HEALTH PLAN BACKGROUND BRIEF LPRO: Legislative Policy and Research Office

OVERVIEW (OHP) As of July 2016, a little over one million OHP is Oregon’s program. There Oregonians were enrolled in the Oregon are several health care programs available for Health Plan (OHP) and Children’s Health low-income Oregonians through OHP: Insurance Program (CHIP) programs, which  is funded through Medicaid. Medicaid is OHP Plus for children ages 0-18 and funded by a mix of federal and state dollars adults ages 19-64; and provides benefits based on Oregon’s  OHP Plus Supplemental for pregnant Prioritized List of Health adults ages 21 or older; and Services. The current CONTENTS Prioritized List of Health  OHP with Limited Services can be found here. OVERVIEW Drug for adults who qualify for both Medicaid and Medicaid provides coverage OREGON HEALTH PLAN (OHP) Part D. for the aged, blind and people with disabilities and The federal matching rate OHP SERVICE DELIVERY SYSTEM for the coverage is available for households with incomes expansion population is 100 COORDINATED CARE that up to 133 percent of percent of all costs through ORGANIZATIONS the Federal Poverty Level (calendar year) 2016. The (FPL), 185 percent of FPL FEDERAL TRANSFORMATION match percentage goes to 95 for pregnant women and WAIVER percent in 2017, 94 percent infants and up to 300 in 2018, 93 percent in 2019 percent for all children in STAFF CONTACT and 90 percent for 2020 foster care, adopted children and beyond. and children in families with household incomes up to 300 percent of FPL. In Coverage: Benefits and services covered by addition, CHIP is available for children with OHP include: household incomes up to 300 percent of FPL. People with Medicaid coverage may also have  Chemical dependency care; Medicare benefits or private coverage through  Dental services; an employer or individual policy.  Hearing exams and hearing aids;

 Home health;  Hospice care;

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 Hospital care; The delivery system is enhanced by 19 federally qualified health centers (FQHCs), 21  Immunizations and vaccines; Indian and Tribal Health Services (IHS), six of  Laboratory tests and X-rays; which are FQHCs and 495 Patient-Centered Primary Care Homes (PCPCHs), as well as  Maternity, prenatal and newborn care; numerous Rural Health Clinics (RHCs) and  Medical care provided by physician, nurse hospitals that serve OHP members. practitioner or physician assistant; COORDINATED CARE  Medical equipment and supplies; ORGANIZATIONS  Medical transportation; House Bill 3650 (2011) and Senate Bill 1580  Mental health care; (2012) transformed the OHP delivery system through the creation of CCOs. CCOs are  Physical, occupational and speech networks of all types of health care providers therapy; who have agreed to work together in their  Prescription drugs; and local communities for people who receive health care coverage under OHP.  Vision services. Currently, there are 16 fully integrated CCOs OHP SERVICE DELIVERY SYSTEM that provide comprehensive physical, behavioral and dental health services. The On August 1, 2012, Coordinated Care major goals of CCOs are early identification Organizations (CCOs) became the primary of conditions and disorders that may need delivery system for OHP services. treatment, and placing a priority on Due to federal law, state policies or because a prevention in order to avoid disease and CCO or other Organization future medical conditions to the greatest (MCO) may not provide services in some parts extent possible. of the state, approximately five percent of CCOs are locally established throughout OHP enrollees receive their care through the Oregon and each operates on its own global Fee-For-Service (FFS) system. FFS means the budget with a methodology that allows for state directly pays providers for services. A growth at a fixed rate from year to year. CCOs significant portion of the FFS population is are accountable for the health outcomes of the comprised of those with federal exemptions population they serve and these outcomes are from mandatory managed care enrollment monitored closely by the Oregon Health such as Medicare or documented Tribal Authority (OHA) and the federal government. heritage. CCOs are governed by a partnership among Another approximately five percent of health care providers, community members, Medicaid and CHIP enrollees are served by and stakeholders. The CCOs have financial other types of MCOs, such as fully capitated responsibility and risk. They develop new health plans (FCHPs) or physician care models of care and have more flexibility than organizations (PCOs). the prior delivery systems.

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The Oregon Health System Transformation percent) by the end of the first year, and two Center is the state’s hub for health system percentage points (to 3.4 percent) by the end innovation and improvement, and is key to of the second year of the waiver. encouraging the widespread adoption of the To ensure costs are reduced by improving CCO model of care. The Center’s goal is to quality and not through withholding care, increase the rate of innovation needed to CCOs and the state are held to quality deliver better health care at lower costs, and to metrics. There are financial incentives for improve the health of Oregonians. The CCOs to achieve performance benchmarks. Center supports CCOs by organizing The Quality and Access quarterly reports can Learning Collaboratives, a Council of Clinical be found at: Innovators, as well as conferences, workshops http://www.oregon.gov/oha/Metrics/Pages/ and technical assistance to entities throughout ccos.aspx. the delivery system. More on the waiver and associated reports can Additionally, each CCO is assigned an be found at: Innovator Agent, who works for OHA and http://www.oregon.gov/oha/healthplan/pag serves as a single point of contact between the es/waiver.aspx. CCO and OHA. Innovator Agents provide data to CCOs and assist CCO providers and governance boards develop strategies that support quality improvement and innovations in care. STAFF CONTACT Each CCO is required to convene a Community Advisory Council (CAC) that is Sandy Thiele-Cirka comprised of consumers—who make up a Legislative Policy and Research Office majority of the membership—representatives 503-986-1286 of the community, and local government. [email protected] CACs meet regularly to ensure that the health needs of the community are brought forth to, and met by, the CCO. Please note that the Legislative Policy and Research Office provides centralized, nonpartisan research FEDERAL TRANSFORMATION and issue analysis for Oregon’s legislative branch. WAIVER The Legislative Policy and Research Office does not provide legal advice. Background Briefs contain Through an agreement with the federal general information that is current as of the date of government that specifies all aspects of publication. Subsequent action by the legislative, Oregon’s Health System Transformation, executive or judicial branches may affect accuracy. Oregon received an investment of $1.9 billion over five years (July 2012-June 2017) to prevent cuts in the OHP through the transition to CCOs. In exchange, the state has agreed to reduce the per capita growth of Medicaid/CHIP costs by one percentage point (from 5.4 percent annual growth to 4.4

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