Credits to deductibles and out-of-pocket expenses; requirements; process. (1) 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

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

(b) The enrollee does not submit the claim to the insurer; and

(c) 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.

(2) An insurer shall:

(a) 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

(b) 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.

(3) Notwithstanding ORS 750.055 (1)(i), this section does not apply to a health maintenance organization as defined in ORS 750.005. [2025 c.120 §2]

Note: See note under 743B.275.