Blog: Health Insurers Out Of Compliance With State Law – iHeart

Oregon insurers failed to fully comply with the Reproductive Health Equity Act (RHEA) in several areas, the Oregon Division of Financial Regulation concluded in a report the division released today. RHEA requires health insurers to cover certain reproductive health, sexual health, and other health care services – including contraception and abortion – without imposing cost sharing.

The report, which summarizes marketwide findings, came after the division discovered variations in coverage on RHEA claims and indications of potential widespread noncompliance with the law – specifically the inappropriate application of cost sharing for some services covered by RHEA. This prompted the division to conduct an audit – called a market conduct examination – on RHEA coverage and the insurers’ application of the law.

Generally, violations included failure to implement claims adjudication processes that identify services covered, failure to pay claims according to the requirements of the law, misinterpretation of cost-share requirements, improper application of medical management during claims adjudication, failure to update claims adjudication systems resulting in improper consumer cost share for RHEA services, and outdated consumer and provider complaint handling practices. Not every violation was found at every insurer. 

Some insurers failed to provide coverage of certain benefits until 2020 or later, including preventive services covered by the Affordable Care Act. Examinations also determined that specified services required to be covered without cost share by RHEA were being violated. Those violations included abortion, anemia screening, contraception, pregnancy screening, sterilization, and sexually transmitted infection screening.

The division is finalizing insurer-level reports for public release. As part of that process, the Insurance Code requires the division to provide an opportunity for insurers to review and comment on findings in a hearing with the division. Once finalized, the individual insurer reports will be published and made available to the public. In the interest of transparency, the division is releasing this anonymized, aggregate report while individual reports are being collated. 

In 2017, the Oregon Legislature passed House Bill 3391 – known as the Reproductive Health Equity Act. Some services required to be covered by RHEA are also required without cost sharing as a preventive service under the Affordable Care Act. Health benefit plans, such as individual, small group, and large group, are subject to RHEA. Other plans, such as those offered by a self-insured employers and Medicare, and plans that provide limited benefits, are not subject to RHEA. The enacted provisions of RHEA were applicable to commercial health insurance plans issued, renewed, modified, or extended on or after Jan. 1, 2019.

Source: Oregon Division of Financial Regulation

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