Specialty care means care you receive from a provider in a special area. Some examples are cardiology for heart disease, orthopedics for bone and joint problems, and endocrinology for problems such as diabetes.
If you and your PCP decide that you should see a specialist, your PCP will give you a referral.
However, you can see some kinds of specialists without seeing your PCP first. See the section “Referrals to Other Providers and Direct Access to Specialists” on page 22 of your Member Handbook.
Lab tests, x-rays and other procedures
Health Share pays for these services if your provider orders them.
If you need care provided at a hospital, your PCP or specialist will arrange for your care. Health Share will pay for those services.
A number of family planning services are covered by Health Share. They include:
• Physical exams
• Contraceptive education
• Contraceptive supplies, such as condoms, birth control pills and intrauterine devices (IUDs).
• Emergency contraception (the “morning after” pill)
• Sterilization (tubal ligations and vasectomies)
Related services also covered include:
• Pap smears.
• Pregnancy tests.
• Screening and counseling for sexually transmitted diseases (STDs), including AIDS and HIV.
• Abortions. (Contact DMAP at 503-945-5772, toll-free at 1-800-527-5772, or TTY/TDD 711 for more information.)
Skilled nursing facility care
Health Share will pay for care in a skilled nursing facility for up to 20 days after you have been in the hospital. Additional skilled care may be covered by DMAP.
Benefits for members who are under age 21 or pregnant:
• There is no limit to coverage of eye exams and new glasses if they are medically necessary. For example, if you experience a change in your vision that requires new glasses. Medical necessity is decided by your PCP or other health care provider.
• Oregon Health Plan will pay for contact lenses only for a few conditions.
Benefits for members who are age 21 or over:
• Glasses are also covered:
• Within 120 days after cataract surgery
• Up to one year after corneal transplant
• Oregon Health Plan covers contact lenses only for a few conditions.
If you have an eye injury or infection, call your PCP. Your PCP may refer you to a specialist.
If you are pregnant, you can receive additional dental and vision coverage. Call your caseworker if you become
pregnant or are now pregnant but haven’t notified your caseworker.
To find your caseworker, please call the Oregon Health Plan at 1-800-699-9075, TTY/ TDD 711.