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Your Medical Benefits

Sick? Let’s get you well again. Feeling fine? Let’s keep you that way! Your primary care provider (PCP) will work with you to meet your health care needs. If you need care from any other provider, hospital or clinic, your PCP is able to assist in coordinating services.

See below some of your covered medical benefits as a member of IHN-CCO. These services are covered when given by an in-network provider. If you think you need a service that is not listed below, you or your provider should contact us before you get the service. 

The services listed are subject to the Prioritized List of Health Services and IHN-CCO and Oregon Health Plan rules. Benefits are subject to change.

Explore your coverage

Doctor Visits

Service Your Cost* Approval/Referral Limits to Care
Primary care provider $0 Not required No limit with assigned PCP
Specialist $0 Referral required from your PCP, except for dental, women's health, or behavioral health providers No limit with In-Network Specialist

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Preventive Services

Service Your Cost* Approval/Referral Limits to Care
Well-child visits for babies, children, and teens  $0 Not Required As recommended by PCP
Routine physicals $0 Not Required
As recommended by PCP
Women's exams $0 Not Required As recommended by PCP
Mammograms (breast x-rays) for women $0 Not Required As recommended by PCP
Family planning $0 Not Required Sterilization requires consent form be fully completed by physician and member before services are given
Colonoscopies and endoscopies
$0  Not Required Virtual Colonoscopies are not covered  
Prostate exams for men $0  Not Required Covered as a specialist visit if member presents with a problem
Screening for sexually transmitted diseases (STDs)
$0 Not Required No limits
Testing and counseling for AIDS and HIV
$0 Not required No limits

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Prescription Drugs

Service Your Cost* Approval/Referral Limits to Care
Contraceptives $0 Some drugs may require approval with a prescription Up to a 90 day supply with prescription 
Other medications $0 Some drugs may require approval with a prescription
Up to a 30 day supply with prescription 
Mental health medications
N/A Not covered by IHN-CCO Mental Health Medications are Covered by OHP, see Prescription Drug Benefits for more details 

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Laboratory and X-Ray

Service Your Cost* Approval/Referral Limits to Care
Blood draw $0 Referral required No limit
X-Rays $0 Referral required No limit
CT scans $0 Referral and approval required As recommended with approval
MRIs $0 Referral and approval required As recommended with approval

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Immunizations/Shots

Service Your Cost* Approval/Referral Limits to Care
Preventative vaccines $0 Not required Vaccines must be given at your provider's office. Flu shots may be given at an In-Network pharmacy or health department. See Covered Pharmacies.
Work, education or travel vaccines N/A Not a covered benefit These vaccines are not covered by IHN-CCO or OHP 
Immunization schedule for birth-6 years 269.28 KB
Immunization schedule for 7-18 years 207.64 KB
Immunization schedule 19 years and older 138.26 KB

*This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Pregnancy Care

Service Your Cost* Approval/Referral Limits to Care
Prenatal visits with your provider $0 Not Required No limit
Child birthing/Lamaze/breast feeding classes
$0 Not Required Covered if provided at a hospital in IHN-CCOs service area (Linn, Benton, and Lincoln Counties). Contact Customer Service for details. 
Breast pump $0 Approval Required Covered with approval when provided by a contracted DME supplier.
Routine vision services
$0 Approval Required Available for pregnant women. Contact Customer Service for details. 
Postpartum care (the care you get after your baby is born)  $0 Not required Newborn babies need their own coverage, mother needs to enroll newborn by contacting her DHS caseworker or OHP Client Services.
Circumcision for boys
N/A Approval is required if performed as an inpatient or outpatient surgery  
Not covered unless medically necessary 

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Labor and Delivery

Service Cost* Approval/Referral Limits to Care
Inpatient hospital admission $0 Approval required for stays longer than 2 days for normal vaginal births, and for stays longer than 4 days for C-section. Inpatient hospital admission for the purposes of childbirth do not require approval unless the hospital stay is for more than 48 hours after delivery for a vaginal birth, or 96 hours for a cesarean (C-section). Emergency services do not require approval. 
Newborn inpatient stay
$0 Not required for stays less than 5 days
Approval is required for newborn stays of 5 days or longer 

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Hospital Stays

Service Cost* Approval/Referral Limits to Care
Emergencies $0 Not required No limit
Scheduled surgery $0 Approval required No limit with approval

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Outpatient Surgery

Service Cost* Approval/Referral Limits to Care
Ambulatory surgical center or operating room $0 Approval required No limit with approval
In office procedures $0 Referral may be required May be limits depending on service

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Therapy

Service Cost* Approval/Referral Limits to Care
Physical therapy (PT) $0 Approval required if more than 30 visits per calendar year  No limits on visits for the first year following a serious injury to spinal cord, traumatic brain or cerebral vascular injuries.
Occupational therapy (OT)
$0 Approval required if more than 30 visits per calendar year  No limit on visits for the first year following a serious injury to spinal cord, traumatic brain or cerebral vascular injuries.
Speech therapy (ST)  $0  Approval required if more than 30 visits per calendar year   No limit on visits for the first year following a serious injury to spinal cord, traumatic brain or cerebral vascular injuries.
Massage therapy $0 Approval required Massage Therapy is only covered when provided with other treatments during the same Physical Therapy Session. See PT and OT benefits. 

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Vision

Service Cost* Approval/Referral Limits to Care
Eye Exams $0 Contact Customer Service Available for pregnant women and children 20 years and younger
Eye Hardware $0 Contact Customer Service Available for pregnant women and children 20 years and younger
Medical Eye Exams  $0 Contact Customer Service Available for all members with limitations

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Specialty Services

Service Cost* Approval/Referral Limits to Care
Acupuncture $0 Approval required Approval based on OHP guidelines
Abortion N/A Not covered by IHN-CCO Covered by OHA, contact OHP Member Services at 1-800-273-0557 with questions
Chiropractor $0 Approval required Approval based on OHP guidelines
Hearing exams and screenings  $0 Referral required No limits
Hearing aids $0 Approval required Adults who meet criteria are limited to one (1) hearing aid every five (5) years, (two (2) may be authorized if certain criteria are met). Children who meet criteria are allowed two (2) hearing aids every three (3) years.
Home health $0 Not required Custodial care is not included and is not covered
Hospice $0 Not required No limits
Medical equipment and supplies  $0 Approval required except for diabetic supplies, incontinent supplies and CPAP supplies.  Approval and limits based on OHP guidelines. Contact Customer Service for details.
Skilled Nursing Facilities (SNF)   $0 Approval required Limits apply. Contact Customer Service for details.

 

* This cost only applies when services are given by an In-Network Provider. Any services with an Out-of-Network Provider must have prior authorization or approval, unless it is an emergency. If you do not get approval, you may have to pay. 

Member Handbooks

The information on this page is a summary of your IHN-CCO benefits. For a full description of the benefits and services available to you, read your IHN-CCO Member Handbook.

2017 Member Handbook - Medical/Mental/Dental 1.02 MB
2017 Member Handbook - Mental/Dental only 1.02 MB
2017 Member Handbook - Mental only 1003.46 KB

Prioritized List of Health Services

Non-covered services

Unfortunately, IHN-CCO and Oregon Health Plan cannot cover everything. We try to cover the most important services to treat common medical problems and keep you healthy. Some examples of non-covered medical services are:

  • Treatment for conditions that get better on their own without going to the doctor, like colds
  • Treatment for conditions that can be treated at home, such as corns, calluses and some skin conditions
  • Cosmetic surgeries or treatments that only improve appearance, not function
  • Services to help you get pregnant

Getting care

IHN will be your main contact for any questions you may have about your primary care provider (PCP). Your PCP will manage your medical care and treatment and make sure that you see specialists when needed. You can call your PCP’s office any time of day or night, every day of the week. Even if the office is closed, there is still someone available to help you.

Please ask your provider’s office about their ADA accessibility, like ramps and elevators, if you have special needs. Some doctors speak languages besides English. You can ask if the clinic has a provider who speaks your language.

IHN will help you choose a PCP or change your PCP if one has already been assigned to you. Make sure that you tell us if you are getting medical services that you need to continue. IHN doesn’t limit the PCP you choose, as long as they are in IHN’s provider network and accepting new patients. Review the current list of in-network PCPs or contact Customer Service.

IHN-CCO will help you choose a PCP or change your PCP if one has already been assigned to you. Make sure that you tell us if you are getting medical services that you need to continue. IHN-CCO doesn’t limit the PCP you choose, as long as they are in IHN-CCO’s provider network and accepting new patients. Choose or change your primary care provider by filling out this card and mailing it to us.

Review the current list of in-network PCPs
Contact Customer Service

Please ask your provider’s office about their ADA accessibility, like ramps and elevators, if you have special needs.

Some doctors speak languages besides English. You can ask if the clinic has a provider who speaks your language. You can have a language or sign language interpreter at your appointments if you want one. Learn more about IHN-CCO's Interpreter Services.

A specialist is a provider who treats only certain health problems. For example, there are specialists who treat heart problems, joint pain or skin problems. Your PCP will usually be the one who decides if you need to see a specialist. This is done by what is called a referral. If your PCP thinks you should see a specialist they will send or call in a referral to the specialist. Some referrals also require approval, or prior authorization, from IHN-CCO.

Review the list of in-network specialists
Contact Customer Service

Find care

Looking for a medical provider or clinic covered by OHP/IHN-CCO network? 

Find Care in Your Community

Forms and downloads

Here are a few forms you or your provider may need. These forms relate to your medical coverage:

Authorized Representative Form 26.1 KB
You have the right to choose an Authorized Representative. This person has your permission to discuss your health information with IHN-CCO.
Choose Primary Care Provider Card 80.33 KB
Choose or change your primary care provider by filling out this card and mailing it to us.
Prior Authorization Request Form 23.95 KB
This form is for your provider. It is used to request an approval, or prior authorization, for medical services.