Parents tell us...
"Why is this so complicated?"
"I had no idea Oregon had a department to help solve insurance issues."
"My teen turns 18 soon. How can I keep him on our insurance?"
"Welcome to my other part-time job: Insurance Appeals Expert."
Where to get insurance
If you don’t have insurance through an employer, the Oregon Health Authority can connect you with trained insurance assistors and community partners to help you find an affordable plan. They can help you find out if your child qualifies for the Oregon Health Plan too.
If your child qualifies for Community Developmental Disability Programs, they may be eligible for the Oregon Health Plan as secondary coverage. Speak to your child's case manager about this.
If your child is an American Indian or Alaskan Native, they are eligible for Indian health services.
How does insurance work?
Insurance is complicated but necessary for you to understand. We have provided some great resources to learn the basics.
Consumer reports: Understanding health insurance
Health Service Resource Administration: "From Coverage to Care"
Healthcare.gov: What is a summary of benefits?
Healthcare.gov: Comparing insurance plans
Healthcare.gov: Re-enrolling or changing insurance in the middle of the year
Family Voices: Insurance Jargon
Who can help me coordinate my child's health care?
If your child has Oregon Health Plan OHP and requires a lot of providers, medications, or appointments, you may be eligible for help coordinating that care from an "Exceptional needs care coordinator", "Intensive care manager", or" Community health worker". You can also ask for a "Family peer support worker", who is a trained family member and will understand what you are going through. See our OR F2F HIC tip sheet: Getting to know your ENCC provider for instructions on how to request care coordination help.
Most plans that are not OHP also provide help. Call the number on your child's insurance card and ask? "Is there is someone who can provide care coordination?" Some medical home primary care offices also offer care coordination.
What if I need to appeal an insurance denial?
Insurance sometimes does not cover what you think it should. You have a right to appeal the insurer's decision. Many families succeed in their appeals. You should involve your health care provider to make your case. Sometimes all it takes is for the provider to submit the bill with a different code for services.
This guide from the Patient Advocate Foundation: A Patient's Guide to Navigating the Insurance Appeals Process can tell you more.
For appeals in the state of Oregon. Consumer Guide to Health Insurance Appeals (440-5184) (oregon.gov)
Below are some general guidelines for appealing an insurance decision, but call us for more detailed information based on your specific situation.
First, make sure you have a denial in writing. Only a representative from your insurance company can issue a denial. If you have the Oregon Health Plan, you will receive that denial in writing in the mail.
Second, call your insurance company's customer service line. You may be on hold for a while, but be persistent and have the denied claim in front of you so you are ready to talk when you are connected. Always write down or record what is said and the name of the person you spoke with. This insurance problem tracker sheet is useful in keeping track of who said what.
Third, if the customer service line does not resolve the problem, there is still help. In order to get the right people to help you, you must know the type of plan your child has. Some of the main types of insurance are:
- Oregon health plan (Medicaid)
- Group plans
- Individual plans
- Self-insured plans
- Military insurance
- Indian Health Services
If your employer pays for your insurance plan, it is probably a "group plan". If you work for a big company or institution that you might have a "self-insured plan". You can find out which type you have by asking the human resources department at your company. Some resources for help are below. If you need more help 855-323-6744 (English) or 503-931-8930 (Spanish).
Oregon Department of Consumer and Business Services: DCBS can help you with group plans or a plan you purchased from the Oregon Marketplace. Call 1-888-877-4894 (toll-free) or e-mail email@example.com.
US Department of Labor Employee Benefits Advisor: EBSA can help you with self-insured plans or call 206-757-6632.
If your child's plan is from the Oregon Health Plan, you have several places to get help. Start with your Coordinated Care Organization's Customer Service Department. If you need more help, call us at 855-323-6744 or 503-931-8930 (Spanish)
Fourth, if you request a hearing. There are advocates who help you understand the hearing process. They will help you gather all of the information you need to make your case, and make sure that the insurance company followed all of the procedures around your claim. Call us if you need help finding an advocate.
Double or dual coverage
Many families with special health care needs have children with two insurance plans. For example, children who receive Community Developmental Disability Program services may have OHP, as well as a policy from their parents' work. Or, if both parents have insurance through their work, the child may be on both plans. Double coverage is good because, it saves you on deductibles, co-pays and out of pocket expenses, but it can get confusing. Almost always, when there are two policies, the private insurance pays first and then OHP pays second. If you have two insurance plans, it is important to let your providers know which insurance pays first and which one pays second. If you do not know which one pays first, contact your employer's human resources department.
Resources for those with no insurance
You may be able to get some health, mental health, or dental care from one of the following resources:
County public health departments
Community health fairs may offer free screenings or care on a first-come first-served basis. To find a health fair, you can contact your county public health department or dial 211info
Employee Assistance Programs (EAP): Ask your employer if it provides an EAP. EAPs offer free or reduced-cost mental health services for employees and families.
Many hospitals and clinics offer discounts, so before any procedure, ask for a financial screening to see if you qualify.
More tips can be found on the OR F2F HIC tip sheet: When Insurance Won't Pay
Inclusion of resources on our site does not imply endorsement nor does exclusion mean we do not think it is valuable. We work to keep our list of resources current and relevant but it is not exhaustive.
If you have any questions call or email us tel. 855-323-6744 (English) o 833-990-9930 (español) firstname.lastname@example.org