ORS Chapter 414 — Medical Assistance

ORS 414.025. Definitions for ORS chapters 411, 413 and 414. As used in this chapter and ORS chapters 411 and 413, unless the context or a specially applicable statutory definition requires otherwise: (1)(a) Alternative payment methodology means a payment other than a fee-for-services payment, used by coordinated care organizations as compensation for the provision of integrated and coordinated health care and services. (b) Alternative payment methodology includes, but is not limited to: (A) Shared savings arrangements; (B) Bundled payments; and (C) Payments based on episodes. (2) Behavioral health assessment means an evaluation by a behavioral health clinician, in person or using telemedicine, to determine a patients need for immediate crisis stabilization. (3) Behavioral health clinician means: (a) A licensed psychiatrist; (b) A licensed psychologist; (c) A licensed nurse practitioner with a specialty in psychiatric mental health; (d) A licensed clinical social worker; (e) A licensed professional counselor or licensed marriage and family therapist; (f) A certified clinical social work associate; (g) An intern or resident who is working under a board-approved supervisory contract in a clinical mental health field; or (h) Any other clinician whose authorized scope of practice includes mental health diagnosis and treatment. (4) Behavioral health crisis means a disruption in an individuals mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individuals mental or physical health. (5) Behavioral health home means a mental health disorder or substance use disorder treatment organization, as defined by the Oregon Health Authority by rule, that provides integrated health care to individuals whose primary diagnoses are mental health disorders or substance use disorders. (6) Category of aid means assistance provided by the Oregon Supplemental Income Program, aid granted under ORS 411.877 to 411.896 and 412.001 to 412.069 or federal Supplemental Security Income payments. (7) Community health worker means an individual who meets qualification criteria adopted by the authority under ORS 414.665 and who: (a) Has expertise or experience in public health; (b) Works in an urban or rural community, either for pay or as a volunteer in association with a local health care system; (c) To the extent practicable, shares ethnicity, language, socioeconomic status and life experiences with the residents of the community the worker serves; (d) Assists members of the community to improve their health and increases the capacity of the community to meet the health care needs of its residents and achieve wellness; (e) Provides health education and information that is culturally appropriate to the individuals being served; (f) Assists community residents in receiving the care they need; (g) May give peer counseling and guidance on health behaviors; and (h) May provide direct services such as first aid or blood pressure screening. (8) Coordinated care organization means an organization meeting criteria adopted by the Oregon Health Authority under ORS 414.572. (9) Dually eligible for Medicare and Medicaid means, with respect to eligibility for enrollment in a coordinated care organization, that an individual is eligible for health services funded by Title XIX of the Social Security Act and is: (a) Eligible for or enrolled in Part A of Title XVIII of the Social Security Act; or (b) Enrolled in Part B of Title XVIII of the Social Security Act. (10)(a) Family support specialist means an individual who meets qualification criteria adopted by the authority under ORS 414.665 and who provides supportive services to and has experience parenting a child who: (A) Is a current or former consumer of mental health or addiction treatment; or (B) Is facing or has faced difficulties in accessing education, health and wellness services due to a mental health or behavioral health barrier. (b) A family support specialist may be a peer wellness specialist or a peer support specialist. (11) Global budget means a total amount established prospectively by the Oregon Health Authority to be paid to a coordinated care organization for the delivery of, management of, access to and quality of the health care delivered to members of the coordinated care organization. (12) Health insurance exchange or exchange means an American Health Benefit Exchange described in 42 U.S.C. 18031, 18032, 18033 and 18041. (13) Health services means at least so much of each of the following as are funded by the Legislative Assembly based upon the prioritized list of health services compiled by the Health Evidence Review Commission under ORS 414.690: (a) Services required by federal law to be included in the states medical assistance program in order for the program to qualify for federal funds; (b) Services provided by a physician as defined in ORS 677.010, a nurse practitioner licensed under ORS 678.375, a behavioral health clinician or other licensed practitioner within the scope of the practitioners practice as defined by state law, and ambulance services; (c) Prescription drugs; (d) Laboratory and X-ray services; (e) Medical equipment and supplies; (f) Mental health services; (g) Chemical dependency services; (h) Emergency dental services; (i) Nonemergency dental services; (j) Provider services, other than services described in paragraphs (a) to (i), (k), (L) and (m) of this subsection, defined by federal law that may be included in the states medical assistance program; (k) Emergency hospital services; (L) Outpatient hospital services; and (m) Inpatient hospital services. (14) Income has the meaning given that term in ORS 411.704. (15)(a) Integrated health care means care provided to individuals and their families in a patient centered primary care home or behavioral health home by licensed primary care clinicians, behavioral health clinicians and other care team members, working together to address one or more of the following: (A) Mental illness. (B) Substance use disorders. (C) Health behaviors that contribute to chronic illness. (D) Life stressors and crises. (E) Developmental risks and conditions. (F) Stress-related physical symptoms. (G) Preventive care. (H) Ineffective patterns of health care utilization. (b) As used in this subsection, other care team members includes but is not limited to: (A) Qualified mental health professionals or qualified mental health associates meeting requirements adopted by the Oregon Health Authority by rule; (B) Peer wellness specialists; (C) Peer support specialists; (D) Community health workers who have completed a state-certified training program; (E) Personal health navigators; or (F) Other qualified individuals approved by the Oregon Health Authority. (16) Investments and savings means cash, securities as defined in ORS 59.015, negotiable instruments as defined in ORS 73.0104 and such similar investments or savings as the department or the authority may establish by rule that are available to the applicant or recipient to contribute toward meeting the needs of the applicant or recipient. (17) Medical assistance means so much of the medical, mental health, preventive, supportive, palliative and remedial care and services as may be prescribed by the authority according to the standards established pursuant to ORS 414.065, including premium assistance under ORS 414.115 and 414.117, payments made for services provided under an insurance or other contractual arrangement and money paid directly to the recipient for the purchase of health services and for services described in ORS 414.710. (18) Medical assistance includes any care or services for any individual who is a patient in a medical institution or any care or services for any individual who has attained 65 years of age or is under 22 years of age, and who is a patient in a private or public institution for mental diseases. Except as provided in ORS 411.439 and 411.447, medical assistance does not include care or services for a resident of a nonmedical public institution. (19) Patient centered primary care home means a health care team or clinic that is organized in accordance with the standards established by the Oregon Health Authority under ORS 414.655 and that incorporates the following core attributes: (a) Access to care; (b) Accountability to consumers and to the community; (c) Comprehensive whole person care; (d) Continuity of care; (e) Coordination and integration of care; and (f) Person and family centered care. (20) Peer support specialist means any of the following individuals who meet qualification criteria adopted by the authority under ORS 414.665 and who provide supportive services to a current or former consumer of mental health or addiction treatment: (a) An individual who is a current or former consumer of mental health treatment; or (b) An individual who is in recovery, as defined by the Oregon Health Authority by rule, from an addiction disorder. (21) Peer wellness specialist means an individual who meets qualification criteria adopted by the authority under ORS 414.665 and who is responsible for assessing mental health and substance use disorder service and support needs of a member of a coordinated care organization through community outreach, assisting members with access to available services and resources, addressing barriers to services and providing education and information about available resources for individuals with mental health or substance use disorders in order to reduce stigma and discrimination toward consumers of mental health and substance use disorder services and to assist the member in creating and maintaining recovery, health and wellness. (22) Person centered care means care that: (a) Reflects the individual patients strengths and preferences; (b) Reflects the clinical needs of the patient as identified through an individualized assessment; and (c) Is based upon the patients goals and will assist the patient in achieving the goals. (23) Personal health navigator means an individual who meets qualification criteria adopted by the authority under ORS 414.665 and who provides information, assistance, tools and support to enable a patient to make the best health care decisions in the patients particular circumstances and in light of the patients needs, lifestyle, combination of conditions and desired outcomes. (24) Prepaid managed care health services organization means a managed dental care, mental health or chemical dependency organization that contracts with the authority under ORS 414.654 or with a coordinated care organization on a prepaid capitated basis to provide health services to medical assistance recipients. (25) Quality measure means the health outcome and quality measures and benchmarks identified by the Health Plan Quality Metrics Committee and the metrics and scoring subcommittee in accordance with ORS 413.017 (4) and 413.022 and the quality metrics developed by the Behavioral Health Committee in accordance with ORS 413.017 (5). (26) Resources has the meaning given that term in ORS 411.704. For eligibility purposes, resources does not include charitable contributions raised by a community to assist with medical expenses. (27) Social determinants of health means: (a) Nonmedical factors that influence health outcomes; (b) The conditions in which individuals are born, grow, work, live and age; and (c) The forces and systems that shape the conditions of daily life, such as economic policies and systems, development agendas, social norms, social policies, racism, climate change and political systems. (28) Tribal traditional health worker means an individual who meets qualification criteria adopted by the authority under ORS 414.665 and who: (a) Has expertise or experience in public health; (b) Works in a tribal community or an urban Indian community, either for pay or as a volunteer in association with a local health care system; (c) To the extent practicable, shares ethnicity, language, socioeconomic status and life experiences with the residents of the community the worker serves; (d) Assists members of the community to improve their health, including physical, behavioral and oral health, and increases the capacity of the community to meet the health care needs of its residents and achieve wellness; (e) Provides health education and information that is culturally appropriate to the individuals being served; (f) Assists community residents in receiving the care they need; (g) May give peer counseling and guidance on health behaviors; and (h) May provide direct services, such as tribal-based practices. (29)(a) Youth support specialist means an individual who meets qualification criteria adopted by the authority under ORS 414.665 and who, based on a similar life experience, provides supportive services to an individual who: (A) Is not older than 30 years of age; and (B)(i) Is a current or former consumer of mental health or addiction treatment; or (ii) Is facing or has faced difficulties in accessing education, health and wellness services due to a mental health or behavioral health barrier. (b) A youth support specialist may be a peer wellness specialist or a peer support specialist. [1965 c.556 2; 1967 c.502 3; 1969 c.507 1; 1971 c.488 1; 1973 c.651 10; 1974 c.16 1; 1977 c.114 1; 1981 c.825 3; 1983 c.415 3; 1985 c.747 9; 1987 c.872 1; 1989 c.697 2; 1989 c.836 19; 1991 c.66 6; 1995 c.343 42; 1995 c.807 1; 1997 c.581 22; 1999 c.59 107; 1999 c.350 1; 1999 c.515 1; 2003 c.14 188; 2005 c.381 13; 2007 c.70 190; 2007 c.486 11; 2007 c.861 18,18a; 2009 c.595 264; 2009 c.867 36; 2010 c.73 1; 2011 c.69 7; 2011 c.602 20,69; 2011 c.700 5; 2013 c.688 68; 2015 c.3 45; 2015 c.389 9; 2015 c.765 25; 2015 c.792 5; 2015 c.798 3; 2015 c.836 3; 2017 c.273 3; 2017 c.618 2,3; 2019 c.358 6; 2021 c.514 2; 2021 c.569 12; 2021 c.667 20; 2023 c.584 11] Note: The amendments to