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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 info@paritytrack.org.

Action in the Regulatory Arena

2018

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
Notes: None

2016

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:

  • Cannot make GI/GD a pre-existing condition for which coverage will be limited or denied
  • Cannot deny or limit a service because it is associated with treatment of GI/GD if they do not deny or limit the same service for other medical conditions
  • Cannot exclude any service just because it is associated with GI/GD or only when it is used in connection with GI/GD or gender reassignment; exclusions as such would be deemed discrimination
  • Must cover certain medical services for people, regardless of their perceived gender, such as prostate exams for people who are biologically male but identify as women

04/2016

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:

11/2014

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:

  • Must make coverage decisions for behavioral health services the same way they do for other medical services
  • Cannot categorically deny all forms of a treatment that might be medically necessary, thereby making state and federal mandates “effectively meaningless”
  • Review their appeals decisions and independent review organization (IRO) decisions for guidance on how to handle future behavioral health claims
  • Medical necessity determinations and whether a behavioral health service is considered experimental must be “no more restrictive” than for other medical services
  • Cannot tell insureds verbally that a service is not covered; must encourage insureds to submit a claim and then the plan can deny the claim in writing
  • Must use peer-reviewed scientific studies and national or international clinical standards when making medical necessity determinations
  • Make available to providers and insureds the plan’s medical necessity criteria and instances of how certain denials do not meet these criteria

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:

  • History of state law and the plans to which it applies (pg. 3)
  • Types of plans the different state and federal laws apply to and how (pg. 4)
  • Coverage requirements of state law (pg. 4-5)
  • Coverage requirements due to the Federal Parity Law and the ACA (pg. 5-6)
  • Explanation of requirements related to quantitative treatment limitations and non-quantitative treatment limitations (pg. 6)
  • Exclusions under state law and how federal law impacts these (pg. 7-8)
  • States how DCBS will be monitoring external review decisions made by IROs to see if those decisions reveal patterns of possible non-compliance with state and federal law (pg. 9)

11/2014

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:

  • Must consider autism claims as mental health claims subject to state and federal parity laws
  • ABA services cannot be categorically denied as experimental
  • Cannot have categorical exclusions that effectively results in denial of all ABA or other medically necessary services
  • ABA is considered a medical service
  • May not refuse to credential certain groups of providers in a way that would effectively limit medically necessary mental health treatment
  • Understand the the 25 hour per week language about ABA in state law is a floor for weekly ABA; if plans consider it a limit they are violating the Federal Parity Law
  • Must comply with the parity bulletin summarized above in relation to services for autism

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:

  • Plans to which the state law applies (pg. 3)
  • Coverage requirements under state law (pg. 3-4)
  • Requirements under the Federal Parity Law (pg. 4)
  • Exclusions or limitations (pg. 4)
  • Provider qualifications under state law (pg. 4-5)
  • Independent review organization decisions and their implications (pg. 5)

11/2014

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:

  • How DCBS monitors independent review organization decisions to determine if insurer denial patterns need to be reviewed
  • Claims determinations must be available in writing and be relatively predictable
  • Oregon’s benchmark plan must provide coverage for applied behavioral analysis (ABA) treatment
  • Credentialing requirements for ABA must be developed in the same manner as other provider credentialing requirements

6/2013

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:

  • All conditions in the DSM are covered, except for several exceptions that are not generally not considered mental illnesses or substance use disorders
  • Copayments, coinsurance, reimbursement, and deductibles must be the same for behavioral health services as they are for other medical services, including preventive care services and prescription medications
  • The processes for determining prescription medication formularies must be the same for behavioral health medications as they are for other medications
  • Plans must use a single definition for medical necessity that applies to both behavioral health services and other medical services and plans must make sure this definition is applied uniformly to all behavioral health services
  • Plans can only use non-quantitative treatment limitations (NQTLs) for behavioral health services if they use those same NQTLs the same way for other medical services

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.

3/2013

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:

  • Specifies specific disorder codes for behavioral health conditions in the DSM -IV plans must cover
  • Identifies specific disorder codes for behavioral health conditions in the ICD that plans are not required to cover
  • Clarifies that behavioral health coverage must comply with the Federal Parity Law

The DCBS also made a questions and answers document (pdf | Get Adobe® Reader®) to accompany this bulletin.

12/2012

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:

  • Cannot make GI/GD a pre-existing condition for which coverage will be limited or denied
  • Cannot deny or limit a service because it is associated with treatment of GI/GD if they do not deny or limit the same service for other medical conditions
  • Cannot exclude any service just because it is associated with GI/GD or only when it is used in connection with GI/GD or gender reassignment; exclusions as such would be deemed discrimination
  • Must cover behavioral health services for GI/GD for all people and that the DCBS would issue further regulations to clarify any inconsistencies between state law and state regulations
  • Must cover certain medical services for people, regardless of their perceived gender, such as prostate exams for people who are biologically male but identify as women

The DCBS also released a document called “Insurance and Gender Identity Fact Sheet” (pdf | Get Adobe® Reader®) for insurers and consumers shortly after this bulletin was issued.

8/2011

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.

2006

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
Notes: N/A

Oregon Parity Law

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.

Behavioral Health 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.

This section specifically mentions that deductibles and coinsurance for inpatient care, outpatient care, and residential treatment cannot be greater than what are used for other medical services.

Annual maximums, annual limits, lifetime maximums, and lifetime limits must be similar to those used 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).

Autism

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.

Financial requirements and in-network and out-of-network policies must be the same as those in place for other medical services.

Rehabilitation services are defined as:

  • Physical therapy
  • Occupational therapy
  • Speech therapy

Get Support

Oregon Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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