Medical Debt on OHP?

If you are or were an OHP member, your medical provider can bill you ONLY when ALL of the following are true:

1. The medical service is something that your OHP plan does not cover
2. BEFORE you received the service, you signed a VALID WAIVER  form
3. The waiver form listed the estimated cost of the service
4. The waiver  form said OHP does not cover the service

and…

5.     The waiver form said you agree to pay the bill yourself.

These protections usually only apply if the medical provider knew or should have known you had OHP. Also, they only apply to providers who participate in the OHP program (but most providers do).

OAR 410-120-1280

Sometimes, your medical provider doesn’t do the paperwork correctly, and won’t get paid for that reason. That doesn’t make you responsible for the payment.  If you already received the service and OHP refuses to pay your medical provider, your provider still can’t bill you unless you signed the waiver form. You may receive a notice from OHA or your CCO, saying that your provider isn’t going to be paid. Remember, that notice doesn’t mean you have to pay.

If your provider or OHP plan tells you that the service isn’t covered by OHP, you still have the right to challenge that decision by filing an appeal with the planor by asking for a hearing. For more information, see the flyer on www.Oregonlawhelp.orgcalled “Oregon Health Plan: If you are Denied Services or have a Complaint.”

OAR 410-141-3262, 410-141-3264; 410-120-1860

What should I do if I get a bill?

Even if you don’t legally have to pay the debt, DO NOT IGNORE the bills.

Many providers send unpaid bills to collections agencies and even sue in court for the unpaid bills. It is much more difficult to fix the problem once that happens. As soon as you get a bill for a service that you received while you were on OHP, you should:

1. Call the provider and tell them that you were on OHP. Ask them to bill OHP. If you are in an OHP plan called a CCO, you should also contact the CCO and tell them that the provider is billing you for an OHP service. You can ask them to help you with the provider.
2. Send the provider and the CCO (if you are a CCO member) a letter, saying that you disagree with the bill, that you were on OHP at the time of the service, and that they should make sure that the bill is paid under OHP. Keep a copy of the letter for your records.
3. Follow up and make sure that OHP has paid the bill.
4. If you still get a bill, call the Oregon Health Authority’s Client Services Unit at (1)(800) 273-0557 and ask them to help you to get the bill cleared up.
5. If you receive court papers, call an attorney immediately. You can also call the Public Benefits Hotlineat 1-800-520-5292for legal advice and help. There are consumer laws that can help you when you are wrongfully billed while on OHP.

I was in the hospital, and OHP paid for that, but now I am getting bills from other providers. What can I do?

When you go to the hospital or the emergency room, you may be treated by a provider who doesn’t work for the hospital.  For example, the emergency room doctors may have their own practice and provide services in the emergency room.  They may send you a separate bill.  If you have surgery in a hospital, there will be a separate bill for the hospital, the surgeon, and maybe even the lab, the radiologist, and the anesthesiologist. Just because the hospital has been paid by OHP, it doesn’t mean that the other providers were paid by OHP. You shouldn’t ignore bills from people who treated you in the hospital.  If you get other bills, call each provider and let them know that they should bill OHP.  You should follow the steps above for each of the bills you receive.

When will I have to pay for medical services on OHP?

1. You may have to pay for services that are covered by OHP if you see a provider that does not take OHP or, if you are in a CCO, you see a provider who isn’t part of your CCO. Before you get medical care or go to a pharmacy, make sure that they are part of your CCO or, if you have an open medical card, make sure that they accept OHP.
2. You will have to pay for services if you weren’t eligible for OHP when you received the service.
3. You will have to pay for services if it isn’t covered by OHP and you sign an agreement to pay before you receive the service.
4. Even if your service is covered by OHP, there may be a co-payment that you are responsible for. You can’t be denied services if you can’t make your co-payment, but you will still owe the money to your provider. If you have questions about a co-payment, you can call your CCO or the OHA Client Services Unit at (1)(800) 273-0557.