In Oregon, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is the
Oregon Health Plan (OHP) benefit for:
- Medicaid or CHIP-enrolled OHP members under age 21 and
- OHP members who qualify for Young Adults with Special Health Care Needs
(YSHCN) benefits.
EPSDT covers comprehensive and preventive health care services. This includes physical, dental, vision, hearing, behavioral health and pharmacy services.
- All covered services must be EPSDT Medically Necessary and EPSDT Medically or Dentally Appropriate. But not all EPSDT Medically or Dentally Appropriate services are covered services.
- Oregon Health Authority (OHA) and coordinated care organizations (CCOs) must review on a case-by-case basis for medical necessity and medical or dental appropriateness before denying any EPSDT care.
This means providers must not refuse to render or refer for care they believe is EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate). Instead, they should ask OHA or the member's CCO to review whether the care is necessary, appropriate and covered.
To learn more:
RACs represent people and communities most impacted by the proposed rule changes. RAC members help review rule changes. They also help OHA understand the racial equity and economic impacts of the proposed rule changes. Anyone is welcome to observe a RAC and provide feedback during the public comment period.
OHA is hosting a RAC via Zoom to review and discuss proposed changes to:
- General Rules (Division 120): Billing rules and OHP 3165 (Agreement to Pay) form; technical correction to Non-Participating Provider rule
- Housekeeping changes for multiple Chapter 410 programs
The RAC will be Thursday, July 23, from 9 to 11:30 a.m. Pacific Time.
OHA is continuing work on the 2027 CCO capitation rates. The rates determine how much OHA pays each month to CCOs for serving OHP members. OHA contracts with Mercer to support the actuarial development and certification of the CCO rates.
Where we are in the process:
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Data analysis (April-June 2026): OHA and Mercer reviewed the 2025 financial and claims experience, along with early 2026 data, to build the components needed to set 2027 capitation rates.
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Budget determination (July 2026): OHA and Mercer will determine the statewide rate and build CCO-unique factors, which include hospital, regional and member risk adjustments.
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Rate delivery and CCO feedback (August 2026): OHA will share the draft 2027 rates with CCOs on August 12 for their review and meet with CCOs to discuss. OHA will also share the 2027 contract language. Following this review, if CCOs do not intend to continue serving OHP members in 2027, they must notify OHA by September 2.
Commitment to transparency
OHA continues to expand transparency in the rate setting process. The following are helpful links to learn more about the 2027 rate setting process:
This fall, OHA will also present preliminary findings for the 2027 rates to the Oregon Health Policy Board. Public comment is open during those meetings and providers are encouraged to participate!
More updates will follow in upcoming editions of "Provider Matters."
Amended dispensing limitations for certain hormone medications
OAR 410-121-0146 now allows OHA to reimburse pharmacies for fee-for-service prescriptions of up to a 365-day supply of select hormone medications. This applies to preferred drugs in the following classes:
- Estrogen – Standard Therapeutic Class 61
- Progesterone - Standard Therapeutic Class 62
- Aldosterone antagonists - Standard Therapeutic Class 53
- Androgens - Standard Therapeutic Class 60
- Gonadotropin-releasing hormone (GNRH) agonists - Specific Therapeutic Classes P1M, P1P, V1O
This change is effective July 9, 2026.
 July 1, 2026 Behavioral Health Fee Schedule now available
OHA has posted an updated behavioral health fee schedule, effective July 1, 2026. Changes include:
- Visual changes, including the addition of rate effective dates for each code
- Several federally mandated price adjustments to medication rates
- Youth service rate increases
The Medication-Assisted Treatment (MAT) list has also been updated to reflect price changes, along with billing clarification for methadone administration. Please find these resources here:
For 1915(i) Home and Community Based Services (HCBS) providers and referring community partners: Change to interRAI Community Mental Health (CMH) assessment tool effective July 31, 2026
Starting July 31, 2026, OHA will use the interRAI CMH instrument to determine service eligibility for the 1915(i) HCBS program.
- The interRAI CMH replaces the Level of Service Inventory (LSI) for 1915(i) HCBS.
- The LSI will continue to be used to assess needs of individuals younger than 21 years of age residing in Young Adults in Transition (YAT) Homes.
OHA has published a new guide for providers to:
- Learn how interRAI scores inform residential rates
- Review the process for functional needs assessments and person-centered service planning
- Review how to submit reconsiderations to the IQA (Comagine Health)
Approved Culturally and Linguistically Specific Providers (7/2/2026)
Frequently Asked Questions: Medicaid Rule Changes for Board-Registered Behavioral Health Associates (7/2/2026)
Oregon Medicaid Pharmaceutical Services Prior Authorization Criteria (7/1/2026)
Oregon Medicaid Preferred Drug List (7/1/2026)
Health-Related Social Needs (HRSN) Nutrition Education and Pantry Stocking Guidance on the HRSN Information for Providers page (6/26/2026)
Recent rule revisions
OAR 410-121-0146: AmendS dispensing limitations to allow 12-month dispensing for selected treatments. No public comment was received.
OARs 410-120-0000, 410-120-1215, 410-120-1221, 410-120-1225: Adoption of fee-for-service (FFS) care coordination rules.
OAR 410-172-0660: Amends behavior health rules to require Board Registered Associates to work in organizations with a Certificate of Approval from Oregon Health Authority to bill Medicaid. Public comment for the rulemaking will be posted soon.
OARs 410-121-0030 410-121-0040: Amended to update the Oregon Medicaid Pharmaceutical Services Prior Authorization Criteria and Oregon Medicaid Preferred Drug List, implementing recommendations from the Pharmacy and Therapeutics Committee. No public comment was received.
OARs 410-141-3515, 410-141-3585, 410-141-3720, 410-141-3835, 410-141-3845, 410-141-3920, 410-141-3935, 410-141-3955, 410-141-3960: Amended to update and clarify rules for CCOs, including comprehensive review of service area change rule.
OARs 410-125-0045, 410-125-0220: Amended to allow Caring Contacts to be a Medicaid-covered service as part of suicide prevention efforts.
OAR 410-141-3545: Amended to allow CCOs to contract with certain out-of-state outpatient behavioral health provider organizations.
If you are new to OHP, be sure to join OHA's next monthly webinar series about navigating Open Card OHP (fee-for-service Medicaid). OHA holds this three-session series the second week of each month.
What you will learn:
- How to use the OHP Provider Resources website at OHP.Oregon.gov/Providers and provider tools
- Steps to receive payments
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Billing through the MMIS Provider Portal at https://www.or-medicaid.gov
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Checking eligibility for services
- And much more to support your success!
This is a great opportunity to get familiar with essential resources, ask questions and build confidence in working with OHA.
Meeting accommodations:
For people who speak or use a language other than English, people with disabilities or people who need additional support, we can provide free help. Please email Medicaid Provider Training at ProviderTraining-Medicaid@oha.oregon.gov or call 800-336-6016. We accept all relay calls.
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