Primary Focus: Mandated Benefit: SUD
Title/Description: Treatment of chemical dependency, including alcoholism, and mental or nervous conditions; rules
Citation: ORS § 743A.168
Summary: A group health insurance policy providing coverage for hospital or medical expenses, other than limited benefit coverage, shall provide coverage for expenses arising from the diagnosis of and treatment for chemical dependency, including alcoholism, and for mental or nervous conditions 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.
ORS § 743A.168 also sets out definitions as well as related provisions with regard to the coverage.
Effective Date: January 1, 2018
Notes: Formerly 743.556. Amended by Ore. HB 3091.
Primary Focus: Access to services/Eligibility
Title/Description: Provider networks; rules
Citation: ORS § 743B.505
Summary: An insurer offering a health benefit plan in this state that provides coverage to individuals or to small employers, as defined under the law, through a specified network of health care providers shall:
(a) Contract with or employ a network of providers that is sufficient in number, geographic distribution and types of providers to ensure that all covered services under the health benefit plan, including mental health and substance abuse treatment, are accessible to enrollees without unreasonable delay.
Effective Date: May 25, 2017
Notes: Amended by Ore. HB 2341.
Sponsor: Health Care
Status: Signed into law 8/2017
Summary: This bill changed the section of state insurance law so that the Department of Consumer and Business Services must do the following:
The bill authorized a maximum of $600,000 to fund the examinations and report above.
Sponsor: Office of the Governor
Status: Signed into law 5/2015
Summary: This bill changed the section of state insurance law so that insurance plans had to meet health care provider network standards. Among other things, the bill requires that a plan’s provider network have a sufficient number, geographic distribution, and type of providers to ensure access to covered services. The bill specifically mentions that mental health and substance use treatment must be accessible.
Sponsor: Rep. Conger, Sen. Devlin, Rep. McLane, Rep. Parrish, Sen. Hass, and Sen. Johnson
Status: Signed into law 8/2013
Summary: This bill changed the section of the state insurance law about autism coverage to what it is currently, particularly the requirements about applied behavior analysis. Scroll to the bottom of the page to read the summary of this section of the law.
Sponsor: Rep. Barnhart and Rep. Greenlick
Status: Signed into law 6/2013
Summary: This bill changed the parity section of the state insurance law so that insurance plans are no longer exempt from covering court-ordered services that are the result of a conviction for driving while intoxicated.
Primary Focus: Parity: General
Title/Description: Services provided by psychologist
Citation: ORS § 743A.048
Summary: 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 licensed psychologist:
(1) The insured under such policy or contract shall be free to select, and shall have direct access to, a licensed psychologist, 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.
Effective Date: None listed.
Notes: Formerly 743.709.
Sponsor: Requested by the Oregon Health Authority
Status: Signed into law 6/2011
Summary: This bill changed state law so that court-ordered services that are the result of a conviction for driving while intoxicated can be covered by Medicaid, if the services are medically necessary.
Sponsor: Rep. Buckley
Status: Signed into law 6/2009
Summary: This bill changed state law so that if a plan provides coverage for services offered by a clinical social worker, the plan must also cover services provided by a professional counselor or marriage and family therapist.
There is a section in the Oregon Insurance law relevant to behavioral health coverage parity and 2 sections about autism coverage.
It is not possible to provide direct links to either section of the state insurance law because of the functionality of Oregon’s website. To find the sections, go to this link and scroll to section 743A.168 for the section about behavioral health coverage and scroll to section 743A.190 for the section about autism coverage and then scroll to the very bottom for additional autism coverage.
This section of the state insurance law requires large employer fully-insured plans and small employer fully-insured plans to cover behavioral health services “at the same level” and with treatment limitations “no more restrictive” than what is in place for other medical services.
Plans are not required to cover more than 45 consecutive days of residential treatment.
Plans are allowed to use utilization review, prior authorization and other non-quantitative treatment limitations (NQTLs), and there is no language in this section of the law that requires plans to apply these NQTLs similarly to how they are used with other medical care. However, utilization review must be conducted according to the standards of National Committee for Quality Assurance or Medicare review standards of the Centers for Medicare and Medicaid Services.
Plans are required to cover out-of-network providers for behavioral health services, even if there are in-network providers that provide those services. However, this does not require coverage for out-of-network services to be at the same level as coverage for in-network services.
This section also states that the Oregon Department of Consumer and Business Services and the Oregon Health Authority may implement regulations related to this section of the law.
Section 743A.164 requires plans to cover injuries resulting from the use of drugs or alcohol in a way that is “no more restrictive” than how they cover injuries that are not the result of drug or alcohol use (see section instructions above this section for how to find 743A.164).
The sections of the law relevant to autism and pervasive developmental disorder require large employer fully-insured plans, small employer fully-insured plans, individual plans state employee plans, and public school teacher plans to cover services for pervasive developmental disorder that are medically necessary for children through age 17. Medically necessary is defined as an insurance plan’s definition for medical necessity “that applies uniformly to all covered services”.
Pervasive developmental disorder is defined as “autism spectrum disorder, developmental delay, developmental disability, or mental retardation.”
Autism spectrum disorder is defined as it is in the DSM -V.
Plans must cover 25 hours per week of applied behavior analysis for children up through age 17 who were diagnosed with autism before age 9; plans can require prior authorization before the services start. Once coverage for applied behavior analysis begins, it will continue as long as it is considered medically necessary and the child shows improvement towards the goals identified in his or her treatment plan.
Insurance plans may review a child’s treatment plan no more than once every 6 months. The insurance plan can request modification of the treatment plan if child is not progressing towards the goals of the treatment plan.
Rehabilitation services are defined as:
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