MedicaidCoverageHigh impact
Early and Periodic Screening, Diagnostic & Treatment (EPSDT) benefit expansion
Oregon Health Plan·OR · Pediatrics, Family Medicine·Plan contract
Effective date
Jan 1, 2023
We identified it
Jun 20, 2026
Summary
Oregon is expanding EPSDT (Early and Periodic Screening, Diagnostic & Treatment) benefits for Medicaid patients under 21, removing previous restrictions and requiring coverage of all medically necessary services even if they're not on the prioritized list. This significantly broadens covered services for pediatric and adolescent Oregon Health Plan members.
Action Required
By January 1, 2023: Billing team must update prior authorization processes for Oregon Health Plan members under 21 to allow case-by-case medical necessity determinations for all services, even those previously denied as 'below the line' on Oregon's prioritized list. Update billing system to flag that denials cannot be based solely on service being unfunded. Train staff that all denial decisions for pediatric OHP members must include Notice of Adverse Benefit Determination and appeal rights. Monitor OHA's EPSDT webpage for final guidance documents and submit questions to EPSDT.Info@odhsoha.oregon.gov.