Oregon
In Oregon:
- Medicaid services are delivered primarily through 16 Coordinated Care Organizations (CCOs). The Oregon CCO is a network of all types of health care providers who have agreed to work together in their local communities to serve people who receive Medicaid coverage. (In Oregon Medicaid coverage is referred to as the Oregon Health Plan.) The CCOs are responsible for providing physical, behavioral, and oral health services. Enrollment in a CCO is mandatory for nearly all adults and children who live in an area served by CCOs. There were a total of 652,846 beneficiaries enrolled in Oregon’s Medicaid program as of July 2011.* Of these, 640,912 were enrolled in managed care.
- The Oregon Health Plan operates under an 1115 Medicaid Demonstration Waiver awarded to the Oregon Health Authority and most recently renewed in 2012. The waiver allows for: establishment of the CCOs, flexibility in the use of Federal funds for flexible services, and significant Federal investment.
- Behavioral health, mental health and substance abuse services are integrated into and delivered by the CCOs. Some CCOs also deliver dental services. The Oregon Health Plan contracts with different dental plans in counties where the CCO does not offer dental services.
As of 2012, 385,795 individuals were eligible for EPSDT through the Oregon Health Plan. According to CMS data from 2012, Oregon achieved an EPSDT screening ratio of 57% and a participation ratio of 43%. 153,184 children received dental services of any kind, with 136,323 receiving preventive dental services.
* Note that all data for Oregon was collected before the shift to CCOs in mid-2012.
Last updated April 2014
| Medical Necessity |
Under the Oregon Administrative Rules “Medically Appropriate” means:
“(127) “Medically Appropriate” means services and medical supplies that are required for prevention, diagnosis or treatment of a health condition that encompasses physical or mental conditions, or injuries and which are:
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| Initiatives to Improve Access |
The Oregon Health Policy Board (the entity that serves as the oversight body for the Oregon Health Authority) and the Oregon Early Learning Council created a joint subcommittee focused on integrating child healthcare and early learning policies with the goal of having children healthy and ready to receive education. The subcommittee’s work has included a number of recommendations on integrating the early learning system with the CCOs, as well as providing additional support in the area of developmental screening. |
| Reporting & Data Collection | The Oregon Health Authority is required to regularly report to the Oregon Health Policy Board, the Governor, and the legislative Assembly on its progress in implementing Coordinated Care Organizations (CCOs). Oregon has also released a set of Year 1 CCO Accountability Metrics for reporting purposes in the first year, which include measures of developmental screening by 36 months and mental health assessments for children in Department of Human Services custody. Additionally the Oregon Health Authority (OHA) will collect CMS CHIPRA Core Measures, including:
The Oregon Health Authority is also tracking 17 CCO incentive metrics. The incentive metrics include several that are specific to children:
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| Behavioral Health |
Oregon has worked to improve screening practices among pediatric primary care providers to increase identification of young children with developmental, behavioral, and/or psychosocial delays.
State regulations specify that if mental health or substance abuse conditions are discovered during a primary care screening, physicians may refer children to the Addictions and Mental Health Services Division (AMH). Additionally, Oregon’s Medicaid fee schedule allows providers to bill the 96110 code for developmental screening, and the 96111 code for more extended developmental testing.
Oregon’s Coordinated Care Organizations (CCOs) are required to contract with Community Mental Health Programs (CMHPs), which provide services to persons with mental or emotional disorders and developmental disabilities. The CMHPs are often county mental health departments and are responsible for providing a range of Integrated Services and Supports for behavioral health, including services for children. Developmental screening in the first 36 months of life is an incentive measure for the CCOs.
Oregon’s CCO contracts also stipulate that, starting July 1, 2014, the CCOs will provide a Child and Adolescent Needs and Strengths Comprehensive Screening (CANS Oregon) and a Mental Health Assessment for all children within 60 days of notification that the child is entering foster care.
For more information about behavioral health services for children enrolled in Medicaid, see: “Behavioral Health in the Medicaid Benefit for Children and Adolescents: Oregon.”
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| Support to Providers and Families |
Support to Providers
The Oregon Health Authority created a Transformation Center to support the CCOs with the adoption of the coordinated care model through technical assistance, learning collaboratives, and peer-to-peer learning. The Transformation Center staffs Innovator Agents to directly assist the CCOs, and coordinates learning collaboratives to create opportunities for learning best practices. The CCO Learning Collaborative, for example, has held monthly sessions since July 2014 and has covered topics including Prenatal Care and Developmental Screening. The state also maintains a Child Health Provider Toolkit of resources, including developmental screening instruments, guidelines, and referral forms. |
| Care Coordination |
Oregon’s Coordinated Care Organizations (CCOs), which enroll both adults and children, are based on the coordinated care model, key elements of which include:
Oregon’s contracts with the CCOs mandate that they must adopt both a Community Health Assessment (CHA) and a Community Health Improvement Plan (CHP). The contracts also stipulate that: “To the extent practicable, Contractor shall include in the CHA and CHP a strategy and plan for:
The CCOs are designed to have the flexibility needed to support models of care that are patient-centered, team-focused, and reduce disparities. The CCOs coordinate services to focus on prevention, chronic illness management, and person-centered care. The CCOs have one budget that grows at a fixed rate for mental, physical, and (for some) dental care; and they are held accountable for the health outcomes of the populations they serve. The Oregon CCO model also builds upon and integrates the Patient-Centered Primary Care Home Program (PCPCH). The PCPCH is the Oregon’s name for the Patient Centered Medical Home. Oregon’s CCOs are required to implement PCPCHs to the extent possible. |
| Oral Health |
Several of the Coordinated Care Organizations (CCOs) provide dental services. For Oregon Health Plan enrollees belonging to a CCO that does not provide dental services, the state has a web site to help beneficiaries find a dentist. The Oregon Health Plan maintains a Prioritized List of Dental Health Services that details covered services for adults and children. Oregon’s services for children include:
The Oregon Health Plan also is participating in initiatives related to Oral Health including the Early Childhood Cavities Prevention campaign, which launched the First Tooth Project, designed to help providers implement preventive oral health services for infants and toddlers under the age of 3 into their current practice. |
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
