Services That Are Limited or Not Covered by the Oregon Health Plan (OHP)

OHP Does Not Cover All Treatments for All Health Conditions

Some services are limited. This means they are only covered for certain conditions.

Some services are not covered. This means they are not part of an OHP benefit package, or they are not usually covered for any condition.
OHP has a list of covered treatments and conditions, called the Prioritized List of Health Services.

Your provider should tell you if a service is limited or not covered before providing the service. Ask about your choices. Before providing any health care service, all providers should tell patients:

If OHP covers the service.
When services will exceed benefit limits (e.g., more frequent dental care than OHP covers).
Their options if OHP does not cover the service or the services exceed benefit limits.

OHP may pay for services you get outside Oregon when:

It is a medical emergency or
The service is not readily available in Oregon, and your CCO or OHA approved the service.

OHP will not cover any health care services you get outside the United States, including Canada and Mexico.

For all services you get outside Oregon, the provider must accept OHP. If the provider does not accept OHP, you must pay for the services.

If you need services outside Oregon:

In an emergency, make sure the hospital knows you are an OHP member. Show your CCO ID and your Oregon Health ID card.
If it’s not an emergency, your CCO or OHA must approve the service first. Out-of-state services require prior authorization (see below).

Prior authorization means OHP or your CCO must approve a service before you can get it. Services that may need approval include:

Dental services
Durable medical equipment and supplies (such as wheelchairs, hospital beds, breast pumps)
Home health care
Hospital stays
Imaging services (such as MRIs)
Medical equipment and supplies (such as diabetic supplies, diapers, catheters)
Out-of-state services
Physical or occupational therapy
Physical health drugs not listed on the Preferred Drug List or your CCO's formulary
Speech and language services
Specialty services
Transplants
Vision services for non-pregnant adults age 21 and over
Services not covered according to the Prioritized List of Health Services.

Note: This is not a full list of the services that may need prior authorization. Your doctor will know if a service needs it.

Ask your provider to ask OHP or your CCO if you can get certain services. This is called a “prior authorization request.” You and your provider will get a Notice of Adverse Benefit Determination if the request is denied.

If you think OHP should cover the service, you can ask your CCO or OHA to review the request again. The CCO review is called an appeal. The OHA review is called a hearing. Learn more about appeals and hearings.
If, after CCO and OHA review, OHP will still not cover the service, you can choose to pay for the service yourself.

Some things OHP does not pay for are:

Treatment for conditions that you can take care of at home or that get better on their own (colds, corns, calluses and some skin conditions)
Cosmetic surgeries or treatments that are for appearance only
Treatments that do not usually work
Services to help you get pregnant and
Services that OHP or your CCO decide are not necessary based on a medical review.

This happens if the patient has a covered condition that could get better if the condition that isn’t covered is treated.

This means you may need to pay the bill if you:

Use a provider that does not accept OHP or
Are in a CCO but use a provider who is not in the CCO's network.

For Children or Youth under Age 21:

OHP or your CCO must cover all services needed for their health and development. This includes services that are limited or not covered for adults. Beginning January 1, 2023, OHP may cover some services for children and youth that weren't covered before.

If OHP members under age 21 need a service:

Ask their health care provider about getting the service.
The provider will consider personal needs and medical history.
They may need to ask OHP or your CCO for approval.

Learn more about services covered for children and youth under age 21.

What to Do If You Want to Get a Non-Covered Service

There may be times when you want to receive a service that OHP does not cover. When this happens, you can:

Look for other ways to get the service
Get a second opinion. You may find another provider who will charge you less for the service.
If there no other options, you can agree to pay for the service.

Ask your doctor if there's a less expensive medication
Ask if an equivalent drug is covered
Ask if this prescription needs approval
Ask your doctor for samples from the drug company and
Apply for free medication from the drug company's Patient Assistance Program.

Ask your provider if:

The provider has tried all other covered options available for treating your condition and
There is a hospital, medical school, dental school, service organization, free clinic or county health department that might provide this service or help you pay for it.

To get a service that is not covered by OHA or your CCO, you and your provider must sign a form before you receive the service. The form must list:

The name or description of the service
The estimated cost of the service
A statement that OHP does not cover the service and
Your signature agreeing to pay the bill yourself.

OHP has three Agreement to Pay forms for providers to use. Providers can use different forms, but only if they say the same things as these forms.

The OHP 3166 for prescriptions,
The OHP 4109 for planned community births, and
The OHP 3165 for other health care services.

Ask your provider if you can get a reduced rate for the service or a discount as a person paying for services privately.

There may be services from other providers — such as hospital, anesthesia, therapy, lab or X-ray services — that go with the service you want. You will have to pay for these too.