(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to:
(a) Deductibles, copayments or coinsurance;
(b) Prior authorization or utilization review requirements; or
(c) Treatment limitations regarding the number of visits or the duration of treatment.
(3) As used in this section:
(a) "Medically necessary" means in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan.
(b) "Pervasive developmental disorder" means a neurological condition that includes autism spectrum disorder, developmental delay, developmental disability or mental retardation.
(c) "Rehabilitation services" means physical therapy, occupational therapy or speech therapy services to restore or improve function.
(4) The provisions of ORS 743A.001 do not apply to this section.
(5) The definition of "pervasive developmental disorder" is not intended to apply to coverage required under ORS 743A.168 or section 2, chapter 771, Oregon Laws 2013. [2007 c.872 §2; 2013 c.771 §7]
Note: The amendments to 743A.190 by section 20, chapter 771, Oregon Laws 2013, become operative January 2, 2030. See section 24, chapter 771, Oregon Laws 2013, as amended by section 6, chapter 674, Oregon Laws 2015, and section 2, chapter 650, Oregon Laws 2021. The text that is operative on and after January 2, 2030, is set forth for the user’s convenience.
(1) A health benefit plan, as defined in ORS 743B.005, must cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.
(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to:
(a) Deductibles, copayments or coinsurance;
(b) Prior authorization or utilization review requirements; or
(c) Treatment limitations regarding the number of visits or the duration of treatment.
(3) As used in this section:
(a) "Medically necessary" means in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan.
(b) "Pervasive developmental disorder" means a neurological condition that includes autism spectrum disorder, developmental delay, developmental disability or mental retardation.
(c) "Rehabilitation services" means physical therapy, occupational therapy or speech therapy services to restore or improve function.
(4) The provisions of ORS 743A.001 do not apply to this section.
(5) The definition of "pervasive developmental disorder" is not intended to apply to coverage required under ORS 743A.168.
Note: 743A.190 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.