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 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, 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) A reference to a
specific version of a code or manual, including but not limited to references
to ICD-10, CPT, Diagnostic and Statistical Manual of Mental Disorders, (DSM-5),
Fifth 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 insurer must:
(a) Use the following naming convention:
"[Name of Insurer] Standard [Bronze/HSA/Silver] Plan." The name of insurer may
be shortened to an easily identifiable acronym that is commonly used by the
insurer in consumer facing publications.
(b) Include a service area or network
identifier in the plan name if the plan is not offered on a statewide basis
with a statewide network.
(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,
836-053-1405,
836-053-1407 and
836-053-1408;
(c) The federal Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act,
29 U.S.C.
1185a and implementing regulations at
45 CFR
146.136 and
147.160; and
(d) For plan years beginning on or after
January 1, 2019, Chapter 721, Oregon Laws 2017 (Enrolled House Bill 3391).
(7) Coverage must
provide essential health benefits as defined in OAR
836-053-0012.
(8) Except when a specific benefit exclusion
applies, or a claim fails to satisfy the insurer's definition of medical
necessity or fails to meet other issuer requirements the following coverage
must be provided:
(a) Ambulatory
services;
(b) Emergency
services;
(c) Hospitalization
services;
(d) Maternity and newborn
services;
(e) Rehabilitation and
habilitation services including:
(A)
Professional physical therapy services;
(B) Professional occupational
therapy;
(C) Physical therapy
performed by an occupational therapist; and
(D) Professional speech therapy;
(f) Laboratory services;
(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)
(A) Prescription drug coverage at the greater
of:
(i) At least one drug in every United
States Pharmacopeia (USP) category and class as the prescription drug coverage
of the plan described in OAR
836-053-0012(2);
or
(ii) The same number of
prescription drugs in each category and class as the prescription drug coverage
of the plan described in OAR
836-053-0012(2).
(B) Insurers must submit the
formulary drug list for review and approval. The formulary drug list must
comply with filing requirements posted on the Department of Consumer and
Business Services website.
(C) For
plan years beginning on or after January 1, 2017 insurers must use a pharmacy
and therapeutics committee that complies with the standards set forth in
45 CFR
156.122.
(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,
29 U.S.C.
1185a, 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 the cost-sharing matrix as adopted
in Exhibit 1 to this rule.
(b) For
a silver plan, in accordance with the coinsurance, copayment and deductible
amounts and coverage requirements for a silver plan set forth in the
cost-sharing matrix as adopted in Exhibit 2 to this rule.
(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.
To view attachments referenced in rule text,
click here to view
rule.
Statutory/Other Authority: ORS
731.244 &
45 CFR
156.135(g)
Statutes/Other Implemented: ORS
743B.130
