This page lists some of the action toward parity compliance undertaken by Oregon regulatory agencies since 2008.
Are we missing any actions taken by state regulatory agencies? Let us know at firstname.lastname@example.org.
Primary Focus: Parity: General
Agency: Health Systems
Title/Description: Extends Period for Requesting Prior Authorization of Behavioral Health Services from 30 to 90 Days
Citation: DMAP 109-2018; Chapter 410
Summary: This amends rules pertaining to mental health and substance use disorder benefits by extending the period of time one may request prior authorization for such benefits from within 30 days to within 90 days of the date of service.
Effective Date: 1/1/2019
The Department of Consumer and Business Services (DCBS) released a proposed bulletin withdrawing their 12/2012 bulletin to insurers about coverage for people with conditions related to gender identity (GI) or gender dysphoria (GD). The purpose of this bulletin was to clarify prohibitions against discrimination based on GI and GD. Among other things, this bulletin adopts the mental health parity requirements present in the 2012 bulletin:
The DCBS issued regulations establishing the requirements for Oregon’s benchmark health benefit plan for years beginning on and after January 1, 2017. The rules contain the following provisions related to parity:
The DCBS issued a bulletin that explained to insurance plans what is required of them under the parity section of the state insurance law and the regulations that apply to it, what is required of them under the Federal Parity Law and its final regulation, and what is required of them relating to parity under the Affordable Care Act. This bulletin specifically expects plans to do the following:
The bulletin then goes into great detail about the state law, the Federal Parity Law and its final regulation, the ACA and its final regulation, and how all of this applies to various plans:
The DCBS issued a bulletin that explained to plans what is required of them under the section of the state insurance law about autism coverage, in addition to how the Federal Parity Law and the Affordable Care Act (ACA) affect how plans must cover autism services, including applied behavior analysis (ABA). The bulletin specifically expects plans to do the following:
The bulletin then goes into greater detail about the state law, the Federal Parity Law and its final regulation, the ACA and its final regulation, and how all of this applies to various plans:
The DCBS released a Frequently Asked Questions (pdf | Get Adobe® Reader®) related to the two Mental Health Parity and Autism Spectrum Disorder Bulletins released during the same month. The FAQ clarifies the following information:
The DCBS issued updated regulations that apply to the parity section of the state insurance law. In addition to restating some of the requirements of the law, the regulations clarify several things:
It is not possible to directly link to this regulation. To read it, click here and scroll down to 836-053-1404 and 836-053-1405, found near the bottom of the page.
The DCBS issued a bulletin to insurers clarifying requirements for individual plans and small employer fully-insured plans that are offered on the marketplace. This bulletin was rescinded by the 11/2014 bulletin about parity, summarized above, and the link to the bulletin is no longer available.
Among many other things, the bulletin advises plans of the following related to parity:
The DCBS issued a bulletin (pdf | Get Adobe® Reader®) to insurers about coverage for people with conditions related to gender identity (GI) or gender dysphoria (GD). The bulletin listed a number of requirements for insurance plans:
The DCBS fined Health Net of Oregon (pdf | Get Adobe® Reader®) $5,000 dollars for denying coverage for behavioral health services because the patients did not get prior authorization from Health Net. The DCBS took this action after investigating consumer complaints.
Primary Focus: Mandated Benefit: Provider
Agency: The Department of Consumer and Business Services, Insurance Regulation
Title/Description: General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency
Citation: OAR 836-053-1405
Summary: A group health insurance policy issued or renewed in this state shall provide coverage or reimbursement for medically necessary treatment of mental or nervous conditions and chemical dependency, including alcoholism, at the same level as, and subject to limitations no more restrictive than those imposed on coverage or reimbursement for medically necessary treatment for other medical conditions.
Effective Date: 2006
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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