Oregon Surprise Billing Laws

Oregon HB 2610 (ORS 743B.450), effective January 1, 2020, is Oregon's primary surprise billing law. It predates the federal No Surprises Act (effective January 1, 2022) and covers both state-regulated insurance plans and ERISA self-funded plans.

Overview

A surprise bill occurs when a patient receives medical care from an out-of-network (OON) provider and faces an unexpected, substantial bill. Oregon law protects patients from these surprise bills in two key scenarios: emergency care at any facility, and scheduled non-emergency services at in-network facilities. The federal No Surprises Act extends these protections to ERISA self-funded plans and adds additional coverage for providers at in-network facilities.

Both the state and federal rules establish that patients are responsible only for in-network cost-sharing amounts. OON providers must bill the insurer and cannot collect the difference from the patient unless the patient provides advance written consent.

Key Requirements

• Emergency care: Patients pay in-network cost-sharing only, regardless of provider network status or facility network status.
• Scheduled services at in-network facilities: OON providers cannot balance bill without 72-hour advance written consent from the patient.
• In-network cost-sharing applies: Deductible, copay, and coinsurance are calculated using in-network rates and amounts.
• Good Faith Estimates: OON providers must provide cost estimates before scheduled services so patients can understand their financial responsibility.
• 72-hour advance written consent: Any exception requires documented, signed consent that clearly discloses OON status and higher costs.
• Independent Dispute Resolution (IDR): Federal IDR process applies for payment disputes between providers and insurers over surprise billing coverage.

Penalties and Enforcement

Violations of surprise billing protections result in enforcement action by Oregon DFR (state-regulated plans) or CMS (ERISA plans and Medicare Advantage). Penalties include:

• Civil penalties and fines assessed against insurers and providers.
• Requirement to pay the disputed claim amount.
• Restitution to affected patients.
• Market conduct examinations and corrective action orders.

Appeals and Dispute Resolution

If a patient receives a surprise bill despite applicable protections:

• Notify the health plan in writing, identifying the service type, dates, facility, provider network status, and applicable law.
• Request that the insurer pay the OON provider at the in-network rate and adjust the patient's responsibility accordingly.
• File a complaint with the Oregon DFR (state-regulated plans) or CMS (ERISA plans) if the dispute is not resolved within 30 days.
• Invoke the federal Independent Dispute Resolution (IDR) process if the provider and insurer cannot agree on the appropriate payment amount.

Federal Law and Coordination

The federal No Surprises Act provides parallel protections for ERISA self-funded plans, Medicare Advantage plans, and certain other plan types not covered by Oregon state law. The federal rule also establishes the Independent Dispute Resolution (IDR) process for provider-insurer disputes over payment amounts. When both state and federal law apply, patients receive protection from the more favorable standard. Oregon's earlier effective date (2020 vs. 2022) means Oregon patients benefited from surprise billing protections before the federal standard took effect.

Common Questions

Key Statutes

• ORS 743B.450: Oregon surprise billing protections.
• Federal No Surprises Act (Pub. L. 116-171, 45 CFR §149.430-149.440).
• CMS IDR Process (45 CFR §149.520 et seq.).