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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
ServiceServiceServiceColonoscopies and Endoscopies Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareVirtual Colonoscopies are not covered
ServiceServiceServiceFamily Planning Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required
Limits to CareLimits to CareLimits to CareSterilization requires consent form be fully completed by physician and member before services are given
ServiceServiceServiceMammograms (breast x-rays) for women Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralReferral required Limits to CareLimits to CareLimits to CareAs recommended by PCP
ServiceServiceServiceProstate exams for men Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareCovered as a specialist visit if member presents with a problem
ServiceServiceServiceRoutine physicals Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareAs recommended by PCP
ServiceServiceServiceScreening for sexually transmitted diseases (STDs)
Your Cost*Your Cost*Your Cost*$0  Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareNo limits
ServiceServiceServiceTesting and counseling for AIDS and HIV Your Cost*Your Cost*Your Cost*$0  Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareNo limits
ServiceServiceServiceWell-child visits for babies, children, and teens
Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareAs recommended by PCP
ServiceServiceServiceWomen's Exams
Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareAs recommended by PCP

 

* 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
ServiceServiceServiceContraceptives Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralSome drugs may require approval with a prescription Limits to CareLimits to CareLimits to CareUp to a 90 day supply with prescription 
ServiceServiceServiceMental health medications** Your Cost*Your Cost*Your Cost*N/A Approval/ReferralApproval/ReferralApproval/ReferralNot covered by IHN-CCO
Limits to CareLimits to CareLimits to CareMental Health Medications are Covered by OHP, see Prescription Drug Benefits for more details 
ServiceServiceServiceOther medications
Your Cost*Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralSome drugs may require approval with a prescription Limits to CareLimits to CareLimits to CareUp to a 30 day supply with prescription 

 

* 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. 

** These benefits are covered by OHA and are subject to change. Please call member services at 1-800-273-0557 to confirm benefits at time of service. 

Laboratory and X-Ray

Service Your Cost* Approval/Referral Limits to Care
ServiceServiceBlood draw Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralReferral required Limits to CareLimits to CareNo limit
ServiceServiceCT Scans Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralReferral and approval required Limits to CareLimits to CareAs recommended with approval
ServiceServiceMRIs Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralReferral and approval required Limits to CareLimits to CareAs recommended with approval
ServiceServiceX-Rays Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralReferral required Limits to CareLimits to CareNo limit

 

* 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 and Postpartum Care

 
Service Your Cost* Approval/Referral Limits to Care
ServiceServiceBreast pump Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval required Covered with approval when provided by a contracted DME supplier.
ServiceServiceChild birthing/Lamaze/breast feeding classes
Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralNot required Limits to CareLimits to CareCovered if provided at a hospital in IHN-CCOs service area (Linn, Benton, and Lincoln Counties). Contact Customer Service for details. 
Postpartum care (the care you get after your baby is born)  Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralNot required Limits to CareLimits to CareNo limit with In-Network Provider
ServiceServicePrenatal visits with your doctor
Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralNot required Limits to CareLimits to CareNo limit
ServiceServiceRoutine vision services Your Cost*Your Cost*$0 Approval/ReferralApproval/ReferralApproval required Limits to CareLimits to CareAvailable for pregnant women. 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. 

Labor and Delivery

 
Service Cost* Approval/Referral Limits to Care
ServiceServiceServiceInpatient hospital admission Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralApproval required for stays longer than 2 days for normal vaginal births, and for stays longer than 4 days for C-section. Limits to CareLimits to CareLimits to CareInpatient 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. 

 

* 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
ServiceEmergencies Cost*$0 Approval/ReferralNot required Limits to CareNo limit
ServiceScheduled surgery Cost*$0 Approval/ReferralApproval required Limits to CareNo 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. 

Newborn Care

 
Service Cost* Approval/Referral Limits to Care
ServiceCircumcision for newborn boys Cost*N/A Approval/ReferralApproval is required if performed as an inpatient or outpatient surgery  Limits to CareNot covered unless medically necessary
ServiceNewborn Inpatient Stay Cost*$0 Approval/ReferralNot required for stays less than 5 days Limits to Care

Newborns will require their own insurance. Call the state of Oregon or your case manager to tell him about the birth and to get your newborn enrolled on the OHP.

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. 

Outpatient Surgery

Service Cost* Approval/Referral Limits to Care
ServiceAmbulatory surgical center or outpatient hospital Cost*$0 Approval/ReferralApproval required Limits to CareNo limit with approval
ServiceIn office procedures Cost*$0 Approval/ReferralReferral may be required Limits to CareMay 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
ServiceServiceMassage therapy Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval required Massage Therapy is only covered when provided with other treatments during the same Physical Therapy Session. See PT and OT benefits.  
ServiceServiceOccupational therapy (OT)
Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval required if more than 30 visits per calendar year  Limits to CareLimits to CareNo limit on visits for the first year following a serious injury to spinal cord, traumatic brain or cerebral vascular injuries. Prior approval required for more than 30 visits to verify injury.
ServiceService Physical therapy (PT)  Cost*Cost*$0  Approval/ReferralApproval/ReferralApproval required if more than 30 visits per calendar year   Limits to CareLimits to CareNo limit on visits for the first year following a serious injury to spinal cord, traumatic brain or cerebral vascular injuries. Prior approval required for more than 30 visits to verify injury. 
Speech therapy (ST)  Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval required if more than 30 visits per calendar year limit on visits for the first year following a serious injury to spinal cord, traumatic brain or cerebral vascular injuries. Prior approval required for more than 30 visits to verify injury. 

 

* 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
ServiceServiceEye Hardware Cost*Cost*$0 Approval/ReferralApproval/ReferralContact Customer Service Limits to CareLimits to CareAvailable for adults 21 and over only if pregnant or certain medical conditions diagnoses
ServiceServiceMedical Eye Exams Cost*Cost*$0 Approval/ReferralApproval/ReferralContact Customer Service Limits to CareLimits to CareAvailable for all members with limitations
Routine Eye Exams Cost*Cost*$0 Approval/ReferralApproval/ReferralContact Customer Service Available for adults 21 and over only if pregnant or certain medical conditions diagnoses

 

* 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
ServiceServiceServiceAbortion** Cost*Cost*Cost*N/A Approval/ReferralApproval/ReferralApproval/ReferralNot covered by IHN-CCO Covered by OHP, contact OHP Member Services at 1-800-273-0557 with questions
ServiceServiceServiceAcupuncture Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralApproval required Approval based on OHP guidelines
ServiceServiceServiceChiropractor Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralApproval required for out of network Limits to CareLimits to CareLimits to CareApproval based on OHP guidelines and the Prioritized list
ServiceServiceServiceHearing exams and screenings  Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralReferral required Limits to CareLimits to CareLimits to CareNo limits
ServiceServiceServiceHearing aids Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralApproval required Limits to CareLimits to CareLimits to CareAdults 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.
ServiceServiceServiceHome health Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareNonmedical assistance is not included and is not covered
ServiceServiceServiceHospice Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralNot required Limits to CareLimits to CareLimits to CareNo limits
ServiceServiceServiceMedical equipment and supplies  Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralApproval required except for diabetic supplies, incontinent supplies and CPAP supplies.  Limits to CareLimits to CareLimits to CareApproval and limits based on OHP guidelines. Contact Customer Service for details.
ServiceServiceServiceSkilled Nursing Facilities (SNF)   Cost*Cost*Cost*$0 Approval/ReferralApproval/ReferralApproval/ReferralApproval required Limits to CareLimits to CareLimits to CareLimits 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.

** These benefits are covered by OHA and are subject to change. Please call member services at 1-800-273-0557 to confirm benefits at time of service. 

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.

2018 Member Handbook - Medical/Mental/Dental 491.71 KB
2018 Member Handbook - Mental/Dental only 483.72 KB
2018 Member Handbook - Mental only 462.45 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 61.44 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.