Written by a parent, not a doctor. Nothing here is medical advice.

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Ask Oregon Health Plan to review care your child needs (EPSDT)

Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.

What it is

Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.

For a child under 21 on Medicaid, medically necessary care that fits a Medicaid benefit category must be covered, even when the plan’s usual list leaves it out. It is a coverage protection, not cash, and a doctor’s order is not automatic approval; the clinician explains the need and the plan reviews it.

Rules
  • The service must fit a federal Medicaid benefit category and meet medical-necessity rules.
  • For a CCO denial, an appeal is due within 60 calendar days of the adverse-benefit notice. The CCO normally decides within 16 calendar days after receiving the appeal, or within 72 hours for an approved urgent appeal. An extension of up to 14 calendar days needs the member’s request or a justified need for more information that is in the member’s interest; the CCO must give the required notice. A state hearing is normally available within 120 calendar days of the appeal-resolution notice, or after the CCO fails required appeal timing or notice rules. Open Card members request an OHA hearing directly, normally within 60 calendar days of OHA’s denial; they do not first appeal to a CCO.
  • For a CCO decision to reduce, suspend or end an existing service, ask the social worker to check the notice immediately. To keep qualifying services during review, both the appeal and a request to continue services must be timely: request continuation by the later of 10 calendar days after the adverse notice is sent or the proposed action date. The service must have been ordered by an authorized provider and its original authorization must not have expired. After an appeal denial, request both a state hearing and continued services within 10 calendar days of the appeal-resolution notice—not the ordinary 120-day hearing window. If the final decision goes against you, repayment may be sought for services provided only because of continuation; ask about the written repayment terms before agreeing. Open Card uses OHA’s direct-hearing process, not the CCO appeal sequence.
What you get
  • A route to coverage of nursing, equipment, therapies or other care the plan’s standard list omits.
  • Expedited review when waiting could harm your child.
What it is not
  • Not a promise of any service requested, and not a cash program.
If you decide to apply
  1. Ask the Oregon Health Plan care manager, in writing, to review the specific service under EPSDT.
  2. Have the clinician send records describing the service, frequency, expected benefit and the risk of going without.
  3. If denied, get the reason in writing and appeal within the deadline; ask for urgent review when needed.

Medicaid: EPSDT · Official page ↗

Records
  • Keep the request date and the plan’s reference number.
Good to know

Ask for a named care manager at the plan as soon as your child is enrolled; that is who receives these requests. If a service might be cut, do not wait for the reduction to happen before asking about continued services.

Other details
  • This applies inside Medicaid only; a work plan has its own appeal route (below).

Related Oregon card: Nurses and aides at home through the Oregon Health Plan.

Official sources
Ask your social worker

“Once our child is on Oregon Health Plan, if a service is refused, can the team ask for an EPSDT review, and who at the plan would we contact?”

Why I’m asking: We want to know the route before a refusal happens.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the plan for a care manager, keep a two-week log of the daily tasks, and put every request in writing under Medicaid's rule that a child under 21 gets what is medically needed.

Your social worker

Gets the care manager assigned and sends the request to the right approval desk.

The care team

Writes the order and the letter of medical necessity naming the service, the frequency and the risk without it.

Who decides
The Medicaid plan or agency, on medical necessity
Ask your social worker
“Can you get us a care manager at the Medicaid plan? Will the team write the letter asking for home nursing, equipment and rides?”

How to apply

First step: Ask the Medicaid plan for a care manager. Put the request in writing and ask for review under EPSDT.

  1. Ask the Medicaid plan for a care manager.
  2. Put the request in writing under EPSDT.
  3. Ask the clinician to write what the service corrects, how often, and the risk without it.

Where it starts: Written request to the plan's care manager. Medicaid appeal if denied

What to gather

  • The doctor's order and a letter of medical necessity
  • A two-week log of the daily tasks at home
  • Any denial letter, with the date

How long: An appeal of a “no” is decided within 30 days, or 72 hours when waiting is unsafe.

What a yes looks like

An approval with hours or units and a start date.

What a no looks like, and the next move

A written denial with appeal rights. Appeal within the notice's period and ask for benefits to continue.

Watch out

  • “Not a covered benefit” is not the end of it for a child. Ask the plan to review the request under Medicaid's rule that a child under 21 gets what is medically needed, in writing.
  • Medical necessity is still reviewed. The doctor's letter must say what the service corrects or prevents, how often, and what happens without it.
  • Nursing and personal care fit. A parent's wages for care usually do not, unless the state runs a paid-caregiver option.
  • Hospice does not mean stopping chemo for a Medicaid child. Since 2010 a child under 21 can have hospice and treatment at the same time. A CHIP-only plan can choose not to cover hospice; if it does, the same rule applies.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 8, 2026.

What it is worth

Home nursing, personal care, equipment, therapies and transport paid by Medicaid on the doctor's word.

Covers: Private-duty nursing at home · Personal care · Feeding pumps, oxygen and other equipment · Therapies and behavioral health · Rides to treatment

Legal protection: Correct-or-ameliorate standard for any service in a Medicaid category · The state owes the benefit even when a managed-care plan says no · Hospice does not mean stopping treatment: since March 23, 2010 a Medicaid child under 21 can have hospice and curative care at the same time (a doctor still certifies a prognosis within six months for hospice)

What it costs the family: Part of Medicaid. No separate premium.

The eligibility facts, as published

Age under
21
Medicaid required
yes

Decisions this site cannot make: Medical necessity · Medicaid service category (section 1905(a))

Expect friction on: Prior approval · Clinical documentation

The trap: Medicaid's rule that a child under 21 gets what is medically needed changes the standard, not the review: the doctor's letter still has to say what the service corrects, how often, and what happens without it.

What changes by state: Nothing in the rule. The plan's forms and the state's paid-caregiver option do.

Where I read this

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