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.
Ways OHA Will Get Feedback
OHA will hold at least one virtual meeting for each of these groups by October 2024:
- Community partners,
- CCOs and
- Fee-for-service (open card) contractors
The goal of the meetings is to:
- Describe the change to the benefit structure
- Answer questions about the change
- Get input about possible impacts to these groups
Starting this fall, OHA also plans to meet with CCOs and community partners. OHA will discuss project updates and operational decisions at these meetings.
HERC 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.