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OHP Rate Development

Overview

The Oregon Health Plan (OHP) is our state Medicaid program. It provides health coverage for low-income Oregonians that include working families, children, pregnant women, single adults, seniors and more. The Oregon Health Authority (OHA) has contracted with a variety of health entities, known as Coordinated Care Organizations or CCOs, to manage and deliver health care for most of these people eligible for Medicaid. OHA pays CCOs to cover these individuals with capitation rates. Capitation rates are a predetermined payment that depends on the individual's OHP eligibility status and is paid to CCOs on a monthly basis dependent on enrollment. 

These capitation rates are developed and certified by OHA's contracted actuaries on a yearly basis. The process and methodology used to develop capitation rates are governed by federal and state regulations. CMS requires Oregon's capitation rates be Actuarially Sound and follow applicable Actuarial Standards of Practice, which are developed by the Actuarial Standards Board

OHA releases 2023 CCO capitation rates 

October 20, 2022

Oregon Health Authority (OHA) has finalized the 2023 capitation rates for coordinated care organizations (CCOs). These rates are the per-member-per-month amounts the state pays CCOs to coordinate health care for Oregonians who are members of the Oregon Health Plan (OHP). Overall CCOs rates were below the legislatively approved budget for 2023 and CCOs continue to be financially stable. Financial statements for CCOs through Q2 2020 can be found here, along with additional CCO program financial summaries.

The baseline 2023 CCO rate growth was -0.6% compared to 2022; significantly below the long-term growth rate goal of 3.4%. The slow per member baseline growth was driven in part by reduced costs and higher enrollment producing a relatively healthier covered population. This allowed OHA to reinvest savings into behavioral health reimbursements increases, along with additional funds from the legislature for behavioral health totaling $221 million or 3.0% CCO rate growth. OHA is also providing a temporary increase for large hospital reimbursement from 80% of Medicare to 85% of Medicare ($84 million, 1.2%). With these enhancements factored in, the CCO 2023 rates will be 3.6% higher than in 2022.

The average net per-member per-month payment in 2023 will be $507.90, which is approximately 3.6% more than the comparable average per-member-per-month payment in 2022. The rates are actuarially sound and are below the allowable growth target.


2019-2023 Capitation Rate Reports

2019-2023 Contract Rate Sheets

Dental Distribution Plan Summary

The SB 5561 bill appropriates $19 million General Fund to the Oregon Health Authority (OHA) for a one-time increase in payments to dental care providers to support costs associated with maintaining access and service levels for medical assistance program enrollees. OHA has distributed this funding, using a methodology recommended by dental care and coordinated care organizations. Below are the follow-up reports summarizing how the funds were spent to meet the intent of appropriation.


Questions?

Please contact:
Actuarial Services


For more information

  
American Academy of Actuaries
CMS Medicaid Home
Coordinated Care Organizations
Forecasting Reports
Health Evidence Review Commission (HERC)
Oregon Health Plan