Oregon Statutes

Amends ORS 414.766, 743A.168 and 743B.505

HB 3046 amends existing state law by requiring substantive improvements on how insurers and coordinated care organizations  cover MH/SUD services.  The new statutory provisions will implement the basic requirements embedded in the Federal Parity Law for the covered entities to assess and report how the “processes, strategies, evidentiary standards and other factors used to apply nonquantitative treatment limitations (NQTLs) for MH/SUD treatment are comparable to and applied no more stringently that similar factors for medical/surgical treatment.

The new law requires detailed annual reporting addressing  requirements, including how insurers reimburse for MH/SUD services.  The new amendments also add more detail identifying what the relevant behavioral health clinical specialties are which are protected under the new requirements.  In addition, insurers and coordinated care organizations need to follow generally accepted standards of care (in large part based on the Wit vs. United case) which addresses proper levels of care and the need to treat co-occurring behavioral health conditions among other coverage principles.

In addition, the state law identifies a process of how generally accepted standards of care will be followed during any “medical necessity, utilization, or other clinical review is conducted for the diagnosis, prevention or treatment of behavioral health conditions or relating to service intensity, levels of care placement, continued stay or discharge….”  The state also will ensure that insurer networks are providing sufficient access to a range of MN/SUD professionals, which includes factoring the patient’s age, language, culture and complex behavior health conditions.

Most of the amendments go into effect January 1, 2025, but the requirements for utilization management (i.e. OR HB 3046, Section 8) will go into effect January 1, 2023.

Enacted through OR HB 3046; signed by the Governor on July 27, 2021.  Elements of the law are based on The Kennedy Forum’s Six Step Compliance Guide and two model laws to promote parity and the generally accepted standards of care.  Click here for those resources.

A group health insurance policy providing coverage for hospital or medical expenses, other than limited benefit coverage, shall provide coverage for expenses arising from the diagnosis of and 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.
ORS § 743A.168 also sets out definitions as well as related provisions with regard to the coverage.

Formerly 743.556. Amended by Ore. HB 3091.

An insurer offering a health benefit plan in this state that provides coverage to individuals or to small employers, as defined under the law, through a specified network of health care providers shall:
(a) Contract with or employ a network of providers that is sufficient in number, geographic distribution and types of providers to ensure that all covered services under the health benefit plan, including mental health and substance abuse treatment, are accessible to enrollees without unreasonable delay.

Amended by Ore. HB 2341.

This bill changed the section of state insurance law so that the Department of Consumer and Business Services must do the following:

• Examine historical data to determine if insurers were paying in-network behavioral health providers reimbursement rates that were “equivalent” to those in place for in-network medical providers.
• Examine insurers to determine if utilization management practices for outpatient behavioral health care was more restrictive than utilization management practices for other medical outpatient care, particularly regarding the approval or denial of outpatient sessions of longer duration.
• Examine if insurers pay “equivalent” reimbursement rates for time-based procedural codes for both in-network behavioral health providers and in-network medical providers.
• Examine whether the methodology insurers use to set reimbursement rates for in-network behavioral health providers was equivalent to the methodology used to set reimbursement rates for in-network medical providers.
• Submit a report documenting the results of the above examinations by September 1, 2019.

The bill authorized a maximum of $600,000 to fund the examinations and report above.

This bill changed the section of state insurance law so that insurance plans had to meet health care provider network standards. Among other things, the bill requires that a plan’s provider network have a sufficient number, geographic distribution, and type of providers to ensure access to covered services. The bill specifically mentions that mental health and substance use treatment must be accessible.

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 licensed psychologist:
(1) The insured under such policy or contract shall be free to select, and shall have direct access to, a licensed psychologist, 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 insured’s behalf for the services performed.