Health plans - Oregon

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. Oregon laws include the following provisions:

• Plans that cover hospital or medical expenses must cover treatment for chemical dependency including alcoholism and for mental or nervous conditions. (743.556)
• Plans must provide payment, coverage, or reimbursement for supplies, equipment, and diabetes self-management programs associated with the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes. (743.694)
• If the plan covers prescriptions, it must not deny coverage of a drug for a particular indication solely on the grounds that the indication has not been approved by the United States Food and Drug Administration if the Health Resources Commission determines that the drug is recognized as effective for the treatment of that indication. (743.697)
• Plans must cover emergency services without prior authorization. (743.699)Information that is otherwise privileged or confidential must not be disclosed. (743.839)
• Plans cannot deny coverage for service because the service was rendered at any hospital owned or operated by the State of Oregon or any state approved community mental health and developmental disabilities program. (743.701)
• Optometric services must be covered whether the services are provided by an optometrist or a physician. (743.703)
• Plans must cover maxillofacial prosthetic services considered necessary for adjunctive treatment. (743.706)
• Newly born children are covered from the moment of birth and adopted children upon placement for adoption, coverage includes necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. (743.707)
• If psychological services are covered, the insured may select, and shall have direct access to, a psychologist. (743.709)
• The plan cannot deny coverage or be canceled solely because the mother of the insured used drugs containing diethylstilbestrol prior to the insured’s birth. (743.710)
• If the policy provides for payment of a surgical service, the performance of such surgical service by any dentist is compensable. (743.719)
• If the plan covers nurse practitioners, the services rendered must be covered whether they are provided by a nurse practitioner or physician. (743.712)
• If the plan covers dental health, it must cover the services of a denturist as well as a dentist. (743.713)
• If the plan covers the services of clinical social workers the participant is entitled to such services upon referral by a physician or psychologist. (743.714)
• Reimbursement for treatment of Tourette Syndrome must be made on the basis of the diagnosis and treatment modality employed. (743.717)
• Plans must provide the same payments for costs of maternity to unmarried women that it provides to married women, including the wives of insured persons choosing family coverage; and the same coverage for the child of an unmarried woman that the child of an insured married person choosing family coverage receives. (743.721)
• The plan must provide optional coverage for acupuncturist performed by a physician or licensed acupuncturist. (743.722)
• The plan must cover treatment of inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in tissues. (743.726)
• Plans must cover nonprescription elemental enteral formula for home use, if the formula is medically necessary for the treatment of severe intestinal malabsorption and a physician has issued a written order for the formula and the formula comprises the sole source, or an essential source, of nutrition. (743.729)
• If the plan provides coverage of eye care services, it must allow participants to receive covered eye care services on an emergency basis without first receiving a referral or prior authorization from a primary care provider. (743.842)
• Plans offering managed health insurance or preferred provider organization insurance must provide continuity of care. (743.854)
• The plan must allow a standing referral if the authorized physician determines that the participant needs continuing care from a specialist. (743.856)
• If an applicant for insurance is asked to take a genetic test, the use of the test must be revealed to the applicant and specific authorization obtained from the applicant. (746.135)
• Effective January 1, 2010, plans may pay cash dividends to enrollees who participate in a program approved by the insurer that promotes healthy behaviors. These dividends are not premium variations.

State

Contact

Oregon Insurance Division

Regulations

Oregon Revised Statutes

Chapter 743 Health and Life Insurance

https://www.oregonlegislature.gov/bills_laws/ors/ors743.html

§743.556, 743.694, 743.697, 743.699, 743.701, 743.703, 743.706, 743.707, 743.709, 743.710, 743.712, 743.713, 743.714, 743.717, 743.719, 743.721, 743.722, 743.726, 743.729, 743.839, 743.842, 743.854, 743.856.

Chapter 746 Trade Practices

https://www.oregonlegislature.gov/bills_laws/ors/ors746.html

§746.135

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)