Health Related Social Needs

Health Related Social Needs (HRSN) are social, community, cultural, and economic needs that that affect well-being. Things like access to food, housing, and transportation, clean safe neighborhoods, education, and a sense of community are all a part of health. As part of supporting these basic needs Oregon’s HRSN benefits will be available to some Oregon Health Plan members with social risk factors that include needing climate related devices, housing supports and nutrition supports.

To learn more about HRSN services go to Oregon Health Authority: HRSN web page.

To learn more about becoming a Community Partner for HRSN benefits go to the Community Capacity Building Funds web page.

Members who have social risk factors may be eligible for HRSN benefits:

Climate supports are devices to keep members healthy during extreme weather. They include air conditioners for heat risks, air filtration devices to protect against wildfire smoke, portable heaters, mini refrigeration units for medications and portable power supplies to keep medical devices running during power outages.

Housing supports help people stay housed. They include help with the cost of rent and utilities, help keeping a place to live and help communicating with landlords.

Nutrition supports help people with nutrition-related health conditions eat to stay healthy. They include help to buy food, including fruits, vegetables and medically-tailored meals and education to help people have a healthy diet on a budget.

Outreach and engagement supports help people find the resources they need. These include HRSN services and other medical and nonmedical benefits.

HRSN benefits are for members experiencing life transitions that can lead to a drop in health. Eligible transition population criteria include:

  • Involvement with Child Welfare.
  • Adults and youth leaving some residential mental health treatment programs.
  • Recently eligible for Medicare/Medicaid coverage.
  • Released from a detention center, Oregon Youth Authority facilities, jail or prison.
  • Experiencing homelessness or at risk for homelessness.

Members with an OHP plan that qualifies for HRSN AND in one of these transition populations can be assessed for clinical risk factors. While each benefit has different health need requirements some examples include:

  • Pregnancy.
  • Complex mental and behavioral health needs.
  • Complex physical health needs including some chronic conditions.
  • Children under the age of six.
  • Developmental disabilities.

Additionally, qualifying members must meet the following:

  • Has not received similar requested device in the last 36 months.
  • Can safely use the climate device in their primary place of residence, as applicable.
  • Live in their own home, rent their own home, live with friends/family or live in an RV with a reliable power source (can be a generator).

How Do Members Find Out If They Are Eligible?

HRSN provider partners in the community are able to support members with an initial assessment through Unite Us.

Contact IHN-CCO customer service.

Become an HRSN Provider


IHN-CCO is working throughout the region to build a network of community based providers who can connect members with HRSN benefits. Providers can be Community Based Organizations (CBOs), governmental entities, clinics, social service providers or other organizations. All types of organizations are eligible to become HRSN service providers.

HRSN providers are required to:

  • Be accessible to IHN-CCO members who qualify for HRSN services.
  • Have demonstrated experience effectively serving priority populations.
  • Provide trauma informed culturally and linguistically appropriate services.
  • Demonstrate a history or responsible financial administration.
  • Be able to participate in the Closed Loop Referral process.

Additionally, some HRSN benefits have specific requirements, see below.

Housing services providers must have knowledge of the principles, methods and procedures of housing services as covered under the waiver or of comparable services meant to support individuals in obtaining and maintaining stable housing.

Nutrition services providers must have knowledge of the principles, methods and procedures of the nutrition services covered under the waiver or of comparable services meant to support an individual in obtaining food security and meeting their nutritional needs. Nutrition service providers must follow best practice standards for food safety.

Outreach and engagement providers must have knowledge of the principles, methods and procedures of these services or comparable services meant to outreach and engage the populations covered under the waiver and connect them to benefits and services to meet their needs.

HRSN Providers

Providers will need to be able to obtain Oregon Medicaid provider ID number and work with IHN-CCO to complete all necessary enrollment steps. If you are interested in becoming a provider please fill out the provider interest form and our IHN-CCO team will work with you to assess next steps.

Outreach and Engagement is an essential part of connecting members with benefits. HRSN Providers can:

  • Work with IHN-CCO to conduct outreach to members who might be eligible.
  • Support members who reach out directly to learn more.
  • Help people find their CCO or direct them to OHP Open Card services.
  • Support members filling out the HRSN Request Form or utilize Unite Us to request services.
  • Provide resources around approved or denied referrals. Members will learn if they are approved for HRSN services within 14 days of completing the HRSN screening.
    • If approved, the CCO will contact the person and refer them to providers for services.
    • If not approved, the CCO will contact the person by mail. Providers can help people ask for an appeal or hearing or can refer them to an OHP ombudsperson.
    • Providers can work with IHN-CCO to see if they can get the same or similar services through Health Related Services or other programs.

IHN-CCO will be primarily utilizing Unite Us to manage closed loop referrals, meaning that referring organizations will be notified of the status of a referral. HRSN provider partners will be able to access Unite Us to receive and send referrals. They will also have access to a shared resource directory and be able to communicate with IHN-CCO. Additional options are available for organizations or individuals who are unable or unwilling to utilize Unite Us.

Providers agree to:

  • Deliver services and notify IHN-CCO through Unite Us or other means agreed upon within 30 days of receiving a referral.
  • Communicate with IHN-CCO if unable to fulfill or deliver an accepted referral.
  • Help with repairs or replacements (climate devices) as well as answering basic questions for proper care and use of devices.

HRSN provider organizations will be able to invoice IHN-CCO for approved services through Unite Us, medical claims or submitting approved invoice.

Review OHA’s Climate-related fee schedule from March 2024 or go to OHA’s fee schedule web page and look for the most current version. Invoices must be received within 120 calendar days of delivering services or equipment.

Providers should work with IHN-CCO to ensure all information remains current and they remain enrolled as HRSN Providers. If a provider wishes to disenroll refer to the provider agreement or contact IHN-CCO for appropriate steps


For additional information on becoming an HRSN Provider or to enroll as an OHP Open Card provider visit the OHA HRSN Services or utilize this Provider Journey Guide.

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