Title 56, Insurance

(1) If a group health benefit plan, as described in ORS 743B.005, provides for coverage for services performed by a clinical social worker or nurse practitioner, the plan also must cover services provided by a professional counselor or marriage and family therapist licensed under…

(1) As used in this section: (a)(A) “Audio only” means the use of audio telephone technology, permitting real-time communication between a health care provider and a patient for the purpose of diagnosis, consultation or treatment. (B) “Audio only” does not include: (i) The use of…

As used in ORS 743A.062, “peer-reviewed medical literature” means scientific studies printed in journals or other publications that publish original manuscripts only after the manuscripts have been critically reviewed by unbiased independent experts for scientific accuracy, valid…

(1) As used in this section: (a) “Conflict of interest” means: (A) Present employment, ownership or control by a covered entity, pharmaceutical manufacturer, pharmacy benefit manager or health benefit plan as defined in ORS 743B.005; or (B) Third party employment, ownership or co…

(1) A prescription drug benefit program, or a prescription drug benefit offered under a health benefit plan as defined in ORS 743B.005, must provide for reimbursement for up to a 90-day supply of a prescription drug dispensed by a pharmacy, as defined in ORS 689.005, if: (a) The …

(1) All health insurance policies that provide a prescription drug benefit, except those policies in which coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this subsection, must include coverage for prescription dr…

An insurer offering a health benefit plan, as defined in ORS 743B.005, that provides coverage of prescription eye drops shall provide coverage for one early refill of a prescription for eye drops to treat glaucoma if all of the following criteria are met: (1) The refill is reques…

(1) A prescription drug benefit program, or a prescription drug benefit offered under a health benefit plan as defined in ORS 743B.005 or under a student health insurance policy, must provide payment, coverage or reimbursement for: (a) Prescription contraceptives; and (b) If cove…

(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…

(1) A health benefit plan that provides coverage for cancer chemotherapy treatment must provide coverage for a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or …

(1) As used in this section: (a) “Health benefit plan” has the meaning given that term in ORS 743B.005. (b) “Insulin” has the meaning given that term in ORS 689.696. (2) A health benefit plan offered in this state may not require an enrollee in the plan to incur cost-sharing or o…

(1) All policies providing health insurance, as defined in ORS 731.162, except those policies whose coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this section, shall include coverage for a nonprescription elemen…

(1) As used in this section, “carrier,” “enrollee” and “health benefit plan” have the meanings given those terms in ORS 743B.005. (2) A health benefit plan offered in this state must reimburse in full the cost to a provider of delivering universal newborn nurse home visiting serv…

(1) As used in this section, “pregnancy care” means the care necessary to support a healthy pregnancy and care related to labor and delivery. (2) All health benefit plans as defined in ORS 743B.005 must provide payment or reimbursement for expenses associated with pregnancy care …

(1) As used in this section: (a) “Doula” has the meaning given that term in ORS 414.667. (b) “Lactation counselor” and “lactation educator” have the meanings given those terms in ORS 676.665. (2) A health benefit plan, as defined in ORS 743B.005, in this state that reimburses the…

(1) Except as provided in subsections (2) and (3) of this section, a health benefit plan, as defined in ORS 743B.005, may not require a copayment or impose a coinsurance requirement or a deductible on the covered health services, medications and supplies that are medically necess…

Each policy of health insurance shall provide: (1) The same payments for costs of maternity to unmarried women that it provides to married women, including the spouses in marriages of insured persons choosing family coverage; and (2) The same coverage for the child of an unmarrie…

No policy of health insurance may be denied or canceled by the insurer solely because the mother of the insured used drugs containing diethylstilbestrol prior to the insured’s birth. [Formerly 743.710]

(1)(a) All individual and group health benefit plans, as defined in ORS 743B.005, that include coverage for a family member of the insured shall also provide that the health insurance benefits applicable for children in the family shall be payable with respect to: (A) A child of …

(1) Every health insurance policy that covers hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases, shall provide coverage of mammograms as follows: (a) Mammograms for the purpose of diagnosis in symptomatic or high-r…

(1) As used in this section: (a) “Diagnostic breast examination” means an examination used to evaluate an abnormality of the breast that is detected or suspected from a screening examination for breast cancer or by any other means of examination using: (A) Diagnostic mammography;…

All policies providing health insurance, except those policies whose coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this section, shall include coverage for pelvic examinations and Pap smear examinations as follo…

(1) All health benefit plans, as defined in ORS 743B.005, shall include coverage of the human papillomavirus vaccine for beneficiaries under the health benefit plan who are at least 11 years of age but no older than 26 years of age. (2) ORS 743A.001 does not apply to this section…

(1) A health insurance policy that covers hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases, shall provide coverage for a complete and thorough physical examination of the breast, including but not limited to a cli…

(1) As used in this section, “mastectomy” means the surgical removal of all or part of a breast or a breast tumor suspected to be malignant. (2) All insurers offering a health benefit plan as defined in ORS 743B.005 shall provide payment, coverage or reimbursement for mastectomy …

(1) The Department of Consumer and Business Services shall make written materials available on the department’s website to educate breast cancer patients about the availability of insurance coverage for breast reconstruction surgery and breast prostheses following a mastectomy. T…

(1) As used in this section: (a) “Accepted standard of care” means standards of care and clinical practice guidelines that are: (A) Generally recognized by health care providers practicing in relevant clinical specialties; and (B) Based on valid, evidence-based sources. (b) “Auto…

(1) All health benefit plans, as defined in ORS 743B.005, shall include coverage of the treatment of perimenopause, menopause and postmenopause, including but not limited to the following: (a) Hormone therapy including combination estrogen and hormone medicines, combination estro…

(1) A health benefit plan, as defined in ORS 743B.005, shall provide coverage for all colorectal cancer screening examinations and laboratory tests assigned either a grade of A or a grade of B by the United States Preventive Services Task Force. (2) If an insured is 50 years of a…

(1) A health benefit plan, as defined in ORS 743B.005, that provides coverage of radiation therapy for the treatment of prostate cancer must provide coverage for proton beam therapy for the treatment of prostate cancer on a basis no less favorable than the coverage of radiation t…

(1) A health benefit plan, as defined in ORS 743B.005, shall reimburse the cost of: (a) Bilateral cochlear implants if medically appropriate for the treatment of hearing loss; and (b) The fitting, programming and reprogramming of bilateral or unilateral cochlear implants or other…

(1) As used in this section: (a) “Assistive listening device” means devices used with or without hearing aids or cochlear implants to provide access to sound or improve the ability of a user with hearing loss to hear in various listening situations, such as being located a distan…

(1) As used in this section: (a) “Device” means: (A) An orthotic device. (B) A prosthetic device. (b) “Orthotic device” means a rigid or semirigid device supporting a weak or deformed leg, foot, arm, hand, back or neck, or restricting or eliminating motion in a diseased or injure…

(1) The Legislative Assembly declares that all group health insurance policies providing hospital, medical or surgical expense benefits, other than limited benefit coverage, include coverage for maxillofacial prosthetic services considered necessary for adjunctive treatment. (2) …

(1) As used in this section, “craniofacial anomaly” means a physical disorder identifiable at birth that affects the bony structures of the face or head, including but not limited to cleft palate, cleft lip, craniosynostosis, craniofacial microsomia and Treacher Collins syndrome.…

A health insurance policy providing coverage for hospital or medical expenses, other than limited benefit coverage, shall provide, at the request of the applicant, coverage for expenses arising from treatment for alcoholism. The following conditions apply to the requirement for s…

(1) As used in this section: (a) “Behavioral health assessment” means an evaluation by a provider, in person or using telemedicine, to determine a patient’s need for behavioral health treatment. (b) “Behavioral health condition” has the meaning prescribed by rule by the Departmen…

(1) As used in this section: (a) “Behavioral health home” means an entity providing behavioral health services that the Oregon Health Authority has found to meet the core attributes established under ORS 413.259 for a behavioral health home. (b) “Patient centered primary care hom…

(1) A health benefit plan as defined in ORS 743B.005 must provide payment, coverage or reimbursement of at least $500 for a tobacco use cessation program for a person enrolled in the plan who is 15 years of age or older. (2) As used in this section, “tobacco use cessation program…

(1) As used in this section: (a) “Group health insurance” has the meaning given that term in ORS 731.098. (b) “Health benefit plan” has the meaning given that term in ORS 743B.005. (c) “Substance use disorder” has the meaning given that term in the fifth edition of the Diagnostic…

(1) A health benefit plan, as defined in ORS 743B.005, shall provide coverage of medically necessary therapy and services for the treatment of traumatic brain injury. (2) This section is exempt from ORS 743A.001. [2009 c.423 §2]

For purpose of coverage by group health insurers, health care service contractors and health maintenance organizations, reimbursement for treatment of Tourette Syndrome shall be made on the basis of the diagnosis and treatment modality employed. [Formerly 743.717] Note: See 743A.…

(1) As used in this section: (a) “Health benefit plan” has the meaning given that term in ORS 743B.005. (b) “Originating site” means a location where health services are provided or where the patient is receiving a telemedical health service. (c) “Telemedical” means delivered thr…

(1) All individual and group health insurance policies providing coverage for hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases, shall include coverage for treatment of inborn errors of metabolism that involve amin…

(1) A health benefit plan, as defined in ORS 743B.005, 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…

(1) A health benefit plan, as defined in ORS 743B.005: (a) Shall provide coverage for the routine costs of the care of patients enrolled in and participating in approved clinical trials; (b) May not exclude, limit or impose additional conditions on the coverage of the routine cos…

(1) As used in this section: (a) “Eye care practitioner” means an optometrist or ophthalmologist licensed by the State of Oregon. (b) “Eye care services” means health care services related to the care of the eye and related structures as specified by a health benefit plan. (c) “H…

(1) As used in this section: (a) “Child abuse assessment” has the meaning given that term in ORS 418.782. (b) “Children’s advocacy center” has the meaning given that term in ORS 418.782. (c) “Forensic interview” has the meaning given that term in ORS 418.782. (d) “Health benefit …

(1) As used in this section: (a) “Detainee” means an insured who is: (A) In the custody of a local supervisory authority pending the disposition of charges; or (B) In a detention facility pending final adjudication by a juvenile court. (b) “Detention facility” has the meaning giv…

Notwithstanding any other provision of law, a health benefit plan that is not a grandfathered health plan: (1) Must provide coverage of preventive health services as prescribed by the United States Department of Health and Human Services pursuant to 42 U.S.C. 300gg-13 in rules ad…