The following definitions apply to OAR 410-138-0000 through 410-138-0390:

1. (1) “Assessment” means the act of gathering information and reviewing historical and existing records of an eligible client in a target group to determine the need for medical, educational, social, or other services. To perform a complete assessment, the case manager shall gather information from family members, medical providers, social workers, and educators, if necessary.
2. (2) “Care Plan” means a Targeted Case Management (TCM) Care Plan that is a multidisciplinary plan that contains a set of goals and actions required to address the medical, social, educational, and other service needs of the eligible client based on the information collected through an assessment or periodic reassessment.
3. (3) “Case Management” means services furnished by a case manager to assist individuals eligible under the Medicaid State Plan Amendment (SPA) in gaining access to and effectively using needed medical, social, educational, and other services (such as housing or transportation) in accordance with 42 CFR 441.18. See also the definition for Targeted Case Management.
4. (4) “Centers for Medicare and Medicaid Services (CMS)” means the federal agency under the U.S. Department of Health and Human Services that provides the federal funding for Medicaid and the Children’s Health Insurance Program (CHIP).
5. (5) “Children and Youth with Special Health Care Needs (CYSHCN)” means those children and youth who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.
6. (6) “Department” means the Department of Human Services (Department).
7. (7) “Division” means the Oregon Health Authority’s Medicaid Division.
8. (8) “Duplicate Payment” means more than one payment made for the same services to meet the same need for the same client at the same point in time.
9. (9) “Eligible Client” means an individual who is found eligible for Medicaid or the Children’s Health Insurance Program (CHIP) by the Oregon Health Authority (Authority) and eligible for case management services (including TCM services) as defined in the Medicaid State Plan at the time the services are furnished.

10. (10) “Federal Financial Participation (FFP)” means the portion paid by the federal government to states for their share of expenditures for providing Medicaid services. FFP was created as part of the Title XIX, Social Security Act of 1965. There are two objectives that permit claims under FFP. They are:

    1. (a) To assist individuals eligible for Medicaid to enroll in the Medicaid program; and
    2. (b) To assist individuals on Medicaid to access Medicaid providers and services. The second objective involves TCM.
11. (11) “Federal Medical Assistance Percentage (FMAP)” means the percentage of federal matching dollars available to a state to provide Medicaid services. The FMAP is calculated annually based on a three-year average of state per capita personal income compared to the national average. The formula is designed to provide a higher federal matching rate to states with lower per capital income. No state receives less than 50 percent or more than 83 percent.
12. (12) “Medical Assistance Program” means a program administered by the Division that provides and pays for health services for eligible Oregonians. The Medical Assistance Program includes TCM services provided to clients eligible under the Oregon Health Plan (OHP) Title XIX and the Children’s Health Insurance Program (CHIP) Title XXI.
13. (13) “Monitoring” means ongoing face-to-face or other contact to conduct follow-up activities with the participating eligible client or the client’s health care decision makers, family members, providers, or other entities or individuals when the purpose of the contact is directly related to managing the eligible client’s care to ensure the care plan is effectively implemented.
14. (14) “Oregon Health Plan (OHP)” means the Medicaid program in Oregon that is known as the OHP and governed by a series of laws passed by the Oregon Legislature with the intention of providing universal access to healthcare to Oregonians. OHP is also governed by many federal laws.
15. (15) “Perinatal (for the purpose of the State Plan amendment for Public Health Nurse Home Visiting, Babies First!, CaCoon, and Nurse-Family Partnership TCM)” means the period inclusive of pregnancy through two years postpartum.
16. (16) “Reassessment” means periodically re-evaluating the eligible client to determine whether or not medical, social, educational, or other services continue to be adequate to meet the goals and objectives identified in the care plan. Reassessment decisions include those to continue, change, or terminate TCM services. A reassessment shall be conducted at least annually or more frequently if changes occur in an eligible client’s condition, or when resources are inadequate, or the service delivery system is non-responsive to meet the client’s identified service needs.
17. (17) “Reentry Targeted Case Management (also known as Targeted Case Management Services For Eligible Juveniles)” refers to the targeted case management services that will be provided as part of the Reentry FCAA Services to FCAA-Covered Youth as defined in OAR 410-155-0000 and OAR 410-155-0010.
18. (18) “Referral” means performing activities such as scheduling appointments that link the eligible client with medical, social, or educational providers, or other programs and services, and follow-up and documentation of services obtained.
19. (19) “Targeted Case Management (TCM) Services” means case management services furnished to a specific target group of eligible clients under the Medicaid State Plan to gain access to needed medical, social, educational, and other services (such as housing or transportation).
20. (20) “Unit of Government” means a city, a county, a special purpose district, or other governmental unit in the state.
21. (21) “Cost-sharing” means the Federal Financial Participation (FFP) matching program in which the TCM provider as a public entity, unit of government, must pay the non-federal matching share of the amount of the TCM claims.
22. (22) “Newborn Nurse Home Visiting Program (NNHV)” has the meaning described in OAR 333-006-0010. The program provides services to Medicaid-eligible newborns and their families. The program is governed by Public Health, Division 6 OAR 333-006-0000 to 333-006-333-006-0160. “Newborn Nurse Home Visiting Program” and “Universally Offered Newborn Nurse Home Visiting Program” can be used synonymously. Family Connects Oregon is the model being used to deliver the Newborn Nurse Home Visiting Program and can be used synonymously. NNHV is exempt from cost-sharing requirements.

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 23-2014, f. & cert. ef. 4-4-14
DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04
HR 20-1992, f. & cert. ef. 7-1-92