ORS 743A.067
Reproductive health services


(1)

As used in this section:

(a)

“Contraceptives” means health care services, drugs, devices, products or medical procedures to prevent a pregnancy.

(b)

“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.

(c)

“Health benefit plan” has the meaning given that term in ORS 743B.005 (Definitions), excluding Medicare Advantage Plans and including health benefit plans offering pharmacy benefits administered by a third party administrator or pharmacy benefit manager.

(d)

“Prior authorization” has the meaning given that term in ORS 743B.001 (Definitions).

(e)

“Religious employer” has the meaning given that term in ORS 743A.066 (Contraceptives).

(f)

“Utilization review” has the meaning given that term in ORS 743B.001 (Definitions).

(2)

A health benefit plan offered in this state must provide coverage for all of the following services, drugs, devices, products and procedures:

(a)

Well-woman care prescribed by the Department of Consumer and Business Services by rule consistent with guidelines published by the United States Health Resources and Services Administration.

(b)

Counseling for sexually transmitted infections, including but not limited to human immunodeficiency virus and acquired immune deficiency syndrome.

(c)

Screening for:

(A)

Chlamydia;

(B)

Gonorrhea;

(C)

Hepatitis B;

(D)

Hepatitis C;

(E)

Human immunodeficiency virus and acquired immune deficiency syndrome;

(F)

Human papillomavirus;

(G)

Syphilis;

(H)

Anemia;

(I)

Urinary tract infection;

(J)

Pregnancy;

(K)

Rh incompatibility;

(L)

Gestational diabetes;

(M)

Osteoporosis;

(N)

Breast cancer; and

(O)

Cervical cancer.

(d)

Screening to determine whether counseling related to the BRCA1 or BRCA2 genetic mutations is indicated and counseling related to the BRCA1 or BRCA2 genetic mutations if indicated.

(e)

Screening and appropriate counseling or interventions for:

(A)

Tobacco use; and

(B)

Domestic and interpersonal violence.

(f)

Folic acid supplements.

(g)

Abortion.

(h)

Breastfeeding comprehensive support, counseling and supplies.

(i)

Breast cancer chemoprevention counseling.

(j)

Any contraceptive drug, device or product approved by the United States Food and Drug Administration, subject to all of the following:

(A)

If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, a health benefit plan may provide coverage for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.

(B)

If a contraceptive drug, device or product covered by the health benefit plan is deemed medically inadvisable by the enrollee’s provider, the health benefit plan must cover an alternative contraceptive drug, device or product prescribed by the provider.

(C)

A health benefit plan must pay pharmacy claims for reimbursement of all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration.

(D)

A health benefit plan may not infringe upon an enrollee’s choice of contraceptive drug, device or product and may not require prior authorization, step therapy or other utilization review techniques for medically appropriate covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.

(k)

Voluntary sterilization.

(L)

As a single claim or combined with other claims for covered services provided on the same day:

(A)

Patient education and counseling on contraception and sterilization.

(B)

Services related to sterilization or the administration and monitoring of contraceptive drugs, devices and products, including but not limited to:
(i)
Management of side effects;
(ii)
Counseling for continued adherence to a prescribed regimen;
(iii)
Device insertion and removal; and
(iv)
Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the enrollee’s provider.

(m)

Any additional preventive services for women that must be covered without cost sharing under 42 U.S.C. 300gg-13, as identified by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services as of January 1, 2017.

(3)

A health benefit plan may not impose on an enrollee a deductible, coinsurance, copayment or any other cost-sharing requirement on the coverage required by this section. A health care provider shall be reimbursed for providing the services described in this section without any deduction for coinsurance, copayments or any other cost-sharing amounts.

(4)

Except as authorized under this section, a health benefit plan may not impose any restrictions or delays on the coverage required by this section.

(5)

This section does not exclude coverage for contraceptive drugs, devices or products prescribed by a provider, acting within the provider’s scope of practice, for:

(a)

Reasons other than contraceptive purposes, such as decreasing the risk of ovarian cancer or eliminating symptoms of menopause; or

(b)

Contraception that is necessary to preserve the life or health of an enrollee.

(6)

This section does not limit the authority of the Department of Consumer and Business Services to ensure compliance with ORS 743A.063 (Ninety-day supply of prescription drug refills) and 743A.066 (Contraceptives).

(7)

This section does not require a health benefit plan to cover:

(a)

Experimental or investigational treatments;

(b)

Clinical trials or demonstration projects, except as provided in ORS 743A.192 (Clinical trials);

(c)

Treatments that do not conform to acceptable and customary standards of medical practice;

(d)

Treatments for which there is insufficient data to determine efficacy; or

(e)

Abortion if the insurer offering the health benefit plan excluded coverage for abortion in all of its individual, small employer and large employer group plans during the 2017 plan year.

(8)

If services, drugs, devices, products or procedures required by this section are provided by an out-of-network provider, the health benefit plan must cover the services, drugs, devices, products or procedures without imposing any cost-sharing requirement on the enrollee if:

(a)

There is no in-network provider to furnish the service, drug, device, product or procedure that is geographically accessible or accessible in a reasonable amount of time, as defined by the Department of Consumer and Business Services by rule consistent with the requirements for provider networks in ORS 743B.505 (Provider networks); or

(b)

An in-network provider is unable or unwilling to provide the service in a timely manner.

(9)

An insurer may offer to a religious employer a health benefit plan that does not include coverage for contraceptives or abortion procedures that are contrary to the religious employer’s religious tenets only if the insurer notifies in writing all employees who may be enrolled in the health benefit plan of the contraceptives and procedures the employer refuses to cover for religious reasons.

(10)

If the Department of Consumer and Business Services concludes that enforcement of this section may adversely affect the allocation of federal funds to this state, the department may grant an exemption to the requirements but only to the minimum extent necessary to ensure the continued receipt of federal funds.

(11)

An insurer that is subject to this section shall make readily accessible to enrollees and potential enrollees, in a consumer-friendly format, information about the coverage of contraceptives by each health benefit plan and the coverage of other services, drugs, devices, products and procedures described in this section. The insurer must provide the information:

(a)

On the insurer’s website; and

(b)

In writing upon request by an enrollee or potential enrollee.

(12)

This section does not prohibit an insurer from using reasonable medical management techniques to determine the frequency, method, treatment or setting for the coverage of services, drugs, devices, products and procedures described in subsection (2) of this section, other than coverage required by subsection (2)(g) and (j) of this section, if the techniques:

(a)

Are consistent with the coverage requirements of subsection (2) of this section; and

(b)

Do not result in the wholesale or indiscriminate denial of coverage for a service. [2017 c.721 §2; 2019 c.284 §5]
Note: See 743A.001 (Automatic repeal of certain statutes on individual and group health insurance).
Note: 743A.067 (Reproductive health services) 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.

Source: Section 743A.067 — Reproductive health services, https://www.­oregonlegislature.­gov/bills_laws/ors/ors743A.­html.

743A.001
Automatic repeal of certain statutes on individual and group health insurance
743A.010
Services provided by state hospital or state approved program
743A.012
Emergency services
743A.014
Payments for ambulance care and transportation
743A.018
Services provided by osteopathic physician
743A.020
Services provided by acupuncturist
743A.024
Services provided by clinical social worker
743A.028
Services provided by denturist
743A.032
Surgical services provided by dentist
743A.034
Services provided by expanded practice dental hygienist
743A.036
Services provided by licensed nurse practitioner or licensed physician assistant
743A.040
Services provided by optometrist
743A.044
Services provided by physician assistant
743A.048
Services provided by psychologist
743A.051
Services provided by pharmacist
743A.052
Services provided by professional counselor or marriage and family therapist
743A.058
Telemedicine services
743A.060
Definition for ORS 743A.062
743A.062
Prescription drugs
743A.063
Ninety-day supply of prescription drug refills
743A.064
Prescription drugs dispensed at rural health clinics
743A.065
Early refills of prescription eye drops for treatment of glaucoma
743A.066
Contraceptives
743A.067
Reproductive health services
743A.068
Orally administered anticancer medication
743A.069
Insulin
743A.070
Nonprescription enteral formula for home use
743A.078
Newborn nurse home visiting services
743A.080
Pregnancy and childbirth expenses
743A.082
Diabetes management for pregnant women
743A.084
Unmarried women and their children
743A.088
Use by mother of diethylstilbestrol
743A.090
Natural and adopted children
743A.100
Mammograms
743A.104
Pelvic examinations and Pap smear examinations
743A.105
HPV vaccine
743A.108
Physical examination of breast
743A.110
Mastectomy-related services
743A.111
Consumer education about post-mastectomy services
743A.124
Colorectal cancer screenings and laboratory tests
743A.130
Proton beam therapy
743A.140
Bilateral cochlear implants
743A.141
Hearing aids and hearing assistive technology systems
743A.148
Maxillofacial prosthetic services
743A.150
Treatment of craniofacial anomaly
743A.160
Alcoholism treatment
743A.168
Behavioral health treatment
743A.170
Tobacco use cessation programs
743A.175
Traumatic brain injury
743A.180
Tourette Syndrome
743A.185
Telemedical health services for treatment of diabetes
743A.188
Inborn errors of metabolism
743A.190
Children with pervasive developmental disorder
743A.192
Clinical trials
743A.250
Emergency eye care services
743A.252
Child abuse assessments
743A.260
Inmates
743A.262
Preventive health services
743A.264
Disease outbreaks, epidemics and conditions of public health importance
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