2022-2027 Medicaid 1115 Demonstration Waiver

Why Is the 2022-2027 Waiver Important?

Where we are born, live, learn, work, play, and age can affect our health and quality of life. Access to continuous health coverage promotes better health. Supporting social needs through Oregon Health Plan (OHP) coverage helps Oregon:

Better coordinate services for people when they most need stability.
Align with other health policy initiatives in our state to achieve health equity.

Achieving health equity will help Oregon to:

Improve the lives of individuals who face historic and contemporary injustices;
Increase individual, family and community resilience; and
Reduce health disparities for groups most affected by injustice and discrimination.

What's Changing in the 2022-2027 Waiver

OHP now covers all health care children on OHP need for their health and development, from birth to age 21. This is true even if the care is not covered according to the Prioritized List of Health Services. OHP must cover all medically necessary and medically appropriate care.

Learn more about EPSDT.

Children with OHP have coverage from birth until their sixth birthday. This means families do not need to renew OHP benefits to keep children covered. They can also get the health care their child needs in their most formative years.

People age six and older have two full years of OHP coverage. This helps people have better health over the long-term.

Learn more about continuous eligibility.

OHP will provide housing, climate and nutrition support for people in challenging situations, such as:

Homeless or at risk of losing housing
Extreme weather events
Leaving state or Tribal custody

Health-related social needs services are expected to begin in 2024-2025.

Learn more about health-related social needs.

New or existing organizations that provide housing, climate or nutrition support can apply for Community Capacity Building Funds. Organizations can use these funds to get ready to serve as an HRSN provider.

Learn more about these funds.

Oregon is working to offer more benefits to young adults with special health care needs.

Examples of special health care needs:

Physical, intellectual and developmental disabilities
Longstanding medical conditions like asthma, diabetes, or spina bifida
Behavioral or mental health issues like depression or substance use disorder

Starting in 2025, qualifying young adults with special health care needs on OHP will get:

The extra vision and dental services that kids get on OHP
All medically necessary and medically appropriate care (also known as EPSDT)
Things like free air conditioners or help finding safe and low-cost housing.

Learn more about these supports.

Per the CMS letter of approval for Oregon's 2022-2027 waiver, the waiver for the Prioritized List will end Dec. 1, 2026. By Jan. 1, 2027, CMS requires Oregon to do the following:

Transition its authority to structure the Prioritized List for adults to align with state plan rules. To comply with Federal requirements, Oregon will at a minimum need to define and describe the decision-making process for covered and non-covered services in the State Plan.

The state must define in the State Plan the:

Categories of services; and
Amount, duration, and scope of services.

OHA's Benefit Update Project will work to make these changes. Learn more about the project.

Oregon's Quality Incentive Program pays bonuses to coordinated care organizations (CCOs) for:

The quality of health care OHP members receive,
Whether they can get health care in the right place at the right time, and
Other activities that show how well CCOs care for OHP members.

OHP members and communities will have a greater voice in this program. This way, the program will reward CCOs for activities that:

Matter the most to the community and
Have the greatest chance of improving the long-term health of OHP members.

Oregon will also have “upstream" and “downstream" metrics.

Upstream metrics focus on things CCOs can do to prevent poor health and health inequity. Example: Culturally responsive health care services or services in an OHP member's preferred language.

Downstream metrics show health outcomes. These metrics will align with Medicaid metrics used across the country. Example: Diabetes care and well child visits.