Chapter 743A — Health Insurance: Reimbursement of Claims

2023 EDITION

HEALTH INSURANCE: REIMBURSEMENT OF CLAIMS

INSURANCE

743A.001 Automatic repeal of certain statutes on individual and group health insurance

743A.010 Services provided by state hospital or state approved program

743A.012 Emergency services

743A.014 Payments for ambulance care and transportation

743A.018 Services provided by osteopathic physician

743A.020 Services provided by acupuncturist

743A.024 Services provided by clinical social worker

743A.028 Services provided by denturist

743A.032 Surgical services provided by dentist

743A.034 Services provided by expanded practice dental hygienist

743A.036 Services provided by licensed nurse practitioner or licensed physician assistant

743A.040 Services provided by optometrist

743A.044 Services provided by physician assistant

743A.048 Services provided by psychologist

743A.051 Services provided by pharmacist

743A.052 Services provided by professional counselor or marriage and family therapist

743A.058 Telemedicine services

743A.060 Definition for ORS 743A.062

743A.062 Prescription drugs

743A.063 Ninety-day supply of prescription drug refills

743A.064 Prescription drugs dispensed at rural health clinics

743A.065 Early refills of prescription eye drops for treatment of glaucoma

743A.066 Contraceptives

743A.067 Reproductive health services

743A.068 Orally administered anticancer medication

743A.069 Insulin

743A.070 Nonprescription enteral formula for home use

743A.078 Newborn nurse home visiting services

743A.080 Pregnancy and childbirth expenses

743A.082 Diabetes management for pregnant women

743A.084 Unmarried women and their children

743A.088 Use by mother of diethylstilbestrol

743A.090 Natural and adopted children

743A.100 Mammograms

743A.101 Supplemental or diagnostic breast examinations

743A.104 Pelvic examinations and Pap smear examinations

743A.105 HPV vaccine

743A.108 Physical examination of breast

743A.110 Mastectomy-related services; expedited external review required

743A.111 Consumer education about post-mastectomy services

743A.124 Colorectal cancer screenings and laboratory tests

743A.130 Proton beam therapy

743A.140 Bilateral cochlear implants

743A.141 Hearing aids and assistive listening devices

743A.145 Orthotic and prosthetic devices; rules

743A.148 Maxillofacial prosthetic services

743A.150 Treatment of craniofacial anomaly

743A.160 Alcoholism treatment

743A.168 Behavioral health treatment; qualified providers; rules

Note Application of ORS 743A.001 to ORS 743A.168 and 750.055--1987 c.411 §7

743A.169 Behavioral and physical health services provided on same day or in same facility; behavioral health services provided by behavioral health home specialist or patient centered primary care home specialist

743A.170 Tobacco use cessation programs

743A.175 Traumatic brain injury

743A.180 Tourette Syndrome

743A.185 Telemedical health services for treatment of diabetes

743A.188 Inborn errors of metabolism

743A.190 Children with pervasive developmental disorder

743A.192 Clinical trials

743A.250 Emergency eye care services

743A.252 Child abuse assessments

743A.260 Inmates

743A.262 Preventive health services; cost sharing

743A.264 Disease outbreaks, epidemics and conditions of public health importance

(Temporary provisions relating to coverage of applied behavior analysis are compiled as notes following ORS 743A.264)

743A.310 Primary care visits; rules

743A.315 Treatment for pediatric autoimmune neuropsychiatric disorders

743A.325 Gender-affirming treatment; rules

743A.001 Automatic repeal of certain statutes on individual and group health insurance. (1) Except as provided in subsection (4) of this section, any statute described in subsection (2) of this section that becomes effective on or after July 13, 1985, is repealed on the sixth anniversary of the effective date of the statute, unless the Legislative Assembly specifically provides otherwise.

(2) This section governs any statute that applies to individual or group health insurance policies and does any of the following:

(a) Requires the insurer to include coverage for specific physical or mental conditions or specific hospital, medical, surgical or dental health services.

(b) Requires the insurer to include coverage for specified persons.

(c) Requires the insurer to provide payment or reimbursement to specified providers of services if the services are within the lawful scope of practice of the provider and the insurance policy provides payment or reimbursement for those services.

(d) Requires the insurer to provide any specific coverage on a nondiscriminatory basis.

(e) Forbids the insurer to exclude from payment or reimbursement any covered services.

(f) Forbids the insurer to exclude coverage of a person because of that person’s medical history.

(3) A repeal of a statute under subsection (1) of this section does not apply to any insurance policy in effect on the effective date of the repeal. However, the repeal of the statute applies to a renewal or extension of an existing insurance policy on or after the effective date of the repealer as well as to a new policy issued on or after the effective date of the repealer.

(4) This section does not apply to ORS 743A.020, 743A.080, 743A.100, 743A.104 and 743A.108. [Formerly 743.700]

743A.010 Services provided by state hospital or state approved program. No policy of health insurance shall exclude from payment or reimbursement losses incurred by an insured for any covered service because the service was rendered at any hospital owned or operated by the State of Oregon or any state approved community mental health program or community developmental disabilities program. [Formerly 743.701; 2011 c.720 §221]

743A.012 Emergency services. (1) As used in this section:

(a) “Behavioral health assessment” means an evaluation by a behavioral health clinician, in person or using telemedicine, to determine a patient’s need for immediate crisis stabilization.

(b) “Behavioral health clinician” means:

(A) A licensed psychiatrist;

(B) A licensed psychologist;

(D) A licensed clinical social worker;

(E) A licensed professional counselor or licensed marriage and family therapist;

(F) A certified clinical social work associate;

(G) An intern or resident who is working under a board-approved supervisory contract in a clinical mental health field; or

(H) Any other clinician whose authorized scope of practice includes mental health diagnosis and treatment.

(c) “Behavioral health crisis” means a disruption in an individual’s mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individual’s mental or physical health.

(d) “Emergency medical condition” means a medical condition:

(A) That manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would:

(i) Place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy;

(ii) Result in serious impairment to bodily functions; or

(iii) Result in serious dysfunction of any bodily organ or part;

(B) With respect to a pregnant woman who is having contractions, for which there is inadequate time to effect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to the health or safety of the woman or the unborn child; or

(e) “Emergency medical screening exam” means the medical history, examination, ancillary tests and medical determinations required to ascertain the nature and extent of an emergency medical condition.

(f) “Emergency medical service provider” has the meaning given that term in ORS 682.025.

(g) “Emergency medical services transport” means an emergency medical services provider’s evaluation and stabilization of an individual experiencing a medical emergency and the transportation of the individual to the nearest medical facility capable of meeting the needs of the individual.

(h) “Emergency services” means, with respect to an emergency medical condition:

(A) An emergency medical services transport;

(B) An emergency medical screening exam or behavioral health assessment that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and

(C) Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to stabilize a patient, to the extent the examination and treatment are within the capability of the staff and facilities available at a hospital.

(i) “Grandfathered health plan” has the meaning given that term in ORS 743B.005.

(j) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(k) “Prior authorization” has the meaning given that term in ORS 743B.001.

(L) “Stabilize” means to provide medical treatment as necessary to:

(A) Ensure that, within reasonable medical probability, no material deterioration of an emergency medical condition is likely to occur during or to result from the transfer of the patient to or from a facility; and

(B) With respect to a pregnant woman who is in active labor, to perform the delivery, including the delivery of the placenta.

(2) All insurers offering a health benefit plan shall provide coverage without prior authorization for emergency services.

(3) A health benefit plan, other than a grandfathered health plan, must provide coverage required by subsection (2) of this section:

(a) For the services of participating providers, without regard to any term or condition of coverage other than:

(A) The coordination of benefits;

(B) An affiliation period or waiting period permitted under part 7 of the Employee Retirement Income Security Act, part A of Title XXVII of the Public Health Service Act or chapter 100 of the Internal Revenue Code;

(D) Applicable cost-sharing; and

(b) For the services of a nonparticipating provider:

(A) Without imposing any administrative requirement or limitation on coverage that is more restrictive than requirements or limitations that apply to participating providers;

(B) Without imposing a copayment amount or coinsurance rate that exceeds the amount or rate for participating providers;

(D) Subject only to an out-of-pocket maximum that applies to all services from nonparticipating providers.

(4) All insurers offering a health benefit plan shall provide information to enrollees in plain language regarding:

(a) What constitutes an emergency medical condition;

(b) The coverage provided for emergency services;

(d) The appropriate use of 9-1-1.

(5) An insurer offering a health benefit plan may not discourage appropriate use of 9-1-1 and may not deny coverage for emergency services when 9-1-1 is used.

(6) This section is exempt from ORS 743A.001. [Formerly 743.699; 2011 c.500 §38; 2017 c.273 §4; 2019 c.358 §41; 2021 c.312 §1]

743A.014 Payments for ambulance care and transportation. (1) As used in this section, “health benefit plan” has the meaning given that term in ORS 743B.005.

(2) Notwithstanding ORS 743.543, with respect to a health benefit plan or a Medicare supplement insurance policy that provides coverage for ambulance care and transportation, the insurer shall indemnify directly the provider of the ambulance care and transportation. [Formerly 743.718; 2013 c.91 §1; 2015 c.588 §4]

Note: See 743A.001.

743A.018 Services provided by osteopathic physician. (1) As used in this section:

(a) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(b) “Osteopathic physician” means a person who holds a degree of Doctor of Osteopathic Medicine and is licensed under ORS 677.100 to 677.228.

(2) An insurer that offers a health benefit plan that reimburses the cost of an osteopathic manipulative treatment provided by an osteopathic physician shall reimburse the cost of the evaluation conducted by the osteopathic physician that resulted in the osteopathic manipulative treatment.

(3) An insurer may not deny reimbursement for an osteopathic manipulative treatment or an evaluation described in subsection (2) of this section on the basis that the evaluation is conducted on the same date that the osteopathic manipulative treatment is provided. [2018 c.31 §2]

Note: See 743A.001.

Note: 743A.018 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.020 Services provided by acupuncturist. (1) An individual or group health insurance policy that provides coverage for acupuncture services performed by a physician shall provide coverage for acupuncture services performed by an acupuncturist licensed under ORS 677.757 to 677.770.

(2) The coverage required by subsection (1) of this section may be made subject to provisions of the policy that apply to other benefits under the policy, including, but not limited to, provisions related to deductibles and coinsurance and shall be computed in the same manner whether performed by a physician or an acupuncturist.

(3) Subsection (1) of this section does not require group practice health maintenance organizations that are federally qualified pursuant to Title XIII subchapter XI of the Public Health Service Act (42 U.S.C. 300e et seq.) to employ acupuncturists licensed under ORS 677.757 to 677.770.

(4) This section also applies to health care service contractors, as defined in ORS 750.005, and trusts carrying out multiple employer welfare arrangements, as defined in ORS 750.301. [2007 c.313 §2]

Note: 743A.020 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.024 Services provided by clinical social worker. Whenever any individual or group health insurance policy or blanket health insurance policy described in ORS 743.536 (3) provides for payment or reimbursement for any service within the lawful scope of service of a clinical social worker licensed under ORS 675.530:

(1) The insured under the policy shall be entitled to the services of a clinical social worker licensed under ORS 675.530, upon referral by a physician or psychologist.

(2) The insured under the policy shall be entitled to have payment or reimbursement made to the insured or on behalf of the insured for the services performed. The payment or reimbursement shall be in accordance with the benefits provided in the policy and shall be computed in the same manner whether performed by a physician, by a psychologist or by a clinical social worker, according to the customary and usual fee of clinical social workers in the area served. [Formerly 743.714; 2009 c.442 §46]

743A.028 Services provided by denturist. Notwithstanding any provisions of any policy of insurance covering dental health, whenever such policy provides for reimbursement for any service that is within the lawful scope of practice of a denturist, the insured under such policy shall be entitled to reimbursement for such service, whether the service is performed by a licensed dentist or a licensed denturist as defined in ORS 680.500. [Formerly 743.713]

Note: 743A.028 was added to and made a part of the Insurance Code by law but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.032 Surgical services provided by dentist. Notwithstanding any provision of a policy of health insurance, whenever the policy provides for payment of a surgical service, the performance for the insured of such surgical service by any dentist acting within the scope of the dentist’s license is compensable if performance of that service by a physician acting within the scope of the physician’s license would be compensable. [Formerly 743.719]

743A.034 Services provided by expanded practice dental hygienist. (1) If a policy of insurance covering dental health provides for coverage for services performed by a dentist licensed under ORS chapter 679, the policy must also cover the services when they are performed by an expanded practice dental hygienist, as defined in ORS 679.010, who has entered into a provider contract with the insurer.

(2) The provisions of ORS 743A.001 do not apply to this section. [2011 c.716 §11]

Note: 743A.034 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.036 Services provided by licensed nurse practitioner or licensed physician assistant. (1) Whenever any policy of health insurance provides for reimbursement for a primary care or mental health service provided by a licensed physician, the insured under the policy is entitled to reimbursement for such service if provided by a licensed physician assistant or a licensed nurse practitioner if the service is within the lawful scope of practice of the physician assistant or nurse practitioner.

(2)(a) The reimbursement of a service described in subsection (1) of this section that is provided by a licensed physician assistant or a licensed nurse practitioner who is in an independent practice shall be in the same amount as the reimbursement paid under the policy to a licensed physician performing the service in the area served.

(b) As used in this subsection, “independent practice” means the licensed physician assistant or the licensed nurse practitioner bills insurers for services provided by the physician assistant or nurse practitioner using the:

(A) Diagnosis and procedure codes applicable to the services;

(B) Physician assistant’s or nurse practitioner’s own name; and

(i) The physician assistant or nurse practitioner; and

(ii) If required by the insurer, the facility in which the physician assistant or nurse practitioner provides the services.

(3) This section does not apply to group practice health maintenance organizations that are federally qualified pursuant to Title XIII of the Health Maintenance Organization Act or other insurers that employ physicians, licensed physician assistants or licensed nurse practitioners to provide primary care or mental health services and do not compensate such practitioners on a fee-for-service basis.

(4) An insurer may not reduce the reimbursement paid to a licensed physician in order to comply with this section. [Formerly 743.712; 2013 c.430 §§1,4; 2015 c.377 §1; 2016 c.54 §1; 2019 c.358 §42]

743A.040 Services provided by optometrist. Notwithstanding any provision of any policy of health insurance, whenever the policy provides for payment or reimbursement for a service that is within the lawful scope of practice of a licensed optometrist, the insurer shall provide payment or reimbursement for the service, whether the service is performed by a physician or a licensed optometrist. Unless the policy provides otherwise, there shall be no reimbursement for ophthalmic materials, lenses, spectacles, eyeglasses or appurtenances thereto. [Formerly 743.703]

743A.044 Services provided by physician assistant. (1) An insurer may not refuse a claim solely on the ground that the claim was submitted by a physician assistant rather than by a physician, podiatric physician or employer with whom the physician assistant has entered into a collaboration agreement, as defined in ORS 677.495.

(2) This section is exempt from ORS 743A.001. [Formerly 743.725; 2010 c.43 §9; 2021 c.349 §17]

743A.048 Services provided by psychologist. Whenever any provision of any individual or group health insurance policy or contract provides for payment or reimbursement for any service which is within the lawful scope of a psychologist licensed under ORS 675.010 to 675.150:

(1) The insured under such policy or contract shall be free to select, and shall have direct access to, a psychologist licensed under ORS 675.010 to 675.150, without supervision or referral by a physician or another health practitioner, and wherever such psychologist is authorized to practice.

(2) The insured under such policy or contract shall be entitled to have payment or reimbursement made to the insured or on the insured’s behalf for the services performed. Such payment or reimbursement shall be in accordance with the benefits provided in the policy and shall be the same whether performed by a physician or a psychologist licensed under ORS 675.010 to 675.150. [Formerly 743.709]

743A.050 [Formerly 743.798; repealed by 2017 c.206 §16]

743A.051 Services provided by pharmacist. Notwithstanding any provisions of a health benefit plan as defined in ORS 743B.005, whenever the plan provides for payment or reimbursement for a service that is within the lawful scope of practice of a pharmacist, the insurer:

(1) May provide payment or reimbursement for the service when the service is provided by a pharmacist; and

(2) Shall provide, in the same manner as would be provided for any other health care provider, payment or reimbursement for:

(a)(A) The prescription of emergency refills of insulin and associated insulin-related devices and supplies as described in ORS 689.696; and

(B) The service provided by the pharmacist;

(b)(A) The prescription, dispensation and administration of preexposure and post-exposure prophylactic antiretroviral therapies pursuant to ORS 689.704 and any rules adopted by the State Board of Pharmacy under ORS 689.645 and 689.704; and

(B) The service provided by the pharmacist; and

(c)(A) The prescription and dispensation of other prescription drugs by a licensed pharmacist if the State Board of Pharmacy or any state law authorizes the drug to be prescribed and dispensed by pharmacists licensed under ORS chapter 689; and

(B) The service provided by the pharmacist.

(3) This section is exempt from ORS 743A.001. [2015 c.362 §8; 2019 c.95 §5; 2021 c.365 §4]

Note: 743A.051 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.052 Services provided by professional counselor or marriage and family therapist. (1) If a group health benefit plan, as described in ORS 743B.005, provides for coverage for services performed by a clinical social worker or nurse practitioner, the plan also must cover services provided by a professional counselor or marriage and family therapist licensed under ORS 675.715 to 675.835 when the counselor or therapist is acting within the counselor’s or therapist’s lawful scope of practice.

(2) Health maintenance organizations may limit the receipt of covered services performed by professional counselors and marriage and family therapists to services provided by or upon referral by providers contracting with the health maintenance organization. Health maintenance organizations and health care service contractors may create substantive plan benefit and reimbursement differentials at the same level as, and subject to limitations not more restrictive than, those imposed on coverage or reimbursement of expenses arising out of other medical conditions and apply them to contracting and noncontracting providers.

(3) The provisions of ORS 743A.001 do not apply to this section. [2009 c.549 §2]

Note: 743A.052 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.058 Telemedicine services. (1) As used in this section:

(a)(A) “Audio only” means the use of audio telephone technology, permitting real-time communication between a health care provider and a patient for the purpose of diagnosis, consultation or treatment.

(B) “Audio only” does not include:

(i) The use of facsimile, electronic mail or text messages.

(ii) The delivery of health services that are customarily delivered by audio telephone technology and customarily not billed as separate services by a health care provider, such as the sharing of laboratory results.

(b) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(c) “Health professional” means a person licensed, certified or registered in this state to provide health care services or supplies.

(d) “Health service” means physical, oral and behavioral health treatment or service provided by a health professional.

(e) “Originating site” means the physical location of the patient.

(f) “State of emergency” includes:

(A) A state of emergency declared by the Governor under ORS 401.165; or

(B) A state of public health emergency declared by the Governor under ORS 433.441.

(g) “Telemedicine” means the mode of delivering health services using information and telecommunication technologies to provide consultation and education or to facilitate diagnosis, treatment, care management or self-management of a patient’s health care.

(2) A health benefit plan and a dental-only plan must provide coverage of a health service that is provided using telemedicine if:

(a) The plan provides coverage of the health service when provided in person by a health professional;

(b) The health service is medically necessary;

(c) The health service is determined to be safely and effectively provided using telemedicine according to generally accepted health care practices and standards; and

(d) The application and technology used to provide the health service meet all standards required by state and federal laws governing the privacy and security of protected health information.

(3) Except as provided in subsection (4) of this section, permissible telemedicine applications and technologies include:

(a) Landlines, wireless communications, the Internet and telephone networks; and

(b) Synchronous or asynchronous transmissions using audio only, video only, audio and video and transmission of data from remote monitoring devices.

(4) During a state of emergency, a health benefit plan or dental-only plan shall provide coverage of a telemedicine service delivered to an enrollee residing in the geographic area specified in the declaration of the state of emergency, if the telemedicine service is delivered using any commonly available technology, regardless of whether the technology meets all standards required by state and federal laws governing the privacy and security of protected health information.

(5) A health benefit plan and a dental-only plan may not:

(a) Distinguish between rural and urban originating sites in providing coverage under subsection (2) of this section or restrict originating sites that qualify for reimbursement.

(b) Restrict a health care provider to delivering services only in person or only via telemedicine.

(d) Require an enrollee to have an established patient-provider relationship with a provider to receive telemedicine health services from the provider or require an enrollee to consent to telemedicine services in person.

(e) Impose additional certification, location or training requirements for telemedicine providers or restrict the scope of services that may be provided using telemedicine to less than a provider’s permissible scope of practice.

(f) Impose more restrictive requirements for telemedicine applications and technologies than those specified in subsection (3) of this section.

(g) Impose on telemedicine health services different annual dollar maximums or prior authorization requirements than the annual dollar maximums and prior authorization requirements imposed on the services if provided in person.

(h) Require a medical assistant or other health professional to be present with an enrollee at the originating site.

(i) Deny an enrollee the choice to receive a health service in person or via telemedicine.

(j) Reimburse an out-of-network provider at a rate for telemedicine health services that is different than the reimbursement paid to the out-of-network provider for health services delivered in person.

(k) Restrict a provider from providing telemedicine services across state lines if the services are within the provider’s scope of practice and:

(A) The provider has an established practice within this state;

(B) The provider’s employer operates health clinics or licensed health care facilities in this state;

(D) The patient was referred to the provider by the patient’s primary care or specialty provider located in this state.

(L) Prevent a provider from prescribing, dispensing or administering drugs or medical supplies or otherwise providing treatment recommendations to an enrollee after having performed an appropriate examination of the enrollee in person, through telemedicine or by the use of instrumentation and diagnostic equipment through which images and medical records may be transmitted electronically.

(m) Establish standards for determining medical necessity for services delivered using telemedicine that are higher than standards for determining medical necessity for services delivered in person.

(6) A health benefit plan and a dental-only plan shall:

(a) Work with contracted providers to ensure meaningful access to telemedicine services by assessing an enrollee’s capacity to use telemedicine technologies that comply with accessibility standards, including alternate formats, and providing the optimal quality of care for the enrollee given the enrollee’s capacity;

(b) Ensure access to auxiliary aids and services to ensure that telemedicine services accommodate the needs of enrollees who have difficulty communicating due to a medical condition, who need an accommodation due to disability or advanced age or who have limited English proficiency;

(c) Ensure access to telemedicine services for enrollees who have limited English proficiency or who are deaf or hard-of-hearing by providing interpreter services reimbursed at the same rate as interpreter services provided in person; and

(d) Ensure that telemedicine services are culturally and linguistically appropriate and trauma-informed.

(7) The coverage under subsection (2) of this section is subject to:

(a) The terms and conditions of the health benefit plan or dental-only plan; and

(b) Subject to subsection (8) of this section, the reimbursement specified in the contract between the plan and the health professional.

(8)(a) A health benefit plan and dental-only plan must pay the same reimbursement for a health service regardless of whether the service is provided in person or using any permissible telemedicine application or technology.

(b) Paragraph (a) of this subsection does not prohibit the use of value-based payment methods, including capitated, bundled, risk-based or other value-based payment methods, and does not require that any value-based payment method reimburse telemedicine health services based on an equivalent fee-for-service rate.

(9) This section does not require a health benefit plan or dental-only plan to reimburse a health professional:

(a) For a health service that is not a covered benefit under the plan;

(b) Who has not contracted with the plan; or

(c) For a service that is not included within the Healthcare Procedure Coding System or the American Medical Association’s Current Procedural Terminology codes or related modifier codes.

(10) This section is exempt from ORS 743A.001. [2009 c.384 §2; 2015 c.340 §1; 2017 c.309 §5; 2021 c.117 §3]

Note: 743A.058 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.060 Definition for ORS 743A.062. As used in ORS 743A.062, “peer-reviewed medical literature” means scientific studies printed in journals or other publications that publish original manuscripts only after the manuscripts have been critically reviewed by unbiased independent experts for scientific accuracy, validity and reliability. “Peer-reviewed medical literature” does not include internal publications of pharmaceutical manufacturers. [Formerly 743.695]

743A.062 Prescription drugs. (1) As used in this section, “medical assistance program” means the state program that provides medical assistance as defined in ORS 414.025.

(2) An insurance policy or contract providing coverage for a prescription drug to a resident of this state may not:

(a) Exclude coverage of the drug for a particular indication solely on the grounds that the indication has not been approved by the United States Food and Drug Administration if the Health Evidence Review Commission established under ORS 414.688 or the Pharmacy and Therapeutics Committee established under ORS 414.353 determines that the drug is recognized as effective for the treatment of that indication:

(A) In publications that the commission or the committee determines to be equivalent to:

(i) The American Hospital Formulary Service drug information;

(ii) “Drug Facts and Comparisons” (Lippincott-Raven Publishers);

(iii) The United States Pharmacopoeia drug information; or

(iv) Other publications that have been identified by the United States Secretary of Health and Human Services as authoritative;

(B) In the majority of relevant peer-reviewed medical literature; or

(b) For an insured who is enrolled in the medical assistance program:

(A) Except as provided in subsection (3) of this section, require a prescription for the drug to be filled or refilled at a mail order pharmacy; or

(B) Require a prescription for the drug to be filled or refilled at a pharmacy that is not a local pharmacy enrolled in the medical assistance program.

(3) Subsection (2)(b)(A) of this section does not prohibit an insurer from requiring a medical assistance recipient to fill or refill a prescription for a specialty drug at a mail order pharmacy that is a specialty pharmacy.

(4) Required coverage of a prescription drug under this section shall include coverage for medically necessary services associated with the administration of that drug.

(5) Nothing in this section requires coverage for any prescription drug if the United States Food and Drug Administration has determined use of the drug to be contraindicated.

(6) Nothing in this section requires coverage for experimental drugs not approved for any indication by the United States Food and Drug Administration.

(7) This section is exempt from ORS 743A.001. [Formerly 743.697; 2011 c.720 §222; 2021 c.339 §1]

743A.063 Ninety-day supply of prescription drug refills. (1) A prescription drug benefit program, or a prescription drug benefit offered under a health benefit plan as defined in ORS 743B.005, must provide for reimbursement for up to a 90-day supply of a prescription drug dispensed by a pharmacy, as defined in ORS 689.005, if:

(a) The prescription drug is covered by the program or plan;

(b) An initial 30-day supply of the prescription drug has been previously dispensed to the program or plan member; and

(c) The quantity of the prescription drug dispensed does not exceed the total remaining quantity of the prescription drug that the prescribing practitioner authorized to be dispensed through refills.

(2) The coverage required by subsection (1) of this section may be limited by the terms and conditions of a pharmacy network contract, or a prescription drug benefit program or health benefit plan, that are related to the reimbursement rate of the prescription drug.

(3) The coverage required by subsection (1) of this section may be limited by formulary restrictions that are related to the prescription drug.

(4) This section does not apply to the reimbursement of prescription drugs classified as a controlled substance in Schedule II.

(5) This section is exempt from ORS 743A.001. [2015 c.661 §2]

Note: 743A.063 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.064 Prescription drugs dispensed at rural health clinics. (1) All health insurance policies that provide a prescription drug benefit, except those policies in which coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this subsection, must include coverage for prescription drugs dispensed by a licensed practitioner at a rural health clinic for an urgent medical condition if there is not a pharmacy within 15 miles of the clinic or if the prescription is dispensed for a patient outside of the normal business hours of any pharmacy within 15 miles of the clinic.

(2) The coverage required by subsection (1) of this section is subject to the terms and conditions of the prescription drug benefit provided under the policy.

(3) As used in this section, “urgent medical condition” means a medical condition that arises suddenly, is not life-threatening and requires prompt treatment to avoid the development of more serious medical problems. [Formerly 743.793]

Note: See 743A.001.

743A.065 Early refills of prescription eye drops for treatment of glaucoma. An insurer offering a health benefit plan, as defined in ORS 743B.005, that provides coverage of prescription eye drops shall provide coverage for one early refill of a prescription for eye drops to treat glaucoma if all of the following criteria are met:

(1) The refill is requested by an insured less than 30 days after the later of:

(a) The date the original prescription was dispensed to the insured; or

(b) The date that the last refill of the prescription was dispensed to the insured.

(2) The prescriber indicates on the original prescription that a specific number of refills will be needed.

(3) The refill does not exceed the number of refills that the prescriber indicated under subsection (2) of this section.

(4) The prescription has not been refilled more than once during the 30-day period prior to the request for an early refill. [2011 c.660 §25]

Note: See 743A.001.

Note: 743A.065 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.066 Contraceptives. (1) A prescription drug benefit program, or a prescription drug benefit offered under a health benefit plan as defined in ORS 743B.005 or under a student health insurance policy, must provide payment, coverage or reimbursement for:

(a) Prescription contraceptives; and

(b) If covered for other drug benefits under the program, plan or policy, outpatient consultations, including pharmacist consultations, examinations, procedures and medical services that are necessary to prescribe, dispense, deliver, distribute, administer or remove a prescription contraceptive.

(2) The coverage required by subsection (1) of this section:

(a) May be subject to provisions of the program, plan or policy that apply equally to other prescription drugs covered by the program, plan or policy, including but not limited to required copayments, deductibles and coinsurance; and

(b) Must reimburse a health care provider or dispensing entity for a dispensing of contraceptives intended to last for a:

(A) Three-month period for the first dispensing of the contraceptive to an insured; and

(B) Twelve-month period for subsequent dispensings of the same contraceptive to the insured regardless of whether the insured was enrolled in the program, plan or policy at the time of the first dispensing.

(3) As used in this section, “prescription contraceptive” means a drug or device that requires a prescription and is approved by the United States Food and Drug Administration to prevent pregnancy.

(4) A religious employer is exempt from the requirements of this section with respect to a prescription drug benefit program or a health benefit plan it provides to its employees. A “religious employer” is an employer:

(a) Whose purpose is the inculcation of religious values;

(b) That primarily employs persons who share the religious tenets of the employer;

(d) That is a nonprofit organization under section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code.

(5) This section is exempt from the provisions of ORS 743A.001. [2007 c.182 §3; 2015 c.412 §1; 2017 c.289 §4]

Note: 743A.066 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.067 Reproductive health services. (1) As used in this section:

(a) “Contraceptives” means health care services, drugs, devices, products or medical procedures to prevent a pregnancy.

(b) “Enrollee” means an insured individual and the individual’s spouse, domestic partner and dependents who are beneficiaries under the insured individual’s health benefit plan.

(c) “Health benefit plan” has the meaning given that term in ORS 743B.005, excluding Medicare Advantage Plans and including health benefit plans offering pharmacy benefits administered by a third party administrator or pharmacy benefit manager.

(d) “Prior authorization” has the meaning given that term in ORS 743B.001.

(e) “Religious employer” has the meaning given that term in ORS 743A.066.

(f) “Utilization review” has the meaning given that term in ORS 743B.001.

(2) A health benefit plan offered in this state must provide coverage for all of the following services, drugs, devices, products and procedures:

(a) Well-woman care prescribed by the Department of Consumer and Business Services by rule consistent with guidelines published by the United States Health Resources and Services Administration.

(b) Counseling for sexually transmitted infections, including but not limited to human immunodeficiency virus and acquired immune deficiency syndrome.

(A) Chlamydia;

(B) Gonorrhea;

(D) Hepatitis C;

(E) Human immunodeficiency virus and acquired immune deficiency syndrome;

(F) Human papillomavirus;

(G) Syphilis;

(H) Anemia;

(I) Urinary tract infection;

(J) Pregnancy;

(K) Rh incompatibility;

(L) Gestational diabetes;

(M) Osteoporosis;

(N) Breast cancer; and

(O) Cervical cancer.

(d) Screening to determine whether counseling related to the BRCA1 or BRCA2 genetic mutations is indicated and counseling related to the BRCA1 or BRCA2 genetic mutations if indicated.

(e) Screening and appropriate counseling or interventions for:

(A) Tobacco use; and

(B) Domestic and interpersonal violence.

(f) Folic acid supplements.

(g) Abortion.

(h) Breastfeeding comprehensive support, counseling and supplies.

(i) Breast cancer chemoprevention counseling.

(j) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, subject to all of the following:

(A) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, a health benefit plan may provide coverage for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.

(B) If a contraceptive drug, device or product covered by the health benefit plan is deemed medically inadvisable by the enrollee’s provider, the health benefit plan must cover an alternative contraceptive drug, device or product prescribed by the provider.

(C) A health benefit plan must pay pharmacy claims for reimbursement of all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration.

(D) A health benefit plan may not infringe upon an enrollee’s choice of contraceptive drug, device or product and may not require prior authorization, step therapy or other utilization review techniques for medically appropriate covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.

(k) Voluntary sterilization.

(L) As a single claim or combined with other claims for covered services provided on the same day:

(A) Patient education and counseling on contraception and sterilization.

(B) Services related to sterilization or the administration and monitoring of contraceptive drugs, devices and products, including but not limited to:

(i) Management of side effects;

(ii) Counseling for continued adherence to a prescribed regimen;

(iii) Device insertion and removal; and

(iv) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the enrollee’s provider.

(m) Any additional preventive services for women that must be covered without cost sharing under 42 U.S.C. 300gg-13, as identified by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services as of January 1, 2017.

(3) A health benefit plan may not impose on an enrollee a deductible, coinsurance, copayment or any other cost-sharing requirement on the coverage required by this section. A health care provider shall be reimbursed for providing the services described in this section without any deduction for coinsurance, copayments or any other cost-sharing amounts.

(4) Except as authorized under this section, a health benefit plan may not impose any restrictions or delays on the coverage required by this section.

(5) This section does not exclude coverage for contraceptive drugs, devices or products prescribed by a provider, acting within the provider’s scope of practice, for:

(a) Reasons other than contraceptive purposes, such as decreasing the risk of ovarian cancer or eliminating symptoms of menopause; or

(b) Contraception that is necessary to preserve the life or health of an enrollee.

(6) This section does not limit the authority of the Department of Consumer and Business Services to ensure compliance with ORS 743A.063 and 743A.066.

(7) This section does not require a health benefit plan to cover:

(a) Experimental or investigational treatments;

(b) Clinical trials or demonstration projects, except as provided in ORS 743A.192;

(d) Treatments for which there is insufficient data to determine efficacy; or

(e) Abortion if the insurer offering the health benefit plan:

(A) Has a certificate of authority to transact insurance in this state issued by the Department of Consumer and Business Services; and

(B) Excluded coverage for abortion in all of its individual, small employer and large employer group plans during the 2017 plan year.

(8) If services, drugs, devices, products or procedures required by this section are provided by an out-of-network provider, the health benefit plan must cover the services, drugs, devices, products or procedures without imposing any cost-sharing requirement on the enrollee if:

(a) There is no in-network provider to furnish the service, drug, device, product or procedure that is geographically accessible or accessible in a reasonable amount of time, as defined by the Department of Consumer and Business Services by rule consistent with the requirements for provider networks in ORS 743B.505; or

(b) An in-network provider is unable or unwilling to provide the service in a timely manner.

(9) An insurer may offer to a religious employer a health benefit plan that does not include coverage for contraceptives or abortion procedures that are contrary to the religious employer’s religious tenets only if the insurer notifies in writing all employees who may be enrolled in the health benefit plan of the contraceptives and procedures the employer refuses to cover for religious reasons.

(10) If the Department of Consumer and Business Services concludes that enforcement of this section may adversely affect the allocation of federal funds to this state, the department may grant an exemption to the requirements but only to the minimum extent necessary to ensure the continued receipt of federal funds.

(11) An insurer that is subject to this section shall make readily accessible to enrollees and potential enrollees, in a consumer-friendly format, information about the coverage of contraceptives by each health benefit plan and the coverage of other services, drugs, devices, products and procedures described in this section. The insurer must provide the information:

(a) On the insurer’s website; and

(b) In writing upon request by an enrollee or potential enrollee.

(12) This section does not prohibit an insurer from using reasonable medical management techniques to determine the frequency, method, treatment or setting for the coverage of services, drugs, devices, products and procedures described in subsection (2) of this section, other than coverage required by subsection (2)(g) and (j) of this section, if the techniques:

(a) Are consistent with the coverage requirements of subsection (2) of this section; and

(b) Do not result in the wholesale or indiscriminate denial of coverage for a service.

(13) This section is exempt from ORS 743A.001. [2017 c.721 §2; 2019 c.284 §5; 2022 c.45 §12; 2023 c.228 §12]

Note: 743A.067 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.068 Orally administered anticancer medication. (1) A health benefit plan that provides coverage for cancer chemotherapy treatment must provide coverage for a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits.

(2) As used in this section, “health benefit plan” has the meaning given that term in ORS 743B.005.

(3) The provisions of ORS 743A.001 do not apply to this section. [2007 c.566 §2]

Note: 743A.068 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.069 Insulin. (1) As used in this section:

(a) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(b) “Insulin” has the meaning given that term in ORS 689.696.

(2) A health benefit plan offered in this state may not require an enrollee in the plan to incur cost-sharing or other out-of-pocket costs, as adjusted under subsection (3) of this section, that exceed $75 for each 30-day supply of a type of insulin prescribed for the treatment of diabetes or $225 for each 90-day supply.

(3) The Department of Consumer and Business Services shall, by rule, annually adjust the maximum cost specified in subsection (2) of this section by the percentage increase, if any, in the cost of living for the previous calendar year, based on changes in the Consumer Price Index for All Urban Consumers, West Region (All Items), as published by the Bureau of Labor Statistics of the United States Department of Labor.

(4) The coverage under this section may not be subject to a deductible imposed by a health benefit plan.

(5) This section does not prohibit a health benefit plan from using a drug formulary or other utilization review protocol applicable to prescription drug coverage under the plan.

(6) This section is not subject to ORS 743A.001. [2021 c.160 §2]

Note: 743A.069 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.070 Nonprescription enteral formula for home use. (1) All policies providing health insurance, as defined in ORS 731.162, except those policies whose coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this section, shall include coverage for a nonprescription elemental enteral formula for home use, if the formula is medically necessary for the treatment of severe intestinal malabsorption and a physician has issued a written order for the formula and the formula comprises the sole source, or an essential source, of nutrition.

(2) The coverage required by subsection (1) of this section may be made subject to provisions of the policy that apply to other benefits under the policy including, but not limited to, provisions related to deductibles and coinsurance. Deductibles and coinsurance for elemental enteral formulas shall be no greater than those for any other treatment for the condition under the policy.

(3) This section is exempt from ORS 743A.001. [Formerly 743.729; 2009 c.703 §1]

743A.078 Newborn nurse home visiting services. (1) As used in this section, “carrier,” “enrollee” and “health benefit plan” have the meanings given those terms in ORS 743B.005.

(2) A health benefit plan offered in this state must reimburse in full the cost to a provider of delivering universal newborn nurse home visiting services, as prescribed by the Oregon Health Authority by rule under ORS 433.301 (7) and (8).

(3) The coverage must be provided without any cost-sharing, coinsurance or deductible applicable to the services.

(4) Carriers must offer the services in their health benefit plans but enrollees are not required to receive the services as a condition of coverage and may not be penalized or in any way discouraged from declining the services.

(5) A carrier must notify an enrollee about the services whenever an enrollee adds a newborn to coverage.

(6) A carrier may use in-network providers or may contract with local public health authorities to provide the services.

(7) Carriers shall report to the authority, in the form and manner prescribed by the authority, data regarding claims submitted for services covered under this section to monitor the provision of the services.

(8) This section is exempt from ORS 743A.001. [2019 c.552 §3; 2022 c.94 §1]

Note: 743A.078 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.080 Pregnancy and childbirth expenses. (1) As used in this section, “pregnancy care” means the care necessary to support a healthy pregnancy and care related to labor and delivery.

(2) All health benefit plans as defined in ORS 743B.005 must provide payment or reimbursement for expenses associated with pregnancy care and childbirth. Benefits provided under this section shall be extended to all enrollees, enrolled spouses and enrolled dependents. [Formerly 743.693; 2011 c.500 §39]

743A.082 Diabetes management for pregnant women. (1) Except as provided in subsections (2) and (3) of this section, a health benefit plan, as defined in ORS 743B.005, may not require a copayment or impose a coinsurance requirement or a deductible on the covered health services, medications and supplies that are medically necessary for a woman to manage her diabetes during the period of each pregnancy, beginning with conception and ending six weeks postpartum.

(2) Subsection (1) of this section does not apply to a high deductible health plan described in 26 U.S.C. 223.

(3) The coverage required by subsection (1) of this section may be limited by network and formulary restrictions that apply to other benefits under the plan. Subsection (1) of this section does not apply to services, medications, test strips and syringes that are not covered due to the network or formulary restrictions.

(4) An insurer may require an enrollee or the enrollee’s health care provider to notify the insurer orally, in a timely manner, that the enrollee is diabetic and is pregnant or has given birth and is within six weeks postpartum. [2013 c.682 §2; 2014 c.74 §1]

Note: 743A.082 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.084 Unmarried women and their children. Each policy of health insurance shall provide:

(1) The same payments for costs of maternity to unmarried women that it provides to married women, including the spouses in marriages of insured persons choosing family coverage; and

(2) The same coverage for the child of an unmarried woman that the child of an insured married person choosing family coverage receives. [Formerly 743.721; 2015 c.629 §61]

743A.088 Use by mother of diethylstilbestrol. No policy of health insurance may be denied or canceled by the insurer solely because the mother of the insured used drugs containing diethylstilbestrol prior to the insured’s birth. [Formerly 743.710]

743A.090 Natural and adopted children. (1)(a) All individual and group health benefit plans, as defined in ORS 743B.005, that include coverage for a family member of the insured shall also provide that the health insurance benefits applicable for children in the family shall be payable with respect to:

(A) A child of the insured from the moment of birth; and

(B) An adopted child effective upon placement for adoption.

(b) All individual and group health benefit plans, as defined in ORS 743B.005, that include coverage for a family member of the insured shall also provide that the health insurance benefits applicable for children in the family shall be payable with respect to a disabled child of the insured who is 26 years of age or older, if:

(A) The insured provides a statement from a physician certifying that the child has an ongoing disability that prevents the child from engaging in self-sustaining employment;

(B) The child was covered by a parent’s insurance for at least two years immediately before the time the child exceeded the age for eligibility for coverage under the parent’s insurance; and

(C)(i) The insured claims the child as a dependent of the insured for tax purposes;

(ii) The child files a tax return properly showing adjusted gross income that does not exceed 150 percent of the federal poverty level; or

(iii) The insured is the legal guardian of the insured’s child.

(2) The coverage of natural and adopted children required by subsection (1) of this section shall consist of coverage of preventive health services and treatment of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

(3) If payment of an additional premium is required to provide coverage for a child, the policy may require that notification of the birth of the child or of the placement for adoption of the child and payment of the premium be furnished to the insurer within 31 days after the date of birth or date of placement in order to effectuate the coverage required by this section and to have the coverage extended beyond the 31-day period.

(4) In any case in which a policy provides coverage for dependent children of participants or beneficiaries, the policy shall provide benefits to dependent children placed with participants or beneficiaries for adoption under the same terms and conditions as apply to the natural, dependent children of the participants and beneficiaries, regardless of whether the adoption has become final.

(5) As used in this section:

(a) “Child” means an individual who is:

(A) Under 26 years of age; or

(B) Disabled and 26 years of age or older, for purposes of coverage under subsection (1)(b) of this section.

(b) “Disabled” means to have a developmental disability, mental illness or a physical disability that began prior to the age of 26 and that prevents an individual from engaging in self-sustaining employment.

(c) “Placement for adoption” means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of the adoption of the child. The child’s placement with a person terminates upon the termination of such legal obligations.

(d) “Self-sustaining employment” means employment with annual earnings that exceed 150 percent of the federal poverty level.

(6) The provisions of ORS 743A.001 do not apply to this section. [Formerly 743.707; 2011 c.500 §40; 2013 c.681 §33; 2021 c.342 §5]

743A.100 Mammograms. (1) Every health insurance policy that covers hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases, shall provide coverage of mammograms as follows:

(a) Mammograms for the purpose of diagnosis in symptomatic or high-risk individuals at any time upon referral of an individual’s health care provider; and

(b) An annual mammogram for the purpose of early detection for an individual 40 years of age or older, with or without referral from the individual’s health care provider.

(2) An insurance policy described in subsection (1) of this section must not limit coverage of mammograms to the schedule provided in subsection (1) of this section if the individual is determined by the individual’s health care provider to be at high risk for breast cancer. [Formerly 743.727; 2017 c.152 §4]

743A.101 Supplemental or diagnostic breast examinations. (1) As used in this section:

(a) “Diagnostic breast examination” means an examination used to evaluate an abnormality of the breast that is detected or suspected from a screening examination for breast cancer or by any other means of examination using:

(A) Diagnostic mammography;

(B) Breast magnetic resonance imaging; or

(b) “Supplemental breast examination” means an examination of the breast, such as breast magnetic resonance imaging or breast ultrasound, that is:

(A) Used to screen for breast cancer when there is no abnormality seen or suspected; and

(B) Based on personal or family medical history or other factors that increase an individual’s risk of breast cancer.

(2) Except as provided in ORS 742.008, a carrier offering a group health benefit plan or an individual health benefit plan in this state that reimburses the cost of supplemental or diagnostic breast examinations may not impose on the coverage of a medically necessary supplemental or diagnostic breast examination:

(a) A deductible;

(b) Coinsurance;

(d) Other out-of-pocket expenses. [2023 c.468 §2]

Note: See 743A.001.

Note: 743A.101 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.104 Pelvic examinations and Pap smear examinations. All policies providing health insurance, except those policies whose coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this section, shall include coverage for pelvic examinations and Pap smear examinations as follows:

(1) Annually for individuals 18 to 64 years of age; and

(2) At any time upon referral of an individual’s health care provider. [Formerly 743.728; 2017 c.152 §5]

743A.105 HPV vaccine. (1) All health benefit plans, as defined in ORS 743B.005, shall include coverage of the human papillomavirus vaccine for beneficiaries under the health benefit plan who are at least 11 years of age but no older than 26 years of age.

(2) ORS 743A.001 does not apply to this section. [2009 c.630 §2; 2017 c.152 §6]

Note: 743A.105 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.108 Physical examination of breast. (1) A health insurance policy that covers hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases, shall provide coverage for a complete and thorough physical examination of the breast, including but not limited to a clinical breast examination, performed by a health care provider to check for lumps and other changes for the purpose of early detection and prevention of breast cancer as follows:

(a) Annually for individuals 18 years of age and older; and

(b) At any time at the recommendation of an individual’s health care provider.

(2) An insurance policy must provide coverage of physical examinations of the breast as described in subsection (1) of this section regardless of whether a health care provider performs other preventative health examinations or makes a referral for other preventative health examinations at the same time the health care provider performs the breast examination.

(3) This section applies to health care service contractors, as defined in ORS 750.005, and trusts carrying out a multiple employer welfare arrangement, as defined in ORS 750.301. [Formerly 743.791; 2017 c.152 §7]

Note: 743A.108 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.110 Mastectomy-related services; expedited external review required. (1) As used in this section, “mastectomy” means the surgical removal of all or part of a breast or a breast tumor suspected to be malignant.

(2) All insurers offering a health benefit plan as defined in ORS 743B.005 shall provide payment, coverage or reimbursement for mastectomy and for the following services related to a mastectomy as determined by the attending physician and enrollee to be part of the enrollee’s course or plan of treatment:

(a) All stages of reconstruction of the breast on which a mastectomy was performed, including but not limited to nipple reconstruction, skin grafts and stippling of the nipple and areola;

(b) Surgery and reconstruction of the other breast to produce a symmetrical appearance;

(d) Treatment of physical complications of the mastectomy, including lymphedemas; and

(e) Inpatient care related to the mastectomy and post-mastectomy services.

(3) An insurer providing coverage under subsection (2) of this section shall provide written notice describing the coverage to the enrollee at the time of enrollment in the health benefit plan and annually thereafter.

(4) A health benefit plan must provide a single determination of prior authorization for all services related to a mastectomy covered under subsection (2) of this section that are part of the enrollee’s course or plan of treatment.

(5) When an enrollee requests an external review of an adverse benefit determination as defined in ORS 743B.001 by the insurer regarding services described in subsection (2) of this section, the insurer or the Director of the Department of Consumer and Business Services must expedite the enrollee’s case pursuant to ORS 743B.252 (5).

(6) The coverage required under subsection (2) of this section is subject to the same terms and conditions in the plan that apply to other benefits under the plan.

(7) This section is exempt from ORS 743A.001. [Formerly 743.691; 2011 c.208 §1; 2011 c.500 §41]

743A.111 Consumer education about post-mastectomy services. (1) The Department of Consumer and Business Services shall make written materials available on the department’s website to educate breast cancer patients about the availability of insurance coverage for breast reconstruction surgery and breast prostheses following a mastectomy. The department shall update the materials at least annually.

(2) The department shall place a link to the educational materials described in subsection (1) of this section close to links on the website to information for consumers about health insurance and under a tab designated “Breast Reconstruction Education.” The materials must include links to information about breast reconstruction surgery published by governmental entities with a nexus to this state or nonprofit organizations with expertise in breast reconstruction surgery, including but not limited to information about:

(a) The availability of the option to have breast reconstruction surgery following a mastectomy including that the breast reconstruction surgery may be performed at the time of a mastectomy or may be delayed until a later date.

(b) Prostheses or breast forms as alternatives to breast reconstruction surgery.

(c) The requirements of the Women’s Health and Cancer Rights Act of 1998 (P.L. 105-277) including the right to breast reconstruction surgery following a mastectomy even if the surgery is delayed until a later date.

(3) The department may include educational information about breast reconstruction surgery in newsletters or similar publications that the department sends to consumers or carriers on a weekly or monthly basis. [2017 c.163 §2]

Note: 743A.111 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 743A or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.

743A.120 [Formerly 743.794; repealed by 2017 c.206 §16]

743A.124 Colorectal cancer screenings and laboratory tests. (1) A health benefit plan, as defined in ORS 743B.005, shall provide coverage for all colorectal cancer screening examinations and laboratory tests assigned either a grade of A or a grade of B by the United States Preventive Services Task Force.

(2) If an insured is 50 years of age or older, an insurer may not impose cost sharing on the coverage required by subsection (1) of this section and the coverage shall include, at a minimum:

(a)(A) Fecal occult blood tests;

(B) Colonoscopies, including the removal of polyps during a screening procedure; or

(b) A colonoscopy, including the removal of polyps during the procedure, if the insured has a positive result on any fecal test assigned either a grade of A or a grade of B by the United States Preventive Services Task Force.

(3) If an insured is at high risk for colorectal cancer, the coverage required by subsection (1) of this section shall include colorectal cancer screening examinations and laboratory tests as recommended by the treating physician.

(4) For the purposes of subsection (3) of this section, an individual is at high risk for colorectal cancer if the individual has:

(a) A family medical history of colorectal cancer;

(b) A prior occurrence of cancer or precursor neoplastic polyps;

(c) A prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Crohn’s disease or ulcerative colitis; or

(d) Other predisposing factors.

(5) Subsection (2)(b) of this section does not apply to a high deductible health plan described in 26 U.S.C. 223. [Formerly 743.799; 2014 c.9 §1; 2015 c.206 §1]

Note: See 743A.001.

Note: 743A.124 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.130 Proton beam therapy. (1) A health benefit plan, as defined in ORS 743B.005, that provides coverage of radiation therapy for the treatment of prostate cancer must provide coverage for proton beam therapy for the treatment of prostate cancer on a basis no less favorable than the coverage of radiation therapy including with respect to prior authorization or other utilization review requirements.

(2) This section is exempt from ORS 743A.001. [2019 c.466 §2; 2021 c.384 §1; 2023 c.106 §1]

Note: 743A.130 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.140 Bilateral cochlear implants. (1) A health benefit plan, as defined in ORS 743B.005, shall reimburse the cost of:

(a) Bilateral cochlear implants if medically appropriate for the treatment of hearing loss; and

(b) The fitting, programming and reprogramming of bilateral or unilateral cochlear implants or other assistive listening devices performed by licensed audiologists.

(2) For purposes of ORS 746.230, a reasonable investigation of a claim for bilateral cochlear implants must include a request to the treating surgeon for a written recommendation based on peer-reviewed medical literature and for the medical findings that support the recommendation.

(3) A health benefit plan shall reimburse the cost of repair and replacement parts for a cochlear implant if the repair or parts are not covered by a warranty and are necessary for the device to be functional for the user.

(4) A health benefit plan shall reimburse the costs described in this section when prescribed by a licensed health professional even if over-the-counter items and services are available without a prescription.

(5) An adverse determination on a claim for coverage under this section must include a prominent notice to the enrollee of the enrollee’s rights to file grievances and request appeals and reviews under ORS 743B.250 and must provide a toll-free telephone number or chat line for enrollees to seek assistance in contesting the denial of or limitation on coverage.

(6) Coverage under this section may not be subject to a deductible, except as provided in ORS 742.008.

(7) The provisions of this section are exempt from ORS 743A.001. [2007 c.504 §2; 2018 c.9 §1; 2023 c.424 §3]

Note: 743A.140 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.141 Hearing aids and assistive listening devices. (1) As used in this section:

(a) “Assistive listening device” means devices used with or without hearing aids or cochlear implants to provide access to sound or improve the ability of a user with hearing loss to hear in various listening situations, such as being located a distance from a speaker, in an environment with competing background noise or in a room with poor acoustics or reverberation.

(b) “Hearing aid” means any nondisposable, wearable instrument or device designed to aid or compensate for impaired human hearing and any necessary ear mold, part, attachments or accessory for the instrument or device, except batteries and cords.

(2) A health benefit plan, as defined in ORS 743B.005, shall provide payment, coverage or reimbursement for:

(a) One hearing aid per hearing impaired ear if:

(A) Prescribed, fitted and dispensed by a licensed audiologist with the approval of a licensed physician; and

(B) Medically necessary for the treatment of hearing loss in an enrollee in the plan who is:

(i) 18 years of age or younger; or

(ii) 19 to 25 years of age and enrolled in a secondary school or an accredited educational institution.

(b) Ear molds and replacement ear molds:

(A) As medically necessary and at least four times per plan year for enrollees who are younger than eight years of age; and

(B) As medically necessary and at least once per year for enrollees who are:

(i) Eight to 18 years of age; or

(ii) 19 to 25 years of age and enrolled in a secondary school or an accredited educational institution.

(d) Necessary diagnostic and treatment services at least twice per year for enrollees who are younger than four years of age and at least once per year for enrollees who are four years of age or older, including:

(A) Hearing tests appropriate for an enrollee’s age or developmental need;

(B) Hearing aid checks and conformity evaluations; and

(e) Bone conduction sound processors, if necessary for appropriate amplification of the hearing loss.

(f) Assistive listening devices for an enrollee who is younger than 19 years of age, if necessary to provide access to sound and provide appropriate amplification of the hearing loss.

(g) Other components required for a hearing device to function properly and effectively, including but not limited to:

(A) Bone-conducting sound processor headbands; and

(B) Prosthetic device parts.

(h) The cost of repair or replacement parts for a hearing aid or other assistive listening device if the repair or parts are not covered by a warranty and are necessary for the device to be functional for the user, regardless of the age of the user.

(3) An insurer may not impose any financial or contractual penalty upon an audiologist if an enrollee elects to purchase a hearing aid or other device priced higher than the benefit amount by paying the difference between the benefit amount and the price of the hearing aid or other device.

(4) A health benefit plan shall provide the benefits described in subsection (2)(a), (e) and (f) of this section:

(a) Every 36 months; or

(b) For hearing aids, more frequently than every 36 months if modifications to an existing hearing aid will not meet the needs of an enrollee who is:

(A) Under 19 years of age; or

(B) 19 to 25 years of age and enrolled in a secondary school or an accredited educational institution.

(5) An insurer must contract with pediatric audiologists in sufficient numbers and geographic locations in this state to comply with ORS 743B.202 and 743B.505.

(6) Insurance producers shall ensure that enrollees have access to navigators or other assisters to facilitate the diagnosis of hearing loss and needed amplification and ensure that technologies are available to treat hearing loss in enrollees who are 19 years of age or younger. Upon receiving a claim for reimbursement for the diagnosis of hearing loss, an insurer shall provide notice of the coverage limits to the enrollee or to the parent or legal guardian of the enrollee. With respect to enrollees with hearing loss who are younger than 19 years of age, an insurer shall provide educational materials to the parent or legal guardian of the enrollee and shall have a process in place to ensure that appropriate technologies are available.

(7) The payment, coverage or reimbursement required under this section may be subject to provisions of the health benefit plan that apply to other durable medical equipment benefits covered by the plan, including but not limited to provisions relating to coinsurance and prior authorization, but may not be subject to deductibles except as provided in ORS 742.008.

(8) A health benefit plan shall reimburse the costs described in this section when prescribed by a licensed health professional even if over-the-counter items and services are available without a prescription.

(9) This section is exempt from ORS 743A.001. [2009 c.553 §2; 2011 c.500 §42a; 2015 c.515 §26; 2018 c.9 §2; 2023 c.424 §4]

Note: 743A.141 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.144 [2007 c.374 §2; 2016 c.11 §4; repealed by 2017 c.206 §16]

743A.145 Orthotic and prosthetic devices; rules. (1) As used in this section:

(a) “Orthotic device” means a rigid or semirigid device supporting a weak or deformed leg, foot, arm, hand, back or neck, or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or neck.

(b) “Prosthetic device” means an artificial limb device or appliance designed to replace in whole or in part an arm or a leg.

(2) All individual and group health insurance policies providing coverage for the expenses of hospital, medical or surgical services or supplies shall provide coverage for prosthetic and orthotic devices that are medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that are not solely for comfort or convenience. The coverage required by this subsection includes all services and supplies medically necessary for the effective use of a prosthetic or orthotic device, including design formulation, fabrication, material and component selection, measurements, fittings, static and dynamic alignments and patient instruction in the use of the device.

(3) The Director of the Department of Consumer and Business Services shall adopt and annually update rules listing the prosthetic and orthotic devices covered under this section. The list shall be no more restrictive than the list of prosthetic and orthotic devices and supplies in the Medicare fee schedule for Durable Medical Equipment, Prosthetics, Orthotics and Supplies, but only to the extent consistent with this section.

(4) The coverage required by subsection (2) of this section may be made subject to, and no more restrictive than, the provisions of a health insurance policy that apply to other benefits under the policy.

(5) The coverage required by subsection (2) of this section shall include any repair or replacement of a prosthetic or orthotic device that is determined medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that is not solely for comfort or convenience.

(6) If the coverage under subsection (2) of this section is provided through a managed care organization, the insured shall have access to medically necessary clinical care and to prosthetic and orthotic devices and technology from not fewer than two distinct Oregon prosthetic and orthotic providers in the managed care organization’s provider network.

(7) This section is exempt from ORS 743A.001. [2023 c.113 §2]

Note: 743A.145 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.148 Maxillofacial prosthetic services. (1) The Legislative Assembly declares that all group health insurance policies providing hospital, medical or surgical expense benefits, other than limited benefit coverage, include coverage for maxillofacial prosthetic services considered necessary for adjunctive treatment.

(2) As used in this section, “maxillofacial prosthetic services considered necessary for adjunctive treatment” means restoration and management of head and facial structures that cannot be replaced with living tissue and that are defective because of disease, trauma or birth and developmental deformities when such restoration and management are performed for the purpose of:

(a) Controlling or eliminating infection;

(b) Controlling or eliminating pain; or

(c) Restoring facial configuration or functions such as speech, swallowing or chewing but not including cosmetic procedures rendered to improve on the normal range of conditions.

(3) The coverage required by subsection (1) of this section may be made subject to provisions of the policy that apply to other benefits under the policy including, but not limited to, provisions relating to deductibles and coinsurance.

(4) The services described in this section shall apply to individual health policies entered into or renewed on or after January 1, 1982. [Formerly 743.706; 2016 c.11 §5]

743A.150 Treatment of craniofacial anomaly. (1) As used in this section, “craniofacial anomaly” means a physical disorder identifiable at birth that affects the bony structures of the face or head, including but not limited to cleft palate, cleft lip, craniosynostosis, craniofacial microsomia and Treacher Collins syndrome.

(2) All health benefit plans, as defined in ORS 743B.005, providing coverage of hospital, surgical or dental services, shall provide coverage for dental and orthodontic services for the treatment of craniofacial anomalies if the services are medically necessary to restore function.

(3) This section does not require coverage for the treatment of:

(a) Developmental maxillofacial conditions that result in overbite, crossbite, malocclusion or similar developmental irregularities of the teeth; or

(b) Temporomandibular joint disorder.

(4) Coverage required by this section may be subject to copayments, deductibles and coinsurance imposed on similar services by the terms of the plan.

(5) This section does not limit or supersede any coverage required by ORS 743A.028, 743A.032 or 743A.148.

(6) This section is exempt from ORS 743A.001. [2012 c.21 §2]

Note: 743A.150 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.160 Alcoholism treatment. A health insurance policy providing coverage for hospital or medical expenses, other than limited benefit coverage, shall provide, at the request of the applicant, coverage for expenses arising from treatment for alcoholism. The following conditions apply to the requirement for such coverage:

(1) The applicant shall be informed of the applicant’s option to request this coverage.

(2) The inclusion of the coverage may be made subject to the insurer’s usual underwriting requirements.

(3) The coverage may be made subject to provisions of the policy that apply to other benefits under the policy, including but not limited to provisions relating to deductibles and coinsurance.

(4) The policy may limit hospital expense coverage to treatment provided by the following facilities:

(a) A health care facility licensed as required by ORS 441.015.

(b) A health care facility accredited by the Joint Commission.

(5) Except as permitted by subsection (3) of this section, the policy may not limit payments thereunder for alcoholism to an amount less than $4,500 in any 24-consecutive month period and the policy shall provide coverage, within the limits of this subsection, of not less than 80 percent of the hospital and medical expenses for treatment for alcoholism. [Formerly 743.412; 2016 c.11 §6; 2017 c.17 §56]

Note: See 743.402.

743A.164 [Formerly 743.480; 2017 c.21 §73; repealed by 2017 c.206 §16]

743A.168 Behavioral health treatment; qualified providers; rules. (1) As used in this section:

(a) “Behavioral health assessment” means an evaluation by a provider, in person or using telemedicine, to determine a patient’s need for behavioral health treatment.

(b) “Behavioral health condition” has the meaning prescribed by rule by the Department of Consumer and Business Services.

(c) “Behavioral health crisis” means a disruption in an insured’s mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the insured’s mental or physical health.

(d) “Facility” means a corporate or governmental entity or other provider of services for the treatment of behavioral health conditions.

(e) “Generally accepted standards of care” means:

(A) Standards of care and clinical practice guidelines that:

(i) Are generally recognized by health care providers practicing in relevant clinical specialties; and

(ii) Are based on valid, evidence-based sources; and

(B) Products and services that:

(i) Address the specific needs of a patient for the purpose of screening for, preventing, diagnosing, managing or treating an illness, injury or condition or symptoms of an illness, injury or condition;

(ii) Are clinically appropriate in terms of type, frequency, extent, site and duration; and

(iii) Are not primarily for the economic benefit of an insurer or payer or for the convenience of a patient, treating physician or other health care provider.

(f) “Group health insurer” means an insurer, a health maintenance organization or a health care service contractor.

(g) “Median maximum allowable reimbursement rate” means the median of all maximum allowable reimbursement rates, minus incentive payments, paid for each billing code for each provider type during a calendar year.

(h) “Prior authorization” has the meaning given that term in ORS 743B.001.

(i) “Program” means a particular type or level of service that is organizationally distinct within a facility.

(j) “Provider” means:

(A) A behavioral health professional or medical professional licensed or certified in this state who has met the credentialing requirement of a group health insurer or an issuer of an individual health benefit plan that is not a grandfathered health plan as defined in ORS 743B.005 and is otherwise eligible to receive reimbursement for coverage under the policy;

(B) A health care facility as defined in ORS 433.060;

(D) A day or partial hospitalization program;

(E) An outpatient service as defined in ORS 430.010; or

(F) A provider organization certified by the Oregon Health Authority under subsection (9) of this section.

(k) “Relevant clinical specialties” includes but is not limited to:

(A) Psychiatry;

(B) Psychology;

(D) Addiction medicine and counseling; and

(E) Behavioral health treatment.

(L) “Standards of care and clinical practice guidelines” includes but is not limited to:

(A) Patient placement criteria;

(B) Recommendations of agencies of the federal government; and

(m) “Utilization review” has the meaning given that term in ORS 743B.001.

(n) “Valid, evidence-based sources” includes but is not limited to:

(A) Peer-reviewed scientific studies and medical literature;

(B) Recommendations of nonprofit health care provider professional associations; and

(2) A group health insurance policy or an individual health benefit plan that is not a grandfathered health plan providing coverage for hospital or medical expenses, other than limited benefit coverage, shall provide coverage for expenses arising from the diagnosis of behavioral health conditions and medically necessary behavioral health treatment at the same level as, and subject to limitations no more restrictive than, those imposed on coverage or reimbursement of expenses arising from treatment for other medical conditions. The following apply to coverage for behavioral health treatment:

(a) The coverage may be made subject to provisions of the policy that apply to other benefits under the policy, including but not limited to provisions relating to copayments, deductibles and coinsurance. Copayments, deductibles and coinsurance for treatment in health care facilities or residential facilities may not be greater than those under the policy for expenses of hospitalization in the treatment of other medical conditions. Copayments, deductibles and coinsurance for outpatient treatment may not be greater than those under the policy for expenses of outpatient treatment of other medical conditions.

(b) The coverage of behavioral health treatment may not be made subject to treatment limitations, limits on total payments for treatment, limits on duration of treatment or financial requirements unless similar limitations or requirements are imposed on coverage of other medical conditions. The coverage of eligible expenses of behavioral health treatment may be limited to treatment that is medically necessary as determined in accordance with this section and no more stringently under the policy than for other medical conditions.

(A) A behavioral health assessment;

(B) No less than the level of services determined to be medically necessary in a behavioral health assessment of the specific needs of a patient or in a patient’s care plan:

(i) To effectively treat the patient’s underlying behavioral health condition rather than the mere amelioration of current symptoms such as suicidal ideation or psychosis; and

(ii) For care following a behavioral health crisis, to transition the patient to a lower level of care;

(D) Treatment at the least intensive and least restrictive level of care that is safe and most effective and meets the needs of the insured’s condition;

(E) A lower level or less intensive care only if it is comparably as safe and effective as treatment at a higher level of service or intensity;

(F) Treatment to maintain functioning or prevent deterioration;

(G) Treatment for an appropriate duration based on the insured’s particular needs;

(H) Treatment appropriate to the unique needs of children and adolescents;

(I) Treatment appropriate to the unique needs of older adults; and

(J) Coordinated care and case management as defined by the Department of Consumer and Business Services by rule.

(d) The coverage of behavioral health treatment may not limit coverage for treatment of pervasive or chronic behavioral health conditions to short-term or acute behavioral health treatment at any level of care or placement.

(e) A group health insurer or an issuer of an individual health benefit plan other than a grandfathered health plan shall have a network of providers of behavioral health treatment sufficient to meet the standards described in ORS 743B.505. If there is no in-network provider qualified to timely deliver, as defined by rule, medically necessary behavioral treatment to an insured in a geographic area, the group health insurer or issuer of an individual health benefit plan shall provide coverage of out-of-network medically necessary behavioral health treatment without any additional out-of-pocket costs if provided by an available out-of-network provider that enters into an agreement with the insurer to be reimbursed at in-network rates.

(f) A provider is eligible for reimbursement under this section if:

(A) The provider is approved or certified by the Oregon Health Authority;

(B) The provider is accredited for the particular level of care for which reimbursement is being requested by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities;

(C) The patient is staying overnight at the facility and is involved in a structured program at least eight hours per day, five days per week; or

(D) The provider is providing a covered benefit under the policy.

(g) A group health insurer or an issuer of an individual health benefit plan other than a grandfathered health plan must use the same methodology to set reimbursement rates paid to behavioral health treatment providers that the group health insurer or issuer of an individual health benefit plan uses to set reimbursement rates for medical and surgical treatment providers.

(h) A group health insurer or an issuer of an individual health benefit plan other than a grandfathered health plan must update the methodology and rates for reimbursing behavioral health treatment providers in a manner equivalent to the manner in which the group health insurer or issuer of an individual health benefit plan updates the methodology and rates for reimbursing medical and surgical treatment providers, unless otherwise required by federal law.

(i) A group health insurer or an issuer of an individual health benefit plan other than a grandfathered health plan that reimburses out-of-network providers for medical or surgical services must reimburse out-of-network behavioral health treatment providers on the same terms and at a rate that is in parity with the rate paid to medical or surgical treatment providers.

(j) Outpatient coverage of behavioral health treatment shall include follow-up in-home service or outpatient services if clinically indicated under criteria and guidelines described in subsection (5) of this section. The policy may limit coverage for in-home service to persons who are homebound under the care of a physician only if clinically indicated under criteria and guidelines described in subsection (5) of this section.

(k)(A) Subject to the patient or client confidentiality provisions of ORS 40.235 relating to physicians, ORS 40.240 relating to nurse practitioners, ORS 40.230 relating to psychologists, ORS 40.250 and 675.580 relating to licensed clinical social workers and ORS 40.262 relating to licensed professional counselors and licensed marriage and family therapists, a group health insurer or issuer of an individual health benefit plan may provide for review for level of treatment of admissions and continued stays for treatment in health facilities, residential facilities, day or partial hospitalization programs and outpatient services by either staff of a group health insurer or issuer of an individual health benefit plan or personnel under contract to the group health insurer or issuer of an individual health benefit plan that is not a grandfathered health plan, or by a utilization review contractor, who shall have the authority to certify for or deny level of payment.

(B) Review shall be made according to criteria made available to providers in advance upon request.

(C) Review shall be performed by or under the direction of a physician licensed under ORS 677.100 to 677.228, a psychologist licensed by the Oregon Board of Psychology, a clinical social worker licensed by the State Board of Licensed Social Workers or a professional counselor or marriage and family therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists, in accordance with standards of the National Committee for Quality Assurance or Medicare review standards of the Centers for Medicare and Medicaid Services.

(D) Review may involve prior approval, concurrent review of the continuation of treatment, post-treatment review or any combination of these. However, if prior approval is required, provision shall be made to allow for payment of urgent or emergency admissions, subject to subsequent review. If prior approval is not required, group health insurers and issuers of individual health benefit plans that are not grandfathered health plans shall permit providers, policyholders or persons acting on their behalf to make advance inquiries regarding the appropriateness of a particular admission to a treatment program. Group health insurers and issuers of individual health benefit plans that are not grandfathered health plans shall provide a timely response to such inquiries. Noncontracting providers must cooperate with these procedures to the same extent as contracting providers to be eligible for reimbursement.

(L) Health maintenance organizations may limit the receipt of covered services by enrollees to services provided by or upon referral by providers contracting with the health maintenance organization. Health maintenance organizations and health care service contractors may create substantive plan benefit and reimbursement differentials at the same level as, and subject to limitations no more restrictive than, those imposed on coverage or reimbursement of expenses arising out of other medical conditions and apply them to contracting and noncontracting providers.

(3) This section does not prohibit a group health insurer or issuer of an individual health benefit plan that is not a grandfathered health plan from managing the provision of benefits through common methods, including but not limited to selectively contracted panels, health plan benefit differential designs, preadmission screening, prior authorization of services, utilization review or other mechanisms designed to limit eligible expenses to those described in subsection (2)(b) of this section provided such methods comply with the requirements of this section.

(4) The Legislative Assembly finds that health care cost containment is necessary and intends to encourage health insurance plans designed to achieve cost containment by ensuring that reimbursement is limited to appropriate utilization under criteria incorporated into the insurance, either directly or by reference, in accordance with this section.

(5)(a) Any medical necessity, utilization or other clinical review conducted for the diagnosis, prevention or treatment of behavioral health conditions or relating to service intensity, level of care placement, continued stay or discharge must be based solely on the following:

(A) The current generally accepted standards of care.

(B) For level of care placement decisions, the most recent version of the levels of care placement criteria developed by the nonprofit professional association for the relevant clinical specialty.

(C) For medical necessity, utilization or other clinical review conducted for the diagnosis, prevention or treatment of behavioral health conditions that does not involve level of care placement decisions, other criteria and guidelines may be utilized if such criteria and guidelines are based on the current generally accepted standards of care including valid, evidence-based sources and current treatment criteria or practice guidelines developed by the nonprofit professional association for the relevant clinical specialty. Such other criteria and guidelines must be made publicly available and made available to insureds upon request to the extent permitted by copyright laws.

(b) This subsection does not prevent a group health insurer or an issuer of an individual health benefit plan other than a grandfathered health plan from using criteria that:

(A) Are outside the scope of criteria and guidelines described in paragraph (a)(B) of this subsection, if the guidelines were developed in accordance with the current generally accepted standards of care; or

(B) Are based on advancements in technology of types of care that are not addressed in the most recent versions of sources specified in paragraph (a)(B) of this subsection, if the guidelines were developed in accordance with current generally accepted standards of care.

(c) For all level of care placement decisions, an insurer shall authorize placement at the level of care consistent with the insured’s score or assessment using the relevant level of care placement criteria and guidelines as specified in paragraph (a)(B) of this subsection. If the level of care indicated by the criteria and guidelines is not available, the insurer shall authorize the next higher level of care. If there is disagreement about the appropriate level of care, the insurer shall provide to the provider of the service the full details of the insurer’s scoring or assessment using the relevant level of care placement criteria and guidelines specified in paragraph (a)(B) of this subsection.

(6) To ensure the proper use of any criteria and guidelines described in subsection (5) of this section, a group health insurer or an issuer of an individual health benefit plan shall provide, at no cost:

(a) A formal education program, presented by nonprofit clinical specialty associations or other entities authorized by the department, to educate the insurer’s or the issuer’s staff and any individuals described in subsection (2)(k) of this section who conduct reviews.

(b) To stakeholders, including participating providers and insureds, the criteria and guidelines described in subsection (5) of this section and any education or training materials or resources regarding the criteria and guidelines.

(7) This section does not prevent a group health insurer or issuer of an individual health benefit plan that is not a grandfathered health plan from contracting with providers of health care services to furnish services to policyholders or certificate holders according to ORS 743B.460 or 750.005, subject to the following conditions:

(a) A group health insurer or issuer of an individual health benefit plan that is not a grandfathered health plan is not required to contract with all providers that are eligible for reimbursement under this section.

(b) An insurer or health care service contractor shall, subject to subsection (2) of this section, pay benefits toward the covered charges of noncontracting providers of services for behavioral health treatment. The insured shall, subject to subsection (2) of this section, have the right to use the services of a noncontracting provider of behavioral health treatment, whether or not the behavioral health treatment is provided by contracting or noncontracting providers.

(8)(a) This section does not require coverage for:

(A) Educational or correctional services or sheltered living provided by a school or halfway house;

(B) A long-term residential mental health program that lasts longer than 45 days unless clinically indicated under criteria and guidelines described in subsection (5) of this section;

(C) Psychoanalysis or psychotherapy received as part of an educational or training program, regardless of diagnosis or symptoms that may be present;

(D) A court-ordered sex offender treatment program; or

(E) Support groups.

(b) Notwithstanding paragraph (a)(A) of this subsection, an insured may receive covered outpatient services under the terms of the insured’s policy while the insured is living temporarily in a sheltered living situation.

(9) The Oregon Health Authority shall establish a process for the certification of an organization described in subsection (1)(j)(F) of this section that:

(a) Is not otherwise subject to licensing or certification by the authority; and

(b) Does not contract with the authority, a subcontractor of the authority or a community mental health program.

(10) The Oregon Health Authority shall adopt by rule standards for the certification provided under subsection (9) of this section to ensure that a certified provider organization offers a distinct and specialized program for the treatment of mental or nervous conditions.

(11) The Oregon Health Authority may adopt by rule an application fee or a certification fee, or both, to be imposed on any provider organization that applies for certification under subsection (9) of this section. Any fees collected shall be paid into the Oregon Health Authority Fund established in ORS 413.101 and shall be used only for carrying out the provisions of subsection (9) of this section.

(12) The intent of the Legislative Assembly in adopting this section is to reserve benefits for different types of care to encourage cost effective care and to ensure continuing access to levels of care most appropriate for the insured’s condition and progress in accordance with this section. This section does not prohibit an insurer from requiring a provider organization certified by the Oregon Health Authority under subsection (9) of this section to meet the insurer’s credentialing requirements as a condition of entering into a contract.

(13) The Director of the Department of Consumer and Business Services and the Oregon Health Authority, after notice and hearing, may adopt reasonable rules not inconsistent with this section that are considered necessary for the proper administration of this section. The director shall adopt rules making it a violation of this section for a group health insurer or issuer of an individual health benefit plan other than a grandfathered health plan to require providers to bill using a specific billing code or to restrict the reimbursement paid for particular billing codes other than on the basis of medical necessity.

(14) This section does not:

(a) Prohibit an insured from receiving behavioral health treatment from an out-of-network provider or prevent an out-of-network behavioral health provider from billing the insured for any unreimbursed cost of treatment.

(b) Prohibit the use of value-based payment methods, including global budgets or capitated, bundled, risk-based or other value-based payment methods.

(c) Require that any value-based payment method reimburse behavioral health services based on an equivalent fee-for-service rate. [Formerly 743.556; 2009 c.442 §47; 2009 c.549 §11; 2013 c.375 §1; 2013 c.581 §1; 2013 c.681 §62; 2016 c.11 §7; 2017 c.6 §29; 2017 c.17 §57; 2017 c.273 §5; 2017 c.409 §35; 2019 c.284 §6; 2019 c.285 §5; 2021 c.629 §§5,8]

Note: Section 7, chapter 411, Oregon Laws 1987, provides:

Sec. 7. Application of ORS 743A.001 to ORS 743A.168 and 750.055. ORS 743.145 [renumbered 743A.001] does not apply to section 2 of this Act [743A.168] because section 2 of this Act constitutes a reenactment of ORS 743.557 and 743.558 [section 2, chapter 698, Oregon Laws 1977, and section 2, chapter 613, Oregon Laws 1973, both repealed in 1987] or to ORS 750.055 because of its amendment by this Act. [1987 c.411 §7]

(a) “Behavioral health home” means an entity providing behavioral health services that the Oregon Health Authority has found to meet the core attributes established under ORS 413.259 for a behavioral health home.

(b) “Patient centered primary care home” means an entity providing health care services that the authority has found to meet the core attributes established under ORS 413.259 for a patient centered primary care home.

(2) An individual or group policy or certificate of health insurance that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, may not:

(a) Exclude coverage for a behavioral health service or a physical health service on the basis that the behavioral health service and physical health service were provided on the same day or in the same facility.

(b) Impose a copayment for physical health services provided by an in-network provider in a behavioral health home on the same day or in the same facility that a copayment was charged for behavioral health services.

(c) Impose a copayment for behavioral health services provided by an in-network provider in a patient centered primary care home on the same day or in the same facility that a copayment was charged for physical health services.

(d) Require prior authorization for a covered behavioral health service provided by a specialist in a behavioral health home or a patient centered primary care home.

(3) Subsection (2)(a) of this section does not apply to a health benefit plan in which providers are reimbursed by payment of a fixed global budget, using a value-based payment arrangement or using other alternative payment methodologies.

(4) This section is exempt from ORS 743A.001. [2022 c.37 §7]

Note: 743A.169 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.170 Tobacco use cessation programs. (1) A health benefit plan as defined in ORS 743B.005 must provide payment, coverage or reimbursement of at least $500 for a tobacco use cessation program for a person enrolled in the plan who is 15 years of age or older.

(2) As used in this section, “tobacco use cessation program” means a program recommended by a physician that follows the United States Public Health Service guidelines for tobacco use cessation. “Tobacco use cessation program” includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products.

(3) This section is exempt from ORS 743A.001. [2009 c.503 §2]

Note: 743A.170 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.175 Traumatic brain injury. (1) A health benefit plan, as defined in ORS 743B.005, shall provide coverage of medically necessary therapy and services for the treatment of traumatic brain injury.

(2) This section is exempt from ORS 743A.001. [2009 c.423 §2]

743A.180 Tourette Syndrome. For purpose of coverage by group health insurers, health care service contractors and health maintenance organizations, reimbursement for treatment of Tourette Syndrome shall be made on the basis of the diagnosis and treatment modality employed. [Formerly 743.717]

Note: See 743A.001.

743A.184 [Formerly 743.694; repealed by 2017 c.206 §16]

743A.185 Telemedical health services for treatment of diabetes. (1) As used in this section:

(a) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(b) “Originating site” means a location where health services are provided or where the patient is receiving a telemedical health service.

(c) “Telemedical” means delivered through a two-way electronic communication, including but not limited to video, audio, Voice over Internet Protocol or transmission of telemetry, that allows a health professional to interact with a patient, a parent or guardian of a patient or another health professional on a patient’s behalf, who is at an originating site.

(2) A health benefit plan must provide coverage of a telemedical health service provided in connection with the treatment of diabetes if:

(a) The plan provides coverage of the health service when provided in person by the health professional;

(b) The health service is medically necessary;

(d) One of the participants in the telemedical health service is a representative of an academic health center.

(3) A health benefit plan may not distinguish between rural and urban originating sites in providing coverage under subsection (2) of this section.

(4) A health benefit plan may subject coverage of a telemedical health service under subsection (2) of this section to all terms and conditions of the plan, including but not limited to deductible, copayment or coinsurance requirements that are applicable to coverage of a comparable health service when provided in person.

(5) This section does not require a health benefit plan to reimburse a provider for a health service that is not a covered benefit under the plan. [2011 c.312 §2]

Note: See 743A.001.

Note: 743A.185 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.188 Inborn errors of metabolism. (1) All individual and group health insurance policies providing coverage for hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases, shall include coverage for treatment of inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in tissues. Coverage shall include expenses of diagnosing, monitoring and controlling the disorders by nutritional and medical assessment, including but not limited to clinical visits, biochemical analysis and medical foods used in the treatment of such disorders.

(2) As used in this section, “medical foods” means foods that are formulated to be consumed or administered enterally under the supervision of a physician, as defined in ORS 677.010, that are specifically processed or formulated to be deficient in one or more of the nutrients present in typical nutritional counterparts, that are for the medical and nutritional management of patients with limited capacity to metabolize ordinary foodstuffs or certain nutrients contained therein or have other specific nutrient requirements as established by medical evaluation and that are essential to optimize growth, health and metabolic homeostasis.

(3) This section is exempt from ORS 743A.001. [Formerly 743.726]

743A.190 Children with pervasive developmental disorder. (1) A health benefit plan, as defined in ORS 743B.005, must cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.

(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to:

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(3) As used in this section:

(a) “Medically necessary” means in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan.

(b) “Pervasive developmental disorder” means a neurological condition that includes autism spectrum disorder, developmental delay, developmental disability or mental retardation.

(c) “Rehabilitation services” means physical therapy, occupational therapy or speech therapy services to restore or improve function.

(4) The provisions of ORS 743A.001 do not apply to this section.

(5) The definition of “pervasive developmental disorder” is not intended to apply to coverage required under ORS 743A.168 or section 2, chapter 771, Oregon Laws 2013. [2007 c.872 §2; 2013 c.771 §7]

Note: The amendments to 743A.190 by section 20, chapter 771, Oregon Laws 2013, become operative January 2, 2030. See section 24, chapter 771, Oregon Laws 2013, as amended by section 6, chapter 674, Oregon Laws 2015, and section 2, chapter 650, Oregon Laws 2021. The text that is operative on and after January 2, 2030, is set forth for the user’s convenience.

743A.190. (1) A health benefit plan, as defined in ORS 743B.005, must cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(3) As used in this section:

(b) “Pervasive developmental disorder” means a neurological condition that includes autism spectrum disorder, developmental delay, developmental disability or mental retardation.

(c) “Rehabilitation services” means physical therapy, occupational therapy or speech therapy services to restore or improve function.

(4) The provisions of ORS 743A.001 do not apply to this section.

(5) The definition of “pervasive developmental disorder” is not intended to apply to coverage required under ORS 743A.168.

Note: 743A.190 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.192 Clinical trials. (1) A health benefit plan, as defined in ORS 743B.005:

(a) Shall provide coverage for the routine costs of the care of patients enrolled in and participating in approved clinical trials;

(b) May not exclude, limit or impose additional conditions on the coverage of the routine costs for items and services furnished in connection with participation in an approved clinical trial; and

(c) May not include provisions that discriminate against an individual on the basis of the individual’s participation in an approved clinical trial.

(2) As used in this section, “routine costs”:

(a) Means all medically necessary conventional care, items or services consistent with the coverage provided by the health benefit plan if typically provided to a patient who is not enrolled in a clinical trial.

(b) Does not include:

(A) The drug, device or service being tested in the approved clinical trial unless the drug, device or service would be covered for that indication by the health benefit plan if provided outside of an approved clinical trial;

(B) Items or services required solely for the provision of the drug device or service being tested in the clinical trial;

(C) Items or services required solely for the clinically appropriate monitoring of the drug, device or service being tested in the clinical trial;

(D) Items or services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient;

(E) Items or services customarily provided by a clinical trial sponsor free of charge to any participant in the clinical trial; or

(F) Items or services that are not covered by the health benefit plan if provided outside of the clinical trial.

(3) As used in this section, “approved clinical trial” means a clinical trial that is:

(a) Funded by the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, the United States Department of Defense or the United States Department of Veterans Affairs;

(b) Supported by a center or cooperative group that is funded by the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, the United States Department of Defense or the United States Department of Veterans Affairs;

(c) Conducted as an investigational new drug application, an investigational device exemption or a biologics license application subject to approval by the United States Food and Drug Administration; or

(d) Exempt by federal law from the requirement to submit an investigational new drug application to the United States Food and Drug Administration.

(4) The coverage required by this section may be subject to provisions of the health benefit plan that apply to other benefits within the same category, including but not limited to copayments, deductibles and coinsurance.

(5) An insurer that provides coverage required by this section is not, based upon that coverage, liable for any adverse effects of the approved clinical trial.

(6) This section is exempt from ORS 743A.001. [2009 c.274 §2; 2013 c.681 §34]

743A.250 Emergency eye care services. (1) As used in this section:

(a) “Eye care practitioner” means an optometrist or ophthalmologist licensed by the State of Oregon.

(b) “Eye care services” means health care services related to the care of the eye and related structures as specified by a health benefit plan.

(2) Any insurer that offers a health benefit plan that provides coverage of eye care services shall allow any enrollee to receive covered eye care services on an emergency basis without first receiving a referral or prior authorization from a primary care provider. However, an insurer may require the enrollee to receive a referral or prior authorization from a primary care provider for any subsequent surgical procedures. Nothing in this subsection shall be construed to require that covered eye care services rendered by an eye care practitioner on an emergency basis be furnished in a hospital or similar medical facility.

(3) An insurer described in subsection (2) of this section may not:

(a) Impose a deductible or coinsurance for eye care services that is greater than the deductible or coinsurance imposed for other medical services under the health benefit plan.

(b) Require an eye care practitioner to hold hospital privileges as a condition of participation as a provider in the health benefit plan.

(4) Nothing in this section:

(a) Requires an insurer to provide coverage or reimbursement of eye care services;

(b) Requires an insurer to provide coverage or reimbursement of refractive surgery, ophthalmic materials, lenses, eyeglasses or other appurtenances; or

(c) Prevents an enrollee from receiving eye care or other covered services from the enrollee’s primary care provider in accordance with the terms of the enrollee’s health benefit plan.

(5) This section is exempt from ORS 743A.001. [Formerly 743.842]

Note: 743A.250 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.252 Child abuse assessments. (1) As used in this section:

(a) “Child abuse assessment” has the meaning given that term in ORS 418.782.

(b) “Children’s advocacy center” has the meaning given that term in ORS 418.782.

(d) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(2) A health benefit plan shall provide payment to or reimburse a children’s advocacy center for the services provided by the center:

(a) In conducting a child abuse assessment of a child enrolled in the plan; and

(b) That are related to the child abuse assessment including, but not limited to:

(A) A forensic interview; and

(B) Mental health treatment.

(3) The payment or reimbursement made in accordance with this section must be proportionate to the scope and intensity of the services provided by the children’s advocacy center.

(4) This section is exempt from ORS 743A.001. [2015 c.100 §4; 2019 c.141 §28]

Note: 743A.252 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.260 Inmates. (1) As used in this section:

(a) “Detainee” means an insured who is:

(A) In the custody of a local supervisory authority pending the disposition of charges; or

(B) In a detention facility pending final adjudication by a juvenile court.

(b) “Detention facility” has the meaning given that term in ORS 419A.004.

(d) “Supervisory authority” has the meaning given that term in ORS 144.087.

(2) Except as provided in subsection (4) of this section, an insurer offering a health benefit plan may not deny reimbursement for any service or supply covered by the plan or cancel the coverage of an insured under the plan on the basis that:

(a) The insured is a detainee;

(b) The insured receives publicly funded medical care while in the custody of a local supervisory authority or in a detention facility; or

(c) The care was provided to the insured by an employee or contractor of a county, a local supervisory authority or a detention facility, if the employee or contractor meets the credentialing criteria of the health benefit plan.

(3) An insurer shall reimburse a county for the costs of covered services or supplies provided to a detainee, in an amount that is no less than 115 percent of the Medicare rate for the service or supply.

(4) An insurer offering a health benefit plan may:

(a) Deny coverage for the treatment of injuries resulting from a violation of law;

(b) Exclude from any requirements for reporting quality outcomes or performance, any covered services provided to a detainee;

(c) Impose utilization controls under the health benefit plan that apply to services provided by in-network providers to insureds who are not in custody or in a detention facility, including a requirement for prior authorization;

(d) Impose the requirements for billing and medical coding for covered services provided to a detainee that the insurer imposes on other providers;

(e) Deny coverage of diagnostic tests or health evaluations required, as a matter of course, for all detainees;

(f) Limit coverage of hospital and ambulatory surgical center services provided to a detainee to services provided by in-network hospitals and ambulatory surgical centers; and

(g) Reimburse an out-of-network renal dialysis facility at either the in-network or the out-of-network rate paid by the insurer for dialysis provided to a detainee.

(5)(a) An insurer may not refuse to credential a health care provider who is an employee or contractor of a county, a local supervisory authority or a detention facility on the basis that the employee or contractor provides the services in a facility operated by the local supervisory authority or in a detention facility.

(b) If an insurer refuses to credential a health care provider who is an employee or contractor of a county, a local supervisory authority or a detention facility, the insurer must give written notice to the provider explaining the reasons for the refusal.

(6) This section does not:

(a) Impair any right of an employer to remove an employee from coverage under a health benefit plan;

(b) Release carriers from the requirement to coordinate benefits for persons who are insured by more than one carrier; or

(7) A public body, as defined in ORS 174.109, may not pay health benefit plan premiums on behalf of a detainee. [2014 c.97 §2; 2017 c.329 §1]

Note: See 743A.001.

Note: 743A.260 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.262 Preventive health services; cost sharing. Notwithstanding any other provision of law, a health benefit plan that is not a grandfathered health plan:

(1) Must provide coverage of preventive health services as prescribed by the United States Department of Health and Human Services pursuant to 42 U.S.C. 300gg-13 in rules adopted and in effect on January 1, 2023; and

(2) May not impose cost-sharing requirements on an enrollee for preventive health services, except as allowed by federal law. [Formerly 743B.120; 2023 c.42 §1]

743A.264 Disease outbreaks, epidemics and conditions of public health importance. (1) As used in this section:

(a) “Condition of public health importance” has the meaning given that term in ORS 431A.005.

(b) “Disease outbreak” has the meaning given that term in ORS 431A.005.

(A) Is enrolled in a health benefit plan; and

(B) The Public Health Director determines may be affected by a disease outbreak, epidemic or other condition of public health importance.

(d) “Epidemic” has the meaning given that term in ORS 431A.005.

(e) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(f) “Insurer” means a person with a certificate of authority to transact insurance in this state.

(g) “Utilization review” has the meaning given that term in ORS 743B.001.

(2) If the director determines that there exists a disease outbreak, epidemic or other condition of public health importance in a geographic area of this state or statewide, an insurer shall, for enrollees in a health benefit plan offered by the insurer, cover the cost of necessary antitoxins, serums, vaccines, immunizing agents, antibiotics, antidotes and other pharmaceutical agents, medical supplies or other prophylactic measures approved by the United States Food and Drug Administration that the director deems necessary to prevent the spread of the disease, epidemic or other condition of public health importance.

(3) An insurer may not restrict coverage under subsection (2) of this section by:

(a) Requiring that the health services be administered by an in-network provider;

(b) Imposing cost-sharing requirements that are greater than the cost-sharing requirements for similar covered services;

(d) Limiting coverage in any manner that prevents an enrollee from accessing the necessary health services. [2017 c.719 §2; 2019 c.284 §7]

Note: See 743A.001.

Note: 743A.264 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

(Temporary provisions relating to coverage of applied behavior analysis)

Note: Sections 2 and 22, chapter 771, Oregon Laws 2013, provide:

Sec. 2. (1) As used in this section and section 3a, chapter 771, Oregon Laws 2013:

(a)(A) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce significant improvement in human social behavior, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, that is provided by:

(i) A licensed health care professional as defined in ORS 676.802;

(ii) A behavior analyst or assistant behavior analyst licensed under ORS 676.810; or

(iii) A behavior analysis interventionist registered under ORS 676.815 who receives ongoing training and supervision by a licensed behavior analyst, by a licensed assistant behavior analyst or by a licensed health care professional.

(B) “Applied behavior analysis” does not mean psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy and long-term counseling as treatment modalities.

(b) “Autism spectrum disorder” has the meaning given that term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association.

(d) “Health benefit plan” has the meaning given that term in ORS 743B.005.

(e) “Medically necessary” means in accordance with the definition of medical necessity that is specified in the policy or certificate for the health benefit plan and that applies to all covered services under the plan.

(f) “Treatment for autism spectrum disorder” includes applied behavior analysis for up to 25 hours per week and any other mental health or medical services identified in the individualized treatment plan, as described in subsection (6) of this section.

(2) A health benefit plan shall provide coverage of:

(a) The screening for and diagnosis of autism spectrum disorder by a licensed neurologist, pediatric neurologist, developmental pediatrician, psychiatrist or psychologist, who has experience or training in the diagnosis of autism spectrum disorder; and

(b) Medically necessary treatment for autism spectrum disorder and the management of care, for an individual who begins treatment before nine years of age, subject to the requirements of this section.

(3) This section does not require coverage for:

(a) Services provided by a family or household member;

(b) Services that are custodial in nature or that constitute marital, family, educational or training services;

(c) Custodial or respite care, equine assisted therapy, creative arts therapy, wilderness or adventure camps, social counseling, telemedicine, music therapy, neurofeedback, chelation or hyperbaric chambers;

(d) Services provided under an individual education plan in accordance with the Individuals with Disabilities Education Act, 20 U.S.C. 1400 et seq.;

(e) Services provided through community or social programs; or

(f) Services provided by the Department of Human Services or the Oregon Health Authority, other than employee benefit plans offered by the department and the authority.

(4) An insurer may not terminate coverage or refuse to issue or renew coverage for an individual solely because the individual has received a diagnosis of autism spectrum disorder or has received treatment for autism spectrum disorder.

(5) Coverage under this section may be subject to utilization controls that are reasonable in the context of individual determinations of medical necessity. An insurer may require:

(a) An autism spectrum disorder diagnosis by a professional described in subsection (2)(a) of this section if the original diagnosis was not made by a professional described in subsection (2)(a) of this section.

(b) Prior authorization for coverage of a maximum of 25 hours per week of applied behavior analysis recommended in an individualized treatment plan approved by a professional described in subsection (2)(a) of this section for an individual with autism spectrum disorder, as long as the insurer makes a prior authorization determination no later than 30 calendar days after receiving the request for prior authorization, notwithstanding ORS 743B.423.

(6) If an individual is receiving applied behavior analysis, an insurer may require submission of an individualized treatment plan, which shall include all elements necessary for the insurer to appropriately determine coverage under the health benefit plan. The individualized treatment plan must be based on evidence-based screening criteria. An insurer may require an updated individualized treatment plan, not more than once every six months, that includes observed progress as of the date the updated plan was prepared, for the purpose of performing utilization review and medical management. The insurer may require the individualized treatment plan to be approved by a professional described in subsection (2)(a) of this section, and to include the:

(a) Diagnosis;

(b) Proposed treatment by type;

(d) Anticipated outcomes stated as goals, including specific cognitive, social, communicative, self-care and behavioral goals that are clearly stated, directly observed and continually measured and that address the characteristics of the autism spectrum disorder; and

(e) Signature of the treating provider.

(7)(a) Once coverage for applied behavior analysis has been approved, the coverage continues as long as:

(A) The individual continues to make progress toward the majority of the goals of the individualized treatment plan; and

(B) Applied behavior analysis is medically necessary.

(b) An insurer may require periodic review of an individualized treatment plan, as described in subsection (6) of this section, and modification of the individualized treatment plan if the review shows that the individual receiving the treatment is not making substantial clinical progress toward the goals of the individualized treatment plan.

(8) Coverage under this section may be subject to requirements and limitations no more restrictive than those imposed on coverage or reimbursement of expenses arising from the treatment of other medical conditions under the policy or certificate, including but not limited to:

(a) Requirements and limitations regarding in-network providers; and

(b) Provisions relating to deductibles, copayments and coinsurance.

(9) This section applies to coverage for up to 25 hours per week of applied behavior analysis for an individual if the coverage is first requested when the individual is under nine years of age. This section does not limit coverage for any services that are otherwise available to an individual under ORS 743A.168 or 743A.190, including but not limited to:

(a) Treatment for autism spectrum disorder other than applied behavior analysis or the services described in subsection (3) of this section;

(b) Applied behavior analysis for more than 25 hours per week; or

(c) Applied behavior analysis for an individual if the coverage is first requested when the individual is nine years of age or older.

(10) Coverage under this section includes treatment for autism spectrum disorder provided in the individual’s home or a licensed health care facility or, for treatment provided by a licensed health care professional as defined in ORS 676.802 or a behavior analyst or assistant behavior analyst licensed under ORS 676.810 or a behavior analysis interventionist registered under ORS 676.815, in a setting approved by the health care professional, behavior analyst or assistant behavior analyst.

(11) An insurer that provides coverage of applied behavior analysis in accordance with a decision of an independent review organization that was made prior to January 1, 2016, shall continue to provide coverage, subject to modifications made in accordance with subsection (7) of this section.

(12) ORS 743A.001 does not apply to this section. [2013 c.771 §2; 2015 c.674 §9; 2019 c.284 §11; 2023 c.500 §6]

Sec. 22. Section 2, chapter 771, Oregon Laws 2013, is repealed January 2, 2030. [2013 c.771 §22; 2021 c.650 §1]

743A.310 Primary care visits; rules. (1) As used in this section, “primary care” means outpatient behavioral health services, nonspecialty medical services or the coordination of health care for the purpose of:

(a) Promoting or maintaining behavioral and physical health and wellness; and

(b) Diagnosis, treatment or management of acute or chronic conditions caused by disease, injury or illness.

(2) An individual or group policy or certificate of health insurance that is not offered on the health insurance exchange and that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, shall, in each plan year, reimburse the cost of at least three primary care visits for behavioral health or physical health treatment.

(3) The coverage under subsection (2) of this section:

(a) May not be subject to copayments, coinsurance or deductibles, except as provided in ORS 742.008 and subsection (5) of this section; and

(b) Is in addition to one annual preventive primary care visit that must be covered without cost-sharing.

(4) An insurer that offers a qualified health plan on the health insurance exchange must offer at least one plan in each metal tier offered by the insurer that provides the coverage described in subsections (2) and (3) of this section.

(5) The Department of Consumer and Business Services may adopt rules to allow an individual or group policy or certificate of health insurance to impose a copayment of not more than $5 for a primary care visit if necessary to comply with the requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (P.L. 110-343).

(6) This section does not apply to health benefit plans offered to public employees by insurers that contract with the Public Employees’ Benefit Board or the Oregon Educators Benefit Board.

(7) This section is exempt from ORS 743A.001. [2022 c.37 §6; 2023 c.425 §5]

Note: 743A.310 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

743A.315 Treatment for pediatric autoimmune neuropsychiatric disorders. (1) A health benefit plan, as defined in ORS 743B.005, must cover the cost of up to three monthly immunomodulatory courses of intravenous immunoglobulin therapy for the treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, when the following conditions have been met:

(a) Clinically appropriate trials, which may be done concurrently, of two or more less-intensive treatments were:

(A) Not effective;

(B) Not tolerated; or

(C) Did not result in sustained improvement in symptoms, as measured by a lack of clinically meaningful improvement on a validated instrument directed at the patient’s primary symptom complex; and

(b) A pediatric subspecialist was consulted and the pediatric subspecialist and the patient’s primary care provider recommend the treatment. For an adolescent patient, the consultation may be with an adult subspecialist.

(2) The health benefit plan may require that the patient be clinically reevaluated at three-month intervals.

(3) This section is exempt from ORS 743A.001. [2023 c.111 §2]

Note: 743A.315 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

Note: Sections 1, 3 and 7, chapter 111, Oregon Laws 2023, provide:

Sec. 1. Sections 2 [743A.315] and 3 of this 2023 Act are added to and made a part of the Insurance Code. [2023 c.111 §1]

Sec. 3. For billing and diagnostic purposes, the coverage described in section 2 of this 2023 Act [743A.315] may be coded as autoimmune encephalitis until the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific billing and diagnostic code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome. [2023 c.111 §3]

Sec. 7. Section 3 of this 2023 Act is repealed on January 2, 2028. [2023 c.111 §7]

743A.325 Gender-affirming treatment; rules. (1) As used in this section:

(a) “Carrier” has the meaning given that term in ORS 743B.005.

(b) “Gender-affirming treatment” means a procedure, service, drug, device or product that a physical or behavioral health care provider prescribes to treat an individual for incongruence between the individual’s gender identity and the individual’s sex assignment at birth.

(2) A carrier offering a health benefit plan in this state may not:

(a) Deny or limit coverage under the plan for gender-affirming treatment that is:

(A) Medically necessary as determined by the physical or behavioral health care provider who prescribes the treatment; and

(B) Prescribed in accordance with accepted standards of care.

(b) Apply categorical cosmetic or blanket exclusions to medically necessary gender-affirming treatment.

(c) Exclude as a cosmetic service a medically necessary procedure prescribed by a physical or behavioral health care provider as gender-affirming treatment, including but not limited to:

(A) Tracheal shave;

(B) Hair electrolysis;

(D) Revisions to prior forms of gender-affirming treatment; and

(E) Any combination of gender-affirming treatment procedures.

(d) Issue an adverse benefit determination denying or limiting access to gender-affirming treatment unless a physical or behavioral health care provider with experience prescribing or delivering gender-affirming treatment has first reviewed and approved the denial of or the limitation on access to the treatment.

(3) A carrier described in subsection (2) of this section must:

(a) Satisfy any network adequacy standards under ORS 743B.505 related to gender-affirming treatment providers; and

(b)(A) Contract with a network of gender-affirming treatment providers that is sufficient in numbers and geographic locations to ensure that gender-affirming treatment services are accessible to all enrollees without unreasonable delay; or

(B) Ensure that all enrollees have geographical access without unreasonable delay to out-of-network gender-affirming treatment services with cost-sharing or other out-of-pocket costs for the services no greater than the cost-sharing or other out-of-pocket costs for the services when furnished by an in-network provider.

(4) The Department of Consumer and Business Services shall:

(a) Evaluate compliance with this section in each examination or analysis of the market conduct of a carrier under ORS 731.300; and

(b) Adopt rules to implement the provisions of this section.

(5) This section is exempt from ORS 743A.001. [2023 c.228 §20]

Note: 743A.325 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

Note: Sections 59 (1), 21 and 22, chapter 228, Oregon Laws 2023, provide:

Sec. 59. (1) Section 20 of this 2023 Act [743A.325] applies to health benefit plans issued, renewed or extended on or after January 1, 2024. [2023 c.228 §59(1)]

Sec. 21. The Department of Consumer and Business Services shall conduct a targeted market conduct examination of all carriers that are subject to the requirements of section 20 of this 2023 Act [743A.325] to ensure compliance with section 20 of this 2023 Act. The examinations must be completed no later than January 2, 2027. [2023 c.228 §21]

Sec. 22. No later than December 31, 2026, the Department of Consumer and Business Services shall report to the interim committees of the Legislative Assembly related to health, in the manner provided in ORS 192.245, on the implementation of section 20 of this 2023 Act [743A.325]. [2023 c.228 §22]

_______________