Or. Admin. Code § 836-053-0008

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

Section 836-053-0008 - Essential Health Benefits for Plan Years 2014, 2015 and 2016

(1) This rule applies to plan years beginning January 1, 2014 through December 31, 2016.

(2) As used in the Insurance Code for plan years beginning January 1, 2014 through December 31, 2016 only:

(a) "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 set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov.

(b) "Essential health benefits" means the following coverage provided in compliance with 45 CFR 156 :

(A) The base-benchmark health benefit plan, excluding the 24-month waiting period for transplant benefits;

(B) Pediatric dental benefits;

(C) Pediatric vision benefits; and

(D) Habilitative services.

(c) "Habilitative benefits" means the rehabilitative services provisions of the base benchmark when the services are medically necessary for the maintenance, learning or improving skills and function for daily living.

(d) "Pediatric dental benefits" means the benefits described in the children's dental provisions of the State Children's Health Insurance Plan as set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov. Pediatric dental benefits are payable to persons under 19 years of age.

(e) "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 set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov. Pediatric vision benefits are payable to persons under 19 years of age.

(3) 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.

Or. Admin. Code § 836-053-0008

ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16; ID 5-2016, f. & cert. ef. 4/26/2016; ID 15-2023, minor correction filed 06/23/2023, effective 6/23/2023

Statutory/Other Authority: ORS 731.097

Statutes/Other Implemented: ORS 731.097