Changing How Oregon Organizes OHP (Medicaid) Benefits
Since 1994, Oregon has used the
Prioritized List of Health Services to help determine what OHP covers. This list ranks health conditions and their treatments.
- Services that are most effective or most important for overall health rank higher.
- Services not needed or less effective rank lower.
The Oregon Legislature sets a funding line. This line sets how many services OHP covers on the Prioritized List. Services above the line are covered. Services below the line are usually not covered. This line has not moved since 2012.
Oregon is the only state that uses a Prioritized List. The Health Evidence Review Commission manages the list. The commission is an independent body that:
- Looks at the science behind treatments,
- Decides what treatments are medically necessary, and
- Gets feedback from members on which services OHP should cover.
Medically necessary means the services are:
- Needed for diagnosis or treatment and
- Backed by science.
What Is Changing?
The federal Centers for Medicare & Medicaid Services told Oregon Health Authority (OHA) to stop using the Prioritized List by Jan. 1, 2027. Instead, OHA must group services into categories and decide which services to cover. These decisions will be in
Oregon's Medicaid State Plan.
- The federal government sets these categories. It also sets which categories are mandatory and optional.
- OHP will cover all medically necessary services in covered categories.
- Optional categories will clearly list covered and non-covered benefits.
- Oregon will decide which new optional benefits to cover.
This matches how other states define Medicaid-covered services.
What This Change Means for OHP Members
Members will not lose benefits because of this change. All services covered today will still be covered on and after Jan. 1, 2027.
- Starting in January 2027, OHP will cover medically necessary treatments for more health conditions, such as tension headaches and fibromyalgia.
- OHP will still not cover treatments that are cosmetic or medically unnecessary.
- OHA or the member's coordinated care organization (CCO) may still need to approve some services.
The Health Evidence Review Commission will still:
- Review evidence and community input on clinical services,
- Support public, transparent processes,
- Seek opportunities for community engagement,
- Produce guidance on the medical necessity of some services, and
- Document conditions and their covered treatments.
Health Care Partners: OHA Values and Needs Your Input
OHA opportunity for community partner engagement
Oregon Health Authority (OHA) is seeking nominations for members of the Benefit Update Project (BUP) Workgroup to help support the required transition away from the state’s use of the Prioritized List. The goal of the BUP Workgroup is to study the potential impacts, and ways to limit the potential impacts, of phasing out the Prioritized List of health services. The workgroup will be led by OHA.
OHA is looking for people who have a wide range of experiences and backgrounds. BUP Workgroup members can expect approximately 5 hours of meetings per month through the end of 2025, including time to prepare for each meeting. Meetings will be virtual and held approximately twice per month. Members may be eligible to receive compensation for their time. OHA is looking for people to fill the following seats:
- One representative from the disability rights community
- One representative of a dental care organization
- One representative of a statewide behavioral health association
- One Tribal health representative: an individual who is a member of, or who represents, a Federally Recognized Tribe in Oregon. The Tribal Health Representative will be identified by the Tribes.
- One representative from a community-based provider (e.g., FQHC)
- One representative from a health system
- One representative from a legal aid organization
- One current member of the Health Evidence Review Commission (HERC)
- Five representatives from Coordinated Care Organizations (CCOs), who have relevant roles in financial operations, actuarial analysis, and or medical management, or claims adjudication (including at least one from a rural service area and one from an urban service area).
If you are interested in nominating yourself or someone else, you can find the application here: https://forms.office.com/g/nA7x2eFavn. Applications are open until July 16, 2025. BUP Workgroup members will be announced in early August 2025, with meetings occurring between August and December 2025.
If you have additional questions, please reach out to hherc.info@oha.oregon.gov.
OHA will present at regular meetings to:
- Describe the change to the benefit structure
- Answer questions about the change
- Get input about possible impacts to these groups.
All Come – Quarterly virtual meeting on the 1st Wednesday of the month at 10 a.m. Pacific Time starting in January. Register here.
Para Todos – Quarterly virtual meeting in Spanish on the 1st Wednesday of the month at 2 p.m. Pacific Time. Register here.
Medicaid Advisory Committee/Advising Consumer Experience subcommittee – Monthly meeting. OHA will provide project updates at one meeting per quarter. View the meeting schedule.
Listening Session – OHA will hold the session Jan. 29, 2025 at 9:05 a.m. Pacific Time over Zoom. OHA will send invitations to the session.
Health Evidence Review Commission – The commission typically meets every 1 or 2 months. View the meeting schedule.
CCO Operations Workgroup – OHA will hold the first meeting in January 2025, where the workgroup will set the cadence for future meetings. The workgroup will occasionally invite providers to attend, depending on he scheduled topics.
CCO Quality and Health Outcomes Committee – Monthly meeting. View the meeting schedule.
Ad hoc participation in provider conferences/forums – OHA will make an effort to occasionally attend conferences and forums where discussion about the project is appropriate.
Health Evidence Review Commission – The commission typically meets every 1 or 2 months. View the meeting schedule.
CCO Operations Workgroup – OHA will hold the first meeting in January 2025, where the workgroup will set the cadence for future meetings. The workgroup will occasionally invite providers to attend, depending on the scheduled topics.
CCO Quality and Health Outcomes Committee – Monthly meeting. View the meeting schedule.
Legislative updates – Leadership of the 1115 waiver project will provide regular updates to the Oregon Legislature.
.All Come – Quarterly virtual meeting on the 1st Wednesday of the month at noon Pacific Time. Register here.
Para Todos – Quarterly virtual meeting in Spanish on the 1st Wednesday of the month at 2 p.m. Pacific Time. Register here.
Health Evidence Review Commission – The commission typically meets every 1 or 2 months. View the meeting schedule.
Listening Session Material
OHA held listening sessions from August through November 2024 and January 2025. The 2024 sessions were for community partners, CCOs and fee-for-service (open card) contractors. The 2025 sessions were for health care providers.
The information in this material is current as of the presentation date. Project decisions continue to evolve with health care partner input.