Traditional health workers 

When members have health needs that aren’t covered by a health plan or other services, CareOregon offers funds for health-related services (HRS). HRS must be consistent with a member’s treatment plan, as developed by their primary care team or other treatment providers. The services will be documented in the member’s treatment plan and clinical record. For that reason, members without a current provider relationship need to establish one in order to receive health-related services funds.

Providers who would like to learn more about the basic framework of Health-Related Services flex process, regulatory requirements and how to access this resource, please watch this webinar by clicking here. 

What HRS covers

These funds cover items or services that aren’t covered under standard health plan services but will improve a person’s health. Health plans cover provider visits, pharmacy benefits and durable medical equipment. Durable medical equipment (DME) is a covered benefit, which means equipment that would be covered as DME is not eligible for HRS funds. (For a list of items covered by DME with no authorization required, click here.)

Health-related services funds cover services like:

• Helping a person get a cell phone if having one will give them better access to their providers.
• Transit passes for members who need transportation for health-related needs beyond covered appointments.
• Buying an air conditioner for a person whose health is affected by the warmth and airflow in their home.
• Vouchers for a yoga studio for a person whose back pain will be helped by an exercise class.
• A class on cooking healthy meals for a person with diabetes.

This is not an exhaustive list. Any requested items will be evaluated for consistency with a member’s health needs and treatment plan.

Requesting HRS funds

Limitations of health-related services: The Oregon Administrative Rules restrict health-related services to items not paid for with grant money, funding separate from CCO contract revenue, or normal clinical service billing. In other words, health-related services may be used only if other funding is not available. Before you make a request, please be sure there is no other funding available.

Making a health-related services request: Any health care provider, primary care team, care coordination staff member working directly with members, or other subcontractors of CareOregon’s network may request the use of HRS for a member. CareOregon encourages our community-based organization (CBO) partners to help our shared members access HRS. CBOs can work with members and their treatment providers to identify the need, and the provider can submit a request.

All HRS requests must include medical documentation (care plan, progress notes, chart notes, etc.) and information about the member’s diagnosis.

Evaluating requests

CareOregon evaluates all completed request forms based on:

• The member’s eligibility and whether the request fits their treatment plan.
• A sustainability plan to support the member’s ongoing needs, because CCOs may not be able to support these needs in the long term.
• Whether other community resources or safety net funds (besides HRS) were pursued before the request was made.

We provide members with a written outcome and copy the requesting provider (and member representatives, if applicable). Often, this involves asking for more information about the member, which may include the member's budget information. Requests cannot be fulfilled until all information is received.

Depending on the nature of the request, if more details about the budget is indicated, this form can be used to provide that information.

Questions? Email us at social.determinants@careoregon.org.