All Insurance Policy Changes (Page 497)

Continuing from page 496. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Dental examinations under the OHP Recommended Periodicity Schedule
Oregon Health Plan·Identified Jun 20, 2026
Oregon Health Plan has updated their recommended periodicity schedule for dental examinations. This policy change affects providers serving OHP (Oregon Medicaid) members and establishes new guidelines for the frequency and timing of covered dental exam services.
Medium impact
Changes to the continuity of care disenrollment process, effective February 1, 2017
Oregon Health Plan·Effective Feb 1, 2017
Oregon Health Authority (OHA) standardized the continuity of care disenrollment process for Oregon Health Plan (OHP) members seeking fee-for-service coverage. Members must now complete form OHP 416 and submit to their PCP, who then requests medical review through OHA's prior authorization process. Prior auth decisions are tracked under PA Assignment 'Fee-for-Service OHP' with code G9399.
Low impact
Request for comment - State Plan Amendment to add CCBHC Program
Oregon Health Plan·Identified Jun 20, 2026
Oregon Health Authority proposes to add Certified Community Behavioral Health Clinics (CCBHCs) as recognized Medicaid providers through a State Plan Amendment to continue the program after the current demonstration ends June 30, 2019. This is a public notice requesting comments by May 17, 2019, and would maintain the same provider criteria and enhanced Medicaid reimbursement rates for comprehensive behavioral health services.
Low impact
Provider Announcement
Oregon Health Plan·Identified Jun 20, 2026
Oregon Health Authority is proposing to eliminate mandatory disenrollment from Coordinated Care Organizations (CCOs) for members seeking Out-of-Hospital Birth (OOHB) coverage. This allows OHP members to maintain CCO enrollment while accessing OOHB as a fee-for-service benefit for low-risk pregnancies, improving continuity of care across physical, oral, and behavioral health services.
High impact
OCC 1 override for fee-for-service prescriptions ends September 2, 2019
Oregon Health Plan·Effective Sep 3, 2019
Oregon Health Plan (OHP) is ending the use of Other Coverage Code (OCC) 1 override for fee-for-service pharmacy prescriptions effective September 3, 2019. Pharmacies must stop using OCC 1 to override claim denials and instead use appropriate OCC codes 2, 3, or 4 based on primary payer processing. Claims submitted with OCC 1 after the effective date will be denied.
High impact
Request for Comment - State Plan Amendment to increase fee-for-service SUD rates
Oregon Health Plan·Effective Oct 1, 2019
Oregon Health Authority is implementing rate increases for substance use disorder (SUD) and mental health services under Medicaid fee-for-service, effective October 1, 2019. SUD treatment codes will receive increases ranging from 10% to 38%, while mental health services will receive 4% increases.
Medium impact
Request for comment - State Plan Amendment to increase TCM home visiting rate - Comments due November 1, 2019
Oregon Health Plan·Effective Nov 1, 2019
Oregon Medicaid is increasing fee-for-service reimbursement rates by 29% for Targeted Case Management Maternal and Child Health home visiting programs (Babies First!, CaCoon, Family Connects®, and Nurse Family Partnership®) effective November 1, 2019. The rate is being rebased from 2012 costs to 2019 costs and is billed using treatment code T1017.
Medium impact
MS-DRG and LTC-DRG updates and inpatient claim reprocessing
Oregon Health Plan·Effective Oct 1, 2019
Oregon Medicaid is updating to Version 37 of the MS-DRG grouper software effective October 1, 2019, which changes 9 Oregon Unique DRG codes (317-325 become 521-529). The state will automatically reprocess all affected inpatient claims paid between October 1-November 3, 2019.
Medium impact
Provider Announcement
Oregon Health Plan·Effective Jan 1, 2020
Oregon Health Authority (OHA) is opening 15 dental procedure codes for fee-for-service Medicaid payment effective January 1, 2020. These codes cover space maintainer management, orthodontic appliance repairs, retainer services, and dental case management for patients with special health care needs. Billing teams must update their systems to recognize these newly covered codes and begin billing OHA for eligible Oregon Health Plan members not enrolled in coordinated care organizations.
Medium impact
Provider Announcement
Oregon Health Plan·Effective Jan 1, 2020
Oregon Health Plan now requires pharmacies to use the new OHP 3166 form (Client Agreement to Pay for Pharmacy Services) when OHP members elect to pay out-of-pocket for prescriptions. This applies to non-covered drugs, prior authorization delays, or member preference scenarios. Pharmacies must obtain member and pharmacy representative signatures, maintain copies for 5 years, and retain records per OAR 410-120-1360(2).
Medium impact
Request for Comment - Draft Medicaid State Plan Amendment to Align MH and SUD Services - Comments due Feb. 21, 2020
Oregon Health Plan·Identified Jun 20, 2026
Oregon's Health Authority is proposing a Medicaid State Plan Amendment to expand Substance Use Disorder (SUD) treatment services by aligning coverage with mental health services, including residential treatment facilities, recovery support services, and transitional housing. New CPT/HCPCS codes will be added to the Medicaid fee schedule for SUD providers, requiring billing system updates once codes are finalized.
Low impact
Request for comment – Draft SUD 1115 Waiver Application - Comments due February 21, 2020
Oregon Health Plan·Identified Jun 20, 2026
This is a public notice requesting comments on Oregon's proposed Substance Use Disorder (SUD) 1115 Waiver application to CMS. If approved, the waiver would expand Medicaid coverage for residential SUD treatment in facilities with 16+ beds, add recovery support services, and provide transitional housing support—currently not eligible for Medicaid funding. This is a regulatory proposal stage with no immediate billing impact; however, approval could significantly expand covered SUD services and billing opportunities in Oregon.
Medium impact
Provider Announcement
Oregon Health Plan·Effective Jan 15, 2020
Oregon Health Authority clarifies retainer payment policies for residential behavioral health settings. Providers can request retainer payments for temporary absences only (within 2 business days, with completed form), cannot bill retainer payments for evicted residents, and must avoid duplicate billing of retainer payments (T2033) and residential care payments (T1020) on the same date. Duplicate claims will be flagged for recoupment.
Medium impact
Provider Announcement
Oregon Health Plan·Identified Jun 20, 2026
Failed to analyze policy change
Low impact
Provider Announcement
Oregon Health Plan·Effective Oct 1, 2019
Oregon Health Authority (OHA) is waiving the requirement for Coordinated Care Organizations (CCOs) to attest that all Hepatitis C DAA drugs subject to 340B pricing were reimbursed at the 340B entity's actual acquisition cost plus dispensing fees. This waiver also eliminates the requirement to reprice drugs at the 340B ceiling price if reported costs are higher. The attestation was due April 30, 2021, for the 2020 benefit year, but this waiver retroactively removes this compliance obligation.
Medium impact
Provider Announcement
Oregon Health Plan·Effective Oct 1, 2019
Oregon Medicaid has corrected a clerical error in the CCO contract effective October 1, 2019. CCOs must now report Notices of Adverse Benefit Determination (NOABDs) for Applied Behavioral Analysis and Hepatitis C treatment for the previous calendar QUARTER (not year) within 45 days after each calendar quarter ends. Billing teams must update their reporting schedules and documentation processes immediately.
High impact
Provider Announcement
Oregon Health Plan·Effective Oct 1, 2019
The Oregon Health Authority clarified conflicting requirements between CCO contracts and state/federal regulations affecting NEMT attendants, consent forms, member disenrollment, claims payment notices, encounter data submission, and continued benefits during appeals. Billing teams must follow the regulatory hierarchy: CFR takes precedence over OAR, which takes precedence over contract language. Key changes include: encounter data submission within 45 days of adjudication (not monthly), claims payment notices only for denied claims (not approved), and corrected member disenrollment reasons per OAR 410-141-3810.
Low impact
Provider Announcement
Oregon Health Plan·Effective Jan 30, 2020
The Oregon Health Authority is waiving the requirement for certain Coordinated Care Organizations (CCOs) to submit an annual rate of growth report due by April 30, 2020. This waiver applies only to CCOs without a predecessor contract for a substantially similar service area in 2019. All CCOs must resume submitting this report by April 30, 2021, and those subject to the waiver are relieved from corrective action plans and sanctions for 2020 only.
Medium impact
Provider Announcement
Oregon Health Plan·Effective Jan 1, 2020
Starting January 1, 2020, youth with a primary diagnosis of Autism Spectrum Disorder (ASD) became newly eligible for Wraparound services under procedure codes H2021 and H2022. This eligibility was previously missed during Oregon's 2014 Wraparound implementation and has now been officially paired by the Health Evidence Review Commission.
Low impact
Provider Announcement
Oregon Health Plan·Identified Jun 20, 2026
This is an informational announcement from the Oregon Health Authority about a new Intensive In-Home Behavioral Health Treatment (IIBHT) program funded by the legislature. The OHA is hosting a series of webinars (beginning February 13, 2020) to educate behavioral health stakeholders, coordinated care organizations, and providers about the program's clinical standards, Medicaid rules, authorization requirements, and implementation details. No immediate billing or coding changes are mandated by this announcement.
Low impact
Provider Announcement
Oregon Health Plan·Identified Jun 20, 2026
This is an informational announcement from Oregon Health Authority (OHA) regarding the establishment of a new Intensive In-Home Behavioral Health Treatment (IIBHT) program funded with $6.6 million. OHA is hosting a series of webinars to inform stakeholders about clinical standards, program rules, Medicaid authorization requirements, and implementation details. No immediate billing or coding changes are mandated in this announcement.
Medium impact
Provider Announcement
Oregon Health Plan·Effective Feb 21, 2020
Oregon Health Plan now explicitly covers specific ICD-10 diagnosis codes (Z69.010, Z69.020, Z62.820, Z63.8, F43.8) as primary diagnoses for behavioral health treatment of trauma, abuse, neglect, and relational problems in children. Billing teams must accept and process claims with these diagnoses paired with appropriate behavioral health treatment codes without denial.
Low impact
Change in reporting of member enrollment in Patient Centered Primary Care Homes 02242020
Oregon Health Plan·Effective Feb 24, 2020
Oregon Health Authority changed Patient Centered Primary Care Home (PCPCH) enrollment reporting requirements for Coordinated Care Organizations from quarterly to annual submission. The first annual report under the new CCO 2.0 contract is due by January 30, 2021.
Low impact
Provider Announcement
Oregon Health Plan·Effective Oct 1, 2019
The Oregon Health Authority has waived the requirement for Coordinated Care Organizations (CCOs) to submit Patient Centered Primary Care Homes (PCPCH) work plans by February 15, 2020. This waiver eliminates the need to submit plans for increasing PCPCH membership and tier advancement targets, though all other PCPCH contract requirements remain in effect.
Low impact
Provider Announcement
Oregon Health Plan·Effective Oct 1, 2019
The Oregon Health Authority (OHA) has waived the requirement for Coordinated Care Organizations (CCOs) to submit a Social Determinants of Health and Equity (SDOH-E) Spending Readiness Self-Assessment by June 30, 2020. This waiver applies to CCO 2.0 contracts effective October 1, 2019, but does not relieve CCOs of other SDOH-E requirements under the contract.

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Dental examinations under the OHP Recommended Periodicity Schedule

Changes to the continuity of care disenrollment process, effective February 1, 2017

Request for comment - State Plan Amendment to add CCBHC Program

Provider Announcement

OCC 1 override for fee-for-service prescriptions ends September 2, 2019

Request for Comment - State Plan Amendment to increase fee-for-service SUD rates

Request for comment - State Plan Amendment to increase TCM home visiting rate - Comments due November 1, 2019

MS-DRG and LTC-DRG updates and inpatient claim reprocessing

Provider Announcement

Provider Announcement

Request for Comment - Draft Medicaid State Plan Amendment to Align MH and SUD Services - Comments due Feb. 21, 2020

Request for comment – Draft SUD 1115 Waiver Application - Comments due February 21, 2020

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Provider Announcement

Change in reporting of member enrollment in Patient Centered Primary Care Homes 02242020

Provider Announcement

Provider Announcement