1.    I've applied for Oregon Health Plan services and they were denied.  What can I do?

IF YOU ARE IN A HEALTH PLAN:

If you have been denied services, or your services have been reduced or cut off, you have to be given a "Notice of Action" and have a right to appeal the decision. If you are on a 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 service 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 decision or "Notice of Action" from the Plan.

The "Notice of Action" will describe how to appeal. You have 45 days from the date of the "Notice of Action" to ask for the appeal.  Your request does not have to be in writing.

OAR 410-141-0260, 026,-0262

OAR 410-141-0262 (2), (3), (6)

Within 45 days of your asking for the appeal, the appeal should be decided and you will get a "Notice of Appeal Resolution".  If you disagree, you have a right to a hearing in the Oregon Medical Assistance Program (OMAP) Hearing Process.

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 need to be by the Oregon Medical Assistance Program office (OMAP) and it will contain information about your hearing rights.

OAR 410-120-1860

2.    How do I get a hearing?

The request for a hearing must be made in writing, using a special state DHS Form 443 (Administrative Hearing Request.)  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 HERE for a directory of legal aid programs.

The hearing request form must be received by OMAP or the Employment Department Hearing Officer Panel within 45 days from the date of the written "Notice of Appeal Resolution" you got from the Plan.  If you are "fee-for-service" (open medical card), within 45 days from the date of the written notice from OMAP.

In cases where your services were reduced or cut off, you might have the right to continued 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 continued 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 Hearing Officer Panel. The hearings are usually held over the telephone.  Someone from OMAP will represent OMAP.  Usually, employees of the Plan will be witnesses.  You also will be asked to testify and you have the right to present evidence and witnesses.  The ALJ will write a decision based on the evidence and the law.  The Plan is 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 your local Legal Aid office for possible advice or representation.  Go HERE 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 complaint.  (It is a good idea to give a written complaint, 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 has up to 30 days to resolve the complaint. If the complaint involves a denial of service or service coverage, the Plan is required to treat this as a Request for an Appeal. (See above). If you told them the 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) (b)(B)

OAR 410-141-0262; 410-141-0261(5) (b)

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 Advocate Services Office of OMAP at 1-800-273-0557.