Your OHP Benefits

For more resources and video transcript, visit our Getting Started with FamilyCare Health webpage.

The Oregon Health Plan (OHP) decides which benefits are available to people who sign up for coverage. Many, but not all, health care services are covered.

To find out what benefits you have with FamilyCare Health, look at your member ID card.

If your member ID card says CCOA, you have physical, dental, and mental health benefits.
If your member ID card says CCOB, you have physical and mental health benefits.
If your member ID card says CCOE, you have mental health benefits.
If your member ID card says CCOG, you have dental and mental health benefits.

The below benefits apply to most, though not all, members. Listed benefits are for contracted providers; seeing a non-contracted provider requires prior authorization from FamilyCare Health. Benefits are subject to change. To confirm your benefits, please contact FamilyCare Health at 503-222-2880 or 800-458-9518 toll-free (TTY 711).

 

2017

Doctor Visits Your Cost Authorization/Referral Limits
Primary Care Provider $0 Not required No limit with assigned PCP
Specialist $0 Prior Authorization required from your PCP, except for contracted women's health or behavioral health providers for routine care services Number of visits based on plan's approval
Preventive Services Your Cost Authorization/Referral Limits
Well Child visits for babies, children and teens $0 Not required As recommended
Routine physicals $0 Not required As recommended
Well Women visits $0 Not required As recommended
Mammograms (breast x-rays) for women $0 Physician's order required As recommended
Family Planning $0 Not required No limits
Prostate exams for men $0 Not required No limits
Screening for sexually transmitted diseases (STDs) $0 Not required No limits
Testing and counseling for AIDS and HIV $0 Not required No limits
Prescription Drugs (Up to a 30-day supply) Your Cost Authorization/Referral Limits
Many but not all drugs are available with a provider's prescription. A full list can be found in our Medicaid Formulary. No cost for covered drugs. Mental health drugs are managed by the state. Copays for those drugs vary. See the Oregon Health Authority website for more information Some drugs may require prior authorization in addition to a prescription. No limit with a prescription and prior authorization, if required. If a drug requiring prior authorization is denied, it will not be covered
Hospital Stays Your Cost Authorization/Referral Limits
Emergencies $0 Not required No limit
Scheduled Surgery $0 Authorization required No limit
Dental Care Your Cost Authorization/Referral Limits
Exams, Cleaning, and Fluoride Treatment $0 Not required One annual exam for adults; two for children age 18 years old and younger; follow-up care allowed
X-rays $0 Not required Covered annually; Panoramic or full mouth x-ray series every 5 years.
Sealants $0 Not required Once every 5 years for permanent molars for children under 16 years of age only
Basic restorative care like a filling $0 Not required No limit
Extractions (removing teeth) $0 Authorization required for wisdom teeth. Not required for other extractions No limit. This benefit does not apply to orthodontics
Root Canals $0 Authorization required Contact FamilyCare Health to find out your Dental Care Organization (DCO)
Dental urgent or immediate treatment (Emergency) $0 Not required No limit
Orthodontic treatment $0 Authorization required Contact FamilyCare Health to find out your Dental Care Organization (DCO)
Stainless Steel Crowns $0 Authorization required For all primary teeth for children; for posterior permanent teeth for adults
Dentures and partials $0 Authorization required Full dentures every 10 years and partial dentures every 5 years for adults
Gum Disease $0 Authorization required Deep cleaning for gum disease every 2 years for adults. Routine care for gum disease every 6 months for adults.
Mental Health Your Cost Authorization/Referral Limits
Routine, Outpatient Counseling and Therapy $0 Not required Self-referral to contracted providers
Exceptional Needs Services $0 Authorization required Call FamilyCare Health for details; Click here for more info
Alcohol and Drug Services Your Cost Authorization/Referral Limits
Routine Outpatient Counseling/Therapy $0 Not required Self-referral to contracted providers
Residential Treatment $0  Authorization required Approval based on OHP guidelines. Call FamilyCare Health for details
Detox $0 Authorization required Self-referral to contracted providers
Laboratory and X-Ray Your Cost Authorization/Referral Limits
Blood Draw $0 Physician's order required No limit
X-Rays $0 Physician's order required No limit
CT Scans $0 Physician's order required No limit
MRIs $0 Authorization required No limit
Immunizations/Shots Your Cost Authorization/Referral Limits
Vaccines $0 for recommended vaccines Not required for recommended vaccines Flu vaccines can be given at your provider's office or another location, such as a pharmacy or health department. Vaccines for travel not covered
Pregnancy Care Your Cost Authorization/Referral Limits
Our BabyCare program can help new moms get prepared for baby. $0 Not required Please let FamilyCare Health and the Oregon Health Authority know when you are expecting
Prenatal visits with your provider $0 Not required No limit
Routine vision services $0 Not required Available for pregnant women and children 20 years and younger. Use a VSP provider for your vision care (Contact VSP at 800-877-7195 or https://www.vsp.com)
Additional dental benefits $0 Authorization required Additional cleanings, fluoride treatments, and anterior crowns if dentally appropriate. Contact your Dental Care Organziation
Birthing Classes $0 Not required Contact FamilyCare Health for details
Prenatal vitamins $0 Not required Prenatal supplements are covered with a prescription
Labor and Delivery Your Cost Authorization/Referral Limits
Vaginal and Cesarean deliveries $0 Not required Please let FamilyCare Health and the Oregon Health Authority know when you have delivered. You will need to separately apply for OHP for your child. Home births are not covered. Please contact OHP Client Services for home birth options
Tubal ligation $0 Not required Sterilization consent form required for 15 and older
Breast pumps $0 Not required Prescription required from provider and supplied by our contracted durable medical equipment providers.
Postpartum care, care you get after your baby is born $0 Not required No limit
Lactation classes $0 Not required No limit
Circumcisions for boys $0 Not required To be completed within 90 days of birth. After 90 days a prior authorization is required; call FamilyCare Health for Details
Therapy Your Cost Authorization/Referral Limits
Physical Therapy $0 Authorization required 30 combined visits (PT, OT & ST) allowed per calendar year
Occupational Therapy $0 Authorization required 30 combined visits (PT, OT & ST) allowed per calendar year
Speech Therapy $0 Authorization required 30 combined visits (PT, OT & ST) allowed per calendar year
Acupuncture $0 Authorization required Number of visits based on plan's approval
Chiropractic $0 Authorization required Number of visits based on plan's approval
Alternative Therapy Management (ATM) $0 Authorization required (No authorization for first 15 visits) Contact FamilyCare Health for details
Vision Your Cost Authorization/Referral Limits
Eye Exams $0 Not required. Contact VSP Available for pregnant women, children (20 years and younger), and eligible adults with medical diagnoses of Aphakia, pseudoaphakia, congenital aphakia, keratoconus, or cataract surgery
Eye Glasses $0 Not required. Contact VSP Available for pregnant women and children (20 years and younger), and eligible adults with medical diagnoses of Aphakia, pseudoaphakia, congenital aphakia, keratoconus, or cataract surgery
Medical Eye Exams $0 Authorization required Number of visits based on plan's approval
Speciality Services Your Cost Authorization/Referral Limits
Medical Equipment and Supplies $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Hearing Aids and Exams $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Home Health $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Skilled Nursing Facilities $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Hospice $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Osteopath $0 Authorization required Approval based on OHP Guidelines, limitations may apply, call FamilyCare Health for details
Medical Transportation Your Cost Authorization/Referral Limits
Contact Ride To Care to schedule a ride: 503-416-3955 or https://www.ridetocare.healthcare $0 Authorization required Limitations may apply, call FamilyCare Health for details

 

2016

Doctor Visits Your Cost Authorization/Referral Limits
Primary Care Provider $0 Not required No limit with assigned PCP
Specialist $0 Prior Authorization required from your PCP, except for dentists, women's health or behavioral health providers Number of visits based on plan's approval
Preventive Services Your Cost Authorization/Referral Limits
Well Child visits for babies, children and teens $0 Not required As recommended
Routine physicals $0 Not required As recommended
Well Women visits $0 Not required As recommended
Mammograms (breast x-rays) for women $0 Physician's order required As recommended
Family Planning $0 Not required No limits
Prostate exams for men $0 Not required No limits
Screening for sexually transmitted diseases (STDs) $0 Not required No limits
Testing and counseling for AIDS and HIV $0 Not required No limits
Prescription Drugs (Up to a 30-day supply) Your Cost Authorization/Referral Limits
Many but not all drugs are available with a provider's prescription. A full list can be found in our Medicaid Formulary. No cost for covered drugs. Mental health drugs are managed by the state. Copays for those drugs vary. See the Oregon Health Authority website for more information Some drugs may require prior authorization in addition to a prescription. No limit with a prescription and prior authorization, if required. If a drug requiring prior authorization is denied, it will not be covered
Hospital Stays Your Cost Authorization/Referral Limits
Emergencies $0 Not required No limit
Scheduled Surgery $0 Authorization required No limit
Dental Care Your Cost Authorization/Referral Limits
Exams, cleaning, and x-rays $0 Not required One annual exam for adults; two for children; follow-up care allowed
Basic restorative care like a filling $0 Not required No limit
Extractions (removing teeth) $0 Authorization required for wisdom teeth. Not required for other extractions No limit. This benefit does not apply to orthodontics
Stainless Steel Crowns $0 Authorization required For all primary teeth for children; for posterior permanent teeth for adults
Dentures and partials $0 Authorization required Full dentures every 10 years and partial dentures every 5 years for adults
Gum Disease $0 Authorization required Deep cleaning for gum disease every 2 years for adults. Routine care for gum disease every 6 months for adults.
Mental Health Your Cost Authorization/Referral Limits
Routine, Outpatient Counseling and Therapy $0 Not required No limit
Exceptional Needs Services $0 Authorization required Call FamilyCare Health for details
Alcohol and Drug Services Your Cost Authorization/Referral Limits
Counseling/Therapy $0 Not required Members can choose the provider they want to see within our Network
Residential Treatment $0  Authorization required Approval based on OHP guidelines. Call FamilyCare Health for details
Detox $0 Authorization required Self Referral to contracted providers
Laboratory and X-Ray Your Cost Authorization/Referral Limits
Blood Draw $0 Physician's order required No limit
X-Rays $0 Physician's order required No limit
CT Scans $0 Physician's order required No limit
MRIs $0 Authorization required No limit
Immunizations/Shots Your Cost Authorization/Referral Limits
Vaccines $0 for recommended vaccines Not required for recommended vaccines Vaccines can be given at your provider's office or another location, such as a pharmacy or health department. Vaccines for travel not covered
Pregnancy Care Your Cost Authorization/Referral Limits
Prenatal visits with your provider $0 Not required No limit
Postpartum care, care you get after your baby is born $0 Not required No limit
Routine vision services $0 Not required Available for pregnant women and children 20 years and younger
Assistance with breast feeding, including breast pumps $0 Not required No limit
Circumcisions for boys $0 Not required Done within 90 days of birth
Labor and Delivery Your Cost Authorization/Referral Limits
Our BabyCare program can help new moms get prepared for baby. $0 Not required Please let FamilyCare Health and the Oregon Health Authority know when you are expecting and when you have delivered. You will need to separately apply for OHP for your child. Home births are not covered. Please contact OHP Client Services for home birth options
Therapy Your Cost Authorization/Referral Limits
Physical Therapy $0 Authorization required 30 combined visits (PT, OT & ST) allowed per calendar year
Occupational Therapy $0 Authorization required 30 combined visits (PT, OT & ST) allowed per calendar year
Speech Therapy $0 Authorization required 30 combined visits (PT, OT & ST) allowed per calendar year
Vision Your Cost Authorization/Referral Limits
Eye Glasses $0 Not required. Contact VSP Available for pregnant women and children 20 years and younger
Medical Eye Exams $0 Authorization required Number of visits based on plan's approval
Speciality Services Your Cost Authorization/Referral Limits
Medical Equipment and Supplies $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Hearing Aids and Exams $0 Prior Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Home Health $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Skilled Nursing Facilities $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Hospice $0 Authorization required Approval based on OHP Guidelines, call FamilyCare Health for details
Chiropractor $0 Prior Authorization required Approval based on OHP Guidelines, limitations may apply, call FamilyCare Health for details
Acupuncture $0 Prior Authorization required Approval based on OHP Guidelines, limitations may apply, call FamilyCare Health for details
Osteopath $0 Prior Authorization required Approval based on OHP Guidelines, limitations may apply, call FamilyCare Health for details

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