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.
“Alternative payment methodology” includes, but is not limited to:
Shared savings arrangements;
Bundled payments; and
Payments based on episodes.
“Behavioral health assessment” means an evaluation by a behavioral health clinician, in person or using telemedicine, to determine a patient’s need for immediate crisis stabilization.
“Behavioral health clinician” means:
A licensed psychiatrist;
A licensed psychologist;
A licensed nurse practitioner with a specialty in psychiatric mental health;
A licensed clinical social worker;
A licensed professional counselor or licensed marriage and family therapist;
A certified clinical social work associate;
An intern or resident who is working under a board-approved supervisory contract in a clinical mental health field; or
Any other clinician whose authorized scope of practice includes mental health diagnosis and treatment.
“Behavioral health crisis” means a disruption in an individual’s 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 individual’s mental or physical health.
“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.
“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:
Eligible for or enrolled in Part A of Title XVIII of the Social Security Act; or
Is a current or former consumer of mental health or addiction treatment; or
Is facing or has faced difficulties in accessing education, health and wellness services due to a mental health or behavioral health barrier.
A “family support specialist” may be a peer wellness specialist or a peer support specialist.
“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.
“Health insurance exchange” or “exchange” means an American Health Benefit Exchange described in 42 U.S.C. 18031, 18032, 18033 and 18041.
“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 (Prioritized list of health services):
Services required by federal law to be included in the state’s medical assistance program in order for the program to qualify for federal funds;
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 state’s medical assistance program;
Emergency hospital services;
Outpatient hospital services; and
Inpatient hospital services.
“Income” has the meaning given that term in ORS 411.704 (Definitions for ORS 411).(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:
Substance use disorders.
Health behaviors that contribute to chronic illness.
Life stressors and crises.
Developmental risks and conditions.
Stress-related physical symptoms.
Ineffective patterns of health care utilization.
As used in this subsection, “other care team members” includes but is not limited to:
Qualified mental health professionals or qualified mental health associates meeting requirements adopted by the Oregon Health Authority by rule;
Peer wellness specialists;
Peer support specialists;
Community health workers who have completed a state-certified training program;
Personal health navigators; or
Other qualified individuals approved by the Oregon Health Authority.
An individual who is a current or former consumer of mental health treatment; or
An individual who is in recovery, as defined by the Oregon Health Authority by rule, from an addiction disorder.
“Peer wellness specialist” means an individual who meets qualification criteria adopted by the authority under ORS 414.665 (Traditional health workers utilized by coordinated care organizations) 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.
“Person centered care” means care that:
Reflects the individual patient’s strengths and preferences;
Reflects the clinical needs of the patient as identified through an individualized assessment; and
Is based upon the patient’s goals and will assist the patient in achieving the goals.
“Personal health navigator” means an individual who meets qualification criteria adopted by the authority under ORS 414.665 (Traditional health workers utilized by coordinated care organizations) and who provides information, assistance, tools and support to enable a patient to make the best health care decisions in the patient’s particular circumstances and in light of the patient’s needs, lifestyle, combination of conditions and desired outcomes.
“Resources” has the meaning given that term in ORS 411.704 (Definitions for ORS 411). For eligibility purposes, “resources” does not include charitable contributions raised by a community to assist with medical expenses.
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;
To the extent practicable, shares ethnicity, language, socioeconomic status and life experiences with the residents of the community the worker serves;
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;
Provides health education and information that is culturally appropriate to the individuals being served;
Assists community residents in receiving the care they need;
May give peer counseling and guidance on health behaviors; and