Health Care

Finding access to health care, health insurance in particular, is typically a discouraging process for everyone, and it is a myth that finding good health care upon release is impossible. It is possible, and although it can be a complicated process, it is one of the most important things that you can do to thrive after release.

Finding care for your medical needs as soon as possible should be a priority, in addition to all the other areas of your life that you are thinking about like housing, finding a job, and reconnecting with family and friends. Although it is not necessarily a prerequisite for finding care, it is important to secure health insurance as soon as you can. However, keep in mind that if you are suffering from mental health or substance abuse issues, it is essential to address those first. See “Health Care Resources” for a list of free and low-cost options.

How to find health care that is suited to your needs:

• Review your physical and mental needs, particularly in relation to the area that you live—urban or rural—and how that might affect your access to care. Every county, no matter how rural, has a health department that offers clinics, essential needs like flu shots, mental health care and other resources. Those departments are listed in “Health Care Resources” as well. If you suffer or have suffered in the past with substance abuse or anger issues, or if you have a history of depression, Post-Traumatic Stress Disorder (PTSD), or other mental disorders, it is important to seek out a place where you can seek treatment while you are getting settled and taking care of other areas of your life. Remember, even without health insurance, there are low-cost or sliding-scale clinics that may be able to help you.
• Make a list of potential needs—for example, care for any chronic illnesses such as asthma or diabetes, eyeglasses, back or other chronic pain, flu shots, or preventative care. It will be easier to look for providers or clinics with a full assessment of what you may need.

As you read this, there are a few things to keep in mind. First, access to health care is continuously being modified due to federal and state politics. Particularly with regard to the Medicaid and Affordable Care Act, any information provided here is subject to change. Resources that will be able to give up-to-date information are provided in “Health Care Resources,” and it is important to keep apprised of current changes in the law. In addition, nothing in this section should be taken as medical advice. Rather, this guide is essentially a list of options for medical care. The lists provided are not recommendations in terms of the quality of care provided, they are just options for you to begin searching or to contact for further research.

Key Terms

While you may already be familiar with many of these terms, it might be helpful to have them handy as you navigate through the process of obtaining health care.

• Affordable Care Act (ACA): (Sometimes informally referred to as “Obamacare.”) Most of the ACA’s provisions went into effect in 2014. Because the ACA is responsible for a lot of the expanded coverage and laws that affect Oregon’s Medicaid program and Oregon’s health care “marketplace,” it affects a large portion of the state’s population. It is important to familiarize yourself with current changes in the ACA, as it is controversial and constantly challenged and debated in Congress.
• Authorization: An authorization for a certain type of care means that insurance will cover a portion of the payment due for the service. Many times, certain procedures or appointments will require pre-authorization. This is different from a “referral” (listed below).
• Behavioral Health: This term is used for services that provide psychiatric or psychological treatments for mental health, substance abuse, or anger management.
• Benefit Package: The bundle of covered services under a health insurance plan for which you are eligible.
• Coordinated Care Organization (CCO): Under the Oregon Health Plan (OHP), a CCO is a local health care network that exists in every county and includes different health providers and services for people who receive care. If you are covered under OHP, your CCO is your main resource for finding providers and services for which you will be covered.
• Co-Insurance: The percentage of a covered health service for which you are responsible for payment. Typically, you will pay co-insurance plus any deductibles owed.
• Co-Payment: The amount you are required to pay as your share of the cost of a service or treatment, such as a doctor appointment, hospital outpatient visit, or for a prescription drug. It is usually a predetermined, set amount, not a percentage.
• Deductible: The amount you will owe for health care services that your insurance plan covers, before your insurance plan begins to cover costs. It may not apply to all services.
• Dental Emergency Services: Services provided for severe tooth pain, unusual swelling of the face or gums, or an avulsed tooth. This is often covered separately from general dental care.
• Detoxification: The process of removing drugs and alcohol from an individual’s system. It is not typically provided as part of long-term care (long-term care for substance abuse is often provided through recovery services).
• Emergency Care: (Different from “Urgent Care”). Emergency care is classified as treatment for a sudden medical condition that requires immediate medical attention. In Oregon, emergency services are covered if the absence of those services would result in (1) placing an individual’s health in serious jeopardy, (2) serious impairment to bodily function, or (3) serious dysfunction of any organ or body part. If you are feeling suicidal or feel like you will cause harm to yourself, you should also seek emergency care from an emergency room as soon as you can.
• Emergency Medical Transportation: Transportation, such as an ambulance, that is separately charged from the medical condition. In most cases, it involves a skilled medical professional, such as an Emergency Medical Technician (EMT) and immediate transport to a hospital for emergency medical care. This is separate from medical transportation provided by certain counties in rural areas for access to medical services.
• Fee-for-Service Provider: Under Medicaid/OHP, a health care provider who is not reimbursed under a CCO or a Prepaid Health Plan (PHP).
• Generic Drug: Generic medications have the same drug/chemicals as a marketed brand-name drug in dosage, safety and performance, and works in the same way as the brand-name drug. Most doctors will prescribe generic prescriptions because they are less-expensive and just as effective.
• Inpatient Care: Care or medical service that requires hospital admission for an extended period of time.
• Institutionalization: Admission to a hospital to receive intensive care for a period of 30 days or more.
• Medicaid: A federal and state-funded program for medical assistance administered in Oregon by the Oregon Health Authority (OHA). It is also referred to as OHP for purposes of this manual.
• Medical Care Identification: The identification (ID) card, commonly called the “medical card,” issued by an insurance provider which contains the policy information providers need, as well as other information such as your co-payment amount.
• Medicare: A federal program that offers health insurance benefits for individuals aged 65 and over.
• Medication Management: A program provided by a practitioner to oversee and optimize the best drug therapy program. This usually occurs with a regular psychiatrist or primary care physician, and not with drugs prescribed in an emergency situation.
• Network: The hospitals and other facilities, providers, and suppliers that your health insurer has contracted with to provide services that will be covered under your plan.
• Nurse Practitioner: A licensed registered nurse who can perform many of the services that a doctor is able to perform, including prescribing medication and seeing individual patients.
• Occupational Therapy: Treatment for individuals who lack the ability to adapt or cope with everyday activities, because of physical injury or psychological disabilities. The therapy typically includes task-oriented activities.
• Oregon Health Authority (OHA): Oregon’s health agency responsible for the administration of medical assistance programs, and that oversees the Oregon Health Plan (OHP).
• Oregon Health Plan (OHP): The OHP is Oregon’s state Medicaid program.
• Oregon Health Care Marketplace: The Oregon Health Care Marketplace is the state’s health insurance exchange under the ACA. Its website offers information on private insurance and Medicaid.
• Out-of-Pocket Maximum: The most that you will pay during a policy period (typically one year) before your health insurance plan will start to pay 100% of the covered essential benefits. It includes the yearly deductible and may also include any cost-sharing you have after the deductible.
• Outpatient Care: Treatment received in a hospital that does not require an overnight stay.
• Prepaid Health Plan (PHP): A managed health, dental, chemical dependency/substance abuse, or mental health organization that contracts with the OHA on a managed or prepaid basis under OHP.
• Preauthorization: A decision made under your health insurance plan that a certain service, treatment plan, or prescription drug is medically necessary and will be covered.
• Preventative Services: Routine health services, such as check-ups and screenings, to prevent future health problems, or to detect existing illnesses at an early stage (this can include services like flu shots, vaccines, mammograms, blood pressure tests, depending on what is recommended for you).
• Premium: The cost of your health insurance plan. You will usually pay it yearly, although it can be monthly or quarterly. It is not included in the deductible, co-payment, or co-insurance.
• Primary Care: A primary care doctor provides general care, can refer you to specialists for other services, and keeps track of your health over an extended period of time.
• Psychiatric Emergency Services (PES): Mental and behavioral health services provided when individuals are experiencing suicidal thoughts or engaging in harmful or disturbing behavior that require immediate attention. (Note: all suicidal thoughts require immediate attention.)
• Psychiatry (versus Therapy): A psychiatrist is a medical provider that prescribes medications, whereas psychologists and counselors provide therapy services to treat patients in behavior and mental illness. A psychology session is typically longer and more continuous.
• Recovery (versus Detoxification): When you hear of “detoxification,” it is most likely in reference to the step of cleaning out a person’s system of drugs or alcohol. “Recovery” refers to the process in which a person is treated for substance abuse and remains substance-free.
• Referral: The transfer of a specific type of care from one provider to another. It typically involves a request for a consultation, evaluation, or approval for specific services.
• Sliding Scale Payment Program or Sliding Fee Schedule: A payment program or agreement provided to individuals (usually low-income) who qualify, which provides lower rates based on ability to pay.
• Specialist: A physician who focuses on a specific area of medicine, such as a cardiologist or gynecologist. A non-physician specialist is a provider who has more training in a specific area of health care.
• Urgent Care (versus Emergency Care): Health services that are provided when medically appropriate and immediately necessary to prevent a serious condition or deterioration of a person’s health that is a result of unforeseen illness or injury. Typically, you would seek urgent care for conditions that you need treatment for in the immediate future, and cannot make an immediate appointment with a primary care provider or specialist.
• Vision Services (versus Eye Care): Services that provide corrective eyewear (eyeglasses, contact lenses), including eye exams to determine your visual abilities/eye prescription.

Health Insurance

Obtaining health insurance is critical to living a healthy lifestyle, but it can also be a very complicated and overwhelming process. Thankfully, there are plenty of resources and other forms of help that are provided here in Oregon to aid you in finding a plan that you can afford, and that will serve your needs effectively. You may have been able to speak with someone before release about certain options, such as Medicaid. You may have even been able to apply for coverage before release that begins the day you leave. However, if this is not the case, do not be discouraged.

Upon release, you will either already be enrolled in some form of public or private health insurance, or you will not be enrolled, but could be eligible for either. If you are already enrolled, your priority will be to find out if you have maintained enrollment, and if not, how to reactivate your benefits once you are released. There are too many different outcomes and policies based on the different types of insurance to provide general information here, but you should contact your health insurance provider as soon as you can. If you are a veteran, you may have more options for benefits from the VA health care system. If so, you should contact your closest VA Regional Office for more information.

Oregon’s Health Insurance Marketplace (Affordable Care Act Insurance)

Upon release, you are eligible to apply for health insurance though Oregon’s health insurance (ACA) marketplace at any time of the year, not just during the enrollment period. If you are released outside of the general public enrollment time period, you are eligible for a “special enrollment period” for up to 60 days from your release. However, unlike Medicaid, you are not able to get a head start on your application before release, so the application is something that you must take care of as soon as you can.

Anyone can apply for health insurance on Oregon’s health care marketplace, not just low-income individuals (unlike Medicaid). The application process will provide information—based on your income and needs—on insurance plans for which you are eligible.

The starting point for an application is on Oregon’s marketplace website, or the federal health care website. The site also contains information about coverage, how to obtain local help, and information for OHP members.

Oregon: www.heathcare.oregon.gov

Federal: www.healthcare.gov

2017 Update: There is No More State-Run Exchange Under CoverOregon.

Private insurance on Oregon’s health care marketplace includes Kaiser Permanente, Moda, PacificSource, Providence Health Plan, and BridgeSpan. Under the ACA, you may be eligible for financial assistance or subsidized health insurance. In 2017, for one person (single household), if your income is $48,240 a year or under, you will qualify.

For information on qualifications for other household sizes, follow this link:

http://healthcare.oregon.gov/marketplace/coverage/Pages/financial-assistance.aspx

Almost all the counties in Oregon offer assistance for ACA marketplace enrollment through their public health departments. If you do not feel comfortable going through the application process yourself, or if it is difficult for you to find regular access to a computer, contact the department for more information and help. See “Health Care Resources” to find a public health department near you!

Before you begin the application process, you will want to gather the following information, so it is easily accessible:

• information about your household, including addressed for each member that needs coverage
• social security numbers of each individual you would like to cover
• any employer and income details (pay stubs or Wage and Tax statements (W-2) forms)
• an estimate of your household income for the coming year
• policy number of any current health insurance plan that covers any member of your household

Under current law, health insurance companies cannot deny you coverage, or charge you more if you have a pre-existing condition, such as asthma, diabetes, or a diagnosed mental illness. Benefits cannot be limited either for pre-existing conditions.

Medicaid

Applications for Medicaid are accepted year-round. In Oregon, Medicaid is provided through the Oregon Health Plan (OHP), thus the terms “Medicaid” and “OHP” here are interchangeable and refer to the same plan. Qualification for Medicaid takes into account your income, household size, age, disability status, and family status, including any dependent children. Importantly, you must submit an application to find out if you qualify for Medicaid!

There are three ways to apply:

1. Online
2. Filling out a paper application and mailing it to a Medicaid office
3. Visiting a local Medicaid office

In Oregon, coverage is available to all individuals—including non-disabled adults without dependent children—who earn up to 138% on the federal poverty level. In 2017, this was $16,664 a year for a single adult. Nearly all inmates’ income falls below this level while they are in jail or prison, and eligibility can continue upon release. If you were already receiving Medicaid coverage, you may have been able to maintain enrollment with suspended coverage.

If you are eligible and enroll in OHP, your health care services will be provided through your local Coordinated Care Organization (CCO) or a Prepaid Health Plan (PHP), defined in “Key Terms.” Your CCO is responsible for providing and arranging covered services, and are required to provide benefit packages. See “Health Care Resources” to locate the CCO in your county!

How to Locate Resources

Once you are insured, you will need to find out which providers in your area accept your insurance. For OHP, this information will be provided by your CCO. For private health insurance, provider information is typically provided through a search engine on the insurer’s web site.

If you have a provider in mind that you wish to use, you can also call the provider directly and ask if your insurance plan is accepted. In some cases, your insurance plan may assign you with a provider, but you can usually change providers if you want to. Urgent care clinics and emergency rooms are also able to refer specialized care, if you need to follow-up with a doctor after an urgent or emergency visit.

It is recommended that you make an appointment with a primary care provider as soon as you can after release. This is because a primary care doctor can start keeping your health records, help you manage any chronic conditions, and link or refer you to specialists if you need them. It is much easier to get referrals from a central source rather than searching for different specialist doctors on your own. A primary care appointment can be made for most health problems—think of primary care as the “hub” of your health care.

Another place to begin searching for resources is through your county’s health department, particularly when it comes to mental health and substance abuse. See “Health Care Resources” to find a health department near you!

Mental Health and Substance Abuse

It is absolutely critical to address your mental health and substance abuse recovery needs as soon as possible. There are several ways  to get the help you need.

Ask yourself these questions to better understand your needs:

• Are you looking for an inpatient program or outpatient treatment option?
• • Generally, an inpatient program is more intensive and immersive than any outpatient treatment option.
• What kind of treatment am I looking for?
• • There are a variety of treatment options available, and determining the best option for you depends on your personal symptoms and needs. Options include, but are not limited to, individual therapy, group therapy, outpatient recovery programs, or inpatient recovery programs.

Things to keep in mind:

• If you are in crisis—feeling suicidal or experiencing a severe relapse—the best course of action is to call a crisis line or go to the nearest emergency room. See “Health Care Resources” to find options near you. If you are in a rural area, this may seem impossible, but crisis lines typically provide options for people suffering a crisis who are unable to get to an emergency room quickly. There are both national and local crisis lines.
• The information provided in “Health Care Resources” is not a representation of all the options in your county! Contact your county health department for listings of public and private options for mental health needs that are low-cost. Oregon counties typically keep full directories and will be able to guide you to the help that you need.
• If you have insurance, public or private, your insurance provider will have a directory of clinics, inpatient, and outpatient programs.
• Another option is to walk-in or call a hospital or urgent care clinic and ask for referrals when you are treated.
• In the directory provided below, not all resources are listed. However, the crisis lines, county health departments and nearest hospitals are listed in order to get started.

Urgent Care Clinics

Urgent care clinics are same-day walk-in medical providers. They are usually low-cost or offer sliding-scale payment plans. An urgent care clinic is not the same as an emergency room. It “bridges the gap” between an emergency room and a primary care appointment. For example, if you are suffering from a serious medical issue that needs urgent attention, such as a severe sinus infection but you do not have a primary care provider or cannot make an appointment with one in the immediate future, an urgent care clinic can provide services. Urgent care clinics treat a wide range of medical issues and needs, and they can also provide referrals if you are suffering from a medical issue that will need longer care or a follow-up.

Most urgent-care clinics provide flu shots. In addition, many pharmacies such as Walgreens and CVS provide flu shots and some other immunizations at low cost for individuals with or without health insurance.

AFC Urgent Care (http://afcurgentcareportland) and ZOOM+Care (www.zoomcare.com) are the large urgent care providers in Multnomah county and around Oregon. Most of the larger Oregon hospitals also provide urgent care as well as emergency services.

You can find full listings of urgent care clinics online:https://www.urgentcarelocations.com/or/oregon-urgent-care

If you are unable to obtain health insurance, there are low-cost options for getting care that you need. To find low-cost or free services, look for terms such as “sliding fee scale” or “payment assistance” when searching providers.

Some primary care services may be free of charge or lost-cost without insurance. Flu shots and other recommended preventative services are often offered at pharmacies such as CVS and Walgreens. Other options include community clinics and free clinics, some of which are listed below in the Resources section.