2013 ORS § 743A.190¹
Children with pervasive developmental disorder

(1) A health benefit plan, as defined in ORS 743.730 (Definitions for ORS 743.730 to 743.773), must cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.

(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to:

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(c) Treatment limitations regarding the number of visits or the duration of treatment.

(3) As used in this section:

(a) Medically necessary means in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan.

(b) Pervasive developmental disorder means a neurological condition that includes Aspergers syndrome, autism, developmental delay, developmental disability or mental retardation.

(c) Rehabilitation services means physical therapy, occupational therapy or speech therapy services to restore or improve function.

(4) The provisions of ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance) do not apply to this section.

(5) The definition of pervasive developmental disorder is not intended to apply to coverage required under ORS 743A.168 (Treatment of chemical dependency, including alcoholism, and mental or nervous conditions). [2007 c.872 §2]

Note 1: The amendments to 743A.190 (Children with pervasive developmental disorder) by section 7, chapter 771, Oregon Laws 2013, apply to health benefit plan policies and certificates offered by the Public Employees Benefit Board or the Oregon Educators Benefit Board for coverage beginning on or after January 1, 2015, and to all other policies and certificates offered for coverage beginning on or after January 1, 2016. See section 23, chapter 771, Oregon Laws 2013. The text that applies from January 1, 2015, or January 1, 2016, until January 2, 2022, is set forth for the users convenience.

743A.190 (Children with pervasive developmental disorder). (1) A health benefit plan, as defined in ORS 743.730 (Definitions for ORS 743.730 to 743.773), must cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.

(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to:

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(c) Treatment limitations regarding the number of visits or the duration of treatment.

(3) As used in this section:

(a) Medically necessary means in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan.

(b) Pervasive developmental disorder means a neurological condition that includes autism spectrum disorder, developmental delay, developmental disability or mental retardation.

(c) Rehabilitation services means physical therapy, occupational therapy or speech therapy services to restore or improve function.

(4) The provisions of ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance) do not apply to this section.

(5) The definition of pervasive developmental disorder is not intended to apply to coverage required under ORS 743A.168 (Treatment of chemical dependency, including alcoholism, and mental or nervous conditions) or section 2, chapter 771, Oregon Laws 2013.

Note 2: The amendments to 743A.190 (Children with pervasive developmental disorder) by section 20, chapter 771, Oregon Laws 2013, become operative January 2, 2022. See section 24, chapter 771, Oregon Laws 2013. The text that is operative on and after January 2, 2022, is set forth for the users convenience.

743A.190 (Children with pervasive developmental disorder). (1) A health benefit plan, as defined in ORS 743.730 (Definitions for ORS 743.730 to 743.773), must cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.

(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to:

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(c) Treatment limitations regarding the number of visits or the duration of treatment.

(3) As used in this section:

(a) Medically necessary means in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan.

(b) Pervasive developmental disorder means a neurological condition that includes autism spectrum disorder, developmental delay, developmental disability or mental retardation.

(c) Rehabilitation services means physical therapy, occupational therapy or speech therapy services to restore or improve function.

(4) The provisions of ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance) do not apply to this section.

(5) The definition of pervasive developmental disorder is not intended to apply to coverage required under ORS 743A.168 (Treatment of chemical dependency, including alcoholism, and mental or nervous conditions).

Note 3: 743A.190 (Children with pervasive developmental disorder) 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.