Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-0008 - Essential Health Benefits for Plan Years 2014, 2015 and 2016
Universal Citation: OR Admin Rules 836-053-0008
Current through Register Vol. 63, No. 9, September 1, 2024
(1) This rule applies to plan years beginning January 1, 2014 through December 31, 2016.
(2) As used in the Insurance Code for plan years beginning January 1, 2014 through December 31, 2016 only:
(a) "Base benchmark health benefit plan"
means the PacificSource Health Plans Preferred CoDeduct Value 3000 35 70 small
group health benefit plan, including prescription drug benefits, as set forth
on the website of the Department of Consumer and Business Services at
dfr.oregon.gov.
(b) "Essential
health benefits" means the following coverage provided in compliance with 45
CFR 156 :
(A) The base-benchmark health
benefit plan, excluding the 24-month waiting period for transplant
benefits;
(B) Pediatric dental
benefits;
(C) Pediatric vision
benefits; and
(D) Habilitative
services.
(c)
"Habilitative benefits" means the rehabilitative services provisions of the
base benchmark when the services are medically necessary for the maintenance,
learning or improving skills and function for daily living.
(d) "Pediatric dental benefits" means the
benefits described in the children's dental provisions of the State Children's
Health Insurance Plan as set forth on the website of the Department of Consumer
and Business Services at dfr.oregon.gov. Pediatric dental benefits are payable
to persons under 19 years of age.
(e) "Pediatric vision benefits" means the
benefits described in the vision provisions of the Federal Employee Dental and
Vision Insurance Plan Blue Vision High Option as set forth on the website of
the Department of Consumer and Business Services at dfr.oregon.gov. Pediatric
vision benefits are payable to persons under 19 years of age.
(3) An insurer that issues a health benefit plan offering essential health benefits may not include as an essential health benefit:
(a) Routine
non-pediatric dental services;
(b)
Routine non-pediatric eye exam services;
(c) Long-term care or custodial nursing home
care benefits; or
(d) Non-medically
necessary orthodontia services.
Statutory/Other Authority: ORS 731.097
Statutes/Other Implemented: ORS 731.097
Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
