What Does OHP Plus Cover: Medical, Dental, Vision, and Behavioral Health

OHP Plus, the main benefit package of the Oregon Health Plan, covers doctor visits, hospital care, prescriptions, dental care, behavioral health treatment, vision and hearing services, pregnancy care, and gender-affirming care at no cost to the member. There are no premiums, co-pays, coinsurance, or deductibles.¹ What varies is the depth of coverage: children under 21 get the broadest benefits, pregnant members get expanded dental and vision, and adults are subject to frequency limits and a state ranking system that decides which conditions and treatments get paid for.

Medical Care and Preventive Services

The core medical benefit covers office visits, hospital stays, surgery, lab work, X-rays, and specialist referrals.² Preventive care includes annual checkups, immunizations for adults and children (flu, COVID, and routine childhood vaccines), cancer screenings such as mammograms and prostate exams, and yearly reproductive health exams.³

Hospital stays require prior authorization from OHP or your Coordinated Care Organization. Services considered cosmetic or not medically necessary are generally excluded.⁴ Emergency care never requires prior approval, and true emergencies are covered even outside Oregon. One caution: if a situation is later determined not to have been a genuine emergency, you could be billed for it.⁵

Prescription Drugs

Most prescriptions are covered at no cost. You should not sign an “Agreement to Pay” form at a pharmacy, because that can make you responsible for the bill.⁶

If you are enrolled in a Coordinated Care Organization, the CCO maintains your drug list. Members not in a CCO follow the statewide OHP Preferred Drug List, which identifies the medications considered most cost-effective for common conditions.⁶ Non-preferred physical health medications require prior authorization. Non-preferred mental health medications do not.⁷ The Oregon Health Authority also covers certain mental health prescriptions directly for all OHP members, regardless of CCO.

Dental Coverage

Dental benefits include checkups, X-rays, cleanings, fluoride treatments, fillings, extractions, and specialist care. Full dentures are covered once every ten years, partial dentures once every five.⁸ For adults, routine cleanings and oral evaluations are generally limited to once per twelve-month period.⁹

Pregnant members get expanded dental benefits during pregnancy and for twelve months after delivery, including additional cleanings as needed, prefabricated crowns, and root canals on back teeth.⁸

Members under 21 get the broadest dental coverage: sealants, crowns, root canals, and treatment for jaw or mouth deformities affecting chewing or speech. Orthodontic treatment is covered when a provider determines the condition causes health problems or prevents proper chewing or speaking. Braces for purely cosmetic reasons are not covered.⁸

Vision, Eye Care, and Hearing

Medical eye exams and treatment for any eye condition, including cataracts, glaucoma, and injuries, are covered for all members. Where adult coverage narrows is on routine vision. Adults 21 and older get a routine vision exam once every 24 months, but glasses and contact lenses are only covered in limited circumstances tied to specific medical conditions such as aphakia or keratoconus.¹⁰ Pregnant adults get expanded vision benefits, including glasses, during pregnancy and for twelve months postpartum.¹¹ Children under 21 are covered for glasses, contact lenses, and vision therapy as medically appropriate.

Hearing aids are covered, along with batteries, fitting, dispensing, and repair.¹² Oregon updated its policy to cover two hearing aids rather than one every five years, after price reductions made the expansion cost-neutral.¹³

Behavioral Health and Substance Use Treatment

Behavioral health care is covered without prior authorization or referral. This includes mental health treatment, substance use disorder treatment, and problem gambling services.¹⁴

Mental health coverage includes evaluations, therapy, medication management, hospital stays, and residential treatment. Substance use services cover screening, assessment, detoxification, medication-assisted treatment, and individual, group, family, and couples counseling. Medications to reduce or stop substance use are covered, including methadone, Suboxone, buprenorphine, and Vivitrol.¹⁴

Additional supports include personal care attendants, peer-delivered services from specialists with lived recovery experience, and children’s services such as applied behavior analysis, intensive in-home behavioral health treatment, and family wraparound services.¹⁴

Pregnancy and Postpartum Care

OHP Plus covers prenatal care, labor and delivery, and postpartum care for twelve months after childbirth. The twelve-month postpartum window was approved by the Centers for Medicare and Medicaid Services in 2022, expanding what had been a 60-day window. You keep medical, dental, and behavioral health services throughout that year.¹⁵

Pregnancy-related benefits also include prenatal vitamins at no cost with a prescription, doula services when the doula is state-certified, and expanded access to acupuncture, chiropractic care, and physical therapy. Pregnant members may also qualify for health-related social needs benefits covering food, housing support, and climate-related devices.¹¹

Gender-Affirming Care

OHP covers all medically necessary gender-affirming treatment prescribed under the Standards of Care for the Health of Transgender and Gender Diverse People. Covered services include hormone therapy, puberty blockers, lab work, mental health therapy, hair removal, speech therapy, and medical tattooing.¹⁶

Surgical coverage includes facial surgery, breast and chest surgery, gonadectomy procedures, genital surgery, and body contouring. Access criteria apply: documented gender dysphoria, informed consent, and assessment by medical and mental health professionals. Adults pursuing surgery are generally expected to complete at least six months of hormone therapy beforehand. Adolescents must have entered puberty and completed at least twelve months of hormone therapy before surgery.¹⁶

Coverage for Members Under 21

Children and young adults under 21 receive the broadest benefits through the Early and Periodic Screening, Diagnostic and Treatment program. Since January 2023, Oregon has covered all medically necessary and appropriate services for this age group regardless of where they fall on the state’s Prioritized List.¹⁷

EPSDT covers well-child visits following Bright Futures guidelines, developmental screenings, lead and anemia testing, immunizations, nutrition assessments, and hearing, vision, and dental screenings. Treatment services include behavioral health (with applied behavior analysis), physical, occupational, and speech therapy, eyeglasses, hearing aids, augmentative communication devices, durable medical equipment, and medical foods or nutritional supplements. As of January 2025, members under 26 with Young Adults with Special Health Care Needs benefits qualify for the same expanded coverage.¹⁷

Therapies, Transportation, Home Health, and Equipment

Physical, occupational, and speech therapy are each covered up to 30 visits per year for rehabilitation (restoring skills after illness, injury, or disability) and up to 30 visits per year for habilitation (learning age-appropriate skills). An additional 30 visits in each category can be authorized after a new acute injury, surgery, or significant change in condition. Members under 21 can go beyond these limits when medically appropriate.¹⁸

Non-emergency medical transportation to covered appointments is included. Rides are arranged through a local transportation brokerage, which must approve the trip in advance. Covered options include taxis, buses, local ride services, and reimbursement for gas, meals, and lodging when needed. An attendant’s travel may be covered if you have a medical need or are under twelve.¹⁹

Home health is covered, as is skilled nursing facility care for up to 100 days following a qualifying hospital stay of at least three days, provided you meet Medicare’s skilled nursing criteria and transfer within 30 days of discharge. Members receiving long-term services through Oregon’s Aging and People with Disabilities program can access nursing facility care without the hospitalization requirement and are not held to the 100-day limit.²⁰ Hospice is covered for members with a life expectancy of six months or less, as determined by a doctor; the hospice agency manages all care and provides counseling for family members.²¹

Durable medical equipment, prosthetics, orthotics, and supplies are covered, including motorized wheelchairs, prosthetic limbs, and blood sugar monitors. Prior authorization is required for specific items.²²

Flexible Services and Health-Related Social Needs

Beyond standard medical care, members in a Coordinated Care Organization may qualify for two additional kinds of support. Flexible services are optional CCO benefits that address social factors affecting health, such as grocery delivery, food vouchers, short-term rental assistance, utility setup fees, temporary housing during recovery, cell phones for telehealth, and items like air conditioners or air filters. CCOs decide case by case, and denials cannot be appealed, though you can file a complaint.²³

Health-related social needs benefits are available to members facing specific life transitions: recent release from incarceration, homelessness or risk of homelessness, child welfare involvement, or recent discharge from a mental health institution. Housing benefits, available since November 2024, cover rent, utility setup, storage fees, and home safety modifications. Nutrition benefits, available since January 2025, include medically tailored meals and nutrition education. Both categories require eligibility beyond standard OHP enrollment.²⁴

How Oregon Decides What’s Covered for Adults

For adult members, coverage is shaped by Oregon’s Prioritized List of Health Services, a ranked list of condition-treatment pairs maintained by the Health Evidence Review Commission. The commission ranks treatments based on clinical effectiveness, cost-effectiveness, and a preference for prevention.²⁵

The legislature funds a specific number of lines each budget cycle. As of February 2026, OHP covers lines 1 through 470, and that funding level is set through December 2026.²⁶ The current list runs to 660 line items, so conditions and treatments ranked below line 470 are generally not covered for adults. The highest-priority lines include maternity and newborn care, preventive services recommended by the U.S. Preventive Services Task Force, substance use treatment, tobacco cessation, contraception, and treatment for major depression, type 1 diabetes, asthma, and HIV/AIDS.²⁵

The Prioritized List does not limit coverage for members under 21, or those under 26 with Young Adults with Special Health Care Needs benefits, who receive all medically necessary services regardless of ranking.²⁷ Diagnostic services needed to establish a diagnosis are also covered no matter where the diagnosis sits on the list.²⁵

One practical note: while the OHP Plus benefit package is set at the state level, provider networks, prescription formularies, and the availability of flexible services vary by Coordinated Care Organization. For questions about a specific provider or medication, check your CCO’s website or call its member services line.²⁸

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