(a) "Allowed amount" means the reimbursement paid by an insurer or health care service contractor to a health care provider for a specified service or group of services covered by a health benefit plan or a health care service contract.

(b) "Emergency services" has the meaning given that term in ORS 743A.012.

(c) "Enrollee" means:

(A) An individual who is enrolled in a health benefit plan or a covered dependent or beneficiary of the individual; or

(B) A subscriber to a health care service contract or a covered dependent or beneficiary of the subscriber.

(d) "Health benefit plan" has the meaning given that term in ORS 743B.005.

(e) "Health care facility" has the meaning given that term in ORS 442.015, excluding long term care facilities.

(f) "Health care service contractor" has the meaning given that term in ORS 750.005.

(g) "In-network" has the meaning given that term in ORS 743B.280.

(h) "Out-of-network" has the meaning given that term in ORS 743B.280.

(2) A provider who is an out-of-network provider for a health benefit plan or health care service contract may not bill an enrollee in the health benefit plan or health care service contract for emergency services or other inpatient or outpatient services provided at an in-network health care facility.

(3) An insurer offering a health benefit plan and a health care service contractor shall reimburse an out-of-network provider for emergency services or other covered inpatient or outpatient services provided at an in-network health care facility in an amount established in accordance with rules adopted by the Department of Consumer and Business Services under subsection (6) of this section.

(4) Subsections (2) and (3) of this section do not apply:

(a) To applicable coinsurance, copayments or deductible amounts that apply to services provided by an in-network provider; or

(b) To services, other than emergency services, provided to enrollees who choose to receive services from an out-of-network provider.

(5) If an enrollee chooses to receive services from an out-of-network provider, the provider shall inform the enrollee that the enrollee will be financially responsible for coinsurance, copayments or other out-of-pocket expenses attributable to choosing an out-of-network provider.

(6) The department shall adopt rules for calculating the reimbursement that must be paid to providers under subsection (3) of this section. The reimbursement must be equal to the median allowed amount paid to in-network health care providers by commercial insurers in this state, based on data collected under ORS 442.373 for the 2015 calendar year, adjusted annually using the U.S. City Average Consumer Price Index for All Urban Consumers (All Items) as published by the Bureau of Labor Statistics of the United States Department of Labor. The Department of Consumer and Business Services may adjust the amount of reimbursement based on the differences in allowed amounts paid to health care providers in certain geographic areas of this state. [2017 c.417 §2; 2018 c.43 §4]

Note: The amendments to 743B.287 by section 6, chapter 43, Oregon Laws 2018, become operative January 2, 2022. See section 7, chapter 43, Oregon Laws 2018. The text that is operative on and after January 2, 2022, is set forth for the user’s convenience. (1) As used in this section:

(a) "Emergency services" has the meaning given that term in ORS 743A.012.

(b) "Enrollee" means:

(A) An individual who is enrolled in a health benefit plan or a covered dependent or beneficiary of the individual; or

(B) A subscriber to a health care service contract or a covered dependent or beneficiary of the subscriber.

(c) "Health benefit plan" has the meaning given that term in ORS 743B.005.

(d) "Health care facility" has the meaning given that term in ORS 442.015, excluding long term care facilities.

(e) "Health care service contractor" has the meaning given that term in ORS 750.005.

(f) "In-network" has the meaning given that term in ORS 743B.280.

(g) "Out-of-network" means a provider or provider group that has not contracted or has indirectly contracted with the insurer or health care service contractor.

(2) A provider who is an out-of-network provider may not bill an enrollee in the health benefit plan or health care service contract for emergency services or other inpatient or outpatient services provided at an in-network health care facility.

(3) Subsection (2) of this section does not apply:

(a) To applicable coinsurance, copayments or deductible amounts that apply to services provided by an in-network provider; or

(b) To services, other than emergency services, provided to enrollees who choose to receive services from an out-of-network provider.

(4) If an enrollee chooses to receive services from an out-of-network provider, the provider shall inform the enrollee that the enrollee will be financially responsible for coinsurance, copayments or other out-of-pocket expenses attributable to choosing an out-of-network provider.

Note: 743B.287 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.

Note: Sections 5 and 8, chapter 43, Oregon Laws 2018, provide:

Sec. 5. No later than July 1, 2020, the Department of Consumer and Business Services shall report to the interim committees of the Legislative Assembly related to health, in the manner provided in ORS 192.245, all of the following:

(1) All consumer complaints presented to the department concerning billing for services provided in in-network facilities by out-of-network providers, as defined in ORS 743B.287, before and after March 1, 2018;

(2) Any effects on the adequacy of provider networks after January 1, 2019, due to the implementation of the amendments to ORS 743B.287 by section 4 of this 2018 Act, measured by the standards prescribed under ORS 743B.505;

(3) Any effects on premium rates after March 1, 2018, due to the implementation of ORS 743B.287; and

(4) Recommendations for methods to ensure compliance with the provisions of ORS 743B.287. [2018 c.43 §5]

Sec. 8. Section 5 of this 2018 Act is repealed on January 2, 2021.

[2018 c.43 §8]