OHP wants to hear from you! We want to make sure you have the information you need. Your feedback can help Umpqua Health Alliance (UHA) and OHP improve member handbooks.
Take the handbook survey! Scan the QR code or go to www.surveymonkey.com/r/tellOHP to answer a few questions.
You can find the most up-to-date handbook here: https://www.umpquahealth.com/members/helpful-resources/member-handbook/. UHA can mail you a handbook. If you need a printed copy, need help or have questions about the handbook, please call Customer Care at 541-229-4842.
We will send you a health survey to help UHA know what support you need. We will ask about your physical, behavioral, dental, developmental, and social health care needs. To learn more about this survey, go to the “Survey about your health” section.
Complete and return your survey in any of these ways:
Phone: 541-229-4842
Fax: 541-677-6038
Mail: Umpqua Health Alliance
3031 NE Stephens St.
Roseburg, OR 97470
Email: CaseManagement@umpquahealth.com
Web: www.umpquahealth.com/members/benefits-programs/care-coordination/
Everyone has a right to know about UHA’s programs and services. All members have a right to know how to use our programs and services.
For people who speak or use a language other than English, people with disabilities or people who need other support, we can give free help. Examples of free help:
• Sign language and spoken language interpreters
• Written materials in other languages
• Braille
• Real-time captioning (CART) • Large print
• Audio and other formats
You or your representative can get member materials like this handbook or CCO notices in other languages, large print, Braille or any format you prefer. Every format has the same information. You will get materials within 5 days of your request. This help is free. Examples of member materials are:
This handbook
List of covered medications
List of providers
Letters, like complaint, denial, and appeal notices
Your use of benefits, complaints, appeals, or hearings will not be denied or limited based on your need for another language or format.
UHA can email you materials. You can ask by filling out the secure contact form on our website at www.umpquahealth.com/contact-us/You can find this member handbook on our website at: https://www.umpquahealth.com/members/helpful-resources/member-handbook/If you need help or have questions, call Customer Care at 541-229-4842 or TTY 711.
You, your representative, family members and caregivers can ask for a certified or qualified health care interpreter. You can also ask for sign language and written translations or auxiliary aids and services. These services are free.
Tell UHA and your provider’s office if you need an interpreter. Tell them what language or format you need. You can also ask UHA for an “I speak” card that you can use at visits.
If you need help, please call us at 541-229-4842 or call OHP Client Services at 800-273-0557 (TTY 711).
If you do not get the help you need from UHA, you can make a complaint or call the Oregon Health Authority’s Public Civil Rights Hotline at 844-882-7889, TTY 711 or email: oha.publiccivilrights@odhsoha.oregon.gov.
UHA Nondiscrimination Notice
YOUR RIGHTS
There are state and federal laws that protect you and your civil rights. UHA can’t treat you differently because of your:
Age
Disability
National origin
Language you speak or how well you know English
Race
Religion
Color
Sex, sexual orientation, or gender identity
Pregnancy or any health issues you have due to being pregnant
How healthy you are or whether you need health services
HELP FROM UHA
If you think that UHA did not treat you fairly, we want to hear from you. UHA’s Section 1557 Coordinator and Customer Care teams are here to help. Here is how you can contact us to get a complaint started:
Hours: Monday to Friday, 8 a.m.- 5 p.m.
Phone: 541-229-4842; Toll Free: 866-672-1551; TTY: 711
Fax: 541-677-5881
Mail: Umpqua Health Alliance
3031 NE Stephens St
Roseburg, OR 97470
Website and Complaint Form: www.umpquahealth.com/appeals-and-grievances/
Email: UHAGrievance@umpquahealth.com
If you want to know more about how UHA’s complaint process works, you can give us a call or look on our website: www.umpquahealth.com/appeals-and-grievances. You can also find this notice posted on our website: https://www.umpquahealth.com/nondiscrimination-policy/
If you have a disability and need help, tell us. Use the contact information above. UHA’s help is free. Some of the things we can do are:
Give you copies in Braille
Give you large print copies
Give you copies in another language
Get help for you from a sign language interpreter
Get help for you from a spoken language interpreter
FILE A COMPLAINT
You have a right to file a complaint with any of these organizations:
Oregon Health Authority (OHA) Civil Rights
Website: www.oregon.gov/OHA/EI
Phone: 844-882-7889, 711 TTY
Email: OHA.PublicCivilRights@odhsoha.oregon.gov
Mail: Office of Equity and Inclusion Division
421 SW Oak St., Suite 750
Portland, OR 97204
Bureau of Labor and Industries Civil Rights Division
Website: https://www.oregon.gov/boli/civil-rights/
Phone: 971-673-0764
Email: boli_help@boli.oregon.gov
Mail: Bureau of Labor and Industries Civil Rights Division
800 NE Oregon St., Suite 1045
Portland, OR 97232
U.S. Department of Health and Human Services Office for Civil Rights (OCR)
Website: ocrportal.hhs.gov/ocr/smartscreen/main.jsf
Phone: 800-368-1019, 800-537-7697 (TDD)
Email: OCRComplaint@hhs.gov
Mail: Office for Civil Rights
200 Independence Ave. SW, Room 509F HHH Bldg.
Washington, DC 20201
We only share your records with people who need to see them. This could be for treatment or for payment reasons. You can limit who sees your records. Tell us in writing if you don’t want someone to see your records or if you want us to share your records with someone. You can ask us for a list of who we have shared your records with.
If you want us to share your records and information with someone, please complete the “Release of Information” form. You can find the form on our website here: https://www.umpquahealth.com/members/helpful-resources/member-documents-forms/ or we can mail you a free copy within 5 business days.
If you want to prevent someone from seeing your records, call UHA Customer Care at 541-229-4842 or TTY 711 and ask for the “Request for Restriction of Heath Information” form.
A law called the Health Insurance Portability and Accountability Act (HIPAA) protects your medical records and keeps them private. This is also called confidentiality. We have a paper called Notice of Privacy Practices that explains how we use our members’ personal information. We will send it to you if you ask. Just call Customer Care and ask for our Notice of Privacy Practices. You can also see it at https://www.umpquahealth.com/members/rights/your-privacy/
A health record has your health conditions and the services you used. It also shows the referrals that have been made for you.
What can you do with health records?
Ask to send your record to another provider.
Ask to fix or correct your records.
Get a copy of your records, including, but not limited to:
Medical records from your provider
Dental records from your dental care provider
Records from UHA
You may be charged a reasonable amount for a copy of the requested records.
There may be times when the law restricts your access. Psychotherapy notes and records prepared for court cases cannot be shared.
Providers may also not share records when, in their professional judgement, sharing records could cause substantial harm to you or another person.
If a provider denies you or your authorized representative copies of your medical records, the provider must give you a written notice. The notice must explain why the request was denied and explain your rights to have another provider review the denial. The notice will also tell you how to make a complaint to the provider or the Secretary of Health and Human Services.
Some questions have been answered or can be asked here https://www.oregon.gov/oha/HSD/OHP/Pages/Questions.aspx
Some UHA members can get extra benefits like rides to the grocery store and farmer’s markets.
Call UHA to find out more.
Refer to the end of handbook for definition of words that may be helpful to know.
If you are looking for:
Benefits. Go to page 39
Primary Care Providers. Go to page 29
Prior Approvals and Referrals. Go to page 42
Rights and Responsibilities. Go to page 23
Rides to Care. Go to page 76
Care Coordination. Go to page 37
Prescriptions. Go to page 82
Emergency Care. Go to page 86
How long it takes to get care. Go to page 66
Grievances, Complaints and Appeals. Go to page 106
Always carry your OHP and UHA member ID cards with you.
Note: These will come separately, and you will receive your OHP ID card before your UHA member ID card.
You can find your UHA ID Card in the welcome packet with this member handbook. Your ID card has the following information:
Your Name
Your ID number
Your Plan Information
Your Primary Care Provider Name and Information
Customer Care Phone Number
Language Access Phone Number
My Primary Care Provider is _________
Their number is ____________
My Primary Care Dentist is_________
Their number is ___________
Other Providers I have are ___________
Their number is _____________
My nonemergent medical transportation (free ride to care) is __________
Their number is _____________
We are glad you are part of UHA. UHA is happy to help with your health. We want to give you the best care we can.
It is important to know how to use your plan. This handbook tells you about our company, how to get care, and how to get the most from your benefits.
How OHP and UHA work together
The Oregon Health Plan (OHP) is free health care coverage for Oregonians. OHP is Oregon’s Medicaid program. It covers physical, dental, social, developmental, and behavioral health care services. OHP will also help with prescriptions and rides to care.
OHP has local health plans that help you use your benefits. The plans are called coordinated care organizations or CCOs. UHA is a CCO. UHA serves most of Douglas County, with the exception of some areas in Reedsport, Gardiner, Winchester Bay, and Scottsburg.
We work with other organizations to help manage some of your benefits, like dental services and rides to care. For a full list of these organizations and services, please see the “Contact Us” section.
CCOs organize and pay for your health care. We pay doctors or providers in different ways to improve how you get care. This helps make sure providers focus on improving your overall health. You have a right to ask about how we pay providers. Provider payments or incentives will not change your care or how you get benefits. For more information, call Customer Care at 541-229-4842 or TTY 711. When you ask for this information, we will send it within 5 business days.
Umpqua Health Alliance has a Community Advisory Council (CAC) made up mostly of Oregon Health Plan members and local community partners. The CAC gives input on how UHA can best serve members and improve community health. Meetings are open to the public, and members are encouraged to attend, share feedback, and bring ideas. If you are interested in joining or want to learn more, call UHA Customer Care at 541-229-4842 or visit www.umpquahealth.com.
All CCOs offer the same OHP benefits. Some offer extra services like new baby items and gym memberships. Learn more about UHA benefits in the “Your benefits” and “Extra Services” sections.
When you enroll in OHP, you will get an Oregon Health ID card. This is mailed to you with your coverage letter. Each OHP member in your household gets an ID card.
Your Oregon Health ID Card will look like this:
When you enroll in a CCO, you will also get a CCO ID card. This card is very important. It shows that you are a(n) UHA member and lists other information like important phone numbers. our primary care provider will also be listed on your ID card.
Your UHA ID card will look like this
Be sure to show your UHA ID card each time you go to an appointment or the pharmacy.
Your coverage letter and UHA ID card will tell you what CCO you are enrolled in. They will also tell you what level of care your CCO plan covers. Use your ID card and the table below to see what type of care is covered for you.
CCO or OHP: Who organizes and pays for your care?
*CCO-F only covers dental health care, unless you have CCO-F plus Open Card for physical and behavioral health.
**Open card is also called fee-for-service.
Learn more about organizing your care in the “Care Coordination” section or see what type of benefits are covered in the “Your Benefits” section.
Contact us The UHA office is open Monday through Friday, from 8:00 a.m. to 5:00 p.m.
We’re closed on the following holidays:
New Year’s Day
Memorial Day
Independence Day
Labor Day
Veteran’s Day
Thanksgiving
Friday after Thanksgiving
Christmas
If UHA has an emergency office closure, we will let you know on a message on our phone lines and email responses. This will also be posted on social media. UHA will have signs on our administrative office doors letting you know as well.
Our office location is:
Umpqua Health Alliance
3031 NE Stephens St.
Roseburg, OR 97470
Call toll free: 541-229-4842 or TTY 711.
We can help you with language access.
Fax: 541-677-6038
Online: www.umpquahealth.com
Mailing address:
Umpqua Health Alliance
3031 NE Stephens St.
Roseburg, OR 97470
If you would like to meet face-to-face with one of our UHA Customer Care representatives, you can schedule a virtual or video meeting with us. You can ask us about your coverage or any questions you have about your health plan. If you would like to schedule a meeting, please contact UHA Customer Care at 541-229-4842 or TTY 711. Or you can go to our website: www.umpquahealth.com/uha-customer-care/ and click the “Schedule a Zoom with UHA Customer Care” button.
Medical benefits, Pharmacy, Vision benefits and Care
Call UHA Customer Care: 541-229-4842 or TTY 711. Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. Learn more in the “Physical Health benefits” section.
Behavioral health, drug, alcohol dependency, or substance use disorder treatment benefits and care
Call Adapt Integrated Health Care
24-hour crisis line: 1-800-866-9780
Youth & families: 541-229-8934
Adults: 541-440-3532
Customer Service Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. Learn more in the “Behavioral health care benefits” section
Dental benefits and care
Call Advantage Dental Customer Care at 866-268-9631. TTY users, please call 711
Hours: Monday through Thursday, 8:00 a.m. to 6:00 p.m. and Fridays 8:00 a.m. to 5:00 p.m.
Advantage Dental’s call center is closed on the following holidays:
New Year’s Day
President’s Day
Memorial Day
Independence Day
Labor Day
Thanksgiving
Friday after Thanksgiving
Christmas Day
Learn more in the “Dental benefits” section.
Free rides to physical care, dental care, or behavioral health care Call Bay Cities Brokerage (BCB) at 877-324-8109 to set up a ride. TTY users, please call 711 Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m.
BCB’s call center is closed on the following holidays:
New Year’s Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Christmas Day
Learn more in the “Rides to Care” section.
OHP Customer Service can help:
Change address, phone number, household status or other case information
Replace a lost Oregon Health ID card
Get help with applying or renewing benefits
Get local help from a community partner
How to contact OHP Customer Service:
Call: 800-699-9075 toll-free (TTY 711)
Web: www.OHP.Oregon.gov
Email: Use the secure email site at https://secureemail.dhsoha.state.or.us/encrypt to send an email to OHP.
For questions or changes about your OHP case, email Oregon.Benefits@odhsoha.oregon.gov.
For questions about CCOs or how to use your medical, email Ask.OHP@odhsoha.oregon.gov.
Tell OHP your full name, date of birth, Oregon Health ID number, address and phone number.
Adoption and Guardianship families should contact the Adoption and Guardianship Medical Eligibility and Enrollment coordinator at:
Call: 503-509-7655
Email: Cw-aa-ga-medicalassist@odhsohs.oregon.gov
Online: https://www.oregon.gov/odhs/adoption/Pages/assistance.aspx
As a member of UHA you have rights. There are also responsibilities or things you have to do when you get OHP. If you have any questions about the rights and responsibilities listed here, call Customer Care at 541-229-4842.
You have the right to exercise your member rights without a bad response or discrimination. You can make a complaint if you feel like your rights have not been respected. Learn more about making complaints on page 107. You can also call an Oregon Health Authority Ombudsperson at 877-642-0450 (TTY 711). You can send them a secure email at www.oregon.gov/oha/ERD/Pages/Ombuds-Program.aspx.
There are times when people under age 18 (minors) may want or need to get health care services on their own. Minors 15 years and older can get medical and dental care without parental consent. To learn more, read “Minor Rights: Access and Consent to Health Care.” This booklet tells you the types of services minors of any gender can get on their own and how their health records may be shared. You can read it at www.OHP.Oregon.gov. Click on “Minor rights and access to care.” Or go to: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le9541.pdf
American Indians and Alaska Natives have a right to choose where they get care. They can use primary care providers and other providers that are not part of our CCO, like:
Tribal wellness centers.
Indian Health Services (IHS) clinics. Find a clinic athttps://ihs.gov/findhealthcare/
Native American Rehabilitation Association of the Northwest (NARA). Learn more or find a clinic at https://www.naranorthwest.org
You can use other clinics that are not in our network. Learn more about referrals and preapprovals on pages 42-43.
American Indian and Alaska Natives don’t need a referral or permission to get care from these providers. These providers must bill UHA. We will only pay for covered benefits. If a service needs approval, the provider must request it first.
American Indian and Alaska Natives have the right to leave UHA any time and have OHP Fee-For-Service (FFS) pay for their care. Learn more about leaving or changing your CCO on pages 97-98.
If you want UHA to know you are an American Indian or Alaska Native, contact OHP Customer Service at 800-699-9075 (TTY 711) or login to your online account at ONE.Oregon.gov to report this.
You may be assigned a qualifying tribal status if any one of the following are true. These questions are also asked on the OHP application:
You are an enrolled member of a Federally Recognized Tribe or a shareholder in an Alaska Native Regional Corporation.
You get services from Indian Health Services, Tribal Health Clinics, or Urban Indian Clinics.
You have a parent or grandparent who is an enrolled member of a Federally Recognized Tribe or a shareholder in an Alaska Native Regional Corporation or Village.
Members who are new to OHP or UHA may need prescriptions, supplies, or other items or services as soon as possible. If you can’t see your primary care provider (PCP) or primary care dentist (PCD) in your first 30 days with UHA:
While you are waiting for an appointment, you can call Care Coordination at 541-229-4842. They can help you get the care you need. Care coordination can help OHP members with Medicare, too. (See the Care Coordination section to learn more)
If you are becoming a new Medicare enrollee, see the Members with OHP and Medicare section for more information.
Make an appointment with your PCP as soon as you can. You can find their name and number on your UHA ID card.
Call Customer Care at 541-229-4842 if you have questions and want to learn about your benefits. They can help you with what you need.
A primary care provider is who you will see for regular visits, prescriptions and care. You can pick one, or we can help you pick one.
Primary care providers (PCPs) can be doctors, nurse practitioners and more. You have a right to choose a PCP within the UHA network. If you do not pick a provider within 90 days of becoming a member, UHA will assign you to a clinic or pick a PCP for you. UHA will notify your PCP of the assignment and send you a letter with your provider’s information.
If at any time you want to change your PCP, call UHA Customer Care at 541-229-4842 or TTY 711. The change is effective the same day.
If you would like a copy of our PCP Assignment Policy, including information on changing PCPs, please call UHA Customer Care. We will mail you a copy, free of charge, within five (5) business days.
There is a limit to your freedom of choice of our in-network PCPs. Some PCPs are not accepting new patients. UHA is also unable to assign to PCPs that are not in our coverage area. Your PCP will work with you to help you stay as healthy as possible. They keep track of all your basic and specialty care needs. Your PCP will:
Get to know you and your medical history.
Provide your medical care.
Keep your medical records up-to-date and in one place.
Help you get free interpreters, written translations, auxiliary aids, and reasonable modifications.
Your PCP will refer you to a specialist or admit you to a hospital if needed.
Each member of your family on OHP must pick a PCP. Each person can have a different PCP.
Don’t forget to ask UHA about a dentist, mental health provider, and pharmacy.
Primary care dentist: Each member must have a primary care dentist. Advantage Dental Services will assign you a PCD, or you can pick one. Your PCD manages your dental care and sends you to specialists if needed. To change your PCD, call Advantage Dental Services at 866-268-9631 (TTY 711). The change is effective the same day.
Your PCD is important because they:
Are your first contact when you need dental care.
Manage your dental health services and treatments.
Arrange your specialty care.
Pharmacy: You may choose any in-network retail or mail-order pharmacy. A list is
available in the Provider Directory at https://providerdirectory.uhaweb.com/ClientApp/pharmacies. You can change pharmacies at any time.
Mental Health Provider: UHA does not assign members to a mental health provider. You do not need a referral to get services from an in-network behavioral health provider. To find one, see UHA’s Provider Directory at https://providerdirectory.uhaweb.com/ClientApp/providers or call UHA Customer Care at 541-229-4842
Please call Customer Care at 541-229-4842 Monday through Friday, 8:00 a.m. to 5:00 p.m. (TTY 711) if you would like to change your PCP, PCD or other providers. You can start seeing your new providers on the day this change is made.
In-network providers UHA works with some providers, but not all of them. Providers that we work with are called in-network or participating providers.
Providers we do not work with are called out-of-network providers. You may be able to see out-of-network providers if needed, but they must work with the Oregon Health Plan.
You may be able to see an out-of-network provider for primary care if:
You are switching CCOs or move from OHP fee-for-service to a CCO (see pages 97-98)
You are American Indian or Alaskan Native (see page 28)
You can choose your PCP, PCD or other providers from the provider directory at: https://providerdirectory.uhaweb.com/ClientApp/providers. You can also call UHA Customer Care for help finding a provider.
Here are examples of information you can find in the Provider Directory:
If a provider is taking new patients.
Provider type (medical, dental, behavioral health, pharmacy, etc).
How to contact them.
Video and phone care (telehealth) options.
Language help (including translations and interpreters).
Modifications for people with disabilities.
You can get a paper copy of the directory. You can get it in another format (such as other languages, large print, or Braille) for free. Call Customer Care at 541-229-4842.
You can make an appointment with your provider as soon as you pick one. Your PCP should be your first call when you need care. They will make an appointment or help you decide what kind of care you need. Your PCP can also refer you to other covered services or resources. Call them directly to make an appointment.
If you are new to your PCP, make an appointment for a check-up. This way they can learn about you and your medical history before you have an issue or concern. This will help you avoid any delays the first time you need to use your benefits.
Before your appointment, write down:
Questions you have for your PCP or other providers.
History of family health problems.
Prescriptions, over-the-counter medications, vitamins or supplements you take.
Call for an appointment during office hours and tell them:
You are a UHA member.
Your name and UHA ID number.
What kind of appointment you need.
If you need an interpreter and the language you need.
Let them know if you are sick and need to see someone that day.
You can get a free ride to your appointment. Learn more about free rides to care on page 76.
Missed appointments Try not to miss appointments. If you need to miss one, call your PCP and cancel right away. They will set up another visit for you. If you don’t tell your provider’s office ahead of time, they may not agree to see you again.
Each provider has their own rules about missed appointments. Ask them about their rules.
Changing your PCP You can change your PCP at any time. If at any time you want to change your PCP, call UHA Customer Care at 541-229-4842 or TTY 711. The change is effective the same day. You may also email us requesting to change at UHCustomerCare@umpquahealth.com. Your PCP choice is guided by UHA’s PCP Assignment Policy, which is based on state rules and UHA procedures. The policy makes sure you always have a provider for your regular care, prescriptions, and referrals. UHA will assign you a PCP if you do not choose one within 90 days, but you can request a different PCP whenever you want. Some PCPs may not be taking new patients.
Changes to UHA providers We will tell you when one of your regular providers stops working with UHA. You will get a letter 30 days before the change happens. If this change was already made, we will send you a letter within 15 days after the change.
Second opinions You have the right to get a second opinion about your condition or treatment. We will arrange your second opinion at no cost to you.
If the provider is in our network: You do not need a referral or prior approval.
If the provider is outside our network: Prior approval from UHA is required, and your Primary Care Provider (PCP) may need to send a referral.
If you need help finding a provider for a second opinion, contact UHA Customer Care.
Shortly after you enroll and if you have a health related change UHA may send you a survey about your health. The survey asks about your general health with the goal of helping reduce risks, keep you healthy, and prevent disease.
You can complete the survey by mailing it in or completing it over the phone. You can also view the survey online https://www.umpquahealth.com/?swp_form%5Bform_id%5D=1&s=HRA. Call UHA Customer Care at 541-229-4842 or TTY 711 and ask to have a Care Coordination team member help you complete it.
The survey asks questions about your general health with the goal of helping reduce health risks, maintain health, and prevent disease.
The survey asks about:
Your access to food and housing.
Your habits (like exercise, eating habits, and if you smoke or drink alcohol).
How you are feeling (to see if you have depression or need a mental health provider).
Your general well-being, dental health and medical history.
Your primary language.
Any special health care needs, such as high-risk pregnancy, chronic conditions, behavioral health disorders, and disabilities, modifications needed, etc.
If you want support from a care coordination team.
Your answers help us find out:
If you need any health exams, including eye or dental exams.
If you have routine or special health care needs.
Your chronic conditions.
If you need long-term care services and supports
Safety concerns.
Difficulties you may have with getting care.
If you need extra help with Care Coordination. See page 37 for Care Coordination.
A care coordination team member will look at your survey. They will call you to talk about your needs and help you understand your benefits.
If we do not get your survey, we will reach out to help make sure it is completed within 90 days of enrollment, or sooner if needed. If you want us to send you a survey you can call UHA Customer Care at 541-229-4842, and we will send you one.
Your survey will be shared with your doctor or other providers to reduce how many times you are asked these questions. Sharing your survey also helps coordinate your care and services.
If you are pregnant, OHP provides extra services to help keep you and your baby healthy. When you are pregnant, UHA can help you get the care you need. It can also cover your delivery and your care for one year after your pregnancy. We will cover after pregnancy benefits for a full year, no matter how the pregnancy ends.
Here’s what you need to do when you find out you’re pregnant:
Tell OHP that you’re pregnant as soon as you know. Call 800-699-9075 (TTY 711) or login to your online account at ONE.Oregon.gov.
Tell OHP your due date. You do not have to know the exact date right now. If you are ready to deliver, call us right away.
Ask us about your pregnancy benefits. UHA offers case management for pregnant women. There are two programs to help, maternity case management and New Day. After the baby is born, UHA also has a program called New Beginnings for children birth to age five. For more information about these programs, see pages 34-35.
Pregnancy Care Options For a list of in-network THW Doula and Midwives in our area, visit portal.umpquahealth.com/ClientApp/providers. You can search by the languages they speak. To contact our Doula Innovator Agent, you can call UHA Customer Care. You can also email us at UHNProviderServices@umpquahealth.com.
After your pregnancy ends:
Call OHP to let them know your pregnancy has ended. You can also ask the hospital to send a newborn notification to OHP. OHP will cover your baby from birth. Your baby will also have UHA.
Get a free nurse home visit with Family Connects Oregon. It is a nurse home visiting program that is free for all families with newborns. A nurse will come to you for a check-up, newborn tips, and resources.
Maternity Case Management is a service of Umpqua Health Alliance for moms in Douglas County on the Oregon Health Plan. They work together with you, your OB doctor and other community providers and agencies to offer support and resources.
Maternity Case Management can help with:
Evaluating your needs.
Connection with an OB/GYN.
Making and keeping your appointments.
Transportation.
Connection to resources.
Additional support.
Are you pregnant and unsure what to do next? Most importantly, see a doctor. You can:
Call your PCP and get a referral.
Call your OB/GYN to make an appointment.
Call UHA Customer Care at 541-229-4842 or TTY 711 and ask for help.
Ask your counselor, case manager, or any community partner for help.
Call to make a self-referral.
Referrals for Maternity Case Management can be sent to UHA Case Management by phone, email or fax.
Office: 541-229-4842 or TTY 711
Email: CaseManagement@umpquahealth.com
Fax: 541-229-8180
New Day is a service of Umpqua Health Alliance for moms in Douglas County on the Oregon Health Plan. They help pregnant women with substance use or other challenges. They work together with you, your OB doctor, and other community providers and agencies to offer support and resources.
The New Day staff can help with:
Evaluating your needs, such as your social, cultural, or health needs
Emotional support.
Counseling.
Buprenorphine Medication Assisted Therapy (MAT).
Methadone/Suboxone plan.
Drug treatment options.
Stop smoking.
Making and keeping your appointments.
Finding resources.
Substance Use During Pregnancy: A lot of things can cause problems for babies before and after they are born. Sometimes those problems last a lifetime. Smoking, alcohol, substance use, marijuana, unsafe housing, poor nutrition, domestic violence, and stress are harmful to pregnant women and their children. The New Day program can help you deal with these things. Even small changes can make a BIG difference.
If you are currently using opiates like heroin or pain pills, or in a methadone or Suboxone program, they can work with a doctor who specializes in Medication-Assisted Treatment (MAT) to help you get through your pregnancy safely. You want a healthy baby, and we want to help get you there.
Our Staff: The New Day program is led by Mandy Rigsby, BA, CCM, NCAC II, CADC II, CGAC I, IMH-E.
Referrals to New Day can be sent to UHA Care Coordination by phone, email, or fax. Arrangements can also be made for a meeting place in the community.
Office: 541-229-4842 or TTY 711
Email: CaseManagement@umpquahealth.com
Referral Fax: 541-229-8180
New Beginnings is a program offered by Umpqua Health Alliance for Oregon Health Plan members in Douglas County. We focus on children birth to age five. We work with the child, family, care providers, and community partners to offer support and resources. The New Beginnings staff create and strengthen partnerships so you can use community resources. This includes:
Counseling
Primary care physicians
Family development centers
Child Advocates
Abuse prevention services
Early Intervention Specialists
Schools and childcare services
Hospitals
Housing and food assistance programs
Women, Infants and Children (WIC)
Dentists
Transportation needs
The Early Years: The first few years of a child’s life are important for the physical and social development of that child. Children in poverty or who lack stable housing and healthy foods can have a hard time coping.
Every parent wants what is best for their child, and that’s where New Beginnings can help. Together, through coordinated care, each child’s unique needs will be identified and addressed. New Beginnings will also help parents create a solid foundation for Douglas County children to grow and thrive.
Do you have a young child? Most importantly, go to well child visits. You can also:
Call your child’s doctor to make an appointment
Call UHA Customer Care at 541-229-4842 (TTY 711)
Ask your counselor, case manager or any community partner for help
Call New Beginnings
Referrals to New Beginnings can be sent to UHA Care Coordination by phone, email, or fax.
Office: 541-229-4842 or TTY 711
Email: CaseManagement@umpquahealth.com
Fax: (541) 229-8180
e want to prevent health problems before they happen. You can make this an important part of your care. Please get regular health and dental checkups to find out what is happening with your health.
Some examples of preventive services:
Shots for children and adults
Dental checkups and cleanings
Mammograms (breast X-rays)
Pap smear
Pregnancy and newborn care
Exams for wellness
Prostate screenings for men
Yearly checkups
Well-child exams
A healthy mouth also keeps your heart and body heathier.
If you have any questions, please call us at 541-229-4842 or 711 (TTY).
UHA can help organize your care. UHA has staff that are part of your care coordination team. UHA staff are committed to supporting members with their care needs and can assist you with finding physical, dental, behavioral, developmental, and social health care where and when you need it.
Developmental health care includes services that help with growth and development, such as early intervention, speech therapy, occupational therapy, and services for children with developmental delays.
Social health care includes services that support your well-being outside of a clinic, such as help with housing, food, transportation, utilities, parenting support, or connections to community resources.
You may get Care Coordination from your patient-centered primary care home (PCPCH), primary care provider, UHA, or other primary care teams. You, your providers or someone speaking on your behalf can ask about Care Coordination for any reason, especially if you have a new care need or your needs are not being met. You can call the number below or visit https://www.umpquahealth.com/members/benefits-programs/care-coordination/ for more information about Care Coordination.
Care Coordination’s goal is to make your overall health better.
UHA must have processes in place that help us find your health care needs. We will help you take charge of your health and wellness.
Your care coordination team will:
Help you understand your benefits and how they work.
Work with you in your preferred language.
Use care programs to help you manage chronic health conditions such as diabetes, heart disease and asthma.
Help with behavioral health issues including depression and substance use disorder.
Help with finding ways to get the right services and resources to make sure you feel comfortable, safe, and cared for.
Help you identify people in your life or community that can be a support.
Help you pick a primary care provider (PCP).
Provide care and advice that is easy to follow.
Help with setting up medical appointments and tests.
Help you set up transportation to your doctor appointments.
Help transition your care when needed.
Help you get care from specialty providers.
Help make sure your providers talk to each other about your health care needs.
Create a care plan with you that meets your health needs.
Your care coordination team can help you find and access other resources in your community, like help for non-medical needs. Some examples are:
Help with finding housing.
Help with rent and utilities.
Nutrition services.
Rides.
Trainings and classes.
Family support.
Social services.
Devices for extreme weather conditions.
Working together for your care Your care coordination team will work closely with you. This team will have different people who will work together to meet your needs, like providers, specialists and community programs you work with. The team will connect you with community and social support resources that may help you. Your care team’s job is to make sure the right people are part of your care to help you reach your goals. We will all work together to support you.
You may need a care plan
You and your care team will decide if a care plan is needed. This plan will help meet your needs and is made with you, your care team and providers. Your plan will list supports and services needed to help you reach your goals. This plan addresses medical, dental, cultural, developmental, behavioral and social needs so you have positive health and wellness results.
The plan will be reviewed and updated at least annually, as your needs change, or if you ask for a review and update. You, your representative and your providers get a copy of your care plan.
You, an authorized representative or provider can request a copy of your care plan or request development of a Care Plan by calling UHA Customer Care at 541-229-4842 or TTY 711 and asking for Care Coordination.
Care Coordination hours and contact information Care Coordination services are available Monday through Friday 8:00 a.m. to 5:00 p.m.
Call UHA Customer Care at 541-229-4842 or TTY 711 to get more information about Care Coordination.
Let UHA know if there is a change in your health, needs or who you are working with so UHA can help coordinate your care.
When you are enrolled in Care Coordination, UHA will give you or your representative the name and phone number of who, from your Care Coordination team, is primarily responsible for coordinating your care.
If your Care Coordinator changes, UHA will send you a letter with information how to contact your new Care Coordinator. You may also receive a call from them.
Members with Medicare You can also get help with your OHP and Medicare benefits. A staff member from UHA care coordination team works with you, your providers, your Medicare Advantage plan and/or your caregiver. We partner with these people to get you social and support services, like culturally specific community-based services.
UHA has a group called a System of Care to remove barriers that youth (aged 0 – 25) with complex needs may face. The group brings together youth and families, providers and system partners from behavioral health, intellectual/developmental disability services, education, child welfare and juvenile justice.
If you are a parent/guardian of a youth with complex needs, or a young adult served by multiple systems, UHA’s System of Care may help you get care and remove barriers. To learn more or to get in touch with UHA’s System of Care, call UHA Customer Care at 541-229-4842 or TTY 711, or email us at UHCustomerCare@umpquahealth.com
You can also learn more via the System of Care Advisory Council at https://www.oregon.gov/oha/hsd/bh-child-family/pages/socac.aspx.
Many services are available to you as an OHP member. How Oregon decides what services to pay for is based on the Prioritized List of Health Services. This list is made up of different medical conditions (called diagnoses) and the types of procedures that treat the conditions. A group of medical experts and ordinary citizens work together to develop the list. This group is called the Oregon Health Evidence Review Commission (HERC). They are appointed by the governor.
The list has combinations of all the conditions and their treatments. These are called condition/treatment pairs.
The condition/treatment pairs are ranked on the list by how serious each condition is and how effective each treatment is.
For members age 21 and older:
Not all condition and treatment pairs are covered by OHP. There is a stopping point on the list called “the line” or “the funding level.” Pairs above the line are covered, and pairs below the line are not. Some conditions and treatments above the line have certain rules and may not be covered.
For members under age 21:
All medically necessary and medically appropriate services must be covered, based on your individual needs and medical history. This includes items “below the line” on the Prioritized List as well as services that don’t appear on the Prioritized List, like Durable Medical Equipment. See page 67 for more information on coverage for members under 21.
Learn more about the Prioritized List at:
https://www.oregon.gov/oha/hsd/ohp/pages/prioritized-list.aspx
Direct Access You do not need a referral or preapproval for some services. This is called direct access. See the charts below for services that are direct access and do not need a referral or preapproval.
See the Benefits Charts on pages 44-59 for more information.
Some services, like surgery or inpatient services, need approval before you get them. This is to make sure that the care is medically needed and right for you. Your provider will take care of this, and may submit information to us to support you getting the service. Even if the provider is not required to send us information, UHA may still need to review your case for medical reasons.
You should know that these decisions are based only on whether the care or service is right for you and if you are covered by UHA. UHA does not reward providers or any other persons for issuing denials of coverage or care. Extra money is never given to anyone who makes a decision to say no to a request for care. Contact UHA Customer Care at 541-229-4842 if you:
Have questions
Need to reach our Utilization Management Department
Need a copy of the clinical guidelines
You might not get the service if it is not approved. We review preapproval requests as quickly as your health condition requires. Most service decisions are made within 7 days. Sometimes a decision may take up to 21 days. This only happens when we are waiting for more information. If you or your provider feel following the standard time frame puts your life, health or ability to function in danger, we can make a faster decision called an “expedited service authorization”. Expedited service decisions are typically made within 72 hours, but there may be a 14-day extension. You have the right to complain if you don’t agree with an extension decision. See page 107 for how to file a complaint.
If you need a preapproval for a prescription, we will make a decision within 24 hours. If we need more information to make a decision, it can take 72 hours.
See page 82 to learn about prescriptions.
You do not need approval for emergency or urgent services or for emergency aftercare services. See page 86 to learn about emergency services.
See the Benefits Charts on pages 44-59 for more information.
For you to get care from the right provider a referral might be needed. A referral is a written order from your provider noting the need for a service.
For example: If your PCP cannot give you services you need, they can refer you to a specialist. If preapproval is needed for the service, your provider will ask UHA for approval.
If there is not a specialist close to where you live or a specialist who works with UHA (also called in-network), they may have to work with the Care Coordination team to find you care out-of-network. To see an out-of-network provider, they must work with the Oregon Health Plan. There is no extra cost if this happens.
A lot of times your PCP can perform the services you need. If you think you might need a referral to a health care specialist, ask your PCP. You do not need a referral if you are having an emergency.
See the Benefits Charts on pages 44-59 for more information.
Some services do not need a referral from your provider. This is called a self-referral. A self-referral means you can look in the provider directory to find the type of provider you would like to see. You can call that provider to set up a visit without a referral. Learn more about the Provider Directory on page 30.
See the Benefits Charts on pages 44-59 for more information.
Preapproval may still be needed for a service when you use self-referral. Talk with your PCP or contact Customer Care if you have questions about if you need a preapproval to get a service.
Physical health benefits See below for a list of medical benefits that are available to you at no cost. Look at the “Service” column to see how many times you can get each service for free. Look At the “How to access” column to see if you need to get a referral or preapproval for the service. UHA will coordinate services for free if you need help.
For a summary of OHP benefits and coverage, please visit OHP.Oregon.gov/Benefits. You can get a paper or electronic copy of the summary by calling 800-273-0057.
If you see an * in the benefit charts, this means a service may be covered beyond the limits listed for members under 21 if medically necessary and appropriate.
The table above is not a full list of services that need preapproval or referral. If you have questions, please call UHA Customer Care at 541-229-4842.
Behavioral health care benefits See below for a list of behavioral health benefits that are available to you at no cost. Behavioral health means mental health and substance use treatment. Look at the “Service” column to see how many times you can get each service for free. Look At the “How to access” column to see if you need to get a referral or preapproval for the service.
If you see an * in the benefit charts, this means a service may be covered beyond the limits listed for members under 21 if medically necessary and appropriate. UHA will coordinate services for free if you need help.
The table above is not a full list of services that need preapproval or referral. If you have questions, please call UHA Customer Care at 541-229-4842.
All Oregon Health Plan members have dental coverage. OHP covers annual cleanings, x-rays, fillings, and other services that keep your teeth healthy.
Healthy teeth are important at any age. Here are some important facts about dental care:
Can help prevent pain.
Healthy teeth keep your heart and body healthy, too.
You should see your dentist once a year.
When you’re pregnant, keeping your teeth and gums healthy can protect your baby’s health.
Fixing dental problems can help you control your blood sugar.
Children should have their first dental check-up by age 1.
Infection in your mouth can spread to your heart, brain and body.
Your primary care dentist (PCD) may refer you to a specialist for certain types of care. Types of dental specialists include:
Endodontists (for root canals)
Pedodontist (for adults with special needs, and children)
Periodontist (for gums)
Orthodontist (in extreme cases, for braces)
Oral surgeons (for extractions that require sedation or general anesthesia).
Please see the table below for what dental services are covered. All covered services are free. These are covered as long as your provider says you need the services. Look at the “Service” column to see how many times you can get each service for free. Look At the “How to access” column to see if you need to get a referral or preapproval for the service. If you see an * in the benefit charts, this means a service may be covered beyond the limits listed for members under 21 if medically necessary and appropriate.
The table above is not a full list of services that need preapproval or referral. If you have questions, please call Customer Care at 541-229-4842.
If you are a member of the Veteran Dental Program or COFA Dental Program (“OHP Dental”), UHA only provides dental benefits and free rides (NEMT) to dental appointments.
OHP and UHA do not provide access to physical health or behavioral health services or free rides for these services.
If you have questions regarding coverage and what benefits are available contact Customer Care at 541-229-4842.
OHP Bridge is a new benefit package that covers adults with higher incomes. OHP Bridge is free. People who can get OHP Bridge must:
Be 19 to 64 years old;
Have an income between 138 percent and 200 percent of the federal poverty level (FPL);
Have an eligible citizenship or immigration status to qualify; and,
Not have access to other affordable health insurance.
If you report a higher income when you renew your OHP, you may be moved to OHP Bridge. Learn more about OHP Bridge at https://www.oregon.gov/oha/hsd/ohp/pages/bridge.aspx.
OHP Bridge is almost the same as OHP Plus. There are a few things that OHP Bridge does not cover, including:
Long-term services and supports (LTSS)
Health related social needs (HRSN)
Health-Related Social Needs (HRSN) are social and economic needs that affect your ability to be healthy and feel well. These services help members who are facing major life changes. Get more information at: https://www.oregon.gov/OHA/HSD/Medicaid-Policy/Pages/HRSN.aspx
Please ask UHA to see what free HRSN benefits are available. HRSN benefits include:
Housing services:
Help with rent and utilities to keep your housing.
Help with other services to support you as a tenant.
Home changes for health such as air conditioners, heaters, air filtration devices, portable power supplies and mini-refrigerators.
Nutrition services:
Help with nutrition education and medically tailored meals. The pantry stocking, and fruit and vegetable benefits are planned to start Summer 2026.
Outreach and engagement services:
Get help connecting to other resources and supports.
You may be able to get some or all of the HRSN benefits if you are an OHP Member, and:
Have recently left or are leaving incarceration (jail, detention, etc.).
Have recently left or are leaving a mental health or substance use recovery facility.
Have been in the Oregon child welfare system (foster care) now or in the past.
Are going from Medicaid-only benefits to qualifying for Medicaid and Medicare.
Have a household income that’s 30% or less of the average yearly income where you live, and you lack resources or support to prevent homelessness.
Are a young adult with special health care needs.
You must also meet other criteria. For questions or to be screened, please contact UHA. UHA can help you to see if you qualify for any of these benefits.
Please note that to be screened and to get HRSN benefits, your personal data may be collected and used for referrals. You can limit how your information is shared.
HRSN benefits are free to you and you can opt out at any time. If you get HRSN benefits, your care coordination team will work with you to make sure your care plan is updated. See page 37 for Care Coordination and care plans.
If you are denied HRSN benefits, you have the right to appeal that decision. See pages 107-114 for more about denials and appeals.
Important Notes:
Rides to care cannot be used for HRSN services.
OHP Bridge does not cover HRSN Services.
HRSN services may take up to six weeks to be approved and delivered.
In Lieu of Services (ILOS)
UHA offers services or settings that are medically appropriate alternatives to services covered by OHP. These are called “in lieu of services” (ILOS). They are offered as helpful options for members. UHA has contracted with Oregon Wellness Network (OWN) to offer the following ILOS:
Diabetes Self-Management Education & Support (DSMES)
These services are designed for members with diabetes. There are two parts to this program:
Online training, support, and help given by a trained diabetes educator or lifestyle coach.
Individual or group sessions that meet each week for six weeks. These services aim to help you manage your diabetes and promote healthy habits.
National Diabetes Prevention Program (National DPP)
A Centers for Disease Control (CDC) recognized online program offered by the National Diabetes Prevention Program (National DPP). This is a year-long program that helps members:
Lose weight.
Adopt healthier habits.
Help reduce their risk of type 2 diabetes.
Deciding if an ILOS is right for you is a team effort. We work with your care team to make the best choice. The choice, however, is yours. You do not have to take part in any of these programs. If you have any questions about any of the benefits or services above, call UHA Customer Care at 541-229-4842 or TTY 711. If an ILOS is no longer going to be offered, UHA will let you know by mail at least 30 days before the change happens. Members have a right to file an appeal, or a grievance, for covered services that are fully or partially denied. For more information on appeals and grievances, please see pages 107-114
UHA pays for your care, but there are some services that we do not pay for. These are still covered and will be paid by the Oregon Health Plan’s Fee-For-Service (open card) program. CCOs sometimes call these services “non-covered” benefits. There are two types of services OHP pays for directly:
Services where you get care coordination from UHA.
Services where you get care coordination from OHP.
Services with UHA care coordination
UHA still gives you care coordination for some services. Care coordination means you will get free rides from Bay Cities Brokerage (BCB) for covered services, support activities and any resources you need for non-covered services.
Contact UHA for the following services:
Planned Community Birth (PCB) services include prenatal and postpartum care for people experiencing low risk pregnancy as determined by the OHA Health Systems Division. OHA is responsible for providing and paying for primary PCB services including at a minimum, for those members approved for PCBs, newborn initial assessment, newborn bloodspot screening test, including the screening kit, labor and delivery care, prenatal visits and postpartum care.
Long term services and support (LTSS) not paid by UHA
Family Connects Oregon services, which provides support for families with newborns. Get more information at https://www.familyconnectsoregon.org/.
Helping members to get access to behavioral health services. Examples of these services are:
Certain medications for some behavioral health conditions
Therapeutic group home payment for members under 21 years old
Long term psychiatric (behavioral health) care for members 18 years old and older
Personal care in adult foster homes for members 18 years and older
For more information or for a complete list about these services, call Care Management at 541-229-4842 or Customer Care at 541-229-4842.
Services that OHP pays for and provides care coordination
Contact OHP for the following services:
Comfort care (hospice) services for members who live in skilled nursing facilities
School-based services that are provided under the Individuals with Disabilities Education Act (IDEA). For children who get medical services at school, such as speech therapy.
Medical exam to find out if you qualify for a support program or casework planning
Services provided to Healthier Oregon Program members
Abortions and other procedures to end pregnancy
Doctor aided suicide under the Oregon Death with Dignity Act and other services
Contact OHP’s Acentra Care Coordination team at 800-562-4620 for more information and help with these services.
You can still get a free ride from BCB for any of these services. See page 76 or more information. Call BCB at 877-324-8109 to schedule a ride or ask questions.
UHA does not limit services based on moral or religious objections. There may be some providers within our network that might have moral or religious objections. Please reach out to us at 541-229-4842 or TTY 711 if you have questions about this. We can help you find a provider who can provide the service.
Access means you can get the care you need. You can get access to care in a way that meets your cultural and language needs. UHA will make sure that your care is coordinated to meet your access needs. See pages 38-40 for more information about Care Coordination. If UHA does not work with a provider who meets your access needs, you can get these services out-of-network. UHA makes sure that services are close to where you live or close to where you want care. This means that there are enough providers in the area and there are different provider types for you to pick from.
We keep track of our network of providers to make sure we have the primary care and specialist care you need. We also make sure you have access to all covered services in your area.
UHA follows the state’s rules about how far you may need to travel to see a provider. The rules are different based on the provider you need to see and the area you live in. Primary Care Providers are “Tier 1”, meaning they will be closer to you than a specialist like Dermatology, who is “Tier 3 If you live in a remote area, it will take longer to get to a provider than if you live in an urban area. If you need help with transportation to and from appointments, see page 76.
The chart below lists the tiers of providers and the time (in minutes) or distance (in miles) of where they are located based on where you live.
For more information about what providers fall into the different tiers, go to OHA’s Network Adequacy website at: https://www.oregon.gov/oha/HSD/OHP/Pages/network.aspx Not sure what kind of area you live in? See the map on the next page:
Figure 1: Map of geographic regions in Oregon as defined for network adequacy. Area distinctions include: Large Urban, Urban, Rural, and County with Extreme Access Considerations (CEAC).
Our providers will also make sure you will have physical access, reasonable accommodations and accessible equipment if you have physical and/or mental disabilities. Contact UHA at 541-229-4842 to request accommodations. Providers also make sure office hours are the same for OHP members and everyone else.
We work with providers to make sure that you will be seen, treated or referred within the times listed below:
* For specialty behavioral healthcare services if there is no room or open spot:
You will be put on a waitlist.
You will have other services given to you within 72 hours.
These services will be temporary until there is a room or an open spot.
If you have any questions about access to care, call Customer Care at 541-229-4842 or TTY 711.
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program provides comprehensive and preventive health care services for OHP members from birth to age 21. This program provides you with the care you need for your health and development. These services can catch and help with concerns early, treat illness, and support children with disabilities.
You do not have to enroll separately in EPSDT; if you are under age 21 and enrolled in OHP you will receive these benefits. Starting in 2025 Young Adults with Special Health Care Needs (ages 19 through 25) may also qualify for EPSDT benefits. Contact UHA for more information.
Any services needed to find or treat illness, injury, or other changes in health.
“Well-child” or “adolescent well visit” medical exams, screenings, and diagnostic services to determine if there are any physical, oral/dental, developmental and mental health conditions for members under age 21.
Referrals, treatment, therapy, and other measures to help with any conditions discovered.
For members under age 21, UHA has to give:
Regularly scheduled examinations and evaluations of physical, mental and behavioral health, developmental, oral/dental health, growth, and nutritional status.
If your UHA doesn’t cover oral/dental health, you can still get these services through OHP by calling 1-800-273-0557.
All medically necessary and medically appropriate services must be covered for members under 21, regardless of whether it was covered in the past (this includes things that are “below the line” on the Prioritized List). To learn more about the Prioritized list, see page 44.
Under EPSDT, UHA will not deny a service without first looking at whether it is medically necessary and medically appropriate for you.
Medically necessary generally means a treatment that is required to prevent, diagnose or treat a condition, or to support growth, development, independence, and participation in school.
Medically appropriate generally means that the treatment is safe, effective, and helps you participate in care and activities. UHA may choose to cover the least expensive option that will work for you.
You should always receive a written notice when something is denied, and you have the right to an appeal if you don’t agree with the decision. For more information, see page 107-114.
This includes all services:
Physical Health;
Behavioral Health ;
Dental Health;
Vision; and,
Social Health Care Needs.
If you or your family member needs EPSDT services, work with your primary care provider (PCP) or talk to a care coordinator by calling 541-229-4842 or TTY 711. They will help you get the care you need. If any services need approval, they will take care of it. Work with your primary care dentist for any needed dental services. All EPSDT services are free.
Call Customer Care at 541-229-4842 or TTY 711
Call Advantage Dental Services at 866-268-9631 to set up dental services or for more information.
You can get free rides to and from covered EPSDT provider visits. Call BCB at 877-324-8109to set up a ride or for more information.
You can also ask your PCP or visit our website at:https://www.umpquahealth.com/services/#well-child-resourcesfor a copy of the periodicity schedule. This schedule tells you when children need to see their PCP.
Covered screening visits are offered at age-appropriate intervals (these include well child visits or adolescent well visits). UHA and your PCP follows the American Academy of Pediatrics and Bright Futures guidelines for all preventive care screenings and well child visits. Bright Futures can be found at: https://www.aap.org/brightfutures. You can use the Well Visit Planner at https://www.wellvisitplanner.org to prepare for these check-ups.
Your PCP will help you get these services and treatment when required by the guidelines.
Screening visits include:
Developmental screening.
Lead testing:
Children must have blood lead screening tests at age 12 months and 24 months. Any child between ages 24 and 72 months with no record of a previous blood lead screening test must get one.
Completion of a risk assessment questionnaire does not meet the lead screening requirement for children in OHP. All children with lead poisoning can get follow up case management services.
Other needed laboratory tests (such as anemia test, sickle cell test, and others) based on age and risk.
Assessment of nutritional status.
At each visit, age-appropriate physical examination is essential, with infant totally unclothed and older children undressed and suitably draped.
Full health and development history (including review of both physical and mental health development).
Immunizations (shots) that meet medical standards:
Child Immunization Schedule (birth to 18 years):
https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
Adult Immunization Schedule (19+):
https://www.cdc.gov/vaccines/imz-schedules/adult-easyread.html
Health guidance and education for parents and children.
Referrals for medically necessary physical and mental health treatment.
Needed hearing and vision tests.
And others.
Covered visits also include unscheduled check-ups or exams that can happen at any time because of illness or a change in health or development.
Your primary care provider may refer you if they find a physical, mental health, substance abuse, or dental condition. Another provider will help with more diagnosis and/or treatment.
The screening provider will explain the need for the referral to the child and parent or guardian. If you agree with the referral, the provider will take care of the paperwork.
UHA or OHP will also help with care coordination, as needed.
Screenings may find a need for the following services, as well as others:
Diagnosis of and treatment for impairments in vision and hearing, including eyeglasses and hearing aids.
Dental care, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health.
Immunizations (if it is determined at the time of screening that immunization is needed and appropriate to provide at the time of screening, then immunization treatment must be provided at that time.).
These services must be provided to eligible members under 21 years old who need them. Treatments that are “below the line” on the Prioritized List of Health Services are covered for members under 21 if they are medically necessary and medically appropriate for that member (see more information above).
If we tell you that the service is not covered by OHP, you still have the right to challenge that decision by filing an appeal and asking for a hearing. See pages 107-114.
UHA will give referral help to members or their representatives for social services, education programs, nutrition assistance programs, and other services.
For more information about EPSDT coverage, you can visit www.Oregon.gov/EPSDT and view a member fact sheet. UHA also has information at www.umpquahealth.com/services.
Young Adults with Special Health Care Needs
Young Adults with Special Health Care Needs (YSHCN) is a new program that gives extra OHP benefits to people ages 19 through 21 who have certain health conditions. The health conditions must have started before age 19. Examples of health conditions are:
Physical, intellectual and developmental disabilities
Long-standing medical conditions like asthma, diabetes, or spina bifida
Behavioral or mental health conditions like depression or substance use
OHP members who qualify for the program will automatically get YSHCN benefits. YSHCN benefits include:
More vision and dental services
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) up to their 26th birthday
Possible access to Health-Related Social Needs (HRSN) services
After 2026, the age limit will increase every year until 2030, when people up to age 25 can get YSHCN benefits.
Traditional Health Workers (THW) provide support and help with questions you have about your health care and social needs. They help with communication between your health care providers and other people involved in your care. They can also connect you with people and services in the community that can support you.
There are a few different kinds of traditional health workers:
Birth Doula: A person who helps people and their families with personal, non-medical support. They help through pregnancy, childbirth, and after the baby is born.
Community Health Worker (CHW): A community health worker understands the people and community where you live. They help you access health and community services. A community health worker helps you start healthy behaviors. They usually share your ethnicity, language, or life experiences.
Personal Health Navigator (PHN): A person who gives information, tools, and support to help you make the best decisions about your health and wellbeing, based on your situation.
Peer Support Specialist (PSS): Someone who has life experiences with mental health and/or addiction and recovery. A PSS may also have been a support to a family member with mental health concerns and/or receiving addiction treatment. They give support, encouragement, and help to those facing addictions and mental health issues.
Peer Wellness Specialist (PWS): A person who works as part of a health home team and speaks up for you and your needs. They support the overall health of people in their community and can help you recover from addiction, mental health, or physical conditions.
THW can help you with many things, like:
Working with you and your care coordinator to find a new provider.
Receiving the care you seek and need.
Connecting you with others to explain your benefits.
Providing information on mental health and/or addiction services and support.
Information and referral about community resources you could use.
Someone to talk to from your community.
Go to provider appointments with you.
Call our THW liaison to find out more about THWs and how to use their services.
UHNProviderServices@umpquahealth.com 541-229-4842 or TTY 711
If we change the contact information for the THW liaison, you can find up-to-date information on our website at www.umpquahealth.com/traditional-health-workers/
Flexible services are extra services UHA offers that are not regular OHP benefits. Flexible services help improve member and community health and well-being. Flexible services include services for members and community benefit initiatives for the larger community. Because flexible services are not regular OHP benefits and are optional for CCOs, members do not have appeal rights for flexible services the same way they do for covered services.
You can read our Flexible Services policy at https://www.umpquahealth.com/members/benefits-programs/health-related-services-flex-spending/.
Flexible services are items or services to help members stay healthy or become healthier. UHA offers these flexible services:
Care coordination
Health Education for members and community
Food services and supports
Housing services and supports
Items for living environment not otherwise covered
Transportation services and supports not otherwise covered
Trauma-informed services and supports
Non-covered services
Examples of other flexible services:
Food supports, such as grocery delivery, food vouchers, or medically tailored meals
Short-term housing supports, such as rental deposits to support moving costs, rent support for a short period of time, or utility set-up fees
Temporary housing or shelter while recovering from hospitalization
Items that support healthy behaviors, such as athletic shoes or clothing
Mobile phones or devices for accessing telehealth or health apps
Other items that keep you healthy, such as an air conditioner or air filtration device
Learn more about health-related services athttps://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le4329.pdf
How to get flexible services for you or family member You can work with your provider to request flexible services or you can call Customer Care at 541-229-4842 to get help requesting a flexible service.
You can also find the form on our website: www.umpquahealth.com/hrsflex/. Flexible services can be requested by both clinical and non-clinical staff on behalf of a member at any time. This includes:
Providers
Primary care teams
Specialists
Health care providers
Care Coordinators
Traditional Health Workers (such as patient navigators, community health workers, peer support specialists and doulas)
Community partners
Members
Family members or representatives
Flexible services are not a covered benefit for members and CCOs are not required to provide them. Decisions to approve or deny flexible services requests are made on a case-by-case basis.
Flexible service requests must meet all these rules:
Likely to improve your health.
Have no billing or encounter codes.
Be health related.
Be consistent with a care/treatment plan.
Likely to be a cost-effective option.
Have no other community resources are available.
To get flexible services, you need to give documents with your request. A few examples of what may be needed from you are:
A recent W9 for the person getting paid.
A bill or receipt showing what you owe.
Proof of how much money you make (from the last 60 days for everyone who lives with you)
Three (3) bids or estimates for repairs, if needed
Proof that you rent or own your home (like a lease)
Medical records or notes to support your qualifying health condition
A care or treatment plan from your provider or case manager
Evidence-based criteria, medical justification, or any additional documentation that the service or item will help your health outcomes.
Health Risk Assessment
We may need more papers to decide if you should get help.
For us to share your health information or to pay for things, you or your representative must sign a paper agreeing to this.
If your flexible service request is denied, you will get a letter explaining your options. You can’t appeal a denied flexible service but you have the right to make a complaint. Learn more about appeals and complaints on page 107.
If you have OHP and have trouble getting care, please reach out to the OHA Ombuds Program. The Ombuds are advocates for OHP members and they will do their best to help you. Please email OHA.OmbudsOffice@odhsoha.oregon.gov or leave a message at 877-642-0450.
Another resource for supports and services in your community is 211 Info. Call 2-1-1 or go to the www.211info.org website for help.
Community benefit initiatives are funding for programs and for the larger community, including CCO members, to improve community health and well-being.
Each year, UHA supports projects and programs that further our community health improvement plan (CHP). Examples of these community benefit initiatives are:
Community-based programs that help families access fresh fruits and veggies through farmers' markets.
Trainings on trauma informed practices.
Gardening opportunities for low income housing units.
Lifestyle Nutrition and Education classes.
And more!
Examples of other community benefit initiatives are:
Classes for parent education and family support
Community-based programs that help folks access fresh fruits and veggies through farmers markets
Community-based programs that help folks get into or maintain safe and stable housing.
Active transportation improvements, such as safe bicycle lanes and sidewalks
School-based programs that support a nurturing environment to improve students’ social-emotional health and academic learning
Training for teachers and child-specific community-based organizations on trauma informed practices
Oral Health Community Care We proudly support members getting oral health services in community settings. Advantage Dental sends dental hygienists with a special permit into schools, Women Infants Children (WIC), Head Start, Medical offices, long-term care facilities and other community locations to complete assessments. They also do some preventive services while they are there, like fluoride or silver fluoride and help people understand how to take care of their teeth.
In places where we don’t have a hygienist to do this, we work with other organizations. Services you have in the community should be free to you if they are covered on your plan. If you aren’t sure, you can ask the person who is doing the services or you can call Member Services.
Open Access Points In most regions in Oregon, we have special agreements with Federally Qualified Health Centers (FQHC), Rural Community Health Centers (RCHC). These special agreements allow our members to be seen in these types of facilities without being assigned to that facility and without a referral.
If you would like to have your oral health care done at one of these types of facilities, you can call the facility and ask if they work with Advantage Dental as an “Open Access Point”. You can also call Member Services and ask for a current list of Open Access Points in your region.
Free rides to care Free rides to appointments for all UHA members. If you need help getting to an appointment, call Bay Cities Brokerage (BCB) for a free ride.
You or your representative can ask for a ride. We may give you a bus ticket, money for a taxi, or have a driver pick you up. We may pay gas money to you, a family member, or a friend to drive you. There is no cost to you for this service. UHA will never bill you for rides to or from covered care.
You can ask Bay Cities Brokerage to pay you back for travel costs. To do this, call BCB tell them you want to request reimbursement. They will send you a reimbursement form by mail, fax, or email. Fill out the form with your trip details, the dates, and why you traveled. Be sure to attach receipts for the costs you want covered, such as gas, meals, or lodging if allowed.
When you are ready, send the form and receipts back to BCB using the mail, fax, or email listed on the form. Keep a copy of everything you send for your own records.
Bay Cities Brokerage will review your request
If it is approved, they will send you payment
Schedule a ride Call BCB at 877-324-8109 (TTY 711) Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. If calling after hours, there is a 24-hour hotline available. BCB’s call center is closed on the following holidays:
New Year’s Day
Memorial Day
Independence Day
Labor Day
Veteran’s Day
Thanksgiving
Christmas Day
Please call at least 2 business days before the appointment to schedule a ride. This will help make sure we can meet your ride needs.
You can get a same or next-day ride. Please call BCB.
You or someone you know can set up more than one ride at a time for multiple appointments. You can schedule rides for future appointments up to 90 days in advance.
What to expect when you call UHA has call center staff who can help with rides in your preferred language and in a way that you can understand. This help is free.
The first time you call we will tell you about the program and talk about your ride needs. We will ask about your physical ability and if you will need someone to travel with you.
When you call to schedule a ride, we will ask for:
Your full name.
Your address and phone number.
Your date of birth.
Name of the doctor or clinic you need to visit.
Date of appointment.
Time of appointment.
Pick-up time after appointment.
If you need an attendant to help you.
Any other special needs (like a wheelchair or service animal).
We will check to see if you are with UHA and if your appointment is for a service that’s covered. You will get more information about your ride within 24 hours. You will get information about your ride request in a way you choose (phone call, email, fax).
If you request a ride less than two (2) days before the scheduled pick-up time, we will give you the phone number of the company who will arrange for your pick up. We may also give you the name and phone number of the driver who will pick you up.
Pick up and drop off You’ll get the ride company or driver’s name and number before your appointment. Your driver will contact you at least 2 days before your ride to confirm details. They will pick you up at your scheduled time. Please be on time. If you are late, they will wait for 15 minutes after your scheduled time. That means if your ride is scheduled for 10 a.m., they will wait for you until 10:15 a.m.
They will drop you off for your appointment at least 15 minutes before it starts.
First appointment of the day: We will drop you off no more than 15 minutes before the office opens.
Last appointment of the day: We will pick you up no later than 15 minutes after the office closes, unless the appointment is not expected to end within 15 minutes after closing.
Asking for more time: You must ask to be picked up earlier or dropped off later than these times. Your representative, parent or guardian can also ask us.
Call if your driver has not arrived by 10 minutes after pickup time: If your driver has not arrived by 10 minutes after your scheduled pickup time, call the ride company. Staff will let you know if the driver is on their way. Drivers must tell the dispatcher before leaving from the pick-up location. Call your provider’s office to let them know your ride is late.
Call if you don’t have a pickup time: If there is no scheduled pickup time for your return trip, call us when you are ready. Your driver will be there within 1 hour after you call.
BCB is a shared ride program. Other passengers may be picked up and dropped off along the way. If you have several appointments, you may be asked to schedule on the same day. This will help us to make fewer trips.
You may ask to have a friend or family member drive you to the appointment. They can get reimbursed (paid) for the miles they drive. Learn more in UHA’s Rider Guide. Get the UHA’s Rider Guide at:https://www.umpquahealth.com/members/benefits-programs/get-a-ride/. You can also call Customer Care at 541-229-4842 to ask for a free paper copy.
You have the right to:
Get a safe and reliable ride that meets your needs.
Be treated with respect.
Ask for interpretation services when talking to Customer Care
Get materials in a language or format that meets your needs.
Get a written notice when a ride is denied.
File a complaint about your ride experience.
Ask for an appeal, ask for a hearing, or ask for both if you feel you have been denied a ride service unfairly.
Your responsibilities are to:
Treat drivers and other passengers with respect.
Call us as early as possible to schedule, change, or cancel a ride
Use seatbelts and other safety equipment as required by law (example: car seats).
Ask for any additional stops, like the pharmacy, in advance.
Call BCB when you know you need to cancel or reschedule your ride, at least 2 hours before the pick-up time.
You can call BCB Monday through Friday from 8:00 a.m. to 5:00 p.m. If you call after hours, you can leave a message. Contact BCB if you have questions or need to make changes to your ride.
When you don’t show up A “no-show” is when you aren’t ready to be picked up on time. Your driver will wait at least 15 minutes after the scheduled pick-up time before leaving. We may restrict your future rides if you have too many no-shows.
Having a restriction means we might limit the number of rides you can make, limit you to one driver, or require calls before each ride. If your ride is denied You will receive a call to let you know that your ride is denied. All denials are reviewed by two staff members before sent to you. If your ride is denied, we will mail you a denial letter within 72 hours of the decision. The notice states the rule and reason for the denial.
You can ask for an appeal with UHA if you do not agree with the denial. You have 60 days from the date of the denial notice to request an appeal. After the appeal, if the denial stands you also have the right to request a State hearing.
We will mail your provider a letter as well, if the provider is part of our provider network and they requested the transportation on your behalf.
You have the right to make a complaint or grievance at any time, even if you have made the complaint before. Some examples of a complaint or grievance are:
Concerns about vehicle safety
Quality of services
Interactions with drivers and providers (such as rudeness)
Ride service requested was not provided as arranged
Consumer rights
Learn more about complaints, grievances, appeals and hearings on page 107.
Rider Guide Get the BCB Rider Guide at: https://www.umpquahealth.com/members/benefits-programs/get-a-ride/. You or your representative can also call Customer Care at 541-229-4842 to ask for a free paper copy. It will be sent in 5 business days. The paper copy can be in the language and format you prefer.
The guide has more information, like:
Wheelchairs and mobility help.
Vehicle safety.
Driver duties and rules.
What to do in an emergency or if there is bad weather.
Long distance appointments.
Meal and lodging reimbursement.
Telehealth (also known as telemedicine and teledentistry) is a way for you to get care without going into the clinic or office. Telehealth means you can have your appointment through a phone call or video call. UHA will cover telehealth visits. Telehealth lets you visit your provider using a:
Phone (audio)
Smart phone (audio/video)
Tablet (audio/video)
Computer (audio/video)
Telehealth means you can have your appointment through a phone call or video call. UHA will cover telehealth visits. To get telehealth, you need a phone, tablet, or other device that supports video and phone capabilities. UHA does not provide or support these technologies. This service is provided by our contracted providers. If you do not have a device for a telehealth visit but must be seen via telehealth, contact UHA for more help. We can offer other possible solutions. If you do not have internet or video access, you can also talk to your provider about what will work for you. Telehealth services are free.
If you do not have internet or video access, talk to your provider about what will work for you.
Not all providers have telehealth options. You should ask about telehealth when you call to make your appointment. To find a provider that provides these services, you can call UHA Customer Care at 541-229-4842 or TTY 7113. You can also go on-line in the Provider Directory at portal.umpquahealth.com/ClientApp/providers. Click “yes” under “Telehealth”:
If you have any audio or video problems with your telehealth visit, please be sure to work with your provider.
UHA members using telehealth have the right to get the physical, dental, and behavioral health services they need.
Some examples of when you can use telehealth are:
When your provider wants to visit with you before refilling a prescription.
Counseling services.
Following up from an in-person visit.
When you have routine medical questions.
If you are quarantined or practicing social distancing due to illness.
If you are temporarily away from home and cannot meet with your doctor in person.
If you are not sure if you need to go into the clinic or office.
Telehealth is not recommended for emergencies. If you feel like your life is in danger, please call 911 or go to the nearest emergency room. See page 86 for a list of hospitals with emergency rooms.
If you do not know what telehealth services or options your provider has, call them and ask.
Telehealth services offered by your provider are private and secure. Each provider will have their own system for telehealth visits, but each system must follow the law.
Below is a list of community health centers that can provide telehealth services for you needs:
Evergreen Family Medicine offers video and phone telehealth services.
Aviva Health offers video and phone telehealth services.
Cow Creek offers phone telehealth services.
Umpqua Health Newton Creek offer video and phone telehealth services.
Adapt Primary Care has a website called doxy.me for telehealth services.
To access this free service, go to doxy.me/sign-in. This may not work on all browsers.
Learn more about privacy and the Health Insurance Portability and Accountability Act (HIPAA) on page 15.
Make sure you take your call in a private room or where no one else can listen in on your appointment with your provider.
Get telehealth services in the language you need.
Have providers who respect your culture and language needs.
Get qualified and certified interpretation services for you and your family. Learn more on page 9-10.
Get in-person visits, not just telehealth visits.
UHA will make sure you have the choice of how you get your visits. A provider cannot make you use telehealth unless there is a declared state of emergency or a facility is using its’ disaster plan.
Get support and have the tools needed for telehealth.
UHA will help identify what telehealth tool is best for you.
CCO will ensure your provider conducts an assessment to see if telehealth is right for you. This includes, but is not limited to:
Need for alternate format;
Access to necessary device(s);
Access to a private and safe location;
Access to internet service;
Understanding of digital devices;
Cultural concerns.
Talk to your provider about telehealth. If you need or prefer in person visits, and your provider is only a telehealth provider, let them know. They can refer you to another provider and tell UHA. You have a choice of how you receive your care and UHA can help coordinate care with another provider. You can also call Customer Care at 541-229-4842 (TTY 711). We are open Monday through Friday, 8:00 a.m. to 5:00 p.m.
Prescription medications To fill a prescription, you can go to any pharmacy in UHA’s network. You can find a list of pharmacies we work with in our provider directory at: https://www.umpquahealth.com/members/benefits-programs/pharmacy/.
You have a right to get interpreter services and auxiliary aids at the pharmacy.
You also have a right to translated prescription labels.
For all prescriptions covered by UHA, bring to the pharmacy:
The prescription.
Your UHA ID card, Oregon Health ID card or other proof of coverage such as a Medicare Part D ID card or Private Insurance card. You may not be able to fill a prescription without them.
UHA’s list of covered medications is at:https://www.umpquahealth.com/members/benefits-programs/pharmacy/.
If you are not sure if your medication is on our list, call us. We will check for you.
If your medication is not on the list, tell your provider. Your provider can ask us to cover it.
UHA needs to approve some medication on the list before your pharmacy can fill them. For these medications, your provider will ask us to approve it.
UHA also covers some over the counter (OTC) medications when your provider or pharmacy prescribes them for you. OTC medications are those you would normally buy at a store or pharmacy without a prescription, such as aspirin.
When your provider asks UHA to approve or cover a prescription:
Doctors and pharmacists at UHA will review the request from your provider.
We will make a decision within 24 hours.
If we need more information to make a decision, it can take 72 hours.
If UHA decides to not cover the prescription, you will get a letter from UHA . The letter will explain:
Your right to appeal the decision
How to ask for an appeal if you disagree with our decision. The letter will also have a form you can use to ask for an appeal.
Call UHA Pharmacy Customer Care at 541-229-4842 (TTY 711) if you have questions. `
UHA has three pharmacies in-network available to all our members that mail some medications to your home address. This is called mail-order pharmacy. If picking up your prescription at a pharmacy is hard for you, mail-order pharmacy may be a good option. Call UHA Pharmacy Customer Care at 541-229-4842 (TTY 711) to:
Learn more about mail-order pharmacy and
Get set up with mail-order pharmacy.
OHP pays for behavioral health medications UHA does not pay for most medications used to treat behavioral health conditions. Instead, OHP pays for them. If you need behavioral health medications:
UHA and your provider will help you get the medications you need.
The pharmacy sends your prescription bill directly to OHP. UHA and your provider will help you get the behavioral health medications you need. Talk to your provider if you have questions. You can also call UHA Customer Care at 541-229-4842 (TTY 711).
Prescription coverage for members with Medicare UHA and OHP do not cover medications that Medicare Part D covers.
If you qualify for Medicare Part D but choose not to enroll, you will have to pay for these medications.
If you have Part D, show your Medicare ID card and your UHA ID card at the pharmacy.
If Medicare Part D does not cover your medication, your pharmacy can bill UHA. If OHP covers the medication, UHA will pay for it.
Learn more about Medicare benefits on page 96.
If you plan to travel out of state, make sure you have enough medication for your trip. To do this, ask to get a prescription refill early. This is called a vacation override. Please call UHA at 541-229-4842 (TTY 711) to find out if this is a good option for you.
We work with the hospitals below for hospital care. You can get emergency care at any hospital. Some hospitals offer a full emergency room to help someone experiencing a mental health crisis but you may go to any hospital for help.
An urgent problem is serious enough to be treated right away, but it’s not serious enough for immediate treatment in the emergency room. These urgent problems could be physical, behavioral or dental.
You can get urgent care services 24 hours a day, 7 days a week without preapproval.
You do not need a referral for urgent or emergency care. For a list of urgent care centers and walk-in clinics see below.
Some examples of urgent physical care are:
Cuts that don’t involve much blood but might need stitches.
Minor broken bones and fractures in fingers and toes.
Sprains and strains.
If you have an urgent problem, call your primary care provider (PCP). You can call anytime, day or night, on weekends and holidays. Tell the PCP office you are a UHA member. You will get advice or a referral. If you can’t reach your PCP about an urgent problem or if your PCP can’t see you soon enough, go to an urgent care center or walk-in clinic. You don’t need an appointment. See list of urgent care and walk-in clinics on page 89.
Your PCP’s information is listed on your UHA ID card. If you need help, call UHA Customer Care at 541-229-4842 (TTY 711).
If you don’t know if your problem is urgent, still call your provider’s office, even if it’s closed. You may get an answering service. Leave a message and say you are a UHA member. You may get advice or a referral of somewhere else to call. You will get a call back from a UHA representative within 30-60 minutes after you called, to talk about next steps.
You can also call UHA's 24-Hour Nurse hotline for help anytime of the day or night. This phone number is 888-516-6166 and they will take after hour calls that are urgent or an emergency. If you make a call that is urgent or emergent, you will receive a call back within 30 minutes. If it’s determined that your call is not urgent, your call will be returned within 60 minutes to gather more information. You or your representative will get a call back as soon as possible for any urgent or emergent calls. If you do not have an emergency and need to contact UHA when we are closed, you can call us at our regular number and leave a message. We will return your call on the next business day.
For non-urgent advice and appointments, please call during business hours.
Evergreen Urgent Care Edenbower
Hours: Monday through Friday from 7:00 am to 7:00 pm, and Saturday and Sunday from 9:00 am to 5:00 pm.
Phone number: 541-677-7200
Address: 2570 NW Edenbower Blvd, Roseburg, OR 97471
Evergreen Urgent Care North
Hours: 7 days a week, 9:00 am to 5:00 pm
Phone number: 541-529-4711
Address: 249 Dakota Street, Sutherlin, OR 97479
Umpqua Health Newton Creek
Hours: Monday through Saturday, 7:00 am to 7:00 pm
Phone number: 541-229-7038
Address: 3031 NE Stephens St, Roseburg OR 97470
Some examples of urgent dental care include:
Tooth pain that wakes you up at night and makes it difficult to chew.
A chipped or broken tooth.
A lost crown or filling.
Abscess (a pocket of pus in a tooth caused by an infection).
If you have an urgent dental problem call your primary care dentist (PCD) If you cannot reach your PCD or you do not have one, call Advantage Dental Services Customer Care at 866-268-9631. They will help you find urgent dental care, depending on your condition. You should get an appointment within 2 weeks, or 1 week if you’re pregnant, for an urgent dental condition.
Call 911 if you need an ambulance or go to the emergency room when you think you are in danger. An emergency needs immediate attention and puts your life in danger. It can be a sudden injury or a sudden illness. Emergencies can also cause harm to your body. If you are pregnant, the emergency can also cause harm to your baby. You can get urgent and emergency services 24 hours a day, 7 days a week without preapproval. You don’t need a referral.
Emergency physical care is for when you need immediate care, and your life is in danger.
Some examples of medical emergencies include:
Broken bones.
Bleeding that does not stop.
Possible heart attack.
Loss of consciousness.
Seizure.
Severe pain.
Difficulty breathing.
Allergic reactions.
More information about emergency care:
Call your PCP or UHA Customer Care within 3 days of receiving emergency care.
You have a right to use any hospital or other setting within the United States.
Emergency care includes post stabilization (after care) services. After care services are covered services related to an emergency condition. These services are given to you after you are stabilized. They help to maintain your stabilized condition. They help to improve or fix your condition.
See a list of hospitals with emergency rooms on page 89.
A dental emergency is when you need same-day dental care. This care is available 24 hours a day and 7 days a week. A dental emergency may require immediate treatment. Some examples are:
A tooth has been knocked out (that is not a childhood “wiggly” tooth).
You have facial swelling or infection in the mouth.
Bleeding from your gums that won’t stop.
For a dental emergency, please call your primary care dentist (PCD). You will be seen within 24 hours. Some offices have emergency walk-in times. If you have a dental emergency and your dentist or PCP cannot help you, you don’t need permission to get emergency dental care. You can go to the emergency room or call Customer Care at 541-229-4842 for help to find emergency dental care.
If none of these options work for you, call 911 or visit the Emergency Room. If you need an ambulance ride, please call 911. See a list of hospitals with emergency rooms on page 89.
A behavioral health emergency is when you need help right away to feel or be safe. It is when you or other people are in danger. An example is feeling out of control. You might feel like your safety is at risk or have thoughts of hurting yourself or others. Call 911 or go to the emergency room if you are in danger.
Behavioral health emergency services do not need a referral or preapproval. UHA offers members crisis help and services after an emergency.
A behavioral health provider can support you in getting services for improving and stabilizing mental health. We will try to help and support you after a crisis.
24-hour crisis line: Toll-free: 1-800-866-9780
Provides same-day walk-in access to behavioral health crisis services from
8:00AM – 5:00PM
Adapt Mobile Crisis Services: Mobile Crisis Counselors can respond to 911 calls and help prevent arrest. If you call 911 for a mental health crisis, request help from mobile crisis. A mental health counselor and case manager will help you de-escalate. They also provide support and other resources. Suicide Prevention Lifeline
1-800-273-TALK (8255)
1-888-628-9454 (Spanish)
Teen Support
oregonyouthline.org/
Text: teen2teen to 839863
A behavioral health crisis is when you need help quickly. If not treated, the condition can become an emergency. Please call one of the 24-hour local crisis lines above or call 988 if you are experiencing any of the following or are unsure if it is a crisis. We want to help and support you in preventing an emergency.
Examples of things to look for if you or a family member is having a behavioral health emergency or crisis:
Considering suicide.
Hearing voices that are telling you to hurt yourself or another person.
Hurting other people, animals or property.
Dangerous or very disruptive behaviors at school, work, or with friends or family.
Here are some things UHA does to support stabilization in the community:
A crisis hotline to call when a member needs help
Mobile crisis team that will come to a member who needs help.
Walk-in and drop-off crisis centers
Crisis respite (short-term care)
Short-term places to stay to get stable
Post stabilization services and urgent care services. This care is available 24 hours a day and 7 days a week. Post Stabilization care services are covered services, related to a medical or behavioral health emergency, that are provided after the emergency is stabilized and to maintain stabilization or resolve the condition.
Crisis response services, 24 hours a day, for members receiving intensive in-home behavioral health treatment.
See more about behavioral health services offered on page 52.
If you have a mental illness and do not treat it, you may risk suicide. With the right treatment, your life can get better.
Common suicide warning signs Get help if you notice any signs that you or someone you know is thinking about suicide. At least 80% of people thinking about suicide want help. You need to take warning signs seriously. Here are some suicide warning signs:
Talking about wanting to die or kill oneself.
Planning a way to kill oneself, such as buying a gun.
Feeling hopeless or having no reason to live.
Feeling trapped or in unbearable pain.
Talking about being a burden to others.
Giving away prized possessions.
Thinking and talking a lot about death.
Using more alcohol or drugs.
Acting anxious or agitated.
Behaving recklessly.
Withdrawing or feeling isolated.
Having extreme mood swings.
Never keep thoughts or talk of suicide a secret!
If you want to talk with someone outside of UHA, call any of the following:
See list of crisis lines on pages 88-89
National Suicide Prevention Lifeline: Call 988 or visit https://988lifeline.org/
The David Romprey Memorial Warmline: 800-698-2392
Crisis Text Line: Text 741741
For teen suicide prevention: Youth Line: 877-968-8491 or text teen2teen to 839863
You can also search for your county mental health crisis number online. They can provide screenings and help you get the services you need.
For a list of additional crisis hotlines, see page 89, or go to https://adaptoregon.org/services/mental-health/.
After an emergency, you may need follow-up care. This includes anything you need after leaving the emergency room. Follow-up care is not an emergency. OHP does not cover follow-up care when you are out of state. Call your primary care provider or primary care dentist office to set up any follow-up care.
You must get follow-up care from your regular provider or regular dentist. You can ask the emergency doctor to call your provider to arrange follow-up care.
Call your provider or dentist as soon as possible after you get urgent or emergency care. Tell your provider or dentist where you were treated and why.
Your provider or dentist will manage your follow-up care and schedule an appointment if you need one.
UHA will help you locate an out of state provider and pay for a covered service when:
You need a service that is not available in Oregon
Or if the service is cost effective
To learn more about how you may be able to get a prescription refill before your trip see page 82.
Emergency care away from home You may need emergency care when away from home or outside of the UHA service area. Call 911 or go to any emergency department. You do not need preapproval for emergency services. Emergency medical services are covered throughout the United States, this includes behavioral health and emergency dental conditions.
Do not pay for emergency care. If you pay the emergency room bill, UHA is not allowed to pay you back. See page 90 for what to do if you get billed.
Emergency care is only covered in the United States.
Please follow steps below if you need emergency care away from home
1. Make sure you have your Oregon Health ID Card and UHA ID card with you when you travel out of state.
2. Show them your UHA ID Card and ask them to bill UHA.
3. Do not sign any paperwork until you know the provider will bill UHA. Sometimes UHA cannot pay your bill if an agreement to pay form has been signed. To learn more about this form see page 101.
4. You can ask that the Emergency Room or provider’s billing office to contact UHA if they want to verify your insurance or have any questions.
5. If you need advice on what to do or need non-emergency care away from home, call UHA for help.
In times of emergency the steps above are not always possible. Being prepared and knowing what steps to take for emergency care out of state may fix billing issues while you are away. These steps may help prevent you being billed for services that UHA can cover. UHA cannot pay for a service if the provider has not sent us a bill.
If you get a bill see section “If your provider sends you a bill, do not pay it” below.
OHP members do not pay bills for covered services When you set up your first visit with a provider, tell the office that you are with UHA. Let them know if you have other insurance, too. This will help the provider know who to bill. Take your ID card with you to all medical visits. UHA pays for all covered, medically necessary and appropriate services in accordance with the Prioritized List of Health Services.
A UHA in-network provider (for a list of in-network providers see page 30) or someone working for them cannot bill you or try to collect any money owed by UHA for services you are not responsible for covering.
Members cannot be billed for missed appointments or errors.
Missed appointments are not billable to you or OHP.
If your provider does not send the right paperwork or does not get an approval, you cannot get a bill for that. This is called provider error.
Members cannot get balance or surprise billing. When a provider bills for the amount remaining on the bill, after UHA has paid, that’s called balance billing. It is also called surprise billing. The amount is the difference between the actual billed amount and the amount UHA pays. This happens most often when you see an out-of-network provider. You are not responsible for these costs.
If you have questions, call Customer Care 541-229-4842.For more information about surprise billing go to https://dfr.oregon.gov/Documents/Surprise-billing-consumers.pdf.
Call UHA for help right away at 541-229-4842, (TTY 711).
You can also call your provider’s billing office and make sure they know you have OHP.
There may be services you have to pay for Usually, with UHA, you will not have to pay any medical bills. When you need care, talk to your provider about options. The provider’s office will check with UHA to see if a treatment or service is not covered. If you choose to get a service that is not covered, you may have to pay the bill. This happens only when you have talked about it and signed an Agreement to Pay form. (Learn more on page 94)
You have to pay the provider if:
You get routine care outside of Oregon. You get services outside Oregon that are not for urgent or emergency care.
You don’t tell the provider you have OHP. You did not tell the provider that you have UHA, another insurance or gave a name that did not match the one on the UHA ID at the time of or after the service was provided, so the provider could not bill UHA. Providers must verify your UHA eligibility at the time of service and before billing or doing collections. They must try to get coverage info prior to billing you.
You continue to get a denied service. You or your representative requested continuation of benefits during an appeal and contested case hearing process, and the final decision was not in your favor. You will have to pay for any charges incurred for the denied services on or after the effective date on the notice of action or notice of appeal resolution.
You get money for services from an accident. If a third-party payer, like car insurance, sent checks to you for services you got from your provider and you did not use these checks to pay the provider.
We don’t work with that provider. When you choose to see a provider that is not in-network with UHA you may have to pay for your services. Before you see a provider that is not in-network with UHA you should call Customer Care or work with your PCP. Prior approval may be needed or there may be a provider in-network that can fit your needs. For a list of in-network Providers see page 30.
You choose to get services that are not covered. You have to pay when you choose to have services that the provider tells you are not covered by UHA. In this case:
The service is something that your plan does not cover.
Before you get the service, you sign a valid Agreement to Pay form. Learn more about the form below.
Always contact UHA Customer Care first to discuss what is covered. If you get a bill, please contact UHA Customer Care right away.
Examples of some non-covered services:
Some treatments, like over the counter medications, for conditions that you can take care of at home or that get better on their own (colds, mild flu, corns, calluses, etc.)
Cosmetic surgeries or treatments for appearance only.
Services to help you get pregnant.
Treatments that are not generally effective.
Orthodontics, except for handicapping malocclusion and to treat cleft palate in children.
If you have questions about covered or non-covered services, please contact UHA Customer Care at 541-229-4842 (TTY 711).
You may be asked to sign an Agreement to Pay form An agreement to pay form is used when you want a service that is not covered by UHA or OHP. The form is also called a waiver. You can only be billed for a service if you sign the Agreement to Pay form. You should not feel forced to sign the form. You can see a copy of the form at https://bit.ly/OHPwaiver.
You do not have to sign the Agreement to Pay form if you do not want to. If you are unsure if you should sign the Agreement to Pay form or have any question about if a benefit is covered, please contact UHA Customer Cares at 541-229-4842 (TTY 711) for help. If UHA or your provider tell you that the service is not covered by OHP, you still have the right to challenge that decision by filing an appeal and asking for a hearing. See page 107.
The following must be true for the Agreement to Pay form to be valid:
The form must have the estimated cost of the service. This must be the same as on the bill.
The service is scheduled within 30 days from the date you signed the form.
The form says that OHP does not cover the service.
The form says you agree to pay the bill yourself.
You asked to privately pay for a covered service. If you choose to do this, the provider may bill you if they tell you in advance the following:
The service is covered and UHA would pay them in full for the covered service.
The estimated cost, including all related charges, the amount UHA would pay for the service. The provider cannot bill you for an amount more than UHA would pay; and,
You knowingly and voluntarily agree to pay for the covered service.
The provider documents in writing, signed by you or your representative, that they gave you the information above, and:
They gave you a chance to ask questions, get more information, and consult with your caseworker or representative.
You agree to privately pay. You or your representative signed the agreement that has all the private pay information.
The provider must give you a copy of the signed agreement. The provider cannot submit a claim to UHA for the covered service listed on the agreement.
Because some out of network emergency providers are not familiar with Oregon’s OHP (Medicaid) rules, they may bill you. You should not be billed for emergency or post-hospitalization care. Contact UHA Customer Care if you get a bill. We have resources to help.
Call us right away if you get any bills from out of state providers. Some providers send unpaid bills to collection agencies and may even sue in court to get paid. It is harder to fix the problem once that happens. As soon as you receive a bill:
Do not ignore medical bills.
Contact UHA Customer Care as soon as possible at 541-229-4842 (TTY 711). Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m.
If you get court papers, call us right away. You may also call an attorney or the Public Benefits Hotline at 800-520-5292 for free legal advice. There are consumer laws that can help you when you are wrongfully billed while on OHP.
If you got a bill because your claim was denied by UHA, contact Customer Care. Learn more about denials, your right to an appeal, and what to do if you disagree with us on pages 107-114.
You can also appeal by sending UHA a letter saying that you disagree with the bill because you were on OHP at the time of service.
We strongly urge you to call Customer Care before you agree to pay a provider.
If your provider asks you to pay a copay, do not pay it! Ask the office staff to call UHA.
UHA pays for all covered services in accordance with the Prioritized List of Health Services, see pages 44-46.
For a brief list of benefits and services that are covered under your OHP benefits with UHA, who also covers case management and care coordination, see pages 44-59. If you have any questions about what is covered, you can ask your PCP or call UHA Customer Care.
No UHA in-network provider or someone working for them can bill a member, send a member’s bill to a collection agency, or maintain a civil action against a member to collect any money owed by UHA for services you are not responsible for.
Members are never charged for rides to covered appointments. See page 76 Members may ask to get reimbursements for driving to covered visits or get bus passes to use the bus to go to covered visits.
Protections from being billed usually only apply if the medical provider knew or should have known you had OHP. Also, they only apply to providers who work with OHP (but most providers do).
Sometimes, your provider does not fill out the paperwork correctly. When this happens, they might not get paid. That does not mean you have to pay. If you already got the service and we refuse to pay your provider, your provider still cannot bill you.
You may get 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 UHA or your provider tell you that the service is not covered by OHP, you still have the right to challenge that decision by filing an appeal and asking for a hearing. See pages 107-114.
In the event of UHA closing, you are not responsible to pay for services we cover or provide.
Members with OHP and Medicare Some people have OHP (Medicaid) and Medicare at the same time. OHP covers some things that Medicare does not. If you have both, Medicare is your main health coverage. OHP can pay for things like medications that Medicare doesn’t cover.
If you have both, you are not responsible for:
Co-pays
Deductibles or
Co-insurance charges for Medicare services, those charges are covered by OHP.
You may need to pay a co-pay for some prescription costs.
There are times you may have to pay deductibles, co-insurance or co-pays if you choose to see a provider outside of the network. Contact your local Aging and People with Disabilities (APD) or Area Agency on Aging (AAA) office. They will help you learn more about how to use your benefits. Call the Aging and Disability Resource Connection (ADRC) at 855-673-2372 to get your local APD or AAA office phone number.
Call Customer Care to learn more about which benefits are paid for by Medicare and OHP (Medicaid), or to get help finding a provider and how to get services.
Providers will bill your Medicare and UHA. UHA works with Medicare and has an agreement that all claims will be sent so we can pay.
Give the provider your OHP ID number and tell them you’re covered by UHA. If they still say you owe money, call Customer Care at 541-229-4842, (TTY 711). We can help you.
Learn about the few times a provider can send you a bill on page 94.
Members with Medicare can change or leave the CCO they use for physical care at any time. However, members with Medicare must use a CCO for dental and behavioral health care.
If you do not have a CCO, your OHP is called Fee-For-Service or open card. This is called “fee-for-service” because the state pays providers a fee for each service they provide. Fee-for-service members get the same types of physical, dental, and behavioral health care benefits as CCO members .
The CCO you have depends on where you live. The rules about changing or leaving a CCO are different when there’s only one CCO in the area and when there are more CCOs in an area.
Members with Medicare and OHP (Medicaid) You can change or leave the CCO you use for physical care at any time. However, members with Medicare must use a CCO for dental and behavioral health care.
American Indians and Alaska Natives with proof of Indian Heritage You can also get care from an Indian Health Services facility, tribal health clinic/program, or urban clinic and OHP fee-for-service.
Service areas with only one CCO: Members with only one CCO in their service area may ask to disenroll (leave) a CCO and get care from OHP fee-for-service at any time for any of the following “with cause” reasons:
The CCO has moral or religious objections about the service you want.
You have a medical reason. When related services are not available in network and your provider says that getting the services separately would mean unnecessary risk. Example: a Caesarean section and a tubal ligation at the same time.
Other reasons including, but not limited to, poor care, lack of access to covered services, or lack of access to network providers who are experienced in your specific health care needs.
Services are not provided in your preferred language.
Services are not provided in a culturally appropriate manner; or
You’re at risk of having a lack of continued care.
If you move to a place that your CCO does not serve, you can change plans as soon as you tell OHP about the move. Please call OHP at 800-699-9075 or use your online account at ONE.Oregon.gov.
Service areas with more than one CCO:
Members with more than one CCO in their service area may ask to leave and change to a different CCO at any time for any of the following “with cause” reasons:
You move out of the service area.
If you move to a place that your CCO does not serve, you can change plans as soon as you tell OHP about the move. Please call OHP at 800-699-9075 or use your online account at ONE.Oregon.gov.
The CCO has moral or religious objections about the service you want.
You have a medical reason. When related services are not available in network and your provider says that getting the services separately would mean unnecessary risk. Example: a Caesarean section and a tubal ligation at the same time.
Other reasons including, but not limited to, poor care, lack of access to covered services, or lack of access to network providers who are experienced in your specific health care needs.
Services are not provided in your preferred language.
Services are not provided in a culturally appropriate manner; or
You’re at risk of having a lack of continued care.
Members with more than one CCO in their service area may also ask to leave and change a CCO at any time for the following “without cause” reasons:
Within 30 days of enrollment if:
You don’t want the plan you were enrolled in, or
You asked for a certain plan and the state put you in a different one.
In the first 90 days after you join OHP or
If the state sends you a “coverage” letter that says you are part of the CCO after your start date, then you have 90 days after that letter date.
After you have been with the same CCO for 6 months.
When you renew your OHP.
If you lose OHP for less than 2 months, are reenrolled into a CCO, and missed your chance to pick the CCO when you would have renewed your OHP.
When a CCO is suspended from adding new members.
At least once every 12 months if the options above don’t apply.
You can ask about these options by phone or in writing. Please call OHP Client Services at 800-273-0557 or email Oregon.Benefits@odhsoha.oregon.gov.
Things to consider: UHA wants to make sure you receive the best possible care. UHA can give you some services that FFS or open card cannot. When you have a problem getting the right care, please let us try to help you before leaving UHA.
If you still wish to leave, there must be another CCO available in your service area for you to switch your plan.
Tell OHP if you want to change or leave your CCO. You and/or your representative can call OHP Customer Care at 800-699-9075 or OHP Client Services 800-273-0557 (TTY 711) from Monday through Friday, 8 a.m. to 5 p.m. PT. You can use your online account at ONE.Oregon.gov or email OHP at Oregon.Benefits@odhsoha.oregon.gov. The effective date of disenrollment will be the first of the month following OHA’s approval of disenrollment.
You can get care while you change your CCO. See page 97 to learn more.
Adoption and Guardianship families should contact the Adoption and Guardianship Medical Eligibility and Enrollment coordinator at:
Call: 503-509-7655
Email: Cw-aa-ga-medicalassist@odhsohs.oregon.gov
Online: https://www.oregon.gov/odhs/adoption/Pages/assistance.aspx
UHA may ask OHA to remove you from our plan if you:
Are abusive, uncooperative, or disruptive to our staff or providers. Except when the behavior is due to your special health care need or disability.
Commit fraud or other illegal acts, such as letting someone else use your health care benefits, changing a prescription, theft, or other criminal acts.
Are violent or threaten violence. This could be directed at a health care provider, their staff, other patients, or UHA staff. When the act or threat of violence seriously impairs UHA’s ability to furnish services to either you or other members.
We must ask the Oregon Health Authority (OHA) for approval before removing you from our plan. If OHA approves the request, you will get a letter letting you know you have been disenrolled (removed) from the CCO. You can make a complaint if you are not happy with the process or if you disagree with the decision. See page 107 for how to make a complaint or ask for an appeal.
UHA cannot ask to remove you from our plan because of reasons related to (but not limited to):
Your health status gets worse.
You don’t use services.
You use many services.
You are about to use services or be placed in a care facility (like a long-term care facility or Psychiatric Residential Treatment Facility)
Special needs behavior that may be disruptive or uncooperative.
Your protected class, medical condition or history means you will probably need many future services or expensive future services.
Your physical, intellectual, developmental, or mental disability.
You are in the custody of ODHS Child Welfare.
You make a complaint, disagree with a decision, ask for an appeal or hearing.
You make a decision about your care that UHA disagrees with.
For more information or questions about other reasons you may be disenrolled, temporary enrollment exceptions or enrollment exemptions, call UHA at 541-229-4842 or OHP Client Services at 800-273-0557. You will get a letter with your disenrollment rights at least 60 days before you need to renew your OHP.
Some members who change plans might still get the same services, prescription drug coverage and see the same providers even if not in-network. That means care will be coordinated when you switch CCOs or move from OHP fee-for-service to a CCO. This is sometimes called “Transition of Care.”
If you have serious health issues, need hospital care or inpatient mental health care, your new and old plans must work together to make sure you get the care and services you need.
This help is for when you have serious health issues, need hospital care, or inpatient mental health care. Here is a list of some examples of when you can get this help:
End-stage renal disease care.
You’re a medically fragile child.
Receiving breast and/or cervical cancer treatment program members.
Receiving Care Assist help due to HIV/AIDS.
Pre and Post-transplant care.
You’re pregnant or just had a baby.
Receiving treatment for cancer.
Any member that if they don’t get continued services may suffer serious detriment to their health or be at risk for the need of hospital or institution care.
The timeframe that this care lasts is:
*Or until your new primary care provider (PCP) has reviewed your treatment plan.
If you are leaving UHA, we will work with your new CCO or OHP to make sure you can get those same services listed below.
If you need care while you change plans or have questions please call UHA Customer Care at: 541-229-4842 (TTY users, call 711) Hours: Monday through Friday, 8:00 a.m. to 9:00 p.m. PST
UHA will make sure members who need the same care while changing plans get:
Continued access to care and rides to care.
Services from their provider even if they are not in the UHA network until one of these happen:
The minimum or approved prescribed treatment course is completed, or
Your provider decides your treatment is no longer needed. If the care is by a specialist, the treatment plan will be reviewed by a qualified provider.
Some types of care will continue until complete with the current provider. These types of care are:
Care before and after you are pregnant/deliver a baby (prenatal and postpartum).
Transplant services until the first year post-transplant.
Radiation or chemotherapy (cancer treatment) for their course of treatment.
Medications with a defined least course of treatment that is more than the transition of care timeframes above.
You can get a copy of the UHA Transition of Care Policy by calling Customer Care at 541-229-4842. It is also on our website on the Member benefits program page at https://www.umpquahealth.com/?swp_form%5Bform_id%5D=1&s=transition+of+care. Please call Customer Care if you have questions.
All adults have the right to make decisions about their care. This includes the right to accept and refuse treatment. An illness or injury may keep you from telling your doctor, family members or representative about the care you want to receive. Oregon law allows you to state your wishes, beliefs, and goals in advance, before you need that kind of care. The form you use is called an advance directive.
If you need more information regarding UHA’s policies and procedures about Advance Directives, go online: https://www.umpquahealth.com/?swp_form%5Bform_id%5D=1&s=Advance+Directives+Policy
An advance directive allows you to:
Share your values, beliefs, goals and wishes for health care if you are unable to express them yourself.
Name a person to make your health care decisions if you could not make them for yourself. This person is called your health care representative and they must agree to act in this role.
The right to share, deny or accept types of medical care and the right to share your decisions about your future medical care.
How to get more information about Advance Directives
We can give you a free booklet on advance directives. It is called “Making Health Care Decisions”. Just call us to learn more, get a copy of the booklet and the Advance Directive form. Call UHA Customer Care at 541-229-4842.
An Advance Directive User’s Guide is available. It provides information on:
The reasons for an Advance Directive.
The sections in the Advance Directive form.
How to complete or get help with completing an Advance Directive.
Who should be provided a copy of an Advance Directive.
How to make changes to an Advance Directive.
To download a copy of the Advance Directive User’s Guide or Advance Directive form, please visit: https://www.oregon.gov/oha/ph/about/pages/adac-forms.aspx
Other helpful information about Advance Directives
Completing the advance directive is your choice. If you choose not to fill out and sign the advance directive, your coverage or access to care will stay the same.
You will not be treated differently by UHA if you decide not to fill out and sign an advance directive.
If you complete an advance directive be sure to talk to your providers and your family about it and give them copies.
UHA will honor any choices you have listed in your completed and signed Advance Directive. If a doctor you work with has a moral objection to honoring your Advance Directive, please call UHA Customer Care at 541-229-4842 or TTY 711. We can help you find another provider who does not have a conscientious objection.
How to report if UHA did not follow an Advance Directive
You can make a complaint to the Health Licensing Office if your provider does not do what you ask in your advance directive.
Health Licensing Office
503-370-9216 (TTY users, please call 711) Hours: Monday through Friday, 8 a.m. to 5 p.m. PT
Mail a complaint to: 1430 Tandem Ave NE, Suite 180 Salem, OR 97301 Email: hlo.info@odhsoha.oregon.gov Online: https://www.oregon.gov/oha/PH/HLO/Pages/File-Complaint.aspx
You can make a complaint to the Health Facility Licensing and Certification Program if a facility (like a hospital) does not do what you ask in your advance directive.
Health Facility Licensing and Certification Program Mail to: 800 NE Oregon Street, Suite 465 Portland, OR 97322 Email: mailbox.hclc@odhsoha.oregon.gov Fax: 971-673-0556 Online: https://www.oregon.gov/OHA/PH/ProviderPartnerResources/HealthcareProvidersFacilities/HealthcareHealthCareRegulationQualityImprovement/Pages/index.aspx
Call UHA Customer Care at 541-229-4842 (TTY 711) to get a paper copy of the complaint form.
How to cancel an Advance Directive To cancel, ask for copies of your advance directive back so your provider knows it is no longer valid. Tear them up or write CANCELED in large letters, sign, and date them. For questions or more info contact Oregon Health Decisions at 800-422-4805 or 503-692-0894 (TTY 711).
What is the difference between a POLST and advance directive?
Portable Orders for Life-Sustaining Treatment (POLST) A POLST is a medical form that you can use to make sure your wishes for treatment near the end of life are followed by medical providers. You are never required to fill out a POLST, but if you have serious illnesses or other reasons why you would not want all types of medical treatment, you can learn more about this form. The POLST is different from an Advance Directive:
To learn more, visit: https://oregonpolst.org/
Email: polst@ohsu.edu or call Oregon POLST at 503-494-3965.
Declaration for Mental Health Treatment Oregon has a form for writing down your wishes for mental healthcare. The form is called the Declaration for Mental Health Treatment. The form is for when you have a mental health crisis, or you can’t make decisions about your mental health treatment. You have the choice to complete this form, when not in a crisis, and can understand and make decisions about your care.
What does this form do for me? The form tells what kind of care you want if you are ever unable to make decisions on your own. Only a court and two doctors can decide if you cannot make decisions about your mental health.
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 3 years. If you become unable to decide during those 3 years, your form will take effect. It will remain in effect until you can make decisions again. You may cancel your declaration when you can make choices about your care. You must give your form both to your PCP and to the person you name to make decisions for you.
To learn more about the Declaration for Mental Health Treatment, visit the State of Oregon’s website at https://aix-xweb1p.state.or.us/es_xweb/DHSforms/Served/le9550.pdf
If your provider does not follow your wishes in your form, you can complain. A form for this is at www.healthoregon.org/hcrqi. Send your complaint to:
Health Care Regulation and Quality Improvement 800 N.E. Oregon St., #465 Portland, OR 97232 Email: Mailbox.HCLC@odhsoha.oregon.gov Phone: 971-673-0540 (TTY: 971-673-0372) Fax: 971-673-0556
We’re a community health plan, and we want to make sure that health care dollars are spent helping our members be healthy and well. We need your help to do that.
If you think fraud, waste, or abuse has happened report it as soon as you can. You can report it anonymously. Whistleblower laws protect people who report fraud, waste, and abuse. You will not lose your coverage if you make a report. It is illegal to harass, threaten, or discriminate against someone who reports fraud, waste, or abuse.
Some examples of fraud, waste and abuse by a provider could be:
A provider charging you for a service covered by UHA
A provider billing for services that you did not receive
A provider giving you a service that you do not need based on your health condition
Some examples of fraud, waste and abuse by a member could be:
Getting items from the Medicaid program and reselling them.
Someone using another person’s ID to get benefits.
UHA is committed to preventing fraud, waste, and abuse. We will follow all related laws, including the State’s False Claims Act and the Federal False Claims Act.
You can make a report of fraud, waste and abuse a few ways:
Call, fax, submit on-line or write directly to UHA. We report all suspected fraud, waste, and abuse committed by providers or members to the state agencies listed below.
Call our hotline: 844-348-4702 (TTY 711) Fax: 541-229-9982 Submit a report online: https://secure.ethicspoint.com/domain/media/en/gui/50894/index.html Write to: Compliance Officer
Umpqua Health Alliance
3031 NE Stephens St.
Roseburg, OR 97470
OR
Report Member fraud, waste and abuse by calling, faxing or writing to:
ODHS Fraud Investigation Unit P.O. Box 14150 Salem, OR 97309 Hotline:1-888-FRAUD0 1 (888-372-8301) Fax: 503-373-1525 Attn: Hotline
Online: https://www.oregon.gov/odhs/financial-recovery/Pages/fraud.aspx
OR
OHA Office of Program Integrity 500 Summer St. NE, E-36 Salem, OR 97301 Hotline: 1-888-FRAUD01 (888-372-8301) Online: https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx
OR
Medicaid Fraud Control Unit (MFCU) Oregon Department of Justice 100 SW Market Street Portland, OR 97201 Phone: 971-673-1880 E-mail: Medicaid.Fraud.Referral@doj.state.or.us
Online: https://www.doj.state.or.us/consumer-protection/sales-scams-fraud/medicaid-fraud/
To report fraud online: https://www.oregon.gov/dhs/abuse/Pages/fraud-reporting.aspx
UHA makes sure all members have access to a grievance system (complaints, grievances, appeals and hearings). We try to make it easy for members to file a complaint, grievance, or appeal and get info on how to file a hearing with the Oregon Health Authority.
Let us know if you need help with any part of the complaint, grievance, appeal, and/or hearings process. We can also give you more information about how we handle complaints/grievances and appeals. Copies of our notice templates are also available. If you need help or would like more information beyond what is in the handbook contact us at:
We will provide you with help to complete forms and other steps needed to file a grievance (complaint), appeal, or hearing. This could be:
Help from a qualified community health worker (i.e., peer specialist or personal navigator) or care coordination services.
Interpreter services or auxiliary (added help or support) aids and services.
A letter in a different language or format. Explaining the grievance (complaint), appeals, and hearings process or providing policies or documents.
A complaint is letting us know you are not satisfied.
A dispute is when you do not agree with UHA or a provider.
A grievance is a complaint you can make if you are not happy with UHA, your healthcare services, or your provider. A dispute can also be a grievance.
To make it easy, OHP uses the word complaint for grievances and disputes, too.
You have a right to make a complaint if you are not satisfied with any part of your care. We will try to make things better. Just call UHA Customer Care at 541-229-4842 or TTY 711. You can also make a complaint with OHA or Ombuds. You can reach OHA at 1-800-273-0557 or Ombuds at 1-877-642-0450.
or
Write:
Umpqua Health Alliance
Attn: Grievance and Appeals
3031 NE Stephens St.
Roseburg, OR 97470
You may also find a complaint form at www.umpquahealth.com/appeals-and-grievances. You can file a complaint about any matter other than a denial for service or benefits and at any time orally or in writing. If you file a complaint with OHA, it will be forwarded to UHA
Examples of reasons you may file a complaint are:
Problems making appointments or getting a ride
Problems finding a provider near where you live
Not feeling respected or understood by providers, provider staff, drivers or UHA
Care you were not sure about, but got anyway
Bills for services you did not agree to pay
Disputes on UHA extension proposals to make approval decisions
Driver or vehicle safety
Quality of the service you received
A representative or your provider may make (file) a complaint on your behalf, with your written permission to do so. We will look into your complaint and let you know what can be done as quickly as your health requires. This will be done within 5 business days from the day we got your complaint. If we need more time, we will send you a letter within 5 business days. We will tell you why we need more time. We will only ask for more time if it’s in your best interest. All letters will be written in your preferred language. We will send you a letter within 30 days of when we got the complaint explaining how we will handle it. If you are unhappy with how we handled your complaint, you can share that with OHP Client Services Unit at 1-800-273-0557 or please reach out to the OHA Ombuds Program. The Ombuds are advocates for OHP members and they will do their best to help you. Please send a secure email at www.oregon.gov/oha/ERD/Pages/Ombuds-Program.aspx or leave a message at 877-642-0450.
Another resource for supports and services in your community is 211 Info. Call 2-1-1 or go to the www.211info.org website for help.
UHA, its contractors, subcontractors, and participating providers cannot:
Stop a member from using any part of the complaint and appeal system process or take punitive action against a provider who ask for an expedited result or supports a member’s appeal.
Encourage the withdrawal of a complaint, appeal, or hearing already filed; or
Use the filing or result of a complaint, appeal, or hearing as a reason to react against a member or to request member disenrollment.
You can call, write a letter or fill out a form that explains why the plan should change its decision about a service.
If we deny, stop, or reduce a medical, dental or behavioral health service, we will send you a denial letter that tells you about our decision. This denial letter is also called a Notice of Adverse Benefit Determination (NOABD). We will also let your provider know about our decision.
If you disagree with our decision, you have the right to ask us to change it. This is called an appeal because you are appealing our decision.
Appeal – When you ask your plan to change a decision you disagree with about a service your doctor ordered. You can call, write a letter or fill out a form that explains why the plan should change its decision. This is called filing an appeal.
Advance Directive – A legal form that lets you express your wishes for end-of-life care. You can choose someone to make health care decisions for you if you can’t make them yourself.
Assessment – Review of information about a patient’s care, health care problems, and needs. This is used to know if care needs to change and plan future care.
Balance bill (surprise billing) - Balance billing is when you get a bill from your provider for a leftover amount. This happens when a plan does not cover the entire cost of a service. This is also called a surprise bill. OHP providers are not supposed to balance bill members.
Behavioral health – This is mental health, mental illness, addiction and substance use disorders. It can change your mood, thinking, or how you act.
Copay or Copayment – An amount of money that a person must pay for services like prescriptions or visits. OHP members do not have copays. Private health insurance and Medicare sometimes have copays.
Care Coordination – A service every member can access that gives you education, support and community resources. It helps you work on your health and find your way in the health care system.
Civil Action – A lawsuit filed to get payment. This is not a lawsuit for a crime. Some examples are personal injury, bill collection, medical malpractice, and fraud.
Co-insurance – The amount someone must pay to a health plan for care. It is often a percentage of the cost, like 20%. Insurance pays the rest.
Consumer Laws – Rules and laws meant to protect people and stop dishonest business practices.
Coordinated care organization (CCO) – A CCO is a local OHP plan that helps you use your benefits. CCOs are made up of all types of health care providers in a community. They work together to care for OHP members in an area or region of the state.
Crisis – A time of difficulty, trouble, or danger. It can lead to an emergency situation if not addressed.
Declaration of Mental Health Treatment – A form you can fill out when you have a mental health crisis and can’t make decisions about your care. It outlines choices about the care you want and do not want. It also lets you name an adult who can make decisions about your care.
Deductible – The amount you pay for covered health care services before your insurance pays the rest. This is only for Medicare and private health insurance.
Devices for habilitation and rehabilitation – Supplies to help you with therapy services or other everyday tasks. Examples include:
Walkers
Canes
Crutches
Glucose monitors
Infusion pumps
Prosthetics and orthotics
Low vision aids
Communication devices
Motorized wheelchairs
Assistive breathing machine
Diagnosis – When a provider finds out the problem, condition, or disease.
Durable medical equipment (DME) – Things like wheelchairs, walkers and hospital beds that last a long time. They don’t get used up like medical supplies.
Early and Periodic Screening Diagnostic and Treatment (EPSDT)- The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program offers comprehensive and preventive health care services to individuals under the age of 21 who are covered by the Oregon Health Plan (OHP). EPSDT provides EPSDT Medically Necessary and EPSDT Medically Appropriate Medicaid-covered services to treat any physical, dental, vision, developmental, nutritional, and mental and behavioral health conditions. Coverage for EPSDT includes all services coverable under the Oregon Health Plan (OHP), when EPSDT Medically Necessary and EPSDT Medically Appropriate for the EPSDT individual.
Emergency dental condition - A dental health problem based on your symptoms. Examples are severe tooth pain or swelling.
Emergency medical condition – An illness or injury that needs care right away. This can be 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. An emergency mental health condition is the feeling of being out of control or feeling like you might hurt yourself or someone else.
Emergency medical transportation – Using an ambulance or Life Flight to get medical care. Emergency medical technicians give care during the ride or flight
ER or ED – It means emergency room or emergency department. This is the place in a hospital where you can get care for a medical or mental health emergency.
Emergency room care – Care you get when you have a serious medical issue and it is not safe to wait. This can happen in an ER.
Emergency services – Care that improves or stabilizes sudden serious medical or mental health conditions.
Excluded services – What a health plan does not pay for. Example: OHP doesn’t pay for services to improve your looks, like cosmetic surgery or things that get better on their own, like a cold.
Federal and State False Claims Act – Laws that makes it a crime for someone to knowingly make a false record or file a false claim for health care.
Grievance – A formal complaint you can make if you are not happy with your CCO, your healthcare services, or your provider. OHP calls this a complaint. 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 healthcare. After you sign up, a company or government agency pays for covered health services. Some insurance programs need monthly payments, called premiums.
Health Risk Assessment – A survey about a member’s health. The survey asks about emotional and physical health, behaviors, living conditions and family history. CCOs use it to connect members to the right help and support.
Home Health Care – Services you get at home to help you live better after surgery, an illness or injury. Help with medications, meals and bathing are some of these services.
Hospice services – Services to comfort a person who is dying and to help their family. Hospice is flexible and can be pain treatment, counseling and respite care.
Hospital outpatient care – When surgery or treatment is performed in a hospital and you leave after.
Hospitalization – When someone is checked into a hospital for care.
Medicaid – A national program that helps with healthcare costs for people with low income. In Oregon, it is called 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 standard treatment.
Medicare – A health care program for people 65 or older. It also helps people with certain disabilities of any age.
Network – The medical, mental health, dental, pharmacy and equipment providers that have a contract with a CCO.
In-Network or Participating Provider – Any provider that works with your CCO. You can see in-network providers for free. Some network specialists require a referral.
Out-of-Network or Non-Participating Provider – A provider who has not signed a contract with the CCO. The CCO doesn’t pay for members to see them. You have to get approval to see an out-of-network provider.
OHP Agreement to Pay (OHP 3165 or 3166) Wavier - A form that you sign if you agree to pay for a service that OHP does not pay for. It is only good for the exact service and dates listed on the form. You can see the blank waiver form at https://bit.ly/OHPwaiver. Unsure if you signed a waiver form? You can ask your provider's office. For additional languages, please visit: www.oregon.gov/oha/hsd/ohp/pages/forms.aspx
Physician services – Services that you get from a doctor.
Plan – A health organization or CCO that pays for its members’ health care services.
POLST – Portable Orders for Life-Sustaining Treatment (POLST). A form that you can use to make sure your care wishes near the end of life are followed by medical providers.
Post-Stabilization Services – Services after an emergency to help keep you stable, or to improve or fix your condition
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 – The cost of insurance.
Prescription drug coverage – Health insurance or plan that helps pay for medications.
Prescription drugs – Drugs that your doctor tells you to take.
Preventive care or prevention – Health care that helps keep you well. Examples are getting a flu vaccine or a check-up each year.
Primary care provider or physician (PCP) – 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, physician’s assistant, osteopath or sometimes a naturopath.
Primary care dentist (PCD) – The dentist you usually go to who takes care of your teeth and gums.
Provider – Any person or agency that provides a health care service.
Referral -- A referral is a written order from your provider noting the need for a service. work with your provider for a referral.
Rehabilitation services – Services to help you get back to full health. These help usually after surgery, injury, or substance abuse. Rehabilitation devices are tools that help with recovery.
Representative – A person chosen to act or speak on your behalf.
Screening – A survey or exam to check for health conditions and care needs.
Skilled nursing care – Help from a nurse with wound care, therapy or taking your medicine. You can get skilled nursing care in a hospital, nursing home or in your own home with home healthcare.
Specialist – A medical provider who has special training to care for a certain part of the body or type of illness.
Suicide – The act of taking one’s own life.
Telehealth – Video care or care over the phone instead of in a provider’s office.
Transition of care – Some members who change OHP plans can still get the same services and see the same providers. That means care will not change when you switch CCO plans or move to/from OHP fee-for-service. This is called transition of care. If you have serious health issues, your new and old plans must work together to make sure you get the care and services you need.
Traditional health worker (THW) – A public health worker who works with healthcare providers to serve a community or clinic. A THW makes sure members are treated fairly. Not all THWs are certified by the state of Oregon. There are six (6) different types of THWs, including:
Community health worker
Peer wellness specialist
Personal health navigator
Peer support specialist
Birth doula
Tribal Traditional Health Workers
Urgent care – Care that you need the same day for serious pain. It also includes care to keep an injury or illness from getting much worse or to avoid losing function in part of your body.
Whistleblower – Someone who reports waste, fraud, abuse, corruption, or dangers to public health and safety.