(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)(a) If labor and delivery services are provided to an individual insured under a health benefit plan or a health care service contract at an out-of-network health care facility due solely to the diversion of the individual from an in-network health care facility during a state or federally declared public health emergency, the health benefit plan or health care service contract:

(A)(i) Shall reimburse the out-of-network provider in accordance with 42 U.S.C. §§ 300gg-111(c) or in accordance with a method adopted by the Department of Consumer and Business Services by rule; and

(ii) May not impose a deductible, out-of-pocket maximum, copayment or coinsurance requirement that exceeds the deductible, out-of-pocket maximum, copayment or coinsurance applicable to in-network providers of labor and delivery services.

(B) Shall provide coverage, as prescribed in ORS § 743A.012 (2) and (3), for emergency medical services transports of the individual between medical facilities if the individual presents with signs of labor.

(b) Paragraph (a)(A)(i) of this subsection does not apply to services provided by an in-network provider at an out-of-network health care facility.

(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. [2017 c.417 § 2; 2018 c.43 4,6; 2022 c.72 § 1]

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.