Oregon Health Plan Rules
Oregon Health Plan (OHP) provides health-care services free or at a low cost to many Oregon residents who have limited income and who do not qualify for traditional Medicaid. There are only so many physicians who will accept OHP. General, vision and mental health are some of the outpatient services available. There are different OHP plans. Some require a copay, but the basic rules apply to all divisions within the OHP program.-
Clients
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You must qualify to receive OHP. Being a child, elderly, blind, disabled, pregnant or needy are standard qualifications. There is a reservation list for those not meeting the standard qualifications. The list works like a lottery; approximately every quarter there is a drawing of 20,000 names of people who may apply for health-care assistance. However, being on this list does not guarantee health-care assistance from OHP.
Providers
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OHP providers must see and care for the needs of pregnant women, those under 19 and disabled people who visit facilities accepting payments from one or more of the OHP divisions. Federal and Oregon statutes require providers to indicate what service was provided and the forms must be signed by the provider. This is to ensure that billing and or acceptance of OHP payments is only for those indicated services. Providers cannot alter services to meet OHP payment requirements or offer services that are not covered under OHP without the patient's knowledge. The provider and anyone on his staff or part of his facility must comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
Hospitals
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Hospitals providing OHP must also take on the responsibility of the medically needy. In case of emergency, patients entering a medical facility without known medical insurance coverage can be seen. In the instance where the patient is denied other insurance, qualifications for OHP can be made at the time of services or retroactively after services have been provided. If the patient does not meet the standard criteria for OHP after submitting and application for coverage, hospitals cannot bill OHP divisions under the standard billing rules. In some special circumstances, however, limited authorization can be provided.
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