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83rd OREGON LEGISLATIVE ASSEMBLY--2025 Regular Session
HOUSE AMENDMENTS TO
HOUSE BILL 2292
By COMMITTEE ON BEHAVIORAL HEALTH AND HEALTH CARE
April 7
On page 1 of the printed bill, line 2, after “ORS” insert “743B.001 and”.
Delete lines 5 through 28 and delete page 2 and insert:
“SECTION 1. Section 2 of this 2025 Act is added to and made a part of the Insurance
Code.
“SECTION 2.(1) An insurer that offers a health benefit plan, as defined in ORS 743B.005,
that reimburses the cost of counseling, prevention services or screening for sexually trans-
mitted infections, shall provide coverage for:
“(a) Drugs that have been approved by the United States Food and Drug Administration
for the prevention of human immunodeficiency virus;
“(b) Services necessary for the commencement or continuation of human
immunodeficiency virus prevention drugs described in this section, including but not limited
to office visits, testing, vaccinations and monitoring services; and
“(c) Drugs that have been approved by the United States Food and Drug Administration
for the treatment of human immunodeficiency virus.
“(2) The coverage under subsection (1)(a) and (b) of this section must be provided without
cost-sharing, coinsurance or deductibles applicable to the services.
“(3) This section is exempt from ORS 743A.001.
“SECTION 3. ORS 743B.425 is amended to read:
“743B.425. (1) An insurer offering a health benefit plan [as defined in ORS 743B.005] may not:
“(a) Require prior authorization:
“(A) During the first 60 days of treatment, including medication therapy, prescribed for opioid
or opiate withdrawal; or
“(B) For post-exposure prophylactic antiretroviral drugs or [ at least one] preexposure
prophylactic antiretroviral [drug] drugs, or drugs prescribed for the treatment of human
immunodeficiency virus or acquired immunodeficiency syndrome ; or
“(b) Restrict the reimbursement for medication therapies, preexposure prophylactic
antiretroviral drugs or post-exposure prophylactic antiretroviral drugs to in-network pharmacists or
pharmacies[; or].
“[(c) Subject to ORS 742.008, require a deductible, copayment, coinsurance or other cost-sharing for
the coverage of human immunodeficiency virus post-exposure prophylactic drugs or therapies prescribed
following a possible exposure to human immunodeficiency virus.]
“(2) This section is not subject to ORS 743A.001.
“(3) This section does not prohibit prior authorization for opioids or opiates prescribed for pur-
poses other than medication therapy or treatment of opioid or opiate abuse or addiction.
“(4) Subsection (1)(b) of this section does not apply to a health maintenance organization as
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defined in ORS 750.005.
“SECTION 4. Section 5 of this 2025 Act is added to and made a part of ORS chapter 414.
“SECTION 5.(1) As used in this section:
“(a) ‘Prior authorization’ has the meaning given that term in ORS 743B.001.
“(b) ‘Step therapy’ has the meaning given that term in ORS 743B.001.
“(2) Notwithstanding ORS 414.325, the Oregon Health Authority and a coordinated care
organization may not require prior authorization or step therapy for drugs prescribed for a
medical assistance recipient for the treatment or prevention of human immunodeficiency
virusif:
“(a) The drug has been approved by the United States Food and Drug Administration for
the treatment or prevention of human immunodeficiency virus; and
“(b) The prescribing provider has determined that the drug is medically necessary.
“(3) Nothing in this section prevents the authority or a coordinated care organization
from performing drug utilization review that may be necessary for patient safety or for en-
suring the prescribed drug is medically accepted as required by section 1927 of the Social
Security Act of 1935 (42 U.S.C. 1396r-8).
“SECTION 6. ORS 743B.001, as amended by section 3, chapter 35, Oregon Laws 2024, is
amended to read:
“743B.001. As used in this section and ORS 743.008, 743.029, 743.035, 743A.190, 743B.195,
743B.197, 743B.200, 743B.202, 743B.204, 743B.220, 743B.225, 743B.227, 743B.250, 743B.252, 743B.253,
743B.254, 743B.255, 743B.256, 743B.257, 743B.258, 743B.310, 743B.400, 743B.403, 743B.405, 743B.420,
743B.422, 743B.423, 743B.424, 743B.425, 743B.450, 743B.451, 743B.452, 743B.453, 743B.454, 743B.505,
743B.550, 743B.555 and 743B.602 and section 2, chapter 35, Oregon Laws 2024:
“(1) ‘Adverse benefit determination’ means an insurer’s denial, reduction or termination of a
health care item or service, or an insurer’s failure or refusal to provide or to make a payment in
whole or in part for a health care item or service, that is based on the insurer’s:
“(a) Denial of eligibility for or termination of enrollment in a health benefit plan;
“(b) Rescission or cancellation of a policy or certificate;
“(c) Imposition of a preexisting condition exclusion as defined in ORS 743B.005, source-of-injury
exclusion, network exclusion, annual benefit limit or other limitation on otherwise covered items or
services;
“(d) Determination that a health care item or service is experimental, investigational or not
medically necessary, effective or appropriate;
“(e) Determination that a course or plan of treatment that an enrollee is undergoing is an active
course of treatment for purposes of continuity of care under ORS 743B.225; or
“(f) Denial, in whole or in part, of a request for prior authorization, a request for an exception
to step therapy or a request for coverage of a treatment, drug, device or diagnostic or laboratory
test that is subject to other utilization review requirements.
“(2) ‘Authorized representative’ means an individual who by law or by the consent of a person
may act on behalf of the person.
“(3) ‘Clinical review criteria’ means screening procedures, decision rules, medical protocols and
clinical guidance used by an insurer or other entity in conducting utilization review and evaluating:
“(a) Medical necessity;
“(b) Appropriateness of an item or health service for which prior authorization is requested or
for which an exception to step therapy has been requested as described in ORS 743B.602; or
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“(c) Any other coverage that is subject to utilization review.
“(4) ‘Credit card’ has the meaning given that term in 15 U.S.C. 1602.
“(5) ‘Electronic funds transfer’ has the meaning given that term in ORS 293.525.
“(6) ‘Enrollee’ has the meaning given that term in ORS 743B.005.
“(7) ‘Essential community provider’ has the meaning given that term in rules adopted by the
Department of Consumer and Business Services consistent with the description of the term in 42
U.S.C. 18031 and the rules adopted by the United States Department of Health and Human Services,
the United States Department of the Treasury or the United States Department of Labor to carry
out 42 U.S.C. 18031.
“(8) ‘Grievance’ means:
“(a) A communication from an enrollee or an authorized representative of an enrollee expressing
dissatisfaction with an adverse benefit determination, without specifically declining any right to
appeal or review, that is:
“(A) In writing, for an internal appeal or an external review; or
“(B) In writing or orally, for an expedited response described in ORS 743B.250 (2)(d) or an ex-
pedited external review; or
“(b) A written complaint submitted by an enrollee or an authorized representative of an enrollee
regardingthe:
“(A) Availability, delivery or quality of a health care service;
“(B) Claims payment, handling or reimbursement for health care services and, unless the
enrollee has not submitted a request for an internal appeal, the complaint is not disputing an ad-
verse benefit determination; or
“(C) Matters pertaining to the contractual relationship between an enrollee and an insurer.
“(9) ‘Health benefit plan’ has the meaning given that term in ORS 743B.005.
“(10) ‘Independent practice association’ means a corporation wholly owned by providers, or
whose membership consists entirely of providers, formed for the sole purpose of contracting with
insurers for the provision of health care services to enrollees, or with employers for the provision
of health care services to employees, or with a group, as described in ORS 731.098, to provide health
care services to group members.
“(11) ‘Insurer’ includes a health care service contractor as defined in ORS 750.005.
“(12) ‘Internal appeal’ means a review by an insurer of an adverse benefit determination made
by the insurer.
“(13) ‘Managed health insurance’ means any health benefit plan that:
“(a) Requires an enrollee to use a specified network or networks of providers managed, owned,
under contract with or employed by the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
“(b) In addition to the requirements of paragraph (a) of this subsection, offers a point-of-service
provision that allows an enrollee to use providers outside of the specified network or networks at
the option of the enrollee and receive a reduced level of benefits.
“(14) ‘Medical services contract’ means a contract between an insurer and an independent
practice association, between an insurer and a provider, between an independent practice associ-
ation and a provider or organization of providers, between medical or mental health clinics, and
between a medical or mental health clinic and a provider to provide medical or mental health ser-
vices. ‘Medical services contract’ does not include a contract of employment or a contract creating
legal entities and ownership thereof that are authorized under ORS chapter 58, 60 or 70, or other
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similar professional organizations permitted by statute.
“(15)(a) ‘Preferred provider organization insurance’ means any health benefit plan that:
“(A) Specifies a preferred network of providers managed, owned or under contract with or em-
ployed by an insurer;
“(B) Does not require an enrollee to use the preferred network of providers in order to receive
benefits under the plan; and
“(C) Creates financial incentives for an enrollee to use the preferred network of providers by
providing an increased level of benefits.
“(b) ‘Preferred provider organization insurance’ does not mean a health benefit plan that has
as its sole financial incentive a hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable amounts that are specified in
the medical services contracts.
“(16) ‘Prior authorization’ means a form of utilization review that requires a provider or an
enrollee to request a determination by an insurer, prior to the provision of health care that is sub-
ject to utilization review, that the insurer will provide reimbursement for the health care requested.
‘Prior authorization’ does not include referral approval for evaluation and management services be-
tween providers.
“(17)(a) ‘Provider’ means a person licensed, certified or otherwise authorized or permitted by
laws of this state to administer medical or mental health services in the ordinary course of business
or practice of a profession.
“(b) With respect to the statutes governing the billing for or payment of claims, ‘provider’ also
includes an employee or other designee of the provider who has the responsibility for billing claims
for reimbursement or receiving payments on claims.
“(18) ‘Step therapy’ means a utilization review protocol, policy or program in which an insurer
requires certain preferred drugs for treatment of a specific medical condition be proven ineffective
or contraindicated before a prescribed drug may be reimbursed.
“(19) ‘Utilization review’ means a set of formal techniques used by an insurer or delegated by
the insurer designed to monitor the use of or evaluate the medical necessity, appropriateness, effi-
cacy or efficiency of health care items, services, procedures or settings.
“SECTION 7. Section 2 of this 2025 Act and the amendments to ORS 743B.425 by section
3 of this 2025 Act apply to health benefit plans offered, renewed or extended on or after the
effective date of this 2025 Act.”.
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