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Oregon Health PlanMedicaid · Coverage · Public notice · ORHigh impact

Notice of Intent – OHA will submit Oregon’s Medicaid Phase-out Plan for the Waiver Authority Related to the Prioritized List

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Jun 20, 2026

Summary

Oregon will phase out its 1115 waiver authority for the Prioritized List by January 1, 2027. Covered services will then be defined by categories of services in the state plan, with the Prioritized List guiding medical necessity policy, so coverage decisions will be based on medical necessity rather than on whether a treatment-condition pair sits above or below the funding line. OHA estimates a 0.7% increase in 2027 CCO capitation rates to reflect coverage of some services previously not covered.

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What to do

by Jan 1, 2027 · 7 steps
01Billing team should expect coverage decisions to be based on medical necessity rather than funding-line position.
02Services that are below the funding line and identified as medically necessary will remain on the Prioritized List and be considered medically necessary with appropriate guidelines.
03Evaluation and management codes may be removed from the Prioritized List, with policy stating they are covered regardless of diagnosis, except for conditions such as infertility that are excluded from the benefit package.
04Guideline notes will be reworded to state that a service is medically necessary for the listed conditions when the same criteria are met, for example bariatric surgery on line 317 and spinal decompression surgery under guideline note 37.
05Individuals denied a covered service have a right to appeal.
06Watch for the CCO contracts and Member Handbook templates that take effect January 1, 2027.
07Essential State Plan Amendments were targeted for submission to CMS Previously due October 1, 2026 (date passed; verify current applicability), so check current applicability of that date before relying on it.

Original notice

Notice of Intent – OHA will submit Oregon’s Medicaid Phase-out Plan for the Waiver Authority Related to the Prioritized List
oregon.gov · Always check the source before changing claims.
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