Or. Admin. Code § 410-141-3500 - Definitions
(1) The following
definitions apply with respect to OAR chapter 410, division 141. The Oregon
Health Authority (Authority) also incorporates the definitions in OAR
410-120-0000,
309-032-0860 for any terms not
defined in this rule.
(2)
"Adjudication" means the act of a court or entity in authority when issuing an
order, judgment, or decree, as in a final Managed Care Entity (MCE) claims
decision or the Authority issuing a final hearings decision. For a final
Managed Care Entity (MCE) claims decision, the date of "Adjudication" is the
date on which an MCE has both (a) processed and (b) either paid or denied a
Member's claim for services.
(3)
"Aging and People with Disabilities (APD)" means the division in the Oregon
Department of Human Services (ODHS) that administers programs for seniors and
people with disabilities, as set forth in OAR
410-120-0000.
(4) "Area Agency on Aging (AAA)" means the
designated entity with which the ODHS contracts in planning and providing
services to elderly populations, as set forth in OAR
410-120-0000.
(5) "The Authority" means the Oregon Health
Authority (OHA).
(6) "Alternate
Format" means any alternate approach to presenting print information to an
individual with a disability. The Americans with Disabilities Act (ADA) groups
the standard alternate formats: braille, large (18 point) print, audio
narration, oral presentation, and electronic file along with other aids and
services for other disabilities, including sign language interpretation and
sighted guide; Centers for Medicare and Medicaid Services (CMS) Section 1557 of
the Affordable Care Act (ACA) outlines requirements for health plans and
providers on alternative formats.
(7) "Auxiliary Aids and Services" means
services available to members as defined in 45 Code of Federal Regulations
(CFR) Part 92.
(8) "Behavioral
Health" means mental health, mental illness, addiction disorders, and substance
use disorders.
(9) "Benefit Period"
means a period of time shorter than the five-year contract term, for which
specific terms and conditions in a contract between a coordinated care
organization and The Authority are in effect.
(10) "Business Day" means any day except
Saturday, Sunday, or a legal holiday. The word "day" not qualified as business
day means calendar day.
(11)
"Capitated Services" means those covered services that an Managed Care Entity
(MCE) agrees to provide for a capitation payment under contract with the
Authority.
(12) "Capitation
Payment" means monthly prepayment to an Managed Care Entity (MCE) for capitated
services to Managed Care Entity (MCE) members.
(13) "Care Coordination" means the act and
responsibility of CCOs to deliberately organize a members service, care
activities and information sharing among all participants involved with a
members care according to the physical, developmental, behavioral, dental and
social needs (including Health Related Social Needs and Social Determinants of
Health and Equity) of the member. Care Coordination requirements are described
in OAR 410-141-3860,
410-141-3865,
410-141-3870, and in accordance
with CFR 438.208.
(14) "Care Plan"
means a care plan that is developed for and in collaboration with the member,
their family, representatives or guardian; and in consultation with the
member's providers, community supports and services, where applicable, to
ensure continuity and coordination of a member's care according to their needs.
Care Plan requirements are described in OAR
410-141-3865 and
410-141-3870.
(15) "Care Profile" means the electronic
record a CCO develops and maintains for all members. The Care Profile is the
platform that receives feeds from different data sources used to identify,
track and manage a member's needs and risk level to direct the frequency of the
CCOs outreach and Care Coordination activities/opportunities that shall be
offered to the member. Care Profile requirements are further described in OAR
410-141-3865 and OAR
410-141-3870.
(16) "Care Setting Transitions" means a
transition between different locations, settings or levels of care.
(17) "Certificate of Authority" means the
certificate issued by Department of Consumer and Business Services (DCBS) to a
licensed health entity granting authority to transact insurance as a health
insurance company or health care service contractor.
(18) "Client" means an individual found
eligible to receive Oregon Health Plan (OHP) health services, whether or not
the individual is enrolled as an CCO member.
(19) "Community Advisory Council (CAC)" means
the CCO-convened council that meets regularly to ensure the CCO is addressing
the health care needs of CCO members and the community consistent with ORS
414.572 and in accordance with
criteria specified in ORS
414.575. CCOs shall seek an
opportunity for tribal participation on CACs to bring nominee(s) to the
attention of the CAC Selection Committee as follows:
(a) In a Service Area where only one (1)
federally recognized tribe exists, the CCO shall seek one (1) tribal
representative to serve on the CAC;
(b) In Service Areas where multiple federally
recognized tribes exist, the CCO shall seek one (1) tribal representative from
each tribe to serve on the CAC; and
(c) In metropolitan Service Areas where no
federally recognized tribe exists, CCOs shall solicit the Urban Indian Health
Program for a representative to serve on the CAC.
(20) "Community Benefit Initiatives" (CBI)
means community-level interventions focused on improving population health and
health care quality.
(21)
"Condition-Specific Program" and "Condition-Specific Facility" mean programs or
facilities that treat a narrowly defined illness, disorder or condition, such
as:
(a) Behavioral and Mental Health
conditions, Substance Use Disorder (SUD) or addiction, including but not
limited to;
(A) Alcohol;
(B) Illicit Drugs; and
(C) Gambling.
(b) Physical Health conditions, including but
not limited to:
(A) Cancer;
(B) Diabetes;
(C) Bariatric Care.
(c) Developmental Disabilities.
(22) "Continuous Inpatient Stay"
means an uninterrupted period of time that a patient spends as inpatient,
regardless of whether there have been changes in assigned specialty or facility
during the stay. This includes discharge transfer to another inpatient
facility, in or out of state, such as another acute care hospital, acute care
psychiatric hospital, skilled nursing facility, psychiatric residential
treatment facility (PRTF) or other residential facility for inpatient care and
services.
(23) "Contract" means an
agreement between the State of Oregon acting by and through The Authority and a
Managed Care Entity (MCE) to provide health services to eligible
members.
(24) "Coordinated Care
Organization (CCO)" means a corporation, governmental agency, public
corporation, or other legal entity that is certified as meeting the criteria
adopted by the Authority under ORS
414.572 to be accountable for
care management and to provide integrated and coordinated health care for each
of the organization's members.
(25)
"Coordinated Care Organization Payment or CCO Payment" means the monthly
payment to a Coordinated Care Organization (CCO) for services the CCO provides
to members in accordance with the global budget.
(26) "Coordinated Care Services" mean a
Managed Care Entity's (MCE) fully integrated physical, behavioral, dental and
social needs (including Health Related Social Needs and Social Determinants of
Health and Equity) services.
(27)
"Corrective Action" or "Corrective Action Plan (CAP)" means an
Authority-initiated request for a Managed Care Entity (MCE) or a Managed Care
Entity (MCE)-initiated request for a subcontractor to develop and implement a
time specific plan for the correction of identified areas of
noncompliance.
(28) "Culturally and
Linguistically Responsive and Appropriate Services" means the provision of
effective, equitable, understandable, and respectful quality care and services
that are responsive to diverse cultural beliefs and practices, preferred
languages, health literacy, and other communication needs. Culturally and
Linguistically appropriate services are further defined in
42 CFR §
59.2.
(29) "Delivery System Network (DSN)" means
the entirety of those Participating Providers who:
(a) Contracts with; or
(b) Are employed by, a CCO for purposes of
providing services to the Members of such CCO. "Provider Network" has the same
meaning.
(30) "Dental
Care Organization (DCO)" has the meaning as provided for in ORS
414.025
(24).
(31) "Dental Health" means conditions of the
mouth, teeth, and gums.
(32)
"Department" means the Oregon Department of Human Services (ODHS).
(33) "Department of Consumer and Business
Services (DCBS)" means Oregon's business regulatory and consumer protection
department.
(34) "Disenrollment"
means the act of removing a member from enrollment with an MCE.
(35) "Diversity of the workforce" refers to
the ethnic, racial, linguistic, gender, and social variation among members of
the health professional workforce. It is generally understood that a more
diverse workforce represents a greater opportunity for better quality health
care service, due to the array of life experiences and empathy of a mix of
providers that can be brought to the delivery of health care.
(36) "Downstream Entity" means any party that
enters into a written contract or other agreement with a CCO's subcontractor
pursuant to which such party performs one or more of the obligations of the
Subcontractor under the subcontractor's subcontract with the CCO. Regardless of
the number of parties that are downstream from a CCO's subcontractor, a party
is deemed a "downstream entity" of a CCO subcontractor if such party is,
pursuant to a written or oral contract or agreement, performing the obligations
the subcontractor is required to perform on behalf of the CCO under its
subcontract therewith.
(37)
"Encounter Data" means the information relating to the receipt of any item(s)
or service(s) by an enrollee under a contract between a State and a Managed
Care Entity (MCE) that is subject to the requirements of
42 CFR
438.242 and
42 CFR
438.818 and under OAR
410-141-3570 and related to
services that were provided to Members regardless of whether the services
provided:
(a) Were covered services,
non-covered services, or other Health-Related Social Needs services;
or
(b) Were not paid; or
(c) Paid for on a Fee- For-Service or
capitated basis; or
(d) Were
performed by a Participating Provider, Non-Participating Provider,
Subcontractor, or Contractor; and
(e) Were performed pursuant to Subcontractor
agreement, special arrangement with a facility or program, or other
arrangement.
(38)
"Enrollment" means the assignment of a member to a Managed Care Entity (MCE)
for management and coordination of health services.
(39) "Family Planning" means services that
enable individuals to plan and space the number of their children and avoid
unintended pregnancies. The Oregon Health Plan covers family planning services
for clients of childbearing age, including minors who are considered to be
sexually active. Family Planning services include:
(a) Annual exams;
(b) Contraceptive education and counseling to
address reproductive health issues;
(c) Prescription contraceptives (such as
birth control pills, patches or rings);
(d) IUDs and implantable contraceptives and
the procedures requires to inserted remove them;
(e) Injectable hormonal contraceptives (such
as Depo-Provera);
(f) Prescribed
pharmaceutical supplies and devices (such as male and female condoms,
diaphragms, cervical caps, and foams);
(g) Laboratory tests including appropriate
infectious disease and cancer screening;
(h) Radiology services;
(i) Medical and surgical procedures,
including vasectomies, tubal ligations and abortions.
(40) "Flexible Services" means those services
that are cost-effective services offered as an adjunct to covered
benefits.
(41) "Global Budget"
means the total amount of payment as established by the Authority to a CCO to
deliver and manage health services for its members including providing access
to and ensuring the quality of those services.
(42) "Grievance System" means the overall
system that includes:
(a) Grievances to a
Managed Care Entity (MCE) on matters other than adverse benefit
determinations;
(b) Appeals to a
Managed Care Entity (MCE) on adverse benefit terminations; and
(c) Contested case hearings through the
Authority on adverse benefit determinations and other matters for which the
member is given the right to a hearing by rule or statute.
(43) "Health Literacy" means the degree to
which individuals have the capacity to obtain, process, and understand basic
health information needed to make appropriate health decisions regarding
services needed to prevent or treat illness.
(44) "Health-Related Services (HRS)" means
non-covered services under Oregon's Medicaid State Plan intended to improve
care delivery and overall member and community health and well-being, as
defined in OAR 410-141-3845. Health-related
services include flexible services and community benefit initiatives.
(45) "Health Risk Assessment (HRA)" means a
survey or questionnaire administered verbally, digitally or in writing, to
collect information from a member, their representative or guardian about key
areas of their health, including their physical, developmental, behavioral,
dental and social needs (including Health Related Social Needs and Social
Determinants of Health). The HRA is intended to inform the coordination of
services and supports that meet the members individualized needs as described
in OAR 410-141-3860,
410-141-3865 and
410-141-3870.
(46) "Health System Transformation" means the
vision established by the Oregon Health Policy Board for reforming health care
in Oregon, including both the Oregon Integrated and Coordinated Health Care
Delivery System and reforms that extend beyond the context of Oregon Health
Plan (OHP).
(47) "Home CCO" means
the CCO enrollment situation that existed for a member prior to placement,
including services received through Oregon Health Plan (OHP) fee-for-service,
based on permanent residency.
(48)
"Indian" and/or "American Indian/Alaska Native (AI/AN)" means any individual
defined at 25 USC
1603(13),
1603(28), or
1679(a), or who
has been determined eligible as an Indian, under
42 CFR
136.12; or as defined under
42 CFR
438.14(a).
(49) "Indian Health Care Provider (IHCP)"
means a health care program operated by the Indian Health Service (IHS) or by
an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise
known as an I/T/U) as those terms are defined in section 4 of the Indian Health
Care Improvement Act (25
U.S.C. §
1603).
(50) "In Lieu of Service" (ILOS) means a
setting or service determined by the Authority to be a medically appropriate
and cost-effective substitute for a Covered Services consistent with provisions
in OAR 410-141-3820. The utilization
and actual cost of an ILOS is included in developing the components of the
Capitation Payment. In lieu of services must meet the requirements of
42 CFR
438.3(e)(2).
(51) "Individual with Limited English
Proficiency" means a person whose primary language for communication is not
English and who has a limited ability to read, write, speak, or understand
English.
(52) "Institution for
Mental Diseases (IMD)" means, as defined in
42 CFR §
435.1010, a hospital, nursing facility, or
other institution of more than 16 beds that is primarily engaged in providing
inpatient psychiatric services such as diagnosis, treatment, or care of
individuals with mental diseases, including medical attention, nursing care,
and related services. Its primary character is that of a facility established
and maintained primarily for the care and treatment of individuals with mental
diseases, whether or not it is licensed as such.
(53) "Legal Holiday" means the days described
in ORS 187.010 and
187.020.
(54) "Licensed Health Entity" means a Managed
Care Entity (MCE) that has a Certificate of Authority issued by DCBS as a
health insurance company or health care service contractor.
(55) "Managed Care Entity (MCE)" is a general
term that means an entity that enters into one or more contracts with the
Authority to provide services in a managed care delivery system, including but
not limited to the following types of entities defined in and subject to 42 CFR
Part 438 : managed care organizations (MCOs), primary care case managers
(PCCMs), prepaid ambulatory health plans (PAHPs), and prepaid inpatient health
plans (PIHPs). A CCO is an MCE for its managed care contract(s) with the
Authority, without regard to whether the contract(s) involves federal funds or
state funds or both.
(56) "Managed
Care Organization (MCO)" is a specific term that means an MCE defined in 42 CFR
Part 438. A CCO is an MCO for its managed care contract(s) subject to federal
managed care requirements specified in 42 CFR Part 438.
(57) "Material Change to Delivery System"
means:
(a) Any change to the CCO's Delivery
System Network (DSN) that may result in more than five (5) percent of either
its total Members or its Members in a county changing the physical location(s)
of where services are received; or
(b) Any change to CCO's DSN that may likely
affect less than five (5) percent of its Members but involves a Provider or
Provider group that is the sole provider specialty type within the overall
Provider Network or is the sole provider specialty type with a practice within
a county in the CCO's service area; or
(c) Any change in CCO's overall operations
that affects its ability to meet a required DSN standard including, but not
limited to: termination or loss of a Provider or Provider group, or any change
likely to affect more than five (5) percent of CCO's total Members or Provider
Network or both; or
(d) Any
combination of the above changes.
(58) "Medicaid-Funded Long-Term Services and
Supports (LTSS)" means all Medicaid funded services CMS defines as long-term
services and supports, including both:
(a)
"Long-term Care," the system through which the Department of Human Services
provides a broad range of social and health services to eligible adults who are
aged, blind, or have disabilities for extended periods of time. This includes
nursing homes and behavioral health care outlined in OAR chapter 410, division
172 Medicaid Payment for Behavioral Health Services, including state
psychiatric hospitals;
(b) "Home
and Community-Based Services," the Medicaid services and supports provided
under a CMS-approved waiver to avoid institutionalization as defined in OAR
chapter 411, division 4 and defined as Home and Community-Based Services (HCBS)
and as outlined in OAR chapter 410, division 172 Medicaid Payment for
Behavioral Health Services.
(59) "Member" means an Oregon Health Plan
(OHP) client enrolled with a CCO.
(60) "Member Representative" means an
individual who can make Oregon Health Plan (OHP)-related decisions for a member
who is not able to make such decisions themselves.
(61) "National Association of Insurance
Commissioners (NAIC)" means the U.S. standard-setting and regulatory support
organization created and governed by the chief insurance regulators from the 50
states, the District of Columbia, and five U.S. territories.
(62) "Non-Participating Provider" means a
provider that does not have a contractual relationship with an MCE and is not
on their panel of providers.
(63)
"Ombudsperson Services" means patient advocacy services available through the
Authority for clients who are concerned about access to, quality of, or
limitations in the health services provided.
(64) "Oregon Health Plan (OHP)" means
Oregon's Medicaid program or related state-funded health programs. Any OHP
contract shall identify whether it concerns Oregon's Medicaid program or a
related state-funded health program, or both.
(65) "Oregon Integrated and Coordinated
Health Care Delivery System" means the set of state policies and actions that
promote integrated care delivery by CCOs to OHP clients, pursuant to ORS
414.570.
(66) "Participating Provider" means a
provider that has a contractual relationship with an MCE. A Participating
Provider is not a Subcontractor solely by virtue of a Participating Provider
agreement with an MCE. "Network Provider" has the same meaning as Participating
Provider.
(67) "Patient-Centered
Primary Care Home (PCPCH)" means a recognized clinic that takes a patient and
family-centered approach to all aspects of care. PCPCHs work with the member
and their health care team to improve and coordinate care and help to eliminate
repetitive procedures. As defined in ORS
414.655, meets the standards
pursuant to OAR 409-055-0040, and has been
recognized through the process pursuant to OAR
409-055-0040 and means the
definition as set forth in OAR
409-055-0010.
(68) "Permanent Residency" means the county
code-zip code combination of the physical residence in which the member/client
lived, as found in the benefit source system, prior to placement and to which
the member/client is expected to return to after placement ends.
(69) "Plan Type" means the designation used
by the Authority to identify which health care services covered by a client's
OHP Plus or equivalent benefit package are paid by a CCO, by the Authority's
fee-for-service program, or both. If a client does not have a plan type
designation, then all of the client's health care services are paid by the
fee-for-service program. Regardless of plan type, some health care services are
carved out from CCOs by contract or rule and are instead paid by the
fee-for-service program. The plan type designations are as follows:
(a) CCOA: Physical, dental, and behavioral
health services are paid by the client's CCO;
(b) CCOB: Physical and behavioral health
services are paid by the client's CCO. Dental services are paid the
fee-for-service program;
(c) CCOE:
Behavioral health services are paid by the client's CCO. Physical health and
dental services are paid by the fee-for-service program;
(d) CCOF: Dental services are paid by the
client's CCO. Physical health and behavioral health services are paid by the
fee-for-service program, except for individuals receiving dental services
through the Compact of Free Association (COFA) Dental Program or the Veteran
Dental Program defined in OAR chapter 141, division 120. Any reference to CCOF
means the benefit package covers dental services only; and
(e) CCOG: Dental and behavioral health
services are paid by the client's CCO. Physical health services are paid by the
fee-for-service program.
(70) "Post Hospital Extended Care Services"
(PHECS). Consistent with 42
USC §
1395x(i), PHECS
means extended care services furnished an individual after transfer from a
hospital in which a member was an inpatient for not less than three (3)
consecutive days before discharge from the hospital in connection with such
transfer. For purposes of the preceding sentence, items and services shall be
deemed to have been furnished to a member after transfer from a hospital, and
the member shall be deemed to have been an inpatient in the hospital
immediately before transfer there from, if the member is admitted to the
skilled nursing facility:
(a) Within thirty
(30) days after discharge from such hospital; or
(b) Within such time as it may be medically
appropriate to begin an active course of treatment, in the case of an
individual whose condition is such that skilled nursing facility care may not
be medically appropriate within thirty (30) days after discharge from a
hospital; and
(c) An individual
shall be deemed not to have been discharged from a skilled nursing facility if,
within thirty (30) days after discharge therefrom, the member is admitted to
such facility or any other skilled nursing facility.
(71) "Potential Member" means an individual
who meets the eligibility requirements to enroll in the Oregon Health Plan but
has not yet enrolled with a specific MCE.
(72) "Primary Care Provider (PCP)" means an
enrolled medical assistance provider who has responsibility for supervising,
coordinating, and providing initial and primary care within their scope of
practice for identified clients. PCPs are health professionals who initiate
referrals for care outside their scope of practice, consultations, and
specialist care, and assure the continuity of medically appropriate client
care. PCPs include:
(a) The following provider
types: physician, naturopath, nurse practitioner, physician associate or other
health professional licensed or certified in this state, whose clinical
practice is in the area of primary care;
(b) A health care team or clinic certified by
the Authority as a PCPCH as defined in OAR
409-055-0010 and OAR
410-120-0000.
(73) "Provider" means an
individual, facility, institution, corporate entity, or other organization
that:
(a) Is engaged in the delivery of
services or items or ordering or referring for those services or items;
or
(b) Bills, obligates, and
receives reimbursement from the Authority's Health Services Division on behalf
of a Provider, (and also termed a "Billing Provider"); and
(c) Supplies health services or items (also
termed a "Rendering Provider").
(74) "Readily Accessible" means electronic
information and services that comply with modern accessibility standards such
as section 508 guidelines, section 504 of the Rehabilitation Act, and W3C's Web
Content Accessibility Guidelines (WCAG) 2.0 AA and successor
versions.
(75) "Service Area" means
the geographic area within which the MCE agreed under contract with the
Authority to provide health services.
(76) "Serious Emotional Disorder" (SED) means
a subpopulation of individuals under age 21 who meet the following criteria:
(a) An infant, child or youth, between the
ages of birth to 21 years of age; and
(b) Must meet criteria for diagnosis,
functional impairment and duration:
(A)
Diagnosis: The infant, child or youth must have an emotional, socio-emotional,
behavioral or mental disorder diagnosable under the DSM-5 or its ICD-10-CM
equivalents, or subsequent revisions (with the exception of DSM "V" codes,
substance use disorders and developmental disorders, unless they co-occur with
another diagnosable serious emotional, behavioral, or mental disorder):
(i) For children three (3) years of age or
younger. The child or youth must have an emotional, socio-emotional, behavioral
or mental disorder diagnosable under the Diagnostic Classification of Mental
Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC:
0-3R) (or subsequent revisions);
(ii) For children four (4) years of age and
older. The child or youth must have an emotional, socio-emotional, behavioral
or mental disorder diagnosable under the Diagnostic Interview Schedule for
Children (DISC) or DSM-5 or its ICD-10-CM equivalents, or subsequent revisions
(with the exception of DSM "V" codes, substance use disorders and developmental
disorders, unless they co-occur with another diagnosable serious emotional,
behavioral, or mental disorder).
(B) Functional impairment: An individual is
unable to function in the family, school or community, or in a combination of
these settings; or the level of functioning is such that the individual
requires multi-agency intervention involving two or more community service
agencies providing services in the areas of mental health, education, child
welfare, juvenile justice, substance abuse, or primary health care;
(C) Duration: The identified disorder and
functional impairment must have been present for at least one (1) year or, on
the basis of diagnosis, severity or multi-agency intervention, is expected to
last more than one (1) year.
(77) Social Determinants of Health and Equity
(SDOH-E) has the meaning provided for in OAR
410-141-3735.
(78) "Special Health Care Needs" means
individuals who have high health care needs, multiple chronic conditions,
mental illness or substance use disorders and either:
(a) Have functional disabilities;
(b) Live with health or social conditions
that place them at risk of developing functional disabilities (for example,
serious chronic illnesses, or certain environmental risk factors such as
homelessness or family problems that lead to the need for placement in foster
care), or
(c) Are a Prioritized
Population member. This includes members who:
(A) Are older adults, individuals who are
hard of hearing, deaf, blind, or have other disabilities;
(B) Have complex or high health care needs,
or multiple or chronic conditions, or SPMI, or are receiving Medicaid-funded
long-term care services and supports (LTSS);
(C) Are children ages 0-5:
(i) Showing early signs of social/emotional
or behavioral problems; or
(ii)
Have a Serious Emotional Disorder (SED) diagnosis.
(D) Are in medication assisted treatment for
SUD;
(E) Are women who have been
diagnosed with a high-risk pregnancy;
(F) Are children with neonatal abstinence
syndrome;
(G) Children in Child
Welfare;
(H) Are IV drug
users;
(I) People with SUD in need
of withdrawal management;
(J) Have
HIV/AIDS or have tuberculosis;
(K)
Are veterans and their families;
(L) Are at risk of first episode
psychosis;
(M) Individuals within
the Intellectual and developmental disability (IDD) populations.
(79) "Subcontract"
means either:
(a) A contract between a CCO and
a subcontractor pursuant to which such subcontractor is obligated to perform
certain work that is otherwise required to be performed by the CCO under its
contract with the State; or
(b) Is
the infinitive form of the verb "to Subcontract", i.e. the act of delegating or
otherwise assigning to a Subcontractor certain work required to be performed by
an MCE under its contract with the State.
(80) "Subcontractor" means an individual or
entity that has a contract with an MCE that relates directly or indirectly to
the performance of the MCE's obligations under its contract with the State. A
Participating Provider is not a Subcontractor solely by virtue of having
entered into a Participating Provider agreement with an MCE.
(81) "Transition of Care" applies to Medicaid
members who are enrolled in a CCO ("the receiving CCO") immediately after
disenrollment from a "predecessor plan" which may be another CCO (including
disenrollment resulting from termination of the predecessor CCO's contract) or
Medicaid fee-for-service (FFS). Transition of Care does not apply to a member
who is ineligible for Medicaid or who has a gap in coverage following
disenrollment from the predecessor plan. Meets the standards pursuant to OAR
410-141-3850."
(82) "Trauma Informed Approach" means
approach undertaken by providers and healthcare or human services programs,
organizations, or systems in providing mental health and substance use
disorders treatment wherein there is a recognition and understanding of the
signs and symptoms of trauma in, and the intensity of such trauma on,
individuals, families, and others involved within a program, organization, or
system and then takes into account those signs, symptoms, and their intensity
and fully integrating that knowledge when implementing and providing potential
paths for recovery from mental health or substance use disorders. The Trauma
Informed Approach also means that providers and healthcare or human services
programs, organizations, or systems and actively resist re-traumatization of
the individuals being served within their respective entities.
(83) "Temporary Placement" means, for
purposes of this rule, hospital, institutional, and residential placement only,
including those placements occurring inside or outside of the service area with
the expectation to return to the Home CCO service area.
(84) "Trauma-informed services" means those
services provided using a Trauma Informed Approach.
(85) "Treatment Plan" means a documented plan
that describes the patient's condition and procedures that shall be needed,
detailing the treatment to be provided and expected outcome and expected
duration of the treatment prescribed by the health care professional. This
therapeutic strategy shall be designed in collaboration with the member, the
member's family, or the member's representative.
(86) "Urban Indian Health Program" (UIHP)
means an urban Indian organization as defined in section 1603 of Title 25 that
has an IHS Title V contract as described in section 1653 of Title 25.
(87) "Workforce diversity capacity" means the
organization's ability to foster an environment where diversity is commonplace
and enhances execution of the organization's objectives. It means creating a
workplace where differences demographics and culture are valued, respected and
used to increase organizational capacity.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
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