Definition


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Parity is about fairness. Americans with behavioral health conditions often have more difficulty getting the treatment and services they need when compared to individuals seeking other medical care. Explore parity-related information regarding legislation, statutes, and regulatory actions since the Federal Parity Law was passed in 2008.

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

State Parity Reports

View the state parity reports to learn about legislation, regulation, and litigation related to parity implementation

State Parity Reports

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Common Violations

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