OAR 410-172-0600: Temporary rule language in effect until 02/15/2027. Acronyms and Definitions

The acronyms and definitions listed in this rule apply to all of the administrative rules included in this chapter 410, division 172 Medicaid Payment for Behavioral Health Services. However, there may be additional acronyms and definitions included in and apply to other specific rules within the division 172 Rules. (1) “Activities of Daily Living (ADLs)” means the functional activities required by an individual for continued well-being, that are essential for health and safety. ADLs relate to the following functional categories: eating, dressing and grooming, bathing and personal hygiene, transferring (including mobility and ambulation), and toileting (including elimination and maintaining continence). Specific ADLs within these categories are outlined in other rules in this division. (2) "Adult" means an individual 18 years of age or older or an emancipated minor. An individual with Medicaid eligibility who needs services specific to children, adolescents, or young adults in transition shall be considered a child until age 21 for the purposes of these rules. Adults who are between the ages of 18 and 21 who are considered children for purposes of these rules shall have all rights afforded to adults as specified in these rules. (3) “ASAM PPC” means the most current publication of the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-related Disorders, which is a clinical guide used in matching individuals to appropriate levels of care. (4) “Authority” means the Oregon Health Authority, the agency established in ORS 413 that administers the funds for Titles XIX and XXI of the Social Security Act, or its designee. It is the single state agency for the administration of the medical assistance program under ORS 414. For purposes of these rules, the agencies under the authority of the Oregon Health Authority are the Public Health Division, Health Systems Division, External Relations, Health Policy and Analytics, Fiscal and Operations, Office of Equity and Inclusion, and the Oregon State Hospital. (5) "Authorized Representative" means, for purposes of the division 172 Rules only, unless expressly defined otherwise in another specific rule in the division 172 Rules, one of the following: (a) A minor child’s parent or, as defined below in this rule, if applicable, a minor child’s legal representative; (b) An individual’s legal representative as defined in this rule; or (c) A person appointed by the individual, or if applicable, appointed by the individual’s legal representative, who is: (A) Age 18 or older; (B) Is not incapacitated; (C) Not a provider paid to provide any health services the individual receives or may receive through Oregon Health Plan, including without limitation personal care services or other home and community- based services, except as permitted under ORS 127.635(3); and (D) Appointed to act on behalf of the individual in making decisions on matters pertaining to the provision of planning and implementation of health care services and supports including, without limitation, personal care services. Appointment by the individual must be made in writing or another method that clearly indicates the individual has freely chosen the identified person as their authorized representative. A person appointed by the individual or the individual’s legal representative may include, without limitation: (i) A person designated by the individual as having power of attorney under ORS 127.002 through 127.045; or (ii) a person designated as a health care representative as defined in 127.505 and appointed in accordance with ORS 127.510. (6) “Behavioral Health” means mental health, mental illness, addiction disorders and substance use disorders. (7) “Behavioral Health Services” means medically appropriate services rendered or made available to a recipient for treatment of a behavioral health diagnosis. (8) "Child" means an individual under the age of 18. An individual with Medicaid eligibility who needs services specific to children, adolescents, or young adults in transition shall be considered a child until age 21 for purposes of these rules. (9) “Community Mental Health Program (CMHP)” means an entity that is responsible for planning and delivery of services for persons with substance use disorders or a mental health diagnosis, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with the Division as defined in OAR 309-019-0105. (10) “Cueing" means giving verbal direction or visual clues and encouragement during the activity to help the individual complete activities without hands-on assistance and may include redirection. (11) "Delegated Nursing Task" means a registered nurse (RN) authorizes a person as described in OAR 851-047-0000 who is not licensed to provide or perform a nursing task. In accordance to OAR chapter 851 division 047, the RN shall, prior to issuing written authorization of a delegated nursing task, assess a specific eligible individual’s care needs, evaluate the person's ability to perform the specific nursing task, provide the person with education and training to perform the nursing task, and supervise and re-evaluate the individual and the person performing the task. (12) "Department" means the Oregon Department of Human Services (ODHS). (13) "Designee" means an organization with which the Authority contracts or has an interagency agreement. (14) "Disability" means a physical, cognitive, or mental health impairment which, for an individual, constitutes or results in a functional limitation in one or more of the activities of daily living described in OAR 410-172-0780. (15) “Division” means the Health Systems Division of the Oregon Health Authority, or its designee. (16) “Family Home” means a dwelling, either through an informal arrangement or property manager’s rental agreement, owned or rented by a relative of the Individual, where the Individuals name is not on the agreement. (17) “Face to Face” means a personal interaction where both words can be heard and facial expressions can be seen in person or through telehealth services where there is a live streaming audio and video, if medically appropriate. (18) "Guardian" means a person who has been appointed by a court to promote and protect the well-being of an individual in keeping with ORS 125.305. (19) "Hands-on" means a provider physically performs all or part of an activity because the individual is unable to do so. (20) “Home” means a dwelling the Individual owns or rents with a formal written arrangement (mortgage, deed, rental agreement, etc.) that includes the Individual’s name and a legally enforceable agreement offering protections against unlawful eviction, substantially similar to the Oregon’s landlord tenant laws. (21) “Immediate Family” means spouses of individuals and parents of minor individuals, including stepparents who are legally responsible for minor children. Immediate family members of an individual are prohibited from working as a provider for that individual. (22) “In-Person” means meeting with someone in the same physical location rather than talking on the phone, e-mailing, or writing to the person. (23) “Instrumental Activities of Daily Living (IADLs)” means self-management activities performed by an individual on a day-to-day basis that are more complex than Activities of Daily Living and support an individual’s health, safety, well-being, and ability to live independently in the community. Instrumental Activities of Daily Living include, but are not limited to meal preparation, light housework, laundry, medication management, transportation, shopping, and money management. Specific IADLs within these categories are described in other rules in this division. (24) “Independent and Qualified Agent (IQA)” means an entity meeting the provider qualification requirements identified in 42 CFR §441.730 and under contract with the Authority to make eligibility determinations, perform functional needs assessments, develop service-plans, and complete independent psychiatric reviews. (25) “Home and Community Based Services (HCBS)” means services and supports that assist eligible individuals to remain in their home and community in accordance with the Code of Federal Regulations, approved Medicaid State Plan authorities, and Oregon Administrative Rules. (26) "Legal Representative" means a person who has been lawfully designated by court order to make financial, health care, or other decisions for another individual. (a) A legal representative may be a: (A) Guardian as defined in section (18) of this rule; or (B) A Health Care Representative as defined in and appointed in accordance with ORS 127.505(13)(c). (b) A legal representative only has authority to act within the scope and limits of their authority as designated by the court order or other agreement authorized by the court. (27) "Medicaid OHP Plus Benefit Package" means: (a) Modified Adjusted Gross Income (MAGI) Medicaid/CHIP as defined at OAR 410-200-0015(58); (b) Oregon Supplemental Income Program Medical (OSIPM) as defined at OAR 410-200-0015(60). (c) Any other Oregon Health Plan (OHP) Plus eligibility category authorized by the Authority that includes coverage for State Plan Personal Care services. (28) “Level of Care” means the type, frequency, and duration of medically appropriate services provided to a recipient of behavioral health services. (29) “Level of Care Determination” means the standardized process implemented to establish the type, frequency, and duration of medically appropriate services required to treat a diagnosed behavioral health condition. (30) "Licensed Medical Practitioner (LMP)” means program staff who meet the following minimum qualifications: (a) Physician licensed to practice in the State of Oregon; or (b) Nurse practitioner licensed to practice in the State of Oregon; or (c) Physician's associate licensed to practice in the State of Oregon; and (d) Whose training, experience, and competence demonstrate the ability to conduct a mental health assessment and provide medication management. (31) "Medicaid" means the federal grant-in-aid program to state governments to provide medical assistance to eligible individuals under Title XIX of the Social Security Act. (32) “Natural Support” means resources and supports (e.g., relatives, friends, significant others, neighbors, roommates, or the community associates) who voluntarily provide services and supports to an individual without the expectation of compensation. Natural supports are identified in collaboration with the individual and the potential "natural support." The natural support is required to have the skills, knowledge, and ability to provide the needed services and supports and shall be identified within the individual’s service plan. (33) “Oregon Health Plan (OHP)” means the services included in the Authority’s medical assistance programs, including without limitation, Medicaid and Healthier Oregon. (34) “Personal Care Services” means the IADLs and ADLS provided by a personal care attendant or a direct support worker to an individual in their home or other non-institutional community location outside the individual’s home. Individuals receiving inpatient services or who are residents of a hospital, nursing facility, intermediate care facility or institution are not eligible to receive personal care services under this Division 172 Rule Set. (35) “Recovery Assistant” means a provider who provides a flexible range of services. Recovery assistants provide face-to-face services in accordance with a service plan that enables a participant to maintain a home or apartment, encourages the use of existing natural supports, and fosters involvement in treatment, social, and community activities. A recovery assistant shall: (a) Be at least 18 years old; (b) Meet the background check requirements described in OAR 950-060-0070; (c) Conform to the standards of conduct as described in OAR 950-060-0080. (36) "Redirection" means to divert the individual from one activity to another activity. (37) "Relative" means a person, excluding an individual's spouse, who is related to the individual by blood, marriage, or adoption. (38) "Service Plan" means a comprehensive plan for services and supports provided to or coordinated for an individual and their family, as applicable, that is reflective of the assessment and the intended outcomes of service. (39) “Spouse” means an individual who is legally married to another individual. (40) “State Medicaid Plan” means the written agreement between the state of Oregon and the federal government that details how the Authority will administer the state’s Medicaid program in compliance with federal law. The State Medicaid Plan serves as the basis for the Authority’s administration of its other medical assistance program. The State Medicaid Plan may also be referred to as the “State Plan” (41) "Sub-Acute Care Facility" means a care center or facility that provides short-term rehabilitation and complex medical services to an individual with a condition that does not require acute hospital care but prevents the individual from being discharged to their home. (42) “Supervision” means, along with cueing, helping the individual know when or how to carry out the task. Supervision may be in the form of monitoring, set-up, reassurance, or stand-by to ensure the individual completes the task. Need for assistance may not be based on possible or preventative measures: (a) "Monitoring" means a provider observes an individual to determine if assistance is needed; (b) “Set-up" means the preparation, cleaning, and maintenance of personal effects, supplies, assistive devices, or equipment so an individual may perform an activity; (c) "Reassurance" means to offer encouragement and support to an individual; (d) "Stand-by" means a provider is at the side of an individual ready to step in and take over the task if the individual is unable to complete the task independently.