Current through Register Vol. 60, No. 12, December 1, 2021
(1) The following
definitions apply with respect to OAR chapter 410, division 141. The Authority
also incorporates the definitions in OAR 410-120-0000, 309-032-0860 for any
terms not defined in this rule.
"Adjudication" means the act of a court or entity in authority when issuing an
order, judgment, or decree, as in a final MCE claims decision or the Authority
issuing a final hearings decision.
(3) "Aging and People with Disabilities
(APD)" means the division in the Department of Human Services (Department) that
administers programs for seniors and people with disabilities, as set forth in
(4) "Area Agency
on Aging (AAA)" means the designated entity with which the Department contracts
in planning and providing services to elderly populations, as set forth in OAR
(5) "The Authority"
means the Oregon Health Authority.
(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; CMS Section 1557 of
the ACA outlines requirements for health plans and providers on alternative
"Auxiliary Aids and
Services" means services available to members as defined in 45
(8) "Behavioral Health" means
mental health, mental illness, addiction disorders, and substance use
(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 Oregon Health 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.
"Capitated Services" means those covered services that an MCE agrees to provide
for a capitation payment under contract with the Authority.
(12) "Capitation Payment" means monthly
prepayment to an MCE for capitated services to MCE members.
"Care Plan" means a documented plan that
addresses the supportive, therapeutic, cultural, and linguistic health of a
member. The member's care plan shall be developed for in collaboration with the
Member and the Member's family or representative, and, if applicable, the
Member's caregiver so that it incorporates their preferences and goals to
ensure engagement and satisfaction. Care plans include, without limitation:
(a) prioritized goals for a member's
interventions and resources that will benefit and support the member's goals
such as peer support, non-traditional services, community services, employment
and housing support;
(d) monitoring and
Payment" means the monthly payment to a CCO for services the CCO provides to
members in accordance with the global budget.
(15) "Certificate of Authority" means the
certificate issued by DCBS to a licensed health entity granting authority to
transact insurance as a health insurance company or health care service
(16) "Client" means an
individual found eligible to receive OHP health services, whether or not the
individual is enrolled as an MCE member.
"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
CCOs shall afford an opportunity for tribal participation on CACs as follows:
(a) In CCO service areas where only one
federally recognized tribe exists, the tribe shall appoint one tribal
representative to serve on the CAC;
(b) In CCO service areas where multiple
federally recognized tribes exist, each tribe shall appoint a tribal
representative to serve on the CAC to ensure full representation of all tribes
within the service area;
metropolitan CCO service areas where no federally recognized tribe exists, CCOs
shall solicit the Urban Indian Health Program for a representative to serve on
Benefit Initiatives" (CBI) means community-level interventions focused on
improving population health and health care quality.
(19) "Contract" means an agreement between
the State of Oregon acting by and through the Authority and an MCE to provide
health services to eligible members.
(20) "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
to be accountable for care management and to provide integrated and coordinated
health care for each of the organization's members.
(21) "Coordinated Care Services" mean an
MCE's fully integrated physical health, behavioral health services, and oral
Action" or "Corrective Action Plan" means an Authority-initiated request for an
MCE or an MCE-initiated request for a subcontractor to develop and implement a
time specific plan for the correction of identified areas of
Organization (DCO)" means a prepaid managed care health services organization
that contracts, on a capitated basis, with the Authority under ORS
or with a coordinated care organization, or both with the Authority and a
coordinated care organization, to provide dental services to medical assistance
recipients. Dental Care Organization also meets the definition of a Prepaid
Ambulatory Health Plan as defined under
(24) "The Department" means the Department of
of Consumer and Business Services (DCBS)" means Oregon's business regulatory
and consumer protection department.
(26) "Disenrollment" means the act of
removing a member from enrollment with an MCE.
(27) "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.
(28) "Enrollment" means the assignment of a
member to an MCE for management and coordination of health services.
"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 insert and remove them;
(e) Injectable hormonal contraceptives (such
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.
(30) "Flexible Services" means those services
that are cost-effective services offered as an adjunct to covered
(31) "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.
"Grievance System" means the overall
system that includes:
(a) Grievances to an
MCE on matters other than adverse benefit determinations;
(b) Appeals to an MCE on adverse benefit
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
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
Services" 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.
(35) "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 OHP.
(36) "Holistic Care" means incorporating the
care of the entire member in all aspects of well-being including physical,
psychological, cultural, linguistic, and social and economic needs of the
member. Holistic care utilizes a process whereby providers work with members to
guide their care and identify needs. This also involves identifying with
principles of holism in a system of therapeutics, such as the practices of
naturopathy or chiropractic and often involving nutritional measures.
(37) "Home CCO" means the CCO enrollment
situation that existed for a member prior to placement, including services
received through OHP fee-for-service, based on permanent residency.
"Indian" and/or "American Indian/Alaska
Native (AI/AN)" means any individual defined at
or who has been determined eligible as an Indian, under
; or as defined under
"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. §
"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
(41) "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
Mental Diseases (IMD)" means, as defined in
42 CFR §
, 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.
(43) "Intensive Care Coordination" (ICC)
refers to the specialized services described in OAR 410-141-3870. These
services have, in other contexts, been labeled Exceptional Needs Care
(44) "Legal Holiday"
means the days described in ORS
(45) "Licensed Health Entity" means an MCE
that has a Certificate of Authority issued by DCBS as a health insurance
company or health care service contractor.
(46) "Managed Care Entity (MCE)" means, an
entity that enters into a contract to provide services in a managed care
delivery system, including but not limited to managed care organizations,
prepaid health plans, primary care case managers and Coordinated Care
(47) "Managed Care
Organization (MCO)" means a contracted health delivery system providing
capitated or prepaid health services, also known as a Prepaid Health Plan
(PHP). An MCO is responsible for providing, arranging, and making reimbursement
arrangements for covered services as governed by state and federal law. An MCO
may be a Chemical Dependency Organization (CDO), Dental Care Organization
(DCO), or Physician Care Organization (PCO).
"Medicaid-Funded Long-Term Services and
Supports (LTSS)" means all Medicaid funded services CMS defines as long-term
services and supports, including both:
"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
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.
(49) "Member" means an OHP client enrolled
with an MCE.
Representative" means an individual who can make OHP-related decisions for a
member who is not able to make such decisions themselves.
(51) "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.
(52) "Non-Participating Provider" means a
provider that does not have a contractual relationship with an MCE and is not
on their panel of providers.
"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.
(54) "Oral Health" means conditions of the
mouth, teeth, and gums.
"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
(56) "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
(57) "Participating Provider"
means a provider that has a contractual relationship with an MCE and is on
their panel of providers.
"Participating Provider Organization" means a group practice, facility, or
organization that has a contractual relationship with an MCE and is on the
MCE's panel and;
(a) An employer of a
provider, if the provider is required as a condition of employment to turn over
fees to the employer; or
facility in which the service is provided, if the provider has a contract under
which the facility submits claims; or
(c) A foundation, plan, or similar
organization operating an organized health care delivery system, if the
provider has a contract under which the organization submits the
(d) Such group practice,
facility, or organization is enrolled with the Authority, and payments are made
to the group practice, facility, or organization; and
(e) An agent if such entity solely submits
billings on behalf of providers and payments are made to each
"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.
(60) "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.
"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 assistant
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 409-027-0005 and OAR
"Provider" means, pursuant to OAR 410-120-0000, an individual, facility,
institution, corporate entity, or other organization that supplies health
services or items, also termed a rendering provider, or bills, obligates, and
receives reimbursement on behalf of a rendering provider of services, also
termed a billing provider (BP). The term provider refers to both rendering
providers and BP unless otherwise specified.
"Provider Organization" means a group
practice, facility, or organization that is:
(a) An employer of a provider, if the
provider is required as a condition of employment to turn over fees to the
(b) The facility in
which the service is provided, if the provider has a contract under which the
facility submits claims; or
foundation, plan, or similar organization operating an organized health care
delivery system, if the provider has a contract under which the organization
submits the claim;
(d) Such group
practice, facility, or organization is enrolled with the Authority, and
payments are made to the group practice, facility, or organization;
(e) An agent if such entity
solely submits billings on behalf of providers and payments are made to each
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.
"Service Area" means the geographic area within which the MCE agreed under
contract with the Authority to provide health services.
"Serious Emotional Disorder" (SED) means
a subpopulation of individuals under age 21 who meet the following criteria:
(a) A child or youth, between the ages of
birth to 21 years of age; and
Must meet criteria for diagnosis, functional impairment and duration:
Diagnosis: The 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):
children 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 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 1 year or, on the
basis of diagnosis, severity or multi-agency intervention, is expected to last
more than 1 year.
"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
(c) Are a Member of the
Prioritized Populations as defined in 410-141-3870.
"Subcontract" means either:
(a) A contract between an MCE and a
subcontractor pursuant to which such subcontractor is obligated to perform
certain work that is otherwise required to be performed by the MCE under its
contract with the State, or
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.
(69) "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
(70) "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
"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.
"Trauma-informed services" means those services provided using a Trauma
Plan" means a documented plan that describes the patient's condition and
procedures that will 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
(74) "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.
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