Current through Register Vol. 63, No. 9, September 1, 2024
(1) This rule
applies to plan years beginning on and after January 1, 2017.
(2) As used in the Insurance Code and OAR
chapter 836:
(a) "Applied behavior analysis"
has that meaning given in ORS
676.802.
(b) "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 provided in
Exhibit 1 to this rule;
(c)
"Behavioral health condition" has the meaning given in OAR
836-053-1404.
(d) "Essential health benefits" or "EHB"
means the following coverage provided in compliance with 45 CFR 156 :
(A) The base-benchmark health benefit plan
with the exclusions and modifications of provisions of that plan as set forth
in section (3) to (7) of this rule;
(B) Pediatric dental benefits;
(C) Pediatric vision benefits; and
(D) Habilitative services and
devices.
(e)
"Habilitative services and devices" 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.
(f) "Pediatric
dental benefits" means the benefits described in the Dental Plan of the Oregon
Health Plan Children's' Health Insurance Plan as provided in Exhibit 2 of this
rule. Pediatric dental benefits are payable to persons under 19 years of
age.
(g) "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 provided
in Exhibit 3 of this rule. Pediatric vision benefits are payable to persons
under 19 years of age.
(h)
"Treatment of a behavioral health condition" includes medical treatments and
prescription drugs used to treat a behavioral health condition.
(3) The following exclusions and
modifications are required supplementation to the base-benchmark health benefit
plan:
(a) The following treatment limitations
and exclusions of coverage currently included in the base-benchmark health
benefit plan are excluded:
(A) The 24-month
waiting period for transplant benefits;
(B) Visit limits for inpatient and outpatient
behavioral health services, including but not limited to habilitative and
rehabilitative benefits;
(C) Age
limits on treatments that would otherwise be appropriate for individuals
outside of the limited age, including but not limited to hearing aids, speech,
physical and occupational therapy used in the treatment of behavioral health
conditions as defined in OAR
836-053-1404;
(D) Exclusions for the treatment of erectile
dysfunction or sexual dysfunction as defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
(E) Exclusions for medically necessary
surgeries and procedures related to sex transformations and gender identity
disorder or gender dysphoria;
(F)
Any blanket exclusion for a diagnosis made using the diagnostic criteria of
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text
Revision (DSM-5-TR).
(G) Exclusions
for court-order screening interviews or drug or alcohol treatment
programs;
(H) Any limitations or
waiting periods for pre-existing conditions;
(I) Time limits for treatment of jaw or teeth
or orthognathic surgery; and
(b) Dollar limits for coverage of durable
medical equipment 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.
(c) The following provisions of the
base-benchmark plan must be modified:
(A) Any
waiting periods must be consistent with limitations imposed by state or federal
law;
(B) Wigs following
chemotherapy or radiation therapy must be covered up to the actuarial
equivalent of $150 per calendar year;
(C) The limitation on cosmetic or
reconstructive surgery to one attempt within 18 months of injury or defect must
be modified to remove these limitations in cases of medical necessity in
accordance with 45 CFR
156.125(a) and to avoid
discrimination based on health factors under
45 CFR
146.121;
(D) Contraceptive coverage must comply with
Centers for Medicare and Medicaid Services guidance and requirements related to
contraception issued jointly by the United States Departments of Labor, Health
and Human Services, and Treasury on May 11, 2015;
(E) Provisions related to telemedical health
services must reflect changes made to ORS
743A.058 by Oregon Laws 2021,
chapter 117 (Enrolled House Bill 2508); and
(F) Housing and travel expenses for
transplant services are not considered essential health benefits;
(4) 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.
(5) If both a state law and federal law
require coverage of the same or similar service, the insurer must assure that
all elements of both laws are met and provide the coverage in the manner most
beneficial to the consumer.
(6) In
the administration of essential health benefits and the EHB base benchmark
health benefit plan, an insurer may not discriminate against a provider acting
within the scope of the provider's license.
(7) In the administration of essential health
benefits and the EHB base benchmark health benefit plan an insurer may not
exclude services provided by a naturopathic physician if the services are
otherwise covered under the plan and the naturopathic physician is acting
within the scope of the provider's license.
(8) In the administration of essential health
benefits and the EHB base benchmark health benefit plan an insurer may not
exclude services provided by a doctor of chiropractic medicine if the services
are otherwise covered under the plan and the doctor of chiropractic medicine is
acting within the scope of the provider's license.
To view attachments referenced in rule text,
click here to view
rule.
Statutory/Other Authority: ORS
731.097
Statutes/Other Implemented: ORS
731.097 & Or Laws 2021, ch
117
