Cover All Kids (CAK) & Healthier Oregon Update from OHA

Most Cover All Kids (CAK) and Healthier Oregon members are not eligible for PPS encounter-rate reimbursement, supplemental (wraparound) payments, and APCM PMPM payments. OHA will reimburse for eligible medically appropriate and necessary services to these members at OHP fee-schedule pricing.

Five categories of Healthier Oregon members, indicated by PERC codes: CA, CB, HL, HM, and HW are eligible for Prospective Payment System (PPS) encounter-rate reimbursement, supplemental (wraparound) payments, and APCM per-member per-month (PMPM) payments.

These PERC codes indicate CAK and Healthier Oregon eligibility.

  • Cover All Kids: CK; CL; CM; CN; CO; CP; or CR.
  • Healthier Oregon: CA; CB; CC; CD; CE; CF; CG; CH; CI; CJ; CQ; CR; H6; H7; H9; HH; HI; HK; HL; HM; HN; HO; HP; HQ; HR; HS; HT; HU; HV; HW; HX; HY; and HZ.

Services provided to Citizenship Waived Medical Plus (CWM Plus) members are still eligible for encounter-rate reimbursement and supplemental (wraparound) payment.

Why is this happening?

Starting July 1, 2022, Healthier Oregon allows income-eligible individuals ages 19-26 and 55 and older to qualify for OHP Plus benefits, regardless of immigration status. Because most OHP Plus benefits for the CAK and Healthier Oregon populations are paid with state funds services for these populations are not eligible for PPS reimbursement.

What should you do?

Verify OHP member eligibility to identify CAK and Healthier Oregon members using the PERC codes listed above. Bill OHA or the member’s CCO for services. Ensure claims and payments for these populations are excluded from the clinic’s supplemental payment (wraparound) report. For APCM clinics, ensure these OHP members are excluded from patient list uploads.