Background
Mental Health Parity was passed to right a wrong. It was unfair to discriminate against mental conditions and chemical dependency. These conditions must be covered at the same level as any medical condition.
Oregon's Mental Health Parity
Mental Health Parity was passed by the 2005 Oregon Legislature. It requires group health insurance policies to cover treatment for mental or nervous conditions and chemical dependency at the same level, with no more restrictions than those imposed on other medical conditions. Oregon's mental health parity law covers most conditions listed in the DSM-TR including Pervasive Developmental Disorders. Exclusions are listed here.
Oregon's mental health parity law does not cover learning disabilities such a reading, math, or disorders of writing expression. Oregon's mental health parity law does not cover mental retardation. (Mental retardation is sometimes a co-morbid condition associated with autism, however autism is the primary diagnosis and therefore covered under Oregon's mental health parity law.)
You are probably wondering why autism is covered under mental health parity because it is a neurobiological condition. Mental health parity in Oregon covers most mental and nervous conditions listed in the DSM-TR as well as chemical dependency. Because Pervasive Developmental Disorders, also referred to as Autism Spectrum Disorders, are contained in the DSM-TR, they are covered under Oregon's mental health parity law. They are also covered under HB 2918 which classifies Pervasive Developmental Disorders as neurological conditions.
Mental health parity took effect on January 1, 2007 for new group health insurance policies and, for renewal policies, the first renewal date after January 1, 2007. Please contact your insurance company to determine the effective date in your plan.
Oregon's mental health parity law only applies to group health policies. It does not apply to individual health insurance or self insured employer group plans. Please ask your employer or the Oregon Insurance Division what kind of plan you have.
Self insured employer plans are subject to the ERISA Act and can only be mandated at a federal level and not a state level. "Federal law prohibits most state regulation of self-insured groups. Many large employers provide health coverage to their employees by paying the cost of the health care directly, rather than by purchasing insurance. Because these employers often contract with insurance companies to administer employee claims, the plans look like insurance to the employees but are not subject to state laws. Federal law does mandate certain benefits, such as maternity coverage, but federal mandates are generally not as extensive as Oregon mandates. For example, Oregon's mental health parity law requires broader coverage than the federal mental health law." - Oregon Insurance Division.
The good news is that most self insured companies choose to follow state mandates. If you work for a self insured company in Oregon, please inform them about Oregon's mental health parity law. This is what the state of Oregon deems to be the appropriate minimum coverage.
Medical necessity is not defined under Oregon's mental health parity law. The law does require insurance policies to contain a single definition of medical necessity that applies uniformly to all medical, mental or nervous conditions and chemical dependency. Contact your insurance company to get the policy definition of medical necessity.
Insurance carriers also have their own definition of what an experimental or investigational treatment or procedure is. Please ask your insurance company for their definition.
If an insurance carrier denies coverage stating a treatment is not medically necessary or is considered investigational or experimental, you have the right to both internal appeals with your insurance company and to an Independent External Review.
The grievance and appeal process involves an initial complaint to your insurance company, followed by a first and second level appeal, and then an optional external review. We recommend that you go all the way through external review. (See parent stories.)
Independent Review Organizations (IROs) will make decisions based on the coverage described in your plan. The IRO may override the insurer's standards for medically necessary or experimental/investigational treatment if the insurance company's standards are unreasonable or are inconsistent with sound medical practice.
If you have any questions about Oregon's mental health parity law, or your rights as a consumer, please contact the Oregon Insurance Division. Free help is available to consumers. Advocates will investigate your complaint, help you get a clear response to your questions, and advocate on your behalf to resolve issues. Download brochure.
SB1 Rules
Written Testimony Submitted at the SB1 Rulemaking Hearing
Hearing Officer's Recommendations concerning the SB1 Rules
Mental Health Parity Rules Press Release
SB1 Complaint Update
As of December 19, 2007:
There have been 35 complaints filed with the Oregon Insurance Division concerning SB1. Of the 35 complaints, 13 were autism related. For monitoring the efficacy of this legislation, it is vitally important to file a complaint with the Oregon Insurance Division if you receive a denial for coverage from your health insurance company. https://www4.cbs.state.or.us/exs/ins/complaint/