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This summer, the Oregon Health Authority (OHA) is updating the Oregon Administrative Rules for EPSDT. OHA, coordinated care organizations (CCOs) and Oregon Health Plan (OHP) providers must follow these rules when deciding about coverage for OHP members under age 21. Read and share these fact sheets with anyone who may be interested in providing feedback about EPSDT rules.
Fact Sheet - English
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EPSDT benefits are for OHP members under age 21. These benefits include comprehensive preventive health care services from birth until they turn age 21, such as:
Coordinated care organizations (CCOs) cover these benefits for CCO members. The Oregon Health Authority (OHA) covers EPSDT benefits for members not enrolled in a CCO (these members have fee-for-service OHP, also known as Open Card coverage).
Most EPSDT services have been provided in Oregon for many years. This includes through adolescent and well child visits and other routine medical, dental and behavioral health care.
Like all other OHP benefits, both OHA and CCOs must ensure that EPDST benefits are provided in a timely manner and at no cost.
All children and youth in Oregon up to age 21 who are enrolled in OHP. This includes children and youth under age 21 who enrolled in OHP through
OHP Covers Me! (Cover All Kids) and
EPSDT coverage ends on a member's 21st birthday.
Screening visits (also known as well child visits or adolescent well visits) at age-appropriate intervals following the American Academy of Pediatrics and Bright Futures guidelines and periodicity schedule. These visits must include:
EPSDT also covers screenings for vision, hearing and oral/dental health.
EPSDT also covers unscheduled check-ups or exams that can happen at any time. This can be due to an illness, injury or a change in condition.
EPSDT covers all medically necessary and medically appropriate services that are required for an OHP member under age 21, including for treatment of conditions identified as part of an EPSDT screening or health exam.
In cases where prior authorization is required, providers can ask OHA or the child's CCO to review services for medical necessity by submitting a prior authorization request as described on the OHP Prior Authorization page.
OHA makes the final determination of medical necessity and medical appropriateness for hearing requests for denied services and for fee-for-service (Open Card) prior authorizations.
Oregon did not renew the longstanding waiver around EPSDT for children. The decision came as a result of clear feedback from the community, advocates, children's service organizations, and other interested parties. Beginning January 1, 2023, OHA and CCOs must cover all medically necessary and medically appropriate services for OHP members under age 21, regardless of placement on the
Prioritized List of Health Services. Medical necessity and medical appropriateness are determined on a case-by-case basis, taking into account the member's needs.
States must cover all medically necessary and medically appropriate services that are part of the federal EPSDT benefit, even if the service is not available or defined under the state's Medicaid plan.
Member fact sheet:
New! Frequently Asked Questions (7/27/2023)
EPSDT Guidance for CCOs (updated 12/27/2022)
Memo and EPSDT Guidance for OHP providers
EPSDT for Behavioral Health and Behavior Rehabilitation Service providers:
EPSDT Overview webinar:
EPSDT Ensuring Access webinar:
Call the phone number listed on your CCO or Plan ID card, or find your CCO's contact information here.
Email OHA's EPSDT staff at EPSDT.Info@odhsoha.oregon.gov.
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