reglab/statecodes huggingface dataset:
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.063 - Ninety-day supply of prescription drug refills.

(1) 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:
(a) The prescription drug is covered by the program or plan;
(b) An initial 30-day supply of the prescription drug has been previously dispensed to the program or plan member; and
(c) The quantity of the prescription drug dispensed does not exceed the total remaining quantity of the prescription drug that the prescribing practitioner authorized to be dispensed through refills.
(2) The coverage required by subsection (1) of this section may be limited by the terms and conditions of a pharmacy network contract, or a prescription drug benefit program or health benefit plan, that are related to the reimbursement rate of the prescription drug.
(3) The coverage required by subsection (1) of this section may be limited by formulary restrictions that are related to the prescription drug.
(4) This section does not apply to the reimbursement of prescription drugs classified as a controlled substance in Schedule II.
(5) This section is exempt from ORS 743A.001. [2015 c.661 §2]
Note:
743A.063 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.065 - Early refills of prescription eye drops for treatment of glaucoma.

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:
(1) The refill is requested by an insured less than 30 days after the later of:
(a) The date the original prescription was dispensed to the insured; or
(b) The date that the last refill of the prescription was dispensed to the insured.
(2) The prescriber indicates on the original prescription that a specific number of refills will be needed.
(3) The refill does not exceed the number of refills that the prescriber indicated under subsection (2) of this section.
(4) The prescription has not been refilled more than once during the 30-day period prior to the request for an early refill. [2011 c.660 §25]
Note:
See 743A.001.
Note:
743A.065 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.066 - Contraceptives.

(1) 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:
(a) Prescription contraceptives; and
(b) If covered for other drug benefits under the program, plan or policy, outpatient consultations, including pharmacist 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:
(a) 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; and
(b) Must reimburse a health care provider or dispensing entity for a dispensing of contraceptives intended to last for a:
(A) Three-month period for the first dispensing of the contraceptive to an insured; and
(B) Twelve-month period for subsequent dispensings of the same contraceptive to the insured regardless of whether the insured was enrolled in the program, plan or policy at the time of the first dispensing.
(3) As used in this section, "prescription contraceptive" means a drug or device that requires a prescription and is 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)(3)(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; 2015 c.412 §1; 2017 c.289 §4]
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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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 743B.005.
(3) The provisions of ORS 743A.001 do not apply to this section. [2007 c.566 §2]
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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.069 - Insulin.

(1) As used in this section:
(a) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(b) "Insulin" has the meaning given that term in ORS 689.696.
(2) 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, as adjusted under subsection (3) of this section, that exceed $75 for each 30-day supply of a type of insulin prescribed for the treatment of diabetes or $225 for each 90-day supply.
(3) The Department of Consumer and Business Services shall, by rule, annually adjust the maximum cost specified in subsection (2) of this section by the percentage increase, if any, in the cost of living for the previous calendar year, based on changes in the Consumer Price Index for All Urban Consumers, West Region (All Items), as published by the Bureau of Labor Statistics of the United States Department of Labor.
(4) The coverage under this section may not be subject to a deductible imposed by a health benefit plan.
(5) This section does not prohibit a health benefit plan from using a drug formulary or other utilization review protocol applicable to prescription drug coverage under the plan.
(6) This section is not subject to ORS 743A.001. [2021 c.160 §2]
Note:
743A.069 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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.
(3) This section is exempt from ORS 743A.001. [Formerly 743.729; 2009 c.703 §1]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.078 - Newborn nurse home visiting services.

(1) As used in this section, "carrier," "enrollee" and "health benefit plan" have the meanings given those terms in ORS 743B.005.
(2) 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).
(3) The coverage must be provided without any cost-sharing, coinsurance or deductible applicable to the services.
(4) Carriers must offer the services in their health benefit plans but enrollees are not required to receive the services as a condition of coverage and may not be penalized or in any way discouraged from declining the services.
(5) A carrier must notify an enrollee about the services whenever an enrollee adds a newborn to coverage.
(6) A carrier may use in-network providers or may contract with local public health authorities to provide the services.
(7) Carriers shall report to the authority, in the form and manner prescribed by the authority, data regarding claims submitted for services covered under this section to monitor the provision of the services.
(8) This section is exempt from ORS 743A.001. [2019 c.552 §3; 2022 c.94 §1]
Note:
743A.078 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.080 - Pregnancy and childbirth expenses.

(1) As used in this section, "pregnancy care" means the care necessary to support a healthy pregnancy and care related to labor and delivery.
(2) 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, enrolled spouses and enrolled dependents. [Formerly 743.693; 2011 c.500 §39]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.082 - Diabetes management for pregnant women.

(1) 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, beginning with conception and ending six weeks postpartum.
(2) Subsection (1) of this section does not apply to a high deductible health plan described in 26 U.S.C. 223.
(3) The coverage required by subsection (1) of this section may be limited by network and formulary restrictions that apply to other benefits under the plan. Subsection (1) of this section does not apply to services, medications, test strips and syringes that are not covered due to the network or formulary restrictions.
(4) An insurer may require an enrollee or the enrollee’s health care provider to notify the insurer orally, in a timely manner, that the enrollee is diabetic and is pregnant or has given birth and is within six weeks postpartum. [2013 c.682 §2; 2014 c.74 §1]
Note:
743A.082 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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 spouses in marriages 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; 2015 c.629 §61]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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 insured’s birth. [Formerly 743.710]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.100 - Mammograms.

(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 individuals at any time upon referral of an individual’s health care provider; and
(b) An annual mammogram for the purpose of early detection for an individual 40 years of age or older, with or without referral from the individual’s 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 individual is determined by the individual’s health care provider to be at high risk for breast cancer. [Formerly 743.727; 2017 c.152 §4]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.101 - Supplemental or diagnostic breast examinations.

(1) As used in this section:
(a) "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:
(A) Diagnostic mammography;
(B) Breast magnetic resonance imaging; or
(C) Breast ultrasound.
(b) "Supplemental breast examination" means an examination of the breast, such as breast magnetic resonance imaging or breast ultrasound, that is:
(A) Used to screen for breast cancer when there is no abnormality seen or suspected; and
(B) Based on personal or family medical history or other factors that increase an individual’s risk of breast cancer.
(2) Except as provided in ORS 742.008, a carrier offering a group health benefit plan or an individual health benefit plan in this state that reimburses the cost of supplemental or diagnostic breast examinations may not impose on the coverage of a medically necessary supplemental or diagnostic breast examination:
(a) A deductible;
(b) Coinsurance;
(c) A copayment; or
(d) Other out-of-pocket expenses. [2023 c.468 §2]
Note:
See 743A.001.
Note:
743A.101 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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 individuals 18 to 64 years of age; and
(2) At any time upon referral of an individual’s health care provider. [Formerly 743.728; 2017 c.152 §5]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.105 - HPV vaccine.

(1) 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.
(2) ORS 743A.001 does not apply to this section. [2009 c.630 §2; 2017 c.152 §6]
Note:
743A.105 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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 individuals 18 years of age and older; and
(b) At any time at the recommendation of an individual’s 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 health examinations or makes a referral for other preventative 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; 2017 c.152 §7]
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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.110 - Mastectomy-related services; expedited external review required.

(1) 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.
(2) 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 physician and enrollee to be part of the enrollee’s 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.
(3) An insurer providing coverage under subsection (2) 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.
(4) A health benefit plan must provide a single determination of prior authorization for all services related to a mastectomy covered under subsection (2) of this section that are part of the enrollee’s course or plan of treatment.
(5) When an enrollee requests an external review of an adverse benefit determination as defined in ORS 743B.001 by the insurer regarding services described in subsection (2) of this section, the insurer or the Director of the Department of Consumer and Business Services must expedite the enrollee’s case pursuant to ORS 743B.252 (5).
(6) The coverage required under subsection (2) of this section is subject to the same terms and conditions in the plan that apply to other benefits under the plan.
(7) This section is exempt from ORS 743A.001. [Formerly 743.691; 2011 c.208 §1; 2011 c.500 §41]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.111 - Consumer education about post-mastectomy services.

(1) 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.
(2) The department shall place a link to the educational materials described in subsection (1) of this section close to links on the website to information for consumers about health insurance and under a tab designated "Breast Reconstruction Education." The materials must include links to information about breast reconstruction surgery published by governmental entities with a nexus to this state or nonprofit organizations with expertise in breast reconstruction surgery, including but not limited to information about:
(a) The availability of the option to have breast reconstruction surgery following a mastectomy including that the breast reconstruction surgery may be performed at the time of a mastectomy or may be delayed until a later date.
(b) Prostheses or breast forms as alternatives to breast reconstruction surgery.
(c) The requirements of the Women’s Health and Cancer Rights Act of 1998 (P.L. 105-277) including the right to breast reconstruction surgery following a mastectomy even if the surgery is delayed until a later date.
(3) The department may include educational information about breast reconstruction surgery in newsletters or similar publications that the department sends to consumers or carriers on a weekly or monthly basis. [2017 c.163 §2]
Note:
743A.111 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 743A or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.124 - Colorectal cancer screenings and laboratory tests.

(1) 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.
(2) If an insured is 50 years of age or older, an insurer may not impose cost sharing on the coverage required by subsection (1) of this section and the coverage shall include, at a minimum:
(a)(A) Fecal occult blood tests;
(B) Colonoscopies, including the removal of polyps during a screening procedure; or
(C) Double contrast barium enemas; and
(b) A colonoscopy, including the removal of polyps during the procedure, if the insured has a positive result on any fecal test assigned either a grade of A or a grade of B by the United States Preventive Services Task Force.
(3) If an insured is at high risk for colorectal cancer, the coverage required by subsection (1) of this section shall include colorectal cancer screening examinations and laboratory tests as recommended by the treating physician.
(4) For the purposes of subsection (3) 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, Crohn’s disease or ulcerative colitis; or
(d) Other predisposing factors.
(5) Subsection (2)(b) of this section does not apply to a high deductible health plan described in 26 U.S.C. 223. [Formerly 743.799; 2014 c.9 §1; 2015 c.206 §1]
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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.130 - Proton beam therapy.

(1) 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 requirements.
(2) This section is exempt from ORS 743A.001. [2019 c.466 §2; 2021 c.384 §1; 2023 c.106 §1]
Note:
743A.130 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.140 - Bilateral cochlear implants.

(1) A health benefit plan, as defined in ORS 743B.005, shall reimburse the cost of:
(a) Bilateral cochlear implants if medically appropriate for the treatment of hearing loss; and
(b) The fitting, programming and reprogramming of bilateral or unilateral cochlear implants or other assistive listening devices performed by licensed audiologists.
(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) A health benefit plan shall reimburse the cost of repair and replacement parts for a cochlear implant if the repair or parts are not covered by a warranty and are necessary for the device to be functional for the user.
(4) A health benefit plan shall reimburse the costs described in this section when prescribed by a licensed health professional even if over-the-counter items and services are available without a prescription.
(5) An adverse determination on a claim for coverage under this section must include a prominent notice to the enrollee of the enrollee’s rights to file grievances and request appeals and reviews under ORS 743B.250 and must provide a toll-free telephone number or chat line for enrollees to seek assistance in contesting the denial of or limitation on coverage.
(6) Coverage under this section may not be subject to a deductible, except as provided in ORS 742.008.
(7) The provisions of this section are exempt from ORS 743A.001. [2007 c.504 §2; 2018 c.9 §1; 2023 c.424 §3]
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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.145 - Orthotic and prosthetic devices; rules.

(1) 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.
(2) All individual and group health insurance policies providing coverage for the expenses of hospital, medical or surgical services or supplies shall provide 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 design formulation, fabrication, material and component selection, measurements, fittings, static and dynamic alignments and patient instruction in the use of the device.
(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 (2) 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 (2) 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 the coverage under subsection (2) of this section is provided through a managed care organization, the insured shall have access to medically necessary clinical care and to prosthetic and orthotic devices and technology from not fewer than two distinct Oregon prosthetic and orthotic providers in the managed care organization’s provider network.
(7) This section is exempt from ORS 743A.001. [2023 c.113 §2]
Note:
743A.145 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.148 - Maxillofacial prosthetic services.

(1) 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.
(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; 2016 c.11 §5]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.150 - Treatment of craniofacial anomaly.

(1) 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.
(2) All health benefit plans, as defined in ORS 743B.005, providing coverage of hospital, surgical or dental services, shall provide coverage for dental and orthodontic services for the treatment of craniofacial anomalies if the services are medically necessary to restore function.
(3) This section does not require coverage for the treatment of:
(a) Developmental maxillofacial conditions that result in overbite, crossbite, malocclusion or similar developmental irregularities of the teeth; or
(b) Temporomandibular joint disorder.
(4) Coverage required by this section may be subject to copayments, deductibles and coinsurance imposed on similar services by the terms of the plan.
(5) This section does not limit or supersede any coverage required by ORS 743A.028, 743A.032 or 743A.148.
(6) This section is exempt from ORS 743A.001. [2012 c.21 §2]
Note:
743A.150 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.160 - Alcoholism treatment.

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:
(1) The applicant shall be informed of the applicant’s option to request this coverage.
(2) The inclusion of the coverage may be made subject to the insurer’s 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.
(5) Except as permitted by subsection (3) of this section, the policy may 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; 2016 c.11 §6; 2017 c.17 §56]
Note:
See 743.402.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.169 - Behavioral and physical health services provided on same day or in same facility; behavioral health services provided by behavioral health home specialist or patient centered primary care home specialist.

(1) As used in this section:
(a) "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.
(b) "Patient centered primary care home" means an entity providing health care services that the authority has found to meet the core attributes established under ORS 413.259 for a patient centered primary care home.
(2) An individual or group policy or certificate of health insurance that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, may not:
(a) Exclude coverage for a behavioral health service or a physical health service on the basis that the behavioral health service and physical health service were provided on the same day or in the same facility.
(b) Impose a copayment for physical health services provided by an in-network provider in a behavioral health home on the same day or in the same facility that a copayment was charged for behavioral health services.
(c) Impose a copayment for behavioral health services provided by an in-network provider in a patient centered primary care home on the same day or in the same facility that a copayment was charged for physical health services.
(d) Require prior authorization for a covered behavioral health service provided by a specialist in a behavioral health home or a patient centered primary care home.
(3) Subsection (2)(a) of this section does not apply to a health benefit plan in which providers are reimbursed by payment of a fixed global budget, using a value-based payment arrangement or using other alternative payment methodologies.
(4) This section is exempt from ORS 743A.001. [2022 c.37 §7]
Note:
743A.169 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.170 - Tobacco use cessation programs.

(1) 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.
(2) As used in this section, "tobacco use cessation program" means a program recommended by a physician that follows the United States Public Health Service guidelines for tobacco use cessation. "Tobacco use cessation program" includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products.
(3) This section is exempt from ORS 743A.001. [2009 c.503 §2]
Note:
743A.170 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.175 - Traumatic brain injury.

(1) 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.
(2) This section is exempt from ORS 743A.001. [2009 c.423 §2]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.185 - Telemedical health services for treatment of diabetes.

(1) As used in this section:
(a) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(b) "Originating site" means a location where health services are provided or where the patient is receiving a telemedical health service.
(c) "Telemedical" means delivered through a two-way electronic communication, including but not limited to video, audio, Voice over Internet Protocol or transmission of telemetry, that allows a health professional to interact with a patient, a parent or guardian of a patient or another health professional on a patient’s behalf, who is at an originating site.
(2) A health benefit plan must provide coverage of a telemedical health service provided in connection with the treatment of diabetes if:
(a) The plan provides coverage of the health service when provided in person by the health professional;
(b) The health service is medically necessary;
(c) The telemedical health service relates to a specific patient; and
(d) One of the participants in the telemedical health service is a representative of an academic health center.
(3) A health benefit plan may not distinguish between rural and urban originating sites in providing coverage under subsection (2) of this section.
(4) A health benefit plan may subject coverage of a telemedical health service under subsection (2) of this section to all terms and conditions of the plan, including but not limited to deductible, copayment or coinsurance requirements that are applicable to coverage of a comparable health service when provided in person.
(5) This section does not require a health benefit plan to reimburse a provider for a health service that is not a covered benefit under the plan. [2011 c.312 §2]
Note:
See 743A.001.
Note:
743A.185 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 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]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.250 - Emergency eye care services.

(1) As used in this section:
(a) "Eye care practitioner" means an optometrist or ophthalmologist licensed by the State of Oregon.
(b) "Eye care services" means health care services related to the care of the eye and related structures as specified by a health benefit plan.
(c) "Health benefit plan" has the meaning provided for that term in ORS 743B.005.
(2) Any insurer that offers a health benefit plan that provides coverage of eye care services shall allow any enrollee to receive covered eye care services on an emergency basis without first receiving a referral or prior authorization from a primary care provider. However, an insurer may require the enrollee to receive a referral or prior authorization from a primary care provider for any subsequent surgical procedures. Nothing in this subsection shall be construed to require that covered eye care services rendered by an eye care practitioner on an emergency basis be furnished in a hospital or similar medical facility.
(3) An insurer described in subsection (2) of this section may not:
(a) Impose a deductible or coinsurance for eye care services that is greater than the deductible or coinsurance imposed for other medical services under the health benefit plan.
(b) Require an eye care practitioner to hold hospital privileges as a condition of participation as a provider in the health benefit plan.
(4) Nothing in this section:
(a) Requires an insurer to provide coverage or reimbursement of eye care services;
(b) Requires an insurer to provide coverage or reimbursement of refractive surgery, ophthalmic materials, lenses, eyeglasses or other appurtenances; or
(c) Prevents an enrollee from receiving eye care or other covered services from the enrollee’s primary care provider in accordance with the terms of the enrollee’s health benefit plan.
(5) This section is exempt from ORS 743A.001. [Formerly 743.842]
Note:
743A.250 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.