OAR 836-053-0027: Copayments for Certain Primary Care Visits

(1) As used in this section, “primary care” means outpatient behavioral health services, non-specialty medical services or the coordination of health care for the purpose of: (a) Promoting or maintaining behavioral and physical health and wellness; and (b) Diagnosis, treatment or management of acute or chronic conditions caused by disease, injury or illness. (2) An individual or group policy or certificate of health insurance that is not offered on the health insurance exchange and that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, shall, in each plan year, reimburse the cost of at least three primary care visits for behavioral health or physical health treatment. (3) The coverage under subsection (2) of this section: (a) May not be subject to copayments, coinsurance or deductibles in excess of $5, except as provided in ORS 742.008; and (b) Is in addition to one annual preventive primary care visit that must be covered without cost-sharing. (4) An insurer that offers a qualified health plan on the health insurance exchange must offer at least one plan in each metal tier offered by the insurer that provides the coverage described in subsections (2) and (3) of this section. (5) This section does not apply to health benefit plans offered to public employees by insurers that contract with the Public Employees’ Benefit Board or the Oregon Educators' Benefit Board.