INSURANCE CONSUMER RIGHTS
According to Oregon Law, your insurance carrier must contract with a sufficient number of accessible providers so that you receive treatment without unreasonable delay (ORS 743B.505). If you are finding it difficult to find a provider that accepts your insurance, COPACT recommends that you report this to the appropriate regulating agency (instructions and contact information for both commercial (private) and state (Medicaid) insurance is below).

Your rights as an insurance consumer:

  • ​​Insurers must provide fair claim settlement practices, including: promptly providing an explanation for the denial of a claim, promptly replying to all communication related to claims, conducting a reasonable investigation before denying a claim, not delaying investigations or payment of claims, and not misrepresenting facts or policy provisions in regard to claims (ORS 746.230(1)(m))

  • ​No statements may be made in any form which are untrue, deceptive or misleading (ORS 746.110)

  • Mental health and substance use treatment must be comparable to physical health treatment. This means that co-payments, deductibles, yearly visit limits, need for prior authorization, proof of medical necessity and access to care must equal that which is offered for physical health services (MHPAEA)

  • Insurers must provide information about the criteria it uses to decide if treatment is medically necessary (MHPAEA)

  • Insurance companies cannot place a dollar limit on how much they will cover over your lifetime. For plans sold or renewed on or after Jan. 1, 2014, federal law prohibits annual dollar limits on coverage of essential benefits (MHPAEA)

  • Insurers must acknowledge nonemergency complaints and appeals within seven days and must make a decision and respond within 30 days (DCBS)

  • If your insurance company rejects your first appeal and your plan is through an employer, you may have the right to a second appeal (DCBS)

  • If your insurance company rejects all appeals, you have the right to an independent external review  by a third party unaffiliated with your insurer (DCBS)

If you suspect your rights have been violated:

FOR COMMERCIAL (PRIVATE) INSURANCE:

Commercial insurance companies are regulated by the Department of Consumer and Business Services and are routinely fined up to $10,000 per violation. Many Oregonians do not fully understand their rights, which means violations often go unnoticed. Insurers cannot be held accountable unless the proper regulating agency knows that they are violating the rules.

If a commercial insurance company has violated any of the above rules, it is imperative that the DCBS be informed. The online complaint process is quick and easy:

Click here to access the online complaint form
  • It is only necessary to complete the required field, marked with a red "*".
  • Though a response to your complaint may be slow, it is very important that the DCBS be informed of any violations as this is the only means to hold insurance providers accountable. ​
Click here to print the PDF complaint form
  • Though a response to your complaint may be slow, it is very important that the DCBS be informed of any violations as this is the only means to hold insurance providers accountable. ​
If you have any questions about your rights in regard to private insurance practices, you can email DCBS directly at: [email protected]  or call:  888-877-4894


To learn more about your rights as an insurance consumer, visit the 
Deparment of Consumer and Business Services (DCBS) website 


You can view the private insurance companies that have been investigated/fined and read the full reports going back several years with this handy search tool:

NOTICES AND ORDERS SEARCH  
Simply choose the year and select, "insurance" for a list of all reports,
or you can enter a specific insurance provider name.

FOR MEDICAID (OHP, OPEN CARD, HEALTHSHARE CCO, ETC):

If you are an OHP member and have been unable to access care or have concerns regarding the quality or amount of care you have received, please contact the Oregon Health Authority Ombuds Program . This Program has a team of Ombudspersons who will advocate on your behalf! 

Contact information:
Send a secure email from the Ombuds Website
Phone: 877-642-0450 or 503-947-2346 (secure, message line only)
(نتكلم العربية  Hablamos Español)

***If your complaint is regarding a specific claim or services that you have already received, 
it is recommended that you contact your CCO directly, first. 
You can find the contact information for your CCO (EX: HealthShare) on the back of your insurance card.***

Click here to read the OHA Administrative Rules for behavioral health)