Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3500 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(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) "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.
(18) "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.
(19) "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.
(20) "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.