Or. Admin. Code § 836-053-1405

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

Section 836-053-1405 - General Requirements for Coverage of Behavioral Health Conditions

(1) A group health insurance policy or an individual health benefit plan issued or renewed in this state shall provide coverage or reimbursement for medically necessary treatment of behavioral health conditions, including but not limited to prescription drugs, at the same level as, and subject to limitations no more restrictive than, those imposed on coverage or reimbursement for medically necessary treatment for medical conditions.

(a) The coverage may be made subject to provisions of the policy that apply to other benefits under the policy, including but not limited to provisions relating to copayments, deductibles and coinsurance. Copayments, deductibles and coinsurance for behavioral health treatment may not be greater than those under the policy for medical conditions.

(b) The coverage of behavioral health treatment may not be made subject to treatment limitations, limits on total payments for treatment, limits on duration of treatment or financial requirements unless similar limitations or requirements are imposed on coverage of medical conditions.

(c) The parity requirements in subsections (1)(a) and (b) must comply with the "predominant" and "substantially all" tests in the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, 29 U.S.C. 1185a and implementing regulations at 45 CFR 146.136 and 45 CFR 147.160.

(d) If annual or lifetime limits apply for treatment of behavioral health conditions the limits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, 29 U.S.C. 1185a and implementing regulations at 45 CFR 146.136 and 147.160.

(e) Classification of prescription drugs into open, closed, or tiered drug benefit formularies, for drugs intended to treat behavioral health conditions must be by the same process as drug selection for formulary status applied for drugs intended to treat medical conditions, regardless of whether such drugs are intended to treat behavioral health conditions or medical conditions.

(f) The coverage of behavioral health treatment may not limit coverage for treatment of pervasive or chronic behavioral health conditions to short-term or acute behavioral health treatment at any level of care or placement.

(g) The coverage of behavioral health treatment must include clinically indicated outpatient coverage including follow-up in-home services or other outpatient services. The policy may limit coverage only if clinically indicated under any medical necessity, utilization or other clinical review conducted for the diagnosis, prevention or treatment of behavioral health conditions or relating to service intensity, level of care placement, continued stay or discharge. Utilization and clinical review policies and procedures must meet the requirements of OAR 836-053-1405(9), (10), (11), and (12), as well as comply with the entire definition of "generally accepted standards of care" in OAR 836-053-1404.

(2) A group health insurer or an issuer of an individual health benefit plan issued of renewed in this state must use the same methodology to set reimbursement rates paid to behavioral health treatment providers that the group health insurer or issuer of an individual health benefit plan uses to set reimbursement rates for medical and surgical treatment providers.

(3) A group health insurer or an issuer of an individual health benefit plan issued or renewed in this state must update the methodology and rates for reimbursing behavioral health treatment providers in a manner equivalent to the manner in which the group health insurer or issuer of an individual health benefit plan updates the methodology and rates for reimbursing medical and surgical treatment providers, unless otherwise required by federal law.

(4) A group health insurance policy or an individual health benefit plan issued or renewed in this state must contain a single definition of medical necessity that applies uniformly to all medical and behavioral health conditions.

(5) A group health insurance policy or an individual health benefit plan in this state shall have policies and procedures in place to ensure uniform application of the policy's definition of medical necessity to all medical and behavioral health conditions.

(6) Subject to subsection (5) of ORS 743A.168 and OAR 836-053-1405(7) through (12) coverage for expenses arising from treatment for behavioral health conditions may be managed through common methods designed to limit eligible expenses to treatment that is medically necessary only if similar limitations or requirements are imposed on coverage for expenses arising from a medical condition. Common methods include, but are not limited to, selectively contracted panels, health policy benefit differential designs, preadmission screening, prior authorization of services, case management, utilization review, or other mechanisms designed to limit eligible expenses to treatment that is medically necessary.

(7) Any medical necessity, utilization or other clinical review, not related to level of care placement decisions, must be based on:

(a) The current generally accepted standards of care; or

(b) Treatment criteria guidelines developed by the nonprofit professional association for the relevant clinical specialty.

(8) For medical necessity, utilization or other clinical review not related to level of care placement decisions, other criteria may be utilized as long as it is based on the current generally accepted standards of care including valid, evidence-based sources.

(9) Any medical necessity, utilization or other clinical review relating to level of care placement decisions must be based on:

(a) The current generally accepted standards of care; and

(b) The version available in 2021 of the levels of care placement criteria developed by the nonprofit professional association for the relevant clinical specialty.

(10) In instances where there are no guidelines or criteria from the nonprofit professional association for the relevant clinical specialty, other criteria may be utilized if the criteria are based on the generally accepted standards of care, and may include advancements in technology of types of care. Other criteria utilized must be made available to the department upon request.

(11) For purposes of medical necessity, utilization or other clinical review relating to level of care placement decisions the following guidelines or criteria will be considered compliant:

(a) For a primary substance use disorder diagnosis in adolescents and adults, the ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd Edition (2013), by the American Society of Addiction Medicine (https://www.asam.org/asam-criteria).

(b) For a primary mental health diagnosis in adults nineteen (19) years of age and older, the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS), Adult Version 20, by the American Association American Association for Community Psychiatry (https://sites.google.com/view/aacp123/resources/locus).

(c) For a primary mental health diagnosis in children six (6) to eighteen (18) years of age, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) by the American Association for Community Psychiatry and the American Academy of Child and Adolescent Psychiatry (https://www.aacap.org/aacap/Member_Resources/Practice_Information/CALOCUS_CASII.aspx).

(d) For a primary mental health diagnosis in children five (5) years of age and younger, Early Child Service Intensity Instrument (ECSII) by the American Academy of Child and Adolescent Psychiatry (https://www.aacap.org/aacap/Member_Resources/Practice_Information/ECSII.aspx).

(12) All level of care placement decisions must be authorized at the level of care consistent with the insured's score or assessment using generally accepted standards of care and the relevant level of care placement criteria and guidelines developed by the nonprofit professional association for the relevant clinical specialty. If the level of care indicated by the criteria and guidelines is not available, the insurer shall authorize the next highest level of care based on the generally accepted standards of care. If there is disagreement about the appropriate level of care, the insurer shall provide to the provider of the service the full details of the insurer's scoring or assessment using the relevant level of care placement criteria and guidelines including information on the generally accepted standards of care or other criteria used to make the level of care decision.

(13) A group health insurer or an individual health benefit plan shall provide, at no cost:

(a) A one-time formal education program for the insurer and insurer staff who conduct medical necessity, utilization and other clinical reviews on the proper use of such reviews. The training must be presented by nonprofit clinical specialty associations or other entities authorized by the department.

(b) Medical necessity, utilization or other clinical review criteria used by the insurer, and any education or training materials regarding medical necessity, utilization or other clinical review criteria to stakeholders, including participating providers and enrollees.

(c) Nothing in this section prohibits a group health insurer or an issuer of an individual health benefit plan from requiring providers to bill in accordance with generally accepted coding standards including the National Correct Coding Initiative.

(14) A group health insurer or an individual health benefit plan may not require providers to bill using a specific billing code or to restrict the reimbursement paid for particular billing codes other than on the basis of medical necessity.

(15) This rule does not:

(a) Prohibit an insured from receiving behavioral health treatment from an out-of-network provider or prevent an out-of-network behavioral health provider from billing the insured for any unreimbursed cost of treatment, to the extent permitted under state and federal law.

(b) Prohibit the use of value-based payment methods, including global budgets or capitated, bundled, risk-based or other value-based payment methods.

(c) Require that any value-based payment method reimburse behavioral health services based on an equivalent fee-for-service rate.

(16) Nothing in this rule prevents a group health insurance policy or an individual health benefit plan from providing coverage for conditions or disorders excepted under the definition of "behavioral health condition" in OAR 836-053-1404.

(17) The director shall review OAR 836-053-1404 to 836-053-1408 and any other materials every two years to determine whether the requirements set forth in the rules are uniformly applied to all medical and behavioral health conditions.

Or. Admin. Code § 836-053-1405

ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13; ID 3-2013, f. 6-10-13, cert. ef. 6-17-13; ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16; ID 5-2016, f. & cert. ef. 4/26/2016; ID 8-2022, amend filed 12/22/2022, effective 1/1/2023

Statutory/Other Authority: ORS 731.244, ORS 743A.168 & Or Laws 2021, ch 629

Statutes/Other Implemented: ORS 743A.168 & Or Laws 2021, ch 629