Navigating health insurance can be complex, and understanding what your plan covers is crucial for accessing the care you need. For Oregon residents utilizing the Oregon Health Plan (OHP), it’s essential to know the scope of services available. Generally, OHP coverage extends to health care services that are part of your specific benefit package, provided within the United States by accepted OHP providers, and deemed medically necessary. This last point, medical necessity, is key – it signifies services vital for maintaining or improving your health. OHP’s coverage is determined by your benefit package and the Prioritized List of Health Services.
To get a clear picture of your individual benefits, your OHP coverage letter is your primary resource. This letter details your specific benefit package. If you can’t locate your coverage letter, you can access this information digitally through your dashboard at ONE.Oregon.gov under “Current Benefits.” Furthermore, a comprehensive guide to your benefits is available in your OHP member handbook.
For those enrolled in a Coordinated Care Organization (CCO), there may be access to flexible services. These are unique services or items, outside the standard OHP benefits, designed to support your journey towards better health and wellbeing.
Exploring OHP Benefit Categories: Plus, Limited Drug, and Bridge
To delve into the specifics of OHP coverage, explore the different types of care detailed below. You can also get a concise overview from the summary of OHP benefits and coverage.
- Behavioral health care: Addressing mental health and substance use disorders is a vital part of overall healthcare. OHP provides access to behavioral health services.
- Care coordination: Navigating the healthcare system can be challenging. Care coordination services help you manage your healthcare journey effectively.
- Dental care: Oral health is integral to general health. OHP includes dental care benefits to ensure access to these essential services.
- Diagnostic and preventive care: Preventive care and early diagnosis are key to long-term health. OHP coverage includes diagnostic and preventive services.
- Emergency care and urgent care: Unexpected health issues require timely attention. OHP covers emergency and urgent care services.
- EPSDT (care from birth to age 21): Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) ensures comprehensive care for children and adolescents from birth to 21 years old.
- Eye and vision care: Vision health is crucial. OHP provides coverage for eye exams and vision care services.
- Gender-affirming care: OHP is committed to inclusive healthcare and covers gender-affirming care services.
- Medical care: General medical care forms the foundation of healthcare coverage. OHP provides access to a range of medical services.
- Pregnancy care: Maternity care is essential for both mother and child. OHP covers comprehensive pregnancy care.
- Prescriptions: Access to necessary medications is vital for managing health conditions. OHP includes prescription coverage.
- Telehealth: Modern healthcare delivery includes telehealth services. OHP covers telehealth for convenient access to care.
- Travel help: Non-Emergency Medical Transportation (NEMT) is available to help members access necessary medical appointments.
- Limited or not covered services: It’s also important to be aware of services that may have limitations or are not covered by OHP.
Furthermore, some OHP members might be eligible for health-related social needs benefits, designed to support members experiencing significant life changes. These benefits include:
- Housing benefits: Addressing housing insecurity can be a critical component of overall health.
- Nutrition benefits: Access to adequate nutrition is fundamental to health and wellbeing.
OHP Dental Specifics
OHP Dental offers dental-only benefits for qualifying Oregon Veterans and Compact of Free Association (COFA) citizens. More information can be found about these programs at OHP’s dental-only programs.
Qualified Medicare Beneficiary (QMB) Program
It’s important to note that the Qualified Medicare Beneficiary (QMB) program operates differently. QMB does not cover direct health care services. Instead, it assists with Medicare costs, covering premiums, copayments (excluding Medicare Part D), and deductibles.
Frequently Asked Questions and Getting Started with OHP
For common questions and more details about the application process, visit the Apply for OHP page.
Starting to use your OHP benefits involves a few key steps:
- Understand your Coordinated Care Organization (CCO): Your CCO is a valuable resource to help you access the care you require.
- Choose a provider: Selecting a healthcare provider who accepts OHP is essential for accessing services.
- Schedule an appointment: Once you have a provider, making an appointment is the next step to receiving care.
For new OHP members, the New to OHP page offers further guidance on getting started.
If you experience changes in your circumstances, such as address or income, it’s important to report these changes to OHP. Learn how to report changes to OHP.
Important Note Regarding Private Health Insurance: If you are eligible for OHP Plus benefits but choose to enroll in a private Qualified Health Plan (QHP) through HealthCare.gov:
- Canceling your OHP does not affect your OHP Plus eligibility.
- As long as you qualify for OHP Plus, you will not be eligible for financial assistance to cover the monthly premiums of a QHP, and you would be responsible for the full cost.
Understanding your OHP coverage empowers you to access the healthcare services you need. By familiarizing yourself with your benefits and the resources available, you can confidently navigate your healthcare journey with OHP.
