ORS Chapter 414 — Medical Assistance

ORS 414.780. Coordinated care organization reporting of data to assess compliance with mental health parity requirements; annual assessment. (1) As used in this section: (a) Behavioral health coverage means mental health treatment and services and substance use disorder treatment or services reimbursed by a coordinated care organization. (b) Coordinated care organization has the meaning given that term in ORS 414.025. (c) Mental health treatment and services means the treatment of or services provided to address any condition or disorder that falls under any of the diagnostic categories listed in the mental disorders section of the current edition of the: (A) International Classification of Disease; or (B) Diagnostic and Statistical Manual of Mental Disorders. (d) Nonquantitative treatment limitation means a limitation that is not expressed numerically but otherwise limits the scope or duration of behavioral health coverage, such as medical necessity criteria or other utilization review. (e) Substance use disorder treatment and services means the treatment of and any services provided to address any condition or disorder that falls under any of the diagnostic categories listed in the substance use section of the current edition of the: (A) International Classification of Disease; or (B) Diagnostic and Statistical Manual of Mental Disorders. (2) No later than March 1 of each calendar year, the Oregon Health Authority shall prescribe the form and manner for each coordinated care organization to report to the authority, on or before June 1 of the calendar year, information about the coordinated care organizations compliance with mental health parity requirements, including but not limited to the following: (a) The specific plan or coverage terms or other relevant terms regarding the nonquantitative treatment limitations and a description of all mental health or substance use disorder benefits and medical or surgical benefits to which each such term applies in each respective benefits classification. (b) The factors used to determine that the nonquantitative treatment limitations will apply to mental health or substance use disorder benefits and medical or surgical benefits. (c) The evidentiary standards used for the factors identified in paragraph (b) of this subsection, when applicable, provided that every factor is defined, and any other source or evidence relied upon to design and apply the nonquantitative treatment limitations to mental health or substance use disorder benefits and medical or surgical benefits. (d) The number of denials of coverage of mental health treatment and services, substance use disorder treatment and services and medical and surgical treatment and services, the percentage of denials that were appealed, the percentage of appeals that upheld the denial and the percentage of appeals that overturned the denial. (e) The percentage of claims for behavioral health coverage and for coverage of medical and surgical treatments that were paid to in-network providers and the percentage of such claims that were paid to out-of-network providers. (f) Other data or information the authority deems necessary to assess a coordinated care organizations compliance with mental health parity requirements. (3) Coordinated care organizations must demonstrate in the documentation submitted under subsection (2) of this section, that the processes, strategies, evidentiary standards and other factors used to apply nonquantitative treatment limitation to mental health or substance use disorder treatment, as written and in operation, are comparable to and are applied no more stringently that the processes, strategies, evidentiary standards and other factors used to apply nonquantitative treatment limitations to medical or surgical treatments in the same classification. (4) Each calendar year the authority, in collaboration with individuals representing behavioral health treatment providers, community mental health programs, coordinated care organizations, the Consumer Advisory Council established in ORS 430.073 and consumers of mental health or substance use disorder treatment, shall, based on the information reported under subsection (2) of this section, identify and assess: (a) Coordinated care organizations compliance with the requirements for parity between the behavioral health coverage and the coverage of medical and surgical treatment in the medical assistance program; and (b) The authoritys compliance with the requirements for parity between the behavioral health coverage and the coverage of medical and surgical treatment in the medical assistance program for individuals who are not enrolled in a coordinated care organization. (5) No later than December 31 of each calendar year, the authority shall submit a report to the interim committees of the Legislative Assembly related to mental or behavioral health, in the manner provided in ORS 192.245, that includes: (a) The authoritys findings under subsection (4) of this section on compliance with rules regarding mental health parity, including a comparison of coverage for members of coordinated care organizations to coverage for medical assistance recipients who are not enrolled in coordinated care organizations as applicable; and (b) An assessment of: (A) The adequacy of the provider network as prescribed by the authority by rule. (B) The timeliness of access to mental health and substance use disorder treatment and services, as prescribed by the authority by rule. (C) The criteria used by each coordinated care organization to determine medical necessity and behavioral health coverage, including each coordinated care organizations payment protocols and procedures. (D) Data on services that are requested but that coordinated care organizations are not required to provide. (E) The consistency of credentialing requirements for behavioral health treatment providers with the credentialing of medical and surgical treatment providers. (F) The utilization review, as defined by the authority by rule, applied to behavioral health coverage compared to coverage of medical and surgical treatments. (G) The specific findings and conclusions reached by the authority with respect to the coverage of mental health and substance use disorder treatment and the authoritys analysis that indicates that the coverage is or is not in compliance with this section. (H) The specific findings and conclusions of the authority demonstrating a coordinated care organizations compliance with this section and with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (P.L. 110-343) and rules adopted thereunder. (6) Except as provided in subsection (5)(b)(D) of this section, this section does not require coordinated care organizations to report data on services that are not funded on the prioritized list of health services compiled by the Health Evidence Review Commission under ORS 414.690. [2021 c.629 3] Note: