This text of Oregon § 743B.292 (Balance billing prohibited for ground ambulance services; health benefit plan reimbursement rate requirements; reporting and database of established local rate; rules; penalties) is published on Counsel Stack Legal Research, covering Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
(1)As used in this section:
(a)“Enrollee” has the meaning given that term in ORS 743B.005. (b)“Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services through a publicly accessible process that includes an analysis of the cost to provide the ground ambulance services by:
(A)The local government entity if the ground ambulance services are provided by ground ambulance services organizations that are owned or operated by the local government entity; or
(B)The contract between a privately owned or operated ground ambulance services organization and the local government entity if the ground ambulance services are provided by a privately owned or operated ground ambulance services organization.
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(1) As used in this section:
(a) “Enrollee” has the meaning given that term in ORS 743B.005.
(b) “Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services through a publicly accessible process that includes an analysis of the cost to provide the ground ambulance services by:
(A) The local government entity if the ground ambulance services are provided by ground ambulance services organizations that are owned or operated by the local government entity; or
(B) The contract between a privately owned or operated ground ambulance services organization and the local government entity if the ground ambulance services are provided by a privately owned or operated ground ambulance services organization.
(c) “Ground ambulance services” means:
(A) The rendering of medical treatment and care at the scene of a medical emergency or while transporting an individual from the scene to an appropriate health care facility when the services are provided by one or more ground ambulance vehicles designed for this purpose; and
(B) Transport between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose.
(d) “Ground ambulance services organization” means a public or private organization licensed by the Oregon Health Authority pursuant to ORS 682.045 to provide ground ambulance services.
(e) “Health benefit plan” has the meaning given that term in ORS 743B.005, except that “health benefit plan” does not include a coverage offered by the Public Employees’ Benefit Board or the Oregon Educators Benefit Board through a commercial insurer, a health care service contractor or a third party administrator.
(f) “Health care facility” means a facility that provides health care services directly to patients, including but not limited to a hospital, clinic, health care provider’s office, health maintenance organization, diagnostic or treatment center, mental health facility, behavioral health service provider, emergency services provider or hospice or nursing home.
(g) “In-network” has the meaning given that term in ORS 743B.275.
(2) A ground ambulance service may not bill an enrollee for covered ground ambulance services if the enrollee has paid the in-network cost-sharing amount specified in the enrollee’s health benefit plan.
(3) A health benefit plan must reimburse the ground ambulance services organization at the established local rate or if an established local rate does not exist, in an amount no less than 325 percent of the Medicare rate.
(4) Ground ambulance services organizations shall submit a catalog of established local rates to the Department of Consumer and Business Services annually and within five calendar days of a change to the rates.
(5) The department shall create a database of established local rates for ground ambulance services. The department shall ensure this database is accessible by the public.
(6) The provisions of this section apply to a self-funded group health plan whether governed by or exempt from the provisions of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.), as amended, only if the self-funded group health plan elects to participate in the provisions of this section by providing notice to the department in the form and manner described by the department by rule.
(7) The Public Employees’ Benefit Board and the Oregon Educators Benefit Board may elect to participate in the coverage provisions described in this section by providing notice to the department in the form and manner described by the department by rule.
(8) This section is exempt from ORS 743A.001.
(9) The department shall make rules to implement the provisions described in this section.
(10) The department may impose civil penalties, as described in ORS 731.988, but may not exceed $1,000 for repeated violations of this section.