Or. Admin. Code § 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.
Notes
Statutory/Other Authority: ORS 731.244 & ORS 743A.168
Statutes/Other Implemented: ORS 743A.168
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