Oregon agrees to sunset limit on benefits for kids on Medicaid

By Amelia Templeton (OPB)Feb. 16, 2022 2:24 p.m.

The Oregon Health Authority is quietly making a major policy change that could give doctors and families more power to negotiate what treatments are covered for children on the Oregon Health Plan.

The state has been taking public comment on its latest five-year proposal for Medicaid and will submit a final draft for federal approval this month.

Oregon uses a list of treatments and conditions covered for all patients on Medicaid, which includes treatments from vaccines to bone marrow transplants for cancer patients. However, people with rarer conditions that are not on the list say they have been denied treatments.Oregon Health Authority

The Lund Report first broke the news of the reversal.

In an email earlier this month, two top state officials said that in response to public feedback, Oregon will not seek to renew a waiver in its Medicaid plan that has allowed it to deviate from a federal standard, known as Early and Periodic Screening, Diagnostic, and Treatment, or EPSDT.

The EPSDT standard requires states to cover all medically necessary treatment for children on Medicaid, regardless of what services states provide to adults.

Oregon has been the only state with federal approval to take a different approach. It limits children’s coverage to a prioritized list of services determined by the legislature and a commission of medical experts appointed by the governor.

The agency is now saying that after a phase-out period, some medical treatments that the state has historically categorized as not prioritized for coverage will be funded on a case-by-case basis.

The new policy will make it easier for children with disabilities and chronic illnesses to access the full range of medical care they need, including less common therapies such as inpatient programs for children with severe autism, advocates say.

“Low-income children who rely on Medicaid are going to be able to get the same medically necessary treatment as their more affluent classmates,” said Meghan Moyer, the public policy director at Disability Rights Oregon.

“It’s a real victory for acknowledging how valuable early treatment is in the lives of people with disabilities and chronic illness.”

Orthodontia for severely misaligned teeth and treatment for chronic ear infections are among the treatments the state doesn’t currently prioritize that will be available going forward to children who can demonstrate a medical need.

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