If the director determines that there exists a disease outbreak, epidemic or other condition of public health importance in a geographic area of this state or statewide, an insurer shall, for enrollees in a health benefit plan offered by the insurer, cover the cost of necessary antitoxins, serums, vaccines, immunizing agents, antibiotics, antidotes and other pharmaceutical agents, medical supplies or other prophylactic measures approved by the United States Food and Drug Administration that the director deems necessary to prevent the spread of the disease, epidemic or other condition of public health importance.
An insurer may not restrict coverage under subsection (2) of this section by:
Requiring that the health services be administered by an in-network provider;
Imposing cost-sharing requirements that are greater than the cost-sharing requirements for similar covered services;
Requiring prior authorization or other utilization review measures; or
(A) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce significant improvement in human social behavior, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, that is provided by:
“Applied behavior analysis” does not mean psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy and long-term counseling as treatment modalities.
“Autism spectrum disorder” has the meaning given that term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association.
“Diagnosis” means medically necessary assessment, evaluation or testing.
“Medically necessary” means in accordance with the definition of medical necessity that is specified in the policy or certificate for the health benefit plan and that applies to all covered services under the plan.
“Treatment for autism spectrum disorder” includes applied behavior analysis for up to 25 hours per week and any other mental health or medical services identified in the individualized treatment plan, as described in subsection (6) of this section.
A health benefit plan shall provide coverage of:
The screening for and diagnosis of autism spectrum disorder by a licensed neurologist, pediatric neurologist, developmental pediatrician, psychiatrist or psychologist, who has experience or training in the diagnosis of autism spectrum disorder; and
Medically necessary treatment for autism spectrum disorder and the management of care, for an individual who begins treatment before nine years of age, subject to the requirements of this section.
This section does not require coverage for:
Services provided by a family or household member;
Services that are custodial in nature or that constitute marital, family, educational or training services;
Custodial or respite care, equine assisted therapy, creative arts therapy, wilderness or adventure camps, social counseling, telemedicine, music therapy, neurofeedback, chelation or hyperbaric chambers;
Services provided under an individual education plan in accordance with the Individuals with Disabilities Education Act, 20 U.S.C. 1400 et seq.;
Services provided through community or social programs; or
Services provided by the Department of Human Services or the Oregon Health Authority, other than employee benefit plans offered by the department and the authority.
An insurer may not terminate coverage or refuse to issue or renew coverage for an individual solely because the individual has received a diagnosis of autism spectrum disorder or has received treatment for autism spectrum disorder.
Coverage under this section may be subject to utilization controls that are reasonable in the context of individual determinations of medical necessity. An insurer may require:
An autism spectrum disorder diagnosis by a professional described in subsection (2)(a) of this section if the original diagnosis was not made by a professional described in subsection (2)(a) of this section.
Prior authorization for coverage of a maximum of 25 hours per week of applied behavior analysis recommended in an individualized treatment plan approved by a professional described in subsection (2)(a) of this section for an individual with autism spectrum disorder, as long as the insurer makes a prior authorization determination no later than 30 calendar days after receiving the request for prior authorization, notwithstanding ORS 743B.423 (Utilization review requirements for insurers offering health benefit plan).
If an individual is receiving applied behavior analysis, an insurer may require submission of an individualized treatment plan, which shall include all elements necessary for the insurer to appropriately determine coverage under the health benefit plan. The individualized treatment plan must be based on evidence-based screening criteria. An insurer may require an updated individualized treatment plan, not more than once every six months, that includes observed progress as of the date the updated plan was prepared, for the purpose of performing utilization review and medical management. The insurer may require the individualized treatment plan to be approved by a professional described in subsection (2)(a) of this section, and to include the:
Proposed treatment by type;
Frequency and anticipated duration of treatment;
Anticipated outcomes stated as goals, including specific cognitive, social, communicative, self-care and behavioral goals that are clearly stated, directly observed and continually measured and that address the characteristics of the autism spectrum disorder; and
Signature of the treating provider.
(a) Once coverage for applied behavior analysis has been approved, the coverage continues as long as:
The individual continues to make progress toward the majority of the goals of the individualized treatment plan; and
Applied behavior analysis is medically necessary.
An insurer may require periodic review of an individualized treatment plan, as described in subsection (6) of this section, and modification of the individualized treatment plan if the review shows that the individual receiving the treatment is not making substantial clinical progress toward the goals of the individualized treatment plan.
Coverage under this section may be subject to requirements and limitations no more restrictive than those imposed on coverage or reimbursement of expenses arising from the treatment of other medical conditions under the policy or certificate, including but not limited to:
Requirements and limitations regarding in-network providers; and
Provisions relating to deductibles, copayments and coinsurance.
Treatment for autism spectrum disorder other than applied behavior analysis or the services described in subsection (3) of this section;
Applied behavior analysis for more than 25 hours per week; or
Applied behavior analysis for an individual if the coverage is first requested when the individual is nine years of age or older.
Coverage under this section includes treatment for autism spectrum disorder provided in the individual’s home or a licensed health care facility or, for treatment provided by a licensed health care professional as defined in ORS 676.802 (Definitions for ORS 676.802, 676.806 and 676.810 to 676.820) or a behavior analyst or assistant behavior analyst licensed under ORS 676.810 (Board duties), in a setting approved by the health care professional, behavior analyst or assistant behavior analyst.
An insurer that provides coverage of applied behavior analysis in accordance with a decision of an independent review organization that was made prior to January 1, 2016, shall continue to provide coverage, subject to modifications made in accordance with subsection (7) of this section.