What Is the Oregon Health Plan (OHP)?

The Oregon Health Plan (OHP) is a program that pays for health care for low-income Oregonians. The State of Oregon and the U.S. Government’s Medicaid program pay for it.

What Is a Coordinated Care Organization (CCO)?

PacificSource Community Solutions is a Coordinated Care Organization (CCO). We are a group of all types of health care providers. We work together on behalf of people in our community who are on OHP. With a CCO, you can get all of your health care services from the same plan.

What Is Covered?

These are examples of services that may be covered. Some benefits are limited depending on your age and if you are pregnant:

• Care for you before your baby is born
• Care for your newborn baby
• Check-ups (medical and dental)
• Drug and alcohol treatment services
• Dental care (exams, cleanings, x-rays)
• Diagnosis (services to find out what is wrong)
• Emergency care
• Family planning supplies (condoms and birth control pills)
• Help to quit using tobacco products, alcohol or drugs
• Hearing aids and hearing aid exams
• Hospital care
• Immunizations (shots) and vaccines
• Interpreter services
• Labor and delivery
• Laboratory tests and x-rays
• Mental health care
• Physical, occupational and speech therapy
• Preventive screenings (mammograms and pap smears (women) and prostate exams (men))
• Prescription drugs
• Transportation to a medical appointments
• Urgent care
• Vision care (eye exams and prescription glasses)

For more information, look at your member handbook or give us a call.

What Isn't Covered

The following services are examples of things that are not covered:

• Treatment for conditions that get better on their own, like colds
• Conditions which have no useful treatment
• Treatments that are not generally effective
• Cosmetic surgeries
• Services to help you get pregnant
• Weight loss programs

What Will I Pay?

You may have to pay for services that are covered by us if you see a provider that does not take OHP or is not part of our provider network. Before you get medical care or go to a pharmacy, make sure that they are in our network.

You can search for a provider or a pharmacy here.

You will have to pay for services if you were not eligible for OHP when you received the service. The date you became eligible for OHP is on your OHP coverage letter from DMAP. You will have to pay for services not covered by OHP if you sign a detailed Agreement to Pay (a waiver) for that specific service before you receive it.

Even if your service is covered by OHP, you may have to pay a copay. You can’t be denied services if you can’t make your copay, but you will still owe the money to your provider.

How do I change my Primary Care Provider (PCP)?

Give us a call. We are happy to help you find a new PCP. You can change your PCP up to two times per year. You can also download the PCP change form, fill it out and return it to us.

I want to see a specialist, what should I do?

If you think you need to see a specialist or other provider, make an appointment with your PCP first. Your PCP will decide what services and tests you may need.

I received two ID cards in the mail – an OHP card and a PacificSource Member ID card. Which do I show to the doctor?

Take your PacificSource ID card to all of your healthcare appointments. Also take it to the pharmacy when you fill a prescription. Keep your OHP ID card in a safe place at home.

Who do I call for dental services?

Call the dental plan listed on your PacificSource Member ID card.

What if I become pregnant?

As soon as you know you are pregnant, call your DHS caseworker. Your caseworker will make sure you don’t lose medical coverage before your baby is born. If you don’t have a caseworker, call OHP at (800) 699-9075.

Care while you are pregnant is very important. Call your PCP to make an appointment for prenatal care. Or, if you’d like, you can select your own obstetrician or prenatal care provider from our Provider Directory.

You will need to call OHP Customer Service or your caseworker if your pregnancy ends.

My doctor sent me a bill. What should I do?

Don’t pay the bill. Call us right away so we can help.

I just moved. What should I do?

Tell your caseworker as soon as possible. If you don’t have a caseworker, call OHP Customer Service at (800) 699-9075.

I’m a new member and want to know if my medications are covered.

PacificSource has a list of covered drugs called a formulary. Pharmacists and doctors decide which drugs should be on the list. Some drugs have additional requirements or limits on coverage.

If you have questions about the list of drugs, or you want us to mail you a copy, give us a call.

You can also find the list online at www.CommunitySolutions.PacificSource.com/Search/Drug.

What if I have both Medicare and Medicaid?

Some people are eligible for both Medicare and Medicaid. They are called “dual eligible” members.

Medicaid (OHP) serves people of any age who have limited income and assets. Medicare serves people who fit at least one of the following descriptions, regardless of income:

• Age 65 or older
• Any age with kidney failure or long-term kidney disease
• People with permanent disabilities who are unable to work

If you are a PacificSource Community Solutions member and you have Medicare coverage, we can help you enroll in a PacificSource Medicare plan. Depending on your location, you may have the option to enroll in a Medicare Advantage with an affiliated carrier.

A PacificSource Medicare Advantage plan will cover your Medicare benefits and prescription drugs covered by Medicare.