Why We Must Prioritize the Prioritized List
Imagine for a moment that you, like 1.4 million Oregonians, are enrolled in the Oregon Health Plan. You have a chronic health condition — for example, type 1 diabetes — requiring you to regularly test your blood sugar and take insulin daily.
If that equipment wasn’t covered under your plan, you’re not sure you could afford it. Without treatment, it could lead to far more serious (and costly) health complications down the line, increasing costs for everyone.
Fortunately, this is where OHP’s Prioritized List of Health Services comes into play.
The Prioritized List has been a foundational element of OHP for more than three decades. It combines conditions and treatments into “lines” and ranks them based on evidence, ensuring more effective treatments are higher on the list than less effective ones.
The total funding from the legislature determines how many of these condition-treatment lines are covered — currently, lines 1 through 469. Whereas Oregon used to balance its Medicaid budget by reducing enrollment (meaning those people get no access) or reducing payment to providers (which creates another barrier to access), the Prioritized List is a transparent, public, evidence-based, and accountable way of determining what is covered by OHP.
Back to our diabetes management scenario: treatment for chronic diseases like type 1 diabetes is within the covered portion of the Prioritized List. Other covered services include maternity care; drug and alcohol treatment; tobacco cessation; and preventative services recommended by the U.S. Preventative Services Task Force.
“By ensuring the most effective treatments are covered for all Medicaid members, Oregon has achieved close to 100% coverage while maintaining reasonable reimbursements to providers. The result is a better use of state resources and long-term sustainability of the Oregon Health Plan.”
— Sarah Kelley Brewer, President and CEO, Trillium Community Health Plan
How the List Works
So, who gets to decide the ranking of condition-treatment lines within the Prioritized List? And what are the criteria?
The Prioritized List is managed by the Health Evidence Review Commission (HERC), which is composed of 13 governor-appointed and Senate-confirmed members:
- Five physician representatives.
- One dentist.
- One public health nurse.
- One behavioral health representative.
- One provider of complementary and alternative medicine.
- One retail pharmacist.
- One insurance industry representative.
- Two consumer representatives.
HERC relies on subcommittees, including the Evidence-based Guidelines Subcommittee (EbGS), the Value-based Benefits Subcommittee (VbBS), and others, which are open to the public. These committees consider peer-reviewed studies, consumer experiences, and other evidence when making recommendations to the HERC.
HERC continually updates the Prioritized List to account for new medical codes, correct technical errors, and incorporate medical advancements. The list is submitted to the legislature for funding consideration to determine benefits covered for the following biennium.
Why Protect It?
Protecting the Prioritized List is one of COHO’s top legislative priorities for 2025. Our coalition is backing legislation to ensure that health care funding continues to prioritize evidence-based services that improve health outcomes, while supporting local CCOs delivering equitable, cost-effective, community-driven care.
The fact remains that Oregon is the only state with this kind of transparent, public, accountable, and evidence-based process to ensure that health care resources can provide the greatest benefit to the greatest number of people.
Our team will remain engaged throughout the 2025 legislative session working to protect the Prioritized List. While there may be calls for reform, any changes should be carefully considered to avoid potentially far-reaching consequences and disruptions to Medicaid delivery.
“Health care providers rely on the Prioritized List to deliver effective care in our communities. It is thanks in large part to the Prioritized List that 97% of Oregonians have health coverage. The list is constantly evolving to meet changes and new advancements in health care.”
— Seamus McCarthy, President and CEO, Yamhill Community Care
