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What’s Changing in the 2022 – 2027 1115 Demonstration Waiver


Continuous OHP enrollment for kids, from birth until their sixth birthday. This means kids will have health care coverage until they turn six and can keep seeing the same health care providers for longer, which results in better health outcomes.  

Two-year continuous OHP enrollment for people age six and up even if their eligibility status changes. Many people who lose OHP health insurance are only ineligible for a short time and then rejoin OHP. This “on and off” OHP results in poorer health outcomes and costs taxpayers money in administrative work. By providing two-year continuous people will have better health over the long-term.

What this means for OHP members

OHP members will get to stay covered longer. Right now, members need to re-enroll every year, and they lose coverage if something changes in their eligibility (like a change in income). In the new waiver, members won't have to re-enroll as often, and temporary changes in eligibility won't make them lose OHP. 

Young children in Oregon will maintain their health care coverage until they are ready for kindergarten.  Extending continuous coverage for young children promotes consistent access to health care to address concerns that may affect school readiness and will improve health inequities across the system.

Social Needs

In the renewed waiver, social supports to help improve health outcomes will be provided in a package of services known as health-related social needs.

Services will be provided for individuals and families who are experiencing transitions in their lives. When people go through major life transitions, like losing housing or being impacted by extreme weather, they often lose access to their health care providers, leading to worse health outcomes.

To help members keep their coverage, stay in touch with their health care providers, and stay healthy, Oregon wants to provide social supports to members as they experience these types of events.

Health-related social needs services are expected to begin in 2024-2025.

Depending on the nature of the transition, parts of the health-related social needs package may include services related to:

​Housing supports may include one or more of the following components:

  • Rental assistance or temporary housing (e.g., rental payments, deposits, utility assistance) for up to 6 months
  • Home modifications (e.g., ramps, handrails, environmental remediation)
  • Pre-tenancy and tenancy support services (e.g., housing application, moving support, eviction prevention)
  • Housing-focused navigation and/or case manager

​Nutrition supports may include one or more of the following components:

  • Links to community-based food resources (e.g., application support for Supplemental Nutrition Assistance Program (SNAP)/Special Supplemental Nutrition Program for Women, Infants and Children (WIC))
  • Nutrition and cooking education
  • Fruit and vegetable prescriptions (for up to 6 months, also known as VeggieRX) and healthy food boxes/meals
  • Medically tailored meal delivery​

​Supports may include one or more of the following components:

  • Payment for devices that maintain healthy temperatures and clean air, including air conditioners, heaters, air filters and generators to operate devices when power outages occur

Who may be eligible for health-related social needs services

The groups who may be eligible for these services under the waiver are as follows:

​Youth is this context is defined as age 19 up to age 26.

Youth with special health care needs are youth who:

  • Have one serious chronic condition as represented by the Pediatric Medical Complexity Algorithm's list of Complex Chronic conditions; or
  • Have a serious emotional disturbance or serious mental health illness; or
  • Have a diagnosed disability through Office of Developmental Disabilities Services; or
  • Have an “Elevated Service Need" or functional limitations as determined by two or more “yes" responses to a screener asking questions.

Under the new waiver, youth with special health care needs will also have increased vision & dental services. Effective transition from pediatric to adult health care results in:

More: • Regular care • Patient satisfaction • Quality of life • Self-care skills

Less: • Gaps in care • Barriers to care • Hospital admission rates • Length of hospital stays

​Youth who are child welfare-involved, and are

  • At risk of transitioning into foster care homes; or
  • Transitioning out of foster care homes; or
  • Aging out of Child Welfare involvement.

​OHP members that are identified as homeless or at imminent risk of homelessness according to the U.S. Department of Housing and Urban Development definition. Note: Initially, funding may only be available for homeless individuals and individuals at risk may be served in future years. ​

OHP covers this benefit for 90 days. Members can access this benefit:

  • Three months before their Medicare coverage starts, and
  • Nine months after Medicare takes effect​.

​Adults and youth released from state or Tribal custody--including prisons, local correctional facilities, tribal correctional facilities, and the Oregon State Hospital.​

​OHP members who reside in a region that is experiencing extreme weather events as declared by the Oregon Governor or Federal government that place the health and safety of residents in jeopardy.​

What this means for OHP members

OHP members who are facing life certain life challenges will have housing and nutrition services available to them to stay healthy at times in their lives when they are experiencing a greater need.

Housing interventions have been found to improve health outcomes and health inequities and decrease health care costs. 

Measuring Outcomes

CCO Quality Incentive Program Committee

Since 2013, Oregon's Quality Incentive Program has paid bonuses to coordinated care organizations' (CCOs) for performing well on certain health metrics or measurements of how well they are providing access to care for OHP members. These health metrics usually change a little bit each year. The program looks at things like the quality of health care OHP members receive and whether they can get health care in the right place and the right time.

In the new waiver, Oregon plans to change the Quality Incentive Program in a few ways:

  • Change committee structure so those most affected by health inequities lead the CCO Quality Incentive Program. More seats for OHP members, community members from diverse communities, individuals with lived experience of health inequities, health equity professionals and researchers.
  • Split its current metrics program into two parts: upstream and downstream. We call them “upstream" and “downstream" because it's like a river — by focusing on things that cause poor health, we can catch and address them before they show up “downstream" as worse health outcomes.
    • One part of the incentive program will consist of upstream metrics that address health equity. Example: a metric that looks at providing culturally responsive health care services in an OHP member's preferred language.
    • The other part of the incentive program will line up with standard downstream health metrics used by other Medicaid organizations across the country. Example: metrics focus that on more traditional medical care, such as diabetes care and well child visits.

What this means for OHP members

In the new waiver, OHP members and communities will have a greater voice in the quality incentive program. The result will be that the program will be measuring and rewarding improvements that matter the most to the community and have the greatest chance of improving the long-term health of OHP members.

Early Periodic Screening, Diagnosis, and Treatment (EPSDT)

Oregon will not seek a renewal of the longstanding waiver around Early Periodic Screening, Diagnosis, and Treatment (EPSDT) for children. EPSDT's purpose is to discover and treat childhood health conditions before they become serious or disabling. The decision comes, in part, from clear feedback from the community, advocates, children's service organizations, and other interested parties.  

The decision also is consistent with the waiver's focus on eliminating health inequities across Oregon.  Oregon will continue to base OHP benefits on the Prioritized List of Health Services, however, the state will arrange for, and make available to children, all medically necessary and medically appropriate services that are required for treatment of conditions identified as part of an EPSDT screening.

What this means for OHP members

Beginning January 1, 2023, all Medicaid-covered medically necessary and medically appropriate services will be made available to children and youth under age 21 on OHP.  

The Prioritized List of Health Services

Oregon will not seek a renewal of the longstanding waiver around Prioritized List of Health Services that determines the Oregon Health Plan benefit package. The intention of the Prioritized List over the 30-year history has been to provide evidence-based decisions regarding benefits through a transparent, public process. Moving forward, the intention is to still have a public process to guide decisions on efficacy and medical necessity criteria. 

The state will need to complete a detailed regulatory and operational review with the potential for meaningful changes in law, rules, or processes to make this change. The state will have until January 1, 2027 to give sufficient time to make necessary changes. Until that time, Oregon will work with CMS and stakeholders to effect all necessary changes to Medicaid benefits and operations.

Return to main waiver page.