Health Care Cost Coordination

HEALTH CARE COST NAVIGATION FOR PARENTS & CAREGIVERS

McKenzie Pediatrics, P.C.

2025

FOR PATIENTS/FAMILIES COVERED BY THE OREGON HEALTH PLAN

For families and children covered by the Oregon Health Plan (in Lane County, this means Trillium OHP or Pacific Source Community Solutions (PSCS), your benefits are set by the Oregon Health Authority.

Many services are available to you as an OHP member. How Oregon decides what services to pay for is based on the Prioritized List of Health Services. This list is made up of different medical conditions (called diagnoses) and the types of procedures that treat the conditions. A group of medical experts and ordinary citizens work together to develop the list. This group is called the Oregon Health Evidence Review Commission (HERC). They are appointed by the governor.

The list has combinations of all the conditions and their treatments. These are called condition/treatment pairs. The condition/treatment pairs are ranked on the list by how serious each condition is and how effective each treatment is.

For members under age 21: All medically necessary and medically appropriate services must be covered, based on your individual needs and medical history. This includes items �below the line� on the Prioritized List as well as services that don�t appear on the Prioritized List, like Durable Medical Equipment.

Learn more about the Prioritized List at: https://www.oregon.gov/oha/hsd/ohp/pages/prioritized-list.aspx

For Trillium members, learn more about Trillium OHP benefits at: www.trilliumohp.com

For PSCS members, learn more about PSCS OHP benefits at: www.PacificSource.com/Medicaid

Direct Access

You have �direct access� to providers when you do not need a referral or preapproval for a service. While some services do require a referral or preapproval, you always have direct access to emergency and urgent services. And if you need preapproval for a prescription, both Trillium OHP and PSCS pledge to make a decision within 24 hours, though if more information is needed to make a decision it can take 72 hours.

Services for children and adolescents that need preapproval include inpatient hospital services, inpatient substance use disorder residential and detox services, medication assisted treatment for substance use disorder, crowns, and root canal therapy on molars.

Services for children and adolescents that need a referral include specialist services, medication assisted treatment for substance use disorder, and dental care through a provider that is not your primary care dentist.

Physical health services that are available to you at no cost through McKenzie Pediatrics include:

�Care coordination services with your McKenzie Pediatrics health care team.
�Case management services through Trillium and PSCS, and through our Community Health Worker.
�Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services (0-20 years old)
�Immunizations
�Interpreter Services
�Preventive Services (routine health care: screenings, check-ups, and counseling to prevent illness, disease, or other health problems)
�Primary Care Provider visits
�Telehealth Services
�Traditional Health Worker/Community Health Worker services

Physical health services that are available to you outside of McKenzie Pediatrics include:

�Acupuncture
�Chiropractor
�Comfort Care & Hospice Services
�Diagnostic X-Rays (referral/order required, authorization not required)
�Diagnostic CTs and MRIs (referral/order required, and authorization required)
�Durable Medical Equipment (authorization required)
�Elective Surgeries/Procedures (authorization required)
�Emergency Medical Transportation
�Family Planning Services
�Gender Affirming Care (authorization required)
�Hearing Services (authorization required)
�Home Health Services (authorization required)
�Inpatient Hospital Services (may need preapproval)
�Laboratory Services (order required)
�Outpatient Hospital Services
�Pharmaceutical Services (some drugs may require authorization in addition to a prescription)
�Physical, Occupational, and Speech Therapy (referral required, and authorization required after 30 visits)
�Rides to Care (non-emergent medical transportation services)
�Routine Vision Services
�Sexual Abuse Exams
�Surgical Procedures (authorization required)
�Woman�s Health Services (including adolescent gynecologic care services)
�Travel Vaccines

Behavioral Health Assessment and Evaluation services are also available with no referral or preapproval. Please discuss with your provider or health care team how to access this service.

FOR PATIENTS/FAMILIES COVERED BY PRIVATE INSURANCE

McKenzie Pediatrics accepts MANY different private insurance plans, each of which has its own unique coverage, benefits, and policies. Our front office staff can verify coverage and determine the co-pay for a clinic visit, but generally it is the responsibility of the policyholder to know the full extent of their coverage.

McKenzie Pediatrics will not deny acute illness care due to an inability to pay a co-pay. However, we do require that a co-pay be paid at the time of well care, preventative, or consultative services. McKenzie Pediatrics follows the American Academy of Pediatrics Bright Futures and the EPSDT guidelines for well-care; private insurances are federally required to cover these services.

McKenzie Pediatrics is also very flexible and willing to work with families to establish payment plans so that care is not interrupted due to an unpaid prolonged outstanding balance. Our practice manager Amy Ward is available Mondays through Thursday to discuss payment plans, and to provide information regarding the cost of visits and treatments. We are also able to provide a menu of visit costs for those needing to pay out-of-pocket for services, and we offer a 20% discount if payment is made in full on the date of service.