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 this rule,
"coverage" includes medically necessary benefits, services, prescription drugs
and medical devices. "Coverage" does not include coinsurance, copayments,
deductibles, other cost sharing, provider networks, out-of-network coverage,
wigs or administrative functions related to the provision of coverage, such as
eligibility and medical necessity determinations.
(3) For purposes of coverage required under
this rule:
(a) "Inpatient" includes but is
not limited to:
(A) Inpatient surgery;
(B) Intensive care unit, neonatal
intensive care unit, maternity and skilled nursing facility services; and
(C) Mental health and substance
abuse treatment.
(b)
"Outpatient" includes but is not limited to services received from ambulatory
surgery centers and physician and anesthesia services and benefits when
applicable.
(c) "Habilitative
benefits" means services and devices that help a person keep, learn, or improve
skills and functioning for daily living (habilitative services). Examples
include therapy for a child who is not walking or talking at the expected age.
These services and devices must include physical and occupational therapy,
speech-language pathology and other services and devices for people with
disabilities in a variety of inpatient or outpatient settings.
(d) A reference to a specific version of a
code or manual, including but not limited to references to ICD-9, CPT,
Diagnostic and Statistical Manual of Mental Disorders, DSM-IV TR, Fourth
Edition; place of service and diagnosis includes a reference to a code with
equivalent coverage under the most recent version of the code or manual.
(4) When offering a
plan required under ORS
743B.130, an issuer must use the
following naming convention: "[Name of Issuer] Oregon Standard [Bronze/ Silver]
Plan."
(5) Coverage required under
ORS 743B.130 must be provided in
accordance with the requirements of sections (6) to (11) of this rule.
(6) Coverage must be provided in a
manner consistent with the requirements of:
(a) 45 CFR 156, except that actuarial
substitution of coverage within an essential health benefits category is
prohibited;
(b) OAR
836-053-1404 and
836-053-1405; and
(c) The federal Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008;
(7) Coverage must provide
essential health benefits as defined in OAR
836-053-0008.
(8) Except when a specific benefit exclusion
applies, or a claim fails to satisfy the issuer's definition of medical
necessity or fails to meet other issuer requirements the following coverage
must be provided:
(a) Ambulatory services
based on the following Place of Service Codes:
(A) 11 - Office;
(B) 12 - Patient's home;
(C) 20 - Urgent care facility;
(D) 22 - Outpatient hospital;
(E) 24 - Ambulatory surgical center;
(F) 25 - Birthing center;
(G) 49 - Independent clinic;
(H) 50 - Federally qualified
health center;
(I) 71 - State or
local public health clinic;
(J) 72
- Rural health clinic;
(b) Emergency services based on Place of
Service Code 23 - Emergency;
(c)
Hospitalization services based on Place of Service Code 21 - Hospital;
(d) Maternity and newborn services
based on the following ICD-9 codes:
(A) V20
to V20.2;
(B) V22 to V39; and
(C) 630-677;
(e) Rehabilitation and habilitation services
based the following ICD-9 or CPT codes:
(A)
Physical Therapy/Professional: 97001-97002, 97010-97036, 97039, 97110, 97112,
97113-97116, 97122, 97128, 97139, 97140-97530, 97535, 97542, 97703, 97750,
97760, 97761-97762, 97799, and S9090;
(B) Occupational Therapy/Professional:
97003-97004 and G0129 in addition to all physical therapy codes if performed by
an occupational therapist;
(C)
Speech Therapy/Professional: 92507-92508, 92526, 92609-92610, and 97532 except
ICD-9 784.49;
(f)
Laboratory services in the CPT code range 8XXXX;
(g) All grade A and B United States
Preventive Services Task Force preventive services, Bright Futures recommended
medical screenings for children, Institute of Medicine recommended women's
guidelines, and Advisory Committee on Immunization Practices recommended
immunizations for children coverage must be provided without cost share; and
(h) Prescription drug coverage at
the greater of:
(A) At least one drug in
every United States Pharmacopeia (USP) category and class as the prescription
drug coverage of the plan described in OAR
836-053-0008(1)(a);
or
(B) The same number of
prescription drugs in each category and class as the prescription drug coverage
of the plan described in OAR
836-053-0008(1)(a).
(9) Copays
and coinsurance for coverage required under ORS
743B.130 must comply with the
following:
(a) Non-specialist copays apply to
physical therapy, speech therapy, occupational therapy and vision services when
these services are provided in connection with an office visit.
(b) Subject to the federal Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, specialist
copays apply to specialty providers including, mental health and substance
abuse providers, if and when such providers act in a specialist capacity as
determined under the terms of the health benefit plan.
(c) Coinsurance for emergency room coverage
must be waived if a patient is admitted, at which time the inpatient
coinsurance applies.
(10) Deductibles for coverage required under
ORS 743B.130 must comply with the
following:
(a) For a bronze plan, in
accordance with the coinsurance, copayment and deductible amounts and coverage
requirements for a bronze plan set forth in Exhibit 1 to this rule. The bronze
plan deductible must be integrated applicable to prescription drugs and all
services except preventive services.
(b) For a silver plan, in accordance with the
coinsurance, copayment and deductible amounts and coverage requirements for a
silver plan set forth in Exhibit 1 to this rule. The silver plan deductible
applies to all services except preventive services, office visits, urgent care,
and prescription drugs.
(c) The
individual deductible applies to all enrollees, and the family deductible
applies when multiple family members incur claims.
(11) Dollar limits for coverage required
under ORS 743B.130 must comply with the
following:
(a) Annual dollar limits must be
converted to a non-dollar actuarial equivalent.
(b) Lifetime dollar limits must be converted
to a non-dollar actuarial equivalent.
Stat. Auth.: ORS
743B.130
Stats. Implemented: ORS
743B.130
