Read the full stored bill text
83rd OREGON LEGISLATIVE ASSEMBLY--2025 Regular Session
Enrolled
House Bill 2013
Sponsored by Representative NOSSE; Representatives MUNOZ, NELSON (Presession filed.)
CHAPTER .................................................
AN ACT
Relating to mental health treatment providers; amending ORS 743A.168.
Be It Enacted by the People of the State of Oregon:
SECTION 1.
ORS 743A.168, as amended by section 3, chapter 70, Oregon Laws 2024, is amended
to read:
743A.168. (1) As used in this section:
(a) “Behavioral health assessment” means an evaluation by a provider, in person or using tele-
medicine, to determine a patient’s need for behavioral health treatment.
(b) “Behavioral health condition” has the meaning prescribed by rule by the Department of
Consumer and Business Services.
(c) “Behavioral health crisis” means a disruption in an insured’s mental or emotional stability
or functioning resulting in an urgent need for immediate outpatient treatment in an emergency de-
partment or admission to a hospital to prevent a serious deterioration in the insured’s mental or
physical health.
(d) “Facility” means a corporate or governmental entity or other provider of services for the
treatment of behavioral health conditions.
(e) “Generally accepted standards of care” means:
(A) Standards of care and clinical practice guidelines that:
(i) Are generally recognized by health care providers practicing in relevant clinical specialties;
and
(ii) Are based on valid, evidence-based sources; and
(B) Products and services that:
(i) Address the specific needs of a patient for the purpose of screening for, preventing, diagnos-
ing, managing or treating an illness, injury or condition or symptoms of an illness, injury or condi-
tion;
(ii) Are clinically appropriate in terms of type, frequency, extent, site and duration; and
(iii) Are not primarily for the economic benefit of an insurer or payer or for the convenience
of a patient, treating physician or other health care provider.
(f) “Group health insurer” means an insurer, a health maintenance organization or a health care
service contractor.
(g) “Median maximum allowable reimbursement rate” means the median of all maximum allow-
able reimbursement rates, minus incentive payments, paid for each billing code for each provider
type during a calendar year.
(h) “Prior authorization” has the meaning given that term in ORS 743B.001.
Enrolled House Bill 2013 (HB 2013-A) Page 1
(i) “Program” means a particular type or level of service that is organizationally distinct within
a facility.
(j) “Provider” means:
(A) A behavioral health professional or medical professional licensed or certified in this state
who has met the credentialing requirement of a group health insurer or an issuer of an individual
health benefit plan that is not a grandfathered health plan as defined in ORS 743B.005 and is oth-
erwise eligible to receive reimbursement for coverage under the policy;
(B) A health care facility as defined in ORS 433.060;
(C) A residential facility as defined in ORS 430.010;
(D) A day or partial hospitalization program;
(E) An outpatient service as defined in ORS 430.010; [or]
(F) A licensed outpatient facility with a certified substance use disorder program that
employs certified alcohol and drug counselor level providers; or
[(F)] (G) A provider organization certified by the Oregon Health Authority under subsection (9)
of this section.
(k) “Relevant clinical specialties” includes but is not limited to:
(A) Psychiatry;
(B) Psychology;
(C) Clinical sociology;
(D) Addiction medicine and counseling; and
(E) Behavioral health treatment.
(L) “Standards of care and clinical practice guidelines” includes but is not limited to:
(A) Patient placement criteria;
(B) Recommendations of agencies of the federal government; and
(C) Drug labeling approved by the United States Food and Drug Administration.
(m) “Utilization review” has the meaning given that term in ORS 743B.001.
(n) “Valid, evidence-based sources” includes but is not limited to:
(A) Peer-reviewed scientific studies and medical literature;
(B) Recommendations of nonprofit health care provider professional associations; and
(C) Specialty societies.
(2) A group health insurance policy or an individual health benefit plan that is not a grandfa-
thered health plan providing coverage for hospital or medical expenses, other than limited benefit
coverage, shall provide coverage for expenses arising from the diagnosis of behavioral health con-
ditions and medically necessary behavioral health treatment at the same level as, and subject to
limitations no more restrictive than, those imposed on coverage or reimbursement of expenses aris-
ing from treatment for other medical conditions. The following apply to coverage for behavioral
healthtreatment:
(a) The coverage may be made subject to provisions of the policy that apply to other benefits
under the policy, including but not limited to provisions relating to copayments, deductibles and
coinsurance. Copayments, deductibles and coinsurance for treatment in health care facilities or
residential facilities may not be greater than those under the policy for expenses of hospitalization
in the treatment of other medical conditions. Copayments, deductibles and coinsurance for outpa-
tient treatment may not be greater than those under the policy for expenses of outpatient treatment
of other medical conditions.
(b) The coverage of behavioral health treatment may not be made subject to treatment limita-
tions, limits on total payments for treatment, limits on duration of treatment or financial require-
ments unless similar limitations or requirements are imposed on coverage of other medical
conditions. The coverage of eligible expenses of behavioral health treatment may be limited to
treatment that is medically necessary as determined in accordance with this section and no more
stringently under the policy than for other medical conditions.
(c) The coverage of behavioral health treatment must include:
(A) A behavioral health assessment;
Enrolled House Bill 2013 (HB 2013-A) Page 2
(B) No less than the level of services determined to be medically necessary in a behavioral
health assessment of the specific needs of a patient or in a patient’s care plan:
(i) To effectively treat the patient’s underlying behavioral health condition rather than the mere
amelioration of current symptoms such as suicidal ideation or psychosis; and
(ii) For care following a behavioral health crisis, to transition the patient to a lower level of
care;
(C) Treatment of co-occurring behavioral health conditions or medical conditions in a coordi-
nated manner;
(D) Treatment at the least intensive and least restrictive level of care that is safe and most ef-
fective and meets the needs of the insured’s condition;
(E) A lower level or less intensive care only if it is comparably as safe and effective as treat-
ment at a higher level of service or intensity;
(F) Treatment to maintain functioning or prevent deterioration;
(G) Treatment for an appropriate duration based on the insured’s particular needs;
(H) Treatment appropriate to the unique needs of children and adolescents;
(I) Treatment appropriate to the unique needs of older adults; and
(J) Coordinated care and case management as defined by the Department of Consumer and
Business Services by rule.
(d) The coverage of behavioral health treatment may not limit coverage for treatment of perva-
sive or chronic behavioral health conditions to short-term or acute behavioral health treatment at
any level of care or placement.
(e) A group health insurer or an issuer of an individual health benefit plan other than a grand-
fathered health plan shall have a network of providers of behavioral health treatment sufficient to
meet the standards described in ORS 743B.505. If there is no in-network provider qualified to timely
deliver, as defined by rule, medically necessary behavioral treatment to an insured in a geographic
area, the group health insurer or issuer of an individual health benefit plan shall provide coverage
of out-of-network medically necessary behavioral health treatment without any additional out-of-
pocket costs if provided by an available out-of-network provider that enters into an agreement with
the insurer to be reimbursed at in-network rates.
(f) A provider is eligible for reimbursement under this section if:
(A) The provider is approved or certified by the Oregon Health Authority;
(B) The provider is accredited for the particular level of care for which reimbursement is being
requested by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities;
(C) The patient is staying overnight at the facility and is involved in a structured program at
least eight hours per day, five days per week; or
(D) The provider is providing a covered benefit under the policy.
(g) A group health insurer or an issuer of an individual health benefit plan other than a
grandfathered health plan must use the same methodology to set reimbursement rates paid to be-
havioral health treatment providers that the group health insurer or issuer of an individual health
benefit plan uses to set reimbursement rates for medical and surgical treatment providers.
(h) A group health insurer or an issuer of an individual health benefit plan other than a
grandfathered health plan must update the methodology and rates for reimbursing behavioral health
treatment providers in a manner equivalent to the manner in which the group health insurer or
issuer of an individual health benefit plan updates the methodology and rates for reimbursing med-
ical and surgical treatment providers, unless otherwise required by federal law.
(i) A group health insurer or an issuer of an individual health benefit plan other than a grand-
fathered health plan that reimburses out-of-network providers for medical or surgical services must
reimburse out-of-network behavioral health treatment providers on the same terms and at a rate that
is in parity with the rate paid to medical or surgical treatment providers.
(j) Outpatient coverage of behavioral health treatment shall include follow-up in-home service
or outpatient services if clinically indicated under criteria and guidelines described in subsection (5)
of this section. The policy may limit coverage for in-home service to persons who are homebound
Enrolled House Bill 2013 (HB 2013-A)Page 3
under the care of a physician only if clinically indicated under criteria and guidelines described in
subsection (5) of this section.
(k)(A) Subject to section 2, chapter 70, Oregon Laws 2024, and to the patient or client
confidentiality provisions of ORS 40.235 relating to physicians, ORS 40.240 relating to nurse practi-
tioners, ORS 40.230 relating to psychologists, ORS 40.250 and 675.580 relating to licensed clinical
social workers and ORS 40.262 relating to licensed professional counselors and licensed marriage
and family therapists, a group health insurer or issuer of an individual health benefit plan may
provide for review for level of treatment of admissions and continued stays for treatment in health
facilities, residential facilities, day or partial hospitalization programs and outpatient services by
either staff of a group health insurer or issuer of an individual health benefit plan or personnel
under contract to the group health insurer or issuer of an individual health benefit plan that is not
a grandfathered health plan, or by a utilization review contractor, who shall have the authority to
certify for or deny level of payment.
(B) Review shall be made according to criteria made available to providers in advance upon
request.
(C) Review shall be performed by or under the direction of a physician licensed under ORS
677.100 to 677.228, a psychologist licensed by the Oregon Board of Psychology, a clinical social
worker licensed by the State Board of Licensed Social Workers or a professional counselor or
marriage and family therapist licensed by the Oregon Board of Licensed Professional Counselors and
Therapists, in accordance with standards of the National Committee for Quality Assurance or
Medicare review standards of the Centers for Medicare and Medicaid Services.
(D) Review may involve prior authorization, concurrent review of the continuation of treatment,
post-treatment review or any combination of these. However, if prior authorization is required,
provision shall be made to allow for payment of urgent or emergency admissions, subject to subse-
quent review. If prior authorization is not required, group health insurers and issuers of individual
health benefit plans that are not grandfathered health plans shall permit providers, policyholders
or persons acting on their behalf to make advance inquiries regarding the appropriateness of a
particular admission to a treatment program. Group health insurers and issuers of individual health
benefit plans that are not grandfathered health plans shall provide a timely response to such in-
quiries. Noncontracting providers must cooperate with these procedures to the same extent as con-
tracting providers to be eligible for reimbursement.
(L) Health maintenance organizations may limit the receipt of covered services by enrollees to
services provided by or upon referral by providers contracting with the health maintenance organ-
ization. Health maintenance organizations and health care service contractors may create substan-
tive plan benefit and reimbursement differentials at the same level as, and subject to limitations no
more restrictive than, those imposed on coverage or reimbursement of expenses arising out of other
medical conditions and apply them to contracting and noncontracting providers.
(3) Except as provided in section 2, chapter 70, Oregon Laws 2024, this section does not prohibit
a group health insurer or issuer of an individual health benefit plan that is not a grandfathered
health plan from managing the provision of benefits through common methods, including but not
limited to selectively contracted panels, health plan benefit differential designs, preadmission
screening, prior authorization of services, utilization review or other mechanisms designed to limit
eligible expenses to those described in subsection (2)(b) of this section provided such methods com-
ply with the requirements of this section.
(4) The Legislative Assembly finds that health care cost containment is necessary and intends
to encourage health insurance plans designed to achieve cost containment by ensuring that re-
imbursement is limited to appropriate utilization under criteria incorporated into the insurance, ei-
ther directly or by reference, in accordance with this section.
(5)(a) Any medical necessity, utilization or other clinical review conducted for the diagnosis,
prevention or treatment of behavioral health conditions or relating to service intensity, level of care
placement, continued stay or discharge must be based solely on the following:
(A) The current generally accepted standards of care.
Enrolled House Bill 2013 (HB 2013-A) Page 4
(B) For level of care placement decisions, the most recent version of the levels of care place-
ment criteria developed by the nonprofit professional association for the relevant clinical specialty.
(C) For medical necessity, utilization or other clinical review conducted for the diagnosis, pre-
vention or treatment of behavioral health conditions that does not involve level of care placement
decisions, other criteria and guidelines may be utilized if such criteria and guidelines are based on
the current generally accepted standards of care including valid, evidence-based sources and current
treatment criteria or practice guidelines developed by the nonprofit professional association for the
relevant clinical specialty. Such other criteria and guidelines must be made publicly available and
made available to insureds upon request to the extent permitted by copyright laws.
(b) This subsection does not prevent a group health insurer or an issuer of an individual health
benefit plan other than a grandfathered health plan from using criteria that:
(A) Are outside the scope of criteria and guidelines described in paragraph (a)(B) of this sub-
section, if the guidelines were developed in accordance with the current generally accepted stand-
ards of care; or
(B) Are based on advancements in technology of types of care that are not addressed in the most
recent versions of sources specified in paragraph (a)(B) of this subsection, if the guidelines were
developed in accordance with current generally accepted standards of care.
(c) For all level of care placement decisions, an insurer shall authorize placement at the level
of care consistent with the insured’s score or assessment using the relevant level of care placement
criteria and guidelines as specified in paragraph (a)(B) of this subsection. If the level of care indi-
cated by the criteria and guidelines is not available, the insurer shall authorize the next higher level
of care. If there is disagreement about the appropriate level of care, the insurer shall provide to the
provider of the service the full details of the insurer’s scoring or assessment using the relevant level
of care placement criteria and guidelines specified in paragraph (a)(B) of this subsection.
(6) To ensure the proper use of any criteria and guidelines described in subsection (5) of this
section, a group health insurer or an issuer of an individual health benefit plan shall provide, at no
cost:
(a) A formal education program, presented by nonprofit clinical specialty associations or other
entities authorized by the department, to educate the insurer’s or the issuer’s staff and any indi-
viduals described in subsection (2)(k) of this section who conduct reviews.
(b) To stakeholders, including participating providers and insureds, the criteria and guidelines
described in subsection (5) of this section and any education or training materials or resources re-
garding the criteria and guidelines.
(7) This section does not prevent a group health insurer or issuer of an individual health benefit
plan that is not a grandfathered health plan from contracting with providers of health care services
to furnish services to policyholders or certificate holders according to ORS 743B.460 or 750.005,
subject to the following conditions:
(a) A group health insurer or issuer of an individual health benefit plan that is not a grandfa-
thered health plan is not required to contract with all providers that are eligible for reimbursement
under this section.
(b) An insurer or health care service contractor shall, subject to subsection (2) of this section,
pay benefits toward the covered charges of noncontracting providers of services for behavioral
health treatment. The insured shall, subject to subsection (2) of this section, have the right to use
the services of a noncontracting provider of behavioral health treatment, whether or not the be-
havioral health treatment is provided by contracting or noncontracting providers.
(8)(a) This section does not require coverage for:
(A) Educational or correctional services or sheltered living provided by a school or halfway
house;
(B) A long-term residential mental health program that lasts longer than 45 days unless clin-
ically indicated under criteria and guidelines described in subsection (5) of this section;
(C) Psychoanalysis or psychotherapy received as part of an educational or training program,
regardless of diagnosis or symptoms that may be present;
Enrolled House Bill 2013 (HB 2013-A) Page 5
(D) A court-ordered sex offender treatment program; or
(E) Support groups.
(b) Notwithstanding paragraph (a)(A) of this subsection, an insured may receive covered outpa-
tient services under the terms of the insured’s policy while the insured is living temporarily in a
sheltered living situation.
(9) The Oregon Health Authority shall establish a process for the certification of an organiza-
tion described in subsection [ (1)(j)(F)] (1)(j)(G) of this section that:
(a) Is not otherwise subject to licensing or certification by the authority; and
(b) Does not contract with the authority, a subcontractor of the authority or a community
mental health program.
(10) The Oregon Health Authority shall adopt by rule standards for the certification provided
under subsection (9) of this section to ensure that a certified provider organization offers a distinct
and specialized program for the treatment of mental or nervous conditions.
(11) The Oregon Health Authority may adopt by rule an application fee or a certification fee,
or both, to be imposed on any provider organization that applies for certification under subsection
(9) of this section. Any fees collected shall be paid into the Oregon Health Authority Fund estab-
lished in ORS 413.101 and shall be used only for carrying out the provisions of subsection (9) of this
section.
(12) The intent of the Legislative Assembly in adopting this section is to reserve benefits for
different types of care to encourage cost effective care and to ensure continuing access to levels
of care most appropriate for the insured’s condition and progress in accordance with this section.
This section does not prohibit an insurer from requiring a provider organization certified by the
Oregon Health Authority under subsection (9) of this section to meet the insurer’s credentialing
requirements as a condition of entering into a contract.
(13) The Director of the Department of Consumer and Business Services and the Oregon Health
Authority, after notice and hearing, may adopt reasonable rules not inconsistent with this section
that are considered necessary for the proper administration of this section. The director shall adopt
rules making it a violation of this section for a group health insurer or issuer of an individual health
benefit plan other than a grandfathered health plan to require providers to bill using a specific
billing code or to restrict the reimbursement paid for particular billing codes other than on the basis
of medical necessity.
(14) This section does not:
(a) Prohibit an insured from receiving behavioral health treatment from an out-of-network pro-
vider or prevent an out-of-network behavioral health provider from billing the insured for any un-
reimbursed cost of treatment.
(b) Prohibit the use of value-based payment methods, including global budgets or capitated,
bundled, risk-based or other value-based payment methods.
(c) Require that any value-based payment method reimburse behavioral health services based
on an equivalent fee-for-service rate.
Enrolled House Bill 2013 (HB 2013-A) Page 6
Passed by House April 21, 2025
..................................................................................
Timothy G. Sekerak, Chief Clerk of House
..................................................................................
Julie Fahey, Speaker of House
Passed by Senate May 21, 2025
..................................................................................
Rob Wagner, President of Senate
Received by Governor:
........................M.,........................................................., 2025
Approved:
........................M.,........................................................., 2025
..................................................................................
Tina Kotek, Governor
Filed in Office of Secretary of State:
........................M.,........................................................., 2025
..................................................................................
Tobias Read, Secretary of State
Enrolled House Bill 2013 (HB 2013-A) Page 7