OAR 836-053-0451: Balance Billing Prohibition and Consumer Cost-Sharing for Ground Ambulance Services

(1) A ground ambulance services organization 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. (a) The enrollee's in-network cost-sharing amount must be calculated using the allowed amount determined under OAR 836-053-0454. The health benefit plan shall provide an explanation of benefits to the enrollee and the ground ambulance services organization that reflects the cost-sharing amount determined under this subsection. (b) The ground ambulance services organization and any agent, trustee, or assignee of the ground ambulance services organization may not balance bill or otherwise attempt to collect from the enrollee any amount greater than the amount determined under subsection (a). (2) A ground ambulance services organization shall refund any amount in excess of the in-network cost-sharing amount to an enrollee within 45 business days of receipt if the enrollee has paid the ground ambulance services organization an amount that exceeds the in-network cost-sharing amount determined under subsection (1)(a). (3) This rule applies to persons covered by a self-funded group health plan, including plans offered by the Public Employees’ Benefit Board or the Oregon Educators Benefit Board, that has elected to participate in the provisions of ORS 743B.292 pursuant to OAR 836-053-0461 .