2007 Oregon Code - Chapter 743a :: Chapter 743A - Health Insurance: Required Reimbursements
Chapter 743A
Health Insurance: Required Reimbursements
2007 EDITION
HEALTH INSURANCE: REQUIRED REIMBURSEMENTS INSURANCE
743A.001 Automatic
repeal of certain statutes on individual and group health insurance
743A.010 Services
provided by state hospital or state approved program
743A.012 Emergency
services
743A.014 Payments
for ambulance care and transportation
743A.020 Services
provided by acupuncturist
743A.024 Services
provided by clinical social worker
743A.028 Services
provided by denturist
743A.032 Surgical
services provided by dentist
743A.036 Services
provided by nurse practitioner
743A.040 Services
provided by optometrist
743A.044 Services
provided by physician assistant
743A.048 Services
provided by psychologist
743A.050 Services
provided by registered nurse first assistant
743A.060 Definition
for ORS 743A.062
743A.062 Prescription
drugs
743A.064 Prescription
drugs dispensed at rural health clinics
743A.066 Contraceptives
743A.068 Orally
administered anticancer medication
743A.070 Nonprescription
enteral formula for home use
743A.080 Pregnancy
and childbirth expenses
743A.084 Unmarried
women and their children
743A.088 Use
by mother of diethylstilbestrol
743A.090 Newly
born and adopted children
743A.100 Mammogram
743A.104 Pelvic
examinations and Pap smear examinations
743A.108 Physical
examination of breast
743A.110 Mastectomy-related
services
743A.120 Prostate
screening examinations
743A.124 Colorectal
cancer screenings and laboratory tests
743A.140 Bilateral
cochlear implants
743A.144 Prosthetic
and orthotic devices
743A.148 Maxillofacial
prosthetic services
743A.160 Alcoholism
treatment
743A.164 Injuries
resulting from alcohol and controlled substances
743A.168 Treatment
of chemical dependency, including alcoholism, and mental or nervous conditions;
rules
Note Application
of ORS 743A.001 to ORS 743A.168 and 750.055--1987 c.411 §7
743A.180 Tourette
Syndrome
743A.184 Diabetes
self-management programs
743A.188 Inborn
errors of metabolism
743A.190 Children
with pervasive developmental disorder
743A.001
Automatic repeal of certain statutes on individual and group health insurance. (1) Except as provided in subsection (4) of
this section, any statute described in subsection (2) of this section that
becomes effective on or after July 13, 1985, is repealed on the sixth
anniversary of the effective date of the statute, unless the Legislative
Assembly specifically provides otherwise.
(2) This section governs any statute that
applies to individual or group health insurance policies and does any of the
following:
(a) Requires the insurer to include
coverage for specific physical or mental conditions or specific hospital,
medical, surgical or dental health services.
(b) Requires the insurer to include
coverage for specified persons.
(c) Requires the insurer to provide
payment or reimbursement to specified providers of services if the services are
within the lawful scope of practice of the provider and the insurance policy
provides payment or reimbursement for those services.
(d) Requires the insurer to provide any
specific coverage on a nondiscriminatory basis.
(e) Forbids the insurer to exclude from
payment or reimbursement any covered services.
(f) Forbids the insurer to exclude
coverage of a person because of that persons medical history.
(3) A repeal of a statute under subsection
(1) of this section does not apply to any insurance policy in effect on the
effective date of the repeal. However, the repeal of the statute applies to a
renewal or extension of an existing insurance policy on or after the effective
date of the repealer as well as to a new policy issued on or after the
effective date of the repealer.
(4) This section does not apply to ORS
743A.020, 743A.080, 743A.100, 743A.104 and 743A.108. [Formerly 743.700]
743A.010
Services provided by state hospital or state approved program. No policy of health insurance shall exclude
from payment or reimbursement losses incurred by an insured for any covered
service because the service was rendered at any hospital owned or operated by
the State of
743A.012
Emergency services. (1) All
insurers offering a health benefit plan shall provide coverage without prior
authorization for:
(a) Emergency medical screening exams;
(b) Stabilization of an emergency medical
condition; and
(c) Emergency services provided by a
nonparticipating provider if a prudent layperson possessing an average
knowledge of health and medicine would reasonably believe that the time
required to go to a participating provider would place the health of the
person, or a fetus in the case of a pregnant woman, in serious jeopardy.
(2) All insurers described in subsection
(1) of this section shall provide information to enrollees in plain language
regarding:
(a) What constitutes an emergency medical
condition;
(b) The coverage provided for emergency
services;
(c) How and where to obtain emergency
services; and
(d) The appropriate use of 9-1-1.
(3) An insurer offering a health benefit
plan may not discourage appropriate use of 9-1-1 and shall not deny coverage
for emergency services solely because 9-1-1 was used.
(4) This section is exempt from ORS
743A.001. [Formerly 743.699]
Note: See definitions in 743.801.
743A.014
Payments for ambulance care and transportation. Any insurance policy issued or issued for
delivery in this state that provides coverage for ambulance care and
transportation shall provide that payments will be made jointly to the provider
of the ambulance care and transportation and to the insured, unless the policy
provides for direct payment to the provider. [Formerly 743.718]
Note: See 743A.001.
743A.020
Services provided by acupuncturist. (1) An individual or group health insurance policy that provides
coverage for acupuncture services performed by a physician shall provide
coverage for acupuncture services performed by an acupuncturist licensed under
ORS 677.757 to 677.770.
(2) The coverage required by subsection
(1) of this section may be made subject to provisions of the policy that apply
to other benefits under the policy, including, but not limited to, provisions
related to deductibles and coinsurance and shall be computed in the same manner
whether performed by a physician or an acupuncturist.
(3) Subsection (1) of this section does
not require group practice health maintenance organizations that are federally
qualified pursuant to Title XIII subchapter XI of the Public Health Service Act
(42 U.S.C. 300e et seq.) to employ acupuncturists licensed under ORS 677.757 to
677.770.
(4) This section also applies to health
care service contractors, as defined in ORS 750.005, and trusts carrying out
multiple employer welfare arrangements, as defined in ORS 750.301. [2007 c.313 §2]
Note: Section 10, chapter 313, Oregon Laws 2007,
provides:
Sec.
10. Section 2 of this 2007
Act [743A.020] and the amendments to ORS 743.700 [renumbered 743A.001], 750.055
and 750.333 by sections 4 to 9 of this 2007 Act apply to health insurance
policies issued or renewed on or after the effective date of this 2007 Act
[January 1, 2008]. [2007 c.313 §10]
Note: 743A.020 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
743A.024
Services provided by clinical social worker. Whenever any individual or group health insurance policy or blanket
health insurance policy described in ORS 743.534 (3) provides for payment or
reimbursement for any service which is within the lawful scope of service of a
clinical social worker licensed under ORS 675.510 to 675.600:
(1) The insured under the policy shall be
entitled to the services of a clinical social worker licensed under ORS 675.510
to 675.600, upon referral by a physician or psychologist.
(2) The insured under the policy shall be
entitled to have payment or reimbursement made to the insured or on behalf of
the insured for the services performed. The payment or reimbursement shall be
in accordance with the benefits provided in the policy and shall be computed in
the same manner whether performed by a physician, by a psychologist or by a
clinical social worker, according to the customary and usual fee of clinical
social workers in the area served. [Formerly 743.714]
743A.028
Services provided by denturist.
Notwithstanding any provisions of any policy of insurance covering dental
health, whenever such policy provides for reimbursement for any service that is
within the lawful scope of practice of a denturist, the insured under such
policy shall be entitled to reimbursement for such service, whether the service
is performed by a licensed dentist or a licensed denturist as defined in ORS
680.500. [Formerly 743.713]
Note: 743A.028 was added to and made a part of the
Insurance Code by the people in the exercise of their initiative power but was
not added to ORS chapter 743A or any series therein. See Preface to Oregon
Revised Statutes for further explanation.
743A.032
Surgical services provided by dentist. Notwithstanding any provision of a policy of health insurance,
whenever the policy provides for payment of a surgical service, the performance
for the insured of such surgical service by any dentist acting within the scope
of the dentists license is compensable if performance of that service by a
physician acting within the scope of the physicians license would be
compensable. [Formerly 743.719]
743A.036
Services provided by nurse practitioner. (1) Whenever any policy of health insurance provides for reimbursement
for any service which is within the lawful scope of practice of a duly licensed
and certified nurse practitioner, including prescribing or dispensing drugs,
the insured under the policy is entitled to reimbursement for such service
whether it is performed by a physician licensed by the Oregon Medical Board or
by a duly licensed nurse practitioner.
(2) This section does not apply to group
practice health maintenance organizations that are federally qualified pursuant
to Title XIII of the Health Maintenance Organization Act. [Formerly 743.712]
743A.040
Services provided by optometrist. Notwithstanding any provision of any policy of health insurance,
whenever the policy provides for payment or reimbursement for a service that is
within the lawful scope of practice of a licensed optometrist, the insurer
shall provide payment or reimbursement for the service, whether the service is
performed by a physician or a licensed optometrist. Unless the policy provides
otherwise, there shall be no reimbursement for ophthalmic materials, lenses,
spectacles, eyeglasses or appurtenances thereto. [Formerly 743.703]
743A.044
Services provided by physician assistant. (1) An insurer may not refuse a claim solely on the ground that the
claim was submitted by a physician assistant rather than by the supervising
physician for the physician assistant.
(2) This section is exempt from ORS
743A.001. [Formerly 743.725]
743A.048
Services provided by psychologist. Whenever any provision of any individual or group health insurance
policy or contract provides for payment or reimbursement for any service which
is within the lawful scope of a psychologist licensed under ORS 675.010 to
675.150:
(1) The insured under such policy or
contract shall be free to select, and shall have direct access to, a
psychologist licensed under ORS 675.010 to 675.150, without supervision or
referral by a physician or another health practitioner, and wherever such
psychologist is authorized to practice.
(2) The insured under such policy or
contract shall be entitled to have payment or reimbursement made to the insured
or on the insureds behalf for the services performed. Such payment or
reimbursement shall be in accordance with the benefits provided in the policy
and shall be the same whether performed by a physician or a psychologist
licensed under ORS 675.010 to 675.150. [Formerly 743.709]
743A.050
Services provided by registered nurse first assistant. (1) An insurer offering a health insurance policy
that provides coverage for hospital, medical or surgical expenses, other than
coverage limited to expenses from accidents or specific diseases, shall provide
payment or reimbursement for professional services performed by a registered
nurse whose certification as a registered nurse first assistant has been
recognized by the Oregon State Board of Nursing under ORS 678.366.
(2) This section also applies to health
care service contractors, as defined in ORS 750.005, and trusts carrying out
multiple employer welfare arrangements, as defined in ORS 750.301. [Formerly
743.798]
Note: See 743A.001.
743A.060
Definition for ORS 743A.062.
As used in ORS 743A.062, peer-reviewed medical literature means scientific
studies printed in journals or other publications that publish original
manuscripts only after the manuscripts have been critically reviewed by
unbiased independent experts for scientific accuracy, validity and reliability.
Peer-reviewed medical literature does not include internal publications of
pharmaceutical manufacturers. [Formerly 743.695]
743A.062
Prescription drugs. (1) No
insurance policy or contract providing coverage for a prescription drug to a
resident of this state shall exclude coverage of that drug for a particular
indication solely on the grounds that the indication has not been approved by
the United States Food and Drug Administration if the Health Resources
Commission determines that the drug is recognized as effective for the
treatment of that indication:
(a) In publications that the commission
determines to be equivalent to:
(A) The American Hospital Formulary
Services drug information;
(B) Drug Facts and Comparisons
(Lippincott-Raven Publishers);
(C) The United States Pharmacopoeia drug
information; or
(D) Other publications that have been
identified by the United States Secretary of Health and Human Services as
authoritative;
(b) In the majority of relevant
peer-reviewed medical literature; or
(c) By the United States Secretary of
Health and Human Services.
(2) Required coverage of a prescription
drug under this section shall include coverage for medically necessary services
associated with the administration of that drug.
(3) Nothing in this section requires
coverage for any prescription drug if the United States Food and Drug
Administration has determined use of the drug to be contraindicated.
(4) Nothing in this section requires
coverage for experimental drugs not approved for any indication by the United
States Food and Drug Administration.
(5) This section is exempt from ORS
743A.001. [Formerly 743.697]
743A.064
Prescription drugs dispensed at rural health clinics. (1) All health insurance policies that
provide a prescription drug benefit, except those policies in which coverage is
limited to expenses from accidents or specific diseases that are unrelated to
the coverage required by this subsection, must include coverage for
prescription drugs dispensed by a licensed practitioner at a rural health
clinic for an urgent medical condition if there is not a pharmacy within 15
miles of the clinic or if the prescription is dispensed for a patient outside
of the normal business hours of any pharmacy within 15 miles of the clinic.
(2) The coverage required by subsection
(1) of this section is subject to the terms and conditions of the prescription
drug benefit provided under the policy.
(3) As used in this section, urgent
medical condition means a medical condition that arises suddenly, is not
life-threatening and requires prompt treatment to avoid the development of more
serious medical problems. [Formerly 743.793]
Note: See 743A.001.
743A.066
Contraceptives. (1) A
prescription drug benefit program, or a prescription drug benefit offered under
a health benefit plan as defined in ORS 743.730 or under a student health
insurance policy, must provide payment, coverage or reimbursement for:
(a) Prescription contraceptives; and
(b) If covered for other drug benefits
under the program, plan or policy, outpatient consultations, examinations,
procedures and medical services that are necessary to prescribe, dispense,
deliver, distribute, administer or remove a prescription contraceptive.
(2) The coverage required by subsection
(1) of this section may be subject to provisions of the program, plan or policy
that apply equally to other prescription drugs covered by the program, plan or
policy, including but not limited to required copayments, deductibles and
coinsurance.
(3) As used in this section, contraceptive
means a drug or device approved by the United States Food and Drug
Administration to prevent pregnancy.
(4) A religious employer is exempt from
the requirements of this section with respect to a prescription drug benefit
program or a health benefit plan it provides to its employees. A religious
employer is an employer:
(a) Whose purpose is the inculcation of
religious values;
(b) That primarily employs persons who
share the religious tenets of the employer;
(c) That primarily serves persons who
share the religious tenets of the employer; and
(d) That is a nonprofit organization under
section 6033(a)(2)(A)(i) or (iii) of the Internal Revenue Code.
(5) This section is exempt from the
provisions of ORS 743A.001. [2007 c.182 §3]
Note: Section 13, chapter 182, Oregon Laws 2007,
provides:
Sec.
13. Section 3 of this 2007
Act [743A.066] and the amendments to ORS 750.055 and 750.333 by sections 8 to
12 of this 2007 Act apply to prescription drug benefit programs, health benefit
plans and student health insurance policies entered into, issued or renewed on
or after the effective date of this 2007 Act [January 1, 2008]. [2007 c.182 §13]
Note: 743A.066 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
743A.068
Orally administered anticancer medication. (1) A health benefit plan that provides coverage for cancer
chemotherapy treatment must provide coverage for a prescribed, orally
administered anticancer medication used to kill or slow the growth of cancerous
cells on a basis no less favorable than intravenously administered or injected
cancer medications that are covered as medical benefits.
(2) As used in this section, health
benefit plan has the meaning given that term in ORS 743.730.
(3) The provisions of ORS 743A.001 do not
apply to this section. [2007 c.566 §2]
Note: Section 8, chapter 566, Oregon Laws 2007,
provides:
Sec.
8. Section 2 of this 2007
Act [743A.068] applies to health benefit plan policies issued or renewed on or
after the effective date of this 2007 Act [January 1, 2008]. [2007 c.566 §8]
Note: 743A.068 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
743A.070
Nonprescription enteral formula for home use. (1) All policies providing health insurance, as defined in ORS
731.162, except those policies whose coverage is limited to expenses from
accidents or specific diseases that are unrelated to the coverage required by
this section, shall include coverage for a nonprescription elemental enteral
formula for home use, if the formula is medically necessary for the treatment
of severe intestinal malabsorption and a physician has issued a written order
for the formula and the formula comprises the sole source, or an essential
source, of nutrition.
(2) The coverage required by subsection
(1) of this section may be made subject to provisions of the policy that apply
to other benefits under the policy including, but not limited to, provisions
related to deductibles and coinsurance. Deductibles and coinsurance for
elemental enteral formulas shall be no greater than those for any other
treatment for the condition under the policy. [Formerly 743.729]
Note: See 743A.001.
743A.080
Pregnancy and childbirth expenses. All health benefit plans as defined in ORS 743.730 must provide
payment or reimbursement for expenses associated with pregnancy care, as
defined by ORS 743.845, and childbirth. Benefits provided under this section
shall be extended to all enrollees, enrolled spouses and enrolled dependents. [Formerly
743.693]
743A.084
Unmarried women and their children. Each policy of health insurance shall provide:
(1) The same payments for costs of
maternity to unmarried women that it provides to married women, including the
wives of insured persons choosing family coverage; and
(2) The same coverage for the child of an
unmarried woman that the child of an insured married person choosing family
coverage receives. [Formerly 743.721]
743A.088
Use by mother of diethylstilbestrol. No policy of health insurance may be denied or canceled by the insurer
solely because the mother of the insured used drugs containing diethylstilbestrol
prior to the insureds birth. [Formerly 743.710]
743A.090
Newly born and adopted children. (1) All individual and group health insurance policies providing
hospital, medical or surgical expense benefits that include coverage for a
family member of the insured shall also provide that the health insurance
benefits applicable for children in the family shall be payable with respect
to:
(a) A newly born child of the insured from
the moment of birth; and
(b) An adopted child effective upon placement
for adoption.
(2) The coverage of newly born and adopted
children required by subsection (1) of this section shall consist of coverage
of injury or sickness, including the necessary care and treatment of medically
diagnosed congenital defects and birth abnormalities.
(3) If payment of a specific premium is
required to provide coverage for a child, the policy may require that
notification of the birth of the child or of the placement for adoption of the
child and payment of the premium be furnished the insurer within 31 days after
the date of birth or date of placement in order to have the coverage extended
beyond the 31-day period.
(4) The following requirements apply to
coverage of an adopted child required by subsection (1)(b) of this section:
(a) In any case in which a policy provides
coverage for dependent children of participants or beneficiaries, the policy
shall provide benefits to dependent children placed with participants or
beneficiaries for adoption under the same terms and conditions as apply to the
natural, dependent children of the participants and beneficiaries, regardless
of whether the adoption has become final.
(b) A policy may not restrict coverage of
any dependent child adopted by a participant or beneficiary, or placed with a
participant or beneficiary for adoption, solely on the basis of a preexisting
condition of the child at the time that the child would otherwise become
eligible for coverage under the plan if the adoption or placement for adoption
occurs while the participant or beneficiary is eligible for coverage under the
plan.
(5) As used in this section:
(a) Child means, in connection with any
adoption, or placement for adoption of the child, an individual who has not
attained 18 years of age as of the date of the adoption or placement for
adoption.
(b) Placement for adoption means the
assumption and retention by a person of a legal obligation for total or partial
support of a child in anticipation of the adoption of the child. The childs
placement with a person terminates upon the termination of such legal
obligations.
(6) The provisions of ORS 743A.001 do not
apply to this section. [Formerly 743.707]
743A.100
Mammogram. (1) Every health
insurance policy that covers hospital, medical or surgical expenses, other than
coverage limited to expenses from accidents or specific diseases, shall provide
coverage of mammograms as follows:
(a) Mammograms for the purpose of
diagnosis in symptomatic or high-risk women at any time upon referral of the
womans health care provider; and
(b) An annual mammogram for the purpose of
early detection for a woman 40 years of age or older, with or without referral
from the womans health care provider.
(2) An insurance policy described in
subsection (1) of this section must not limit coverage of mammograms to the
schedule provided in subsection (1) of this section if the woman is determined
by her health care provider to be at high risk for breast cancer. [Formerly
743.727]
743A.104
Pelvic examinations and Pap smear examinations. All policies providing health insurance,
except those policies whose coverage is limited to expenses from accidents or
specific diseases that are unrelated to the coverage required by this section,
shall include coverage for pelvic examinations and Pap smear examinations as
follows:
(1) Annually for women 18 to 64 years of
age; and
(2) At any time upon referral of the womans
health care provider. [Formerly 743.728]
743A.108
Physical examination of breast.
(1) A health insurance policy that covers hospital, medical or surgical
expenses, other than coverage limited to expenses from accidents or specific
diseases, shall provide coverage for a complete and thorough physical
examination of the breast, including but not limited to a clinical breast
examination, performed by a health care provider to check for lumps and other
changes for the purpose of early detection and prevention of breast cancer as
follows:
(a) Annually for women 18 years of age and
older; and
(b) At any time at the recommendation of
the womans health care provider.
(2) An insurance policy must provide
coverage of physical examinations of the breast as described in subsection (1)
of this section regardless of whether a health care provider performs other
preventative womens health examinations or makes a referral for other
preventative womens health examinations at the same time the health care
provider performs the breast examination.
(3) This section applies to health care
service contractors, as defined in ORS 750.005, and trusts carrying out a
multiple employer welfare arrangement, as defined in ORS 750.301. [Formerly
743.791]
Note: 743A.108 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
743A.110
Mastectomy-related services.
(1) All insurers offering a health benefit plan as defined in ORS 743.730 shall
provide payment, coverage or reimbursement for the following mastectomy-related
services as determined by the attending physician and enrollee to be part of
the enrollees course or plan of treatment:
(a) All stages of reconstruction of the
breast on which a mastectomy was performed, including but not limited to nipple
reconstruction, skin grafts and stippling of the nipple and areola;
(b) Surgery and reconstruction of the
other breast to produce a symmetrical appearance;
(c) Prostheses;
(d) Treatment of physical complications of
the mastectomy, including lymphedemas; and
(e) Inpatient care related to the
mastectomy and post-mastectomy services.
(2) An insurer providing coverage under
subsection (1) of this section shall provide written notice describing the
coverage to the enrollee at the time of enrollment in the health benefit plan
and annually thereafter.
(3) A health benefit plan must provide a
single determination of prior authorization for all mastectomy-related services
covered under subsection (1) of this section that are part of the enrollees
course or plan of treatment.
(4) When an enrollee requests an external
review of an adverse decision by the insurer regarding services described in
subsection (1) of this section, the insurer must expedite the enrollees case
pursuant to ORS 743.857 (4).
(5) The coverage required under subsection
(1) of this section is subject to the same terms and conditions in the plan
that apply to other benefits under the plan.
(6) This section is exempt from ORS
743A.001. [Formerly 743.691]
743A.120
Prostate screening examinations. (1) An insurer offering a health insurance policy that covers
hospital, medical or surgical expenses, other than coverage limited to expenses
from accidents or specific diseases, shall provide coverage for prostate cancer
screening examinations including a digital rectal examination and a
prostate-specific antigen test:
(a) For men who are 50 years of age or
older biennially or as determined by the treating physician; and
(b) For men younger than 50 years of age
who are at high risk for prostate cancer as determined by the treating
physician, including African-American men and men with a family medical history
of prostate cancer.
(2) Health care service contractors, as
defined in ORS 750.005, and trusts carrying out a multiple employer welfare
arrangement, as defined in ORS 750.301, are subject to subsection (1) of this
section. [Formerly 743.794]
Note: See 743A.001.
743A.124
Colorectal cancer screenings and laboratory tests. (1) An insurer offering a health insurance
policy that covers hospital, medical or surgical expenses, other than coverage
limited to expenses from accidents or specific diseases, shall provide coverage
for the following colorectal cancer screening examinations and laboratory
tests:
(a) For an insured 50 years of age or
older:
(A) One fecal occult blood test per year
plus one flexible sigmoidoscopy every five years;
(B) One colonoscopy every 10 years; or
(C) One double contrast barium enema every
five years.
(b) For an insured who is at high risk for
colorectal cancer, colorectal cancer screening examinations and laboratory
tests as recommended by the treating physician.
(2) For the purposes of subsection (1)(b)
of this section, an individual is at high risk for colorectal cancer if the
individual has:
(a) A family medical history of colorectal
cancer;
(b) A prior occurrence of cancer or
precursor neoplastic polyps;
(c) A prior occurrence of a chronic
digestive disease condition such as inflammatory bowel disease, Crohns disease
or ulcerative colitis; or
(d) Other predisposing factors.
(3) Health care service contractors, as
defined in ORS 750.005, and trusts carrying out a multiple employer welfare
arrangement, as defined in ORS 750.301, are also subject to this section. [Formerly
743.799]
Note: See 743A.001.
Note: 743A.124 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
743A.140
Bilateral cochlear implants.
(1) Whenever any policy of health insurance provides for reimbursement of a
cochlear implant, the insured under the policy is entitled to coverage of
bilateral cochlear implants.
(2) For purposes of ORS 746.230, a
reasonable investigation of a claim for bilateral cochlear implants must
include a request to the treating surgeon for a written recommendation based on
peer-reviewed medical literature and for the medical findings that support the
recommendation.
(3) The provisions of this section apply
to a health benefit plan as defined in ORS 743.730.
(4) The provisions of this section are
exempt from ORS 743A.001. [2007 c.504 §2]
Note: Section 8, chapter 504, Oregon Laws 2007,
provides:
Sec.
8. Section 2 of this 2007
Act [743A.140] and the amendments to ORS 750.055 and 750.333 by sections 3 to 7
of this 2007 Act apply to policies or certificates issued or renewed on or
after the effective date of this 2007 Act [January 1, 2008]. [2007 c.504 §8]
Note: 743A.140 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
743A.144
Prosthetic and orthotic devices. (1) All individual and group health insurance policies providing
coverage for hospital, medical or surgical expenses shall include coverage for
prosthetic and orthotic devices that are medically necessary to restore or
maintain the ability to complete activities of daily living or essential
job-related activities and that are not solely for comfort or convenience. The
coverage required by this subsection includes all services and supplies
medically necessary for the effective use of a prosthetic or orthotic device,
including formulating its design, fabrication, material and component selection,
measurements, fittings, static and dynamic alignments, and instructing the
patient in the use of the device.
(2) As used in this section:
(a) Orthotic device means a rigid or
semirigid device supporting a weak or deformed leg, foot, arm, hand, back or
neck, or restricting or eliminating motion in a diseased or injured leg, foot,
arm, hand, back or neck.
(b) Prosthetic device means an
artificial limb device or appliance designed to replace in whole or in part an
arm or a leg.
(3) The Director of the Department of
Consumer and Business Services shall adopt and annually update rules listing
the prosthetic and orthotic devices covered under this section. The list shall
be no more restrictive than the list of prosthetic and orthotic devices and supplies
in the Medicare fee schedule for Durable Medical Equipment, Prosthetics,
Orthotics and Supplies, but only to the extent consistent with this section.
(4) The coverage required by subsection
(1) of this section may be made subject to, and no more restrictive than, the
provisions of a health insurance policy that apply to other benefits under the
policy.
(5) The coverage required by subsection
(1) of this section shall include any repair or replacement of a prosthetic or
orthotic device that is determined medically necessary to restore or maintain
the ability to complete activities of daily living or essential job-related
activities and that is not solely for comfort or convenience.
(6) If coverage under subsection (1) of
this section is provided through a managed care plan, the insured shall have
access to medically necessary clinical care and to prosthetic and orthotic
devices and technology from not less than two distinct Oregon prosthetic and
orthotic providers in the managed care plans provider network. [2007 c.374 §2]
Note: See 743A.001.
Note: 743A.144 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further explanation.
743A.148
Maxillofacial prosthetic services. (1) The Legislative Assembly declares that all group health insurance
policies providing hospital, medical or surgical expense benefits include
coverage for maxillofacial prosthetic services considered necessary for
adjunctive treatment.
(2) As used in this section, maxillofacial
prosthetic services considered necessary for adjunctive treatment means
restoration and management of head and facial structures that cannot be
replaced with living tissue and that are defective because of disease, trauma
or birth and developmental deformities when such restoration and management are
performed for the purpose of:
(a) Controlling or eliminating infection;
(b) Controlling or eliminating pain; or
(c) Restoring facial configuration or
functions such as speech, swallowing or chewing but not including cosmetic
procedures rendered to improve on the normal range of conditions.
(3) The coverage required by subsection
(1) of this section may be made subject to provisions of the policy that apply
to other benefits under the policy including, but not limited to, provisions
relating to deductibles and coinsurance.
(4) The services described in this section
shall apply to individual health policies entered into or renewed on or after
January 1, 1982. [Formerly 743.706]
743A.160
Alcoholism treatment. A
health insurance policy providing coverage for hospital or medical expenses not
limited to expenses from accidents or specified sicknesses shall provide, at
the request of the applicant, coverage for expenses arising from treatment for
alcoholism. The following conditions apply to the requirement for such
coverage:
(1) The applicant shall be informed of the
applicants option to request this coverage.
(2) The inclusion of the coverage may be
made subject to the insurers usual underwriting requirements.
(3) The coverage may be made subject to
provisions of the policy that apply to other benefits under the policy,
including but not limited to provisions relating to deductibles and
coinsurance.
(4) The policy may limit hospital expense
coverage to treatment provided by the following facilities:
(a) A health care facility licensed as
required by ORS 441.015.
(b) A health care facility accredited by
the Joint Commission on Accreditation of Hospitals.
(5) Except as permitted by subsection (3)
of this section, the policy shall not limit payments thereunder for alcoholism
to an amount less than $4,500 in any 24-consecutive month period and the policy
shall provide coverage, within the limits of this subsection, of not less than
80 percent of the hospital and medical expenses for treatment for alcoholism. [Formerly
743.412]
Note: See 743.402.
743A.164
Injuries resulting from alcohol and controlled substances. A health insurance policy other than a
disability income policy shall provide coverage or reimbursement of expenses
for the medical treatment of injuries or illnesses caused in whole or in part
by the insureds use of alcohol or a controlled substance to the same extent as
and subject to limitations no more restrictive than those imposed on coverage
or reimbursement of expenses arising from treatment of injuries or illnesses
not caused by an insureds use of alcohol or a controlled substance. [Formerly
743.480]
Note: Section 4, chapter 128, Oregon Laws 2007,
provides:
Sec.
4. The amendments to ORS
743.480 [renumbered 743A.164] by section 1 of this 2007 Act do not apply to a
policy, contract, subscriber agreement, rider or indorsement delivered or
issued for delivery in this state by an insurer before the effective date of
this 2007 Act [January 1, 2008]. However, the amendments to ORS 743.480 by
section 1 of this 2007 Act apply to a new, and to a renewal or extension of an
existing, policy, contract, subscriber agreement, rider or indorsement
delivered or issued for delivery in this state by an insurer on or after the
effective date of this 2007 Act. [2007 c.128 §4]
Note: See 743.402 and 743A.001.
743A.168
Treatment of chemical dependency, including alcoholism, and mental or nervous
conditions; rules. A group
health insurance policy providing coverage for hospital or medical expenses
shall provide coverage for expenses arising from treatment for chemical
dependency, including alcoholism, and for mental or nervous conditions at the
same level as, and subject to limitations no more restrictive than, those
imposed on coverage or reimbursement of expenses arising from treatment for
other medical conditions. The following apply to coverage for chemical
dependency and for mental or nervous conditions:
(1) As used in this section:
(a) Chemical dependency means the
addictive relationship with any drug or alcohol characterized by a physical or
psychological relationship, or both, that interferes on a recurring basis with
the individuals social, psychological or physical adjustment to common
problems. For purposes of this section, chemical dependency does not include
addiction to, or dependency on, tobacco, tobacco products or foods.
(b) Facility means a corporate or governmental
entity or other provider of services for the treatment of chemical dependency
or for the treatment of mental or nervous conditions.
(c) Group health insurer means an
insurer, a health maintenance organization or a health care service contractor.
(d) Program means a particular type or
level of service that is organizationally distinct within a facility.
(e) Provider means a person that has met
the credentialing requirement of a group health insurer, is otherwise eligible
to receive reimbursement for coverage under the policy and is:
(A) A health care facility;
(B) A residential program or facility;
(C) A day or partial hospitalization
program;
(D) An outpatient service; or
(E) An individual behavioral health or
medical professional authorized for reimbursement under
(2) The coverage may be made subject to
provisions of the policy that apply to other benefits under the policy,
including but not limited to provisions relating to deductibles and
coinsurance. Deductibles and coinsurance for treatment in health care
facilities or residential programs or facilities may not be greater than those
under the policy for expenses of hospitalization in the treatment of other
medical conditions. Deductibles and coinsurance for outpatient treatment may
not be greater than those under the policy for expenses of outpatient treatment
of other medical conditions.
(3) The coverage may not be made subject
to treatment limitations, limits on total payments for treatment, limits on
duration of treatment or financial requirements unless similar limitations or
requirements are imposed on coverage of other medical conditions. The coverage
of eligible expenses may be limited to treatment that is medically necessary as
determined under the policy for other medical conditions.
(4)(a) Nothing in this section requires
coverage for:
(A) Educational or correctional services
or sheltered living provided by a school or halfway house;
(B) A long-term residential mental health
program that lasts longer than 45 days;
(C) Psychoanalysis or psychotherapy
received as part of an educational or training program, regardless of diagnosis
or symptoms that may be present;
(D) A court-ordered sex offender treatment
program; or
(E) A screening interview or treatment
program under ORS 813.021.
(b) Notwithstanding paragraph (a)(A) of
this subsection, an insured may receive covered outpatient services under the
terms of the insureds policy while the insured is living temporarily in a
sheltered living situation.
(5) A provider is eligible for
reimbursement under this section if:
(a) The provider is approved by the
Department of Human Services;
(b) The provider is accredited for the
particular level of care for which reimbursement is being requested by the
Joint Commission on Accreditation of Hospitals or the Commission on
Accreditation of Rehabilitation Facilities;
(c) The patient is staying overnight at
the facility and is involved in a structured program at least eight hours per
day, five days per week; or
(d) The provider is providing a covered
benefit under the policy.
(6) Payments may not be made under this
section for support groups.
(7) If specified in the policy, outpatient
coverage may include follow-up in-home service or outpatient services. The
policy may limit coverage for in-home service to persons who are homebound
under the care of a physician.
(8) Nothing in this section prohibits a
group health insurer from managing the provision of benefits through common
methods, including but not limited to selectively contracted panels, health
plan benefit differential designs, preadmission screening, prior authorization
of services, utilization review or other mechanisms designed to limit eligible
expenses to those described in subsection (3) of this section.
(9) The Legislative Assembly has found
that health care cost containment is necessary and intends to encourage
insurance policies designed to achieve cost containment by ensuring that
reimbursement is limited to appropriate utilization under criteria incorporated
into such policies, either directly or by reference.
(10)(a) Subject to the patient or client
confidentiality provisions of ORS 40.235 relating to physicians, ORS 40.240
relating to nurse practitioners, ORS 40.230 relating to psychologists and ORS
40.250 and 675.580 relating to licensed clinical social workers, a group health
insurer may provide for review for level of treatment of admissions and
continued stays for treatment in health care facilities, residential programs
or facilities, day or partial hospitalization programs and outpatient services
by either group health insurer staff or personnel under contract to the group
health insurer, or by a utilization review contractor, who shall have the
authority to certify for or deny level of payment.
(b) Review shall be made according to
criteria made available to providers in advance upon request.
(c) Review shall be performed by or under
the direction of a medical or osteopathic physician licensed by the Oregon
Medical Board, a psychologist licensed by the State Board of Psychologist
Examiners or a clinical social worker licensed by the State Board of Clinical
Social Workers, in accordance with standards of the National Committee for
Quality Assurance or Medicare review standards of the Centers for Medicare and
Medicaid Services.
(d) Review may involve prior approval,
concurrent review of the continuation of treatment, post-treatment review or
any combination of these. However, if prior approval is required, provision
shall be made to allow for payment of urgent or emergency admissions, subject
to subsequent review. If prior approval is not required, group health insurers
shall permit providers, policyholders or persons acting on their behalf to make
advance inquiries regarding the appropriateness of a particular admission to a
treatment program. Group health insurers shall provide a timely response to
such inquiries. Noncontracting providers must cooperate with these procedures
to the same extent as contracting providers to be eligible for reimbursement.
(11) Health maintenance organizations may
limit the receipt of covered services by enrollees to services provided by or
upon referral by providers contracting with the health maintenance
organization. Health maintenance organizations and health care service
contractors may create substantive plan benefit and reimbursement differentials
at the same level as, and subject to limitations no more restrictive than,
those imposed on coverage or reimbursement of expenses arising out of other
medical conditions and apply them to contracting and noncontracting providers.
(12) Nothing in this section prevents a
group health insurer from contracting with providers of health care services to
furnish services to policyholders or certificate holders according to ORS 743.531
or 750.005, subject to the following conditions:
(a) A group health insurer is not required
to contract with all eligible providers.
(b) An insurer or health care service
contractor shall, subject to subsections (2) and (3) of this section, pay
benefits toward the covered charges of noncontracting providers of services for
the treatment of chemical dependency or mental or nervous conditions. The
insured shall, subject to subsections (2) and (3) of this section, have the
right to use the services of a noncontracting provider of services for the
treatment of chemical dependency or mental or nervous conditions, whether or
not the services for chemical dependency or mental or nervous conditions are
provided by contracting or noncontracting providers.
(13) The intent of the Legislative
Assembly in adopting this section is to reserve benefits for different types of
care to encourage cost effective care and to ensure continuing access to levels
of care most appropriate for the insureds condition and progress.
(14) The Director of the Department of
Consumer and Business Services, after notice and hearing, may adopt reasonable
rules not inconsistent with this section that are considered necessary for the
proper administration of these provisions. [Formerly 743.556]
Note: Section 7, chapter 411, Oregon Laws 1987,
provides:
Sec.
7. Application of ORS 743A.001 to ORS 743A.168 and 750.055. ORS 743.145 [renumbered 743A.001] does not
apply to section 2 of this Act [743A.168] because section 2 of this Act
constitutes a reenactment of ORS 743.557 and 743.558 [both repealed in 1987] or
to ORS 750.055 because of its amendment by this Act. [1987 c.411 §7]
743A.180
Tourette Syndrome. For
purpose of coverage by group health insurers, health care service contractors
and health maintenance organizations, reimbursement for treatment of Tourette
Syndrome shall be made on the basis of the diagnosis and treatment modality
employed. [Formerly 743.717]
Note: See 743A.001.
743A.184
Diabetes self-management programs. (1) Subject to other terms, conditions and benefits in the plan, group
health benefit plans as described in ORS 743.730 shall provide payment,
coverage or reimbursement for supplies, equipment and diabetes self-management
programs associated with the treatment of insulin-dependent diabetes,
insulin-using diabetes, gestational diabetes and noninsulin-using diabetes
prescribed by a health care professional legally authorized to prescribe such
items.
(2) As used in this section, diabetes
self-management program means one program of assessment and training after
diagnosis and no more than three hours per year of assessment and training upon
a material change of condition, medication or treatment that is provided by:
(a) An education program credentialed or
accredited by a state or national entity accrediting such programs; or
(b) A program provided by a physician
licensed under ORS chapter 677, a registered nurse, a nurse practitioner, a
certified diabetes educator or a licensed dietitian with demonstrated expertise
in diabetes. [Formerly 743.694]
Note: See 743A.001.
743A.188
Inborn errors of metabolism.
(1) All individual and group health insurance policies providing coverage for
hospital, medical or surgical expenses, other than coverage limited to expenses
from accidents or specific diseases, shall include coverage for treatment of
inborn errors of metabolism that involve amino acid, carbohydrate and fat
metabolism and for which medically standard methods of diagnosis, treatment and
monitoring exist, including quantification of metabolites in blood, urine or
spinal fluid or enzyme or DNA confirmation in tissues. Coverage shall include
expenses of diagnosing, monitoring and controlling the disorders by nutritional
and medical assessment, including but not limited to clinical visits,
biochemical analysis and medical foods used in the treatment of such disorders.
(2) As used in this section, medical
foods means foods that are formulated to be consumed or administered enterally
under the supervision of a physician, as defined in ORS 677.010, that are
specifically processed or formulated to be deficient in one or more of the
nutrients present in typical nutritional counterparts, that are for the medical
and nutritional management of patients with limited capacity to metabolize
ordinary foodstuffs or certain nutrients contained therein or have other
specific nutrient requirements as established by medical evaluation and that
are essential to optimize growth, health and metabolic homeostasis.
(3) This section is exempt from ORS
743A.001. [Formerly 743.726]
Note: 743A.188 is repealed July 3, 2009. See
section 2, chapter 263, Oregon Laws 2003.
743A.190
Children with pervasive developmental disorder. (1) A health benefit plan, as defined in ORS
743.730, must cover for a child enrolled in the plan who is under 18 years of
age and who has been diagnosed with a pervasive developmental disorder all
medical services, including rehabilitation services, that are medically
necessary and are otherwise covered under the plan.
(2) The coverage required under subsection
(1) of this section, including rehabilitation services, may be made subject to
other provisions of the health benefit plan that apply to covered services,
including but not limited to:
(a) Deductibles, copayments or
coinsurance;
(b) Prior authorization or utilization
review requirements; or
(c) Treatment limitations regarding the
number of visits or the duration of treatment.
(3) As used in this section:
(a) Medically necessary means in
accordance with the definition of medical necessity that is specified in the
policy, certificate or contract for the health benefit plan and that applies
uniformly to all covered services under the health benefit plan.
(b) Pervasive developmental disorder
means a neurological condition that includes Aspergers syndrome, autism,
developmental delay, developmental disability or mental retardation.
(c) Rehabilitation services means
physical therapy, occupational therapy or speech therapy services to restore or
improve function.
(4) The provisions of ORS 743A.001 do not
apply to this section.
(5) The definition of pervasive
developmental disorder is not intended to apply to coverage required under ORS
743A.168. [2007 c.872 §2]
Note: Section 8, chapter 872, Oregon Laws 2007,
provides:
Sec.
8. Section 2 of this 2007
Act [743A.190] applies to health benefit plan policies issued or renewed on or
after the effective date of this 2007 Act [January 1, 2008]. [2007 c.872 §8]
Note: 743A.190 was added to and made a part of the
Insurance Code by legislative action but was not added to ORS chapter 743A or
any series therein. See Preface to Oregon Revised Statutes for further
explanation.
Note: Section 2a, chapter 872, Oregon Laws 2007,
provides:
Sec.
2a. The Health Resources
Commission shall:
(1) Conduct a review of available medical
and behavioral health evidence on the treatment of pervasive developmental
disorders.
(2) In conducting its review, work with
the Public Employees Benefit Board, the Health Services Commission, the Department
of Human Services and the Department of Education.
(3) Report its findings and
recommendations to the Seventy-fifth Legislative Assembly in the manner
provided in ORS 192.245. [2007 c.872 §2a]
_______________
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