Dentist during your first month with AllCare CCO or Medicare. Please call Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY 711, or language access at (888) 260-4297 if you need help.

Involvement in CCO ActivitiesAllCare CCO has three Community Advisory Councils. The Councils give valuable feedback and direction for the CCO. AllCare CCO has one council in Jackson County, one in Josephine County, and one in Curry County. We invite you to apply to serve on the Council in your area. 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 one of our Community Advisory Councils, please call Member Services for an application. You can also find the application on our website at: AllCareHealth.com/CCO/Resources/CCO-Community-Advisory-Council.

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What Your Member ID Card Does for YouTo get medical and behavioral health services, or dental care and prescriptions, you must show your OHP and AllCare CCO Member ID cards. You must show them every time you visit your provider or pharmacy. It is best to keep these cards with you at all times.

An AllCare CCO Member ID card is mailed to you after you get your OHP coverage letter.

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The card is important because it:

• Shows you are a member of AllCare CCO.• Lists your PCP and their telephone number.• Tells you what to do in an emergency.• Has important pharmacy information.

If you lose your AllCare CCO Member ID card, call Member Services right away. Member Services will send you a new card so you can keep visiting your PCP and get your prescriptions filled.

Change of AddressIf you change your address or phone number, you need to call:

• OHP Customer Service at (800) 699-9075, or TTY at 711;• AllCare Health Member Services at (541) 471-4106, toll free at (888) 460-0185,

TTY 711, language access at (888) 260-4297 or Fax at (541) 471-3784.• Your PCP’s office.

Call OHP Customer Service right away if you move out of the AllCare CCO service area (Jackson, Josephine, and Curry counties and parts of Douglas County). OHP will help you change to another plan so you can keep getting health coverage.

Other ways to change your addressIf you have a ONE (OHA) case, you can create an online account by going to: One.Oregon.gov/. In your online account you can update any of your case information.

Members can email changes directly to [email protected]. Put the change you are requesting in the subject line of the email. Change requests can include address change, name correction, or gender correction. The above email is not secure. To send this information in a secure email, go to the Oregon Health Plan website at Oregon.gov/OHA/Pages/Contact-Us.aspx.

Make sure to include your full name, health ID (prime) number, and a telephone number where you can be reached. The eligibility team will call you to validate the change.

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If you do not have access to email, you can also work with a Community Partner (CP). A Community Partner can help you in submitting an address change or correction. CPs have dedicated email access for submitting member changes to OHP.

You can also call OHP at (800) 699-9075 to report, although there will likely be long hold times.

How to Change CCOsIf you want to change to a different CCO, call OHP Customer Service at (503) 378-2666 or (800) 699-9075. There are several chances for you to change your CCO as long as another CCO in your service area is open for enrollment:

• 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 CCOs as soon as you tell OHP Customer Service about the move.

• You can change CCOs for any reason one time each year.• If you are a Native American, an Alaska native, or are also on Medicare, you can

ask to change or leave your CCO at anytime.

When you have a problem getting the right care, please let us try to help you before changing CCOs. Just call our Member Services at (541) 471-4106, toll free (888) 460-0185, hearing impaired (TTY) at 711, or language access at (888) 260-4297 and ask for a Care Coordinator. If you still want to leave or change your CCO, you or someone who represents you, can ask verbally or in writing to be disenrolled. The request can be made directly to the state (or its agent), or to the CCO. The CCO will send on the request to OHA. You may also call OHP directly. The OHP Customer Service number is (503) 378-2666, or toll free at (800) 699-9075.

DisenrollmentA member, or someone who represents the member, can ask verbally or in writing to be disenrolled. The request can be made directly to the state (or its agent), or to the CCO. The CCO will send on the request to OHA.

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AllCare CCO will not disenroll you because of:

• Your health getting worse.• How many services you use.• Physical, intellectual, developmental, or mental disability.• Uncooperative or disruptive behavior resulting from special needs, disability,

or any condition that is a result of your disability, unless it is allowed because:1. The member is in the custody of DHS/Child Welfare.2. Of expected placement in or referral to a psychiatric residential treatment

facility before receiving any services.3. A Member’s decision regarding their own medical care with which

AllCare disagrees.

We may ask the Oregon Health Authority (OHA) to remove you from AllCare CCO if you:

• Have other health insurance.• Move out of the AllCare CCO service area (Jackson, Josephine, and Curry

counties and Glendale and Azalea in Douglas County).

OHA may remove you from your CCO if you:

• Commit fraud, like letting someone else use your healthcare benefits.• Become physically and/or verbally abusive to the staff or property of your

provider or AllCare CCO.

You may change CCOs at certain times if another CCO is available to you. See page 31 for more information on how to change your CCO. OHP may also approve a change if you have a very good medical reason. Please call OHP Client Services at (800) 699-9075 or TTY 711.

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What OHP CoversAllCare CCO will coordinate services for members who need the health services listed below:

Service Who’s Covered?

Preventive care, such as annual physical exams, well-child care, and immunizations (shots)

All members

Medical exams in your PCP’s office and needed treatment

All members

Medical and surgical treatments for covered conditions that are expected to get better with treatment

All members

Nursing home care for covered conditions, up to 20 days

All members

Routine vision servicesMembers ages 0 through 20 years old, and pregnant women

Family planning services and supplies All members

Prescription drugs All members

Hospital and emergency care All members

Doctor visits while you are in the hospital All members

X-ray, laboratory, and other testing services All members

Home health care All members

Hospice care All members

Physical, occupational, and speech therapy All members

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Emergency medical transportation All members

Outpatient alcohol and drug treatment All members

Dental care All members

Mental health All members

Behavioral health rehab services All members

Class 7 & 11 prescription drugs (behavioral health drugs)

All members

Therapeutic foster care reimbursementMembers under 21 years of age

Therapeutic group home reimbursementMembers under 21 years of age

Investigation of members for civil commitment All members

Long-term Psychiatric Care (LTPC)Members 18 years and older

Preadmission Screening and Resident Review (PASRR)

All members seeking admission to a LTPC facility

Juvenile Long-term Psychiatric Care (LTPC) including:

• Secure Children’s Inpatient Program (SCIP) • Secure Adolescent Inpatient Program (SAIP) • Stabilization and Transition Services (STS)

Members 17 years and younger

Personal care in adult foster homesMembers 18 years and older

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Residential mental health services provided in licensed community treatment programs

Members 18 years and older

Abuse investigation and protective services All members

Personal care services All members

ICCP (Intensive Care Coordination Program)

Members who are blind, disabled, or aged 65 years and older. Members with special health care needs, complex medical needs, high health care needs, multiple chronic conditions, or behavioral health issues. Members with severe and persistent mental illness.

Rides to get OHP-covered services All members

Examples of medical problems you might get treatment for include, but are not limited to:

Appendicitis Cancer Eye diseases Kidney stones

Asthma Diabetes Head injuries Pneumonia

Broken bones Ear infections Heart disease Rheumatic fever

Burns Epilepsy Infections Stomach or leg ulcers

Treatment until your condition is stable

Note: AllCare CCO may need to approve some drugs, treatments, visits with providers or specialists, and medical equipment before you can get them.

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Prior AuthorizationsSome services that your provider orders may need a prior authorization (PA). A prior authorization is an advanced approval before you get the service. Some examples of services that need a PA are: elective surgery/procedures, home health, outpatient drugs, infusion services, durable medical equipment, scheduled inpatient hospitalization or skilled nursing facility, specialty care, MRI, genetic testing and rehabilitation therapy. Your provider will submit a PA to us. Your provider can call us for help in getting a PA. If you need to know if a service needs a PA, call Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297. Or you can visit our website at AllCareHealth.com/CCO.

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What OHP Does Not Cover• Colds, diaper rash, sunburns, and other things that will get better without

going to a doctor.• Diseases or conditions for which there is no useful treatment.• Cosmetic treatment.• Services to help you get pregnant.

Call your PCP when you think you need medical treatment. Your PCP will give you advice on what to do. If you have questions about covered or non-covered services, or why a provider may be charging you a copay, please call Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

What AllCare CCO Does Not CoverThe services listed below are covered by OHP Fee-for-Service, but are not covered by AllCare CCO. For more information on these services and how to get them, call OHP Customer Service. Their numbers are (503) 378-2666 and (800) 699-9075.

Here are some examples of services not covered by AllCare CCO but may be covered by OHP. This is not a complete list:

• Midwife home delivery.• Mental health medications (7 & 11 drugs).• Death with Dignity.• Abortion.• Hospice services for members who live in a skilled nursing facility.• Long-term care services.• School-based services that are covered services provided under the

Individuals with Disabilities Education Act (IDEA).• Administrative examinations requested or authorized by another government

agency, CAF, SPD, AMH, OYA, SCF branch office or approved by the Health Systems Division.

• Services provided to Citizen Alien Waived Emergency Medical (CAWEM) recipients or CAWEM Plus-CHIP Prenatal Coverage for emergency medical services only.

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Choosing Your Primary Care ProviderTo get medical services, you must choose an in-network doctor or nurse practitioner as your Primary Care Provider (PCP). You have the right to choose a PCP and where you get your healthcare services. You also have the right to change your choices.

Please choose a doctor from the Find A Doctor search tool on the AllCare Health website at AllCareHealth.com/CCO/Lookup-Tools/Find-A-Doctor. To get a hard copy of the AllCare CCO Provider Directory, or to get it in another format (such as other languages, large print, or braille) at no cost, call Member Services at (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access, (888) 260-4297.

Using the Online “Find A Doctor” SearchYou can search the “Find A Doctor” tool for all available PCPs in your area. Enter your zip code (for example: 97501) and select how far you are willing to travel (for example: 10 miles). Click on the “Accepting New Patients” and “Primary Care Provider” check boxes and press the Submit button. All the doctors who are currently available in that area will show on the page to the right of the search box.

• Family Medicine – gives care to children and adults.• Internal Medicine – gives care to adults only.• Pediatrician – gives care to children only.

Your PCP (doctor or nurse practitioner) will:

• Get to know you and your medical history.• Provide all of your medical care.• Keep your medical records up-to-date and in one place.

If needed, your PCP will:

• Send you to a specialist.• Admit you to a hospital.

If you already have a doctor or nurse practitioner, make sure they are listed in the AllCare CCO Provider Directory. If your PCP is not listed, you must choose a PCP

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who is listed in this directory. It is a good idea to choose a PCP close to where you live.

Once you choose a PCP:

• Fill out the Primary Care Provider Selection Form given to you in the New Member Packet.

• Fold and mail the form in the included, postage paid envelope.• A new AllCare CCO Member ID card will be sent to you. It will have your new

doctor or nurse practitioner’s name and phone number on it.

OHP requires you to choose a PCP within 30 days of enrolling in a CCO. To do this, you need to fill out the back of the PCP Selection Form and return it to us within two weeks. If you have not returned your selection form in time, we will choose a PCP for you. You can change your PCP two (2) times in 12 months.

Changing Your Primary Care ProviderIf you want a new PCP or dental plan, please call Member Services as soon as you decide you want to change. A representative will help you make the change. You cannot see your new PCP or dentist until the change is made by AllCare CCO. When you call, our Member Services representative will tell you when the change will happen. We will send you a new ID card with your new PCP or dental plan’s name and phone number.

You may change your PCP or dental plan two (2) times in 12 months. If you want to change more than two (2) times in 12 months, our Member Services Director must approve the change.

When you change to a new PCP, you will need to request a copy of your medical records from your current PCP. You may be charged reasonable copying fee from your PCP for your records. You should then provide your records to your new PCP.

Patient-Centered Primary Care HomeWe want you to get the best care possible. One way we try to do that is by asking our providers to be recognized by the Oregon Health Authority as a Patient-Centered

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Primary Care Home (PCPCH). That means they can receive extra funds to follow their patients closely and make sure all their medical, dental, and behavioral health needs are met. You can ask at your clinic or provider’s office if they are recognized as a PCPCH or other primary care team.

Meeting Your Primary Care ProviderAfter you get your AllCare CCO Member ID card, please have a physical exam with your new PCP (doctor or nurse practitioner) within 90 days. This first visit helps your PCP get to know you and your medical needs before you get sick.

If the PCP you already see is an AllCare CCO provider and you’ve seen your PCP in the last 12 months, (1 year), a first visit is not necessary. If you have not seen your PCP in the last year, please schedule a physical exam within 90 days (three months) of enrollment.

If You Need an InterpreterWhen you call to set a date and time for your first visit with your PCP, tell the receptionist that you need an interpreter. If your PCP does not already have an interpreter, AllCare Health Member Services can help your PCP get a qualified and certified healthcare interpreter for your PCP visit. The interpreter will be provided by phone or in person, at no cost to you.

If You Cannot Keep an AppointmentIf your PCP has agreed to an office visit with you at a certain date and time, please get there on time. If you cannot make that date and time, call your PCP’s office at least one (1) day before the visit. The receptionist will help you make the visit for a new date and time. If you miss a visit without letting your PCP’s office know, your PCP may not agree to see you again.

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Getting a RideReadyRide gives non-emergency rides to AllCare CCO members.

If you cannot get to a healthcare appointment on your own, you may call ReadyRide for a free ride. This includes any medical, dental, pharmacy, or behavioral health visit that is covered by AllCare CCO.

Who can use ReadyRide?If you are an AllCare CCO member and cannot get to an appointment on your own, you may use this service.

Service area or long-distance ridesWe give rides to AllCare CCO members in Curry, Douglas, Jackson, and Josephine counties. We give long-distance rides to other counties if your doctor orders a service there. Long distance rides have special rules. Please call ReadyRide at (800) 479-7920, Monday through Friday, 8:00 a.m. to 6:00 p.m. to get a ride.

CostThere is no cost to you for this service. Free rides to covered medical, dental, and behavioral health appointments are part of being an AllCare CCO member.

Scheduling a ride Call the ReadyRide Call Center at (800) 479-7920 to get a ride. For hearing impaired, call 711 (Oregon Relay Service). Please call at least two business days

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before you need a ride, Monday through Friday, 8:00 a.m. to 6:00 p.m. You may schedule a ride as early as two months before you need the ride.

Same-day or next-day ridesSame-day rides are allowed for these reasons:

• Your doctor asks you to come in the same-day for a serious condition. This can include rides for lab work or other testing.

• A ride to urgent care because your doctor is not available and you are sick.• A ride for pregnant women to see their OB/GYN, PCP, or to urgent care.• If your doctor refers you to a specialist.• To pick up a medicine you need right away.• Hospital discharges.• For all other reasons, please call at least two business days before your ride,

(800) 479-7920, Monday through Friday, 8:00 a.m. to 6:00 p.m.

Service hoursCall Center hours are Monday through Friday, 8:00 a.m. to 6:00 p.m. The Call Center is closed on New Year’s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving, and Christmas. Please call at least two business days before a holiday.

Rides are available day or night, every day of the year.

A ride in the evening, on weekends, or holidays can be hard for us to schedule. If you need a ride during these times, please call as far ahead as possible.

What to expect when you callThe first time you call, we will tell you about the program and discuss your ride needs. The first call will take between 10 and 15 minutes.

When you call to schedule a ride, we will ask for:

• Your name.• Your address.• Your phone number.• Your date of birth.• Your AllCare CCO member ID number.• Name of the doctor or clinic you need to visit.

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• Address and directions for the doctor or clinic you need to visit.• Date of appointment.• Time of appointment.• Pick-up time after appointment.• Any special needs, such as a wheelchair or service animal.• If you will have anyone traveling with you.• Directions to your home.

When you call to schedule a ride for a child under age 15, we will also will need to know:

• The child’s name, member ID number, and birth date.• If your child requires a child seat.• The name of the adult who will be with your child.

Children under the age of 15 must have an adult with them at all times.

EmergenciesReadyRide does not provide emergency transportation. If you need an ambulance, call 911.

If you have an emergency during your ride please, notify your driver. Your driver will call 911.

Adverse Weather ConditionsIn case of dangerous weather conditions ReadyRide will use all terrain vehicles and/or tire chains on the vehicles used to give rides to members that have to travel on bad roads to get to their appointment. Sub-contractors will be notified to use chains when necessary. If some appointments are not urgent, it may be necessary to re-schedule for you and your driver’s safety. ReadyRide uses the Oregon Department of Transportation’s Trip Check to see road closures. ReadyRide will re-route vehicles if possible.

Your rightsIf you feel you have been denied a ride unfairly, you have the right to an appeal. Your rights are outlined in detail in the “Appeal Rights” section of this Member Handbook on page 88.

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Your dutiesSome of your rides may be shared with other AllCare CCO members. It is your responsibility to treat your driver and other riders with respect. Riders who break the law or cause a safety risk may be asked to leave the vehicle. If this happens, we will work with you to ensure you get the care you need.

How to cancel a rideLocal rides: If you need to cancel or change a local ride, please call ReadyRide at least two hours before the pick-up time.

Long-distance rides: If you need to cancel or change a long-distance ride, please call ReadyRide at least six hours before the pick-up time.

Rides canceled after these times are considered late cancels.

When to be readyPlease be ready five minutes before the pick-up time assigned by ReadyRide. If you are not ready within 15 minutes after your scheduled pickup time, you may be considered a no-show.

Late cancel and no-show policyLate cancels, same day cancellations, and no-shows may cause a problem in getting you the care you need. If you have more than three late canceled rides or more than three missed rides in 90 days we may need to find you a different type of ride. This can include working with your AllCare CCO Care Coordinator.

When is a driver on time?Your driver should arrive within five minutes before your pick-up time and no more than ten minutes after your pick-up time.

If you call for a ride home, your driver should arrive within one hour.

If a driver is not on time, please call (800) 479-7920 to tell us.

Types of ridesRides are scheduled to best meet your needs. This could be a bus ticket, taxicab,

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wheelchair van, stretcher van, gas money to drive yourself, or another type of ride.

Rides may be shared. Shared rides may take longer than driving alone. Your ride should never be longer than two times the amount of time it would take to drive alone.

Travel Reimbursement ProgramIf you or someone you know can drive you to your medical appointment, ReadyRide will pay you back for mileage.

To get paid for your mileage, you must notify ReadyRide before your appointment with the address, the date, and time of your appointment. We will send you a form to request to be paid back for mileage.

You have 45 days from your appointment date to turn in your form to be paid back. After 45 days, you will not be paid.

Where to wait for your rideFor safety, we will only pick you up and drop you off at the address you give us when you call to arrange your ride.

How your driver may help youWe will help you with your travel needs.

If you ask, drivers can come to the door of your home to let you know they are ready for you. Drivers also may come to the main entrance of the clinic when they pick you up.

Drivers may help you through the door into the main lobby of clinics or through the door of your home. Drivers may not help you into medical rooms or other areas of the building. If you need more help, you will need to bring your own helper.

Drivers may not go into your room. Exceptions are when they pick you up from the hospital or with a stretcher car.

Drivers may not help you get ready to go (feeding, dressing, etc.). Drivers may not help you into a wheelchair or help you from a wheelchair to a vehicle.

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Not all drivers are able to help you up and down steps or into buildings if you use a walker or cane. If you use a walker or cane, please let us know so that we can find the right driver.

Drivers cannot accept tips.

Personal helpersYou must arrange for your own helper if you cannot travel alone.

We will pay the fare of one medically necessary helper. We do not pay for your helper’s time.

ChildrenChildren under the age of 15 must have an adult with them at all times. The adult may be:

• The parent or legal guardian.• An adult relative.• An adult with written permission from a parent or legal guardian.• A Department of Human Services (DHS) employee or volunteer.

The adult with the child must bring and install a car seat, if required by law. Drivers may not help install or remove car seats.

Car seats may not be left with your driver during the child’s appointment. You might not have the same driver on the return ride.

Wheelchairs and other equipmentIf you use a wheelchair, we are not able to help you up or down steps. You must have a wheelchair ramp in place. You may ask your driver to help you up and down curbs. If your wheelchair is very large, please let us know so we can send the right vehicle. A very large wheelchair means it is more than 30 inches wide, 48 inches long, or more than 600 pounds with the person in it.

If you use a scooter, you might be asked to ride in the vehicle’s seat for your own safety.

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If you use a walker, a cane, or crutches we will need to put them in a safe place when you get in the vehicle. Your driver will help you with these items.

Oxygen tanks must be tied down during the ride.

Service animals are animals trained to help people with disabilities. They are allowed to ride with you. Please tell us before the ride if you need to bring a service animal on the ride.

Safety beltsRiders must follow safety belt laws. Please tell us if you need a seatbelt extension. If you have a safety belt exemption card, bring it and show it to your driver.

Riders using wheelchairs must use the lap and shoulder belt.

Client privacyYour privacy is important to us. We will keep your information private as required by law.

Contact ReadyRideWe welcome your feedback. Comments and concerns can be directed to us at (800) 479-7920. The Riders Guide is available on the AllCare website at AllCareHealth.com/CCO/Services/Rides-To-Doctor-Appointments.

Seeing A SpecialistA specialist is a doctor with extra training in treating a part of the body, a disease, or a type of injury. Specialists give care that your PCP cannot provide. Most specialty services need a referral from your PCP, so you will need to see your PCP first. Your PCP may also need to ask AllCare CCO to approve the service of a specialist. AllCare CCO will send the approval directly to the specialist. When they receive the approval, the specialist’s office will call you to set up a visit.

Examples of services that require a referral: • Visits with a specialist (such as a podiatrist, a foot doctor; a neurologist,

a nerve specialist; endocrinologist, a hormone specialist; or an orthopedist, a bone and joint specialist).

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• Physical therapy.• Speech therapy.• Occupational therapy.• Home health services.• Hospice.

Examples of services that do not need a referral:• Routine vision exams for pregnant women and children 0 through 20

years old.• Prenatal care with a PCP or OB (pregnancy specialist).• Women’s annual exams and women’s health.• Family planning.• Mental health treatment.• Drug or alcohol addiction treatment.• Dental.

Out-of-Network ProvidersIn most cases, you must see providers that are in the AllCare CCO network. If a network provider is not available, your PCP will ask us if you can see an out-of-network provider. At no cost to you, we will work with your PCP to determine how soon you need to be seen and which specialist you need to see for your medical needs.

If you have already seen a specialist and have questions or concerns, make an appointment with your PCP to discuss any issues. You will need to get AllCare CCO’s approval if you want to see someone outside of the plan’s network.

Second OpinionAllCare CCO covers second opinions at no cost to you. If you want a second opinion about your treatment options, ask your PCP to refer you. You can also let AllCare CCO know that you want to see another provider. If you want to see a provider outside of our network, you or your provider will need to get AllCare CCO’s approval first.

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Physician Incentives and Provider PaymentWe pay a bonus or reward to our providers for keeping you healthy. We do not pay or reward our providers for limiting services and referrals.

You have the right to ask if AllCare CCO has special financial arrangements with its doctors that can affect the number of referrals and other services they use. To get this information, call Member Services and ask for information about physician payment arrangements.

Practice GuidelinesPractice Guidelines are used to create our healthcare policies for treatment and care. You can find our Practice Guidelines on our website at AllCarehealth.com/CCO/Resources/Clinical-Practice-Guidelines.

If you would like a copy of the Practice Guidelines, or get it in another format (such as other languages, large print, or braille) at no cost, please contact Member Services at (541) 471-4106, toll free (888) 460-0185, TTY 711, language access at (888) 260-4297, fax (541) 471-4128.

Copay or BillsAs an AllCare CCO member you do not have to pay for medicine, to see a provider, or any other covered services. If you are asked to pay for a service, please call Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

Your medical or dental provider can send you a bill only if all of the following are true:

• The medical service is something that your OHP plan does not cover. • Before you received the service, you signed a valid Agreement to Pay, OHP

form number 3165 (also called a waiver) and the form:– Showed the estimated cost of the service.– Said that OHP does not cover the service.– Said you agree to pay the bill yourself.

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Always show your AllCare CCO Member ID card. These protections usually only apply if the medical provider knew or should have known you had OHP. These protections also only apply if the provider participates in the OHP program (but 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 cannot bill you. You may receive a notice from us saying that we will not pay for the service. That notice does not mean you have to pay. The provider will write-off the charges.

If we or your provider tell you that the service isn’t covered by OHP, you still have the right to challenge that decision by 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:

1. Call the provider, tell them that you were on OHP, and ask them to bill your CCO.

2. Call AllCare Health Member Services at (541) 471-4106, toll free (888) 460-0185, hearing impaired (TTY) at 711, or language access at (888) 260-4297 right away. Let us know that a provider is billing you for an OHP service. We will help you get the bill cleared up. Do not wait until you get more bills.

3. You can appeal by sending your provider and AllCare CCO 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.

4. Follow up to make sure we paid the bill.5. If you receive court papers, call us right away. You may also call an attorney

or the Public Benefits Hotline at (800) 520-5292 for legal advice and help. There are consumer laws that can help you when you are wrongly billed while on OHP.

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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 emergency room, you may be treated by a provider who doesn’t work for the hospital. For example, the emergency room doctors may have their own practice and provide services in the emergency room. They may send you a separate bill. If you have surgery in a hospital, there will be a separate bill for the hospital, the surgeon, and maybe even the lab, the radiologist, and the anesthesiologist. Just because 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 through 5 on page 51, 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 see a

provider that does not take OHP or is not part of AllCare CCO’s provider network. Before you get medical care or go to a pharmacy, make sure that they are in our provider network.

• You will have to pay for services if you weren’t eligible for OHP when you received the service.

• You will have to pay for services not covered by OHP if you sign a detailed Agreement to Pay for that specific service before you receive it.

If You Have Medicare or Other InsuranceIf you have Medicaid and Medicare, AllCare CCO will coordinate your Medicaid benefits with your Medicare benefits. You are not responsible for deductibles, copays, or coinsurance for Medicare covered benefits and services. If you have other insurance coverage and are on AllCare CCO, let us know by calling OHP Customer Service or AllCare Health Member Services.

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When You Are SickPlease call your Primary Care Provider (PCP) when you become sick. Tell the receptionist or nurse what is wrong. They will tell you whether you need to see your PCP that day, or need to do something else. Take your AllCare CCO Member ID card and your Oregon Health Plan Member ID card with you when you go to your PCP.

If you become sick at night, on weekends, or on holidays, call your PCP. Your PCP provides medical care day and night, every day. If your PCP is not working that day, the answering service will have another on-call doctor help you.

If You Need Care Out-of-TownIf you get sick or hurt 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 EmergenciesIf you have a real emergency when you are away from home, call 911 or go to the nearest emergency room (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 (US) at no cost to you. OHP does not cover emergency and urgent care outside the US. That means OHP will not pay for any care you get in Mexico or Canada.

Nurse Help Line – (844) 747-5656If you have a non-emergency question about your health or the medicines you are taking, you may call this phone number any time of day or night, every day. Specially-trained nurses will ask you how you are feeling and give you advice. All calls are private. The toll free phone number is (844) 747-5656 or TTY at 711.

Urgent CareAlways call your primary care provider’s (PCP) office first. Someone will be able to help you day and night, even on weekends and holidays. If you can’t reach your PCP’s

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office about an urgent problem or they can’t see you soon enough, you can go to an urgent care provider without an appointment at the locations below:

Asante Urgent Care – Grants Pass 537 Union Avenue(541) 507-2170 TTY 711 Monday – Sunday: 8:00 a.m. to 8:00 p.m.

Asante Urgent Care – Medford 555 Black Oak Drive(541) 789-2273 TTY 711 Monday – Sunday: 8:00 a.m. to 8:00 p.m.

Asante Urgent Care – White City 841 Avenue G(541) 789-2273 TTY 711 Monday – Sunday: 8:00 a.m. to 8:00 p.m.

Curry Medical Center – Brookings 500 5th Street(541) 412-2000 TTY 711 Monday – Saturday: 8:00 a.m. to 8:00 p.m. Closed Sunday

Valley Immediate Care – Grants Pass 162 NE Beacon Drive, #103(541) 479-1090 TTY 711 Monday – Friday: 8:00 a.m. to 8:00 p.m. Saturday – Sunday: 9:00 a.m. to 6:00 p.m.

Valley Immediate Care – North Medford 1600 Delta Water Road, Suite 107(541) 858-2515 TTY 711 Monday – Friday: 8:00 a.m. to 8:00 p.m. Saturday – Sunday: 9:00 a.m. to 6:00 pm

Valley Immediate Care – Ashland1401 Siskiyou Boulevard, Suite 1 (541) 488-6848 TTY 711 Monday – Friday: 9:00 a.m. to 6:00 p.m. Saturday – Sunday: 9:00 a.m. to 6:00 p.m.

Valley Immediate Care – South Medford 235 East Barnett Road, Suite 106(541) 773-4029 TTY 711 Monday – Friday: 8:00 a.m. to 8:00 p.m. Saturday – Sunday: 9:00 a.m. to 6:00 p.m.

Urgent problems are things like bad infections, sprains, and strong pain. If you don’t know how urgent the problem is, call your PCP.

Emergency CareIf 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, an injury to teeth or gums, or a mental health emergency. Please

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Emergency Room Urgent Care Go to Urgent Care when your doctor is not available and your life is not in danger. You do not need an appointment. ReadyRide is often available for same day Urgent Care visits.

Severe Stomach or Chest Pain

Severe Burns

Cuts Requiring Stitches

Allergic Reactions

Pink EyeHeart Attack Symptoms

Babies Needing Immediate Care

Stroke Symptoms (Numbness, Paralysis, Slurred Speech, etc.)

Mild Fevers (100.9° or

Lower)

Broken Bones (With No Bones

Showing)

Animal or Insect Bite

High Fevers (101° or Higher)

Serious Eye or Head Injuries

Significant Difficulty Breathing

Minor Burns

Sprains & Strains

Cold & Flu Symptoms

Suspected Drug Overdose or

Poisoning

The Emergency Room should be used for life-threatening issues. The ER is not a place to go for minor illnesses or injuries.

When you or your family member is not feeling well, it is important to get the right care. Use this chart to help you decide if you need to visit the Emergency Room or Urgent Care. This list is not complete. Always use your best judgment to decide if emergency care is needed. When in doubt call 911.


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don’t use the ER for things that can be treated in your doctor or dentist’s office. Sometimes ERs have a long, uncomfortable wait and it can take hours to see a doctor. You should only go there when you have to.

Ambulance services are covered for emergencies. If you use an ambulance for something that is not an emergency, you may have to pay the bill.

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 Jackson County call (541) 774-8201. In Josephine County call (541) 474-5360. In Curry County call (877) 519-9322. You can also call 911, or go to the ER closest to you.

Care After an EmergencyEmergency care is covered until you are stable. Follow-up care to maintain or improve your condition once you are stable is covered by AllCare CCO but it is not considered an emergency. This care is called post-stabilization care. AllCare CCO will pay for post-stabilization care provided by a hospital, even if the hospital is not in our provider network. After you receive emergency treatment, call your PCP or mental health provider to arrange for more follow-up care if you need it.

HospitalsAllCare CCO covers emergency care at any time of day or night, every day, and hospital care if needed. AllCare CCO does not need to approve you going to the hospital for a true emergency. In an emergency, go to the hospital nearest to you. Hospitals in AllCare CCO’s service area are:

Asante Three Rivers Community Hospital *500 SW Ramsey Ave. Grants Pass, OR 97526

(541) 472-7000 TTY (hearing impaired): (541) 472-7001

Asante Rogue Regional Medical Center *2825 East Barnett Road Medford, OR 97504

(541) 789-7000 TTY (hearing impaired): (541) 789-4240 TTY toll free: (800) 944-7073, ext. 4240


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Providence Medical Center * 1111 Crater Lake Highway Medford, OR 97504

(541) 732-5000 Toll free: (877) 541-0588 TTY (hearing impaired): (541) 732-6413 TTY toll free: (888) 326-2686

Sutter Coast Hospital * 800 E. Washington Blvd. Crescent City, CA 95531

(707) 464-8664 TTY 711

Asante Ashland Community Hospital * 280 Maple Street Ashland, OR 97520

(541) 201-4000 TTY (hearing impaired): (541) 201-4102

Curry General Hospital * 94220 Fourth Street Gold Beach, OR 97444

(541) 247-3000 Toll free: (800) 445-8085 TTY 711

* Spanish-speaking staff and interpreter services available.

After You Leave the HospitalYou may get any care you need to make sure your condition stays stable.

If your doctor says you need nursing care after you leave the hospital, care at a “skilled nursing facility”, such as a nursing home, is covered for up to 20 days.

If you have Medicare benefits, skilled care for more than 20 days may be covered by Medicaid or Medicare. Please call Member Services if you need help arranging more skilled nursing care.

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Case and Disease Management ServicesAllCare CCO wants you to reach your health goals and stay as healthy as possible. Our nurses and other case management staff have special training in many chronic health conditions such as diabetes, heart failure, asthma, depression, or high blood pressure. If you have been in the hospital or nursing home, our staff knows how scary it can be. There are many things you or your family may need to remember. We can help you understand your treatment plan and will work closely with your doctors to make sure you have the help you need.

Primary Care Team Specialists, Care Helpers, or Traditional Health WorkersAllCare CCO knows there are times when you may need help in finding the care that is right for you. Your Primary Care Team has people specially trained to do this. These people are called Traditional Health Workers. They can help you with any questions you may have about your healthcare and social needs.

Services that your Primary Care Team can help you connect to:

• Rides to your doctor.• Finding a new provider.• Support available in the community.• Help with food.• Resources for housing.• Financial assistance.• Information on available mental health services and support.• How to get the medical equipment your provider has ordered.

A Traditional Health Worker can help with communication between your healthcare providers, caseworkers, and other people involved in your healthcare. They can answer questions and help you know the benefits and limits of your AllCare CCO benefits.

Traditional Health Care Workers are specially trained healthcare workers. They include Birth Doulas, Personal Health Navigators, Peer Support Specialists, Peer Wellness Specialists, and Community Health Workers.

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For more information, please call our THW liaison at (541) 471-4106, toll free (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

When You Have Special Medical NeedsIntensive Care Coordinators (ICC) help members who have special medical needs. For example, an ICC helps people with disabilities who have special supply and equipment needs, or who need community support services.

If you have special needs, an ICC can help you:

• Choose doctors and other healthcare providers who know about your special needs.

• Get medical equipment that has been prescribed by your PCP.• Connect with local agencies that may be able to help you.• Make sure all of your healthcare providers are working on the same plan of

care for you.• Make sure that you receive quality healthcare that is right for you.• Make sure your providers keep your special needs in mind.

You may request ICC services by calling Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

PrescriptionsIf you need to have a prescription filled, you may go to any pharmacy listed in the AllCare CCO Provider Directory. You will need to take your:

• Prescription.• Oregon Health Plan Member ID card.• AllCare CCO Member ID card.

The pharmacist cannot fill your prescription without these three things. The pharmacist needs special approval to fill some medications. AllCare CCO does not cover all drugs your PCP might prescribe for you. If a drug is denied you will receive a notice informing you of your right to appeal the denial. If AllCare CCO does not cover a certain drug, ask your PCP to ask AllCare CCO about other options.

If you do not see the prescription or OTC medication your provider has prescribed

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for you in our drug list, you can ask us to cover the medication as an exception. If you are unsure if your medication is on our drug list, you can call us to check for you. If you would like us to cover your medication as an exception, tell your provider. Our plan doctors and pharmacists will review the exception and provide you with a decision within 72 hours.

Most medications used to treat mental health conditions are paid for by the Oregon Health Plan through the Fee for Service pharmacy benefit. Please contact AllCare CCO to ask how your medications are covered.

In-Network Retail and Mail-Order PharmaciesAllCare CCO partners with pharmacies all over Oregon. These are our “in-network” pharmacies. In-network pharmacies are retail and mail-order pharmacies that have agreed to fill covered prescriptions for our plan members. You can use the Provider & Pharmacy Directory to find the network pharmacy you want to use. An updated Pharmacy Directory is located on our website at AllCareHealth.com/CCO/Lookup-Tools/Find-A-Facility-Or-Pharmacy. For updated provider information, or to get the Provider & Pharmacy Directory in another format (such as other languages, large print, or braille) at no cost, call Member Services at (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access (888) 260-4297.

Take Charge of Your HealthAllCare CCO has a team ready to help you and your family have a healthier life. Our team can help you manage your illness if you have one. However, only you can take charge of your health. You can do this by making healthy food choices, being as active as you can, and visiting your PCP regularly. Doing these things can keep small health problems from becoming big ones. Making these same good choices for your children, will also help them grow and develop as healthy as possible.

Preventive Healthcare: Keeping You HealthyIn addition to treating you when you are sick, your PCP can help you to stay healthy. Physical exams are an important part of keeping you and your family healthy. When your PCP sees you regularly, it is easier to see and care for health problems before

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they become bigger problems and harder to treat. Your PCP also can tell you how to stay healthy.

Immunizations, also known as shots or vaccines, are an important and effective way to stay healthy. They help your body fight off certain diseases. Infants and children need many shots or vaccines as they grow. Adults should get a shot for tetanus (a very serious infection) every 10 years. Shots or vaccines for the flu and pneumonia are most important if you have a chronic illness, but they also help keep everyone healthy. If you think you need other kinds of shots or vaccines, please talk to your PCP.

AllCare CCO covers preventive healthcare including:• Regular physical exams for children and adults.• Immunizations/shots.• Medical tests such as x-rays and blood tests.• Most other screening tests asked for by your PCP.

Quitting TobaccoAllCare CCO has classes and support groups for people who want to quit using tobacco. These services are free to AllCare CCO members. If you need help quitting tobacco, call our Tobacco Cessation Coordinator at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297. Or, call your PCP. No referral is needed. Your doctor will prescribe a treatment plan for you. AllCare CCO coverage includes nicotine gum, patches, Zyban, and Chantix. We also provide support and counseling to help you quit and stay quit. You can also call toll free at (800) QUIT-NOW, or (800) 784-8669 to be connected to your state’s tobacco quit-line.

Healthy LivingWe have many programs to help you live healthy. See the table page 62 for more benefits you can get as an AllCare CCO member. For more information about any of the programs listed, please contact Member Services at (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access at (888) 260-4297.

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More Member and Community Benefits

Gym MembershipsAllCare CCO members can get a monthly gym membership at low cost. Benefits can include wellness programs, cooking and nutrition classes, childcare, family and youth programs.

Weight Loss, Chronic Pain, and Chronic Conditions

You can sign up for weight loss and chronic health condition programs to help you take control of your health.

Financial Wellness, Seniors, and Disability

As a member, you can get help with Social Security Disability applications. You can also get credit counseling, learn about debt management, and take financial classes.

Housing, Homelessness, Accessibility, and Living Supports

AllCare CCO partners with community programs to help shelter people experiencing homelessness. We also have programs to help improve our members living conditions, if needed.

Family, Child, and Parenting

Parenting classes, childcare, and other family support is available to AllCare CCO members.

Health/Legal Partnership

If legal problems are preventing you from getting good healthcare, AllCare CCO may be able to help through a health/legal partnership program.

Domestic Violence AllCare CCO partners with several programs that can help members who are victims domestic violence.

Nutrition and Hunger

AllCare CCO is part of several community food programs. They include food banks, community gardens, SNAP-matching at the local growers markets, and others. Members can also get home-delivered meals as part of a post-hospital discharge care plan.

Community Engagement and Economic Development

AllCare CCO works with many community partners to make our community healthy and safe. Programs include suicide prevention, help for at-risk youth, foster children and families, job and life skills development, and many others.

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We’re Just a Phone Call Away.

Nurse Help Line(844) 747 5656

Call

24/7/365 For emergency health questions, call your Primary Care Provider (PCP) first. If you call after office hours, an on-call doctor will help you.

For non-emergency health questions, call our Nurse Help Line at:

(844) 747-5656. Nurses are standing by 24/7, even holidays.

We’re Just a Phone Call Away.

Calls are private and FREE.

Nurse Help Line(844) 747 5656

AllCare CCO wants to make sure you and your baby have the best care, from the very beginning.


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Family PlanningAllCare CCO covers family planning services and birth control. You do not need a referral from your PCP for family planning services and supplies.

You may visit any AllCare CCO provider, pharmacy, or your local County Health Department for family planning services and supplies. You may also go to any family planning clinic, doctor, or nurse practitioner who will take your Oregon Health Plan Member ID card.

Covered services and supplies include:

• Sterilization (vasectomies or getting tubes tied. A consent form must be filled out by you 30 days before this procedure).

• Depo-Provera shot.• Norplant implants and IUDs.• Birth control pills, vaginal rings, and patch.• Condoms.

Please remember breastfeeding is not a form of birth control. You can still become pregnant while breastfeeding your baby.

Talk with your PCP to see if other family planning supplies are covered. These services and supplies are available through any provider who will accept your Oregon Health Plan Member ID card.

Transgender HealthAllCare CCO respects the healthcare needs of all our members. This includes trans women, trans men, gender nonconforming, two-spirit, and non-binary members.

AllCare CCO covers gender transition services, such as hormone therapy, counseling, and some surgeries. To learn more, contact Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.


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AbortionsAbortions are a fee-for-service benefit covered by the Oregon Health Plan, not AllCare CCO.

Women’s HealthcareAllCare CCO covers many services for women’s special healthcare needs, including a yearly physical exam that includes:

• Pap test.• Breast exam.• General health assessment.

Mammograms (breast X-rays) are also covered when they are needed or recommended. Talk with your PCP (Primary Care Provider) about how often you need a mammogram.

You may go to your PCP for your annual exam, or you may go to a women’s doctor, also known as a gynecologist. You do not need a referral to get women’s health services.

Pregnancy and Prenatal CareIf you are pregnant, or think you might be, call your PCP right away so that you can start getting prenatal care. Prenatal care keeps you and your baby healthy during your pregnancy. It is very important that you begin prenatal care early and get regular checkups the whole time you are pregnant.

AllCare CCO pregnancy benefits include:

• Prenatal visits.• Labor and delivery (child birth) services.• Postpartum (after the delivery) care.

AllCare CCO has a maternity team to help members throughout their pregnancy, the birth, and up to one year after birth. There are nurses, midwives, and maternal child health advocates available to help you with resources and questions you may have


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during your pregnancy. They can help with breastfeeding instructions, how to get a breast pump, and infant massage to name a few.

AllCare CCO also has the Babe Store where you can purchase new baby items with vouchers you can earn through community partners such as your OB doctor, mental health providers, and many others. To find out more, call Member Services and ask to speak with the maternity department at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

AllCare CCO does not cover home births.

You may see your PCP or an obstetrician (OB – a doctor who specializes in pregnancy care) for your prenatal care. However, your OB doctor does not provide treatment of everyday illnesses and injuries. You should call your PCP for these illnesses and injuries.

During your pregnancy, we can help you find:

• An OB doctor.• Nutritional counseling to help you eat healthy foods.• Birthing classes (we pay for classes taken from contracted instructors).• Parenting classes.

You must choose your doctor from our provider network. For more information about starting pregnancy care, please call your PCP or Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

You also need to contact OHP Customer Service as soon as you know you are pregnant. You should notify OHP Customer Service and AllCare CCO when your pregnancy ends.

Delivery of babies when you are travelingYou should try to stay within AllCare CCO’s service area during the last 30 days of your pregnancy. AllCare CCO will only cover emergency care for you and your baby if you leave AllCare CCO’s service area. This includes your baby’s delivery and newborn check-up at the hospital. AllCare CCO will not cover your prenatal care when traveling outside the AllCare CCO service area.

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After the Baby is BornCall OHP Customer Service at (800) 699-9075, or TTY at 711, as soon as possible after your baby is born to tell them about your new baby. You can also fill out the Newborn Notification Form from the OHA website at Oregon.gov/OHA/Pages/Index.aspx. The sooner you do this, the sooner we will be able to send you an AllCare CCO Member ID card for your baby. This will make it easier for you to get healthcare for your baby.

Newborn CareAllCare CCO benefits for newborns include well-baby care. Well-baby care is a series of regular checkups during a child’s first five years of life. These check-ups help your doctor see and treat problems early before they get worse. We also cover immunizations (shots), also known as vaccines.

CircumcisionAllCare CCO covers circumcision for newborns between one week and four weeks of age if the mother was an AllCare CCO member with physical health coverage at the time of the baby’s birth. This procedure must be done in an office setting, unless AllCare CCO approved getting the circumcision in a different setting.

Immunizations, vaccines (shots)Immunizations (shots) protect our bodies against diseases, such as chickenpox, whooping cough, and measles. These shots work and are very important for children. Your child will need many shots during their first 15 months of life. Your child will need some shots when entering kindergarten and middle school. If you do not know if your child has had all of their shots, or if you have a question about shots, talk to your child’s PCP.

Health Services for Older Children and TeensChildren between the ages of 5 years and 18 years of age can get a well-child check-up once every two years.

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You may take your child to their PCP if you have concerns about your child’s physical, mental, or emotional progress, such as bed wetting, inability to pay attention in school, behavior problems, and mood changes.

Oral Health ProvidersAllCare CCO works with Advantage Dental, Capitol Dental Care, ODS Community Health, and Willamette Dental Group for your dental needs. Please see the handbook for information about your dental plan. You can find the handbook for each dental plan on their websites, listed on page 69 and page 70.

Choosing a Primary Care Dentist (PCD)AllCare CCO partners with Dental Care Organizations (DCO) to manage your dental care. You will need to have a Primary Care Dentist (PCD) at one of AllCare CCO’s DCOs or dental plan. Your PCD will take care of most of your dental care needs.

Please call your assigned dental plan to find a dentist that is accepting new patients. Only go to a different dentist in case of emergency or by a referral from your dental plan.

If you do not know your dental plan, call AllCare Health Member Services at (888) 460-0185, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

Advantage Dental: (866) 268-9631 or TTY 711 8:00 a.m. to 6:00 p.m., Monday - Friday AdvantageDental.com/AdvantageDentalServices.html

Capitol Dental Care: (800) 525-6800 or TTY 711 7:00 a.m. to 7:00 p.m., Monday - Friday CapitolDentalCare.com/Members/Find-A-Dentist/

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Willamette Dental: (855) 433-6825 or TTY 711 7:00 a.m. to 6:00 p.m., Monday - Friday 7:00 a.m. to 4:00 p.m., Saturdays Locations.WillametteDental.com/

ODS: (800) 342-0526 or TTY 711 7:00 a.m. to 7:00 p.m., Monday - Friday ModaHealth.com/Dental/

What Are My Oral Health (Dental) Benefits?

Prevention• Exams (once per year for adults, twice a year for children 18 and under).• Cleanings (once a year for adults, twice a year for children 18 and under).• Fluoride treatments.• X-rays.• Sealants (for children 16 years and under).

RestorativeThese services are covered if your primary care dentist says they are dentally appropriate. Some of these services may need pre-approval from your dental plan.

• Fillings.• Partial dentures every 5 years.• Complete dentures every 10 years.• Stainless steel crowns for premolars/molars (back teeth).• Oral surgery and endodontics.• Tooth removal.• Root canals for front teeth (Incisors and Canines) and Premolars.• 1st Molar Root Canal Therapy (under 21 years old and/or currently pregnant).• 2nd Molar Root Canal Therapy (under 21 years old).

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Dental EmergencyA dental emergency is when you need same-day dental care. Emergencies include a severe toothache or gum swelling, an infection in your gums or teeth, or a tooth that has been knocked out.

For a dental emergency, please call your Primary Care Dentist (PCD). If you cannot reach your PCD or you do not have one, call your dental plan. They will help you find emergency dental care.

Urgent Dental CareUrgent dental care is when you need dental care soon, but not immediate treatment. Examples of urgent dental care are a toothache, swollen gums, or a lost filling.

For urgent dental care call your primary care dentist (PCD). If you cannot reach your PCD or you do not have one, call your dental plan. They will help you find urgent dental care, depending on your condition.

Specialty Dental CareYour PCD may refer you to a specialist if you need one. If you go to a specialist without a referral, you may have to pay the bill. Before paying any medical or dental bills, call AllCare CCO.

If you have any questions about your dental coverage, please call Member Services at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

If You Need a Ride to Your Dental VisitIf you cannot get to an appointment on your own, you may call ReadyRide for a free ride. You can find out more about getting a ride on page 42 to page 48.

Call the ReadyRide Call Center at (800) 479-7920 to get a ride. For hearing impaired, please call 711 (Oregon Relay Service). Please call at least two business days before you need a ride, Monday through Friday, 8:00 a.m. to 6:00 p.m. You may schedule a ride as early as 60 days before you need the ride.

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Vision CareAllCare CCO provides limited vision services, as listed below:

• Children may receive an eye exam and glasses one time every year.• Women who are pregnant may also receive a routine eye exam and glasses.• Diabetics may receive a diabetic eye exam one time every year.

AllCare CCO has eye doctors (optometrists and ophthalmologists) available for vision care. Please call Member Services if you need help finding an eye doctor.

Eye problemsIf your vision suddenly worsens, or if your eyes become infected or injured, see your Primary Care Provider. Your PCP will refer you to a specialist if needed.

Hearing CareIf you think you need a hearing exam, call your PCP for a referral to a specialist. If you were receiving hearing services before enrolling in our plan, please call Member Services about continuing those services.

AllCare CCO will pay for some hearing aids and batteries. Please call Member Services about hearing aid benefits.

Medical EquipmentIf you think you need medical equipment, such as diabetic supplies, walkers, or incontinence supplies, talk to your PCP. Your doctor is best able to decide what you need. If you have any problems getting the supplies you need, call Member Services for help at (541) 471-4106, toll free at (888) 460-0185, TTY at 711, or language access at (888) 260-4297.

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Behavioral Health ServicesBehavioral Health means treatment for Mental Health and Substance Use Disorders.

These services are available to all OHP members at no cost. Important: You do not need prior approval or a referral to get mental health services or services for an alcohol or drug problem from an in-network provider. Many of these services are offered in the places you already get care. Some Primary Care Clinics have Behavioral health services available in the clinic. You might also get some of these services at your Women’s Health clinic, at school, one of the many in-network therapists, or at a Substance Use Disorder treatment program. A Community Mental Health Program (CMHP) will be the best place to get all this care in one place. The list of in-network CMHPs begins on page 82.

Behavioral Health treatment services include:

• Assessment.• Counseling.• Groups.• Medication management.• Skills training. • Case management.• Peer delivered services/peer support.• Programs to help with daily and community living.• Intensive outpatient.• Acupuncture.• Medication Assisted Treatment (MAT) to help you cut down or stop using

alcohol or drugs. These treatments include:1. Methadone.2. Suboxone.3. Buprenorphine.4. Vivitrol.

• Medical detox • Residential treatment for adults, youth and parents with young children.

Peer Delivered Services are services from a peer support specialist or peer wellness

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specialist. These are people who have lived through some of the same things you have. They can:

• Show you how to get the right services for you and your family.• Go to meetings with you.• Support you in your recovery.• Support you in parenting children with special physical or behavioral

health needs.Children and youth might need more support and can access these programs from an in-network Community Mental Health Program (CMHP):

Program What is it? Who is eligible? How do you get it?

Wraparound Care A planning process that helps children and their families achieve their goals by putting them at the center of their care.

Members aged 0 to 17 who have a mental health diagnosis, have complex needs, and have or get help from at least two of the following:• Child welfare

• Special education

• Juvenile justice

• Mental health

• Intellectual/Developmental Disabilities (I/DD)

• Substance Use Disorder

• Homelessness

• Chronic medical condition

Anyone can complete a Wraparound Referral. Any of the agencies listed above can work with a member or family to complete a referral. Referrals are given to your local Community Mental Health Program (CMHP) or directly to the local Wraparound Review Committee.

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Early Assessment and Support Alliance (EASA)

A statewide network of programs which identify youth with symptoms of psychosis as early as possible. EASA provides team based support and treatment.

Members aged 15 to 25 who may be having their first psychotic episode.

Anyone can refer to EASA. If you think you or someone else might be having the first signs of psychosis, you can call your nearest EASA team for more information or to make an appointment.

• Jackson County (541) 770-7768

• Josephine County (541) 244-3138

• Curry County (541) 373-0279

or visit the EASA website at: EasaCommunity.org

Applied Behavior Analysis (ABA)

A service that helps reduce behaviors that interfere with learning or which may be harmful.

Members with Autism

Before a member can be referred to ABA, they must have an evaluation by a doctor with experience diagnosing Autism.

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Parent-Child Interaction Therapy (PCIT)

A treatment for young children that have a behavioral problem. Professionals observe and coach the interactions of parents or caregivers and their child. This helps to improve the child and parent skills and relationship.

Members ages 2 to 7 and their parents or caregivers who are having parent-child relationship or behavioral problems.

Parents or caregivers can call or go to an in-network CMHP to ask about PCIT. They will do an assessment to see if you and your child might benefit from PCIT.

Psychiatric Day Treatment

An intensive five-day-per-week program for children with severe emotional and behavioral problems. This includes mental health treatment, family therapy, and schooling.

Members ages 5 to 15 who have a mental health diagnosis.Their behaviors make life, school, and relationships difficult. They need mental health treatment almost every day for several hours each day.

Parents or caregivers can call or go to an in-network CMHP to ask about Day Treatment. Your child’s school can also refer for Day Treatment. CMHP will do an assessment and talk to your child’s school to see if Day Treatment is the best treatment.

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Psychiatric Residential Treatment Services (PRTS)

An intensive mental health treatment 24 hours a day, 7 days a week for children with severe emotional and behavioral problems.

Members ages 0 to 17 who have serious mental health diagnosis. They need mental health treatment 24 hours a day. Lower levels of care have not made much improvement to their emotions and behaviors.

PRTS is a specialized service that requires your mental health provider and a child psychiatrist to agree that this level of care is needed for your child. You, your child’s school, or another care provider can request that the CMHP start the referral process.

Adults with serious mental illness may need more support and can access these programs from an in-network Community Mental Health Program (CMHP):


Assertive Community Treatment (ACT)

An intensive treatment for adults with serious persistent mental illness (SPMI). ACT provides a team that works with a member in the community. A counselor, case manager, psychiatrist, nurse, and others are on the team.

Adult Members aged 18 and older with a SPMI diagnosis. Their mental health problems make it difficult for them to get treatment at a mental health agency.

A member with SPMI, their family, or another provider can call or go to the in-network CMHP to get screened for ACT services.

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Supported Employment (SE)

A program that helps members with serious mental illness get employment or education.

Adult members aged 18 and older with serious mental illness who express the desire to work or go to school.

Members, their family, or providers can call or go to an in-network CMHP and request SE services. The SE specialist will work with the member to determine which services are best.

Choice Model Coordination for adults with serious mental illness who are in Oregon State Hospital (OSH) or residential programs. The goal is to make sure members are getting mental healthcare at the lowest level of care possible.

Adults aged 18 and older with serious mental illness who need residential or long-term mental healthcare.

The member, their family, or mental health provider can talk to the Choice Model Coordinator for the member’s county.

Curry County Curry Community Health

Jackson County Jackson County Mental Health

Josephine County Options for Southern Oregon

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Mental Health PrescriptionsMost medications that people take for mental illness are paid directly by the Oregon Health Authority (OHA). Please show your pharmacist your Oregon Health Plan Member ID and your AllCare CCO Member ID cards. The pharmacy will know where to send the bill.

Mental Health Crisis HelpYou can get help with a mental health crisis or emergency 24 hours a day, 365 days per year. A mental health emergency is feeling out of control or thinking about hurting yourself or others. You do not need a referral from your provider. You do not need a prior approval from AllCare. You should call one of the crisis lines below. They will help you decide which crisis services might help you.

Declaration for Mental Health TreatmentOregon 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 can complete the form before a mental health crisis occurs while you are able to 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 and 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 a copy of your form to your Primary Care Provider and the person you name to make decisions for you.

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For more information on the Declaration for Mental Health Treatment go to the State of Oregon’s website at: Oregon.gov/OHA/HSD/AMH/Pages/Client-Services.aspx.

If your provider does not follow your wishes in your Declaration for Mental Health Treatment, you can complain. A form for this is at HealthOregon.org/hcrqi. Send your complaint to:

Health Facility Licensing and Certification Program 800 NE Oregon Street, Suite 465 Portland, OR 97232 Email: [email protected] Fax: (971) 673-0556 Phone: (971) 673-0540; TTY: (971) 673-0372

Behavioral Health Provider DirectoryAllCare CCO In-Network Community Mental Health Programs (CMHP):

Jackson CountyOptions for Southern Oregon Bryson Center 200 Beatty Street Medford, OR 97501

(541) 476-2373 Toll free (877) 457-1320 TTY 711

Jackson County Mental HealthFor crisis services only Crisis Line (541) 774-8201

Josephine County Options for Southern Oregon1545 Harbeck Road Grants Pass, OR 97526

(541) 476-2373 Toll free (877) 457-1320 TTY 711 Crisis Line (541) 474-5360

Douglas County Compass Behavioral Health2700 Stewart Parkway, Annex B Roseburg, OR 97471


Curry CountyCurry Community Health 29821 Colvin Street Gold Beach, OR 97444


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other places that provide mental health services. Check with your doctor to see if their office has mental health services available. Check with your child’s school to see what mental health services are offered. Many of the private therapists in our community will accept AllCare CCO as well. Visit the AllCare CCO website for a full list of mental health providers at AllCareHealth.com/CCO/Lookup-Tools/Find-A-Facility-Or-Pharmacy. If you need help finding a mental health provider, or want to get the Provider Directory in another format (such as other languages, large print, or braille) at no cost, call Member Services at (541) 471-4106, toll free at (888) 460-0185, hearing impaired (TTY) 711, or language access at (888) 260-4297.

Alcohol and Drug TreatmentAllCare CCO covers Substance Use Disorder (SUD) treatment to help you stop using alcohol and drugs at no cost to you. You do not need a referral—you may visit a SUD treatment provider on your own. SUD treatment services include:

• Drug and alcohol assessment • Peer services and supports• Outpatient treatment • Intensive outpatient treatment• Residential treatment • Detoxification• Acupuncture • Case management• Mental health screenings (typically done at your doctor’s office)• Medication assisted treatment, including Methadone maintenance• Individual and group counseling for you and your family members• Care coordination for members who need help identifying or connecting to

services. Especially if there are special healthcare needs such as disability, elderly, mental illness, pregnancy, limited English, etc.

Confidentiality: Federal and state laws protect the privacy of all OHP members. No one may release information to anyone outside AllCare CCO about a member’s substance use disorder without the member’s written permission. AllCare CCO and its providers may not release or disclose any information about an OHP member for any purpose except as directed by the OHP member. AllCare CCO and its providers may not give information, except for purposes directly related to the administration of the Oregon Health Plan.

When you call a substance use disorders treatment provider, a counselor will

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schedule a date and time to talk with you about your condition and make a treatment plan.

AllCare CCO In-Network Substance Use Disorder programs:

Josephine County

Adapt 418 NW 6th Street Grants Pass, OR 97526(541) 474-1033 TTY 711

Josephine County Community Corrections Treatment Services 510 NW 4th Street Grants Pass, OR 97526 (541) 474-5165 TTY 711

OnTrack 806 NW 6th Street Grants Pass, OR 97526 (541) 772-1777 TTY 711

OnTrack 535 E River Street, Cave Junction, OR 97523 (541) 772-1777 TTY 711

Grants Pass Treatment Center 1881 NE 7th Street Grants Pass, OR 97526 (541) 955-3210 TTY 711

Choices Counseling Center 109 NW Manzanita Avenue, Grants Pass, OR 97526 (541) 479-8847 TTY 711

Options for Southern Oregon 1545 Harbeck Road Grants Pass, OR 97527 (541) 476-2373 TTY 711

Options for Southern Oregon 1181 SW Ramsey Avenue Grants Pass, OR 97527 (541) 476-2373 TTY 711

Options for Southern Oregon 319 Caves Highway Cave Junction, OR 97523 (541) 476-2373 TTY 711

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Addictions Recovery Center, Inc. 1025 E Main Street Medford, OR 97504(541) 779-1282 TTY 711

Allied Health Services 777 Murphy Road Medford, OR 97504 (541) 772-2763 TTY 711

OnTrack 300 W Main Street Medford, OR 97501 (541) 772-1777 TTY 711

Options for Southern Oregon 200 Beatty Street Medford, OR 97501 (541) 476-2373 TTY 711

Kolpia Counseling Service 607 Siskiyou Blvd. Ashland, OR 97520 (541) 482-1718 TTY 711

Phoenix Counseling Center 149 S Main Street Phoenix, OR 97535 (541) 535-4133 TTY 711

Curry County

Curry Community Health 615 5th Street Brookings, OR 97415 (541) 813-2535 TTY 711

Curry Community Health 29692 Ellensburg Avenue Gold Beach, OR 97465 (541) 813-2535 TTY 711

Curry Community Health 1403 Oregon Street Port Orford, OR 97465 (541) 813-2535

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Fraud, Waste, or AbuseAllCare CCO is committed to preventing Fraud, Waste and Abuse. Every dollar that is spent on fake, abusive or wasteful activities is money that can’t be spent where it is needed most.

Fraud is intentional deception or misrepresentation with knowledge that the information is false. Abuse is payment for items or services that have no valid basis for payment and the provider did not know when they tried to get the payment. Waste is over using of services that are not medically necessary.

There are several ways to report Fraud, Waste and Abuse. We have a toll-free hotline and an anonymous website for reporting. If you think errors, fraud, waste, or abuse, have happened report it as soon as you can! Telling us will help stop other members from becoming victims. Telling us will also help to save your health care benefits. If you have doubts on information about your Explanation of Benefits or believe there may be errors, fraud, waste or abuse, please contact us.

U.S. Department of Health and Human Services Office of Inspector General ATTN: OIG HOTLINE OPERATIONS P.O. Box 23489 Washington, DC 20026

Phone: (800) HHS-TIPS (800-447-8477) TTY: (800) 377-4950 Fax: (800) 223-8164

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DHS Provider Audit Unit 3406 Cherry Ave NE, 2nd Floor Salem, OR 97303

Phone: (888) FRAUD01 (888-372-8301), Monday–Friday, 8:00 a.m. - 5:00 p.m. Fax: ATTN: HOTLINE at (503) 373-1525

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You may also contact the DHS Provider Audit Unit if you think someone is using your personal information for OHP benefits.

You may report Client Fraud cases to:

DHS Investigations Unit P.O. Box 14150 Salem, OR 97309 Phone: (888) 372-8301 Fax: (503) 373-1525

You can also report Client and Provider Fraud cases to:

AllCare CCO anonymous Hot Line Toll Free: (877) 874-8416 7 days a week and 24 hours a day

or, you may submit the complaint online at: AllCarehealth.EthicsPoint.com

This website can be translated to Spanish by clicking on the Español link at the top right hand corner.

Here are some examples of Fraud, Waste and Abuse:

• Billing AllCare CCO for a service you didn’t get.• Billing for a more expensive service than what was provided.• Having medically unnecessary service done just to get more money.• Letting someone else use your health care benefits.• Claiming for member reimbursement of non-emergent medical transportation

when you car pooled with someone else. The law protects people who report Fraud, Waste and Abuse. You cannot lose your job, lose your coverage or be threatened, harassed or discriminated against for reporting.

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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 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 can 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 give you the standard medical treatment for your condition.

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, for example 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 Healthcare.Oregon.gov/SHIBA/Topics/Pages/Advance-Directives.aspx. If you write an Advance Directive, be sure to talk to your providers and your family about it and give them copies. They can only follow your instructions if they have them.

If you change your mind, you can cancel your Advance Directive anytime. To cancel your Advance Directive, ask for the copies back and tear them up, or write CANCELED in large letters, sign and date them. For questions or more information contact Oregon Health Decisions at (800) 422-4805 or (503) 692-0894, TTY 711.

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If your provider does not follow your wishes in your Advance Directive, you can complain. A form for this is at HealthOregon.org/hcrqi. Send your complaint to:

Health Care Regulation and Quality Improvement 800 NE Oregon St, #305 Portland, OR 97232 Email: [email protected] Fax: (971) 673-0556 Phone: (971) 673-0540 TTY: (971) 673-0372

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Grievance System Information and Appeal Rights

How to make a complaint or grievanceIf you are very unhappy with AllCare CCO, your healthcare services, or your provider, you can complain or file a grievance. We will try to make things better. Just call Member Services at (541) 471-4106, toll free (888) 460-0185, hearing impaired (TTY) at 711, language access at (888) 260-4297, or send us a letter to the address on page 6. We will look into your complaint and provide you with our review as quickly as your health requires. This will be done within 5 business days from the day we got your compliant. If we need more time we will send you a letter notifying you that. We will tell you why we need more time to look into your complaint. The letters will be written in your preferred language.

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

How to File an Appeal

Appeals and HearingsIf we deny, stop, or reduce a medical service your provider has ordered, we will mail you a Notice of Action-Adverse Benefit Determination letter explaining why we made that decision. As a member, you have the right to file an appeal. This is when you want us to look at and change a decision we have made about what is covered for you or what AllCare will pay for a service. Your appeal must be filed within 60 days from the date on the denial letter. An appeal form will be provided with the denial letter.

When you submit an appeal, we look at the original decision. We have a new doctor look at your medical records and the service request to see if we were following all the rules correctly. When we have completed the second review we will give you our decision in writing, (Notice of Appeal Resolution) with a hearing request form. This will include how to request a Contested Case Hearing.

An appeal may be filed by you, your appointed representative, or your doctor with written permission from the member in the following ways:

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• By calling Member Services (541) 471-4106, toll free (888) 460-0185, hearing impaired (TTY) at 711, language access at (888) 260-4297. You may also use this number to check on the status of an existing appeal.

• By completing the Denial of Medical Services Appeal and Hearing Request Form and mailing or faxing the completed form back to us.

To file a standard appeal, you must send a written letter telling us why you are appealing the denial. It helps if you give us as much detail as you can about your health. Or you may complete the Denial of Medical Services Appeal and Hearing Request Form (OHP 3302) in place of a letter. Completion of this form is not required to file an appeal. Please include copies of any new information that may help your appeal and mail or fax to the address(s) and/or fax number listed in the How to File section below.

How fast we look at your appeal depends on the type of appeal:

For a decision about payment for services you already receivedAfter we look at your appeal, we have 16 days to make our decision. If we find in your favor, we must issue payment within the 16 days of the date we got your appeal request.

For a standard decision about authorizing medical careAfter we receive your appeal, we have up to 16 days to make a decision. We may make the decision sooner if your health requires. You or AllCare may need extra time to look at your appeal. We can extend the time-frame up to 14 days if you request the extension, or if AllCare can show why we need more time to get information and that it is in your best interest.

For a fast decision about authorizing medical careYou, any doctor, or your authorized representative can ask us to give you a fast appeal (rather than a “standard” appeal). This can be about drugs or services that you have not yet received. If you or your doctor think that waiting for a standard appeal could seriously harm your health or your ability to function. If we give you a fast decision, we must make our decision as fast as your health might require. This will not take longer than 72 hours. We may extend the time-frame by up to 14 days if

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you request the extra time, or if we justify the need for more information and how it is in your best interest. For fast appeal, contact us by telephone or fax at the number listed in the How to File section below.

Provider AppealsWith written permission from you, your provider has a right to appeal for you when their physician’s orders are denied by a CCO.

How to File an Appeal or GrievanceYou may file an appeal or grievance using the following methods:

• Call Member Services: Monday through Friday, 8:00 a.m. to 5:00 p.m. at (541) 471-4106, toll free (888) 460-0185, hearing impaired (TTY) at 711, or language access at (888) 260-4297 or,

• By Fax: (541) 471-3789• By Mail: AllCare CCO

Attention: Appeals 1701 NE 7th Street Grants Pass, OR 97526

How to get an Contested Case Hearing You can have a contested case hearing with an Oregon Administrative Law Judge. You will have 120 days from the date on your Notice of Appeal Resolution to ask the state for a hearing. Your Notice of Action-Adverse Benefit Determination letter will have an Appeal and Hearing Request form that you can send in. You can also ask us to send you an Appeal and Hearing Request form, or call OHP Client Services at (800) 699-9075, TTY 711, and ask for form number 3302.

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 OregonLawHelp.org.

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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 stop it. You must ask us to continue the service within 10 days of getting the Notice of Action-Adverse Benefit Determination letter 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-Adverse Benefit Determination letter.

Fast (expedited) HearingIf 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 the Appeal and Hearing Request form to the OHP Hearings Unit.

We suggest that you include a statement from your provider explaining why it is urgent. You should get a decision within two working days from the date of the Authority receiving the documentation. The Hearings Unit’s fax number is (503) 945-6035.

Get a Copy of Your RecordsYou can have a copy of your medical records. Your PCP has most of your records, so you can ask them for a copy. They may charge a reasonable fee for copies. You can ask us for a copy of the records we have. We do not charge a fee for the copies.

You can have a copy of your mental health records unless your provider thinks this could cause serious problems. Clinical notes made by the psychotherapist during therapy sessions are not available to you.

Your Records are PrivateWe only share your records with people who need to see them for treatment and payment reasons. You can limit who sees your records. If there is someone you don’t want to see your records, please tell us in writing. You can ask us for a list of everyone we have shared your records with.

A law called the Health Insurance Portability and Accountability Act (HIPAA) protects your medical records and keeps them private. This is also called

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confidentiality. We have a paper called Notice of Privacy Practices that explains in detail how we use our members’ personal information. We will send it to you if you ask. Just call Customer Service and ask for our Notice of Privacy Practices.

Words You Should KnowUse this glossary to help you understand words and acronyms used in this handbook.

Advance Directive – A legal document that explains the type of medical treatment you want. It is used if you become unable to tell your healthcare providers yourself.

Advocate – A person who gives you support or helps protect your rights.

AllCare CCO – A Coordinated Care Organization that has contracted with the State of Oregon to provide the Oregon Health Plan in Jackson, Josephine, and Curry counties, and in parts of Douglas County.

Appeal – A request asking your CCO to change a decision you disagree with about a service your doctor ordered. You can write a letter or fill out a form explaining why the plan should change its decision; this is called filing an appeal.

Authorized Representative – A person you say can make decisions and sign things for you. This person could be a family member or guardian. If you want an authorized representative, you must fill out a special form.

Behavioral Health Care – Treatment for mental health conditions or substance use disorders.

Benefits – The services that your health plan pays for.

CCO (Coordinated Care Organization) – A health plan that brings together all kinds of care under one group.

Complaint – A telephone call or letter to us complaining about your healthcare or about one of our network providers. A complaint does not involve coverage or payment disputes (see Appeal).

Community Health Workers – A specially trained person to help you get the best health services needed.

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Contested Case Hearing – A hearing is done by an administrative law judge of the state Office of Administrative Hearings. You can ask for this after you receive a Notice of Action—Adverse Benefit Determination to deny, reduce, or stop benefits.

Copay or Copayment – An amount of money that a person must pay on their own for health services. Oregon Health Plan members do not have copays. Private health insurance and Medicare sometimes have copays.

Declaration for Mental Health Treatment – A legal document for appointing a mental healthcare representative. It gives instructions for mental healthcare providers to follow, before you become unable to direct your own mental healthcare.

DHS – Department of Human Services.

Durable Medical Equipment (DME) – Things like wheelchairs, walkers, and hospital beds. They are durable because they last a long time. They don’t get used up like medical supplies.

Eligible – To meet conditions or requirements for a program.

Emergency – An emergency medical condition means you believe your health will be in serious danger if you don’t get help right away. This includes your unborn baby, if you are pregnant. If you believe you have an emergency medical condition, call 9-1-1 or go directly to the hospital emergency room. Examples of emergencies include, but are not limited to: an illness or injury that needs care right away, bleeding that won’t stop, severe pain, or broken bones. It can be something that will cause some part of your body to stop working right. An emergency mental health condition is feeling out of control, or feeling like hurting yourself or someone else.

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 or helicopter to get medical care. Emergency medical technicians (EMT) give you care during the ride or flight.

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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 department (ED).

ER and ED – Emergency room or emergency department, the place in a hospital where you can get care for a medical or mental health emergency.

Emergency Services – Care that improves or stabilizes sudden serious medical or mental health conditions.

Enroll – To join a program or health plan.

Excluded Services – things that a health plan or OHP doesn’t pay for. Services to improve how you look, like cosmetic surgery, and for things that get better on their own, like a cold, are usually excluded services.

Fee-for-Service – Health care services that are covered by the Oregon Health Authority (OHA). When you are not enrolled in a CCO, you are a fee-for-service member because OHA pays for your care. OHA covers some services not covered by the CCO.

Grievance – A complaint about a plan, provider, or clinic. This type of complaint does not involve coverage or payment disputes (see Appeal). The law says CCOs 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 program that pays for health care. After you sign up for the program, a company or government agency pays for covered health services. Some insurance programs require monthly payments, called premiums.

Hearing – When you ask the Oregon Health Authority (OHA) to review a decision OHA or AllCare CCO made about covering a healthcare service. Hearings are held by an administrative law judge who is not part of AllCare CCO, the Oregon Health Authority, or the Oregon Health Plan.

Home Health Care – Services you get at home to help you live better after surgery, an illness, or injury. Some of these services include help with medications, meals, and bathing.

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Hospice Services – Services to comfort a person during end-of-life care.

Hospital Inpatient Care – Hospital inpatient care is when the patient is admitted to a hospital and stays at least 3 nights.

Hospitalization – When someone is checked into a hospital for care.

Household – People that all live together. This may a spouse, partner, children or other dependents who can be claimed on your taxes.

ICC or Intensive Care Coordinator – (Formerly ENCC Exceptional Needs Care Coordinator) - An AllCare CCO employee who helps members who have difficult or special medical needs. They help members get proper healthcare from providers and other help from community agencies.

Immunizations – Also called vaccines or shots. Medicines that are injected into the body to prevent a person from getting a disease or illness that may cause serious health problems.

Medicaid – A national program that helps with healthcare costs for people with low incomes. In Oregon, it is part of the Oregon Health Plan.

Medically Necessary – Services and supplies that are needed to prevent, diagnose, or treat a medical condition or its symptoms. It can also mean services that are accepted by the medical profession as standard treatment.

Medicare – A healthcare program for people 65 or older. It also helps people with disabilities of any age.

Member Services – A department of AllCare Health that helps you with your questions, problems with your healthcare services, and AllCare CCO benefits.

Network – The medical, behavioral health, dental, pharmacy, and equipment providers that a coordinated care organization (CCO) contracts with to provide services.

Network Provider – Any provider in a CCO’s network of providers. If a member sees network providers, the plan pays the charges. Some specialists within the network require members to get a referral from their primary care provider (PCP).

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Non-Network Provider – A provider who has not signed a contract with the CCO and may not accept the CCO payment as payment-in-full for their services.

Notice of Action – Our written response to you denying any request for service or payment for service.

OHA – Oregon Health Authority. The state agency that oversees the Oregon Health Plan.

OHP – Oregon Health Plan, also known as Medicaid.

Outpatient Care – Outpatient care is surgery or treatment you get in a hospital and then leave afterward.

Participating Provider – A medical professional who is part of AllCare CCO’s network of providers.

Patient-Centered Primary Care Home (PCPCH) – A healthcare clinic that focuses on the patient or member. It includes primary care providers and different specialty providers, all in one place.

Peer Wellness Specialist/Personal Health Navigator – A person who is specially trained to help you get the health services you need.

Physician Services – Services that you get from a doctor.

Plan – A medical, dental, behavioral health organization, or CCO that pays for its members’ health care services.

Preapproval (Prior Authorization or PA) – A document that says your plan will pay for a service. Some plans and services require a PA before you get the service. Doctors usually take care of this.

Premium – What a person pays for insurance coverage. There is no premium with the Oregon Health Plan.

Prescription Drug Coverage – Health insurance or a plan that helps pay for medications.

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Prescription Drugs – Drugs that your doctor tells you to take for your health condition.

Prevention – What you do to help keep yourself healthy and stop you from getting sick. This includes services such as annual checkups and flu shots.

Primary Care Provider or Primary Care Physician – Also referred to as a “PCP.” This is a medical professional who takes care of your health. They are usually the first person you call when you have health issues or need care. Your PCP can be a doctor, nurse practitioner, osteopath, or sometimes a naturopath.

Primary Care Dentist – The dentist you usually go to who takes care of your teeth and gums.

Provider – Any person or agency that provides a healthcare service.

Post-Stabilization – Care to keep you stable or improve your condition after an emergency is over and there is no chance of another emergency.

Rehabilitation Services and Devices – Services or devices to help you get back to full health. These help usually after surgery, injury, or substance abuse.

Renewal – Each year, OHP members must make sure they still qualify for health benefits. This is called renewing. It happens one (1) time every year.

Skilled Nursing Care – Help from a nurse for wound care, therapy, or taking your medicine. You can get skilled nursing care in a hospital, nursing home, or in your own home.

Specialist – A doctor who has extra training in treating a specific part of the body, a disease, or a type of injury.

Traditional Health Care Workers – Specialty healthcare workers. They include Birth Doulas, Personal Health Navigators, Peer Support Specialists, Peer Wellness Specialists, and Community Health Workers.

Urgent Care – Care that you need the same day. It could be for serious pain, or to avoid losing function in part of your body, but is not a medical emergency (life threatening).

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Well-Child Care – A series of regular medical exams where a doctor or nurse practitioner looks for problems with a child’s physical and mental development. These exams help to ensure early and more effective medical treatment.

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Grants Pass Medford Brookings 1701 NE 7th Street, 3629 Aviation Way 580 5th Street, #400 Grants Pass, OR 97526 Medford, OR 97504 Brookings, OR 97415

Revised December 26, 2019

An Oregon Benefit Company

AllCareHealth.com/CCO

Toll free (888) 460-0185 TTY 711 Language access (888) 260-4297

your guide to benefits and services january 2020 allcare cco€¦ · if you get sick: call your...

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