The Oregon Reproductive Health Equity Act (RHEA) was enacted in 2017 to provide a wide range of reproductive health services to health benefit plan enrollees without cost sharing. State-regulated insurance plans, such as individual, small group, and large group, are subject to RHEA. Other plans, such as those sponsored by a self-insured employer and Medicare, are not subject to RHEA. The requirements in RHEA apply to health benefit plans issued, renewed, modified, or extended on or after Jan. 1, 2019.
Starting in 2017, the Division of Financial Regulation continuously worked with the insurance industry and other stakeholders to provide guidance and write rules on the requirements of RHEA, including subsequent legislative changes in 2018 and 2019.
2020 data call
The division issued a data call in 2020 to enable it to evaluate insurer compliance with the law. The data call requested information on a limited set of RHEA-covered services in the individual, small group, and large group markets that revealed variations in coverage and indications of potential widespread noncompliance with the law – specifically the impermissible application of cost sharing for some services covered by RHEA.
Market conduct examinations
Based on the results of the data call, the division decided to conduct simultaneous market conduct examinations of all 12 health insurance companies offering health benefit plans in Oregon to evaluate their compliance with RHEA. Data calls and market exams are both tools the division can use to determine if a market (such as health benefit plans) or individual insurers are in compliance with insurance regulations. While a data call requires a response from insurers to questions posed by the division, a market conduct examination is a formal investigation, similar to an audit, of the insurers' practices, documents, procedures, and other aspects related to the matter under examination.
The division contracted with three examination companies to conduct the examinations under the division's oversight. To ensure consistency in the exam process, the division prepared a detailed Coordinator's Handbook that described required exam elements and examination instructions.
The RHEA examinations covered the period of claims adjudicated from Jan. 1, 2019, to Dec. 31, 2020. All claims with services covered by RHEA were subject to sample testing in the examination. Due to the COVID-19 pandemic, all but one of the examinations were performed remotely and insurers had to provide system access to examination staff to review claims subject to examination.
More information on the process is available on this
The table below displays the findings that were identified through the examinations and which insurers were found to be noncompliant regarding that specific finding. See the individual insurer reports for more information on the results of the examination.
Noncompliance with ORS 743A.067 relating to the processing of claims – The insurer failed to equitably settle claims when the insurer applied member cost share to services or supplies where such services or supplies are required to be provided without member cost share under Oregon law.
Aetna Life Insurance Company, BridgeSpan Health Company, Cigna Health and Life Insurance Company, HealthNet Health Plan of Oregon, Kaiser Foundation Health Plan of the Northwest, Moda Health Plan, PacificSource Health Plans, Providence Health Plan, Regence BlueCross BlueShield of Oregon, Samaritan Health Plans, UnitedHealthcare Insurance Company, and UnitedHealthcare of Oregon
Noncompliance with the requirement to reimburse 12-month contraceptive prescription refills as required by ORS 743A.066 and noncompliance with contraception coverage requirements under 743A.067 – The insurer failed to provide coverage for prescription contraceptive drugs which did not have a therapeutic equivalent and provided inconsistent access to 12-month refills of contraception.
Aetna, BridgeSpan, Regence
Failure to resolve complaints and maintain records in violation of ORS 733.170 and OAR 836-053-1080 – The insurer failed to demonstrate it adequately resolved complaints in some instances. The insurer did not provide the examiners with evidence that the various controls over the complaint, appeal, or grievance processes such as reports are used to monitor and ensure compliance with RHEA. The insurer failed to demonstrate that personnel involved with complaints, appeals, and grievances are aware the requirements related to RHEA.
Cigna, HealthNet, Kaiser, Samaritan
The examinations found that insurers across the market failed to fully comply with RHEA for a combination of reasons. Issues found through examination and other division compliance work in implementing RHEA and reproductive health laws included:
- Non-compliance with ORS 743A.067 relating to the processing of claims;
- Noncompliance with the requirement to reimburse 12-month contraceptive prescription refills as required by ORS 743A.066 and noncompliance with contraception coverage requirements under 743A.067;
- Failure to maintain records as required by ORS 733.170 and 731.300; and
- Failure to resolve complaints in violation of OAR 836-053-1080.
In accordance with ORS 731.312, examination reports were submitted to the division regarding the evidence and findings for each insurance company. Linked below are the individual market conduct examination reports regarding compliance with RHEA. Some insurance companies submitted response letters that are linked next to the individual report.
The division has published several reports related to compliance activities to evaluate insurer implementation of RHEA.