OHA announces intent to modify waiver request

In the announcement you’ll find below, OHA has announced an important change to its waiver renewal proposal which affects the work of the Health Evidence Review Commission (HERC), based on feedback obtained from the public during the public comment process on the waiver renewal. It underscores the continued importance of the work HERC does in developing the core of the benefit package for the Oregon Health Plan for all populations, regardless of eligibility category. This change will also assure that, as required by federal law, children covered under the Oregon Health Plan will have the right to an individual consideration of medical necessity to take into account their individual circumstances, including their developmental stage.

HERC staff have already been working on the comprehensive review of services not covered. Our team will conduct this review in our normal public meeting process, and we welcome suggestions on topics or considerations to include as we complete this analysis. Please send any topic suggestions to herc.info@dhsoha.state.or.us.

 

February 8, 2022

The Oregon Health Authority (OHA) appreciates the clear feedback from the community, including advocates, children’s service organizations and other interested parties, regarding Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services provided to children and adolescents enrolled in the Oregon Health Plan (OHP). OHA has taken this feedback seriously. 

After careful consideration of community input and a comprehensive internal review, OHA has decided to not seek a renewal of its long-standing waiver regarding the EPSDT benefit for children and adolescents in its upcoming 1115(a) Medicaid waiver renewal application in its current structure.

In its waiver application, OHA will propose to the Centers for Medicare & Medicaid Services (CMS) to cover all treatments and services determined as medically necessary in accordance with the EPSDT benefit, after a phase out period, as described below.

The public and transparent process of Oregon’s Health Evidence Review Commission (HERC) and the Prioritized List of Health Services will retain important roles in determining OHP benefits for children, adolescents and adults. Oregon will specifically meet the ESPDT benefit requirements for children and adolescents in the following ways:

• Any treatment covered according to the Prioritized List of Health Services will, by default, be considered medically necessary for all people covered by OHP.
• For services not covered according to the Prioritized List, the medical necessity of services for individual children and adolescents will be considered on a case-by-case basis as required by EPSDT.

In preparation for this transition, OHA will take several steps to ensure that Medicaid-eligible children, adolescents and their families are aware of EPSDT and have access to required screenings and medically necessary treatments. These steps include but are not limited to:

• The HERC will complete a comprehensive review of services not currently covered according to the Prioritized List of Health Services with attention to the unique needs of children and adolescents.
• The HERC will adjust the Prioritized List to ensure that all medically necessary EPSDT services for the population of children and adolescents are covered.
• For services not covered according to the Prioritized List, OHA will ensure there are accessible and effective pathways for individual case-by-case review of medical necessity as required by EPSDT. OHA is aware that these processes can be lengthy and burdensome to providers and families and aims to improve that experience. OHA understands that children, adolescents and families managing complex medical needs require processes that are accessible and responsive to their needs.
• OHA will develop clear guidance and communications for providers and families to ensure they are aware of the change in benefits, including the right to an individual determination of medical necessity.

In order to achieve OHA’s goal of ending health inequities by 2030, barriers to medically necessary care must be removed for children and adolescents in accordance with EPSDT.

OHA appreciates the feedback from all interested parties regarding this important topic and looks forward to ongoing collaboration to optimize child and adolescent health as part of the state’s next Medicaid waiver renewal. If you have questions or feedback, please email 1115Waiver.Renewal@dhsoha.state.or.us.

Sincerely, Jeremy Vandehey, Director, Health Policy and Analytics Division Dana Hittle, State Medicaid Director (Interim), Health Systems Division