CareOregon/Columbia Pacific CCO says new policy will shift Medicaid outpatient behavioral‑health billing to contracted providers; about 500 members affected

CareOregon and Columbia Pacific CCO representatives told Clatsop County commissioners that two policy changes—one already effective and one due Oct. 1—will limit routine outpatient Medicaid reimbursement to contracted providers and to organizations that hold required approvals.

"Effective August 1, the following provider types ... are no longer eligible for reimbursement for routine outpatient mental health and substance use disorder services when billing as an individual provider or under a non contracted or non certificate of approval group," Rachel, a presenter for CareOregon/Columbia Pacific CCO, said during the county meeting.

CCO staff said the changes were intended to align reimbursement rules with industry norms, enable credentialing and oversight, and concentrate resources on providers able to deliver a full continuum of services, including crisis care. Rachel said the policy "impacts about 19 percent of our outpatient behavioral health providers, but only 6 percent of our outpatient utilization," and that the change was expected to affect "about 500 members across our 3 counties, Clatsop, Tillamook, and Columbia."

The CCO described a three‑step outreach and contracting effort: an assessments phase in July that reached out to noncontracted providers who met low volume or language thresholds, a series of provider and member notifications (first notices Aug. 1, member outreach in mid‑August, a follow‑up on Sept. 1 and a third notice at month’s end), and continuing work after Oct. 1 to monitor access and close network gaps.

Rachel described regionally customized thresholds designed to reduce disruption in rural areas: for example, some providers who had seen as few as two members or who served members in other languages were proactively offered contracts. She said many impacted providers were telehealth clinicians not based in local counties and that these providers often see only one or two local members per year.

The CCO presented county‑level detail for Clatsop County, saying 187 unique providers were recorded as serving members who live in Clatsop County and that those nonlocal/telehealth providers represent about 8 percent of outpatient services for Clatsop members. Rachel also said CareOregon’s internal review showed cost differences between provider groups, with "at times, episodes of care cost per episode of care for our non contracted providers can be 50% more expensive," a gap the CCO attributed to limits on utilization monitoring and credentialing among noncontracted providers.

CCO staff emphasized the change is separate from any Oregon Health Authority (OHA) rulemaking. Rachel noted OHA’s own rule process could result in a regulation next summer and said the CCO would align with OHA if a rule change were finalized.

Commissioners asked detailed questions about equity, data and process. Asked why race was included in the analysis, Rachel said the CCO cross‑referenced race and language to ensure BIPOC members were not disproportionately affected, and flagged that American Indian and Alaska Native members showed a higher proportional impact in the CCO’s review. When Commissioner Webb asked who the packet language about higher utilization and higher rates of fraud, waste and abuse applied to, Rachel said that finding referred to the noncontracted provider group after claims and records review.

The CCO said single‑case agreements (short‑term contracts negotiated for medically necessary care when a standing contract does not exist) will continue to be available for members who need services not covered by an existing contract.

The next steps the CCO described include continued outreach to noncontracted providers, expedited contracting offers where feasible, targeted care coordination for high‑risk members, and ongoing monitoring of member access after Oct. 1. Commissioners asked the CCO to provide additional data access and explanation to HSAC and other local advisory bodies so community members can verify the underlying numbers.

The county did not take formal action during the discussion; commissioners said they would continue to monitor implementation and offered to assist with outreach or communication where appropriate.