Health-Related Social Needs (HRSN) Benefits supports the social and economic needs that impact an individual’s ability to maintain their health and well-being.
Oregon’s HRSN Services Benefits Include:
Please review eligibility requirements for each benefit service.
Clinically Appropriate Climate Related Devices Benefit: Available Now
Since March 2024,
Climate-Related benefits launched to include air conditioners for heat risks, air filters to protect against wildfire smoke, and home modifications to protect people from extreme weather.
Clinically Appropriate climate-related devices for Members residing in their home or non-institutional primary residence include:
- Air conditioners for individuals at health risk due to significant heat,
- Heaters for individuals at increased health risk due to significant cold,
- Air filtration devices and, as needed, replacement air filters for individuals at health risk due to compromised air quality,
- Mini refrigeration units as needed for individuals for medication storage, and
- Portable power supplies (PPSs) for individuals who need access to electricity-dependent equipment (e.g., ventilators, dialysis machines, intravenous equipment, chair lifts, mobility devices, communication devices, etc.) or are at risk of public safety power shutoffs (PSPS) that may compromise their ability to use medically necessary devices.
To be eligible for HRSN services, a member must be an OHP member with an eligible health condition, and have or recently experienced one of the following:
- A current OHP member and Yamhill CCO A or B member
- Have experienced one of the following:
- Adult or youth discharged from an eligible behavioral health facility, residential mental health and substance use disorder facility, or inpatient psychiatric unit within the past 12 months.
- Adult or youth released from incarceration within the past 12 months.
- Involved in Oregon’s child welfare system at some point in member’s life.
- Transitioning from Medicaid-only to dual coverage (receiving both Medicaid and Medicare) within the next 3 months or past 9 months.
- Members who are at risk of becoming houseless.
- Young adult, aged 19-26, with Special Healthcare Needs (starting in 2025).
- Meet at least one clinical health condition risk factor. Examples include: (See Table 1 for climate-specific factors)
- Younger than 6 years old with a history of or current clinical risk factor.
- 65 years old or older with a history of or current clinical risk factor.
- Currently pregnant with a history of or current clinical risk factor.
- Have a sensory, physical, intellectual, or developmental disability.
- Need assistance with activities of daily living (ADLs), instrumental activities of daily living (iADLs), or am eligible for long-term services and supports (LTSS).
- Receive in-home hospice care.
- Have complex physical health needs, like a chronic heart or lung condition, kidney disease, diabetes, or a condition that makes me at risk for blood clots or a stroke.
- Have multiple sclerosis.
- Have Parkinson’s.
- Have had a spinal cord injury.
- Have schizophrenia.
- Have bipolar disorder.
- Have an alcohol or substance use disorder.
- Have major depressive disorder and have needed crisis services, hospitalization, or residential treatment in the past 12 months.
- Social risk factor: A Member meets the HRSN Climate Device Social Risk Factor requirement if they reside in their own home or a non-institutional, non-congregate primary residence and has a need that will be aided by one of the following devices: air conditioner, heater, air filtration device, portable power supply (PPSs), and/or mini refrigeration units.
- Examples of climate-related needs:
- Have a health condition that makes extreme heat, cold temperature, poor air quality, or power outage particularly challenging or dangerous
- Individual is currently without a heater, air conditioner, air filter, mini-refrigerator for medications, or a portable power supply that works enough to meet my needs.
- Examples of housing-related needs:
- Require services to navigate, obtain, and sustain housing tenancy or create an accessible and health home environment
- Examples of nutrition-related needs:
- Experience marginal food security, including having anxiety over food sufficiency or shortage of food in the house.
Table 1: Climate Device Clinical Risk Factor Overview
| (Condition must have been active in the past 12 months. Members must meet age or pregnancy criteria at the time of eligibility determination, as relevant.) |
| Climate Device | Clinical Risk Factor |
| Air Conditioner, Air Filtration Device, Heater | | Schizophrenia spectrum and other psychotic disorders | | | Bipolar and related disorders | | | Major depressive disorder with an acute care need in the past 12 months including a suicide attempt, crisis services utilization (emergency department, mobile crisis team, etc.), acute psychiatric hospitalization, or residential treatment | | | One or more of the following substance use disorders: alcohol use disorder, hallucinogen use disorders, inhalant use disorder, opioid use disorder, stimulant use disorder | | | Major neurocognitive disorders | | | Chronic lower respiratory condition including chronic obstructive pulmonary disease (COPD), asthma requiring regular use of asthma controlling medications, restrictive lung disease, fibrosis, chronic bronchitis, bronchiectasis | | | Chronic cardiovascular disease, including cerebrovascular disease and heart disease | | | Spinal cord injury | | | In-home hospice | | | Any sensory, physical, intellectual, or developmental disability that increases health risks during extreme climate events | | | Child less than 6 years of age and currently has, has a history of, or is at risk for at least one of the following:• Heat stroke or heat exhaustion• Hypothermia, frostbite, or chilblains• Malnutrition• Dehydration or is currently breastfeeding• Child maltreatment as defined by the CDC (https://www.cdc.gov/violenceprevention/pdf/CM_Surveillance-a.pdf)Is a child with a special healthcare need (CYSHCN) as defined by HRSA (https://mchb.hrsa.gov/programs-impact/focus-areas/children-youth-special-health-care-needs-cyshcn#i)• An acute or chronic respiratory conditionA respiratory or gastrointestinal infectious disease, or becoming febrile with an infectious illness• Low birth weight of <2500 grams | |
|
| Air Conditioner, Air Filtration Device, Heater | Pregnant and currently has, has a history of, or is at risk for at least one of the following:• Heat stroke or heat exhaustion• Hypothermia, frostbite, or chilblains• An acute or chronic respiratory condition• Infection• High-risk pregnancy as defined by the NIH (https://www.nichd.nih.gov/health/topics/high-risk/conditioninfo)• History of previous pregnancy, delivery, or birth complication including gestational diabetes, preeclampsia, preterm labor, preterm birth, placental abruption, newborn low birth weight, stillbirth• Abuse or interpersonal violence• Malnutrition• Hyperemesis gravidarum and other causes of dehydration |
| Air Conditioner, Air Filtration Device, Heater | Adult 65 years and older and currently has, has a history of, or is at risk for at least one of the following:• Heat stroke or heat exhaustion• Hypothermia, frostbite, or chilblains• Malnutrition• Dehydration• Currently taking medications that impact heat tolerance, including for upper respiratory infections, allergies, COPD, muscle spasms, blood pressure, diuresis, diarrhea, constipation, anti-inflammation, mental health conditions, and sleep• Abuse or neglect• A respiratory or gastrointestinal infectious disease, or becoming febrile with an infectious illness• Mental health condition• Two or more chronic health conditions |
| Air Conditioner, Heater | Chronic Kidney disease, Diabetes mellitus, requiring any medication, oral or insulin Multiple Sclerosis Parkinson’s Disease Previous heat-related or cold-related illness requiring urgent or acute care, ex) emergency room and urgent care visits |
| Air Filtration Device | Individual requires home oxygen use: home oxygen, oxygen concentrators, home ventilator |
| Mini Refrigerator | · Individual uses medications requiring refrigeration. Examples include but are not limited to medications for diabetes mellitus, glaucoma, and asthma; TNF inhibitors
· Enteral and parenteral nutrition |
| Portable Power Supply | Individual needs durable medical equipment (DME) requiring electricity for use. Examples include but are not limited to:• Oxygen delivery systems, including concentrators, humidifiers, nebulizers, and ventilators• Intermittent positive pressure breathing machines• Cardiac devices• In home dialysis and automated peritoneal dialysis• Feeding Pumps• IV infusions• Suction pumps• Power wheelchair and scooter• Lift systems and electric beds• Breast pumps for first 6mo post-partum• Other DME medically required for sustaining life
Individual requires assistive technologies requiring electricity necessary for communication or ADLs. |
| Any Device | Other conditions approved through an individual review for medical exception aligned with OHA’s |
Housing Benefits: Available November 2024
Since November 1, 2024, Housing-Related Benefits supports will be available to eligible individuals who are at-risk of losing their current housing. The aim of these services is to support well-being by preventing homelessness, sustaining current housing and supporting tenancy case management services during times of housing insecurity.
HRSN Covered Benefits include:
- Rent Assistance for up to 6 months including past due months.
- Utilities set up and costs up to 6 months including past due amounts (must be receiving rental assistance to receive utility assistance).
- Tenancy Services (housing case management) for up to 18 months are crucial to support individuals maintain their housing and are offered to members who qualify for any of the other HRSN housing services. Tenancy Services can also be authorized as a stand-alone service.
- Medically-necessary home accessibility modifications and remediations, such as ramp and grab bar installation, pest control, heavy duty cleaning, and hotel costs for members who need temporarily move so that work can be completed in home.
- Storage Fees for members who need to relocate while home modification or remediation is completed.
- Additional benefits may be added in the future.
Eligibility for HRSN Rent Assistance, Utilities Assistance, & Tenancy Services:
To qualify, a Member must meet all of the following criteria:
1. OHP Member and YCCO A or B Member who:
- Is currently housed,
- Needs support staying in home due to inability to pay rent, AND
- Holds a lease or written agreement with their landlord
2. Is at risk of becoming homeless:
- Has an income that is 30% or less than the area median income in their area AND
- Lacks sufficient resources or support network to prevent homelessness
3. Has at least one Housing Clinical Risk Factor
- Complex behavioral health condition
- Developmental disability
- Complex physical health condition
- Needs assistance with Activities of Daily Living/Instrumental Activities of Daily Living or is eligible for Long Term Services and Supports
- Current or past interpersonal violence experience
- Repeated emergency department use (2 or more visits in a 6-month period)
- Repeated crisis encounters
- Currently pregnant or 12 months postpartum and at risk of certain clinical factors
- Less than six years of age and at risk of certain clinical factors
- More than 65 years of age and at risk of certain clinical factors
Eligibility for HRSN Home Modification/Remediation’s:
1. Current OHP Member and YCCO A or B Member and has at least one Housing Clinical Factor
- Complex behavioral health condition
- Developmental disability
- Complex physical health conditions
- Assistance with Activities of Daily Living/Instrumental Activities of Daily Living or is eligible for Long Term Services and Supports
- Current or past interpersonal violence experience
- Repeated emergency department use (2+ visits within 6 months)
- Repeated crisis encounters
- Currently pregnant or 12 months postpartum and at risk of certain clinical factors
- Less than six years of age and at risk of certain clinical factors
- More than 65 years of age and at risk of certain clinical factors
2. Belongs to an HRSN covered Population
- Adults and Youth Released from Incarceration
- Individuals currently or previously involved in Oregon’s Child Welfare system
- Individuals Transitioning to Dual Medicaid and Medicare Status
- Individuals who meet the at-risk of becoming houseless; or
- Young Adults with Special HealthCare Needs ages 19 and 20(starting January 2025)
- Adults and Youth discharged from an HRSN Eligible Behavioral Health Facility:
- Acute Care Psychiatric Hospitals
- Institution for Mental Diseases
- Integrated Psychiatric Residential Treatment Facilities and Residential Substance Use Disorders
- Residential Treatment Facilities (RTF), Residential Treatment Homes (RTH), and Secure Residential Treatment Facilities (SRTF)
- Psychiatric Residential Treatment Facilities (PRTF)
- Residential Substance Use Disorders Treatment Programs
3. Additional Eligibility Requirements
- Member must need the home modification or remediation to help prevent their health condition
- Member must receive landlord approval for home modification or remediation
Outreach & Engagement (O&E) Benefits: Available to eligible members on 11/1/2024
YCCO will incorporate HRSN O&E services into their Care Coordination processes by developing a Person Centered Service Plan (PCSP) for each member who qualifies for HRSN Services.
To be eligible for HRSN Outreach & Engagement Services, a member must be enrolled in OHP and presumed eligible for HRSN
HRSN O&E Services are intended to:
- Identify members who may be eligible for HRSN Services and help them access needed HRSN Services
- Connect members to additional healthcare and non-healthcare services to address overall health and well-being needs
- Be readily accessible, culturally specific and responsive
HRSN Outreach & Engagement Services include:
- Engaging member who may be eligible for HRSN Services
- Identifying and verifying the member’s CCO enrollment or, as applicable, enrollment in OHP’s FFS program
- Verifying the member is presumed HRSN eligible
- Submitting HRSN request to YCCO or OHA
- Working with members to obtain the information necessary to determine HRSN service need
- Helping members maintain enrollment in OHP
- Helping members with obtaining and maintaining other entitlements and benefits: TANF, WIC, SNAP, etc.
- Assisting member with obtaining identification and other required documentation needed to receive benefits and other supports
- Connecting members to settings where basic needs can be met
- Providing members, who may need a medical, peer, social, educational, legal, and other related services, with information and support necessary to connect to resources.
Nutrition Benefits: Available January 2025
Food Benefits (available in January 2025)
Starting January 1, 2025, the below Nutrition Services will be available to eligible members:
- Medically Tailored Meals (MTM) Assessment-an initial assessment and a reassessment, with a licensed dietician (preferred), or, if not available, a primary care provider, to develop a medically appropriate nutrition care plan specific to HRSN MTM service. This service does not require prior authorization.
- Medically Tailored Meals-provide meals to Members with health-related condition(s) for which nutrition supports would improve health outcomes. The service includes: preparation and provision of the prescribed meals consistent with the nutrition care plan and delivery of meal. To receive meals, Members must first be assessed by RDN or PCP to develop a medically appropriate nutrition care plan. Eligibility criteria for MTM Meals follows the same criteria as MTM Assessment. Meals will delivered to the Member’s home or private residence, which may include shelters that do not provide residents with meals.
- Nutrition Education-any combination of educational strategies designed to motivate and facilitate voluntary adoption of food choices and other food and nutrition-related behaviors conducive to health and well-being. The service can consist of nutrition education or information to an individual or group that offers evidence-based or evidence-informed strategies, and/or meal preparation education. This service can be provided one-time or on a recurring weekly or monthly basis. Eligibility criteria for Nutrition Education follows the same criteria as MTM Assessment. Members eligible for the same service through non-HRSN Medicaid or Medicare/Medicaid are not eligible for the HRSN Service. g.)Members receiving Medical Nutrition Therapy (MNT) through their Medicare benefit are not eligible for this service.
Assessment for Medically Tailored Meals Criteria Eligibility Requirements:
- A current OHP member and Yamhill CCO A or B member
- Have experienced one of the following:
- Adult or youth discharged from an eligible behavioral health facility, residential mental health and substance use disorder facility, or inpatient psychiatric unit within the past 12 months.
- Adult or youth released from incarceration within the past 12 months.
- Involved in Oregon’s child welfare system at some point in member’s life.
- Transitioning from Medicaid-only to dual coverage (receiving both Medicaid and Medicare) within the next 3 months or past 9 months.
- Members who are at risk of becoming houseless.
- Young adult, aged 19-20, with Special Healthcare Needs
- Have one Nutrition Clinical Risk Factor:
- Complex Behavioral Health Need; or,
- Developmental Disability Need-Member with an Intellectual Disability or Developmental Disability that requires services or supports to achieve and maintain care goals; or,
- Complex Physical Health Need-Member with a persistent, disabling, progressively or life-threatening physical health condition(s) requiring treatment for stabilization or prevention of exacerbation; or,
- Needs Assistance with ADLs/IADLs or Eligible for LTSS; or,
- Interpersonal Violence Experience-Member who is experiencing or has experienced interpersonal violence (IPV), including domestic violence (DV), sexual violence (SV), or psychological violence.
- Repeated Emergency Department Use and Crisis Encounters-With repeated use of emergency department care of two or more visits in the past (6 months or five or more visits within the past (12) months, or with tow or more crisis encounter in the past (6) months or five (5) or more crisis encounters in the past (12) months, which represents an exacerbation of mental health distress
- Pregnant/Post Partum-a Member who is currently pregnant or up to 12 months postpartum and currently has a history of, or is a risk of at least one of the following:
- Infection
- High-risk pregnancy
- Pregnancy-related death
- History of previous pregnancy, delivery, or birth complications
- Abuse or interpersonal violence
- Malnutrition
- Maternal low birth weight of <2500 grams
- Multiple pregnancy
- A mental health condition or substance use disorder
- Significant life stress, adversity, or trauma
- Children less than 6 years of age and currently has, or has a history of, or at risk for at least one of the following:
- Malnutrition or at risk of developmental or growth delay or impairment as a result of insufficient nutrition;
- Child maltreatment as defined by the CDC;
- Is a child with special healthcare need (CYSHCN);
- Low birth weight of <2500 grams;
- Mental Health condition;
- Significant life or family stress, adversity, or trauma
- Adults 65 years of age or older and currently has, or has a history of, or at risk for at least one of the following:
- Two or more chronic health conditions;
- Social isolation placing the individual at risk for early death, neurocognitive disorders, sleep disruption, cardiovascular disease, and elder abuse;
- Malnutrition;
- Dehydration;
- Abuse or neglect;
- Significant life adversity, stress, or trauma
- Young Adults with Special Health Care Needs (YSHCN) who are aged 19 to 20, with the following clinical risk factors:
- Has one ormore complex chronic conditions as identified in the Pediatric Medical Complexity algorithm (PCMA);
- Has serious emotional disturbance or serious mental health issue indicated by qualifying behavioral health diagnosis;
- Has a diagnosed intellectual or developmental disability;
- Has an “Elevated Service Need” or functional limitations as determined by two or more affirmative responses to a screener;
- Be experiencing Low Food Security or Very Low Food Security-measured by the U.S. Household Food Security Survey Module:
- Low Food Security-Reduced quality, variety, or desirability of diet, and little or no indication of reduced food intake.
- Very Low Food Security: Reports of multiple indications of disrupted eating patterns and reduced food intake.
- Be eligible for the HRSN Medically Tailored Meals service
HRSN Service Providers can be a public or private social service organization or clinic, community organization, or other similar individual or entity that provides HRSN services and helps to connect members with the HRSN benefit.
HRSN Service Provider Qualifications:
the service provider must:
- Be accessible to HRSN participants in your region, which may include having operating hours and staff necessary to meet member need.
- Demonstrate the ability and/or experience to effectively serve at least one of OHA’s Priority Populations.
- Demonstrate qualified service delivery and administrative staff
- Provide culturally and linguistically appropriate, responsive and trauma-informed services
- Demonstrate a history of responsible financial administration.
HRSN Service Provider List
YCAP
Agency Name: Yamhill Community Action Partnership
Office Hours: Monday-Friday, 8 am to 5 pm
HRSN Contact Name: Brittany Hanson
HRSN Contact Phone: (503) 687-1494
HRSN Contact Email: anydooryamhill@yamhillcap.org
Creating Opportunities
Agency Name: Creating Opportunities
Office Hours: Office Hours Vary. M-F
HRSN Contact Name: Cheryl Cisneros
HRSN Contact Phone: 503-559-0424
HRSN Contact Email: support@creatingops.org
Henderson House
Agency Name: Henderson House
Office Hours: 9am – 5pm, Monday – Friday
HRSN Contact Name: Josie Bartlett
HRSN Contact Phone: 503-472-0244 x 308
HRSN Contact Email: Jbartlett@hendersonhouse.org
Polk County
Agency Name: Polk County Family & Community Outreach
Office Hours: Monday-Friday 8am-12pm & 1pm-5pm
HRSN Contact Name: Katrina Reimann
HRSN Contact Phone: 503-751-1644
HRSN Contact Email: reimann.katrina@co.polk.or.us
Just Compassion
Agency Name: Just Compassion EWC
Office Hours: 8:30am-5:00pm
HRSN Contact Name: Matt Bunn
HRSN Contact Phone: 848-333-7232
HRSN Contact Email: matt@justcompassionewc.com
Meals on Wheels People
Agency Name: Meals on Wheels People
Office Hours: M-Th. 8am-4pm
HRSN Contact Name: Client Services Team
HRSN Contact Phone: 503.953.8111
HRSN Contact Email: intake@mowp.org
Oregon Wellness Network
Agency Name: Oregon Wellness Network
Office Hours: M-F 8 – 5pm
HRSN Contact Name: Lavinia Goto
HRSN Contact Phone: 503-304-3408
HRSN Contact Email: health.promotion@nwsds.org
Helping Hands
Agency Name: Helping Hands Reentry Outreach Centers
Office Hours: M-F 9am-5pm
HRSN Contact Name: Joshua Blomquist
HRSN Contact Phone: n/a
HRSN Contact Email: hrsnprogram@helpinghandsreentry.org
Community Wellness Collective
Agency Name: Community Wellness Collective (CWC)
Office Hours: 9-5, Monday through Friday
HRSN Contact Name: Elizabeth Martinez, Lead PSS/CMR
HRSN Contact Phone: (503) 200-2923
HRSN Contact Email: elizabeth@communitywellnesscollective.org
Specific Qualifications for HRSN Providers:
Outreach and Engagement Providers:
- Have the competency and experience to perform activities for the purpose of identifying OHP enrolled individuals presumed eligible for HRSN Climate-Related Services.
- Have knowledge of cultural specificity and responsiveness approaches, community outreach and engagement best practices, eligibility and enrollment policies and practices for OHP members, and local community resources for supporting basic needs.
- Ability to maintain strict confidentiality and handle sensitive information appropriately.
Climate Device Providers and/or Vendors:
- YCCO Service Vendors of Climate-Related Supports must have the ability to appropriately deliver Climate-Related Supports. Installation may be requested for AC Units only. YCCO will require that all contracted installers be licensed and bonded, complete a background check.
HRSN Housing Providers:
- Have knowledge of principles, methods, and procedures of housing services covered under HRSN, or comparable services meant to support individuals in obtaining and maintaining stable housing.
- Be trained, if necessary, to provide the specific service.
- Have the ability to directly meet the member’s needs for the activities listed in the housing service descriptions or the ability to connect members to the appropriate service provider or vendor.
HRSN Nutrition Providers:
- Comply with all applicable federal, state, and local laws governing food safety standards.
- Be trained and accredited on industry standards to provide the specific service. For example) webinar courses offered by SNAP-Ed, CDC-approved training for the National Diabetes Prevention Program Lifestyle Coach, and other trainings from accredited nutrition programs, Certified Nutrition & Wellness Educator, Registered dietician Nutritionist Licensure.
- Have the ability to meet the needs of member’s personal and cultural dietary preferences.
- Have the capacity to provide services on one-time, daily, weekly, or monthly basis.
- If a nutrition service is administered by a gift card/debit card, the HRSN Service Provider must have the ability to administer and coordinate the service, including engaging with members to explain the service, having relationships with food retailers that will accept payment, and monitoring and overseeing use of the cards.
Become an HRSN Service Provider
HRSN Readiness Plan:
- Must meet provider qualification defined above
- Demonstrate readiness to participate in Closed Loop Referral process (explained below)
- Demonstrate readiness for invoicing for services as agreed upon between YCCO and HRSN Service Provider
- Comply with reporting and oversight requirements established by OHA and YCCO
- Comply with applicable laws relating to privacy and security
- Ability to enroll as “encounter only” providers in MMIS, if not an already enrolled provider
*YCCO recognizes that some providers may need additional assistance to participate as a HRSN Provider. YCCO may contract with service providers who do not meet all HRSN Provider Qualifications.
Contact providerrelations@yamhillcco.org to inquire about becoming an HRSN provider.
To begin the process of enrolling as an HRSN service provider:
1. Complete this application.
2. Once you’ve completed the applications, email the OHA Provider Enrollment Team at Provider.Enrollment@odhsoha.oregon.gov to let them know you’ve submitted an application.
Find more information here: https://www.oregon.gov/oha/HSD/OHP/Tools/HRSN-Provider-Journey.pdf
Trainings/Webinars
HRSN Invoicing and Fee Schedule:
YCCO will follow OHA’s HRSN fee schedule to reimburse and/or directly pay through an automated payment system, which is slated to be in effect beginning August 2024. OHA has determined that MMIS will be ready to accept CCO Encounter Data for HRSN Services beginning August 1, 2024.
To receive payment, YCCO will collect the following information from HRSN Service Providers:
- Member identifying information (name, date of birth, Medicaid ID)
- Rendering provider organization
- Qualifying member information
- Date(s) of service
- Location of service
- Description of service provided
- Applicable service code
