Oregon's Medicaid State Plan

Medicaid provides health care insurance for low-income residents through a federal and state partnership. Federal regulations provide a framework for each state to build a unique Medicaid program. Under Section 1902 of the Social Security Act, all states must comply with some basic requirements. States must:

• Serve certain mandatory populations, such as poverty-level children and low-income pregnant women.
• Provide certain mandatory services, such as hospital care and physician services.
• Provide services that are “sufficient in amount, duration, and scope to reasonably achieve (their) purpose.”
• Provide services throughout the state.

A State Medicaid Plan outlines the design of each state’s Medicaid program to the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicaid. Once CMS approves the original Plan, they must also approve all future changes to the Plan before any changes become effective.

When a state wants to change any of the Medicaid benefits it offers, or change the way in which services are offered, it must submit a State Plan Amendment (SPA). Once the CMS Regional Office receives a SPA, it has 90 calendar days to approve or deny the SPA, or send a formal Request for Additional Information (RAI) letter. Sending an RAI stops the 90-day clock. The clock will not start again until CMS receives the state’s written response to the RAI. Another 90-day clock starts at this point. Throughout this process, CMS has the option of asking informal questions via e-mail or phone. Once CMS approves a SPA, the changes can take effect retroactive to the first day of the quarter of the federal fiscal year in which the SPA was submitted. These procedures can make the SPA approval process quite lengthy. 

A state can also request CMS to waive certain federal requirements to allow greater flexibility or expand the Medicaid populations it serves.

Oregon posts its Plan on this Web site for informational purposes only; it is not legally binding, will not contain any pending SPA information and is only current relative to the date on the title page. The CMS Region X office in Seattle, Washington, maintains our official Plan. The files on these pages are available in PDF, which requires the use of Adobe Reader.

• State Plan, Part 1 (176 pgs): Contents, general provisions, attachments
• State Plan, Part 2 (160 pgs): Attachments regarding coverage, eligibility, standards, etc.
• State Plan, Part 3 (202 pgs): Attachments regarding scope of services, quality assurance, payment methodologies, etc.
• State Plan, Part 4 (135 pgs): Attachments regarding claims, liabilities, sanctions, special programs, etc.

For more information about Medicaid State Plans or Waivers in general, go to the CMS Web site.