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Behavioral Health Qualified Directed Payments

Behavioral Health Qualified Directed Payment (QDP/BHDPs) overview

Effective January 1, 2026 the Oregon Health Authority (OHA) has made changes to the qualified directed payments (QDP) framework. This is narrowing the scope of the QDP payments to ensure limited Medicaid resources are prioritized for OHP members with the most complex behavioral health (BH) needs, who require more advanced, coordinated care. CareOregon has adjusted our BH fee schedule to align with OHA’s fee schedule and the updated QDP framework for 2026.

 New definitions and rate structures for 2026

  • “Tier 2 Provider” will become “Team-Based High Acuity Medicaid Provider” (TBHA Medicaid Provider) 
  • Criteria to be a TBHA Medicaid Provider for outpatient (OP) BH and substance use disorder (SUD) services (excludes SUD residential and applied behavior analysis (ABA) services): must meet new standards; has a COA, at least 50% of revenue comes from Medicaid, and offers integrated, team-based care (TBC). 
  • “Tier 1 Provider” will become “Non-Team-Based High Acuity Medicaid Provider” (non-TBHA Medicaid Provider) (excludes SUD residential and ABA services) 

Providers who were previously Tier 2 and have a COA, excluding ABA and SUD residential services, will be paid 2025 rates until OHA releases attestation guidance. All other QDPs will remain in effect, including Culturally and Linguistically Specific Services (CLSS) and Integrated Co-occurring Disorders (ICD). We will align with the new definition of team-based care and provide new rates for providers that don’t meet the new criteria.  

Under OHA’s 2026 Qualified Directed Payment Program, only providers that meet the following criteria are eligible for enhanced rates:

  • Be a Community Mental Health Program offering one or more of the following: 
    • Assertive Community Treatment (ACT)  
    • Early Assessment and Support Alliance (EASA)  
    • Intensive In-Home Behavioral Health Treatment (IIBHT)  
    • IPS Supported Employment programs
  • Or meet all of the following: 
    • Hold a Certificate of Approval from OHA;  
    • Derive at least 50% of annual behavioral health revenue from services to OHP members (previous year); and  
    • Provide integrated, team-based care that includes the following, as clinically indicated:  
      • Psychiatric Services and/or Addiction Medicine Services  
      • Peer-Delivered Services (CRM, PWS, PSS) 
      • Case Management Services
      • Individual, Group and Family Therapy – community based as needed

For further definitions of provider groups that qualify for enhanced payment, we invite you to visit the OHA provider announcements page on their website. CareOregon will continue to follow these updates closely and communicate as more information is available.

ABA and SUD residential services will be reimbursed at 100% of OHA’s fee schedule.

OP mental health (MH) and OP SUD groups who meet the above criteria to become a Team-Based High Acuity Medicaid Provider and receive QDP payments will not experience a rate change. All other OP MH and OP SUD groups will be paid at 90% of DMAP rates.  

  • The OHA fee schedule is available here.  
  • For codes not on the DMAP fee schedule, CareOregon maintains fee schedules that can be found for each CCO:  
    • Health Share fee schedule can be found here.  
    • Jackson Care Connect fee schedule can be found here. 
    • Columbia Pacific CCO fee schedule can be found here.  

ABA and SUD residential services will be reimbursed at 100% of OHA’s fee schedule. 

Providers must submit their attestation information using this form: BH Provider Attestation (2026). Once the submission is received, CareOregon will review it and make a decision in 7-10 business days.

Culturally & Linguistically Specific Services (CLSS) Directed Payment

A uniform payment increase to qualified behavioral health participating/contracted providers who deliver culturally and/or linguistically specific services (CLS services) as defined by the Oregon Administrative Rules (OARs) 309-065-0000, 309-065-0010, 309-065-0020, 309-065-0025, 309-065-0030, 309-065-0040, and 309-065-0050. This increase is in addition to CCO contract rates already in place and any tiered payment and/or QDP rate increases. Payment increases are available based on “Rural” (TN) and Non-Rural (U9) classifications.

Which Providers Qualify?

CareOregon does not assign this status to providers. They are assigned by Oregon Health Authority (OHA). OHA approved providers can be found on the OHA website: Approved CLS Providers. CareOregon reviews this list regularly for updates. Providers must be enrolled as a CLSS provider with OHA.

CLSS organizations and programs, individuals, and bilingual service and sign language providers enrolled as a Medicaid provider must meet criteria defined in OAR Chapter 309, Division 65 and provide the following services:

  • Assertive Community Treatment (ACT)
  • Supported Employment Services (SE)
  • Applied Behavior Analysis (ABA)
  • Wraparound
  • Outpatient Mental Health Treatment and Services (OP MH)
  • Outpatient Substance Use Disorder Treatment and Services (OP SUD) and non-Inpatient withdrawal management

How Do Provider Get Paid the Increased Rate?

For providers designated as follows by the OHA (per their online approved-provider list):

  • CLSS Programs (459)
  • CLSS Organizations (460)
  • CLSS Individual Providers (461)
  • Individual Bilingual Providers (462)
  • Individual Sign Language Provider (463)

Current rate differentials are published on the CareOregon Fee Schedule available in Connect under Resources, or in your provider contract.

  • Please note: CareOregon’s claims processing system cannot process CLS claims when CPT codes and CLS modifiers are billed on separate lines. Claims must be submitted on one line per service. This differs from OHA’s billing guide, and how they will ask you to bill them directly.
    • Modifier U9: Culturally and Linguistically Specific Services for non-rural providers
    • Modifier TN: Culturally and Linguistically Specific Services for rural providers

Integrated Co-occurring Disorder (ICD) Directed Payment

A uniform payment increase for qualified behavioral health providers certified by OHA for integrated treatment of Integrated Co-Occurring Disorders (ICD) rendered by qualified staff per OAR 309-019-0145. This increase is in addition to contracted rates already in place and any other tiered payment and/or CLSS QDP rate increases.

Which Providers Qualify?

CareOregon does not assign this status to providers. They are assigned by Oregon Health Authority (OHA). OHA approved providers can be found on the OHA website: Approved ICD Providers. CareOregon reviews this list regularly for updates.

ICD Program Modifiers & Diagnoses

ICD modifiers identify services provided under the Integrated Co‑Occurring Disorders Program. All ICD claims must include at least two OHA‑approved ICD diagnoses.

ModifierDescription
HHICD services rendered by QMHAs, Peer Support Specialists, ICOD Problem Gambling Specialists, and SUD Treatment Staff
HOICD services rendered by QMHP level or higher certification in a behavioral health field
U2ICD Residential Treatment Services

 

ICD Billing Best Practices

  • Verify the rendering provider type aligns with the modifier selected.
  • Include a minimum of two valid OHA‑approved ICD diagnoses on every ICD claim.
  • Ensure diagnoses are clearly related to the services billed.
  • Use the ICD modifier consistently across all eligible services.
  • If you have any additional questions reach out to your Provider Relations Specialist.

Reach out to your Provider Relations Specialist with any additional questions.                                                                           

Questions?

More information can be found in OHA's 10/17 Provider Matters newsletter for Oregon Health Plan providers: Provider Matters - Updates for Oregon Health Plan providers

For more information on how to contract with CareOregon, please review requirements and our submission form on our Provider Support page.

Questions or additional support? Please contact your Provider Relations Specialist at MetroBHPRS@careoregon.org

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