yamhillcco.org

Your Benefits & Your Rights

We want you to know that as a YCCO member on the Oregon Health Plan, you have access to specific benefits and rights such as: 

  • Physical Health Care
  • Dental Health Care
  • Mental Health Care
  • Medical Transportation
  • Vision and Eye Care
  • Childbirth
  • Hospice Care
  • Alcohol and Drug Treatment

The Benefits you have may be different, please look at your ID card. If you have any questions, please call customer service.

Yamhill Community Care Benefit List

Doctor VisitsAuthorization/Referral?Limits to Care?
Primary Care (PCP) visitsNo approval or referral neededNo limit but you must see your PCP
Specialty visitsNo approval or referral neededNo limit but services must be covered by OHP
Preventative ServicesAuthorization/Referral?Limits to Care?
Well-child visits for babies, children, and teensNo approval or referral neededAs recommended
Routine physicalsNo approval or referral neededAs recommended
Well-women visitsNo approval or referral neededAs recommended
Mammograms (breast X-rays)No approval or referral neededAs recommended; 3D mammograms not covered
Family planningNo approval or referral neededNo limit
Prostate examsNo approval or referral neededNo limit
Stop smokingNo approval or referral neededNo limit
Sexually transmitted infection (STI) screeningNo approval or referral neededNo limit
Testing and counseling for HIV and AIDSNo approval or referral neededNo limit
Prescription DrugAuthorization/Referral?Limits to Care?
Many drugs are available with a prescription. A full list of prescription drugs can be found on the “formulary.” To search the formulary or print a copy go to https://yamhillcco.org/for-members/drug-list/You may need approval, also called “prior authorization”, in addition to your prescription. Your doctor will let you know if you need authorization.Limits vary by prescription drug. Call Pharmacy Customer Service for more info at 877-216-3644
Mental health prescription drugs are not covered by your medical or mental health plan. They are covered by OHP. Your pharmacist will know where to send the bill.Contact OHPContact OHP
Laboratory and X-RayAuthorization/Referral?Limits to Care?
Blood DrawYou need an order from your providerNo limit
X-RaysYou need an order from your providerNo limit
CT ScansYou need an order from your providerNo limit
MRIPrior approval neededNo limit
Immunizations (Shots)  
VaccinesNo approval or referral neededProvider recommended and OHP covered vaccines only. Contact Customer Service for more info.
    Pregnancy Care    Authorization/Referral?Limits to Care?
Prenatal visits with your providerNo approval or referral neededNo limit
Postpartum care (care for the mother after the baby is born)No approval or referral neededNo limit
Routine vision services (pregnant women qualify for vision care)Call Customer Service for more infoCall Customer Service
Help with breast feeding, including breast pumpsNo approval or referral neededCall Customer Service
Labor and deliveryNo approval or referral neededCall Customer Service
Hospital StaysAuthorization/Referral?Limits to Care?
EmergenciesNo approval or referral neededNo limit
Scheduled SurgeryYes, approval is neededCall Customer Service
VisionAuthorization/Referral?Limits to Care?
Routine eye examsNo approval or referral needed

Yes, One exam every 24 months.

For pregnant women and people age 20 or younger only. Call Customer Service for more info.

Eye glassesCall Customer Service

Yes, One pair of glasses every 24 months.

For pregnant women, those with a qualifying medical condition and people age 20 or younger only. Call Customer Service for more info.

Medical eye examsNo approval or referral neededYou must have a covered medical condition. Call Customer Service for more info.
PT/OT/STAuthorization/Referral?Limits to Care?
Physical therapy (PT)Yes, approval is neededCall Customer Service
Occupational therapy (OT)Yes, approval is neededCall Customer Service
Speech therapy (ST)Yes, approval is neededCall Customer Service
Other Specialty ServicesAuthorization/Referral?Limits to Care?
Medical equipment and suppliesYes, approval is neededCall Customer Service
Hearing aids and examsYes, approval is neededCall Customer Service
Home healthYes, approval is neededCall Customer Service
Skilled nursing facilitiesYes, approval is neededCall Customer Service
HospiceYes, approval is neededCall Customer Service
ChiropractorYes, approval is neededCall Customer Service
AcupunctureYes, approval is neededCall Customer Service
Hormone therapy / sex reassignment surgeryYes, approval is neededCall Customer Service

Oregon Health Plan benefits not covered by YCCO

Some services are covered by OHP Fee-for-Service but are not covered by YCCO. For more information on these services call OHP Customer Service at 800-699-9075 or download the OHP handbook on the Member Handbook page. 

Fee-for-Service Examples

  • Midwife home delivery
  • Mental health medications
  • Therapeutic Abortions
  • Long term care services

Want to learn more about your Benefits and rights?

Learn about what’s included in your plan, with full descriptions of your benefits and rights. Download the YCCO Member Handbook in English or Spanish. Please go to our Member Handbook page to download the handbook. 

Your OHP Handbook is a great resource, too!

The Oregon Health Plan has their own handbook, and can be a great resource for you to have as a YCCO member on the Oregon Health Plan. Visit the Member Handbook page to download the OHP Handbook.

 

Your Right to Quality

Coordinated Care

As a YCCO member on the Oregon Health Plan you have rights, such as the ones below.

  • Not feel like you are being treated differently, or discriminated against.
  • Receive care that provides choice, independence and dignity.
  • Be actively involved in making your treatment plan.
  • Be free to report complaints to YCCO, the Oregon Health Authority, the Bureau of Labor and Industries, or the Office of Civil Rights.

Your Rights Expanded

Click on the tabs below to learn more about your rights as a member of Yamhill Community Care on the Oregon Health Plan.

Appeals and Hearings

If we deny, stop, or reduce a service your provider asks for, we will mail you a Notice of Action/Adverse Benefit Determination (NOABD)  letter explaining why we made that decision. If you do not get a NOABD or your provider tells you a service has been denied and you must pay for it you can call Customer Service and ask for one to be sent to you.

Once you receive it you can appeal your denial. You, your provider with your written consent or your authorized representative have a right to ask to change it through an appeal and a state fair hearing. You must first ask for an appeal no more than 60 days from the date on the NOABD letter.

If your appeal decision does not change the denial you can then ask for a state fair hearing. You must ask for a hearing within 120 days from the date on the Notice of Appeal Resolution (NOAR)  letter.

How to appeal a decision

In an appeal, a different health care professional at YCCO will review your case. Ask us for an appeal by:

  •         Calling Customer Service at 855-722-8205 (TTY 711).
  •         Writing us a letter.
  •         Filling out an Appeal and Hearing Request, form number OHP 3302 or MSC 443

Mail or Fax your letter of form to:

Yamhill Community Care

Attn: Appeals and Grievances

P.O. Box 4158

Portland, OR 97208

Fax: YCCO Appeals Coordinator at  503-574-8757

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.

You will get a NOAR from us in 16 days letting you know if the reviewer agrees or disagrees with our decision.

If we need more time to do a good review, we will send you a letter saying why we need up to 14 more days.

Dual-eligible Members And Appeal Rights

If you are enrolled in both YCCO and Medicare, you may have more appeal rights than those listed. Call Customer Service at 855-722-8205 for more info. You can also call Medicare to find out more on your appeal rights with them.

Continuing Benefits During Appeal

If you were getting the benefits we denied prior to the denial, you can keep getting them during your appeal or hearing process.

You must ask for benefits to continue within 10 days of the date on the NOABD letter.

If You Need An Expedited (Fast) Appeal

If you, your provider with your written consent, or your authorized representative believe that you have an urgent medical problem that cannot wait for a regular appeal, tell us that you need a fast appeal. We suggest that you include a statement from your provider or ask them to call us and explain why it is urgent.

If we agree that it is urgent, we will call you with a decision in 72 hours or fast as your health condition requires. If more time is needed to resolve your appeal and it is in your best interest or you ask for it, we will call you or within 2 days we will send you a letter telling you why and resolve your appeal within 14 days.

How To Get An Administrative Hearing

After an appeal, you, your authorized representative, or your provider with your written consent can ask for a state fair hearing with an Oregon Administrative Law Judge.

You will have 120 days from the date on your NOABD to ask the state for a hearing.

Your NOAR letter will have a form that you can send in. You can also ask us to send you an Appeal and Hearing Request form, or call OHP Client Services at 800-273-0557, TTY 711, and ask for form number OHP 3302 or MSC 443.

At the hearing, you can tell the judge why you do not agree with our decision and why the services should be covered. You do not need a lawyer, but you can have one or someone else, like your doctor, with you.

If you hire a lawyer, you must pay their fees. You can ask the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 800-520-5292, TTY 711, for advice and possible representation. Info on free legal aid can also be found at oregonlawhelp.org.

A hearing takes more than 30 days to prepare. While you wait for your hearing, you can keep on getting a service that already started before our original NOABD decision to stop it.

You must ask the state to continue the service within 10 days of the date of our NOAR that confirmed our denial.

Once your hearing takes place and is resolved you will receive a letter (called a “Final Order” telling you the results of your hearing.

Expedited (Fast) Hearings For Urgent Healthcare Problems

If you believe your medical problem cannot wait for a review you can ask for a  fast hearing.

Fax your hearing request form to:

OHP Hearings Unit at 503-945-6035

Include a statement on a form (OHP 3302 or MSC 443) from your provider explaining why it is urgent.

OHA will decide if you are entitled to an expedited hearing within, as nearly as possible, two work days from the date they receive your fast request documents. If OHA Hearings Unit denies a fast hearing request, they will make reasonable efforts to give you prompt oral notice and mail a written notice within two days.

If OHA approves your fast hearing, upon receipt of hearing documents, OHA will resolve your fast hearing no later than three work days.

Continuing Benefits During Hearing

If you were getting the services we denied prior to the denial, you can keep getting them during your hearing process. You must ask for benefits to continue within 10 days of the date on the NOAR.

Grievance System Info

If you want more info on our Grievance System, like our policies or member templates call Customer Service or send your request by email from our website https://yamhillcco.org/contact/ or by emailing info@yamhillcco.org.

End-of-life decisions and Advance Directives (living wills)

Adults 18 years and older can make decisions about their own care, including the right to accept or refuse medical or surgical care. 

It is possible that someday you could become so sick or injured that you cannot tell your providers whether you want a certain care. If you have written an advance directive, also called a Living Will, your providers may follow your instructions.

What you should know about Advance Directives:

  •         If you do not have an advance directive, your providers may ask your family what to do.
  •         If your family cannot or will not decide, your providers will give you the standard medical care for your condition.
  •         If you do not want certain kinds of care like a breathing machine or feeding tube, you can write that down  in an Advance Directive. it lets you decide your care before you need that kind of care – in case you are unable to direct it yourself, such as if you are in a coma.

If you are awake and alert your providers will always listen to what you want.

You can get a form at most hospitals and from many providers. You also can find one online at https://www.oregon.gov/oha/PH/ABOUT/Documents/Advance-Directive.pdf

For questions or more info contact Oregon health Decisions at 800-422-4805 or 503-692-0894, TTY 711.

More things to know about Advance Directives:    

  •         If you write an be sure to talk to your providers and your family about it and give them copies.
  •         Your family and providers can only follow your instructions if they have them.
  •         Some providers and hospitals will not follow Advance Directives for religious, moral or as a matter of conscience reasons. You should ask them about this.

If you change your mind, you can cancel your Advance Directive anytime.

How to Cancel an Advance Directive

To cancel your ask for the copies back and 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.

How to Complain if YCCO Did Not Follow Advance Directive Requirements

If you think YCCO did not follow advance directive requirements you can complain. You can complain to OHA by filling out an OHA complaint form. The form is online here: https://www.oregon.gov/oha/HSD/OHP/Pages/Complaints-Appeals.aspx. You can call 971-673-0540 or TTY 711.

You can mail OHA your complaint here:

Health Care Regulation and Quality Improvement

800 NE Oregon St, #305

Portland, OR 97232

Email: Mailbox.hcls@state.or.us

Fax: 971-673-0556

Phone: 971-673-0540

TTY: 971-673-0372

If you want a paper copy of the OHA complaint form sent to you call YCCO Customer Service at 855-722-8205 (TTY 711).

Declarations for Mental Health Treatment

Oregon has a form called a Declaration for Mental Health Treatment. This form is a legal document. It allows you to make decisions now about future mental health care in case you are unable to make your own care decisions. If you do not have this form in place, and you are not able to make your own decisions, then only a court or two doctors can decide that you cannot make your own care decisions.

Learn more about a Declaration for Mental Health Treatment

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 known, this person will decide what you would want.

A declaration form is only good for three (3) years. If you become unable to decide during those three years, your declaration will remain good until you can make decisions again. You may change or cancel your declaration when you can understand and make choices about your care. You must give your form to your Primary Care

Physician and the person you name to make decisions for you.

For more information on the Declaration for Mental Health Treatment, go to the state of Oregon’s website at: https://aix- xweb1p.state.or.us/es_xweb/DHSforms/ Served/le9550.pdf.

You can talk directly with your mental health provider, if you have one.

If your provider does not follow your wishes in your Declaration for Mental Health Treatment, you can complain. A form for this is at healthoregon.org/hcrqi.

Send your complaint to:

Health Care Regulation and Quality Improvement
800 NE Oregon St, #305
Portland, OR 97232

Email: Mailbox.hcls@state.or.us Fax: 971-673-0556
Phone: 971-673-0540
TTY: 971-673-0372

How To Request A Clinical Practice Guideline

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:
Send a letter to 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

We're here to help.

Call us at 
1-855-722-8205

TTY/TDD 711

Monday – Friday
8am to 5pm