Or. Admin. Code § 836-053-1407

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-1407 - Prohibited Exclusions

(1) An insurer may not deny benefits for a medically necessary treatment or service for a behavioral health condition based solely upon:

(a) The enrollee's interruption of or failure to complete a prior course of treatment;

(b) The insurer's categorical exclusion of such treatment or service when applied to a class of behavioral health conditions; or

(c) The fact that a court ordered the enrollee to receive or obtain the treatment or service for a behavioral health condition, unless otherwise allowed by law.

(2) Nothing in this section:

(a) Requires coverage of a treatment or service that is or may be specifically excluded from coverage under state law.

(b) Prohibits an insurer from including a provision in a contract related to the insurer's general responsibility to pay for any service under the plan such as an exclusion for third party liability.

(c) Requires an insurer to pay for services provided to an enrollee by a school or halfway house or received as part of an educational or training program. However, an insurer may be required to provide coverage of treatment or services related to the enrollee's education that are provided by a provider and that are included in a medically necessary treatment plan.

Or. Admin. Code § 836-053-1407

ID 3-2015, f. & cert. ef. 5/12/2015; ID 8-2022, amend filed 12/22/2022, effective 1/1/2023

Statutory/Other Authority: ORS 731.244 & ORS 743A.168

Statutes/Other Implemented: ORS 743A.168