ORS § 743A.325

Current through 2024 Regular Session legislation

Section 743A.325 - Gender-affirming treatment; rules

(1) As used in this section:

(a) "Carrier" has the meaning given that term in ORS 743B.005.

(b) "Gender-affirming treatment" means a procedure, service, drug, device or product that a physical or behavioral health care provider prescribes to treat an individual for incongruence between the individual's gender identity and the individual's sex assignment at birth.

(c) "Health benefit plan" has the meaning given that term in ORS 743B.005.

(2) A carrier offering a health benefit plan in this state may not:

(a) Deny or limit coverage under the plan for gender-affirming treatment that is:

(A) Medically necessary as determined by the physical or behavioral health care provider who prescribes the treatment; and

(B) Prescribed in accordance with accepted standards of care.

(b) Apply categorical cosmetic or blanket exclusions to medically necessary gender-affirming treatment.

(c) Exclude as a cosmetic service a medically necessary procedure prescribed by a physical or behavioral health care provider as gender-affirming treatment, including but not limited to:

(A) Tracheal shave;

(B) Hair electrolysis;

(C) Facial feminization surgery or other facial gender-affirming treatment;

(D) Revisions to prior forms of gender-affirming treatment; and

(E) Any combination of gender-affirming treatment procedures.

(d) Issue an adverse benefit determination denying or limiting access to gender-affirming treatment unless a physical or behavioral health care provider with experience prescribing or delivering gender-affirming treatment has first reviewed and approved the denial of or the limitation on access to the treatment.

(3) A carrier described in subsection (2) of this section must:

(a) Satisfy any network adequacy standards under ORS 743B.505 related to gender-affirming treatment providers; and

(b)

(A) Contract with a network of gender-affirming treatment providers that is sufficient in numbers and geographic locations to ensure that gender-affirming treatment services are accessible to all enrollees without unreasonable delay; or

(B) Ensure that all enrollees have geographical access without unreasonable delay to out-of-network gender-affirming treatment services with cost-sharing or other out-of-pocket costs for the services no greater than the cost-sharing or other out-of-pocket costs for the services when furnished by an in-network provider.

(4) The Department of Consumer and Business Services shall:

(a) Evaluate compliance with this section in each examination or analysis of the market conduct of a carrier under ORS 731.300; and

(b) Adopt rules to implement the provisions of this section.

(5) This section is exempt from ORS 743A.001.

ORS 743A.325

Added by 2023 Ch. 228, § 20

743A.325 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.

Sections 59 (1), 21 and 22, chapter 228, Oregon Laws 2023, provide:

Sec. 59. (1) Section 20 of this 2023 Act [743A.325] applies to health benefit plans issued, renewed or extended on or after January 1, 2024. [2023 c. 228, § 59(1)]

Sec. 21. The Department of Consumer and Business Services shall conduct a targeted market conduct examination of all carriers that are subject to the requirements of section 20 of this 2023 Act [743A.325] to ensure compliance with section 20 of this 2023 Act. The examinations must be completed no later than January 2, 2027. [2023 c. 228, § 21]

Sec. 22. No later than December 31, 2026, the Department of Consumer and Business Services shall report to the interim committees of the Legislative Assembly related to health, in the manner provided in ORS 192.245, on the implementation of section 20 of this 2023 Act [743A.325]. [2023 c. 228, § 22]