OAR 836-053-0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017

(1)

This rule applies to plan years beginning on and after January 1, 2017.

(2)

As used in the Insurance Code and OAR chapter 836:

(a)

“Applied behavior analysis” has that meaning given in Section 2, chapter 771, Oregon Laws 2013 as amended by Section 9, chapter 674, Oregon Laws 2015.

(b)

“Base benchmark health benefit plan” means the PacificSource Health Plans Preferred CoDeduct Value 3000 35 70 small group health benefit plan, including prescription drug benefits, as provided in Exhibit 1 to this rule;

(c)

“Essential health benefits” or “EHB” means the following coverage provided in compliance with 45 CFR 156:

(A)

The base-benchmark health benefit plan with the exclusions and modifications of provisions of that plan as set forth in section (3) to (7) of this rule.

(B)

Pediatric dental benefits;

(C)

Pediatric vision benefits; and

(D)

Habilitative services and devices.

(d)

“Habilitative services and devices” means services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services and devices must include physical and occupational therapy, speech-language pathology and other services and devices for people with disabilities in a variety of inpatient or outpatient settings.

(e)

“Mental or nervous condition” has that meaning given in OAR 836-053-1404 (Definitions; Noncontracting Providers; Co-Morbidity Disorders).

(f)

“Pediatric dental benefits” means the benefits described in the Dental Plan of the Oregon Health Plan Children’s’ Health Insurance Plan as provided in Exhibit 2 of this rule. Pediatric dental benefits are payable to persons under 19 years of age.

(g)

“Pediatric vision benefits” means the benefits described in the vision provisions of the Federal Employee Dental and Vision Insurance Plan Blue Vision High Option as provided in Exhibit 3 of this rule. Pediatric vision benefits are payable to persons under 19 years of age.

(h)

“Treatment of a mental health condition” includes medical treatments and prescription drugs used to treat a mental or nervous condition.

(3)

The following exclusions and modifications are required supplementation to the base-benchmark health benefit plan:

(a)

The following treatment limitations and exclusions of coverage currently included in the base-benchmark health benefit plan are excluded:

(A)

The 24-month waiting period for transplant benefits;

(B)

Visit limits for inpatient and outpatient mental health services, including but not limited to habilitative and rehabilitative benefits;

(C)

Age limits on treatments that would otherwise be appropriate for individuals outside of the limited age, including but not limited to hearing aids, speech, physical and occupational therapy used in the treatment of mental or nervous conditions as defined in OAR 836-053-1404 (Definitions; Noncontracting Providers; Co-Morbidity Disorders);

(D)

Exclusions for the treatment of erectile dysfunction or sexual dysfunction as defined in the “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” (DSM-5) or the “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition” (DSM-IV);

(E)

Exclusions for medically necessary surgeries and procedures related to sex transformations and gender identity disorder or gender dysphoria;

(F)

Any blanket exclusion for a diagnosis made using the diagnostic criteria of the DSM-5 or the DSM-IV;

(G)

Exclusions for court-order screening interviews or drug or alcohol treatment programs;

(H)

Any limitations or waiting periods for pre-existing conditions;

(I)

Time limits for treatment of jaw or teeth or orthognathic surgery; and

(b)

Dollar limits for coverage of durable medical equipment must comply with the following:

(A)

Annual dollar limits must be converted to a non-dollar actuarial equivalent.

(B)

Lifetime dollar limits must be converted to a non-dollar actuarial equivalent.

(c)

The following provisions of the base-benchmark plan must be modified:

(A)

Any waiting periods must be consistent with limitations imposed by state or federal law;

(B)

Wigs following chemotherapy or radiation therapy must be covered up to the actuarial equivalent of $150 per calendar year;

(C)

The limitation on cosmetic or reconstructive surgery to one attempt within 18 months of injury or defect must be modified to remove these limitations in cases of medical necessity in accordance with 45 CFR 156.125(a) and to avoid discrimination based on health factors under 45 CFR 146.121 (Disposition of body);

(D)

Contraceptive coverage must comply with Centers for Medicare and Medicaid Services guidance and requirements related to contraception issued jointly by the United States Departments of Labor, Health and Human Services, and Treasury on May 11, 2015;

(E)

Provisions related to telemedical health services must reflect changes made to ORS 743A.058 (Telemedical services) by chapter 340, Oregon Laws 2015 (Enrolled Senate Bill 144); and

(F)

Housing and travel expenses for transplant services are not considered essential health benefits;

(4)

An insurer that issues a health benefit plan offering essential health benefits may not include as an essential health benefit:

(a)

Routine non-pediatric dental services;

(b)

Routine non-pediatric eye exam services;

(c)

Long-term care or custodial nursing home care benefits; or

(d)

Non-medically necessary orthodontia services.

(5)

If both a state law and federal law require coverage of the same or similar service, the insurer must assure that all elements of both laws are met and provide the coverage in the manner most beneficial to the consumer.

(6)

In the administration of essential health benefits and the EHB base benchmark health benefit plan, an insurer may not discriminate against a provider acting within the scope of the provider’s license.

(7)

In the administration of essential health benefits and the EHB base benchmark health benefit plan an insurer may not exclude services provided by a naturopathic physician if the services are otherwise covered under the plan and the naturopathic physician is acting within the scope of the provider’s license.

(8)

In the administration of essential health benefits and the EHB base benchmark health benefit plan an insurer may not exclude services provided by a doctor of chiropractic medicine if the services are otherwise covered under the plan and the doctor of chiropractic medicine is acting within the scope of the provider’s license.
[ED. NOTE: Exhibit referenced is available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 836-053-0012 — Essential Health Benefits for Plan Years Beginning on and after January 1, 2017, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-0012.

836‑053‑0000
Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 836‑053‑0001
Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements 836‑053‑0002
Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements 836‑053‑0003
Prohibition of Exclusion Period for Pregnancy 836‑053‑0004
Compliance with Federal and State Law 836‑053‑0005
Prescription Drug Identification Cards 836‑053‑0007
Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements 836‑053‑0008
Essential Health Benefits for Plan Years 2014, 2015 and 2016 836‑053‑0009
Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 836‑053‑0011
Standard Bronze Plan Health Savings Account Eligible Requirement 836‑053‑0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 836‑053‑0013
Oregon Standard Bronze and Silver Health Benefit Plans 836‑053‑0014
Standards and Process for Shortened Period of Market Prohibition 836‑053‑0015
Definition of Small Employer 836‑053‑0017
Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 836‑053‑0019
Purpose 836‑053‑0021
Plans Offered to Oregon Small Employers 836‑053‑0030
Marketing of a Health Benefit Plan to Small Employers 836‑053‑0050
Trade Practices Relating to Small Employer Health Benefit Plans 836‑053‑0063
Rating for Nongrandfathered Small Group Plans 836‑053‑0065
Rating for Grandfathered Small Group Plans 836‑053‑0066
Rating for Transitional Health Benefit Plans Offered to Small Employers 836‑053‑0070
Multiple Employer Welfare Arrangements 836‑053‑0100
Work Related Injuries or Disease 836‑053‑0105
Coordination of Payment for Interim Medical Services 836‑053‑0211
Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan 836‑053‑0221
Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans 836‑053‑0230
Underwriting 836‑053‑0300
Purpose 836‑053‑0310
Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350 836‑053‑0320
Annual Report Requirements for Network Adequacy 836‑053‑0330
Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements 836‑053‑0340
Factor-Based Evidence of Compliance with Network Adequacy Requirements 836‑053‑0350
Provider Directory Requirements for Network Adequacy 836‑053‑0410
Purpose 836‑053‑0415
Cancellation of an Individual Health Benefit Plan Coverage 836‑053‑0418
Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic 836‑053‑0431
Underwriting, Enrollment and Benefit Design 836‑053‑0435
Health Benefit Plan Coverage of Well-woman Preventive Care Services 836‑053‑0465
Rating for Individual Health Benefit Plans 836‑053‑0472
Statutory Authority and Implementation 836‑053‑0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans 836‑053‑0474
Process For Rate Filing for Individual and Small Employer Health Benefit Plans 836‑053‑0475
Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan 836‑053‑0510
Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage 836‑053‑0600
Purpose 836‑053‑0605
Definitions for OAR 836-053-0600 to 836-053-0615 836‑053‑0610
Carrier Response to Request for Confidentiality 836‑053‑0615
Carrier Reporting Requirements 836‑053‑0825
Rescission of a Group Health Benefit Plan 836‑053‑0830
Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy 836‑053‑0835
Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy 836‑053‑0851
Purpose 836‑053‑0857
Definitions 836‑053‑0863
Notifications 836‑053‑0900
Purpose 836‑053‑0910
Rate Filing 836‑053‑1000
Statutory Authority and Implementation 836‑053‑1010
Insurer Policies 836‑053‑1020
Drug Formularies 836‑053‑1030
Written Information to Enrollees 836‑053‑1033
Cultural and Linguistic Appropriateness 836‑053‑1035
Summary of Benefits and Explanation of Coverage 836‑053‑1060
Definitions 836‑053‑1070
Reporting of Grievances 836‑053‑1080
Tracking Grievances 836‑053‑1090
Assistance in Filing Grievances 836‑053‑1100
Internal Appeals Process 836‑053‑1110
Notice of Complaint Filing with Director 836‑053‑1130
Annual Summary, Utilization Review 836‑053‑1140
Appeal and Utilization Review Determinations 836‑053‑1170
Annual Summary, Quality Assessment Activities 836‑053‑1180
Format and Instructions for Report Required by ORS 743.818 836‑053‑1190
Annual Summary, Uniform Indicators of Network Adequacy 836‑053‑1200
Prior Authorization Requirements for Health Benefit Plans 836‑053‑1203
Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans 836‑053‑1205
Uniform Prescription Drug Prior Authorization Request Form 836‑053‑1300
Purpose and Scope 836‑053‑1305
Definitions 836‑053‑1310
Contracting Requirements 836‑053‑1315
Performance Criteria 836‑053‑1317
Professional Qualifications 836‑053‑1320
Conflict of Interest 836‑053‑1325
Procedures for Conducting External Reviews 836‑053‑1330
Criteria and Considerations for External Review Determinations 836‑053‑1335
Procedures for Complaint Investigation 836‑053‑1337
Preliminary Review by Insurer 836‑053‑1340
Timelines and Notice for Dispute That is Not Expedited 836‑053‑1342
Timelines and Notice for Expedited Decision-Making 836‑053‑1345
Quality Assurance Mechanisms 836‑053‑1350
Ongoing Requirements for Independent Review Organizations 836‑053‑1355
Synopses 836‑053‑1360
External Review Reporting 836‑053‑1365
Fees for External Reviews 836‑053‑1400
Format and Instructions for Report Required by ORS 743.748 836‑053‑1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services 836‑053‑1404
Definitions 836‑053‑1405
General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency 836‑053‑1407
Prohibited Exclusions 836‑053‑1408
Required Disclosures 836‑053‑1409
Definitions 836‑053‑1410
Procedures 836‑053‑1415
Instructions 836‑053‑1500
Purpose 836‑053‑1505
Definitions for OAR 836-053-1500 to 836-053-1510 836‑053‑1510
Prominent Carrier Reporting Requirements 836‑053‑1520
Purpose 836‑053‑1525
Definitions 836‑053‑1530
Reporting Requirements 836‑053‑1600
Purpose 836‑053‑1605
Definitions for 836-053-1600 to 836-053-1615 836‑053‑1610
Non-anesthesia-related claims 836‑053‑1615
Anesthesia-related claims
Last Updated

Jun. 8, 2021

Rule 836-053-0012’s source at or​.us