Estimate of costs for out-of-network procedure or service
(1) An insurer offering a health benefit plan as defined in ORS 743B.005 (Definitions) must establish a procedure for providing to an enrollee in the plan a reasonable estimate of the enrollee’s costs for an out-of-network procedure or service covered by the enrollee’s health benefit plan, including the difference between the insurer’s allowable charge and the billed charge for the procedure or service, in advance of the procedure or service, when an enrollee or an enrollee’s authorized representative provides the following information to the insurer:
(a) The type of procedure or service;
(b) The name of the provider;
(c) The enrollee’s member number or policy number;
(d) If requested by the insurer, the site where the procedure or service will be performed; and
(e) The provider’s billed charge amount.
(2) The estimate of costs described in subsection (1) of this section must include an itemization of:
(a) The enrollee’s deductible;
(b) The amount of the deductible that has been met by processed claims;
(c) Coinsurance, copayment or other cost share to be paid by the enrollee for the procedure or service;
(d) Any applicable benefit maximum;
(e) The difference between the insurer’s allowable charge and the billed charge for the procedure or service; and
(f) The insurer’s average payment or allowable charge for the procedure or service if performed in-network.
(3) Subsections (1) and (2) of this section apply to the insurer’s five most common procedures or services within each of the following categories:
(a) Office visits;
(b) Diagnostic radiology and imaging;
(c) Diagnostic pathology and laboratory procedures;
(d) Normal vaginal delivery;
(f) Orthopedic-musculoskeletal surgery; and
(g) Digestive system endoscopy.
(4) In addition to the information specified in subsections (1) and (2) of this section, the insurer’s estimate must include the following disclosures:
(a) That other services may be provided to the enrollee that are medically necessary and appropriate as part of the common procedures, of which the insurer or enrollee may not be aware at the time of the inquiry and for which the enrollee may have additional financial responsibility;
(b) That the enrollee may be responsible for costs of procedures or services not covered by the plan;
(c) How an enrollee may contact the insurer for an explanation, if the estimate differs from the actual cost or if the enrollee has other questions; and
(d) The toll-free telephone number of the consumer advocacy unit of the Department of Consumer and Business Services and the address for the department’s consumer information and complaints website.
(5) An insurer must make the information required by this section available to enrollees and out-of-network providers through an interactive website and by toll-free telephone.
(6) This section does not prohibit an insurer from providing information in addition to or in more detail than the information required by this section. [Formerly 743.876]
Note: See note under 743B.280 (Definitions for ORS 743B.280 to 743B.285).
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.