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OHP Stakeholder Information

Partners and policymakers - Learn how the Oregon Health Plan works and how to get involved.

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Receive OHP Stakeholder updates by email or view recent updates


Questions and answers

Use the drop-down boxes below to search by category or question for the answer you are seeking.

You can also use the Search field to search all columns (for example, enter "coverage" to view questions related to coverage). You can also view our main questions and answers page.​

  
  
Answer
History of OHPWhat is the Oregon Health Plan?
From 1989-1993, the Oregon Legislature passed a series of laws known collectively as the Oregon Health Plan. Senate Bill 27 (1989) extended Medicaid coverage to Oregonians with income below the federal poverty level and established a set of benefits based on a Prioritized List of Health Services.
How to keep informedHow can I get involved?
How OHP worksHow is OHP funded?

OHP is supported by both federal and state funding.

How to keep informedWhat is DMAP currently doing?
Learn about the work DMAP is doing though the monthly “DMAP update" (also posted on our Data and Reports page - Select Report Type "Update").
OHP coverageHow does the Prioritized List of Health Services determine what OHP covers?

It ranks pairs of health conditions and treatments according to effectiveness. The higher a condition and treatment pair is ranked, the more likely OHP will cover it. To learn more visit our Prioritized List page.​

How to keep informedAre public meetings ADA-accessible?

Yes. Public meetings must be held in places that are accessible to people with disabilities. If you or someone you know needs accommodation to attend a public meeting, notify the contact person who is named in each meeting announcement. ​

How to keep informedWhy do you post public meetings?

OHP Public Meetings are posted in accordance with Oregon Administrative Rule 410-120-1385 (Compliance with Public Meetings Law) in DMAP's General Rules program.

DMAP Rule Advisory Committee meetings are posted in accordance with Oregon Revised Statute 183.333 (Policy statement; public involvement in development of policy and drafting of rules).To view the current or proposed rule for these programs, go to the OHP policies page.

How OHP worksWhat are waiver amendments?

Any time we want to change what the Oregon Health Plan (OHP) covers or whom OHP serves, DMAP must ask the federal Centers for Medicare and Medicaid Services to approve the change. Recent requests are listed below along with comments we have received from stakeholders.​

How to keep informedWhat are public notices?

DMAP publishes these notices in the Secretary of State's Oregon Bulletin, or major Oregon newspapers, to notify the public about proposed changes to DMAP programs or Oregon's Medicaid State Plan that happen outside DMAP's administrative rules process.​

OHP coverageWhat services are plans required to cover?
The OHP Rules explain plan coverage. Generally, plan coverage must be comparable to DMAP's fee-for-service coverage.
Mental health drugs​ are always billed to DMAP. All other prescriptions are billed to OHP health plans (CCO, FCHP, PCO).
How to keep informedHow do I find out about upcoming changes to DMAP policies?
OHP coverageWho created the PDL?

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to DMAP for pricing and DMAP made cost-effective selections, creating the PDL. ​

OHP coverageWhere can I find the Preferred Drug List (PDL)?

You can view the current PDL or download Epocrates Rx to view the PDL on your smartphone or tablet.​

OHP coverageHow do drugs get added to the PDL?

The list is updated in January and July. Drug manufacturers who want to propose drugs for PDL consideration can register on the Sovereign States Drug Consortium (SSDC) Web site to submit offers (see OAR 410-121-0030).​

How to keep informedWhen is the next Pharmacy & Therapeutics Committee meeting? How can I get notified of future meetings?
OHP coverageWhere do I find past, current and proposed Prioritized Lists of Health Services?
Use the following links on the HERC website. You can also eSubscribe to receive e-mail updates from HERC whenever Prioritized List information changes or view all recent HERC updates.
How to keep informedHow do you notify the public of upcoming changes to OHP?
Services covered by OHP benefit plans, prior authorization criteria, and billing requirements are outlined in DMAP’s Oregon Administrative Rules. Sign up for DMAP Notices of Proposed Rulemaking to find out proposed changes to DMAP rules.
 
Any time we want to change what OHP covers or whom OHP serves, DMAP must ask the federal Centers for Medicare and Medicaid Services (CMS) to approve the change. Sign up for OHP Public Notices and Meetings to find out when we have sent such a request to CMS.
 
We send OHP provider announcements to inform affected providers about changes to our fee-for-service payment rates. Sign up for OHP Provider Announcements to get these notifications.
How to keep informedWhat are public meetings?
According to Oregon law, any meeting related to medical assistance is a public meeting. DMAP holds the following meetings for the following and posts them on the DMAP Public Meetings Calendar:
  • Rule Advisory Committees for DMAP Oregon Administrative Rules
  • OHP Contractor Workgroups
  • Pharmacy and Therapeutics Committee
How OHP worksHow does OHP set payment rates for its contracted health plans?

The OHA Actuarial Services Unit calculates the cost of providing health care to each OHP member, and uses this information to calculate new payment rates annually. To learn more, view the Per Capita Cost and Capitation Rate reports on the OHP Reports page.

OHP coverageWhat are OHP’s maximum allowable fee-for-service rates?

View DMAP’s fee-for-service fee schedule for an overview of DMAP rates.

How OHP worksWhen do State Plan Amendments become effective?

Once CMS approves a SPA, the changes can take effect retroactive to the first day of the quarter of the federal fiscal year in which the SPA was submitted. These procedures can make the SPA approval process quite lengthy.

How OHP worksWhat is a State Plan Amendment?

When a state wants to change any of the Medicaid  benefits it offers, or change the way in which services are offered, it must  submit a State Plan Amendment (SPA).​

How OHP worksWhat is a Medicaid State Plan?
Under Section 1902 of the Social Security Act, all states must comply with some basic requirements. Each state must:
  • Serve certain mandatory populations, such as poverty-level children and low-income pregnant women.
  • Provide certain mandatory services, such as hospital care and physician services.
  • Provide services that are "sufficient in amount, duration, and scope to reasonably achieve (their) purpose."
  • Provide services throughout the state.
A State Medicaid Plan outlines how each state will meet these requirements. Once CMS approves the original Plan, they must also approve all future changes to the Plan before any changes become effective.

A state can also request CMS to waive certain federal requirements to allow greater flexibility or expand the Medicaid populations it serves.

 

For more information about Medicaid State Plans or Waivers in general, go to the CMS website.

How OHP worksWhat happens when a state submits a State Plan Amendment to CMS?
Once the CMS Regional Office receives a SPA, it has 90 calendar days to approve or deny the SPA, or send a formal Request for Additional Information (RAI) letter.
 
Once the CMS Regional Office receives a SPA, it has 90 calendar days to approve or deny the SPA, or send a formal Request for Additional Information (RAI) letter.
Sending an RAI stops the 90-day clock. The clock will not start again until CMS receives the state's written response to the RAI. Another 90-day clock starts at this point.
 

Throughout this process, CMS has the option of asking informal questions via e-mail or phone.

OHP coverageHow can I view a copy of the model contracts for OHP health plans?

To view a copy of the model contracts, contact Katrina Suchanek​ or Kellie Skenandore of DMAP. ​

How to keep informedWhen does DMAP publish public notices?

DMAP publishes these notices in the Secretary of State's Oregon Bulletin, or major Oregon newspapers, to notify the public about proposed changes to DMAP programs or Oregon's Medicaid State Plan that happen outside DMAP's administrative rules process. ​

History of OHP​Where can I find out about the history of OHP?
View the Quarterly Reports and Historical Documents on our Data and Reports page​. These include:
  • OHP quarterly and annual reports
  • OHP: An historical overview - July 2006
  • OHP Standar​d Reservation List - 2008 final report
How to keep informedHow many people are on OHP?

​View the monthly eligibility reports on our Data and Reports page​.

How to keep informedHow many people are enrolled in OHP health and dental plans?

​View the monthly enrollment reports on our Data and Reports page​.

How to keep informedHow is the OHP population distributed according to age, gender and race/ ethnicity?

​View the monthly demographic reports on our Data and Reports page​.

How OHP worksHow does Oregon operate its Medicaid program?

Oregon operates its Medicaid program under a Section 1115 demonstration waiver approved by the federal Centers for Medicare and Medicaid Services (CMS).

  • The current waiver supports Oregon's Health System Transformation and establishes coordinated care organizations as OHP's primary delivery system.
  • Oregon's Medicaid State Plan defines how Oregon will operate its Medicaid program. ​​
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Read the DMAP Update

Select the month and year of the update you would like to read.

  
  
DMAP Update - December 201312/23/2013
DMAP Update - October 201310/22/2013
DMAP Update - August 20138/23/2013
DMAP Update - June 20136/1/2013
DMAP Update - May 20135/1/2013
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Waiver and State Plan Amendment Status

These documents list the current demonstration amendments and State Plan Amendments submitted for CMS approval.

  
  
Amendment Status - January 20141/28/2014
Amendment Status - November 201311/22/2013
Amendment Status - October 201310/24/2013
Amendment Status - September 20139/1/2013
Amendment Status - August 20138/1/2013
Amendment Status - June 20136/1/2013
Amendment Status - May 20135/1/2013
Amendment Status - April 20134/1/2013
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