Provider updates

What is changing?

Effective October 13, 2026, the Oregon Health Authority (OHA) will carve out certain gender-affirming care (GAC) services for Oregon Health Plan (OHP) members ages 0-17 from Coordinated Care Organization (CCO) Medicaid contracts. OHA will pay for these services through fee-for-service (FFS). CCOs will remain responsible for care coordination and other GAC services not included in the carve-out.

This includes:

• Drugs billed through the pharmacy benefit, regardless of diagnosis code.

• Drugs billed on a hospital or professional claim with a gender dysphoria diagnosis code for youth.
• Surgical procedures with a gender dysphoria diagnosis code for youth.

The code list of carved-out services can be found here. All GAC services not included in the code list should still be billed to the member's CCO.

Providers must be enrolled in OHP Open Card/FFS to continue providing affected carved-out services to OHP members ages 0-17.

What do providers need to do?

• If you are a provider who is already enrolled in Open Card/FFS, you can continue providing affected services and bill OHP Open Card/FFS for those services only.
• If you are a provider who is not yet enrolled in Open Card/FFS, you will need to enroll in Open Card/FFS to continue providing affected gender-affirming care services to youth. Information about enrolling in Open Card/FFS can be found here.

What should providers communicate to members?

Providers should tell patients and families whether they are enrolled in Open Card/FFS. If a provider does not plan to enroll, they should let families know the member will need to transition to an Open Card/FFS-enrolled provider for the carved-out gender-affirming care services. Providers can help members find an Open Card provider using this search tool: https://OHPopencard.org

What will happen with existing prior authorizations?

Existing prior authorizations approved before October 13, 2026, will be honored by OHA. For medications, OHA will honor prior authorizations when there is a history of the drug in the member's previous claims. For procedures, providers may need to submit a prior authorization request and the CCO approval letter for OHA to honor the existing authorization.

How should providers submit new prior authorization requests?

For surgical procedures on or after October 13, 2026, providers should submit new prior authorization requests to OHA by following these instructions.

For medications on or after October 13, 2026, providers should submit new prior authorization requests to OHA by completing the authorization request form and sending it to the pharmacy call center by fax at 1-888-346-0178, by phone at 1-888-202-2126, or through the provider web portal.

Questions?

• Information on GAC services and benefits for OHP members can be found here: https://www.oregon.gov/oha/hsd/ohp/pages/gender-affirming-care.aspx
• More information for providers can be found here: OHA GAC Implementation Guidance for Carve Out_10_02_26.pdf
• For questions, providers should contact OHA Provider Services at 800-336-6016, option 6.