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. 

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.

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

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.

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).

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

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