ORS 743B.277 Credits to deductibles and out-of-pocket expenses; requirements; process

An insurer offering a health benefit plan as defined in ORS 743B.005 shall credit any amount an enrollee pays directly to a health care provider to the enrollee’s deductible and annual out-of-pocket expenses if:

The health care item or service is medically necessary and covered under the enrollee’s health benefit plan;

The enrollee does not submit the claim to the insurer; and

The amount paid to the health care provider is less than the average discounted rate for the item or service paid to an in-network health care provider with the same license.

An insurer shall:

Establish a process for an enrollee to submit a claim for the credit described in subsection (1) of this section, including the necessary documentation the enrollee is required to submit in support of the claim; or

Require an enrollee to utilize the system the insurer uses to process and adjudicate claims to submit a claim for the credit described in subsection (1) of this section.

Notwithstanding ORS 750.055 (1)(i), this section does not apply to a health maintenance organization as defined in ORS 750.005.