Oregon Revised Statutes
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section, any statute described in subsection (2) of this section that becomes effective on or after July 13, 1985, is repealed on the sixth anniversary of the effective date of the statute, unless the Legislative Assembly specifically provides otherwise. This section governs any statute that applies to individual…
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 Oregon or any state approved community mental health program or community developmental disabilities program.
As used in this section: “Behavioral health assessment” means an evaluation by a behavioral health clinician, in person or using telemedicine, to determine a patient’s need for immediate crisis stabilization. “Behavioral health clinician” means: A licensed psychiatrist; A licensed psychologist; A licensed nurse practitioner with a specialty in psychiatr…
As used in this section, “health benefit plan” has the meaning given that term in ORS 743B.005. Notwithstanding ORS 743.543, with respect to a health benefit plan or a Medicare supplement insurance policy that provides coverage for ambulance care and transportation, the insurer shall indemnify directly the provider of the ambulance care and transportation. …
As used in this section: “Health benefit plan” has the meaning given that term in ORS 743B.005. “Osteopathic physician” means a person who holds a degree of Doctor of Osteopathic Medicine and is licensed under ORS 677.100 to 677.228. An insurer that offers a health benefit plan that reimburses the cost of an osteopathic manipulative treatment provided by …
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. The coverage required by subsection (1) of this section may be made subject to provisions of the policy that apply to othe…
Whenever any individual or group health insurance policy or blanket health insurance policy described in ORS 743.536 (3) provides for payment or reimbursement for any service within the lawful scope of service of a clinical social worker licensed under ORS 675.530: The insured under the policy shall be entitled to the services of a clinical social worker li…
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 de…
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 dentist’s license is compensable if performance of that service by a physician acting within the scope of the physician’s license …
If a policy of insurance covering dental health provides for coverage for services performed by a dentist licensed under ORS chapter 679, the policy must also cover the services when they are performed by an expanded practice dental hygienist, as defined in ORS 679.010, who has entered into a provider contract with the insurer. The provisions of ORS 743A.00…
Whenever any policy of health insurance provides for reimbursement for a primary care or mental health service provided by a licensed physician, the insured under the policy is entitled to reimbursement for such service if provided by a licensed physician associate or a licensed nurse practitioner if the service is within the lawful scope of practice of the …
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 th…
An insurer may not refuse a claim solely on the ground that the claim was submitted by a physician associate rather than by a physician, podiatric physician or employer with whom the physician associate has entered into a collaboration agreement, as defined in ORS 677.495. This section is exempt from ORS 743A.001.
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: The insured under such policy or contract shall be free to select, and shall have direct access to, a psychologist licensed under…
Notwithstanding any provisions of a health benefit plan as defined in ORS 743B.005, whenever the plan provides for payment or reimbursement for a service that is within the lawful scope of practice of a pharmacist, the insurer: May provide payment or reimbursement for the service when the service is provided by a pharmacist; and Shall provide, in the same …
If a group health benefit plan, as described in ORS 743B.005, provides for coverage for services performed by a clinical social worker or nurse practitioner, the plan also must cover services provided by a professional counselor or marriage and family therapist licensed under ORS 675.715 to 675.835 when the counselor or therapist is acting within the counsel…
As used in this section: “Audio only” means the use of audio telephone technology, permitting real-time communication between a health care provider and a patient for the purpose of diagnosis, consultation or treatment. “Audio only” does not include: The use of facsimile, electronic mail or text messages. The delivery of health services that are customar…
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 interna…
As used in this section: “Conflict of interest” means: Present employment, ownership or control by a covered entity, pharmaceutical manufacturer, pharmacy benefit manager or health benefit plan as defined in ORS 743B.005; or Third party employment, ownership or control by a covered entity, pharmaceutical manufacturer, pharmacy benefit manager or health be…
A prescription drug benefit program, or a prescription drug benefit offered under a health benefit plan as defined in ORS 743B.005, must provide for reimbursement for up to a 90-day supply of a prescription drug dispensed by a pharmacy, as defined in ORS 689.005, if: The prescription drug is covered by the program or plan; An initial 30-day supply of the p…
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 medi…
An insurer offering a health benefit plan, as defined in ORS 743B.005, that provides coverage of prescription eye drops shall provide coverage for one early refill of a prescription for eye drops to treat glaucoma if all of the following criteria are met: The refill is requested by an insured less than 30 days after the later of: The date the original pres…
A prescription drug benefit program, or a prescription drug benefit offered under a health benefit plan as defined in ORS 743B.005 or under a student health insurance policy, must provide payment, coverage or reimbursement for: Prescription contraceptives; and If covered for other drug benefits under the program, plan or policy, outpatient consultations, i…
As used in this section: “Contraceptives” means health care services, drugs, devices, products or medical procedures to prevent a pregnancy. “Enrollee” means an insured individual and the individual’s spouse, domestic partner and dependents who are beneficiaries under the insured individual’s health benefit plan. “Health benefit plan” has the meaning give…
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. As used in this s…
As used in this section: “Health benefit plan” has the meaning given that term in ORS 743B.005. “Insulin” has the meaning given that term in ORS 689.696. A health benefit plan offered in this state may not require an enrollee in the plan to incur cost-sharing or other out-of-pocket costs that exceed $35 for each 30-day supply of a type of insulin prescrib…
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 trea…
As used in this section, “carrier,” “enrollee” and “health benefit plan” have the meanings given those terms in ORS 743B.005. A health benefit plan offered in this state must reimburse in full the cost to a provider of delivering universal newborn nurse home visiting services, as prescribed by the Oregon Health Authority by rule under ORS 433.301 (7) and (8…
As used in this section, “pregnancy care” means the care necessary to support a healthy pregnancy and care related to labor and delivery. All health benefit plans as defined in ORS 743B.005 must provide payment or reimbursement for expenses associated with pregnancy care and childbirth. Benefits provided under this section shall be extended to all enrollees…
As used in this section: “Doula” has the meaning given that term in ORS 414.667. “Lactation counselor” and “lactation educator” have the meanings given those terms in ORS 676.665. A health benefit plan, as defined in ORS 743B.005, in this state that reimburses the cost of pregnancy and childbirth expenses shall provide coverage for services provided by do…
Except as provided in subsections (2) and (3) of this section, a health benefit plan, as defined in ORS 743B.005, may not require a copayment or impose a coinsurance requirement or a deductible on the covered health services, medications and supplies that are medically necessary for a woman to manage her diabetes during the period of each pregnancy, beginnin…
Each policy of health insurance shall provide: The same payments for costs of maternity to unmarried women that it provides to married women, including the spouses in marriages of insured persons choosing family coverage; and The same coverage for the child of an unmarried woman that the child of an insured married person choosing family coverage receives.
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 insured’s birth.
All individual and group health benefit plans, as defined in ORS 743B.005, 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 child of the insured from the moment of birth; and An adopted child effective upon placement for a…
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: Mammograms for the purpose of diagnosis in symptomatic or high-risk individuals at any time upon referral of an individual’s health care provider; and …
As used in this section: “Diagnostic breast examination” means an examination used to evaluate an abnormality of the breast that is detected or suspected from a screening examination for breast cancer or by any other means of examination using: Diagnostic mammography; Breast magnetic resonance imaging; or Breast ultrasound. “Supplemental breast examinat…
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: Annually for individuals 18 to 64 years of age; and At any time upon refer…
All health benefit plans, as defined in ORS 743B.005, shall include coverage of the human papillomavirus vaccine for beneficiaries under the health benefit plan who are at least 11 years of age but no older than 26 years of age. ORS 743A.001 does not apply to this section. Note: 743A.105 was added to and made a part of the Insurance Code by legislative act…
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…
As used in this section, “mastectomy” means the surgical removal of all or part of a breast or a breast tumor suspected to be malignant. All insurers offering a health benefit plan as defined in ORS 743B.005 shall provide payment, coverage or reimbursement for mastectomy and for the following services related to a mastectomy as determined by the attending p…
The Department of Consumer and Business Services shall make written materials available on the department’s website to educate breast cancer patients about the availability of insurance coverage for breast reconstruction surgery and breast prostheses following a mastectomy. The department shall update the materials at least annually. The department shall pl…
As used in this section: “Accepted standard of care” means standards of care and clinical practice guidelines that are: Generally recognized by health care providers practicing in relevant clinical specialties; and Based on valid, evidence-based sources. “Autologous breast reconstruction procedure” includes but is not limited to: Superior gluteal artery…
All health benefit plans, as defined in ORS 743B.005, shall include coverage of the treatment of perimenopause, menopause and postmenopause, including but not limited to the following: Hormone therapy including combination estrogen and hormone medicines, combination estrogen and progesterone medicines and estrogen-only medicines; SSRIs and SNRIs; Vaginal …
A health benefit plan, as defined in ORS 743B.005, shall provide coverage for all colorectal cancer screening examinations and laboratory tests assigned either a grade of A or a grade of B by the United States Preventive Services Task Force. If an insured is 50 years of age or older, an insurer may not impose cost sharing on the coverage required by subsect…
A health benefit plan, as defined in ORS 743B.005, that provides coverage of radiation therapy for the treatment of prostate cancer must provide coverage for proton beam therapy for the treatment of prostate cancer on a basis no less favorable than the coverage of radiation therapy including with respect to prior authorization or other utilization review req…
A health benefit plan, as defined in ORS 743B.005, shall reimburse the cost of: Bilateral cochlear implants if medically appropriate for the treatment of hearing loss; and The fitting, programming and reprogramming of bilateral or unilateral cochlear implants or other assistive listening devices performed by licensed audiologists. For purposes of ORS 746.…
As used in this section: “Assistive listening device” means devices used with or without hearing aids or cochlear implants to provide access to sound or improve the ability of a user with hearing loss to hear in various listening situations, such as being located a distance from a speaker, in an environment with competing background noise or in a room with …
As used in this section: “Device” means: An orthotic device. A prosthetic device. “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. “Prosthetic device” means an artificial limb device or ap…
The Legislative Assembly declares that all group health insurance policies providing hospital, medical or surgical expense benefits, other than limited benefit coverage, include coverage for maxillofacial prosthetic services considered necessary for adjunctive treatment. As used in this section, “maxillofacial prosthetic services considered necessary for ad…
As used in this section, “craniofacial anomaly” means a physical disorder identifiable at birth that affects the bony structures of the face or head, including but not limited to cleft palate, cleft lip, craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. All health benefit plans, as defined in ORS 743B.005, providing coverage of hospit…
A health insurance policy providing coverage for hospital or medical expenses, other than limited benefit coverage, 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: The applicant shall be informed of the applicant’s option to requ…
As used in this section: “Behavioral health assessment” means an evaluation by a provider, in person or using telemedicine, to determine a patient’s need for behavioral health treatment. “Behavioral health condition” has the meaning prescribed by rule by the Department of Consumer and Business Services. “Behavioral health crisis” means a disruption in an …
As used in this section: “Behavioral health home” means an entity providing behavioral health services that the Oregon Health Authority has found to meet the core attributes established under ORS 413.259 for a behavioral health home. “Patient centered primary care home” means an entity providing health care services that the authority has found to meet the…
A health benefit plan as defined in ORS 743B.005 must provide payment, coverage or reimbursement of at least $500 for a tobacco use cessation program for a person enrolled in the plan who is 15 years of age or older. As used in this section, “tobacco use cessation program” means a program recommended by a physician that follows the United States Public Heal…
As used in this section: “Group health insurance” has the meaning given that term in ORS 731.098. “Health benefit plan” has the meaning given that term in ORS 743B.005. “Substance use disorder” has the meaning given that term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association…
A health benefit plan, as defined in ORS 743B.005, shall provide coverage of medically necessary therapy and services for the treatment of traumatic brain injury. This section is exempt from ORS 743A.001.
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. Note: See 743A.001.
As used in this section: “Health benefit plan” has the meaning given that term in ORS 743B.005. “Originating site” means a location where health services are provided or where the patient is receiving a telemedical health service. “Telemedical” means delivered through a two-way electronic communication, including but not limited to video, audio, Voice ove…
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 …
A health benefit plan, as defined in ORS 743B.005, 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. The coverage required under subsection (…
A health benefit plan, as defined in ORS 743B.005: Shall provide coverage for the routine costs of the care of patients enrolled in and participating in approved clinical trials; May not exclude, limit or impose additional conditions on the coverage of the routine costs for items and services furnished in connection with participation in an approved clinic…
As used in this section: “Eye care practitioner” means an optometrist or ophthalmologist licensed by the State of Oregon. “Eye care services” means health care services related to the care of the eye and related structures as specified by a health benefit plan. “Health benefit plan” has the meaning provided for that term in ORS 743B.005. Any insurer that…
As used in this section: “Child abuse assessment” has the meaning given that term in ORS 418.782. “Children’s advocacy center” has the meaning given that term in ORS 418.782. “Forensic interview” has the meaning given that term in ORS 418.782. “Health benefit plan” has the meaning given that term in ORS 743B.005. A health benefit plan shall provide paym…
As used in this section: “Detainee” means an insured who is: In the custody of a local supervisory authority pending the disposition of charges; or In a detention facility pending final adjudication by a juvenile court. “Detention facility” has the meaning given that term in ORS 419A.004. “Health benefit plan” has the meaning given that term in ORS 743B…
Notwithstanding any other provision of law, a health benefit plan that is not a grandfathered health plan: Must provide coverage of preventive health services as prescribed by the United States Department of Health and Human Services pursuant to 42 U.S.C. 300gg-13 in rules adopted and in effect on January 1, 2023; and May not impose cost-sharing requiremen…
As used in this section: “Condition of public health importance” has the meaning given that term in ORS 431A.005. “Disease outbreak” has the meaning given that term in ORS 431A.005. “Enrollee” means an individual residing in this state who: Is enrolled in a health benefit plan; and The Public Health Director determines may be affected by a disease outbr…
As used in this section, “primary care” means outpatient behavioral health services, nonspecialty medical services or the coordination of health care for the purpose of: Promoting or maintaining behavioral and physical health and wellness; and Diagnosis, treatment or management of acute or chronic conditions caused by disease, injury or illness. An indivi…
A health benefit plan, as defined in ORS 743B.005, must cover the cost of up to three monthly immunomodulatory courses of intravenous immunoglobulin therapy for the treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, when the following conditions have been …
As used in this section: “Carrier” has the meaning given that term in ORS 743B.005. “Gender-affirming treatment” means a procedure, service, drug, device or product that a physical or behavioral health care provider prescribes to treat an individual for incongruence between the individual’s gender identity and the individual’s sex assignment at birth. “He…
An insurer that offers a health benefit plan, as defined in ORS 743B.005, that reimburses the cost of counseling, prevention services or screening for sexually transmitted infections, shall provide coverage for: Drugs that have been approved by the United States Food and Drug Administration for the prevention of human immunodeficiency virus; Services neces…