Oregon OR

Oregon Health Plan (OHP) expresses coverage/PA on its OWN terms via the Prioritized List of Health Services (660 condition-treatment pairs; lines 1-469 funded for OHP Plus as of 2-1-2026), maintained by the Health Evidence Review Commission (HERC). Coverage criteria/conditions live in the Prioritized List Guideline Notes. Statutory PA authority is in OAR chapter 410 division rules (per service). Delivery is ~100% via 16 provider-led full-risk CCOs (each handles its own PA per member CCO) + Open Card FFS residual. FFS PA criteria for OHA-covered services live in service-specific guideline PDFs under oregon.gov/oha/HSD/OHP/Tools/ plus the FFS Prior Authorization Handbook; requests via the Provider Web Portal (PA Inquiry). NOTE: as of Feb 1 2026, new PA/treatment plans go to the member NEW CCO (annual CCO realignment). NOT a WISeR pilot state. Many legacy oregon.gov pinned URLs 404 after a CMS migration (see repin_candidates).

Last award: 2019-10-01 (CCO 2.0 contracts signed; coverage effective 2020-01-01). Next due: Original target 2027-01-01 for CCO 3.0; deferred by HB 2205 to be set in administrative rule. Contracts extended through: 2026-12-31.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How OR requires PA Oregon's Medicaid program, known as the Oregon Health Plan (OHP), requires prior authorization (PA) through a structured system that includes both state-level and managed care organization (MCO)-level processes. The primary mechanism for determining which services require PA is the Prioritized List of Health Services, maintained by the Health Evidence Review Commission (HERC). This list contains 660 condition-treatment pairs, with lines 1-469 funded for OHP Plus as of February 1, 2026. For example, palliative care services are covered under specific CPT codes and require documentation such as E&M services, advance care planning, and symptom management. ## 2. How OR publishes and reports PA The Oregon Health Authority (OHA) is responsible for publishing and reporting on prior authorization requirements. The OHP Provider Manual serves as a central resource for providers, though it has undergone URL changes over time. The current provider manual can be found at [https://www.oregon.gov/oha/HSD/OHP/Pages/Providers.aspx](https://www.oregon.gov/oha/HSD/OHP/Pages/Providers.aspx). Additionally, the Prioritized List of Health Services is maintained by HERC and updated regularly to reflect changes in coverage criteria and effective dates. ## 3. OR's CMS-0057-F and PA-reform compliance posture Oregon has submitted a CMS-0057-F application for its Medicaid program, which includes an 1115 waiver titled "Oregon Health Plan 2022-2027 Demonstration." This waiver aims to implement various reforms, including changes to prior authorization processes. However, specific details about the state's compliance with CMS-0057-F requirements are not provided in the given findings or documents. The carve-out details indicate that behavioral health services are integrated into the Coordinated Care Organizations (CCOs) and pharmacy services are carved in to MCOs with a state carveout list. **WISeR is not applicable to OR** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. ## 4. How OR runs its own program Oregon's Medicaid program is managed through a combination of state agencies and private MCOs. The OHA oversees the overall administration, while CCOs play a significant role in delivering coordinated care. The current fiscal agent for Oregon's fee-for-service (FFS) operations has transitioned from ACS-Inc to Conduent/Gainwell Systems. The program model includes an unspecified foster-care MCO program and behavioral health services integrated into the CCO structure. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Prioritized List of Health Services**: This list is a key determinant for PA requirements and coverage decisions. - **Behavioral Health Integration**: Behavioral health services are seamlessly integrated into the CCO model. - **Frequent URL Changes**: The provider manual has experienced URL changes, indicating ongoing updates to resources. ### Missing/Uncertain: - **Specific MCO Procurement Cycle**: While there is a temporal anchor for the last award in 2019 and next due date deferred by HB 2205, the exact procurement cycle length remains unclear. - **Gold Card Law Details**: The gold card law specifics are unspecified, leaving gaps in understanding how this program operates within OHP. - **Detailed PA Criteria for Specific Services**: While some services like palliative care have specific criteria, others like the Medical Marijuana Program lack detailed PA requirements in the provided documents.