Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1405 - General Requirements for Coverage of Behavioral Health Conditions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A group health
			 insurance policy or an individual health benefit plan issued or renewed in this
			 state shall provide coverage or reimbursement for medically necessary treatment
			 of behavioral health conditions, including but not limited to prescription
			 drugs, at the same level as, and subject to limitations no more restrictive
			 than, those imposed on coverage or reimbursement for medically necessary
			 treatment for medical conditions.
(a) 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
			 copayments, deductibles and coinsurance. Copayments, deductibles and
			 coinsurance for behavioral health treatment may not be greater than those under
			 the policy for medical conditions.
(b) The coverage of behavioral health
			 treatment 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 medical conditions.
(c) The
			 parity requirements in subsections (1)(a) and (b) must comply with the
			 "predominant" and "substantially all" tests in the federal Paul Wellstone and
			 Pete Domenici Mental Health Parity and Addiction Equity Act,
			 29 U.S.C.
			 1185a and implementing regulations at
			 45 CFR
			 146.136 and
			  45 CFR 147.160.
(d) If annual or lifetime limits apply for
			 treatment of behavioral health conditions the limits must comply with the
			 federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
			 Equity Act, 29 U.S.C.
			 1185a and implementing regulations at
			 45 CFR
			 146.136 and
			 147.160.
(e) Classification of prescription drugs into
			 open, closed, or tiered drug benefit formularies, for drugs intended to treat
			 behavioral health conditions must be by the same process as drug selection for
			 formulary status applied for drugs intended to treat medical conditions,
			 regardless of whether such drugs are intended to treat behavioral health
			 conditions or medical conditions.
(f) The coverage of behavioral health
			 treatment may not limit coverage for treatment of pervasive or chronic
			 behavioral health conditions to short-term or acute behavioral health treatment
			 at any level of care or placement.
(g) The coverage of behavioral health
			 treatment must include clinically indicated outpatient coverage including
			 follow-up in-home services or other outpatient services. The policy may limit
			 coverage only if clinically indicated under any medical necessity, utilization
			 or other clinical review conducted for the diagnosis, prevention or treatment
			 of behavioral health conditions or relating to service intensity, level of care
			 placement, continued stay or discharge. Utilization and clinical review
			 policies and procedures must meet the requirements of OAR 836-053-1405(9),
			 (10), (11), and (12), as well as comply with the entire definition of
			 "generally accepted standards of care" in OAR 836-053-1404.