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.
Every two years 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.
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 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. Register for the Jan. 29 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 monthly 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. The sessions were for community partners, CCOs and fee-for-service (open card) contractors. The information in this material is current as of the presentation date. Project decisions continue to evolve with health care partner input.