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Health-Related Social Needs Benefits

Welcome

The Health-Related Social Needs Benefits (HRSN) Dashboard is an interactive data tool. Using this tool, it’s possible to explore Oregon Health Plan (OHP) HRSN benefits data. For example, users can better understand who might be eligible for HRSN benefits, see which community providers deliver HRSN services, understand how many benefits have been received, and learn more about the OHP members that have received the benefit in the time period reflected. The dashboard is updated quarterly.
Dashboard      Filters and Definitions      About the Data      General Information     

Questions about the dashboard? Email HRSN.data@oha.oregon.gov 
Help us improve! Please complete a short survey about your experience using this dashboard. 
Explore other HRSN data by visiting the HRSN Data webpage.

HRSN Data webpage

Dashboard

Please allow a moment for the dashboard to load. Use the dropdown filters to adjust/narrow down the data. The filters will affect data on the current page. Please apply filters separately on each page as needed. Learn what the filter options mean under "Filters and Definitions" below.
To view in full screen mode, click the expand icon Tableau Full Screen icon.png in the bottom right corner.


Filters and Definitions

Health-related social needs (HRSNs) are social and economic needs that affect a person's ability to maintain health and well-being.​

There are four HRSN benefit types available as part of the OHP 1115 Medicaid Demonstration Waiver.

HRSN benefits include:

  1. Home Changes for Health
  2. Housing
  3. Nutritio​n
  4. Outreach and Engagement (O&E)

Read more about the different HRSN services covered under each of the benefit types below. 

Home changes for health benefits (available since March 2024) provide/offer devices that keep people healthy in their homes during extreme weather. These devices help provide members with clean air and healthy temperatures; they help keep medication cold and help keep medical devices, like ventilators, operating during a power outage. They include:

  • Air conditioners
  • Heaters
  • Air filtration devices
  • Air filter replacements
  • Mini refrigerators
  • Portable power supplies

Members can also get help with the installation of the device. These services are described on the dashboard as:

  • Installation of the home changes for health device (each service represents 15 minutes of installation support)
  • Home changes for health supports (new equipment – admin) (each service represents administrative support per device, per member)​

Housing benefits (available since November 2024) help people stay housed. Services include:

  • Paying rent and utility costs (each unit represents one month of bundled forward or arrears rent and utility and/or utility payments)
  • Tenancy support services, which help members get resources and services (each service represents 15 minutes of support)
  • Help paying for utilities arrears (each service represents one month of past-due utility payments for any utility)
  • Paying for utilities set-up (each service represents one instance of utility setup)
  • Help paying for storage fees (each service represents one month of storage payments)
  • Help paying for hotel/Motel stays during home changes for safety (each service represents one day of stay)
  • Providing/offering home changes for safety (medically necessary home accessibility modifications or medically necessary home remediations) (each service represents one member receiving this service)​

Nutrition benefits (available since January 2025) help people with nutrition-related health needs eat to stay healthy. They include help to get medically tailored meals, and education to help people have a healthy diet on a budget. Currently, these include:

  • Medically Tailored Meals (each service is one meal)
  • Nutrition Education (each service is 30 minutes of nutrition education) 

In 2026, additional nutrition benefits will help eligible members obtain fruits, vegetables, and pantry foods.​

Outreach and Engagement (O&E) benefits help people learn about other programs and services, apply for benefits, organize paperwork, and find help in their language.

Each Outreach and Engagement service on the dashboard represents 15 minutes of outreach and engagement performed by community-based organizations registered as HRSN service providers. ​

HRSN benefits are available to OHP members who meet certain requirements. Some requirements apply to all HRSN benefits, while others apply only to specific benefits. To be eligible for a service, a member must meet both the general requirements and any specific requirements for that service. All requirements must be met for a member to be eligible for a service.  

General requirements include:

1) Being enrolled in OHP

2) Belonging to an HRSN covered population

3) Having an HRSN clinical risk factor

4) Needing resources to improve health and wellbeing (having a social risk factor)

The estimates in the dashboard help visualize how many OHP members could potentially meet each eligibility requirement, based on the data available to OHA. For these estimates, we are looking at all HRSN benefits together. In practice, each benefit will have different eligibility requirements. Estimates also focus on potential eligibility and don't consider demand, uptake or access to services.

It is also important to note that some HRSN services are available at the household or family level. The estimates on the dashboard show the number of individual members that might be eligible for a service, but some services, such as housing rent and utility, are only available once per household. ​

Click here to learn more about how households are defined for the rent benefit.

HRSN covered populations are groups experiencing challenging transitions in their lives. There are seven Covered Populations for HRSN benefits, and they include:

Individuals who are homeless

Individuals who are at-risk of homelessness
  • Members with an income that is 30% or less than the area median income where the individual resides according to the most recent available data from the U.S. Department of Housing and Urban Development, lacks sufficient resources or support networks to prevent homelessness,​ and meets any HRSN Housing and Nutrition Clinical Risk Factor.
Adults and youth released from incarceration
  • Members released from incarceration within the past 365 calendar days, including those released from state and federal prisons, local correctional facilities, juvenile detention facilities, Oregon Youth Authority closed custody corrections, or tribal correctional facilities. 

Adults and youth discharged from an HRSN Eligible Behavioral Health facility

  • Members must have been discharged in the last 365 days.
  • Facility types include: Residential Substance Use Disorder (SUD) treatment and Withdrawal Management services, Institutions for Mental Diseases (IMDs) including Specific Oregon State Hospital facilities and community based IMDs, Adult Mental Health Residential Programs, Residential Treatment Facilities (RTF), Residential Treatment Homes (RTH), Secure Residential Treatment Facilities (SRTF), Inpatient Psychiatric Services in Hospitals, Psychiatric Residential Treatment Facilities (PRTF) for children and youth, Sub-Acute Psychiatric Care, Secure Children's Inpatient Treatment Programs (SCIP), Secure Adolescent Inpatient Treatment Programs (SAIP), and Integrated Psychiatric Residential Treatment Facility and Residential Substance Use Disorders Treatment Programs for youth.
Individuals currently or previously involved in Oregon's Child Welfare system
  • Members who are currently or have previously been involved in Oregon's Child Welfare system, including Members who are currently or have previously been: 1) In foster/substitute care; 2) The recipient of adoption or guardianship assistance; 3) Served on an in-home plan; 4). T​he subject of an open child welfare case.
Individuals transitioning to Dual Eligible Medicaid and Medicare Status
  • Members enrolled in Medicaid who are transitioning to dual eligible status with Medicare and Medicaid coverage. Members are in this HRSN covered population for the ninety (90) calendar days before the date Medicare coverage is to take effect and 270 calendar days after.
Individuals identified as Young Adults with Special Health Care Needs (YSHCN)
  • To be eligible for YSHCN benefits, young adults ages 19 and 20 must have at least one qualifying health care need that began before age 19, and individual or family income up to 205 percent of the federal poverty level.
  • This benefit became available on January 1, 2025. OHP members that receive YSHCN benefits meet the HRSN covered population criteria.

Not all HRSN covered populations are eligible for all HRSN services. For example, housing rent and utility HRSN services are only available to members in the “at-risk of homelessness" population.​

Clinical risks are health conditions or medical criteria that members must have to qualify for HRSN Services. These criteria make sure the HRSN service is medically appropriate to help a member maintain or improve their health. Members meet clinical risks by having at least one qualifying clinical risk factor.

Details can be found in the CMS-approved HRSN Services Protocol.

Examples of clinical risk factors for HRSN services include members:

  • With self-attested complex behavioral health needs
  • With acute or chronic complex physical health needs
  • Requiring assistance with an Activity of Daily Living or Instrumental Activity of Daily Living
Learn more about the different clinical risk factors for each specific HRSN service: Effective Jan. 1, 2026, OHA updated clinical risk criteria specifically for the HRSN rent and utility benefit.
  • HRSN Home Changes for Health Devices have a dedicated set of Clinical Risk Factors listed in OAR 410-120- 2005 Table 1.
  • HRSN Housing and Nutrition supports have their own set of Clinical Risk Factors listed in OAR 410-120-2005 Table 2.

Individuals must need resources to improve health and wellbeing to meet social risk factor criteria. Social risk factors broadly indicate what type of service(s) a member might benefit from (e.g., housing versus nutrition). In some cases, the HRSN covered population may be the same as the social risk factor (e.g., being at risk of homelessness serves as both an HRSN covered population and a qualifying social risk factor).​

  1. ​HRSN service providers are organizations that provide HRSN services, which include home changes for health, housing, nutrition, and outreach and engagement benefits. HRSN service providers can choose to provide one, two, or all these benefits to OHP members. In addition, HRSN service providers serve OHP members in ways that are culturally and linguistically appropriate, responsive and trauma informed.
  2. Since HRSN benefits are new, service providers need to contact their local CCO to find out how to join their network and serve CCO members.  OHA also encourages service providers to enroll with OHA to serve Open Card (Fee-for-Service) members.  While many service providers have registered with OHA as HRSN service providers, registration alone does not indicate active service delivery.
  3. This is not an exhaustive HRSN service provider directory. See Data Notes section on providers below.
Learn more about HRSN Information for Providers.
Learn more about HRSN Provider Training.
Learn more about Community Capacity Building Funds (CCBF).
 

About the Data

Where do the data come from?

1.      HRSN Services and Providers Data:

Oregon's Medicaid Management Information System (MMIS) has data on health care services paid for by Medicaid. It also includes information about member and provider enrollment.  Learn more about MMIS.

Contractor reports also provide information on how the HRSN process is working, including who's requesting HRSN benefits, who's been approved or denied for benefits, and why, appeal and grievance data, and timeline from service authorization to delivery.

2.      Demographic Data:

We use data from OHA's REALD & SOGI Repository. In 2023, OHA launched the REALD & SOGI Repository, our central, validated source of race, ethnicity, language and disability (REALD) and Sexual Orientation Gender Identity (SOGI) data.

The REALD & SOGI survey was updated in July 2024. New questions were added, and some existing response options were changed or removed. It is optional for members to respond to these questions and provide this information. While data collection has begun using the updated survey, there data are currently too small to reliably report. Therefore, any responses collected using the updated survey have been crosswalked to the original (2020) survey standards in this dashboard. In most cases, this means that members selecting new response options have been placed into a less granular reporting category. 

For example, an individual who has selected the option of 'English' in response to the updated REALD & SOGI question about race, ethnicity, ancestry, or country of origin would be displayed in this dashboard as 'Western European,' and someone who has selected the option of 'Iranian' would be displayed as 'Middle Eastern.' The data crosswalk used for this process was developed by subject matter experts in the Equity & Inclusion Division, with support provided by analysts in the Health Policy and Analytics Division.

The dashboard will be updated with the groups from the 2024 collection standards when enough data has been collected to reliably report.

Learn more about REALD and SOGI data.

3.      Cross-agency data

We use data from other agencies or systems, such as the ONE Eligibility system and Oregon Department of Human Services (ODHS), to identify members that may belong to an HRSN covered population. The data has been used to estimate the number of members that may be eligible for benefits. It has also been shared with plans (CCOs and Open Card) so that they can provide outreach to members for whom they coordinate care.

​General

  • Some members receiving HRSN services represent families. We currently do not have household composition data available to determine the exact number of families receiving HRSN services.

Member Demographics:

  • REALD are a set of standardized questions and data about a person's: Race, Ethnicity, Language, and Disability. REALD information helps us understand who is most impacted by health inequities and how we can best support these community members to access the services and resources they need to be healthy and thrive. Asking REALD questions empowers individuals to choose whether to share their identities and experiences or to decline. 

Age

  • Age is based on a member's age on the date they first received an HRSN service.

County

  • If a county is shown in grey, it means no members received services in the county.

Gender/Sex

  • The sex categories shown here are based on sex assigned at birth. The gender categories are based on sexual orientation and gender identity (SOGI) methodology. 

Language

  • Some members who report speaking "English only" may still have language access needs, such as requiring sign language interpreters. 

Disability

  • Non-disabled individuals are those who did not report any limitations in daily activities. However, it's important to note that not all disabilities are identified through functional limitations, so results should be interpreted with caution.
  • Independent living/self-care disability includes members who reported having a) difficulty doing errands alone such as visiting a doctor's office or shopping because of a physical, mental, or emotional condition (ages 15 or older), or b) difficulty bathing or dressing (ages 5 and older), or members who did not respond to REALD disability questions but were identified as having a Permanent Disability, receiving Supplemental Social Security Income (SSI), or long-term care (LTC) services.
  • 2+ limitations does not include independent living or self-care disabilities.
  • Mobility only focuses on ambulatory/lower mobility only. 

Services

  • Housing benefits launched in November 2024; however, members, may request rent and utility payments going back to May 2024. 

HRSN Service Providers

  • HRSN service providers are organizations that provide HRSN ser​vices, which include home changes for health, housing, nutrition, and outreach and engagement benefits.
  • HRSN service providers can choose to provide one, two or all benefits to OHP members.
  • HRSN service providers serve OHP members in a way that is culturally and linguistically appropriate, responsive and trauma informed.
  • While many providers have registered in MMIS as HRSN providers, registration alone does not indicate active service delivery.
  • Providers may appear in multiple counties, may be associated with multiple plans, and may offer multiple HRSN benefit types.
  • CCOs and out-of-state providers are included because they can also provide services directly to members.

Privacy Statement

  1. The Oregon Health Authority is committed to protecting the personal and confidential information of clients and employees. Our clients and employees expect the department to protect confidential information--just as you expect your information to be protected by financial institutions, health care providers and others.
  2. Privacy is a right that people have. Security is the protection of that right.

Small Numbers Suppression

  1. Cells with an asterisk (*) indicate number <10 (inclusive of zero). These numbers are suppressed to protect confidentiality and because they may be statistically unreliable. As a result, totals may not reflect the sum of numbers shown across a row or column. Users should not "backwards calculate" to deduce suppressed values, as they may be statistically unreliable.
  2. Percentages based on small counts—particularly when the denominator is fewer than 50—may be unreliable and should be interpreted with caution. Counts should be emphasized instead.  

1.      Are these numbers final?

The number of services delivered and providers delivering services from recent months might change slightly when the dashboard is refreshed. That's because sometimes there is a delay between the date a service was provided and the date a claim for the service was submitted and processed.

2.      How do OHP members get HRSN services?

There are different pathways for OHP members to get HRSN benefits. HRSN services must be requested, and requests for services can be made by the member themselves or a caregiver, or with support from the member's health plan (CCO), HRSN Service Provider, or community organization. Once all the necessary information is gathered, members will get a decision from their health plan on whether they qualify for benefits or not. After a decision is reached, the CCO or HRSN Service Provider will work to get the HRSN benefits to the member.

Learn more by visiting the HRSN Member Journey.

3.      Who are HRSN recipients?

OHP members who meet program eligibility requirements and have been provided benefits through their Health Plans.

4.      What is the difference between the number of members that received a service, and the number of services delivered?

The number of members that received a benefit will represent unique members served. You can see the demographic characteristics of members in the “Demographics" section of the dashboard.

Members can receive more than one HRSN benefit type, or they might be able to receive the same service more than once, depending on the benefit. You can see the number of services provided in the “Services" section of the dashboard.

5.      How many families have received HRSN services?

This dashboard does not consider the number of families served by the benefit. 

 

General Information

Accessibility

You can get data from this display in other languages, large print, braille, or a format you prefer. Email OHA.HealthAnalyticsRequest@odhsoha.oregon.gov .

Suggested Citation  

Oregon's Health-Related Social Needs Benefits Dashboard (2026). Interactive display accessed [MM/DD/YYYY]. Salem, OR: Oregon Health Authority.

https://www.oregon.gov/oha/HPA/ANALYTICS/Pages/Medicaid-Data-Dashboards.aspx 

Request Data

If you need additional data or analysis than what's presented in this dashboard, visit the  Health Analytics Data Request  page. 

Release Notes

This is the original version of the dashboard that has been released. Any major updates to data sources or design will be noted here.