(1) Notwithstanding ORS § 414.065 and 414.690, a coordinated care organization must provide behavioral health services to its members that include but are not limited to all of the following:

Terms Used In Oregon Statutes 414.766

  • 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. See Oregon Statutes 414.025
  • 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. See Oregon Statutes 414.025
  • Coordinated care organization: means an organization meeting criteria adopted by the Oregon Health Authority under ORS § 414. See Oregon Statutes 414.025
  • Gender identity: means an individual's gender-related identity, appearance, expression or behavior, regardless of whether the identity, appearance, expression or behavior differs from that associated with the gender assigned to the individual at birth. See Oregon Statutes 174.100
  • 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. See Oregon Statutes 414.025
  • Sexual orientation: means an individual's actual or perceived heterosexuality, homosexuality or bisexuality. See Oregon Statutes 174.100

(a) For a member who is experiencing a behavioral health crisis:

(A) A behavioral health assessment; and

(B) Services that are medically necessary to transition the member to a lower level of care;

(b) At least the minimum level of services that are medically necessary to treat a member’s underlying behavioral health condition rather than a mere amelioration of current symptoms, such as suicidal ideation or psychosis, as determined in a behavioral health assessment of the member or specified in the member’s care plan;

(c) Treatment of co-occurring behavioral health disorders or medical conditions in a coordinated manner;

(d) Treatment at the least intensive and least restrictive level of care that is safe and effective and meets the needs of the individual’s condition;

(e) For all level of care placement decisions, placement at the level of care consistent with a member’s score or assessment using the relevant level of care placement criteria and guidelines;

(f) If the level of placement described in paragraph (e) of this subsection is not available, placement at the next higher level of care;

(g) Treatment to maintain functioning or prevent deterioration;

(h) Treatment for an appropriate duration based on the individual’s particular needs;

(i) Treatment appropriate to the unique needs of children and adolescents;

(j) Treatment appropriate to the unique needs of older adults;

(k) Treatment that is culturally and linguistically appropriate;

(L) Treatment that is appropriate to the unique needs of gay, lesbian, bisexual and transgender individuals and individuals of any other minority gender identity or sexual orientation;

(m) Coordinated care and case management as defined by the Department of Consumer and Business Services by rule; and

(n) Mental health wellness appointments as prescribed by the Oregon Health Authority by rule.

(2) If there is a disagreement about the level of care required by subsection (1)(e) or (f) of this section, a coordinated care organization shall provide to the behavioral health treatment provider full details of the coordinated care organization’s scoring or assessment, to the extent permitted by the federal Health Insurance Portability and Accountability Act privacy regulations, 45 C.F.R. § parts 160 and 164, ORS § 192.553 to 192.581 or other state or federal laws limiting the disclosure of health information.

(3) The Oregon Health Authority shall adopt by rule a list of behavioral health services that may not be subject to prior authorization. [2017 c.273 § 2; 2021 c.116 § 1; 2021 c.629 § 4]

 

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