This text of Oregon § 743A.112 (Autologous breast reconstruction procedures) is published on Counsel Stack Legal Research, covering Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
(1)As used in this section:
(a)“Accepted standard of care” means standards of care and clinical practice guidelines that are:
(A)Generally recognized by health care providers practicing in relevant clinical specialties; and
(B)Based on valid, evidence-based sources.
(b)“Autologous breast reconstruction procedure” includes but is not limited to:
(A)Superior gluteal artery perforator flap;
(B)Inferior gluteal artery perforator flap;
(C)Intercostal artery perforator flap;
(D)Lateral thigh perforator flap;
(E)Lumbar artery perforator flap;
(F)Muscle sparing transverse upper gracilis flap;
(G)Profunda artery perforator flap;
(H)Superficial inferior epigastric artery flap;
(I)Abdominal perforator exchange flap;
(J)Thoracodorsal artery perforator flap;
(K)Body lift perforator flap
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(1) As used in this section:
(a) “Accepted standard of care” means standards of care and clinical practice guidelines that are:
(A) Generally recognized by health care providers practicing in relevant clinical specialties; and
(B) Based on valid, evidence-based sources.
(b) “Autologous breast reconstruction procedure” includes but is not limited to:
(A) Superior gluteal artery perforator flap;
(B) Inferior gluteal artery perforator flap;
(C) Intercostal artery perforator flap;
(D) Lateral thigh perforator flap;
(E) Lumbar artery perforator flap;
(F) Muscle sparing transverse upper gracilis flap;
(G) Profunda artery perforator flap;
(H) Superficial inferior epigastric artery flap;
(I) Abdominal perforator exchange flap;
(J) Thoracodorsal artery perforator flap;
(K) Body lift perforator flap;
(L) Stacked hemiabdominal extended perforator flap;
(M) Deep inferior epigastric perforator artery;
(N) Hybrid procedures that involve both an autologous breast reconstruction procedure listed in this paragraph and breast implantations; and
(O) Any combination of the procedures listed in this paragraph.
(c) “In-network” has the meaning given that term in ORS 743B.275.
(d) “Out-of-network” has the meaning given that term in ORS 743B.275.
(e) “Revision to autologous breast reconstruction procedure” includes but is not limited to:
(A) Liposuction;
(B) Grafting;
(C) Nipple reconstruction;
(D) Nipple and areola tattoos;
(E) Fat necrosis excision;
(F) Capsulotomy; and
(G) Breast capsulorrhaphy.
(2) When prescribed in accordance with accepted standards of care by a licensed health care provider, a health benefit plan offered in this state that provides coverage of breast reconstruction services must provide coverage for autologous breast reconstruction procedures and all related medically necessary inpatient and outpatient services, procedures and imaging including but not limited to revisions to autologous breast reconstruction procedures.
(3) A health benefit plan that provides coverage of autologous breast reconstruction procedures described in subsection (2) of this section, must provide coverage on a basis no less favorable than the coverage of other covered breast reconstruction services, including utilization review requirements.
(4)(a) A carrier offering a health benefit plan shall:
(A) Satisfy network adequacy standards as described in ORS 743B.505 relating to the coverage required in subsection (2) of this section; and
(B)(i) Contract with a network of providers that is sufficient in numbers and geographic locations to ensure that the services and procedures described in subsection (2) of this section are accessible to all enrollees without unreasonable delay; or
(ii) Contract with an out-of-network provider on a case-by-case basis to ensure that the services and procedures described in subsection (2) of this section are provided to an enrollee without unreasonable delay.
(b) If the carrier does not meet the requirements described in paragraph (a)(B) of this subsection, then the carrier:
(A) May not impose a deductible, out-of-pocket maximum, copayment or coinsurance requirement that exceeds the deductible, out-of-pocket maximum, copayment or coinsurance applicable to in-network providers of the coverage described in this section; and
(B) Must reimburse out-of-network providers for the services and procedures specified in subsection (2) of this section at rates that are no less than the average amount of in-network reimbursement rates paid by the plan for comparable services and procedures.
(c) As used in this subsection, “carrier” has the meaning given that term in ORS 743B.005.
(5) This section is exempt from ORS 743A.001.