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1.  I’m On Oregon Health Plan but the Medical Services I Need Were Denied.  What Can I Do?

If you are in a health plan:

If you have been denied medical services, or your medical services have been reduced or cut off, you have to be given a notice and have a right to appeal the decision. If you get your medical care through a health plan (this will show on your medical ID card) the decision has to be by the Plan, not just the doctor. If a doctor denies a ser-vice or refuses to make a referral to a specialist, for example, you need to ask the doctor’s office to make a request to the Plan in order to get a denial notice from the Plan.  The Notice must tell you that you have the right to a hearing with the Department of Medical Assistance Program office (DMAP) and it will have information about your hearing rights. You may also have a right to ask the Plan to review its decision, but it might take longer if the Plan doesn’t agree with you and you have to go to a DMAP hearing.

OAR 410-141-0262; 410-141-0263; 410-141-0264

You can also file an appeal with your health plan.  Your notice and your member handbook will tell you how to do that. You must do that within 45 days from the date on the notice. The plan has 16 days to make a decision. If you still don’t agree with the plan’s decision, you can ask DHS for a hearing within 45 days from the date of the plan’s appeal decision.

If you are not in a health plan, but are in “Fee for Service” (Open Card):

If you are “fee-for-service” (open medical card) then the decision notice will come from DMAP and it will have information about your hearing rights.

OAR 410-120-1860

2.  How Do I Ask for a Hearing?

In order to have a hearing, you must fill out a hearing request form.  To obtain this form go to your local DHS office and ask the receptionist for a DHS Form 443 (Administrative Hearing Re-quest) or get it on the Internet.  (Go to http://dhsforms.hr.state.or.us/Forms/Served/DE0443.pdf).

To find out about your hearing rights, call the Public Benefits Hotline (1-800-520-5292) or your local Legal Aid office for possible advice or representation.  Go to www.oregonlawhelp.org for a directory of legal aid programs.

The hearing request form must be received by the DMAP Hearings Unit within 45 days from the date of the written  notice you get whether it’s from the Plan or DMAP.  You can take the hear-ing request form to your local DHS office and file it there.  They will send it to DMAP for you.  If you file your appeal with the Plan first, you have 45 days to request a hearing from the date on the “Notice of Appeal Resolution” (the notice your Plan will send you to let you know the results of your Plan appeal).

You have a right to an interpreter at the hearing. You can put your request for an interpreter in when you request the hearing.

In cases where your medical services were re-duced or cut off, you might have the right to continued medical services while you are waiting for the appeal in your Plan or for the hearing. But, you have to ask for the services to be con-tinued right away.

OAR 410-141-0262-4; 410-120-1865

3.  What Happens at a Hearing?

A state administrative law judge (ALJ) conducts the hearing. The ALJ is part of the Employment Department Office of Administrative Hearings. The hearings are usually held over the telephone.  Someone from DMAP will represent DMAP.  If you are on a health plan, someone from your health plan will be at the hearing. You also will be asked to testify and you have the right to present evidence and witnesses.  The ALJ will write a de-cision based on the evidence and the law.  The Plan and DMAP are required to obey the ALJ’s decision.

You have the right to have a lawyer represent you at the hearing.  If you want to have an attorney represent you, call the Public Benefits Hotline at 1-800-520-5292, or call your local Legal Aid office for possible advice or representation.  Go to www.oregonlawhelp.org for a directory of legal aid programs.

OAR 137-003-0600; 137-003-0605; 137-003-0550; OAR 410-120-1875; 137-003-0665

4.  What if I Am Unhappy with the Service or Someone Was Rude to Me?

Plan members who are not satisfied with the services they get under the Oregon Health Plan have the right to file a complaint.

You can file a complaint if you have a general concern about your care or services. Examples include:

• rude treatment,
• a delay in getting an appointment
• a really long wait at the doctor’s office
• a refusal to get you an interpreter if you do not speak English well

5.  How Do I File a Complaint?

Every Plan is required to have written procedures for taking complaints.  Your Plan handbook will describe the complaint process.  Many Plans have forms to use when filing a complaint.

You can either give the complaint in writing or tell the doctor or office staff about your com-plaint.  (It is a good idea to give a written com-plaint, even if you have talked about the problems with the doctor or office staff.)  If you tell someone you have a complaint, the doctor or office staff should tell you how the complaint process works.

OAR 410-141-0260(4); OAR 410-141-0261(1) (a) (B)

6.  When Can I Expect a Response to My Complaint?

The Plan should make a decision about your com-plaint within 5 work days, but they may take up to 30 days to resolve the complaint if they need more time. If you told them  about your  complaint and did not write it, they can make their decision by telling you instead of writing it.  If you wrote the complaint, they have to write the decision.

OAR 410-141-0261(4), (5)

7.  Other Than a Complaint or a Hearing, Are There Other Ways to Get Help for a Problem With the Oregon Health Plan?

Yes.  Another way to get help is to call the Governor’s Advocacy Office at 1-800-442-5238 or the Client Services Unit of DMAP at 1-800-273-0557.

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