information Green booklet Oregon Health Plan (ohp) - ohp 9025

This booklet gives information about:

citizenship and identity (pages 4-8)

care plan (pages 10-11)

are available now (pages 13 and 28)

15)

resources that are available (pages 25-27)

What is DHS? ..........................................................................1

What is CHIP? .........................................................................1

When will you hear from us? ...................................................2

Why do we want to know about everyone who

lives with you? .........................................................................2

Using a mailing address ..........................................................3

Why we need Social Security numbers ...................................4

U.S. citizenship and identity requirements ..............................4

OHP premiums ........................................................................9

Managed care........................................................................10

Eligibility requirements...........................................................13

Non-discrimination statement ................................................15

OHP rights and responsibilities .............................................16

Notice of privacy practices.....................................................18

Other health resources ..........................................................25

Domestic violence resources.................................................28

The Department of Human Services (DHS) is Oregon’s

statewide health and human services agency. The following

divisions are part of DHS:

determines eligibility for programs that provide health care,

cash assistance, and food benefits to people with low

incomes. CAF also ensures that health care is provided for

children in foster care and adoptive placements.

DMAP runs the Medicaid part of the Oregon Health Plan

(OHP). This means DMAP contracts with health care

providers to provide health care to people covered by OHP.

SPD determines eligibility for programs that provide health

care to people who have low income and are disabled, or

blind, or over 65 years of age.

The Oregon Health Plan (OHP) is a state program of health

care for people with low incomes. This health care includes

services for medical care, dental care, mental health and

substance abuse treatment.

Depending on which benefit package you are found eligible

for, OHP benefits may:

were found eligible.

coverage.

receive.

The Children’s Health Insurance Program (CHIP) is a federal

program for children under age 19. DHS workers review OHP

applications for CHIP eligibility.

There are many ways that you may be eligible for OHP. We

will use your completed OHP application to see if you are

eligible for any DHS Medical Program.

Oregon has other health insurance programs that may be

available to you. See the "Other Health Resources" on page

25 for more information.

DHS has 45 days from the date of your request to see if you

qualify. If you are eligible, we will

send you a letter telling you when

your benefits start.

If you have not heard from us within

this time, you may call OHP Central

branch office at 800-699-9075 or

TTY 800-735-2900. Be ready to

give your name and date of birth.

In question 2 on the application we ask that you list everyone

who lives with you. However, we may not need income and

other information about everyone in your household.

If you are 19 or older, we want you to answer questions 3-20

for you and the following people if they live with you:

Anyone else living with you that wants medical benefits, must

apply separately.

There are some exceptions to this if you are under 19 and

married or are under 19 and homeless. Call OHP Central

branch office at 800-699-9075 or TTY 800-735-2900 for

instructions.

Once you are found eligible for OHP, you will begin receiving a

DMAP Medical Care ID monthly by mail. It is important that we

have your correct address. If we don’t have a way to reach you

by mail, you could lose your coverage.

You may want or need to use a mailing address if you:

can also be your "contact" address (see page 13 for more

information), or

You may only use a Post Office (PO) box number if you:

can also be your "contact" address (see page 13 for more

information).

All material will be mailed to your mailing address.

Important: Even if you use a mailing address, we still must

have your home address. If you are homeless, write

"homeless" for your home address and give the zip code for

the place you mainly stay.

The federal laws listed below require anyone applying for

medical benefits to give DHS their Social Security number

(SSN). This requirement does not apply to anyone who is not

applying for benefits. Federal laws (42 USC 1320b-7(a), 7

We will use the SSNs you give us to:

used to verify income, other assets, and to match with other

state and federal records such as IRS, Medicaid, child

support, Social Security and unemployment benefits.

funding sources for the program you apply for or receive

benefits from.

We may use or disclose the SSNs you give to us:

receive benefits from.

benefits.

household.

Most people who are applying for medical benefits need to

show proof of U.S. citizenship and proof of identity.

This requirement does not apply to people who are:

or Social Security Disability Insurance (SSDI).

asking for benefits for the children would only need to

provide the children’s proof of citizenship and identity).

Assistance to Needy Families – TANF).

The documents listed on the next pages can be used to prove

U.S. citizenship and identity.

We must look at your original documents or copies certified

by the issuing agency. We cannot accept photocopies. This

means that you must:

800-699-9075 or TTY 800-735-2900 for locations), or

documents, we will mail them back to you.

You are only required to prove your U.S. citizenship and

identity for DHS benefits once.

If you were born in Oregon after 1920, we may be able to

look up your birth certificate electronically. Remember, a birth

certificate only proves U.S. citizenship. You will still be required

to give us proof of identity.

If you do not have the documents you need, call your local

DHS field office or 800-699-9075 or TTY 800-735-2900:

Pages 7 and 8 list information about how to order birth

certificates from other states and how to get photo ID.

Make sure you return your application as soon as possible,

even if you don’t have all of the documents you need.

The following documents prove both U.S. citizenship and

identity. If you have one of these documents, we do not need

anything else from you.

The following documents only prove your U.S. citizenship. You

must also provide one of the documents listed under "Proof of

identity." This is not a complete list of documents. Some of the

documents listed must meet certain requirements or contain

specific information. For more information, call your local DHS

field office or 800-699-9075 or TTY 800-735-2900.

by the Department of State

U.S. Citizen

Abroad

issued by the Department

of Homeland Security with

the classification code

"KIC"

employment by the U.S.

government before June

1976

service showing a U.S.

place of birth

insurance records

records showing U.S.

citizenship

papers

hospital) records

be used in very rare

circumstances

documents that was

created at least 5 years

before applying for medical

benefits for the first time:

census record

tribal census records of

the Navajo Indians

Statistics official

notification of birth

registration

birth record that is

amended more than 5

years after the person’s

birth, or

the physician or midwife

who was in attendance

at the time of birth

The following documents only prove identity. You must also

provide one of the documents listed under "Proof of U.S.

citizenship." This is not a complete list of documents. Some

of the documents listed must meet certain requirements or

contain specific information. For more information, call your

local DHS field office or 800-699-9075 or TTY 800-735-2900.

license

federal, state, or local

government with the same

information included on

driver’s licenses

or other U.S. American

Indian/Alaska Native tribal

document

record

person’s picture

license

Merchant Mariner card

card

signature on the

application is considered

proof of identity for

children under age 16

when no other identity is

available.

The Oregon Department of Motor Vehicles (DMV) issues

photo IDs to people of any age. There is a cost and you will be

required to show proof of age, identity and address. For more

information:

You can order your birth certificate by contacting the state you

were born in (phone numbers are listed below). The Centers

for Disease Control and Prevention’s Web site lists information

about how to order birth certificates from each state at:

Alabama

334-206-5418

Alaska

907-465-3391

Arizona

602-364-1300

Arkansas

501-661-2174

California

916-445-2684

8am - noon

Colorado

303-692-2200

Connecticut

860-509-7897

Delaware

302-744-4549

Dist. of

Columbia

202-783-1809

Florida

904-359-6900

Georgia

404-679-4701

Hawaii

808-586-4533

Idaho

208-334-5988

Illinois

217-782-6553

Indiana

317-233-2700

Iowa

515-281-4944

Kansas

785-296-1400

Kentucky

502-564-4212

Louisiana

504-568-5152

Maine

207-287-3181

Maryland

410-764-3038

Massachu-

setts

617-740-2600

Michigan

517-335-8656

Minnesota

651-201-5970

Mississippi

601-576-7450

Missouri

573-751-6387

Montana

406-444-2685

Nebraska

402-471-2871

Nevada

775-684-4280

New

Hampshire

603-271-4654

New Jersey

609-292-4087

New Mexico 505-827-0121

New York

City

212-788-4520

New York

State

518-474-3075

North

Carolina

919-733-3526

North Dakota 701-328-2360

Ohio

614-466-2531

Oklahoma

405-271-4040

Oregon

971-673-1190

Pennsylvania 724-656-3100

Rhode Island 401-222-2811

South

Carolina

803-898-3630

South Dakota 605-773-4961

Tennessee

615-741-1763

Texas

512-458-7111

Utah

801-538-6105

Vermont

802-863-7275

Virginia

804-662-6200

Washington

360-236-4300

West Virginia 304-558-2931

Wisconsin

608-266-1371

Wyoming

307-777-7591

Some adult clients are required to make a monthly payment

for health care coverage. This monthly payment is called a

premium.

The amount of your premium is based on your gross income

and family size. The premium amount stays the same until you

reapply.

If you are required to pay a premium, a bill will be mailed to

you each month. You must pay your premium every month,

even if you didn’t see your health care provider. Your premium

will begin the date your coverage begins.

OHP does not charge premiums to clients who are:

through an Indian Health Services program (see page 15

for requirements),

(TANF),

standard,

care services,

(CAWEM) program.

You will not lose coverage during your current enrollment

period just because you have a past-due premium. However,

when your enrollment period is ending and you reapply, you

will need to pay all billed premiums before you can qualify for

another six months of coverage.

You will receive a notice when it is time to reapply. When

you reapply, your worker will tell you if you have past-due

premiums and give you a deadline by which to pay them. If

Any clients in the household (children, for example) who are

not required to pay premiums may still reapply. If they are

eligible, these clients will continue to receive benefits even if

others in the household do not renew their coverage.

When you apply for the OHP, you may need to choose a type

of Managed Care, either an OHP Managed Care Plan and/or

Primary Care Manager (PCM) (see "Exceptions" on the next

page).

With your application you may receive one of the following:

OHP Medical and Dental Plans you can choose from in

your area.

Plans that are not available in your area at this time.

are no OHP Medical Plans available to you and you must

choose a PCM. Your PCM will provide the same types of

care that you would get through an OHP Medical Plan. Your

PCM will be your Primary Care Provider.

Write the name of the OHP

Medical Plan or PCM and

OHP Dental Plan you choose

in question 17.

If you do not choose an OHP

Managed Care Plan and/or

PCM, your application may be

delayed or denied.

If you are reapplying for OHP benefits you will not receive a

comparison chart or PCM list. You will remain in your current

OHP Managed Care Plan and/or PCM unless you write new

names in question 17.

Below are reasons you will not be enrolled in an OHP

Managed Care Plan or with a PCM. If any of these apply to

you, follow the instructions listed for your exception.

1) There are no OHP Managed Care Plans and/or PCMs

available in your area write "none available."

2) You are an American Indian/Alaska Native or eligible for

benefits through an Indian Health Services program, write

"AI/AN." See page 15 for more information and instructions.

3) You are already seeing a provider who is not part of an

available OHP Medical Plan and you:

OHP Medical Plan after the surgery), or

currently enrolled in an OHP Medical Plan (you will need

to choose an OHP Medical Plan after the baby is born).

Send a note with your application explaining this to us.

4) You are seeing a provider who is not part of an available

OHP Dental Plan and you have a dental surgery scheduled.

Send a note with your application explaining this to us. You

will need to choose an OHP Dental Plan after the surgery.

5) You have been diagnosed with End Stage Renal Disease

(ESRD) or receive routine dialysis treatment, or you have

received a kidney transplant within the last 36 months.

If any of these are true about you or anyone you are

applying for, you must check yes in question 6 on your

application. If this person is age 19 or over, complete Part

A of the Disability Information (OHP 7214) form in the

Oregon law (ORS 192.518 to 192.526) allows DHS and OHP

Managed Care Plans to share the following protected health

information, without your authorization, with an OHP Managed

Care Plan for the purpose of treatment activities when the

OHP Managed Care Plan is providing behavioral or physical

health services to you:

provided to you:

Page 18 of this booklet gives information about DHS privacy

practices and your privacy rights in the DHS Notice of Privacy

Practices.

To help determine your eligibility we look at the size of your

family, gross income, and resources:

includes things like money from

a job, child support, workers’

compensation, and unemployment.

checking and savings accounts,

stocks, and bonds. Your home and

car do not count as resources.

You must send proof of the income you listed. Proof can be a

copy of your pay stubs, or a letter from your employer or the

person who paid you. A letter from your employer must include

a contact name and phone number.

If your partner or spouse makes you afraid by threatening,

yelling, or physically hurting you or your children, you may be

a victim of domestic violence.

If you are a victim of domestic violence, check yes in question

12 on your application. See page 28 for more information

about domestic violence.

Special rules apply to victims of domestic violence. If you have

questions, call OHP Central branch office at 800-699-9075 or

TTY 800-735-2900. As a victim of domestic violence you:

more information), and

care coverage from absent parents if there are safety

concerns for you or your children.

To get information on safe ways to pursue child support and

health care coverage, contact your local DHS (listed under

Department of Human Resources) or child support office

(listed under Department of Justice) in the "State" section of

your telephone book.

If you are a full-time higher education student (not including

Adult Basic Education [ABE], English as a Second Language

[ESL], General Education Development [GED] or high school

equivalency programs), you may be eligible if you have:

for the 2007/2008 school year or are eligible for a Pell

Grant, and

major medical health insurance,

or an HMO in the last six months

(other than OHP coverage).

If you meet these requirements, send

a copy of the first page of your current

Student Aid Report (SAR) with your

completed OHP application.

Your SAR will show your EFC. To

receive an SAR you must apply for

financial aid using the Free Application

for Federal Student Aid (FAFSA).

People with certain disabilities may qualify for a higher level of

medical coverage.

If anyone you are applying for has a disability, check yes in

question 6. If the person with the disability is 19 or older, you

must also complete Part B of the Disability Information (OHP

DHS defines American Indians/Alaska Natives as follows:

group, or

Secretary of the Interior pursuant to the Alaska Native

Claims Settlement Act, 43 U.S.C. 1601, or

Services program.

If you are an American Indian/Alaska Native, check yes

in question 8 on your application. American Indian/Alaska

Natives:

Plan or receive health care services through an Indian

Health Services program or a federally recognized tribal

clinic. If you would like to continue receiving services

through an Indian Health Services program or federally

recognized tribal clinic, write "AI/AN" in question 17.

If you meet DHS’ definition of an American Indian/Alaska

Native, you must send a copy of one of the following proofs

with your completed application:

eligibility.

DHS will not discriminate against anyone.

This means DHS will help all who qualify.

DHS will not deny help to anyone based on age, race, color,

national origin, sex, religion, political beliefs or disability.

You can file a complaint if you think DHS treated you differently

because of any of these reasons.

The following are your rights and responsibilities under the

OHP. Please read them carefully to be sure you understand

them. Ask questions if you do not understand.

care coverage from absent parents. This is if you think the

absent parent would cause harm to you or your child.

must release it to operate the OHP.

have 45 days from the date of the notice to do this. You

must use the Administrative Hearing Request form (DHS

443). You can request this form from any DHS office. We

can help you fill it out.

coverage from absent parents unless you think the absent

parent would cause harm to you or your child.

if health insurance becomes available through an

employer)

before using OHP benefits.

or request a hearing through DMAP if you have problems

getting health care.

for may qualify. For example: unemployment compensation,

Social Security, railroad retirement, Veterans’ benefits,

lodge and union benefits, Workers’ Compensation benefits,

medical insurance, Medicare, and other benefits.

child or unborn child who has an absent parent, unless:

your child, or

Program benefits, or

coverage for yourself.

Working with the Child Support Program can mean:

parent.

(establishing paternity).

expenses.

"Support" means money you get for you or your children,

like alimony or child support. It includes cash ordered to

help you pay for your child’s medical expenses.

When you get DHS medical coverage for your child, you

are "assigning" the state the right to keep the cash medical

support anyone in your family gets from another person.

The money goes to repay the state for the medical benefits

your child gets.

This means that while you are getting DHS medical

benefits, the state will keep all cash medical support

payments received for you to help pay for your child’s

medical expenses.

This notice describes how medical information about you may

be used and disclosed and how you can get access to this

information. Please review it carefully.

The Department of Human Services (DHS) is required to tell

you about our privacy practices for health information. The

Notice of Privacy Practices will tell you how DHS may use

or disclose health information about you. This information is

called Protected Health Information (PHI). Not all situations will

be described. DHS is required to protect health information by

federal and state law. DHS is required to follow the terms of

the notice currently in effect.

For treatment. DHS may use or disclose PHI with health

care providers who are involved in your health care. For

example, information may be shared to create and carry out

a plan for your treatment.

For payment. DHS may use or disclose PHI to get payment or

to pay for the services you receive. For example, DHS may

provide PHI to bill your health plan for health care provided

to you.

For health care operations. DHS may use or disclose PHI in

order to manage its programs and activities. For example,

DHS may use PHI to review the quality of services you

receive.

you reminders for medical care or checkups. DHS may send

you information about health services that may be of interest

to you.

For public health activities. DHS is the public health agency

that keeps and updates vital records, such as births and

deaths. DHS is the public health agency that tracks and

takes action to control some diseases.

For health oversight. DHS may use or disclose PHI for

government health care oversight activities. Examples are

audits, investigations, inspections, and licenses.

For law enforcement and as required by law. DHS will

disclose PHI for law enforcement and other purposes as

required or allowed by federal or state law.

For disputes and lawsuits. DHS will disclose PHI in

response to a court order. DHS will disclose PHI in response

to an administrative order. If you are involved in a lawsuit

or dispute, DHS may share your information in response to

legal requirements.

Worker’s compensation. DHS may disclose PHI as allowed

by law to worker’s compensation or like programs.

For abuse reports and investigations. DHS is required

by law to receive reports of abuse. It is also required to

investigate reports of abuse.

For government programs. DHS may use and disclose

PHI for public benefits under other government programs.

An example would be to figure out Supplemental Security

Income (SSI) benefits.

To avoid harm. DHS may disclose PHI in order to avoid a

serious threat to your health and safety or to the health and

safety of a person or the public.

For research. DHS uses PHI for studies and to develop

reports. These reports do not identify specific people.

a deceased person to a coroner. DHS may also share

information about a deceased person to a medical examiner

or to a funeral director.

Disclosures to family, friends, and others. DHS may

disclose PHI to your family or other persons who are

involved in your health care. You have the right to object to

the sharing of this information.

For disaster relief. Should there be a disaster, DHS may

disclose information about you to any agency helping in

relief efforts. DHS may share information about you to tell

your family about your condition or location.

authorization. For other purposes, DHS will ask for your

written permission before using or disclosing PHI. You may

cancel this permission at any time in writing. DHS cannot

take back any uses or disclosures already made with your

permission.

Other laws protect PHI. Many DHS programs have other

laws for the use and disclosure of health information about

you. For example, usually you must give your written

permission for DHS to use and disclose your mental health

and chemical dependency treatment records.

When information is kept by DHS for its work as a public

health agency, other state and federal laws govern the public

health records. The public health records are not subject to the

rights described below.

Right to see and get copies of your records. In most cases,

you have the right to look at or get copies of your health

records. You must make the request in writing. You may be

charged a fee for the cost of copying your records.

You may ask to change or add missing information to health

records DHS created about you, if you think there is a

mistake. You must make the request in writing, and provide

a reason for your request. DHS may deny your request in

certain circumstances.

Right to get a list of disclosures. You have the right to ask

DHS for a list of your PHI disclosures made after April 14,

2003. You must make the request in writing. This list will

not include the times that information was disclosed for

treatment, payment, or health care operations. The list will

not include information provided directly to you or your

family, or information that was sent with your authorization.

If you request a list more than once during a 12-month

period, you may be charged a fee.

You have the right to ask that DHS limit how your health

information is used or disclosed. You must make the

request in writing and tell DHS what information you want

to limit and to whom you want the limits to apply. DHS is

not required to agree to the restriction. You can request in

writing or verbally that the restrictions be ended.

Right to revoke permission. If you are asked to sign an

authorization to use or disclose PHI, you can cancel that

authorization at any time. You must make the request in

writing. This will not affect information that has already been

shared.

the right to ask that DHS share PHI with you in a certain

way or in a certain place. For example, you may ask DHS to

send information to your work address instead of your home

address. You must make this request in writing. You do not

have to explain the reason for your request.

Right to file a complaint. You have the right to file a

complaint if you do not agree with how DHS has used or

disclosed health information about you.

Right to get a copy of this notice. You have the right to ask

for a copy of this notice at any time.

To use any of the privacy rights listed in this notice, you may

contact your local DHS office. You may also contact the

Governor’s Advocacy Office at the address listed at the end of

this notice. DHS may deny your request.

If DHS denies your request, DHS will send you a letter that

tells you the reason. DHS will tell you how you can ask for a

review of the denial.

You may contact any of the people listed below if you want to

file a privacy complaint. You may also contact them to report

a problem with how DHS has used or disclosed your health

information.

Your benefits will not be affected by any complaints you make.

DHS cannot hold it against you if you file a complaint. DHS

cannot hold it against you if you cooperate in an investigation.

DHS cannot hold it against you if you refuse to agree to

something that you believe to be unlawful.

Governor’s Advocacy Office

500 Summer St. NE, E17

Salem, OR 97301-1097

Phone: 800-442-5238

Fax: 503-378-6532

U.S. Department of Health and Human Services

2201 Sixth Ave - Mailstop RX-11

Seattle, WA 98121

Phone: 800-368-1019

TTY: 800-537-7697

You can contact the DHS Privacy Officer if you have any

questions about this notice. You can contact the DHS Privacy

Officer if you need more information on privacy.

State of Oregon DHS Privacy Officer

500 Summer St. NE, E24

Salem, Oregon 97301

Phone: 503-945-5780

Fax: 503-947-5396

In the future, DHS may change its Notice of Privacy Practices.

Any changes will apply to information DHS already has. It will

also apply to information DHS receives in the future.

A copy of the new notice will be posted at each DHS site and

facility. A copy of the new notice will be provided as required

by law. You may ask for a copy of the current notice anytime

you visit a DHS facility. You can also get a copy of the current

notice on-line, at

Each of the programs listed in this section have different

eligibility requirements. For more information, or to apply for

any of these programs, call the toll-free number or go to the

Web site address listed.

You may be eligible for Medicare if you:

There are premiums for some parts of the program.

Medicare offers its members hospital and medical insurance.

Medicare does not cover long-term care or prescriptions and

usually does not pay for all of the medical care needed by

its members. Medicare members may be eligible for other

programs listed in this section.

The state program, called Qualified Medicare Beneficiaries

(QMB) helps low-income people pay the cost of Medicare. To

apply for this program, call your local Seniors and People with

Disabilities Division (SPD) or Area Agency on Aging (AAA)

office or 800-282-8096 or TTY 800-735-2900.

Call FHIAP or visit their Web site for current eligibility

requirements. FHIAP may not have openings for new

members when you call. However, FHIAP sends applications

out on a first-come, first-served basis so it’s a good idea to put

your name on the FHIAP Reservation List.

As a FHIAP member you will pay a percentage of your

insurance premium costs and any copayments or deductibles

that your health insurance plan requires.

FHIAP will help members pay for health insurance plans

offered by employers or the private insurance market.

Anyone who has been turned down for health insurance

because of a pre-existing medical condition.

Costs vary by age and location.

OMIP allows you to purchase insurance from private

companies who are part of the program. OMIP is not a low-

cost health insurance program. FHIAP can help pay the costs

for this program.

All Oregon small businesses and individuals needing

assistance obtaining health insurance.

Free

OPHP provides assistance, education, and agent referrals to

all small businesses and individuals in making informed health

insurance choices.

Veterans of the U.S. Armed Forces, their spouse, widow, or

child.

Free consultation. Some veterans’ affairs medical services

require a copayment.

Veterans’ benefits include:

The ODVA will help you seek benefits from the federal

Department of Veterans’ Affairs (VA) and other veterans

programs.

Domestic violence affects the entire family. We want you and

your family to be safe. No one deserves to be abused.

If you are a victim of domestic violence, you can get help in

one of the following ways (men can also call these numbers):

local crisis provider, or

888-235-5333

800-735-2900 TTY, or

503-235-5333 in Portland, or

800-799-SAFE

800-787-3224 TTY

The following is a list of some of the warning signs of an

abusive relationship. You may be in an abusive relationship if

your current or past partner or spouse:

chokes you, or

No one deserves to be abused. You have a right to be safe

from harm. If you are a victim of domestic violence, you

are not alone. Call one of the numbers shown above for

confidential help in creating a safety plan and to get support