Your Benefits, Your Rights & Responsibilities

Care while you change or leave a CCO

Some members who change plans might still get the same services, prescription drug coverage and see the same providers even if they are not in-network. That means care will be coordinated when you switch CCO plans or move from OHP fee-for-service to a CCO. This is sometimes called “Transition of Care (TOC).”

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.

When you need the same care while changing plans

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.
• 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 YCCO, 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 YCCO Customer Service at: 855-722-8205 (TTY users, call 711) Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. PST

YCCO 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 YCCO 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 YCCO Transition of Care Policy by calling Customer Service at 855-722-8205.  It is also on our website on the documents and forms page in the member policies section. Please call Customer Service if you have questions.

If you want more info or a copy of the YCCO Care Coordination Policy you can call Customer Service at 855-722-8205,  it is also located here. The information above is not currently in the Care Coordination Policy and is available here TOC Additional Info.

If you need the TOC info in your language, large print, braille, or format you prefer, including oral interpretation, at no cost to you call Customer Service. You can reach Customer Service Monday through Friday, 8 a.m. to 5 p.m. at 855-722-8205 or TTY 711.

Complaints?

YCCO and our providers want you to get the best care possible.

What is a complaint?

• A complaint is letting us know you are not satisfied.
• A dispute is when you do not agree with YCCO or a provider.
• A grievance is a complaint you can make if you are not happy with YCCO, 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 Customer Service at 855-722-8205, TTY 711 or our Complaint Department at 833-257-2192 (TTY 711). If you need help in your language, just tell them. 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.

If you want to put your complaint in writing you can mail, email or fax us a letter. You do not have to use a form if you want to use the YCCO complaint form it is here. You can also use the OHP form here https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/he3001.pdf

Send your letter, email, or form the way you want to here is our contact info:

• Fax: 503-765-9675
• Mail: Yamhill Community Care
• Attn: Grievance Specialist
  P.O. Box 5490
  Salem, OR 97304
• Email: complaints@yamhillcco.org

*You may have personal info in your email put “secure” in the subject line so your info is protected.

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 YCCO
• Care you were not sure about, but got anyway
• Bills for services you did not agree to pay
• Disputes on YCCO 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.

How long does the complaint process take?
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 received the complaint explaining how we will handle it.

What if I don’t like the results of my complaint?

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 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.

More info about complaints is located in your Member handbook.

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.

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.

You have to get a denial letter before you can ask for an appeal.

Providers should not deny a service. They have to ask YCCO if you can get approval for a service.

If your provider says that you cannot have a service or that you will have to pay for a service, you can ask us for a denial letter (NOABD). Once you have the denial letter, you can ask for an appeal.

You or someone with written permission to speak for you. That could be your doctor or an authorized representative can ask for an appeal. You must ask no more than 60 days from the date on the NOABD letter.

Reasons you may file an appeal:

• You asked to be paid for mileage for non-emergent medical appointments and you were denied
• We denied, stopped, or limited a medical, dental, or behavioral health service.
• You were denied a request for a non-emergent medical transportation service

How to appeal a decision
You can ask for an appeal orally or in writing. Ask us for an appeal by:

• Calling Customer Service at 855-722-8205 (TTY 711) or our Appeal Department at 833-257-2192 (TTY 711).
• Writing us a letter.
• Emailing us at appeals@yamhillcco.org
• Filling out an Appeal and Hearing Request form number OHP 3302- it is sent with your NOABD letter. You can also get one
  • OHA 3302 Appeal and Hearing Request (English)
  • OHA 3302 Appeal and Hearing Request (Spanish) 

You can mail, fax or email your letter or form to:

• Fax: 503-765-9675
• Email: appeals@yamhillcco.org
• Mail: Yamhill Community Care                                                                      Attn: Appeals & Grievance Specialist                                                       P.O. Box 5490                                                                                                        Salem, OR 97304

If you want help with your appeal, call Customer Service and we can fill out an appeal form for you to sign.

You can ask your authorized representative, a certified community health worker, peer wellness specialist, or personal health navigator to help you. You may also call the Public Benefits Hotline at 800-520-5292 for legal advice and help.

 After I file my appeal what happens?

Once we get your request, we will look at the original decision. A new doctor will look at your medical records and the service request to see if we followed the rules correctly. You can give us any more information you think would help us review the decision.

To support your appeal, you have the right to:

• Give information and testimony in person or in writing.
• Make legal and factual arguments in person or in writing.

You must do these things within appeal timeframes listed below.

How long do you get to review my appeal?

We have 16 days to review your request and reply. If we need more time, we will send you a letter. We have up to 14 more days to reply.

What if I need a faster reply?
You can ask for a fast appeal. This is also called an expedited appeal. Ask for a fast appeal if waiting for the regular appeal could put your life, health or ability to function in danger. Call us at 833-257-2192 or fax the request form to 503-765-9675. The form will be sent with the denial letter. You can also get it at https://bit.ly/request2review.  We will call you and send you a letter, within 1 business day, to let you know we have received your request for a fast appeal.

How long does a fast appeal take?
If you get a fast appeal, we will make our decision as quickly as your health requires, no more than 72 hours from when the fast appeal request was received. We will do our best to reach you and your provider by phone to let you know our decision. You will also get a letter.

At your request or if we need more time, we may extend the timeframe for up to 14 days.

If a fast appeal is denied or more time is needed, we will call you and you will receive written notice within two days. A denied fast appeal request will become a standard appeal and needs to be resolved in 16 days or possibly be extended 14 more days.

If you don’t agree with a decision to extend the appeal time frame or if a fast appeal is denied, you have the right to file a complaint.

We will send you a letter with our appeal decision. This appeal decision letter is also called a Notice of Appeal Resolution (NOAR). If you agree with the decision, you do not have to do anything.

More info about appeals is located in your member handbook.

Still don’t agree? Ask for a hearing.

You have the right to ask the state to review the appeal decision. This is called asking for a hearing. You must ask for a hearing within 120 days of the date of the appeal decision letter (NOAR).

What if I need a faster hearing?
You can ask for a fast hearing. This is also called an expedited hearing.

Use the online hearing form at https://bit.ly/ohp-hearing-form to ask for a normal hearing or a faster hearing.

You can also call the state at 800-273-0557 (TTY 711) or use the request form that will be sent with the letter. Get the form at https://bit.ly/request2review. You can send the form to:

• OHA Medical Hearings
  500 Summer St NE E49
  Salem, OR 97301
• Fax: 503-945-6035

The state will decide if you can have a fast hearing 2 working days after getting your request.

Who can ask for a hearing?
You or someone with written permission to speak for you. That could be your doctor or an authorized representative.

What happens at a hearing?
At the hearing, you can tell the Oregon Administrative Law judge why you do not agree with our decision about your appeal. The judge will make the final decision.

More info about hearings is located in your member handbook.

Advance Directive

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.

You can get a copy of the YCCO Advance Directive Policy by calling Customer Service at 855-722-8205. It is also on our website on the documents and forms page in the member policies section.

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                          YCCO also offers more information about advance directives on our website here https://yamhillcco.org/members/benefits-and-rights/.

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 with 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 YCCO 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.
• YCCO 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 contact YCCO Customer Service at 855-722-8205 TTY 711). Customer Service can help you get another provider that is better suited for you.

How to report if YCCO did not follow advance directive requirements

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/complaint.aspx

Call YCCO Customer Service at 855-722-8205 (TTY 711) to get a paper copy of the complaint form you want.

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.

The patient’s doctor would decide if POLST fits their needs. Learn more about this form on the POLST website here: https://polst.org/frequently-asked-questions-for-patients/

You can read the YCCO Advance Directive Policy and Procedure here: https://yamhillcco.org/members/documents-and-forms/

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://aixxweb1p.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

More info on Declaration for Mental Health Treatment can be found here: https://www.oregon.gov/oha/hsd/ohp/pages/decisions.aspx

A copy of the form and instructions can be found here: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le9550.pdf

You can request a copy of the clinical practice guideline that was used to make a decision about your care.

You can also review the Clinical Guidelines on our Provider pages by clicking here. 

You can make your request by doing one of the following:

Email:
Send an email to info@yamhillcco.org

Please include

• Your name
• Your email address
• The reason for your request
• The guideline you are requesting.

All emailed requests will be sent an email response.

Mail:
YCCO Quality Assurance
807 NE 3rd St
McMinnville, OR 97128

Please include:

• Your name
• Your address
• The reason for your request
• The guideline you are requesting