Jacksoncareconnect Member Handbook

Jackson Care Connect
Member Handbook
January 1, 2023
A quick guide
Are you pregnant? What else can we do for you?

We have plenty of resources for Through our various community
expecting members! Go to page 11 resources and programs, Jackson
to learn about our Strong Families Care Connect gives extra help to
program for pregnant members. Or, go to members of all ages. Go to page 11,
“If You Are Pregnant,” on page 55 for “Jackson Care Connect Community Programs”
more information. for more information.
Do you speak another language? Have questions?

If you are learning English, we can Go to page 69, “Frequently Asked
get an interpreter and translation Questions,” or Call Customer
services for you. Go to page 4, Service, 8 a.m.-5 p.m. Monday-
“Having an Interpreter at Appointments,” Friday Toll-free: 855-722-8208, TTY 711.
for more information. You can also send us a secure message at
jacksoncareconnect.org/portal
Want to give us your opinion?
We need to hear from members Want to watch a video
like you to help us build a healthier to get started?
community. Join our Community If you don’t want to read this
Advisory Council and help shape the future whole book, we have a video for
of your health plan! Go to page 13, “Getting that! You can watch our video, “Welcome to
Involved as a Member,” for more information. Jackson Care Connect and OHP,” by visiting
our website at jacksoncareconnect.org/
membervideo
What is covered under this plan?
Know what services and benefits
are yours, under Jackson Care Want to see this handbook on the web?
Connect and the Oregon Health You can find this book in electronic format
Plan. Go to page 25, “Covered Benefits and on our website at jacksoncareconnect.org/
Services,” and page 34, “Preventive Health memberhandbook
and Wellness” for more information.
i
Member Handbook
All members and their Todos los miembros y

representatives have a right las personas que los
to know about and use our representan tienen derecho
programs and services. We a conocer y usar nuestros
give these kinds of free help: programas y servicios.
• Sign language Brindamos los siguientes
tipos de ayuda gratuita:
• Spoken language
interpreters • Lenguaje de señas;
• Materials in other languages • Intérpretes;
• Braille, large print, audio, • Materiales en otros
and any way that works idiomas; y
better for you • Braille, letra grande, audio y
If you need help or have cualquier otro formato que
questions, please call le funcione mejor.
Customer Service at Si necesita ayuda o tiene
855-722-8208, TTY 711. preguntas, llame a Atención al
Cliente al 855-722-8208, TTY
If you do not speak English,
(la línea de retransmisión): 711.
have difficulty understanding
English or need sign Si usted necesita un intérprete
language interpretation, let en sus citas, infórmele al
your provider’s office know consultorio de su proveedor
when you call to make your que necesita uno y para
appointment. You have a legal qué idioma. Hay información
right to interpretation, and the disponible sobre los
services are free. Intérpretes de Atención de
Salud en oregon.gov/oha/oei
ii
Jackson Care Connect To report concerns, get help making a
complaint or to get more information, please
does not discriminate contact our Grievance Coordinator:
Mailing address:
Jackson Care Connect must follow Jackson Care Connect
state and federal civil rights laws. We Attn: Grievance Coordinator
cannot treat members or potential 315 SW Fifth Ave
members unfairly in any of our programs Portland, OR 97204
or activities because of a person’s: Call: 855-722-8208, TTY 711
• Age Fax: 503-416-1313
• Color
Email: customerservice@careoregon.org
Complaint form:
• Disability
jacksoncareconnect.org/contact-us
• Gender identity
• Health status or need for services You can also file a complaint with:
• Marital status Oregon Health Authority (OHA)
• National origin Please call the OHP Client Services unit
(CSU) toll free at 800-273-0557 or OHA's
• Race
Ombudsman at 503-947-2346 or toll free at
• Religion 877-642-0450.
• Sex
Oregon Health Authority Civil Rights
• Sexual orientation
Mailing address:
Everyone has a right to enter, exit and use
Office of Equity and
buildings and services. They also have
Inclusion Division
the right to get information in a way they
421 SW Oak St., Suite 750
understand. This includes receiving written
Portland, OR 97204
material in other formats that work for you
(large print, audio, braille, etc.). Your use of Call: 844-882-7889, TTY 711
benefits, grievance, appeals or hearings Email: OHA.PublicCivilRights@
will not be denied or limited based on your odhsoha.oregon.gov
need for another language or format. Online:
If you don’t speak English, this also oregon.gov/OHA/OEI
includes free interpretation services oregon.gov/boli/civil-rights
and written information/material in the
language you speak. Jackson Care
Connect will make reasonable changes
to policies, practices and procedures by
talking with you about your needs.
iii
Member Handbook
Bureau of Labor and Industries Jackson Care Connect

Civil Rights Division Office location:
Mailing address: 33 N Central Avenue,
800 NE Oregon St., Suite 1045 Suite 320
Portland, OR 97232 Medford, OR 97501
Call: 971-673-0764 Mailing address:
Email: crdemail@boli.state.or.us PO Box 40328
You also have a right to file a civil rights Portland, OR 97240-0328
complaint with the U.S. Department of Health Call: Toll-free: 855-722-8208
and Human Services Office for Civil Rights.
TTY: 711
Contact that office one of these ways:
Text: 503-488-2882
U.S. Department of Health and Human
Fax: 503-416-3723
Services Office of Civil Rights
Web: jacksoncareconnect.org
Mailing address:
Office hours:
200 Independence Ave SW
Room 509F HHH Bldg 8 a.m. to 5 p.m.,
Washington, D.C. 20201 Monday through Friday
Call: Toll-free: 800-368-1019 For holiday closures, see page 1.
TDD: 800-537-7697
Email: OCRComplaint@hhs.gov
Online: ocrportal.hhs.gov/ocr/smartscreen/main.jsf
Complaint form:
hhs.gov/ocr/office/file/index.html
iv
English: You can get this letter in other languages, large print, braille or a
format you prefer. You can also ask for an interpreter. This help is free.
Call 855-722-8208 or TTY 711. We accept relay calls. You can get help from
a certified and qualified health care interpreter.
Spanish: Puede obtener este documento en otros idiomas, en letra grande,

braille o en un formato que usted prefiera. También puede recibir los servicios
de un intérprete. Esta ayuda es gratuita. Llame al servicio de atención al cliente
855-722-8208 o TTY 711. Aceptamos todas las llamadas de retransmisión.
Usted puede obtener ayudar de un intérprete certificado y calificado en
atención de salud.
Vietnamese: Quý vị có thể nhận tài liệu này bằng một ngôn ngữ khác, theo định
dạng chữ in lớn, chữ nổi Braille hoặc một định dạng khác theo ý muốn. Quý vị
cũng có thể yêu cầu được thông dịch viên hỗ trợ. Sự trợ giúp này là miễn phí. Gọi
855-722-8208 hoặc TTY (Đường dây Dành cho Người Khiếm thính hoặc Khuyết tật
về Phát âm) 711. Chúng tôi chấp nhận các cuộc gọi chuyển tiếp. Quý vị có thể
nhận được sự giúp đỡ từ một thông dịch viên có chứng nhật và đủ tiêu chuẩn
chuyên về chăm sóc sức khỏe.
Chinese: ��
��
855-722-8208 �� 711��
��
v
Member Handbook
Russian: Вы можете получить это письмо на другом языке, напечатанное

крупным шрифтом, шрифтом Брайля или в предпочитаемом вами формате.
Вы также можете запросить услуги переводчика. Эта помощь
предоставляется бесплатно. Звоните по тел. 855-722-8208 или TTY 711. Мы
принимаем звонки по линии трансляционной связи. Вы можете получить
помощь от аккредитованного и квалифицированного медицинского
переводчика.
Korean: 이 서신은 다른 언어, 큰 활자, 점자 또는 선호하는 형식으로

받아보실 수 있습니다. 통역사를 요청하실 수도 있습니다. 무료
지원해 드립니다. 855-722-8208 또는 TTY 711에 전화하십시오.
저희는 중계 전화를 받습니다. 공인 및 자격을 갖춘 의료서비스 전문
통역사의 도움을 받으실 수 있습니다.
Japanese: この書類は、他の言語に翻訳されたもの、拡
大文字版、点字版、その他ご希望の様式で入手可能で
す。また、通訳を依頼することも可能です。本サービ
スは無料でご利用いただけます。855-722-8208 また
は TTY 711までお電話ください。電話リレーサービス
でも構いません。認定または有資格の医療通訳者から
支援を受けられます。
Arabic:
/‫ أو ﻣﻄﺒﻮﻋﺔ ﻋ‬،EF‫ﺨﻂ ﻛﺒ‬6 ‫ أو ﻣﻄﺒﻮﻋﺔ‬،‫ﻠﻐﺎت أﺧﺮى‬6 ‫ﺬا اﻟﺨﻄﺎب‬0 /‫ﻢ اﻟﺤﺼﻮل ﻋ‬%‫!ﻤﻜﻨ‬
W ّ
‫ﺬە‬0 ‫ إن‬.Z
[ ‫ﺟﻢ ﺷﻔ‬E‫ﻢ ﻃﻠﺐ ﻣ‬%‫ﻤﺎ !ﻤﻜﻨ‬V .‫ﻢ‬%!‫ﻐﺔ اﻟﻤﻔﻀﻠﺔ ﻟﺪ‬P‫ﻘﺔ ﺑﺮا!ﻞ أو ﺣﺴﺐ اﻟﺼ‬IH‫ﻃ‬
‫ﻞ‬l‫ﺴﺘﻘ‬n .711 ‫ﺔ‬l‫ﺎﺗ‬k‫ﻗﺔ اﻟ‬Ei‫ أو اﻟﻤ‬855-722-8208 /‫ اﺗﺼﻠﻮ ﻋ‬.‫ﺔ‬P‫اﻟﻤﺴﺎﻋﺪة ﻣﺠﺎﻧ‬
.‫ﺎﻟﻤﺎت اﻟﻤﺤﻮﻟﺔ‬%‫اﻟﻤ‬
vi
Romanian: Puteți obține această scrisoare în alte limbi, cu un font mărit, în
limbajul Braille sau într-un alt format preferat. De asemenea, puteți solicita un
interpret. Acest ajutor este gratuit. Apelați 855-722-8208 sau TTY 711. Acceptăm
apelurile prin releu. Puteți obține ajutor de la un interpret certificat și calificat în
domeniul sănătății.
Cambodian:
អ" ក $ ច ទ ទ ួ ល ) ន ស ំ ប ុ / ត េ ន ះ 3 4 5 េ ផ 7 ង េ ទ 9 ត
; រ េ ) ះ ព ុ ម? 3 អ ក 7 រ ធ ំ ៗ
អ ក 7 រ ស ំ B ប ់ ម ន ុ ស 7 ព ិ ; រ ែ ភ" ក
ឬ 3 ទ / ម ង់ ែ ដ ល អ" ក ច ង ់ ) ន ។
អ" ក ក ៏ $ ច េ ស" K ស ុ ំ រ ក អ" ក ប ក ែ / ប 4 5 ផ ង ែ ដ រ ។
ជ ំ នួ យ េ ន ះ គ ឺ ឥ ត គ ិ ត ៃ ថ S េ ទ ។ ចូ រ ទ ូ រ ស ័ ព V េ W េ ល ខ
855-722-8208 ឬ TTY េលខ 711។
េ យ K ង ទ ទ ួ ល យ ក ; រ េ b ប cd e ន ប នf ។
អ" ក $ ច ទ ទ ួ ល ) ន អ" ក ជ ួ យ ប ក ែ / ប 4 5 ែ ខg រ
ែ ដ ល h ត ់ i ន ស jk ប ័ / ត l ង ប ក ែ / ប 4 5 m ក ់ ទ ង ន ឹ
ងែផ" កេពទo។.
Oromo: Xalayaa kana afaanota birootiin, barreeffama gurguddaan kan maxxanfame,
Bireeliin ykn bifa barbaaddaniin argachuu dandeessu. Turjumaanaafis gaafachuu
dandeessu. Deggersi kun bilisa. 855-722-8208 ykn TTY 711 irratti bilbilaa. Bilbila relay ni
fudhanna. Nama kunuunsa fayyaaf afaan hiiku kan ragaa Mirkanaawaa qabu (certified)
ta’e irraa gargaarsa argachuu dandeessu.
German: Sie können dieses Dokument in anderen Sprachen, in Großdruck, in

Brailleschrift oder in einem von Ihnen bevorzugten Format erhalten. Sie können
auch einen Dolmetscher anfordern. Diese Hilfe ist gratis. Wenden Sie sich an
855-722-8208 oder per Schreibtelefon an 711. Wir nehmen Relaisanrufe an.
Sie können die Hilfe eines zertifizierten und qualifizierten Dolmetschers für
das Gesundheitswesen in Anspruch nehmen.
vii
Member Handbook
Farsi:
‫ ﺑرﯾل ﯾﺎ ﺑﮫ ﻓرﻣت دﻟﺧواه دﯾﮕری ﻧﯾ ز‬،‫ ﺧط درﺷت‬،‫ﻣﯽﺗواﻧﯾد اﯾن ﻧﺎﻣﮫ را ﺑﮫ زﺑﺎنھﺎی دﯾﮕر‬
.‫ اراﺋﮫ اﯾن ﮐﻣﮏ راﯾﮕﺎن اﺳت‬.‫ ﻣﯽﺗواﻧﯾد ﻣﺗرﺟم ﺷﻔﺎھﯽ ﻧﯾ ز درﺧواﺳت ﮐﻧﯾد‬.‫درﯾﺎﻓت ﮐﻧﯾد‬
‫ﺑﺎ‬855-722-8208 ‫ ﯾﺎ‬TTY 711 .‫ ﻣﺎ ﺗﻣﺎس ھﺎی رﻟﯽ را ﻣﯽ ﭘذﯾرﯾم‬.‫ﺗﻣﺎس ﺑﮕﯾرﯾد‬
.‫ﻣﯽ ﺗواﻧﯾد ا ز ﯾﮏ ﻣﺗرﺟم ﺷﻔﺎھﯽ ﻣﻌﺗﺑر و واﺟد ﺷراﯾط ﻣراﻗﺑت ھﺎی ﺻﺣﯽ ﮐﻣﮏ ﺑﮕﯾرﯾد‬
French: Cette lettre peut être disponible dans d'autres langues, en gros
caractères, en braille ou dans un format de votre choix. Vous pouvez également
demander à être assisté d'un interprète. Cette assistance est gratuite. Appelez le
855-722-8208 ou le TTY 711. Nous acceptons les appels relais. Vous pouvez
obtenir l'aide d'un interprète agréé et qualifié en matière de soins de santé.
É
Thai: ท่านสามารถขอรับจดหมายฉบับนี ได้ในภาษาอื ä ๆ,
น
ä านต้องการ
ในรูปแบบตัวอักษรขนาดใหญ่, อักษรเบรลล ์ หรือในรูปแบบทีท่
นอกจากนี É ท่านยังสามารถขอรับบริการล่ามภาษาได้ด้วย บริการนี มี
É ให้ฟรี โทร.
855-722-8208 หรือ TTY 711 เรายอมรับสายโทรประเภทรีเลย ์
ท่านสามารถขอรับความช่วยเหลือได้จากล่ามเฉพาะทางด้านการดูแลสุขภาพทีมี ä
คุณสมบัตแิ ละผ่านการรับรอง
viii
Contents
Welcome to Jackson Care Connect......... 1 Getting to Health Care Appointments

(Non-Emergent Medical Transportation)
Getting Care When You Need It................ 2 ...........................................................................38
What is the Oregon Health Plan Pharmacy and Prescription
(OHP)?................................................................ 7 Drug Benefits.................................................41
What is a Coordinated Care Dental Health Care......................................44
Organization (CCO)?..................................... 8
Mental Health and Substance Use
Jackson Care Connect Programs.............11 Disorder Services........................................49
Getting Involved as a Member.................13 If You Are Pregnant.................................... 55
Your Rights as a Jackson Care How to Disenroll or Change CCOs........57
Connect Member on OHP.........................14
Other Things You Should Know............. 59
Working With Your Primary Care
Provider (PCP)................................................ 17 Complaints and Appeals...........................64
Emergencies, Urgent Care Notice of Privacy Practices.......................68

and Crises..................................................... 22
Frequently Asked Questions.................. 69
Covered Benefits and Services............. 25
Member Handbook Definitions................ 71
Preventive Health and Wellness.............34
ix
Welcome to Dental Health Services
Advantage Dental
Jackson Care Connect Toll-free: 866-268-9631
We’re glad to have you as a member of Capitol Dental

Jackson Care Connect. We are a group of Toll-free: 800-525-6800
all types of health care providers who work ODS
together for people on the Oregon Health Plan Toll-free: 800-342-0526
(OHP) in your community. This model is known
Transportation services
as a Coordinated Care Organization, or CCO.
TransLink
With a CCO, you can get all of your health Toll-free: 888-518-8160
care services from the same plan. This
includes medical, dental and mental health Oregon Health Plan
care and substance use disorder services. OHP Customer Service
Some partners in our CCO include the Toll-free: 800-699-9075, TTY 711
following organizations:
Medical and Behavioral Health Services coordinates your care by:
Jackson Care Connect • Connecting you with a primary care
Toll-free: 855-722-8208, TTY 711 provider (PCP), your “doctor”
Fax: 503-416-3723 • Making sure all your doctors talk to each
Office location: other about your health care needs
33 N Central Avenue, • Giving you information and access to
Suite 320 prevention services
Medford, OR 97501
• Helping you avoid trips to the
Mailing address:
emergency room or hospital
PO Box 40328
Portland, OR 97240-0328 • Giving you advice that is easy to
Web: jacksoncareconnect.org understand and follow
Monday through Friday, 8 a.m. to 8 p.m. • Making sure you have all the local
and statewide resources you need
Offices closed on:
to stay healthy, safe, comfortable and
New Year’s Day
Martin Luther King, Jr. Day feeling cared for
Memorial Day Our goal is to help you receive the best
Juneteenth health care and services possible within
Independence Day
your community, when you need them. We
Labor Day
work closely with community and social
Thanksgiving Day
Day after Thanksgiving
Christmas 1
Member Handbook
agencies too. So if you face challenges like Getting Care When

homelessness or hunger, or have several
health conditions, we can connect you with You Need It
people who can help.
Getting started
Questions about your health Here are some tips to help you get the care
We want to make sure we're giving you the you need:
best care we can. That’s why we’ll send you • Find your assigned PCP and dentist. Make
or call you with a Health Risk Screening. appointments with them, and call them first
We do this when you are a new member whenever you need care. They are your
and will send you one every year after that partners for good health (Pages 17, 44)
(or sooner if your health changes). These • You are assigned a PCP within 30 days of
questions help us learn more about you and enrollment, to save time and effort. If you
your needs and how we can best support would like to change your PCP, please call
you! Once we have your answers, our Care Customer Service (Page 18)
Coordination team will review them. We may • You have access to providers within:
call you to share some health resources - 30 miles or 30 minutes of where you
that can help you. We may also get in touch live, if you live in an urban area
with your primary care provider or others - 60 miles or 60 minutes of where you
live, if you live in a rural area
involved in your care to make sure we’re
- (See pages 17, 44, 50)
working as a team to serve you. If you
provide sensitive health information, we'll • Bring both your Jackson Care
Connect Member ID card and a photo
ask your permission before we share it. If
ID to all appointments (Page 6)
you want us to send you a survey, contact
• If you have no way to get to a
Customer Service at 855‑722‑8208. covered health appointment, a
free program called “Translink” can
help get you there (Page 38)
• Call ahead if you cannot make
it. Your provider’s office will set
up a new visit (Page 18)
Please read this handbook and keep it in a
safe place. If you want another copy, we can
mail it to you or your representative, free of
charge. We can also email you a copy, with
your permission. Just call Customer Service at
855-722-8208, TTY 711, and we will send it to
you within five business days.
2
If you don’t want to read this entire book If you also have coverage through Medicare,
check out your Easy Guide. Or visit our call Customer Service and let them know.
website at jacksoncareconnect.org/member- They’ll help you coordinate Medicaid and
resources and watch a short video, “The Medicare benefits, fill existing prescriptions,
Oregon Health Plan and You.” and more. See pages 10 and 61 for more info.
Jackson Care Connect Customer Service Making appointments

Call Customer Service if you have Call your provider if you need to make an
questions about: appointment. You can see your provider
in person, or you can make a telehealth
• Benefits appointment with many clinics. A telehealth
• Finding or changing your primary care appointment is an appointment by phone
provider (PCP) or video, so you don't have to leave home.
• Using your PCP’s services Each provider uses their own secure
• Authorization (approval) for medical telehealth system to provide care. Telehealth
services and supplies appointments are available for physical health,
• Prescription drugs mental health, substance use disorder and
even some dental appointments. Telehealth
• Where to buy medical supplies
or equipment services must be appropriate to your culture
and background. We work closely with our
• Prenatal (before birth) care, and
providers to make sure as many of them as
participating prenatal care providers
possible can offer telehealth options, when
• A bill you received from your provider they are medically appropriate for members
when you were covered by Jackson who want them. Here are some reasons you
Care Connect might want a telehealth appointment:
• You have simple needs or questions for
New members who need your provider that might not require an
service immediately in-person visit.
If you haven't seen your PCP, and you need • You have a prescription that needs to
care, or prescriptions, supplies or other be refilled, but it requires a check-in with
necessary items during your first month as a your provider.
member, call Customer Service. They’ll help • You do not feel comfortable leaving home
fill existing prescriptions, get medical supplies because of the coronavirus (COVID-19) or
and coordinate services. Please make an other health issues.
appointment with your assigned PCP, primary Your provider cannot ask that you only use
dental provider (PDP) or mental health or telehealth (unless there is a declared state of
substance use disorder provider right away so emergency or their office is working under a
facility disaster plan). Talk to them about what
you can receive any ongoing care you need.
kind of appointment is best for your needs.
3
Member Handbook
For video appointments, you need a If your provider does not have one at your
smartphone, computer or tablet with a camera visit or if you need interpretation at the
and a secure internet connection. Ask your pharmacy or while making an appointment,
provider whether health-related services or call Customer Service at 855-722-8208 to get
items are available to support your health an interpreter on the line.
care needs. If you have questions or want to
know more about telehealth visits, call our You may have been provided with a Preferred
Customer Service at 855-722-8208, TTY 711. Language Card as part of your new member
packet. Carry this card with you to let health
care staff know you need interpretation.
Having an interpreter at appointments
If you do not speak English, have difficulty
understanding English, or need American Sign Plan information
Language interpretation for an in-person or Jackson Care Connect sends you
telehealth appointment, request information about:
an interpreter from your provider when you • Covered benefits and services.
make an appointment. In-person interpreters
can be available with at least 48 hours' notice. • How to find a provider.
You have a legal right to free interpretation. • How to get care for covered services
when you are outside our service area
(Jackson County).
• How Jackson Care Connect decides
if new medical equipment should be a
covered benefit.
• Any law changes that affect your plan,
at least 30 days before the changes
take place.
4
Your Oregon Health ID card OHA Coverage Letter
The Oregon Health Authority (OHA) sends The Oregon Health Authority (OHA) sends
you one Oregon Health ID card that has your you a coverage letter that has your:
name, client number and the date the card • Benefit package.
was issued. All eligible members in your
• Coordinated care plan name.
household receive their own Oregon Health
ID cards. This letter shows information for everyone
in your household who has an Oregon Health
Keep your Oregon Health ID card in a safe
ID card. You do not need to take this letter to
place. OHA only sends a new card if you
your health care appointments or to pharmacies.
change your name or if you ask for a new card.
OHA will send you a new coverage letter if
If your Oregon Health ID card is not correct,
you ask for one or if your coverage changes.
or you get a new card with your name but a
different Client ID, call OHP Customer Service
right away at 800-699-9075, TTY 711. Copays
We do not charge copays.
If your provider asks you to pay a copay

Member Name please do not pay it. Instead, ask the clinic
staff to call our Customer Service Department.
Members – Visit OHP.Oregon.gov

to learn about your coverage and
how to report income, address, and
other household changes online.
For questions, call 800-237-0557.
Providers – This card does not guarantee

coverage. Verify coverage, enrollment and
more at https://www.or-medicaid.gov.
5
Member Handbook
Your Jackson Care Connect ID card Keep your card with you at all times
When you become a Jackson Care Connect You’ll need it for:
member, we will mail you a Member ID Card • Medical appointments
within 30 days. Your Member ID Card lists your
• Dental appointments
PCP. It also lists important contact information.
• Mental health appointments
If you or a family member changes PCPs, you
• Substance use disorder
will get a new Jackson Care Connect ID card.
treatment appointments
If you lose your ID card, please call Customer
Service and we will send you another one. • Picking up prescriptions
• Emergencies
If you need care before you receive your
Jackson Care Connect ID card, please call us.
We will help you get the services you need.
Take your Jackson Care Connect ID card and

a photo ID to all your health care and dental
appointments and to the pharmacy when you
fill a prescription.
Plan: OHP Plus

Case ID: ABCDEFG
RxBIN: 610011
RxPCN: IRX
RxGrp: CORMCAID
Member: Member ID: Primary Care Provider:
MEMBER NAME XXX1234 OHSU FAMILY HEALTH CENTER
This card is for identification only and does not certify eligibility.
y.
For admissions and out-of-network care, please call Customer Service.
Send claims to: Advantage Dental 866-268-9631

PO Box 40328 Member and Provider
Portland, OR Customer Service 855-722-8208
97240-0328 TTY/TDD 711
Electronic Payer ID: Pharmacy provider line 866-843-5126
93975
JacksonCareConnect.org
For urgent care, call your clinic 24 hours a day.
In an emergency, go to the nearest hospital
or call 911. Call your clinic for follow-up care
the day after you get emergency care.
6
What is the Oregon Health OHP Customer Service
Plan (OHP)? Call OHP Customer Service if you:
• Need to change your address, telephone
number, name or family status.
OHP is a program that pays for the health care
• Have other health insurance coverage.
of low-income people in Oregon. The state of
• Become pregnant, give birth, or adopt
Oregon and the U.S. government's Medicaid
a child.
program pay for it. It covers things like doctor
• Need to replace a lost or stolen
visits, prescription drugs, hospital stays and
OHP ID Card.
dental care. It also covers mental health
• Move outside of our service area
services, help with smoking, substance use (Jackson County).
disorder services, and getting to health care
• Want an OHP Handbook sent to you.
appointments. OHP also can provide glasses,
hearing aids, medical equipment and home A phone call is the best way to reach OHP
health care if you qualify. Customer Service.
The OHP website has more details about Call toll-free, 800-699-9075, TTY 711.
what is covered. For more information, You also can reach OHP Customer Service by
go to: ohp.oregon.gov email at: oregon.benefits@dhsoha.state.or.us
You may also review the Oregon Health Plan Use the DHS/OHA secure email site at
Handbook. It has information on the Oregon secureemail.dhsoha.state.or.us/encrypt
Health Plan that may not be in this handbook. to send your email to OHP. Include your full
You can read it online at ohp.oregon.gov, or name, date of birth, Oregon Health ID number
you can call OHP Customer Service (see next and phone number.
section) and request a paper copy.
7
Member Handbook
What is a Coordinated receive after you are accepted. OHP uses

several different CCOs to serve its members,
Care Organization (CCO)? including Jackson Care Connect.
CCOs are companies that contract with the

state of Oregon to manage your health care.
What are Managed Care and
Fee-for-Service?
They are set up so that all your providers —
doctors, nurses, counselors, dentists — work The OHA pays managed care companies
together to prevent disease and improve your a set amount each month to provide their
health and the health of everyone on the OHP members the health care services they need.
in your community. Instead of just treating you Most OHP members must receive managed
when you get sick, CCOs work with you to medical, mental health and dental care.
keep you healthy and help you manage your
Health services for OHP members not in
health conditions.
managed care are paid by OHA. This is called
For example, there may be added services fee-for-service (FFS) because OHA pays
for members with chronic conditions like providers a fee-for-services they provide. It is
diabetes, asthma and heart disease, or for also called an “open card.”
those with other health needs.
Native Americans and Alaska natives on
For most people, CCOs pay for medical, OHP can choose to receive managed care
dental and behavioral health services. Some or have an open card. If you are on Medicare
people have CCOs only for dental or mental in addition to OHP, you can also have an
health. The Oregon Health Authority (OHA) open card. OHP members can choose to
pays each CCO a monthly fee to take care of have open card if they have an important
many of your health care needs. For services OHP-approved medical reason. Talk to OHP
to be covered, you must use providers who Customer Service about the best way to
are in the CCO’s provider network. receive your medical care.
What is the difference between Jackson What is a Patient-Centered

Care Connect and OHP? Primary Care Home?
The OHP is Oregon’s Medicaid program. We want you to get the best care possible.
Jackson Care Connect is one of several One way we try to do that is by asking our
CCOs that the state contracts with to provide providers to be recognized by the OHA as a
health care services to people on the OHP. Patient-Centered Primary Care Home (PCPCH).
When you apply for OHP, the OHA handles That means they can receive extra funds to
your application and sets the benefits that you follow their patients more closely, and make
sure their medical, dental and behavioral
8
health needs are met. You can ask at your • Personal Health Navigator (PHN): A person
clinic or provider’s office if it is a PCPCH. who can provide information, assistance,
tools, and support to help a patient to
At a PCPCH, a Primary Care Team will partner make the best health care decisions.
with you to manage your care and support • Peer Support Specialist (PSS): A person
your whole-person health. who provides support services to people
Some roles on a Primary Care Team may include: who currently use drugs or alcohol or
have a mental health condition. This is
• Medical Assistants someone who has life experiences with
• Nurses mental health, addiction and recovery.
• Traditional Health Workers Or they may have been a parent of a
• Panel Coordinators child with mental health or substance
• Co-located providers such as Behavioral use treatment. They also provide
Health Providers or Dietitians support to people who are in recovery or
receiving treatment for drug or alcohol
For help finding a PCPCH, please call
use or mental health conditions.
Customer Service at 855-722-8208, TTY 711.
• Peer Wellness Specialist (PWS): A
person who has experience living
Traditional Health Workers with a mental health condition that
provides support to those with mental
A Traditional Health Worker (THW) is a health and physical conditions.
person who has similar life experiences
• Community Health Worker (CHW): A
with the people they work with and provide trusted member of the community who
information, tools and support. They can assist serves as the link between the health
you in getting services and care that support system, social services network, and
your health and well-being by helping with community. They support, promote,
things like: and advocate for improved quality
• Navigating the health system and cultural competency of services
for all community members. They
• Understanding your benefits
help you form healthy behaviors.
• Connection to community resources
• Cross-cultural communication THWs can be found in community-based
• Connection to health care providers organizations and in clinics. They are a free
benefit. No referral is needed.
You can access five different types of THW:
• Doula: A birth companion who provides For more info or to get connected to a local
personal, nonmedical support to THW, contact our THW Liaison at 503-416-3906
pregnant people and families throughout or by email at jccthw@careoregon.org. If the
a person’s pregnancy, childbirth, name or contact info for your THW changes,
and post-partum experience. we will update the details on our website.
9
Member Handbook
To get connected to peer delivered services, touch with a staff member who is specially
ask your provider if they have peers that can trained in care coordination.
be added to your treatment team. You can
also visit traditionalhealthworkerregistry.
oregon.gov to find contact info for peer Intensive Care Coordination
support specialists. Services (ICCS)
ICCS is like Coordinated Care Services, but it
is for our highest-need and most vulnerable
Care Coordination Services (CCS) members. Some people who qualify for ICC
Our Care Coordination Services are available services may be:
to all Jackson Care Connect members.
• Older adults, those who are
When you request these services, a care
hard of hearing, deaf, blind or
coordinator will help you: have other disabilities.
• Work with the health care system • Those who have high health care needs,
• Navigate our CCO system multiple chronic conditions, or severe
• Find primary care and other types of and persistent mental illness (SPMI).
providers • Individuals receiving Medicaid-
• Access community and social services funded long-term care services
and supports (LTSS).
• Get services and medical equipment
• Those who are in medication-
• Coordinate your care among your
assisted treatment (MAT) for
providers if you have:
Substance Abuse Disorder (SUD).
- a disability
• People who have been diagnosed
- several chronic conditions with a high-risk pregnancy.
- special health care needs • IV drug users.
- and more • Those who have a SUD in need
CCS supports your whole-person health. That of withdrawal management.
means your physical health, but also your • Individual with HIV/AIDS or
mental and oral health, too. We will create a who has tuberculosis.
care plan that is based on your needs, so you • Veterans and their families.
can reach your health care goals. • Those at high risk of first
episode psychosis.
If you have both Medicaid and Medicare, we
• Those within the intellectual and
can also help coordinate your care between
development disability (IDD) population.
them. We want to make sure you get the care
and services you need. • And others.
Your ICCS team can include you, your PCP,
No referral is needed for Coordinated a care coordinator, and others involved in
Care Services. Call Customer Service at your health care. Your care coordinator will
855-722-8208, TTY 711. We will put you in make sure you know who they are and how
to reach them. They will work with you to
10
navigate the health system, connect you Jackson Care Connect
to appropriate providers, services, and
resources to meet your health needs. Your Community Programs
care coordinator will work with you and
your providers to make a care plan that As a nonprofit CCO, we put our
includes your wants and your goals related money back into our community
to your health. This may include assisting instead of shareholder profits.
with scheduling appointments, getting a
wheelchair or other equipment, understanding Each year, money from our budget is used
your medications, or connecting you to social to serve the residents of Jackson County
service resources like housing, SNAP benefits, who may need special services or more
and transportation. Your care coordinator will support. This includes special programs for
our Jackson Care Connect members. It also
work with you and your providers to create
includes additional programs that support
your plan within ten days of starting ICCS.
our entire community, not just Jackson Care
The plan will be updated every 90 days or
Connect members.
sooner. You will get a copy of your plan when
it is created, and any time there are changes Each year these programs change, depending
to it, and you can request a copy at any time. on our local needs. These needs are identified
by our Community Advisory Council (CAC)
Once they have your plan, your care members who live in Jackson County.
coordinator will make sure all your providers
talk to each other, answer your questions, Some of these programs are included here
and will work together to make sure your in this section. If you need more information
plan meets your needs. These include your on our programs, please visit our website at
medical, spiritual, financial, cultural, and jacksoncareconnect.org, or call Customer
educational needs, as well as others. Service during business hours.
No referral is needed for ICCS. Your care Strong Families

coordination team can be reached during
normal business, 8 a.m. to 5 p.m. Monday We support you and your children from
prenatal care through young adulthood:
through Friday. Call Customer Service at
855‑722‑8208, TTY 711. We will put you in • Starting Strong offers supplies, education
touch with a specially trained staff member. and emotional support for pregnant
If you need to reach us after hours, please members and those with children ages 0-4.
email us at info@jacksoncareconnect.org • Strong Kids supports kids ages
or call 855-722-8208 or TTY 711. Leave a 4-12 with behavioral health,
message with your contact details and times wellness programs and more.
that you are available. We will reach out and • Strong Teens supports youth ages 13-20
coordinate options that work for you. If you in establishing good health habits.
are only available after hours, we will work to
Learn more at
schedule a time that fits your needs. jacksoncareconnect.org/strongfamilies
11
Member Handbook
YMCA wellness programs How you need it: Nothing should get in
We want to make sure our members have the the way of getting care. Not your income.
best path to eating right and gaining healthy Not your language. Not your race. Not your
exercise habits. gender. Not any disabilities you may have. Not
where you live. Or anything else. We believe
This is why Jackson Care Connect partners getting care should be as easy as possible,
with the Ashland and Rogue Valley Family for all our members.
YMCAs to offer discounted memberships to
our adult and youth members. Our providers will make sure you will have
physical access, reasonable accommodations
At the YMCA, you can access health and and accessible equipment if you have
fitness programs that can help keep you well. physical and/or mental disabilities. Contact us
if you have special needs. Office hours for our
These include:
providers are the same for OHP members and
• Special weight loss programs everyone else.
• Cooking classes
• Workshops on healthy eating When you have access to the you need and
deserve, you and your family can live healthier
To see a schedule of events and
and more satisfying lives.
programs, please visit our website at
jacksoncareconnect.org/YMCA.
Culturally-sensitive health education
You also can find more information
by calling Customer Service. We respect the dignity and the diversity of
our members and the communities where
Access to care they live. We want to make sure our services
address the needs of people of all cultures,
OHP and Jackson Care Connect work hard
languages, races, ethnic backgrounds,
to make sure our members get the care they
abilities, religions, genders, sexual
need and deserve. That means getting care:
orientations, and other special needs of
When you need it: We work with many our members. We want everyone to feel
providers and clinics. This helps you get welcome and well-served in our plan.
appointments and services as quickly as
Our health education programs include
possible. And emergency care is always
self-care, prevention and disease self-
available 24 hours a day, seven days a week.
management. Please call Customer Service
Where you need it: You should always be toll-free at 855-722-8208, TTY 711 for
able to find a provider you trust that's close to more information.
where you live. And if you can't leave home
or don't want to, you can meet with most
providers by phone or video.
12
Getting Involved To get involved, find out more about the CAC,
or share an idea, see the CAC section of our
as a Member website at jacksoncareconnect.org/CAC or
call Customer Service at 855-722-8208.
Community Advisory Council (CAC) TTY users can call 711. You also can send an
Because each CCO is special to its email to info@jacksoncareconnect.org
community with its own local leaders, the
voices of people who live in the community Youth Advisory Council (YAC)
are very important. Jackson Care Connect has
a CAC made up of members like you, as well Young people ages 14-20 are invited to apply
as providers and community members. The to be on the Youth Advisory Council. YAC
CAC is your voice in the health plan. members volunteer at local events, learn how
to interact with school board members and
Most CAC members are Jackson Care develop their leadership skills. YAC members
Connect members. This gives you the chance also meet local health care and community
to take an active role in improving your own leaders, to learn about community issues and
health and that of your family and others in health care advocacy.
your community.
Visit jacksoncareconnect.org/yac or call
Some of the CAC’s duties include: 541-206-7895 to learn more.
• Sharing expertise about how to improve
health in clinics and in the community
• Finding ways to improve existing
Jackson Care Connect programs, as
well as suggesting future programs
• Advising the board of directors on
how to help us respond to members’
needs and plan for community health
• Organizing activities and projects for
Jackson Care Connect members and
the community on health care issues
• Helping with a Community Health
Needs Assessment and Community
Health Improvement Plan for
everyone living in the Jackson County
area–even people not on OHP
13
Member Handbook
Your Rights as a Jackson Care • Free to get mental health and

family planning services and
Connect Member on OHP supplies without a referral.
• Given equal access to the right treatment,
As an OHP client, you will be: services and facilities if you are under
• Treated with dignity, respect and privacy. 18 years of age. To learn more, read
• Free to choose your primary OHP’s “Minor Rights: Access and Consent
care provider (PCP). to Health Care” booklet. It tells you the
types of services minors can get on their
• Urged to tell your PCP about
own and how their health records may be
all your health concerns.
shared. Visit OHP.Oregon.gov and click
• Able to access all care that is covered on “Minor rights and access to care.”
by OHP, at the level of services you
• Able to get care coordination and
need and deserve; and to get prior
be a part of your care planning.
authorizations and permission for
other services when needed. • Free to get help with addiction
to tobacco products, alcohol
• Able to get information on available
and drugs without a referral.
treatment options and alternatives. These
options will be presented in a way that's • Given handbooks and letters
appropriate for your condition, preferred that you can understand.
language and ability to understand. • Able to get a copy of your health
• Able to have a friend or helper records for a reasonable fee.
come to your appointments, and • Able to have corrections made
an interpreter if you want one. to your health records.
• Told about all of your OHP-covered • Able to limit who can see
and non-covered treatment options. your health records.
• Allowed to help make decisions about • Sent a Notice of Adverse Benefit
your health care, including refusing Determination (NOABD) letter if
treatment, without being kept away you are denied a service.
from other people or forced to do • Notified 30 days before the change, or as
something you don’t want to do. soon as possible, if there is a change in
• Given a referral or a second opinion, your benefits. Given information and help
at no cost to you, if you need it. to appeal denials and ask for a hearing.
• Given care when you need it, • Free from any form of restraint or
24 hours a day and 7 days a week. seclusion (isolation) that is not medically
necessary or is used by staff to bully
14
or punish you. Staff may not restrain or Connect in a language you understand
isolate you for the staff’s convenience and in a way that respects your culture,
or retaliation against you. You have the to make sure community based care is
right to report violations to Jackson Care provided in as natural and integrated an
Connect and/or to the Oregon Health Plan. environment as possible, and in a way that
• Allowed to make complaints and keeps you out of the hospital if possible.
receive help filing complaints, and • Provided with necessary and reasonable
to get a response without a bad services to diagnose your condition.
reaction from your plan or provider. • Provided with integrated, person-
• Free to ask the Oregon Health centered care and services that provide
Authority Ombudsperson for help choice, independence, and dignity,
with problems at 503-947-2346 or and that meet accepted standards
toll-free 877-642-0450, TTY 711. of medically appropriate care.
• Be treated by your providers the • Able to have a consistent and stable
same as other people seeking health relationship with a care team that is
care benefits they are entitled to; and responsible for managing your care.
encouraged to work with the your care • Able to receive covered
team, including providers and community preventive services.
resources that are right for your needs.
• Provided with a referral to specialty
• Able to choose a primary care providers for medically appropriate
provider (PCP) or service site and to covered coordinated care services
change those choices as allowed following Jackson Care Connect’s
by Jackson Care Connect rules. referral policy.
• Given the right to agree to treatment • Provided with a clinical record that
or refuse services and be told the documents conditions, services
effects of that decision, except received and referrals made.
for court ordered services.
• Able to transfer a copy of your
• Given written materials describing rights, clinical record to another provider.
responsibilities, benefits, how to access
• Able to write a statement of your
services and what to do in an emergency.
wishes for treatment, including the
• Provided with services and support right to accept or refuse medical,
in a language you understand, and in surgical, or mental health treatment.
a way that respects your culture.
• Able to write directives and
• Provided with care coordination and powers of attorney for health care
transition planning from Jackson Care established under ORS 127.
15
Member Handbook
• Given a notice of an appointment • Follow your providers’ and pharmacists’

cancellation in a timely manner. directions, or ask for another choice.
• Free to exercise your Member Rights • Be honest with your providers to
without being treated badly by Jackson get the best service possible.
Care Connect, your providers, or the • Call OHP Customer Service when
Oregon Health Authority (OHA). you move, are pregnant or are no
• Able to use electronic methods, if longer pregnant.
available and at your request, to • Use your PCP or clinic for diagnostic and
communicate with Jackson Care Connect other care except in an emergency.
and provide member information.
• Get a referral to a specialist from
• Able to work with Jackson Care Connect your PCP or clinic before seeking
staff who are trained in every part of the care from a specialist unless self-
Oregon Health Plan (OHP), including referral to the specialist is allowed.
benefits, grievances and appeals,
• Use urgent and emergency
enrollment and disenrollment, and more.
services appropriately, and notify
your PCP or clinic within 72 hours
As an OHP client, you agree to: of using emergency services.
• Find a doctor or other provider you • Give accurate information to be put in
can work with and tell them all about your clinical record.
your health. • Help your provider or clinic get your
• Treat providers and their staff with clinical records from other providers,
the same respect you want. which may include signing an
authorization for release of information.
• Bring your medical ID cards to
appointments, tell the receptionist that • Ask questions about conditions,
you have OHP and any other health treatments, and other issues related to
insurance, and let them know if you your care that you do not understand.
were hurt in an accident. • Use information provided by Jackson
• Be on time for appointments. Care Connect providers or care
teams to make informed decisions
• Call your provider as soon as possible
about treatment before you get it.
if you can’t make it to an appointment.
• Help your providers make
• Have yearly check-ups, wellness
a treatment plan.
visits and other services to prevent
illness and keep you healthy.
16
• Tell your provider that your health Working With Your Primary
care is covered under OHP before
you get services and, if requested, Care Provider (PCP)
show the provider your Jackson
Care Connect Member ID card. Your PCP clinic assignment
• Call OHP Customer Service to All Jackson Care Connect members have
tell them if you change your a PCP. When you become a Jackson Care
address or phone number. Connect member, we will assign you a primary
• Call OHP Customer Service if you become care clinic. If there is a different provider you
pregnant and when the baby is born. would prefer, you have the right to change
your assignment. This could be a doctor, a
• Call OHP Customer Service if you
nurse practitioner or a physician’s assistant.
have any other insurance available.
Start with your PCP for all of your health
• Pay for non-covered services under care needs.
the provisions described in OAR
410-120-1200 and 410-120-1280 To find a provider you can change to,
visit our online provider directory at
• Let Jackson Care Connect know about
jacksoncareconnect.org/providerdirectory.
any issues or complaints or grievances
You can also contact Customer Service at
you have.
855-722-8208.
If you would like provider information in a print

version, you can print it from our website or
call Customer Service at 855-722-8208, TTY
711. We can mail you provider lists in the ZIP
code and/or specialty service of your choice.
Please note: You are free to choose any

provider you like, but some providers do
not accept new patients. If you need help
finding a provider in your area, or if you
have other questions about a provider
that our online directory does not answer,
including qualifications, specialty and board
certification, please contact Customer Service
and they can assist you.
IMPORTANT: If you are pregnant or have a

baby less than one year old, see your PCP
as soon as possible.
17
Member Handbook
Get to know your PCP Getting in to see your PCP

Your PCP keeps track of your health and care. You can get a routine or follow-up
Make an appointment to see your PCP as appointment within four weeks of the request,
soon as possible. This way, your PCP can or within 72 hours for urgent issues, unless
learn about you and your medical history the reason for a longer wait is documented
before you have a medical problem. This will as part of an initial screening. If you have
help you avoid delays the first time you need a medical emergency, you’ll be seen
to use your benefits. immediately. Or, if needed, your provider will
recommend that you go to the emergency
When you don’t feel well or need a checkup,
room. If you have questions or concerns about
call your PCP to make an appointment and
getting an appointment, call Customer Service
get help deciding what care you need.
at 855-722-8208, TTY 711 for assistance.
Before your appointment, write down any
questions you may have so you remember
Missing PCP appointments
to ask them. Also, write down any history of
family health problems and make a list of any If you must miss an appointment, call your
prescriptions, over-the-counter medications PCP and try to cancel as soon as possible.
and vitamins you take. The clinic will schedule another appointment
for you and make the time available for
another patient.
Making appointments to see your PCP
If you need a medical appointment, call your PLEASE NOTE: Each clinic has its own
PCP’s office or clinic during office hours and: policies about canceling or missing
appointments. Ask your clinic about
• Tell the office or clinic that you are a their policy and keep it in mind when
Jackson Care Connect member. you need to change your schedule.
• Give them your name and You should never be asked to pay for a
Medical ID number. cancellation or missed appointment.
• Tell them why you want an appointment.

Changing your PCP
• Ask about a telehealth appointment if
you want to be seen by phone or video. If you are new to Jackson Care Connect,
you can change your PCP within 30 days
Call in advance for routine, non-emergency of your enrollment. After 30 days, you can
appointments. If you are sick and need a change your PCP up to two times in a six-
same-day appointment, tell the clinic’s staff month period. In some situations, like if
person when you call. you move, we will make an exception.
18
We can help you find a PCP whose office is else — like routine and preventive women’s
convenient for you and who accepts new health care, Pap tests, family planning, and
patients. You may also look in the Primary immunizations (shots). All of this and more can
Care Clinics section of our provider directory, usually be taken care of at your medical home.
available online at jacksoncareconnect.org/
In addition to your PCP, most primary care
providerdirectory
offices have many health professionals to
To change your PCP, call Customer help with all your needs. These may include:
Service at 855-722-8208. After you • Medical Assistants
choose a new PCP, we will mail you a
• Nurses
new Jackson Care Connect ID card that
shows the name of the PCP you chose. • Behavioral Health Specialists
When you choose a new PCP, the change • Pharmacists

is effective right away, but it might take • Dietitians
a few days for your new PCP to get your • Traditional Health Workers, including
information. If you or your PCP has questions
Peer Health Providers, Community
about your PCP assignment or plan benefits,
Health Workers and others
please call Customer Service.
Referrals to other providers and direct

Changes to your PCP
access to specialists
If there is a change and your PCP is no
If you think you need to see a specialist or
longer contracted with Jackson Care
other provider, make an appointment with
Connect, we will send you a letter 30 days
your PCP first. Your PCP will decide which
before the change happens. If this change
services and tests you may need.
was already made, we will send you a
letter within 15 days of the change. Specialty care is care provided by a
specialist provider, such as a cardiologist
for heart problems, orthopedist for bone
Your PCP’s office is your medical home problems or endocrinologist for hormone
Your PCP is supported by a team of people problems or severe diabetes. If you need
who work together to manage whole-person to see a specialist, your PCP will refer you.
health in what we call your “medical home.”
It’s the place you can get care for most of However, you can see specialists for some
your health needs, including many things you kinds of care without seeing your PCP first.
might think would be handled somewhere This is called “direct access to a specialist.”
19
Member Handbook
You can make your own appointment for the Getting approval, also called pre-
following services from a specialist who is a approval or prior authorization (PA)
Jackson Care Connect provider: Some services need approval before you
• Mammograms get the service. This is known as a “prior
• Renal (kidney) dialysis services authorization (PA)” or “pre-approval.” We
you get when you are temporarily review PA requests as quickly as your health
outside the plan’s service area condition requires. Most decisions are
made within 14 days. Sometimes a decision
• Outpatient mental or behavioral
may take up to 28 days. This only happens
health services
when we are waiting for more information.
• Outpatient substance use If you or your provider feel following the
disorder services standard time frame puts your life, health
• Family planning services and supplies or ability to function in danger, we can
• Sexual abuse exams make an “expedited service authorization”
decision. Expedited service decisions are
• Health risk screening for Intensive
typically made within 72 hours, but there
Care Coordination Services (ICCS)
may be a 14-day extension. You can appeal
• Appointments with a women’s this decision. See page 64 for details.
health specialist for routine and
preventive health care services
Planned care out of state
You can get a routine or follow-up
Jackson Care Connect will help you
appointment within four weeks of the request,
locate an out of state provider and
or within 72 hours for urgent issues, unless
pay for a covered service when:
the reason for a longer wait is documented
as part of an initial screening. If you have a • You need a service that is not
medical emergency, you’ll be immediately available in Oregon, or
assessed and either immediately seen or • The service is cost effective.
referred to an emergency department based
on that assessment. You are free to see any
network provider that is accepting patients. Out-of-network providers
A list of providers for these services is in For family planning services and supplies,
Jackson Care Connect’s online provider you can see an out-of-network provider. In
directory at jacksoncareconnect.org/ most other cases, you must see a Jackson
providerdirectory. For information about Care Connect specialist or other provider. If a
out-of-network providers, see below. Jackson Care Connect specialist or provider
is not available, your PCP will ask us if you
20
can see an out-of-network provider. We will When your PCP is out of town or on vacation,
work with your PCP in determining how soon they will arrange for another provider to be
you need to be seen and the specialist you available to give you care and advice.
need to see to address your medical needs.
There is no extra cost if this happens.
If you need care out of town
If you have already seen a specialist and
If you get sick when you are away from
have questions or concerns, make an
home, call your PCP. If you need urgent
appointment with your PCP to discuss any
care, find a local doctor who will see
issues. If you or your PCP want a second
you right away. Ask that doctor to call
opinion from another specialist, at no
your PCP to coordinate your care.
cost to you, your PCP will refer you.
Second opinions
You can get a second opinion at no cost
to you. If you want a second opinion about
your treatment options, ask your PCP to refer
you to another specialist. If you want to see
a provider outside our network, you or your
provider will need to get our approval first.
We will tell you if a referral, approval or signed
release is needed for a second opinion.
Contact Customer Service at 855-722-8208 if
you need help.
After-hours care (evenings,

weekends and holidays)
Your Jackson Care Connect PCP looks
after your care any time of day or night.
Even if your PCP’s office is closed, call
the clinic’s phone number. You will speak
with someone who will contact your PCP,
or give you advice on what to do.
21
Member Handbook
Emergencies, Urgent Care If you need help contacting any of these

hospitals, please call our Customer Service
and Crises at 541-500-0567 or toll-free 855-722-8208.
If you think you need an ambulance, call 911.
If you have an emergency
You can call your primary care clinic, even
Emergencies are serious medical problems that after hours, to make an appointment or talk
need immediate care in an emergency room. about what to do next.
In an emergency, you need medical attention
immediately to prevent loss of life or more injury
to yourself, your child or your unborn child. Dental emergencies
The Oregon Health Authority defines a
Examples of emergencies are:
dental emergency as “dental services
• Chest pain provided for severe tooth pain, unusual
• Head trauma swelling of the face or gums, or an
• Severe shortness of breath avulsed [knocked out] tooth.” If you have
• Mental distress a dental emergency and your dentist or
If you are experiencing an emergency, you PCP cannot help you, you don't need
don’t need permission to get care, and it permission to get emergency dental care.
will be covered. Call 911 or go to the nearest
hospital, including these that are part of
Mental health emergencies
the Jackson Care Connect network:
A mental health crisis is defined as “an actual,
Asante Ashland Community Hospital
or perceived, urgent or emergent situation.”
280 Maple St, Ashland
It involves impaired functions and an urgent
541-201-4000, TTY 711 asante.org
need to address the problem before anyone
Asante Rogue Regional Medical Center is at risk of harm. If you are experiencing a
2825 E Barnett Rd, Medford mental health crisis, your care is fully covered.
541-789-7000, TTY 711 asante.org Please call the following crisis number:
Providence Medford Medical Center • Jackson County: 541-774-8201 or TTY 711
1111 Crater Lake Ave, Medford
541-732-5000, TTY 711 oregon.providence.org
Follow-up care after an emergency
Asante Three Rivers Medical Center
500 SW Ramsey Ave, Grants Pass Emergency rooms will care for you until you
541-472-7000, TTY 711 asante.org are stable. If you need more care, you may be
admitted to the hospital. If not, the emergency
staff will tell you where to go for follow-up
care. If you do not receive this information,
22
contact your PCP on the next business day Mexico, Canada, or anywhere else outside
after your emergency treatment. Follow-up the United States.
care once you are stable is covered, but is not
If you need to go to an emergency room
considered an emergency.
when you are away from home, please follow
these steps:
Post-emergency care 1. Make sure you have your Jackson Care
Post-emergency care refers to covered Connect Member ID card with you.
services you get after an emergency and after 2. When you are at the emergency room,
your condition is stabilized. It is care to help make sure you show them your Member
maintain or improve your condition. Jackson ID card. Ask them if they will send
Care Connect will pay for post-emergency any bills to Jackson Care Connect.
care provided by a hospital (whether or not
3. Do not sign any paperwork until you
the hospital is in our provider network).
know the emergency provider will send
After you receive emergency treatment, the bill to Jackson Care Connect.
call your PCP as soon as possible. You can 4. Call our Customer Service at the number
arrange for more care if you need it. on your Member ID card as soon as
you can. Ask them to talk with the
emergency room staff about any bills.
Planned care out of state
Jackson Care Connect will help you It's ok if you don't remember to do all of this
locate an out of state provider and during an emergency. But if you follow these
pay for a covered service when: steps, you are less likely to get a bill.
• You need a service that is not If you do get a bill for your emergency room
available in Oregon, or visit, do not ignore it. As soon as you get a bill,
• The service is cost effective. this is what you should do:
1. Call our Customer Service right away.
Out-of-town emergencies We will help you get it taken care of.
If you have an emergency when you are 2. Check with us later to make
away from home, call 911 or go to the nearest sure the bill was paid.
emergency room. Your care will be covered 3. If you get court papers in the mail
until you are stable. For follow-up care after about the emergency room bill, call us
the emergency, call your PCP. right away. You can also call the Public
Benefits Hotline at 800-520-5292
OHP covers emergency and urgent care
for legal advice and help. There are
anywhere in the United States, but not in
laws that can help you if you receive
a bill when you shouldn't have.
23
Member Handbook
You can appeal a bill if you receive one. See Here are urgent care clinics that serve
“Complaints and Appeals” on page 64. Jackson Care Connect members:
Asante Urgent Care
Urgent care 555 Black Oak Dr, Medford
541-789-2273
All providers in our network offer after-hours
help — you can reach them 24 hours a day, Asante Urgent Care
seven days a week. Urgent problems are 2841 Ave G, White City
things like severe infections, sprains and 541-789-2273
strong pain that need care within a few days
Providence Stewart Meadows Urgent Care
to prevent an emergency. If you don’t know
70 Bower Drive, #110, Medford
how urgent the problem is, call your PCP.
541-732-3962
When you have an urgent problem, at home Valley Immediate Care
or away, you should: 1401 Siskiyou Blvd, Suite 1, Ashland
1. Call your clinic or provider’s office. 541-488-6848
You can call anytime — day or night,
Valley Immediate Care
24 hours a day, seven days a week.
1600 Delta Waters Rd, North Medford
2. If your PCP isn’t available, ask to speak 541-858-2515
to the clinic nurse or on-call provider.
Valley Immediate Care
3. A health care professional will tell you 1700 E. Barnett Rd, South Medford
what to do. You may be scheduled for 541-773-4029
an appointment with your PCP right
away. If your PCP is not available
within a reasonable time, they may
suggest going to an urgent care
facility. Urgent care is covered and
you do not need permission to get it.
People who need urgent care will

be seen within 72 hours, unless the
reason for a longer wait is documented
as part of an initial screening.
24
Covered Benefits you can ask your PCP or call Customer Service.
You also can reference the OHP Handbook.
and Services It is available on the web at ohp.oregon.gov.
You can also call OHP Client Services and ask
This is a brief list of benefits and services that them to send you a copy. That phone number
are covered under your OHP benefits with is 800-273-0557, TTY 711.
Jackson Care Connect. There are no copays.
If you have any questions about what is covered,

Doctor Visits Authorization/Referral? Limits to Care?
No authorization/ No limit, but you must be
Primary Care (PCP) visits
referral required assigned to a PCP
Authorization may be
required for some services,
Number of visits based
check with your PCP or
Mental health services on your health plan’s approval
outpatient behavior when authorization is required
health provider. See
detailed chart on page 51
required for some services,
Number of visits based
Substance use check with your PCP or
on your health plan’s approval
disorder services outpatient behavior when authorization is required
health provider. See
detailed chart on page 51
Applied behavior Number of visits based on

Yes, authorization required
analysis services your health plan’s approval
Psychiatric emergency No authorization/

No limit
services referral required
Dental services (including required. See page 47 See page 47 for details and
emergency dental) for details and check with check with your dental plan
your dental plan
Referral required
Number of visits based on
Specialty visits for some services,
your health plan’s approval
check with your PCP
25
Member Handbook
Telehealth Referral required

Number of visits based on
(phone, video, email) for some services,
services check with your PCP
No authorization/referral
Urgent care No limit
required
Emergency services No limit
required
Preventive Services Authorization/Referral? Limits to Care?
Well-child visits for babies, No authorization/

As recommended
children and teens referral required
No authorization/
Immunizations As recommended
referral required
Early and periodic

No authorization/
screening, diagnosis and As recommended
referral required
treatment (EPSDT) services
No authorization/
Routine physicals As recommended
referral required
No authorization/
Well-women visits As recommended
referral required
Mammograms No authorization/ As recommended; 3D

(breast X-rays) referral required mammograms not covered
No authorization/
Family planning No limit
referral required
No authorization/
Prostate exams No limit
referral required
No authorization/
Colon cancer screening No limit
referral required
No authorization/ Two quit attempts per year;

Stop smoking
referral required more with approval
26
Preventive Services Authorization/Referral? Limits to Care?
Sexually transmitted No authorization/

No limit
infection (STI) screening referral required
Testing and counseling for No authorization/

No limit
HIV and AIDS referral required
No authorization/
Diabetes prevention No limit
referral required
No authorization/
Nutritional counseling No limit
referral required
Referral required for

some services, check
Diagnostic services As recommended
with your PCP or mental
health provider
Prescription Drugs Authorization/Referral? Limits to Care?

Many drugs are available You may need
with a prescription. authorization in addition
A full list of prescription to your prescription. Limits vary by prescription
drugs can be found in drug. Contact Customer
Your doctor will Service for more information
our formulary at
jacksoncareconnect.org/ let you know if you
druglist need authorization
Some mental health

prescription drugs are
paid for by OHP. They are
Ask your provider about
not paid for by Jackson
which prescriptions Ask your provider about limits
Care Connect like other
are covered
prescription drugs. Your
pharmacist will know where
to send the bill
27
Member Handbook
Laboratory and X-Ray Authorization/Referral? Limits to Care?
Blood draw Check with your PCP No Limit
X-rays Check with your PCP No Limit
CT scans Yes, authorization required No Limit
MRI Yes, authorization required No Limit
Pregnancy Care Authorization/Referral? Limits to Care?
Prenatal visits with No authorization/

No limit
your provider referral required
Newborn care No authorization/

No limit
(first 28 days after birth) referral required
Postpartum care
No authorization/
(care for the mother after No limit
referral required
the baby is born)
Routine vision services

(pregnant people qualify Contact Customer Service Contact Customer Service
for vision care)
Assistance with breast

No authorization/
feeding, including Contact Customer Service
referral required
breast pumps
No authorization/
Labor and delivery Contact Customer Service
referral required
Hospital Stays Authorization/Referral? Limits to Care?
No authorization/ No limit; not covered outside

Emergencies
referral required U.S. or U.S. territories
Number of days based on

Inpatient hospital services Yes, authorization required
28
Hospital Stays Authorization/Referral? Limits to Care?
Referral required
Outpatient hospital services for some services, As recommended
check with your PCP
Referral required
Chemotherapy and
for some services, As recommended
radiation
check with your PCP
Scheduled surgery Authorization required Contact Customer Service
Vision Authorization/Referral? Limits to Care?
For pregnant people

Routine eye exams Contact Customer Service and people age 20 or
younger only
For pregnant people,

those with a qualifying
Eyeglasses Contact Customer Service
medical condition and
people age 20 or younger
Authorization required for

Medical eye exams Contact Customer Service
some services
PT/OT/ST Authorization/Referral? Limits to Care?
Based on OHP guidelines.

Physical therapy (PT) Yes, authorization required
Call Customer Service.

Occupational therapy (OT) Yes, authorization required

Speech therapy (ST) Yes, authorization required

Pain management Yes, authorization required
29
Member Handbook
Other Specialty Services Authorization/Referral? Limits to Care?
Yes, authorization required Approval based on

Medical equipment
for some equipment OHP guidelines.
and supplies
and services Contact Customer Service.

Diabetic supplies for some equipment
and services

Medical appliances for some equipment
and services
Prosthetics and orthotics Yes, authorization required

(e.g., artificial limbs, splints for some equipment
or braces) and services
Emergency detox No limit
required
Number of days based on

Inpatient rehab services Yes, authorization required
Approval based on
Hearing aids and exams Yes, authorization required OHP guidelines.
Contact Customer Service.
Approval based on
Home health Yes, authorization required OHP guidelines.
Approval based on
Skilled nursing facilities Yes, authorization required OHP guidelines.
Long-term care services Contact OHP Contact OHP
Approval based on
Hospice Yes, authorization required OHP guidelines.
30
Other Specialty Services Authorization/Referral? Limits to Care?
No authorization/
Comfort care As recommended
referral required
Approval based on
Chiropractor Yes, authorization required OHP guidelines.
Approval based on
Acupuncture Yes, authorization required OHP guidelines.
Approval based on
Hormone therapy/sex
Yes, authorization required OHP guidelines.
reassignment surgery
No limit. Frequency
required. Contact Customer
Care coordination services and intensity based on
Service to get connected to
situation/need.
your team.
No limit. Frequency
Intensive care coordination required. Contact Customer
and intensity based on
services Service to get connected to
situation/need.
your team.
No limit. Frequency
required. Contact Customer
Case management services and intensity based on
Service to get connected to
situation/need.
your team.
Non-emergent medical
Yes, authorization required No limit
transportation
Emergency transportation No limit
required
Interpretation and language No authorization/referral

No limit
services required
31
Member Handbook
Services covered by OHP, but not Want more information on the services?
provided by Jackson Care Connect Call the KEPRO Care Coordination Team at
Some benefits are covered by the OHP, but 800-562-4620. Need a ride to a service not
provided by agencies other than Jackson provided by Jackson Care Connect? See
Care Connect. We do not make coverage “Getting to Health Care Appointments” on
decisions based on moral or religious beliefs. page 38.
Some examples of services covered by Care Coordination Services are available

OHP that are not provided by Jackson Care for some services that are not provided by
Connect include: Jackson Care Connect. These include, but are
not limited to:
• Physician assisted suicide under the
Oregon Death with Dignity Act, ORS • Planned community birth services
127.800-127.897 • Some long-term care services
• Abortions • Family Connects Oregon services
• Hospice (end of life) services for members • Certain behavioral health services,
who live in a skilled nursing facility including:
• Long-term care services, such as an - Certain medications for some
behavioral health conditions
assisted living facility or in-home care
(ORS 414.631) - Therapeutic foster care reimbursement
for members under 21 years old
• Some school-based services that are - Therapeutic group home payment
covered services; reimbursed with the for members under 21 years old
educational services program - Long term psychiatric (behavioral
• Administrative examinations, such as health) care for members
exams required for some jobs or sports 18 years old and older
(OAR 410-130-0230) - Personal care in adult foster homes
for members 18 years and older
• Services provided to CAWEM, CAWEM
plus CHIP prenatal (CAWEM is emergency Jackson Care Connect will provide
care for non-citizens.) information about how a member can access
non-covered services. Call our Customer
Service at 855-722-8208, TTY 711.
32
Prioritized List of Health Services How does the Prioritized List work?
OHP does not cover everything. The Oregon The list contains hundreds of diseases and
law makers do not have enough money to conditions. Only some of them are covered by
provide services for every type of illness. So OHP due to funding. The cut-off line between
they use the money that is available to pay what is covered and what isn’t covered is
for the most effective services for selected called the Funding Line. All conditions “above
sicknesses and diseases. the line” are covered. Some conditions
and treatments above the line have certain
A list of these sicknesses and diseases is
rules. The conditions “below the line” usually
called the Prioritized List of Health Services.
are not covered by OHP, but there may be
This list was developed by a committee
exceptions. For example, something below
called the Oregon Health Evidence Review
the line could be covered if you have an
Commission (HERC). The HERC is a group of
above the line condition that could improve if
doctors, nurses and others concerned about
the below the line condition is treated.
health care issues in Oregon.
OHP covers reasonable services for finding
This Prioritized List of Health Services is
out what’s wrong. That includes diagnosing
available online at link.careoregon.org/ohp-
a condition that is not currently funded. If a
prioritized-list
health care provider decides on a diagnosis
To create the first prioritized list of health or treatment that’s not funded, OHP will not
services, the HERC held public meetings pay for any more services for that condition.
around Oregon to find out which health issues
The OHP website has more details about the
were important to Oregonians. The HERC
list. Go to ohp.oregon.gov
used that information to rank all health care
procedures in order of effectiveness. HERC
members are appointed by the governor and
meet regularly to update the list.
33
Member Handbook
Preventive Health Jackson Care Connect pays for medications

and telephone counseling with a trained
and Wellness coach to help you stop using tobacco. If you
use tobacco, call Quit for Life toll-free
Jackson Care Connect is committed to at 866-784-8454.
helping you and your family stay well and
live a healthy life. You can help prevent many
serious illnesses and health conditions by
Chemical dependency
(substance use disorder) treatment
making small, healthy lifestyle changes, using
preventive health and wellness services, and If you think you need treatment for a
working with your PCP. substance use disorder, Jackson Care
Connect is here to support you. We cover
Our health and wellness services include: a variety of treatments and services,
• Health checkups including treatment at residential facilities,
• Help to quit using tobacco to help you on the path to recovery.
Please see page 51 for more information
• Immunizations (shots)
on what services are covered.
• Prenatal care for pregnant members
• Mammograms
Baby, child and teen health
• Birth control and family planning options
Your children’s health is important to us. To
• Cancer screening tests keep your children healthy, be sure they
• Substance use disorder screening get their immunizations (shots) and regular
• Depression screening checkups even when they are not sick. Your
child should have a check-up with their PCP
and dentist within three months of becoming
Quitting tobacco a Jackson Care Connect member.
The single most important thing you can do
It is important for your children to get all
to improve your and your family’s health is to
recommended shots. If your child has
stop using tobacco. We have many ways to
missed any shots, make an appointment
support you.
to get them as soon as possible. It’s
We cover several types of support to help you important for your child to be immunized
quit smoking, as well as counseling in your before their second birthday.
doctor’s office or over the telephone. You are
Jackson Care Connect covers unlimited
most likely to be successful when you use
wellness visits (checkups). Children ages
both medication and counseling.
0-3 visit their PCP frequently for shots and
developmental health checks. But visiting
34
a PCP at least once per year for primary • Vaccines, as needed, according
care and dental care is still important for all to a child’s age:
individuals ages 3-21 for additional shots, - Child vaccine schedule:
physicals, health education and other needs. link.careoregon.org/CDC-child-vaccines
- Adult vaccine schedule:
link.careoregon.org/CDC-adult-vaccines
Early and periodic screening, diagnosis
• Lead testing for children between 1-2
and treatment (EPSDT)
years old, or 2-6 years if they haven’t had
With a referral from a provider, the early and one yet. This includes follow-up services
periodic screening, diagnosis and treatment for children with high lead levels.
(EPSDT) program offers well-child exams for
• Other needed laboratory tests (such
the diagnosis and treatment of all children
as anemia test, sickle cell test, and
from ages 0-20. These services are covered,
others) based on age and client risk.
with no cost, to members under age 21 to treat
needed physical, dental, developmental and • Overall unclothed physical exam with
mental health conditions. Children and their an inspection of teeth and gums.
families can get transportation help to get • Health guidance and education
to appointments for these services (see the for parents and children.
“Getting to health care appointments” section • Dental services when needed. See
on page 38 of this booklet to learn more). the “Dental Health Care” section
OHP covers EPSDT screening visits at age- of this booklet to learn more.
appropriate times. OHP follows the American • Health care and treatment to
Academy of Pediatrics and Bright Futures correct or improve defects.
guidelines. Bright Futures can be found at • Services, as needed, for severe,
link.careoregon.org/bright-futures infrequent or chronic conditions.
• An agreement showing your
EPSDT services include:
responsibilities and how long
• Regular exams and screenings to check services will be given.
the health, growth and development of
• Help with referrals for other
infants, children and youth. This includes:
needed services. This includes:
- Physical exams - Social services
- Mental health exams - Education
- Substance use treatment - Nutrition help
- Nutrition checks
Your physical and dental providers can help
- Hearing and vision tests (and glasses
you get EPSDT services — contact them to
and hearing aids, if needed)
learn more and get a referral. If screenings
35
Member Handbook
show that your child needs further care, your • Referrals for specialty care
provider can help you get more help. You can • Acute and urgent care such as sprains,
also call Customer Service with any questions difficulty breathing, and more
at 855-722-8208. Families who have not • Admission to the hospital, if needed
used EPSDT services will be notified about
them every year. More about EPSDT is on our
website at jacksoncareconnect.org/epsdt Family planning services
A number of family planning services and
supplies are covered by Jackson Care
Adult health
Connect and are usually provided by your PCP:
We never grow out of needing wellness
• Physical exams
visits. As adults, wellness visits are
important opportunities for health exams, • Birth control education and counseling
for family planning health issues
tests, getting shots, asking questions
and managing any health conditions • Birth control prescriptions like
with your primary care provider. pills, patches or rings
• Intrauterine devices (IUDs) and
Chronic illness or other conditions may other long-acting contraceptives
make it harder to manage your overall health
• Hormonal birth control you
and increase the chances of having health
inject, like Depo-Provera
complications if you get sick. Depending on
your specific health concerns, your PCP may • Supplies and devices like condoms,
diaphragms, foams and cervical caps
want you to have certain shots more often.
Talk to your PCP about which shots you • Emergency birth control (the
should have and when you should have them. “morning after” pill)
• Medical and surgical procedures, like
tubal ligations and vasectomies
Primary care
• Tests and counseling for sexually
Primary care is general medical care and transmitted infections (STIs),
treatment provided by your PCP. It includes: including AIDS and HIV
• Preventive health care services that • Abortions for medical reasons
catch a health problem early or prevent or elective (your choice)
it from happening (e.g., mammograms/ • Pregnancy tests
breast X-rays, Pap tests, shots)
• Care for ongoing, chronic conditions,
like diabetes or asthma
• Prescriptions
36
Lab tests, X-rays and other procedures PCP will tell you how often you should have a
Jackson Care Connect pays for these medical eye exam.
services when they are needed. With a
referral from your PCP (if required), we cover Benefits for members who are age 20
or younger:
diagnostic services. Diagnostic services
(e.g., MRI or CT scan) help determine the • Eye exams and new glasses are covered
cause or features of an illness or condition. with no limit only if they are medically
necessary (for example, if you experience
a change in your vision that requires new
Hospital care glasses). Medical necessity is decided by
If you need care at a hospital, your PCP or your PCP or other health care provider.
specialist will arrange for your care. • Oregon Health Plan covers contact
lenses only for a few conditions.
Hearing services
Benefits for pregnant members of any age:
If you need hearing services, your PCP will
• Eye exams and new glasses are
make a referral. Jackson Care Connect
covered every 24 months. Glasses are
pays for:
also covered within 120 days after
• Exams once every 12 months. cataract surgery or up to one year
• Up to 60 hearing aid batteries per year. after corneal transplant.
• Up to two hearing aids every five years • Oregon Health Plan covers contact
for adults over 21, and two hearing lenses only for a few conditions.
aids every three years for children.
Hearing aids require authorization. Benefits for members who are 21 or older
and not pregnant:
• Eye exams for prescribing glasses or
Vision care
contact lenses are ONLY covered when
For those who qualify for vision care, call VSP needed to treat medical conditions,
toll-free: 800-877-7195. You do not need a such as an absent natural eye lens,
PCP referral. synthetic eye lens replacement,
If you have an eye injury or infection, call your thinning or “coning” of the eye lens,
PCP. Your PCP may refer you to a specialist. cataracts, and congenital cataracts.
• Glasses are covered within 120 days
Eye exams for the purpose of checking on
after cataract surgery or up to one
your medical condition (for example, people
year after corneal transplant.
with diabetes) are covered. In this case, your
37
Member Handbook
If you are pregnant or become pregnant, be Getting to Health

sure to notify OHP Customer Service so that
you may receive full vision coverage. Care Appointments
You can contact OHP Customer Service
If you have no way to get to a covered
at 800-699-9075, TTY 711.
health appointment, a free program
called Translink can get you there.
Skilled nursing facility care Depending on your needs, you may get
free passes to ride the bus, provided
Jackson Care Connect will pay for care
rides or be reimbursed for travel costs.
in a skilled nursing facility or nursing home
for up to 20 days after you have been in the We offer members two different types of trips:
hospital. Additional skilled care may
be covered by OHP. Medical appointment trips to
• Dental appointments
• Medical exams
Palliative and hospice care
• Mental health care or substance
Please talk to your PCP for more information.
use treatment appointments
FlexTrip transportation to
• Community Advisory Council meetings
• WIC appointments
• Starting Strong store
• JCC-sponsored wellness events
If you need to request a trip, we prefer that

you call 48 hours ahead. But you can also
schedule a trip the day of your appointment.
Some appointments may require you to call

or get approval from Jackson Care Connect
before help can be provided.
Here are some other important details:

• You may schedule trips up to 90 days
in advance.
• You can schedule more than one trip
at a time up to 90 days in advance.
38
• Your driver cannot drop you off more can help determine if you need emergency
than 15 minutes before your provider's services and an ambulance. TransLink does
office opens, unless you request it. not provide emergency transportation. If
• Your driver must pick you up within you need an emergency trip, call 911.
15 minutes after your provider's office
closes, unless you request it.
TransLink member rights
• You have a right to file complaints
TransLink members have the right to:
about your experience.
• Receive safe and reliable transportation
• You have a right to ask for an appeal
that meets your needs.
if a trip you asked for is denied.
• Receive interpretation services.
• Before any request is denied, a second
employee must look at your request. • Get materials in the language or
format that meets your needs.
• If your request for a trip is denied, we will
mail a notice to you and your network • Not be discriminated against by
provider within 72 hours. We will also mail transportation providers, call-
the notice to your network provider, if center representatives or other
that provider requested the trip for you. TransLink passengers.
• Bring a service animal or personal
Monday through Friday 8 a.m. to 5 p.m.
care attendant (PCA) as needed.
Call: 541-842-2060
Please tell the call center about other
Toll-free: 888-518-8160
passengers who will ride with you.
TTY 711
Emotional support animals or pets
Or schedule your request online at rvtd.org must be in an enclosed carrier.
• Bring along a few items if needed, but
For more information about this program, visit
not too many. Items should not exceed
jacksoncareconnect.org/transportation.
2’x2’x2’. For example, you might bring:
You can also learn more in the Jackson Care
Connect Rider’s Guide. - Three grocery bags, or
- One box of food, or
- Two carry-on items
Emergency medical transportation • Be transported in the mobility device
Jackson Care Connect pays of your choosing (like a scooter).
for ambulance transportation in The device should be classified by
emergencies for OHP members. the ADA as a mobility device.
If you are not sure if you need emergency • Request help with seatbelts or
services call your PCP, even after hours. They request a seatbelt extender.
39
Member Handbook
• Get service in a timely manner. • Agree not to be under the influence of

• Share compliments or file grievances or take drugs or alcohol during trips.
(complaints) about your NEMT experience. • Agree not to smoke or vape in or
• Submit an appeal or ask for a hearing near TransLink vehicles. Please stay
(or both) if you feel your service was at least 25 feet from the vehicle.
denied unfairly. See page 64 for details. • Agree not to engage in illegal activity
• Receive a written notice in or around TransLink vehicles or
when a trip is denied. drivers, as well as other members.
• Wear a seat belt, which is an Oregon law.
• Agree to wear a face mask or other
TransLink member responsibilities
face covering over both your nose and
We expect TransLink members to: mouth. This remains in effect while there
• Show respect and use respectful language is a public health emergency, to protect
with all TransLink staff and drivers. yourself and others from COVID-19.
• Keep track of their belongings during • Never abuse or intimidate drivers
a ride, at all times. Don’t leave your or other passengers. This is
things in a TransLink vehicle during your not allowed in any case.
appointment, even if you think the same • Not engage in behavior that discriminates
vehicle will be used for your return trip. against drivers, other passengers
Check the seats and floor before exiting or any TransLink staff or drivers.
to ensure belongings are removed.
• Agree to always keep service animals
• Make changes to a trip or cancel a trip under control. Service animals are
before the trip. To do this, please call not permitted on passenger seats.
TransLink at 541-842-2060 or 888-518-
• Provide a correct size child safety seat
8160 as far in advance as you can.
for any child traveling with you, install
• Request additional stops in advance the seat, and secure the child in the
with TransLink. This includes pharmacy seat. Refer to the TransLink Rider’s
stops. Drivers are only allowed to make Guide for information on when safety
stops that have been approved. seats are required. Please remove the
• Be ready for your pick-up at the time child safety seat from the vehicle at
TransLink gives you. When you’re on time the end of each trip. No personal items
for the pickup, it helps the driver get you should remain in the vehicle while
to your appointment on time. It also helps members are in their appointments.
drivers stay on time for their other rides.
40
• Keep food or drinks in closed containers, Pharmacy and Prescription
and not consume them inside a TransLink
vehicle. Exceptions can be made for Drug Benefits
small snacks for members who need
to regulate their health conditions. If you take prescription drugs, you will want
• Plan ahead and bring along food to take a look at our preferred drug list
(for eating during stops) and (formulary) to find out which drugs we cover.
medication as needed for long Pharmacists and doctors decide which
trips or unexpected delays. drugs should be in the formulary.
• Provide accurate information to TransLink You can find the formulary and information
and our transportation providers. This on coverage limits and requirements on our
will improve the service you receive. website at jacksoncareconnect.org/druglist
If you have questions about the

formulary or want us to mail a copy
to you, call Customer Service.
We may add or remove drugs or change

coverage requirements on drugs. If we remove
a drug from the formulary or add restrictions to
a drug that you are taking, we will tell you
in advance.
Prescription coverage limitations

These drugs are not covered:
• Drugs not listed in the formulary or
drugs removed from the formulary
(Your provider can request a pre-
approval for a drug that is not on
our formulary. They must explain
why it is medically necessary.)
• Drugs used to treat conditions that
are not covered by the Oregon
Health Plan (examples include
fibromyalgia and allergic rhinitis)
• Drugs used for cosmetic purposes
41
Member Handbook
• Drugs that are not approved by the Questions to ask your provider
U.S. Food and Drug Administration about prescriptions
(FDA) and drugs that have little or poor Jackson Care Connect providers are asked
scientific evidence to support their use to prescribe medications that are on our
• Drugs that are being studied and formulary. Drugs that are not on our drug list
are not approved for your disease or are called “non-formulary drugs” and are not
condition. A drug may be approved covered, unless we make an exception.
by the FDA for use with one or more
diseases or conditions, but not approved IMPORTANT: Each time you receive a
for other diseases or conditions. new prescription, ask your provider if it is
covered by Jackson Care Connect and if it
requires pre-approval or has limits.
How to team with your pharmacist
If we don’t cover the specific drug, ask your
Some drugs on the formulary have additional
provider if another drug on our formulary
requirements or limits on coverage that
would work for you.
may include:
• The use of generic drugs when available If your provider decides that our formulary
does not have an acceptable choice or if
• Prior authorization (pre-approval)
another drug requires pre-approval, ask your
• Step therapy (trying other drugs first) provider to contact us and fax a Formulary
• Age restrictions Exception or Prior Authorization Request form.
• Quantity limits Our decisions for prior approval and formulary
exception requests are based only on
We cover some over-the-counter (OTC)
appropriate care and coverage limitations.
drugs such as aspirin. They are listed on the
formulary. You must get a prescription from We approve up to a one-month supply of a
your provider and give it to a pharmacist non-formulary or restricted drug for members
before we can pay for an OTC drug. who were taking the drug before they
became a Jackson Care Connect member,
Drugs used to treat mental health needs
or after their discharge from a hospital or
such as depression, anxiety and psychosis
nursing facility.
are covered directly by the Oregon Health
Authority (OHA). They are not listed on You or your provider may call Customer
our formulary. Your pharmacist sends your Service to ask for a transition supply. Talk to
prescription claim directly to OHA. You may your provider as soon as possible about drugs
have a copay for these drugs. that we cover or ask us for an exception.
42
How to fill your prescriptions Mental Health Prescriptions
Fill your prescriptions at any Jackson Care We don’t cover all prescriptions. Most
Connect network pharmacy. Show your medications that people take for mental
Jackson Care Connect Member ID card and health needs are paid for by OHP “fee-
your photo ID when you fill a prescription. You for-service.” Please show your pharmacist
can find our network pharmacies in our online your Jackson Care Connect Member ID
provider directory at jacksoncareconnect.org/ card and your photo ID. The pharmacy
providerdirectory will know where to send the bill.
Most prescriptions are limited to a supply

of 31 days or less. The earliest date you can Pharmacy network
get a refill is 23 days after you last filled your You have access to a large network of
prescription. For pain medications, the earliest pharmacies. They include regional and
date you can get a refill is 27 days after you national chains and independent pharmacies.
filled your last prescription. We cover 90-day You can fill your prescriptions either at retail
supplies for many medications that treat stores or have them mailed to your door.
chronic diseases like high blood pressure, Mail order forms are available on our website
asthma and diabetes. at jacksoncareconnect.org/memberforms.
We may approve an additional refill in the If you need a prescription filled outside
following situations: Oregon, call Customer Service to find out if
there is a participating pharmacy near you.
• Your medication was lost or stolen
You can fill a prescription at any in-network
• You need extra medication because pharmacy nationwide the same as if you are
you are traveling at your in-network, neighborhood pharmacy.
• You need extra medication because
If you ever use your own money to pay for a
your dosage was changed
prescription, we may be able to refund your
• You need an extra supply to keep money. A refund is based on your benefit
at work or school coverage and the limitations and exclusions
If you have an urgent need for a drug that is of your plan. Please call Customer Service
not on the formulary or that has limits, we may first before using your own money to pay
approve up to a 72-hour emergency supply. for a prescription.
You, your provider or your pharmacist can To request a refund, you must fill out a
call Customer Service to request an Reimbursement Request Form and send
emergency supply. it back to us. You can find this form at
jacksoncareconnect.org/memberforms,
or you may call Customer Service for help.
43
Member Handbook
Dental Health Care Getting started

Once you are assigned to a dental plan, you
We have four dental care plans that we will need to choose a clinic or dental office as
partner with. You will be assigned to one your primary dental provider (PDP). Your PDP
of these four. They are: will work with you to take care of your dental
needs. Call your PDP before getting any
• Advantage Dental Service dental care.
• Capitol Dental Care
To coordinate your dental care, your PDP will:
• ODS
• Be your first contact when you
Your will find your dental plan assignment on need dental care, except in a
your Jackson Care Connect Member ID Card. life-threatening emergency.
Please make sure to show both your Jackson • Arrange for specialty dental care,
Care Connect Member ID Card and your if you need it.
photo ID each time you go to the dentist. • Keep your dental records in one
place to give you better service.
If you lose your Jackson Care Connect
Member ID Card, please call our Customer
Service and request a new card. How to choose a primary dental provider
People who need routine dental care will You may choose a PDP from your dental
be seen within eight weeks (four weeks plan’s provider directory, found on their
for pregnant members) unless there is a website. Or, you can call their customer
documented reason for a longer wait. service number and they will help you.
Changing dental plans

If you are assigned to a dental plan under
Jackson Care Connect and you would like to
be assigned to another plan, please contact
Customer Service at 855-722-8208.
44
Advantage Dental Service Changing your primary dental provider
Provider Directory You may change your PDP two times every
providerportal.advantagedental.com/ year. To choose a new dentist, use the provider
provider/search directory for your assigned dental plan.
Customer Service
Toll-free: 866-268-9631
TTY 711 Emergency and urgent
dental care services
Capitol Dental
Provider Directory Emergency dental care is available any time
capitoldentalcare.com/members/find-a- of day or night. You will receive care within
dentist 24 hours. An emergency is a serious problem
Customer Service that needs immediate care. It could be an
Toll-free: 800-525-6800 injury or sudden severe condition. Some
TTY 711 examples of emergency situations are:
• Bad infection
ODS
Provider Directory • Bad abscesses (an abscess is a
odscommunitydental.com/members blister on your gum tissue)
Customer Service • Severe tooth pain (pain that does not stop
Toll-free: 800-342-0526 when you take over-the-counter pain killers)
TTY 711
• A tooth that is knocked out
Urgent dental care is dental care that needs

prompt, but not immediate treatment. Some
examples of urgent situations are a toothache,
swollen gums, and a lost filling.
Some dental services require pre-approval

from your dental plan, but emergency or
urgent dental care does not.
If you need urgent dental care, you will

receive it within one to two weeks at the most.
Pregnant members who need urgent dental
care will be seen within one week.
45
Member Handbook
Local care for emergency If you are pregnant

and urgent dental care It is very important to see a dentist before
Emergency and urgent dental care do not you have your baby. Dental visits are safe
require pre-approval. But if possible, call during pregnancy. Having a healthy mouth
your PDP for guidance before going to the before your baby is born may help your
emergency room or an urgent care clinic. If baby avoid cavities as they grow up.
it is after hours, the answering service will Please see the section above on how
forward your call to an on-call dentist, who will to make an appointment.
call you back. If you do not have a dentist yet,
you can call the dental customer service on
your Jackson Care Connect Member ID card Dental care for children
and they will help you. It is very important for children to get
regular dental care. Early childhood
cavities are the most common chronic
Out-of-area emergency conditions in the US and are one of the
and urgent dental care top reasons students miss school.
If you are traveling outside of our service
Jackson Care Connect covers regular fluoride
area and have an emergency, first try to call
varnish. For 6 and 12 year molars, children
your PDP (same instructions as above). If you
should receive sealants, which are white
need emergency dental care out of the area,
plastic coatings that “seal” the grooves of
ask that dentist to send your dental plan a
permanent molars to protect against cavities.
detailed bill and the chart notes describing
the dental emergency.
IMPORTANT: After you see a dentist for a

dental emergency, please call your own PDP
to arrange for further care if it is needed.
46
Dental benefits and services
IMPORTANT: Benefits may require prior approval and may have limits.
Dental Benefits Authorization/Referral? Limits to Care?
At least one exam and

cleaning every 12 months
for adults
Exams, cleanings, X-rays
required
Two exams and cleanings
every 12 months for
members 18 and under
Basic restorative care (fillings) No limit
required
Only available for

Authorization may be qualifying members or
Dentures and partials
required incidents, call your dental
health plan for details
Every five years for

Sealants children 15 and under with
required
permanent molars
Approval based on OHP

Stainless steel crowns guidelines, contact your
required
dental health plan
required for wisdom teeth;
Extractions (removing teeth) No limit
may be required for
other extractions
Urgent or immediate dental No authorization/referral

No limit
treatment (emergency) required
47
Member Handbook
If you have a chronic condition Referrals to other dental providers

If you have diabetes or another chronic and dental specialists
condition, dental health can greatly affect If you need to see a specialist or other
your immune system and heart health. For provider, your PDP will refer you. Referrals
example, gum disease can make diabetes are made on a case-by-case basis when your
very hard to control, and increase the chances dentist feels it is necessary. Your dental plan
of heart disease and stroke. Routine dental must approve the referral before you go to
cleanings at least once per year can help your appointment.
control these conditions and prevent severe
health issues. IMPORTANT: Going to a specialist without
a referral from your PDP could result in you
having to pay the bill. Always check with
How to make an appointment your PDP before getting dental services.
• Call your PDP during office hours. You See “When you may have to pay for
services,” on page 60 for more information.
can find the phone number in your dental
health plan’s provider directory or by
calling Customer Service
• Tell the office you are a Jackson Care
Connect member and why you want to
see a dentist
• You may be able to have a telehealth
(phone or video) appointment for some
dental needs. Ask the office when you
call them.
• Remember to take your Jackson Care
Connect Member ID Card and your photo
ID with you to the appointment
• If you need sign language or an
interpreter at your appointment,
be sure to tell the clinic staff when
you make the appointment
• If you need assistance getting to your
appointment, please refer to “Getting to
health care appointments” on page 38
48
Mental Health and Substance We offer:
Use Disorder Services • Outpatient therapy

• Case management
IMPORTANT: You do not need a referral, • Care coordination
formal diagnosis or previous mental health • Medication management
care to get mental health services from a
network provider. • Children’s services
• Intensive outpatient adult service
Mental health services are available to
all OHP members. You can get help with • Inpatient care when required
depression, anxiety, family problems and Mental Health treatment services may include:
difficult behaviors, to name a few. We cover
• Assessment or evaluation to help
a mental health assessment to find out what
decide what services you need
kind of help you need, case management,
therapy and care in a psychiatric hospital if • Counseling or programs that help
you need it. manage mental health conditions
• Programs to help with daily
Mental illness may include:
and community living
• Depression
• Hospital care for mental illness
• Anxiety
• Peer wellness specialists who
• Schizophrenia can provide support
• Problems that result from physical • Emergency services
or sexual abuse
• Medications needed to help manage
• Bipolar disorder mental health conditions
• Attention Deficit Hyperactivity • Programs that teach life and social skills
Disorder (ADHD)
• Skills training for parents and children
• Problems resulting from drug
or alcohol use
• Feelings of hopelessness
• Thoughts of hurting yourself or others
49
Member Handbook
Making appointments to Specialty mental health services

see a mental health provider You and your mental health professional
You do not need a referral from your PCP or may decide you need specialty mental
a formal diagnosis to get routine outpatient health services. These services may require
mental health services. See below for details pre-approval and may include:
about specialty mental health services. • Talking with a mental health specialist
Call Jackson Care Connect at 855-722-8208. • Special testing or evaluation
Hours: 8 a.m. to 5 p.m., Monday - Friday • A referral to a special treatment
Some appointments can be done over the program or community-based service
phone or on video (telehealth appointments). • Intensive Community Based Services
Ask Customer Service when you call. for children
You can also call this number or 911 • Case Management services for adults
if you are in crisis. • Residential care
• Intensive live-in care for children
Behavioral health in primary care • Care and help for families who
need a break
Your PCP may refer you to a Behavioral Health
Clinician for a 15-30 minute visit. The clinician • Services to help at-risk and
will focus on a particular problem. After talking homeless youth
to you, the clinician will help you make any • Psychiatry
changes you want to make, help with stress or • Applied behavioral analysis: a
problems at home or school. treatment that helps people change
Your Behavioral Health Clinician can help you: their behavior, sometimes used for
people with brain injuries, dementia,
• Create a healthy lifestyle by changing
tics, fears or other conditions
eating and exercise habits, or learning
relaxation skills, ways to sleep better If you need a routine (that is, non-urgent)
and how to have good friends
behavioral health appointment, you’ll have a
• Reflect on harmful habits like using first assessment within seven days. A second
alcohol, tobacco and drugs, or getting
appointment will be scheduled as clinically
angry easily and hurting people’s feelings
— the clinician can help you make changes appropriate — that is, when your provider
for the better, even if they are small decides you need it.
• Cope with stress, including
loss and sadness
• Apply self-care techniques to manage pain,
diabetes, medications and other issues
50
Mental health & substance use disorder benefits
IMPORTANT: You do not need a referral to get most mental health services, substance use
disorder or recovery support services from a network Specialty mental health services may
require pre-approval.
Mental Health Authorization/Referral? Limits to Care?
Outpatient counseling/ No authorization/referral

No limit
therapy required
Assessment and No authorization/referral
No limit
evaluation services required
Specialty mental health
Yes, authorization/referral
services (exceptional Call Jackson Care Connect
required
needs services)
Yes, authorization/referral
Residential treatment Call Jackson Care Connect
required
Mental health drugs are Mental health drugs are
not covered by your not covered by your
physical or mental physical or mental
health plan. health plan.
Mental health drugs
They are covered by OHP. They are covered by OHP.
Your pharmacist will know Your pharmacist will know
where to send the bill. where to send the bill.
Assertive Community
Treatment (ACT) and Call Jackson Care Connect
required
wraparound services
Substance Use Disorder Authorization/Referral? Limits to Care?
Outpatient counseling/ No authorization/referral

No limit
therapy required
Assessment and No authorization/referral
No limit
evaluation services required
Residential treatment No limit
required
Detoxification (withdrawal No authorization/referral
No limit
management) required
51
Member Handbook
Mental health crisis • If you are getting Intensive In-Home

You do not need approval to call the crisis line Behavioral Health Treatment, crisis
or get emergency services. You can use those response services are available 24 hours
services whenever you feel you are having an a day.
emergency. You also don’t need a diagnosis
or to already be engaged with a health
provider to get crisis or emergency services. How to get help for a
mental health crisis
A mental health crisis means a person needs
Call: 541-774-8201
help quickly so the situation does not become
Toll free: 888-363-8755
an emergency.
A mental health emergency is a situation You can also call 911 if you are in crisis.
where your health or safety, or the safety of
others, would be in serious danger if you did
Things to look for if you or someone you
not get help immediately.
know is having a mental health crisis:
If you already have a mental health provider, • You or a member of your family
your provider’s office will tell you how to are considering suicide
reach them during a mental health crisis. If
you are having a crisis, follow the plan made • You or a member of your family
with your mental health professional. If you are hearing voices to hurt
feel you need services immediately, call yourself or another person
your provider’s office and ask for an urgent • You or a member of your family hurts
appointment, contact the crisis line or call other people, animals or property
911. Members with urgent mental health or
substance use treatment needs will be seen • You or a member of your family has
within 24 hours. dangerous or highly disruptive behaviors
in school, work, or with friends or with
Other important information family, and the behaviors are new or not
being addressed by a mental
• Post-stabilization care is available 24 hours
a day, seven days a week. This is care you health provider
receive after a mental health crisis • You or a member of your family
or emergency. feels out of control
• Calling a crisis hotline or using a mobile
crisis service can help you become stable
during a crisis or emergency. This can
help you avoid:
- Going to an emergency department
- Being admitted to an acute care facility
- Getting arrested
52
Suicide prevention You can also call any of the following outside
One concern that may come with of Jackson Care Connect:
untreated mental health needs is a risk of • National Suicide Prevention Lifeline
suicide. With appropriate treatment, 800-273-TALK (8255), online at
your life can improve dramatically. suicidepreventionlifeline.org
• The David Romprey Memorial Warmline
What are the most common warning signs? at: 800-698-2392
As many as 80 percent of those thinking about • Crisis Text Line (741741)
suicide want others to be aware of their
emotional pain and stop them from dying. For teen suicide prevention:
A warning sign does not mean a person is
YouthLine: call 877-968-8491 or
going to attempt suicide, but it should be
text teen2teen to 839863
taken seriously. Suicide warning signs include:
• Acting anxious or agitated;
Substance use disorder services
behaving recklessly
(also called alcohol and drug
• Displaying extreme mood swings treatment services)
• Giving away prized possessions
IMPORTANT: You do not need to call
• Increasing the use of alcohol or drugs
Jackson Care Connect for a referral for
• Planning a way to kill oneself, such as most substance use disorder treatment or
buying a gun recovery support services from a network
• Preoccupation with death provider. You can talk to your PCP or
contact treatment services directly.
• Talking about wanting to die or
wanting to kill oneself If you are in need of substance use disorder
• Talking about feeling hopeless treatment services, you can get information
or having no reason to live by talking to your PCP, your mental health
treatment provider or your local community
• Talking about feeling trapped or in
mental health provider. You also can contact
unbearable pain
Customer Service to find out who can provide
• Talking about being a burden to others services. Available substance use disorder
• Withdrawing or feeling isolated treatment services include:
• Outpatient therapy
Never keep talk of suicide a secret!
• Medication Assisted Treatment (MAT),
also called Medication Supported
Recovery (no authorization required
for the first 30 days of treatment)
53
Member Handbook
• Detox • If you are an IV drug or heroin user,

a provider will see you immediately
• Inpatient and residential
to decide what care you need. If
• Peer recovery support your provider requests it, you will be
admitted to residential care within 14
You may need pre-approval from us before days. Or, if you are put on a waitlist,
we will cover some services. If you need within 120 days at the most.
detox or inpatient treatment and there are no • If you are an opioid drug user, a
beds available in our service area, you may provider will see you within 72 hours
seek treatment anywhere in the state that to decide what care you need.
has open beds and be transported there • If you need medication-assisted treatment
at no cost. Contact Customer Service for (MAT), a provider will see you within 72
more information. hours to decide what care you need.
• If you are in one of the following groups,
The following services do not require a provider will see you immediately
pre-approval from us: to decide what care you need. If no
providers are available, you will be put
Outpatient office visits (allows you to stay in on a waitlist. While you wait, you will
your community and receive services): receive “fill-in” services within 72 hours.
• Outpatient counseling, assessments Those services may include referrals,
and screenings methadone support, HIV/AIDS testing,
outpatient substance use treatment,
• Group sessions
lower risk substance use residential
• Individual sessions services, withdrawal management, and
• Acupuncture evaluation for other services. Treatment
at the level of care that’s right for you
• Specialty outpatient services
must happen within 120 days after you’re
• Medication Assisted Treatment put on a waitlist. These groups include:
(MAT), including methadone - Pregnant people
- Veterans and their families
Residential services:
- Women with children
• Detoxification (withdrawal management)
- Unpaid caregivers, families and
• Residential treatment services children from birth to age 5
See the Online Provider Directory for a list of - Children with serious
providers. Go to jacksoncareconnect.org/ emotional disturbance
providerdirectory - People with HIV/AIDS or tuberculosis
- People at risk of a first
episode of psychosis
Urgent substance use treatment - People with intellectual or
When you have an urgent need, we will make developmental disabilities (I/DD)
sure you get the care you need quickly.
54
If You Are Pregnant As soon as possible after your baby is born,
• Call OHP Customer Service to
enroll your baby in the OHP.
It is very important for your health and your
This is not done automatically.
baby’s health to get maternity care while
you are pregnant. • If you received all your medical care from
an obstetrician or prenatal care provider
We cover: during your pregnancy, you need to
• Prenatal care (care for you choose a PCP now. Call Customer Service
before your baby is born) to help you find a PCP near you.
• Childbirth
• Postpartum care (care for you Information for birth parents
after your baby is born)
Oregon’s A Safe Place for Newborns
• Care for your newborn baby Law allows either birth parent to leave a
• Nursing support and breast pumps newborn infant at an authorized facility,
such as a hospital, doctor’s office during
• Dental care for you and your baby
business hours, birthing clinic, police
• Services to quit smoking or fire station or sheriff’s office.
As soon as you know you are pregnant: There are no legal penalties for making this
choice if the baby is 30 days old or younger,
1. Call OHP Customer Service. They
is given to a staff person and shows no signs
will make sure you don’t lose OHP
of abuse.
benefits while you are pregnant.
They can also help you get additional If you need support, want to talk to someone
services that you may need. about this decision, or need information on
adoption, counseling or other social services,
2. Call your PCP and make an appointment
call 800-SAFENET (800-723-3638).
for prenatal care. If you prefer, you can
pick your own obstetrician/prenatal If you decide to take your baby to “a safe
care provider. place for newborns” facility, you will not have
to answer questions. You will be offered
You can find a list of providers who can deliver
information and phone numbers for county
your baby in our online provider directory
child welfare offices. You will be asked to fill
on our website at jacksoncareconnect.org/
out a voluntary health questionnaire about the
providerdirectory
infant. You may leave at any time.
55
Member Handbook
Babies receive medical attention if they There are two types of health-related
need it. The staff person who accepts services: flexible services and community
the baby contacts DHS, and the baby benefit initiatives (CBI). Flexible services
is placed in a temporary home. include things like:
If you change your mind, you can seek • A cell phone for better access to providers
custody of the baby. A court hearing will • Food or farmers market vouchers
be held on the first business day after • Items that improve mobility
the day the baby is left. There will be
• Sleep aids
several court hearings after that date.
Your ability to seek custody of the baby CBI help improve community health and
will depend on how quickly the court improve the quality of health care. Examples
moves to end the parents’ rights. of CBI include:
• Starting a diabetes health program
Online resources: in a local community center
Parent resources: link.careoregon.org/oha- • Creating a farmers market in a
parenting-resources neighborhood with few grocery stores
Talk to your provider or care coordinator

Health-related services about what’s keeping you from getting and
Jackson Care Connect wants to make sure staying healthy. Members of your care team
your unique health needs are addressed, so can make requests for health-related services
you are as healthy as possible. That’s why funds. We’ll send a written notice to you
your benefits include access to a fund for and the person who made the request, to
what OHP calls “health-related services.” This let you know if your request is approved. If
fund covers items or services that will help your request is denied, you are able to file a
keep you healthy as a supplement to the complaint but may not appeal the decision.
other services listed in this booklet.
56
How to Disenroll or • If you lose OHP eligibility for two months
or fewer, are re-enrolled, and therefore
Change CCOs missed your disenrollment window.
• For any other reason, one time each year.
The CCO you have depends on where you
• If you move to a place that your CCO
live. Some areas have more than one CCO. In
those areas, there are rules about when you doesn’t serve, you can change CCOs as
can change your CCO. soon as you call OHP Member Services
at 800-699-9075 and tell them about
When you have a problem getting the right
the move.
care, please let us try to help you before
changing plans. Just call Customer Service • If you are a Native American or Alaska
and ask for our Care Coordinator. If you still native with proof of Indian Heritage, or
want to leave or change your CCO, call OHP are also on Medicare, you can ask to
Customer Service at 800-273-0557. change or leave your CCO anytime.
Reasons why you might choose to leave
How to change CCOs Jackson Care Connect on your own include:
The CCO you have depends on where you • Jackson Care Connect does not restrict
live. Some areas have more than one CCO. services based on moral or religious
In those areas, there are rules about when objections; however, if you feel that we do
you can change your CCO.
not cover a service you seek because of
You can change CCOs once a year. If you such objections, you may choose to leave.
want to change call OHP Customer Service at • If you need related services (for example
800-699-9075. You can also make a request a cesarean section and a tubal ligation)
in writing. You can change CCOs: to be performed at the same time, not
• If you are not new to OHP, you all related services are available within
can change CCOs during the first the network, and your PCP determines
30 days after you re-enroll. that receiving the services separately
• If you are new to OHP, you can change would subject you to unnecessary risk.
CCOs during the first 90 days after • If you have other reasons, including poor
you enroll. quality of care, lack of access to services
• When you renew your OHP covered under the contract, or lack of
coverage (usually once a year). access to participating providers who
know how to deal with your health
• If you have been enrolled in
care needs.
your CCO for six months.
57
Member Handbook
We may ask the OHA to remove you from We will honor written documentation of prior
our plan if you: authorization for ongoing services. Items that
• Are abusive to our staff or providers. you are already getting, such as prescriptions
or medical supplies, will still be available to
• Commit fraud, such as letting someone
you during the transition. Please make an
else use your health care benefits.
appointment with your new physical health,
• Move out of our service area. oral health, mental health or substance use
• Lose your OHP eligibility. disorder treatment provider right away so you
can update your treatment plan and keep
We cannot ask that you be removed getting any ongoing care you need.
from our plan because:
• Your health has gotten worse. Some members who change OHP plans can
still get the same services and see the same
• You are using a lot of services. providers. That means care will not change
• Your behavior is disruptive or when you switch CCO plans or move from
abusive because of a mental health OHP fee-for-service to a CCO. If you have
condition or special needs. serious health needs, your new and old plans
• Your history suggests you may need must work together to make sure you get the
more services in the future. care and services you need.
• You filed an appeal or a grievance. This transition of care period lasts for:
• You make choices about your medical • 30 days for physical health and dental
care that we disagree with. health, and 60 days for mental health;
• You are in the custody of • OR, until your new providers review your
ODHS Child Welfare. treatment plan.
For members who are dually eligible for

Transitioning from one CCO to another, Medicaid and Medicare, the transition period
or from fee-for-service to a CCO lasts for 90 days.
Are you are switching to Jackson Care If you try to refill a medication or use previous
Connect from another CCO, or from OHP services and you are told you do not have
fee-for-service? We may reach out to help you coverage, please let us know right away, so
transition over to your new benefits. we can help!
For some members, Jackson Care Connect If you feel that you need help with your
will receive information from your previous transition, please call our Customer Service
plan, which will help us continue your care. at 855-722-8208. For more information about
transitions of care, go to jacksoncareconnect.
org/care-transition
58
Who can get the same care when they Other Things You
switch plans?
Should Know
This help is for members who have serious
health issues. It is also for members who need
hospital care or inpatient mental health care. OHP members don’t pay bills for
Here are some examples: covered services
• Members who need end-stage renal When you schedule your first appointment
with a provider, tell the scheduler that you
disease care
are with Jackson Care Connect, or any other
• Medically fragile children private medical insurance you may have.
• Breast and cervical cancer treatment This will help the provider know who to bill.
program members Jackson Care Connect pays for all covered
services on the Prioritized List of Health
• Members getting Care Assist help due to
Services, including any relevant Guidance
HIV/AIDS Notes and Statements of Intent (see page 32
• Members who had a transplant to learn more).
• Members who are pregnant If your health care provider sends you a
or just had a baby bill, don’t pay it. Instead, call our Customer
• Members getting treatment for cancer Service right away, toll-free at 855-722-8208,
TTY 711.
• Any member that if they don’t get
continued services may suffer serious Your medical provider can send you a bill only
detriment to their health or be at risk for if all of the following are true:
the need of hospital or institution care 1. The medical service is something that
If you need care while you change plans, your OHP plan does not cover
please call our Customer Service at 2. Before you received the service, you
855-722-8208, TTY 711. OHA will send you signed a valid Agreement to Pay form
a notice about your rights for changing (also called a waiver)
plans at least 60 days before the start of our 3. The form showed the estimated
enrollment period. cost of the service, and that cost does
not change
4. The form said that OHP does not
cover the service
5. The form said you agree to pay the
bill yourself
6. The service is scheduled within 30 days
of you signing the form
59
Member Handbook
These protections usually only apply if expect this bill, it’s sometimes called a
the medical provider knew or should “surprise bill.” This is not allowed.
have known you had OHP. Also, they only
apply to providers who participate in the
OHP program (but most providers do). If When you may have to pay for services
all of the above is true, a provider may Generally, you will not have to pay any medical
take legal steps to make you pay if your bills. However, there are a few exceptions:
bill is unpaid after more than 90 days.
You have to pay the provider if you:
Sometimes, your medical provider doesn’t • Receive services outside Jackson Care
do the paperwork correctly and won’t get Connect’s contracted network. Contracted
paid for that reason. That doesn’t mean you providers meet the provider enrollment
have to pay. If you already received the requirements from the OHA and the
service and we refuse to pay your medical Center for Medicare & Medicaid Services
provider, your provider still can’t bill you. (CMS). Non-participating providers may
You may receive a notice from us saying also meet these requirements, but you
that we will not pay for the service. That may not have this information when you
notice does not mean you have to pay. receive services from them. To make sure
The provider will write-off the charges. you will not receive medical bills from a
If we or your provider tell you that the service non-contracted provider, ask whether
isn’t covered by OHP, we will send you a your provider and any others that they
Notice of Adverse Benefit Determination work with (such as labs or imaging) are
(NOABD) letter. The notice will tell you how enrolled with the OHA to provide services
to appeal the decision, if you want to. to Jackson Care Connect members.
• Receive checks from a third-party
No provider or anyone working on behalf payer, like car insurance, for services
of your provider can bill you, send you to performed by your provider
collections or take you to court for amounts
Jackson Care Connect is supposed to pay. • Choose to have services that the provider
tells you are not covered by Jackson
Providers can’t bill you if they make an Care Connect. In this case, the provider
error, like an error in submitting a claim. must tell you the cost of each service,
“Balance” or “surprise” billing is also not and that you are responsible for paying
allowed. For example, if you see an out-of- for the service. The provider must also
network provider and we don’t cover the ask you to sign a written form stating that
whole cost, the out-of-network provider you were told this information, and that
may try to bill you for the difference. This you knowingly and voluntarily agreed
is called “balance billing.” When you don’t to pay for non-covered services.
60
Members with both Medicaid and true whether you are in a CCO, prepaid health
other insurance plan or OHP fee-for-service (open card).
Members enrolled in both Medicaid (OHP) No permission or referral is needed
and Medicare are referred to as “dual to see these providers. They can be
eligible” members. Dual eligible members found in our online provider directory at
are automatically enrolled in a local CCO jacksoncareconnect.org/providerdirectory
plan. These members don’t pay co-pays
or have any other costs or cost sharing. You can also see Native American providers
that are not in our network. However, Native
Members may also have other coverage American providers that are not part of
through an employer, retirement plan and/ our network must follow the same rules as
or an individual health plan. Members network providers. Only covered benefits
with dual eligibility may or may not have will be paid. If a service requires prior
both Medicaid and Medicare in addition authorization, the provider must request it
to their other coverage. If you have other before providing the service. A list of services
insurance, they are the primary payer over that need prior authorization is posted on
Medicaid or Medicare. In some cases, our website under the “Provider Forms and
Medicaid will cover benefits that the other Policies” section.
insurance doesn’t cover. This depends on
the plan. It is your responsibility to provide If you have questions about your benefits
all insurance coverage information to the under the American Recovery and Restoration
medical offices providing services to you Act, please contact OHP Customer Service.
and to the medical plans that you are If you need help understanding our pre-
covered under. If you do not, your claims authorization rules, please contact Columbia
could be delayed or not paid. Please call our Pacific CCO Customer Service for help.
Customer Service with questions or to report
any additional coverages you may have.
Outside the United States
Please call Customer Service before Jackson Care Connect will not cover any
you agree to pay a provider. health services you get outside the United
States, including Canada and Mexico.
Native rights
American Indians and Alaska Natives can New technology
receive their care from an Indian Health The OHP decides if new technologies
Service (IHS) clinic or tribal wellness center, and new uses of current technologies are
or the Native American Rehabilitation included in your benefit package. If you have
Association of the Northwest (NARA). This is questions about whether or not a service is
covered, please call Customer Service.
61
Member Handbook
Changing your address or phone number need that kind of care. The form you use
If you move or change your phone number, is called an Advance Directive. If you have
let OHP Customer Service know. It is your written an Advance Directive, also called a
responsibility to let OHP know about these living will, your providers must follow your
changes within 30 days of the change. If instructions. If you don’t have an Advance
you don’t, you could lose your Jackson Care Directive, your providers may ask your family
Connect benefits. You can reach OHP: what to do. If your family can’t or won’t decide,
Online: ONE.oregon.gov your providers will take the usual steps in
By telephone (toll-free): 800-699-9075, treating your conditions.
TTY 711. This is the best way to reach OHP If you don’t want certain kinds of treatment,
Customer Service. like a breathing machine or feeding tube, you
By email: oregon.benefits@dhsoha.state. can write that down in an Advance Directive.
or.us. Use the DHS/OHA secure email site It lets you decide your care before you need
at secureemail.dhsoha.state.or.us/encrypt that kind of care - in case you are unable to
to send your email to OHP. Include your full direct it yourself, such as if you are in a coma.
name, date of birth, Oregon Health ID number If you are awake and alert your providers will
and phone number. always listen to what you want.
Also, you will need to tell your PCP clinic Jackson Care Connect follows all state and
your new information. If you need a new PCP federal laws about Advance Directives. We
clinic after you move, please let us know. Our will honor any choices you have listed in your
Customer Service staff can help you choose a completed and signed Advance Directive.
new PCP. You can get an Advance Directive form at
no cost by calling our Customer Service at
End of life decisions and Advance 855‑722‑8208, TTY 711. You can also get it
Directives (living wills) from Oregon Health Decisions by calling
Adults 18 years and older have the right toll-free 800-422-4805 or online at
to make decisions about their own care, link.careoregon.org/advance-directive-forms.
including refusing treatment. They can also If you write an Advance Directive, be sure to
appoint a health care representative to talk to your providers and your family about
make decisions for them if they can’t make it and give them copies. They can only
decisions for themselves. It’s possible that follow your instructions if they have them.
someday you could become so sick or injured Some providers and hospitals will not follow
that you can’t tell your providers whether you Advance Directives for religious or moral
want a certain treatment or not. Oregon law reasons. You should ask them about this.
says you have the right to state your wishes,
If you change your mind, you can cancel your
beliefs, and goals in advance, before you
Advance Directive anytime. To cancel your
62
Advance Directive, ask for the copies back This form allows you to make choices about
and tear them up, or write CANCELED in large the kinds of care you want and do not want.
letters, sign and date them. It can be used to name an adult to make
decisions about your care. The person you
You can view our full advance directive
name must agree to speak for you and follow
policies at link.careoregon.org/advance-
your wishes. If your wishes are not in writing,
directive-policy
this person will decide what you would want.
If you think Jackson Care Connect did not
A declaration form is only good for three (3)
follow Advance Directive requirements, or if
years. If you become unable to decide during
your provider does not follow your wishes
those three years, your declaration will remain
in your Advance Directive, you can complain.
good until you can make decisions again. You
A form for this is at healthoregon.org/hcrqi
may change or cancel your declaration when
Send your complaint to: you can understand and make choices about
Health Care Regulation and your care. You must give your form to your
Quality Improvement Primary Care Provider and the person you
Mail: 800 NE Oregon St, #305 name to make decisions for you.
Portland, OR 97232
For more information on the Declaration for
Email:
Mailbox.hcls@state.or.us Mental Health Treatment, go to the state of
Fax: 971-673-0556 Oregon’s website at: link.careoregon.org/
Phone: 971-673-0540 or-declaration-mental-health. You can talk
TTY: 971-673-0372 directly with your mental health provider, if
you have one.
For questions or more information contact
Oregon Health Decisions at 800-422-4805 or If your provider does not follow your wishes in
503-241-0744, TTY 711. your Declaration for Mental Health Treatment,
you can complain. A form for this is at
healthoregon.org/hcrqi
Declaration for Mental Health Treatment
Send your complaint to:
Oregon has a form called a Declaration
Health Care Regulation and
for Mental Health Treatment. This form
Quality Improvement
is a legal document. It allows you to
make decisions now about future mental Mail: 800 NE Oregon St, #305
Portland, OR 97232
health care in case you are unable to
make your own care decisions. Email:
Mailbox.hcls@state.or.us
Fax: 971-673-0556
Only a court and two doctors can decide that
Phone: 971-673-0540
you cannot make your own care decisions.
TTY: 971-673-0372
63
Member Handbook
Provider incentives and reimbursement Complaints and Appeals

You have the right to ask if we have
special financial arrangements with How to make a complaint or grievance
our providers that can affect the use
of referrals and other services. If you are unhappy with Jackson Care
Connect, your health care services, your
To find out, call our Customer Service provider, or TransLink’s services, you have
department at 855-722-8208 the right to complain or file a grievance at
and ask for information about our any time, for anything other than a denial
physician payment arrangements. of service. Your provider or authorized
representative may also file a grievance on
IMPORTANT TO KNOW: Our Care your behalf with your written consent. We will
Management and Pharmacy units make try to make things better. Just call Customer
authorization (payment) decisions about Service at 855-722-8208, TTY 711 or send us
medical/surgical services, home health a letter to the address on page 66. Or, call
services, pharmacy and other benefits.
the OHP Client Services unit (CSU) toll free
Jackson Care Connect pays doctors or at 800-273-0557, or OHA’s Ombudsman at
providers in different ways to improve how 503‑947‑2346 or toll free at 877-642-0450.
you get care. This helps make sure providers
Jackson Care Connect will work to resolve
focus on improving your overall health.
your complaint or grievance as quickly as your
You have a right to ask about how we pay
health condition requires. If we need more
providers. Provider payments or incentives
than five business days, we will send you a
will not change your care or how you get
letter to let you know why. You will receive a
benefits. For more information, call Customer
final answer within 30 calendar days. We will
Service at 855-722-8208.
not tell anyone about your complaint unless
you ask us to.
Appeals and hearings

If we deny, stop or reduce a medical service
your provider has ordered, we will mail you
a Notice of Adverse Benefit Determination
(NOABD) letter explaining why we made that
decision. You have a right to ask to change
it through an appeal and a state fair hearing.
You must ask for an appeal no more than
60 days from the date on the NOABD letter.
64
You can ask for a denial notice that shows a Who can ask for an appeal?
service is not covered if: You or someone with written permission to
• You did not receive a written speak for you. That could be your provider or
notice of denial, or; an authorized representative.
• Your provider tells you that you will need
to pay for a service that is not covered
How to get an administrative hearing
How to appeal a decision After an appeal, you can ask for a state fair
hearing with an Oregon Administrative Law
In an appeal, a different health care
Judge. You will have 120 days from the date
professional at Jackson Care Connect will
on your Notice of Appeal Resolution (NOAR)
review your case. Ask us for an appeal by:
to ask the state for a hearing. Your NOAR
• Calling Customer Service at letter will have a form that you can send in.
855-722-8208, TTY 711 or You can also ask us to send you an Appeal
• Writing us a letter or and Hearing Request form, or call OHP Client
• Filling out an Appeal and Hearing Services at 800-273-0557, TTY 711, and ask
Request, OHP form OHP 3302 for form OHP 3302 or MSC 443.
or MSC 443
If you want help with this, call and we can fill At the hearing, you can tell the judge why
out an appeal form for you to sign. You can you do not agree with our decision and why
ask someone like a friend or case manager to the services should be covered. You do
help you. You may also call the Public Benefits not need to hire a lawyer, but you can have
Hotline at 800-520-5292 for legal advice a lawyer with you, or have someone else
and help. You will get a Notice of Appeal help you at the hearing. You can fill out the
Resolution from us in 16 days letting you section in the hearing request form to name
know if the reviewer agrees or disagrees with a representative who will speak for you at the
our decision. If we need more time to do a hearing. The representative can be anyone
good review, we will send you a letter saying you choose, including your provider. If you
why we need up to 14 more days. If we fail to hire a lawyer you must pay their fees. You can
adhere to required time frames for processing ask the Public Benefits Hotline (a program
standard/extended appeals, it is your right to of Legal Aid Services of Oregon and the
request an administrative hearing. Oregon Law Center) at 800-520-5292, TTY
711, for advice and possible representation.
You can keep getting a service if you started Information on free Legal Aid can also be
getting it before our decision to deny, stop found at oregonlawhelp.org
or reduce it. You must ask us to continue the
service within 10 days of getting the NOABD A hearing takes more than 30 days to
letter that stopped it. prepare. While you wait for your hearing,
65
Member Handbook
you can keep getting a service if you To request an expedited (fast) hearing from
started getting it before our original Notice OHA, fax your hearing request form to:
of Adverse Benefit Determination (NOABD) OHP Hearings Unit at 503-945-6035.
decision to stop it. You must ask the state
Include a statement on a form (OHP 3302 or
to continue the service within 10 days of
MSC 443) from your provider explaining why
getting our Notice of Appeal Resolution that
it is urgent. We will include this form when
confirmed our denial. If you choose to still get
we send you a Notice of Adverse Benefit
the denied benefit or service, you may have
Determination (NOABD) letter. You can get this
to pay for it. If we change our decision during
form in your preferred language by calling our
the appeal, or if the judge agrees with you at
Customer Service or OHP Client Services. You
the hearing, you will not have to pay.
can also find it online at link.careoregon.org/
oha-forms. If OHP agrees that it is urgent, the
Expedited hearings or appeals when you Hearings Unit will call you in three workdays.
have urgent medical problems If a fast appeal is denied or more time is
Do you and your provider believe that needed, we will call you and you will receive
you have an urgent medical problem written notice within two days. A denied
that cannot wait for a regular appeal? fast appeal request will become a standard
Tell us that you need a fast (expedited) appeal and needs to be resolved in 16 days
appeal. We suggest that you include a or possibly be extended 14 more days.
statement from your provider or ask them
to call us and explain why it is urgent. IMPORTANT TO KNOW: Appealing a
decision will not affect continuation of
If we agree that it is urgent, we will call
service with Jackson Care Connect.
you with a decision within 72 hours. However, you may have to pay for
For the quickest results, you may call services delivered during the appeal
process if the decision to deny or limit
Customer Service at 855-722-8208 or fax
the service is upheld.
your appeal form to: Jackson Care Connect
Appeals Coordinator at 503-416-8118.
Or, you can mail your appeal form to:

Dual-eligible members and appeal rights
Jackson Care Connect If you are enrolled in both Jackson Care
Attn: Appeals and Grievances Connect and Medicare, you may have more
P.O. Box 40328 appeal rights. Contact Customer Service for
Portland, OR 97204 more information.
66
Reporting suspected fraud, waste Report fraud, waste and abuse to Jackson
and abuse Care Connect. Contact our Customer
Jackson Care Connect is committed to Service department via a contact
preventing fraud, waste and abuse. We method shown below. If you wish, you
comply with all applicable laws, including can also make an anonymous report
the Oregon False Claims Act and the federal by calling Ethics Point at 888-331-6524
False Claims Act. or filing a report at ethicspoint.com
We’re a community health plan, and Mail: Jackson Care Connect

we want to make sure that health care Attn: FWA
dollars are spent helping our members be 315 SW Fifth Ave
healthy and well. We need your help to
Portland, OR 97204
do that. If you think fraud, waste or abuse
has happened, report it as soon as you Call: 855-722-8208, TTY 711
can. You can report it anonymously. Fax: 503-416-3723
Email:
customerservice@careoregon.org
Examples of provider fraud:
We will send each report of suspected fraud,
• Billing for services you didn’t receive waste and abuse to the appropriate state
• Charging for covered services agency listed below. You can also report
• Giving you a service you don’t need suspected provider fraud directly to either of
these agencies:
Examples of member fraud: Medicaid Fraud Control Unit (MFCU)
• Going to multiple providers to get Oregon Department of Justice
prescriptions for the same drug 100 SW Market Street
• Using transportation benefits for Portland, OR 97201
non-medical-related business Phone: 971-673-1880
Fax: 971-673-1890
• Lending your Member ID card or
using another person’s card OR
OHA Office of Program Integrity (OPI)

3406 Cherry Ave NE
Salem, OR 97303-4924
Fax: 503-378-2577
Hotline: 1-888-FRAUD01 (888-372-8301)
link.careoregon.org/oha-report-fraud
67
Member Handbook
If you wish, you may also contact the following Notice of Privacy Practices
organization if you suspect fraud, waste or
abuse by a member:
Jackson Care Connect’s Notice of Privacy
DHS Fraud Investigation Unit Practices tells you what we can and cannot do
PO Box 14150 with your personal health information. It also
Salem, OR 97309 explains what laws we must follow to keep
Hotline: 1-888-FRAUD01 (888-372-8301) your information secure.
Fax: 503-373-1525 Attn: Hotline
link.careoregon.org/oha-report-fraud Your provider only shares your health
records with people who need to see them
The law protects people who report fraud and for treatment and payment reasons. You
abuse under applicable Whistleblower laws. If can limit who sees your health records. If
you report fraud or abuse, you cannot: there is someone you don’t want to see your
• Lose your job health records, please tell your provider in
writing. You can ask your provider for a list
• Lose your coverage
of everyone your provider has shared your
• Be threatened, harassed or health records with.
discriminated against
If you would like a copy of our Notice of
Privacy Practices, please call Customer
Service at 855-722-8208 and we will send
you one, or you can visit link.careoregon.org/
jcc-privacy
68
Frequently Asked Q. I want to see a mental health specialist.
What should I do?
Questions
A. You do not need a referral from your PCP.
Call Jackson Care Connect Customer Service
Q. How do I change my primary care and they can help you find a provider. You can
provider (PCP), dentist, mental health or find more information on page 50, “Making
substance use provider? appointments to see a mental health provider.”
A. To change your PCP or mental health
Q. Does my plan cover vision services?
provider, call Jackson Care Connect Customer
Service at 855-722-8208 and we will be A. OHP does cover some vision services.
happy to help you. You can also find a new Please see “Vision care,” on page 37.
provider using our online provider search at
jacksoncareconnect.org/providerdirectory. Q. I am pregnant and would like to begin
To change your dentist, you’ll need to call my prenatal care right away. How can I find
their customer service phone number(s) an OB/GYN that will deliver my baby at the
located on the back of your Jackson Care hospital I want?
Connect ID Card. A. Contracted providers can be found using
our online provider search on our website at
Q. Why was I assigned to a provider
jacksoncareconnect.org/providerdirectory. If
when I already have a doctor?
you do not have internet access, or just prefer
A. Our system matches new members with to call us for the information, we would be
PCPs in the area they live. If you already see glad to help you. Call Customer Service
a PCP in our network, just give us a call. We’re at 855-722-8208. If you already have an
more than happy to update our records. OB/GYN, you can ask which hospitals your
OB/GYN works with.
Q. I want to see a specialist.
What should I do? Q. I’m a new member. I need to refill a
A. If you and your PCP decide that you should prescription for medication from my last
see a specialist, your PCP will give you a insurance and get diabetes supplies. What
referral. See the section “referrals to other should I do?
providers and direct access to specialists,” A. Call Customer Service. You may be eligible
on page 19 for more information. for a transitional supply. Talk to your Jackson
Care Connect provider as soon as possible
about medical supplies and/or drugs that
we cover.
69
Member Handbook
Q. I just moved, I have a new baby, or I Q. How can I be sure that I’ll be able to
changed my name. Who do I tell? see who I want under the OHP and
A. Please call OHP Customer Service at Jackson Care Connect?
800-699-9075 and let them know what has A. We have a large network of hospitals,
changed. If you have a DHS caseworker, providers and pharmacies in Jackson County.
please call them instead of calling OHP. You We work with you to build a team – your
can find more information in the section providers, behavioral health specialists,
“Changing your address or phone number,” dentists, pharmacists and everyone at
on page 62. Jackson Care Connect – and to get you
high quality care to meet your needs. If we
Q. I’m a new member and would like to cannot find the resources you need in our
know if my medications are covered. service area, our provider network covers
A. Jackson Care Connect maintains a the whole state.
list of covered drugs called a formulary.
You can find it on our website at Q. Where does the money come from
jacksoncareconnect.org/druglist. Please to pay for my OHP benefits?
talk with your doctor about the medications A. OHP is paid for by federal and state
you need. Your doctor may need to submit taxes with the amount decided by Oregon
a prior authorization or may need to make a law makers. In turn, funding is passed on to
change to a covered drug. (We do not cover Jackson Care Connect by the OHP, so that we
Mental Health drugs. Mental Health drugs may provide you with the care you need to
are covered by the OHP. Your pharmacy will stay healthy.
bill these medications to the OHP.) If you
are a new member and are unable to fill a Q. My doctor sent me a bill.
medication prescription, you may qualify for What should I do?
a transition supply. Please call us to find out if A. Don’t pay the bill. See the section “OHP
you qualify. members don’t pay bills for covered services,”
on page 59, for more information.
Q. If I, or someone I care about, is
considering suicide, who can help?
A. Talk to someone right away. See
“Mental health crisis/Suicide prevention” on
pages 52-53 of this handbook for the phone
numbers to call if you or someone you know
are in crisis or considering suicide.
70
Q. When will I have to pay for medical Member Handbook
services on OHP?
Definitions
A. You may have to pay for services:
• If you see a provider that does not take
Appeal – Asking a plan to change a decision
OHP or is not part of our provider network
you disagree with about a service your doctor
• If you weren’t eligible for OHP when you ordered. You can write a letter or fill out a form
received the service explaining why the plan should change its
• If you sign a detailed Agreement to Pay for decision; this is called filing an appeal.
a specific service that OHP doesn’t cover
Copay – An amount of money that a person
before you receive it
must pay out-of-pocket for each health
For more information, see “OHP members service. Oregon Health Plan members do not
don’t pay bills for covered services,” page 59. have copays. Private health insurance and
Medicare sometimes have copays.
Q. I was in the hospital, and OHP paid for
Durable medical equipment (DME) –
that, but now I am getting bills from other
providers. What should I do? Medical equipment like wheelchairs, walkers
and hospital beds. They are durable because
A. When you go to the hospital or the they don’t get used up like medical supplies.
emergency room, you may be treated by a
provider who doesn’t work for the hospital. Emergency medical/dental condition –
For example, the emergency room doctors An illness or injury that needs care
may have their own practice and provide immediately, like bleeding that won’t stop,
services in the emergency room. They may severe pain and broken bones. It can be
send you a separate bill. If you have surgery in something that will cause some part of your
a hospital, there will be a separate bill for the body to stop working right. An emergency
hospital, the surgeon, and maybe even the mental health condition is feeling out of
lab, the radiologist, and the anesthesiologist. control, or feeling like hurting yourself or
Just because the hospital has been paid by someone else.
OHP, it doesn’t mean that the other providers
Emergency transportation – Using an
were paid by OHP. Do not ignore bills from
ambulance or Life Flight to get medical care.
people who treated you in the hospital. If
Emergency medical technicians (EMT) give
you get other bills, call each provider and
care during the ride or flight.
ask them to bill us. See the section “OHP
members don’t pay bills for covered services,” ER and ED – Emergency room and
on page 56 for more information. emergency department, the place in a
hospital where you can get care for a
medical or mental health emergency.
71
Member Handbook
Emergency services – Care that improves Medically necessary – Services and

or stabilizes serious medical, dental or mental supplies that are needed to prevent, diagnose
health conditions. or treat a medical condition or its symptoms. It
can also mean services that are accepted by
Excluded services – Things that a health
the medical profession as standard treatment.
plan doesn’t pay for. Services to improve your
looks, like cosmetic surgery, and for things Network – The medical, mental health,
that get better on their own, like colds, are dental, pharmacy and equipment providers
usually excluded. that a coordinated care organization (CCO)
contracts with.
Grievance – A complaint about a plan,
provider or clinic. The law says CCOs must Network provider – Any provider in a CCO’s
respond to each complaint. network. If a member sees network providers,
the plan pays the charges. Some network
Health insurance – A program that pays for
specialists require members to get a referral
some or all of its members’ health care costs.
from their primary care provider (PCP).
A company or government agency makes the
rules for when and how much to pay. Non-network provider – A provider who
has not signed a contract with the CCO,
Home health care – Services you get at
and may not accept the CCO payment as
home to help you live better after surgery, an
payment-in-full for their services.
illness or injury. Help with medications, meals
and bathing are some of these services. Physician services – Services that you get
from a doctor.
Hospice services – Services to comfort a
person who is dying and their family. Hospice Plan – A medical, dental, mental health
is flexible and can include pain treatment, organization or CCO that pays for its
counseling and respite care. members’ health care services.
Hospital inpatient and outpatient care – Preapproval (preauthorization, or PA) –

Hospital inpatient care is when the patient A document that says your plan will pay for a
is admitted to a hospital and stays at least service. Some plans and services require this
three (3) nights. Outpatient care is surgery or before you get the service.
treatment that your doctor doesn’t think will
Prescription drugs – Drugs that your doctor
need you to stay overnight in a hospital.
tells you to take.
Primary dental provider – Also referred to

as a “PDP,” this is the dentist who takes care
of your teeth and gums.
72
Primary care provider or Primary
care physician – Also referred to as a “PCP,”
this is a medical professional who takes
care of your health. They are usually the first
person you call when you have health issues
or need care. Your PCP can be a doctor,
nurse practitioner, physician’s assistant,
osteopath, or sometimes a naturopath.
Provider – Any person or agency that

provides a health care service.
Rehabilitation services – Special services to

improve strength, function or behavior, usually
after surgery, injury, or substance abuse.
Skilled nursing care – Help from a nurse

with wound care, therapy, or taking your
medicine. You can get skilled nursing care in
a hospital, nursing home, or in your own home
with home health care.
Specialist – A medical professional who has

special training to care for a certain part of the
body or type of illness.
Telehealth -- A telehealth appointment

is a phone or video appointment with
a provider. Many providers are now
offering this service for health needs and
checkups. Contact your provider to learn
what telehealth options they offer.
Urgent care – Care that you need the same

day for serious pain, to keep an injury or
illness from getting much worse, or to avoid
losing function in part of your body.
73
33 N Central Avenue, Suite 320
Medford, OR 97501
Phone: 541-500-0567
Toll-free: 855-722-8208
TTY 711
Secure message: jacksoncareconnect.org/portal
jacksoncareconnect.org
facebook.com/jacksoncareconnect
OHP-JCC-22-3657
JCC-22413757-EN-1209

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Jackson Care Connect

Are you pregnant? What else can we do for you?

Do you speak another language? Have questions?

All members and their Todos los miembros y

Bureau of Labor and Industries Jackson Care Connect

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Welcome to Jackson Care Connect......... 1 Getting to Health Care Appointments

Emergencies, Urgent Care Notice of Privacy Practices.......................68

We’re glad to have you as a member of Capitol Dental

agencies too. So if you face challenges like Getting Care When

Jackson Care Connect Customer Service Making appointments

If your provider asks you to pay a copay

Members – Visit OHP.Oregon.gov

Providers – This card does not guarantee

Take your Jackson Care Connect ID card and

Plan: OHP Plus

Send claims to: Advantage Dental 866-268-9631

What is a Coordinated receive after you are accepted. OHP uses

CCOs are companies that contract with the

What is the difference between Jackson What is a Patient-Centered

No referral is needed for ICCS. Your care Strong Families

Your Rights as a Jackson Care • Free to get mental health and

• Given a notice of an appointment • Follow your providers’ and pharmacists’

If you would like provider information in a print

Please note: You are free to choose any

IMPORTANT: If you are pregnant or have a

Get to know your PCP Getting in to see your PCP

• Tell them why you want an appointment.

When you choose a new PCP, the change • Pharmacists

Referrals to other providers and direct

After-hours care (evenings,

Emergencies, Urgent Care If you need help contacting any of these

People who need urgent care will

If you have any questions about what is covered,

Applied behavior Number of visits based on

Psychiatric emergency No authorization/

Telehealth Referral required

Preventive Services Authorization/Referral? Limits to Care?

Well-child visits for babies, No authorization/

Early and periodic

Mammograms No authorization/ As recommended; 3D

No authorization/ Two quit attempts per year;

Sexually transmitted No authorization/

Testing and counseling for No authorization/

Referral required for

Prescription Drugs Authorization/Referral? Limits to Care?

Some mental health

Laboratory and X-Ray Authorization/Referral? Limits to Care?

Blood draw Check with your PCP No Limit

X-rays Check with your PCP No Limit

CT scans Yes, authorization required No Limit

MRI Yes, authorization required No Limit

Pregnancy Care Authorization/Referral? Limits to Care?

Prenatal visits with No authorization/

Newborn care No authorization/

Routine vision services

Assistance with breast