Medicaid Rules in Oregon

Oregon offers three benefit packages to its Medicaid recipients. The Oregon Health Plan standard benefit is a limited benefit package for uninsured adults not meeting eligibility requirements for the other two Medicaid programs. OHP Plus is a full-benefit package for adults and children, and the OHP with Limited Drug covers the same services as the OHP Plus plan with the exception of prescription drugs. It does not cover prescription drugs paid for by Medicare. All three plans have similar rules for citizenship, administration and determination of coverage for medical procedures.

Citizenship

• If you apply for Medicaid in Oregon and state you are a U.S. citizen, you will be required to show proof of your identity and citizenship. Citizenship and identity can be proved by providing a U.S. passport, certificate of naturalization or certificate of U.S. citizenship. If those documents are not available, a combination of documents is used to verify both citizenship and identity. The Oregon Department of Human Services provides a list of acceptable documentation. If you are not a U.S. citizen, you must provide proof of your legal immigration status. If you are receiving Medicare or Supplemental Security Income, or are only applying for food benefits or cash benefits (known as Temporary Assistance to Needy Families), you do not need to provide proof of citizenship. Additionally, if you are applying for benefits for your children only, you will not have to provide proof of citizenship for yourself. However, you would only need to provide proof of identity and citizenship for your children.

Coverage Determination

• OHP covers medical services based on the Prioritized List of Health Services. Medical procedures are ranked in order of effectiveness. Because the state does not have enough money to pay for all medical procedures available, it uses the available money to pay for the procedures ranked most effective. The managed care plans and healthcare providers in Oregon use the list to determine if a service is covered under OHP. OHP will cover services for conditions that are not funded only if the service is related to a condition that is funded.

Administration

• OHP offers services through two different types of plan structures. In a managed care plan, a primary care manager or primary care physician is responsible for coordinating your healthcare. Payment for charges on any nonemergency or nonurgent services, received from providers not in your plan, may be your responsibility. If you are not enrolled in a managed care plan, then you will be enrolled in a fee for service plan. This plan allows you to receive medical services from any provider that accepts OHP. The provider bills the Division of Medical Assistance Programs for services provided, and DMAP will pay the provider a fee for the service.