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

Physical Health
Covered Services

Services covered
when using an in-network provider

Physical Health Provider Visits

Is preapproval or referral required?

Amount, duration, and scope of benefits

Primary Care (PCP)
visits

No preapproval or
referral needed

No limit but you must
see your PCP

Specialty visits

No preapproval or
referral needed

No limit but services
must be covered by OHP

Telehealth
(telemedicine or virtual visits)

Some
services are not available via telehealth. Ask your provider if yours can be
done this way

No preapproval or
referral needed

No limit

Acupuncture

No preapproval or
referral is needed

Approval
based on OHP guidelines & for specific conditions

 

Call Customer Service

Limit is combined 30
visits per 12-month calendar year with OT, PT & Chiropractic

Chiropractic

No preapproval or
referral is needed

Approval based on OHP
guidelines & for specific conditions

 

Call Customer Service

Limit is combined 30
visits per 12-month calendar year with OT, PT & Acupuncture

Physical Health Preventative Services

Is preapproval or referral required?

Amount, duration, and scope of benefits

Well-child visits for
babies, children, and teens

No preapproval or
referral needed

As recommended

Routine physicals

No preapproval or
referral needed

As recommended

Well-women visits

No preapproval or
referral needed

As recommended

Mammograms (breast
X-rays)

No preapproval or
referral needed

As recommended; 3D
mammograms not covered

Family planning

No preapproval or
referral needed

No limit

Prostate exams

No preapproval or
referral needed

No limit

Early & Periodic Screening, Diagnosis,
and Treatment (EPSDT)

Is preapproval or referral required?

Amount, duration, and scope of benefits

Well-child visits for
babies, children, and teens

No preapproval or
referral needed

As recommended

Routine physicals

No preapproval or
referral needed

As recommended

Vaccines

No preapproval or
referral needed

Provider recommended
and OHP covered vaccines only

 

Call Customer Service
for more info

Help with breast
feeding, including breast pumps

No preapproval or
referral needed

No limit

Nutrition Services

No preapproval or
referral needed

No limit

Social Supports

No preapproval or
referral needed

No limit

Routine
eye exams

People
age 20 or younger

 

No preapproval or
referral needed

May need referral for
non-routine services

Limited
to 1 exam every 12 months

Call Customer Service for more
info

Eyeglasses (lenses
& frames) for
children age 20 or younger

 

 

May need a referral
& preapproval with a valid prescription from vision provider

Approval
based on OHP guidelines

 

Limited
to new glasses every 12 months

 

Call
Customer Service for more info

Hearing aids and
exams

Yes, preapproval
and/or a referral is needed

Limit and/or approval
based on OHP guidelines & type of care/aid

 

Call Customer Service
or talk to your provider

Prescription Drug

Is preapproval or referral required?

Amount, duration, and scope of benefits

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/members/pharmacy-drug-list/

You must have a
prescription from your provider and some drugs need approval. Your provider
will let you know if you need approval.

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 OHP

Contact OHP

Laboratory and X-Ray

Is preapproval or referral required?

Amount, duration, and scope of benefits

Blood Draw

You need an order
from your provider

No limit

X-Rays

You need an order
from your provider

No limit

CT Scans

You need an order
from your provider

No limit

MRI

Prior approval needed

You need an order
from your provider

No limit

Immunizations (Shots)

Is preapproval or referral required?

Amount, duration, and scope of benefits

Vaccines

No preapproval or
referral needed 

Provider
recommended and OHP covered vaccines only

 

Call Customer
Service for more info

Pregnancy Care

Is preapproval or referral required?

Amount, duration, and scope of benefits

Prenatal visits with
your provider

No preapproval or
referral needed

No limit

Postpartum care (care
for the mother after the baby is born)

No preapproval or
referral needed

No limit

Routine vision
services (pregnant women qualify for vision care)

No preapproval or
referral needed

Yes. One exam every
24 months

Help with breast
feeding, including breast pumps

No preapproval or
referral needed

No Limit

Labor and delivery

No preapproval or
referral needed

Limit is based on
type of care and delivery Talk to your provider

Hospital & Urgent Care

Is preapproval or referral required?

Amount, duration, and scope of benefits

Emergencies

No preapproval or
referral needed

No limit

Scheduled Surgery

Yes, preapproval is
needed

Limit
and/or approval based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Inpatient
Rehabilitation

Yes, preapproval is
needed

Limit
and/or approval based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Inpatient
Habilitation

Yes, preapproval is
needed

Limit
and/or approval based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Outpatient Hospital
Services (a service that is done at the hospital such as chemotherapy or
radiation)

Yes, preapproval is
needed

Limit
and/or approval based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Urgent Care Services

No preapproval or
referral needed

No limit

Vision 

Is preapproval or referral required?

Amount, duration, and scope of benefits

Routine
eye exams for
Pregnant people age 21 and older

Routine
services: no preapproval or referral needed

Non-routine
services may need referral

Limited
to 1 exam every 24 months.

 

Call
Customer Service for more info

Routine
eye exams for

Children
and pregnant people age 20 or younger

Routine
services: no preapproval or referral needed

Non-routine
services may need referral

Limited
to 1 exam every 12 months

 

Call
Customer Service for more info

Eyeglasses

(lenses
& frames) for

Pregnant
people age 21 and over and people age 21 and over with a qualifying medical
condition

May need
referral & preapproval

Must have a valid prescription
from vision provider

Approval
based on OHP guidelines

 

Limited
to 1 pair of glasses every 24 months

 

Eyeglasses
must be bought through SWEEPS

 

Call Customer Service for more
info

Eyeglasses

(lenses
& frames) for

Children
and pregnant people age 20 or younger

May need referral &
preapproval

Must have a valid prescription
from vision provider

Approval
based on OHP guidelines

 

Limited
to 1 pair of glasses every 12 months

 

Eyeglasses
must be bought through SWEEPS

 

Call Customer Service for more
info

Medical eye exams

No preapproval or
referral needed

Approval based on OHP
guidelines

Call Customer Service

Contact Lenses

May need referral & preapproval

Only covered if you have the
condition Keratoconus

Physical, Occupational, & Speech
Therapies

Is preapproval or referral required?

Amount, duration, and scope of benefits

Physical therapy (PT)

Yes, preapproval is
needed

Approval based on OHP
guidelines & type of care

Call Customer Service

 

Limit is combined 30
visits per 12-month calendar year with OT,

Chiropractic &
Acupuncture

Occupational therapy
(OT)

Yes, preapproval is
needed

Approval based on OHP
guidelines & type of care

Call Customer Service

 

Limit is combined 30
visits per 12-month calendar year with PT, Chiropractic & Acupuncture

Speech therapy (ST)

Yes, preapproval is
needed

Limit and/or approval
based on OHP guidelines & type of care 

 

Call Customer
Service 

or speak to your
provider

Other Physical Health Services

Is preapproval or referral required?

Amount, duration, and scope of benefits

Medical equipment and
supplies

Yes, preapproval is
needed with a valid order from your provider

Limit and/or approval
based on OHP guidelines & type of service, equipment, or supply

 

Call Customer
Service 

Hearing aids and
exams

Yes, preapproval is
needed

Limit and/or approval
based on OHP guidelines & type of care/aid

 

Call Customer Service

Home health

Yes, preapproval is
needed

Limit and/or approval
based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Hormone therapy / sex
reassignment surgery

Yes, preapproval is
needed

Limit and/or approval
based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Skilled nursing
facilities

Yes, preapproval is
needed

Limit and/or approval
based on OHP guidelines & type of care

 

Call Customer Service
or speak to your provider

Sexual Abuse Exams

No preapproval or
referral needed

No limit

Sexually transmitted
infection (STI) screening

No preapproval or referral
needed

No limit

Stop smoking

No preapproval or
referral needed

No limit

Testing and
counseling for HIV and AIDS

No preapproval or
referral needed

No limit

Support Services 

Is preapproval or referral required?

Amount, duration, and scope of benefits

Care Coordination

No preapproval or
referral needed

No limit

Case Management

No referral is needed

Must have special
health care needs

No limit

Comfort Care &
Hospice

Yes, preapproval is
needed

Limit and/or approval
based on OHP guidelines & type of care

 

Call Customer Service
or talk to your provider

Intensive Care
Coordination (ICC) 

No referral is
needed. Must have special health care needs

No limit

Traditional Health
Worker or Tribal Traditional Health Worker Services (services from a
Community Health Worker, Birth Doula, Peer Support or Peer Wellness
Specialist, or Personal Health Navigator

No preapproval or
referral required

No limit

Interpreter Services

Is preapproval or referral required?

Amount, duration, and scope of benefits

Language
Interpretation (in person, phone, or video)

No preapproval or
referral needed

No limit

Sign Language
Interpretation (in person or video)

No preapproval or
referral needed

No limit

Transportation

Is preapproval or referral required?

Amount, duration, and scope of benefits

Emergency medical
transportation

No, must be used for
emergency services only

No limit

Non-emergent medical transportation
(NEMT)

No, must be used for
approved non-emergent medical visits

No limit


Health Related Services

Health Related Services (HRS) HRS are services in addition to covered health care services under the OHP and are intended to improve health quality, care delivery and overall member and community health and well-being. HRS include flexible services and community benefit initiatives. The YCCO HRS program aids in the best use of funds to address members social risks factors, like where you live, to improve community well-being. 

Examples of flexible services are: 

  • Short-term housing support 
  • Ride to the grocery store to buy food 
  • A scale to help monitor your weight 

Examples of community benefit initiatives are: 

  • Classes for parent education and family support 
  • Home visiting services 

You can work with your provider to request HRS or you or your representative can submit a request. Flex Funds Request Form. You can fax the form to 503-857-0767 or email it to info@yamhillcco.org. You can also call Customer Service and ask for the form to be sent you you, in your language, braille, large print, or the format you need, including access to a certified or qualified interpreter, this is free.  If you have any questions call Customer Service at 855-722-8205 and ask to speak to Care Coordination or the Community Health Hub.  

After submitting a request, you will receive notice if it is approved or not. You will receive a letter if the request is denied. You cannot appeal or request a hearing with this kind of denial but can file a complaint if you disagree by contacting Customer Service at 855-722-8205. More info about filing a complaint is located in the Grievance System section of the member handbook and on the website here https://yamhillcco.org/members/.  

YCCO does not share member specific HRS info outside of the HRS process. When your request is received it is shared with only those that are noted in the request, this could be your provider, caregiver or the entity related to your request. 

Transitions of Care (TOC) while you change CCOs or move from fee for service (FFS) to YCCO

Some members who change OHP plans can still get the same services, prescription drug coverage and see the same providers even if not in-network. That means care will not change when you switch CCO plans or move from OHP fee-for-service to a CCO.

Learn more about Transitions of Care

If you have serious health issues, your new and old plans must work together to make sure you get the care and services you need.

Who can get the same care while changing plans

This help is for members who have serious health issues, need hospital care, or inpatient mental health care. Here is a list of some examples of those who can get this help:

  • Members who need end-stage renal disease care;
  • Medically fragile children;
  • Breast and cervical cancer treatment program members;
  • Members getting Care Assist help due to HIV/AIDS;
  • Members who had a transplant;
  • Members who are pregnant or just had a baby;
  • Members getting treatment for cancer; or
  • 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 time frame that the transition lasts is:

  • 90 days for members who have Medicare and Medicaid (dual eligible).
  • For other members, the shorter of:
    • 30 days for physical and oral health and 60 days for behavioral health.
    • Until the member’s new PCP reviews their care plan.

YCCO will make sure members who need transition of care get:

  • Continued access to care and non-emergency medical transportation (NEMT).
  • Allow 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
    • The reviewing provider decides that the care is no longer medically 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:
    • Prenatal and postpartum care
    • Transplant services through the first-year post-transplant
    • Radiation or chemotherapy for their course of treatment or
    • Drugs with a defined least course of treatment that is more than the transition of care period

 If you are changing CCOs and need care transition call Care Management at 503-574-7247 or Customer Service at 855-722-8205.

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 P&P pdf. 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.

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.

To hear about these rights instead, you can listen here:

 

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. 

An advance directive, also called a living will or durable power of attorney is a written document that 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.

YCCO Does Not have any limitations regarding the implementation of an advance directive as a matter of conscience. YCCO is not required to provide care that conflicts with an advance directive.

What you should know about Advance Directives:

  •   If you write an Advance Directive 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. 

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

How to Make an Advance Directive & More Info

  • 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/Pages/ADAC-Forms.aspx
  •  For questions or more info contact Oregon health Decisions at 800-422-4805 or 503-692-0894, TTY 711.

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.

A Declaration for Mental Health Treatment 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