2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.012 - Emergency services.

(1) As used in this section:
(a) "Behavioral health assessment" means an evaluation by a behavioral health clinician, in person or using telemedicine, to determine a patient’s need for immediate crisis stabilization.
(b) "Behavioral health clinician" means:
(A) A licensed psychiatrist;
(B) A licensed psychologist;
(C) A licensed nurse practitioner with a specialty in psychiatric mental health;
(D) A licensed clinical social worker;
(E) A licensed professional counselor or licensed marriage and family therapist;
(F) A certified clinical social work associate;
(G) An intern or resident who is working under a board-approved supervisory contract in a clinical mental health field; or
(H) Any other clinician whose authorized scope of practice includes mental health diagnosis and treatment.
(c) "Behavioral health crisis" means a disruption in an individual’s mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individual’s mental or physical health.
(d) "Emergency medical condition" means a medical condition:
(A) That manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would:
(i) Place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy;
(ii) Result in serious impairment to bodily functions; or
(iii) Result in serious dysfunction of any bodily organ or part;
(B) With respect to a pregnant woman who is having contractions, for which there is inadequate time to effect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to the health or safety of the woman or the unborn child; or
(C) That is a behavioral health crisis.
(e) "Emergency medical screening exam" means the medical history, examination, ancillary tests and medical determinations required to ascertain the nature and extent of an emergency medical condition.
(f) "Emergency medical service provider" has the meaning given that term in ORS 682.025.
(g) "Emergency medical services transport" means an emergency medical services provider’s evaluation and stabilization of an individual experiencing a medical emergency and the transportation of the individual to the nearest medical facility capable of meeting the needs of the individual.
(h) "Emergency services" means, with respect to an emergency medical condition:
(A) An emergency medical services transport;
(B) An emergency medical screening exam or behavioral health assessment that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and
(C) Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to stabilize a patient, to the extent the examination and treatment are within the capability of the staff and facilities available at a hospital.
(i) "Grandfathered health plan" has the meaning given that term in ORS 743B.005.
(j) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(k) "Prior authorization" has the meaning given that term in ORS 743B.001.
(L) "Stabilize" means to provide medical treatment as necessary to:
(A) Ensure that, within reasonable medical probability, no material deterioration of an emergency medical condition is likely to occur during or to result from the transfer of the patient to or from a facility; and
(B) With respect to a pregnant woman who is in active labor, to perform the delivery, including the delivery of the placenta.
(2) All insurers offering a health benefit plan shall provide coverage without prior authorization for emergency services.
(3) A health benefit plan, other than a grandfathered health plan, must provide coverage required by subsection (2) of this section:
(a) For the services of participating providers, without regard to any term or condition of coverage other than:
(A) The coordination of benefits;
(B) An affiliation period or waiting period permitted under part 7 of the Employee Retirement Income Security Act, part A of Title XXVII of the Public Health Service Act or chapter 100 of the Internal Revenue Code;
(C) An exclusion other than an exclusion of emergency services; or
(D) Applicable cost-sharing; and
(b) For the services of a nonparticipating provider:
(A) Without imposing any administrative requirement or limitation on coverage that is more restrictive than requirements or limitations that apply to participating providers;
(B) Without imposing a copayment amount or coinsurance rate that exceeds the amount or rate for participating providers;
(C) Without imposing a deductible, unless the deductible applies generally to nonparticipating providers; and
(D) Subject only to an out-of-pocket maximum that applies to all services from nonparticipating providers.
(4) All insurers offering a health benefit plan shall provide information to enrollees in plain language regarding:
(a) What constitutes an emergency medical condition;
(b) The coverage provided for emergency services;
(c) How and where to obtain emergency services; and
(d) The appropriate use of 9-1-1.
(5) An insurer offering a health benefit plan may not discourage appropriate use of 9-1-1 and may not deny coverage for emergency services when 9-1-1 is used.
(6) This section is exempt from ORS 743A.001. [Formerly 743.699; 2011 c.500 §38; 2017 c.273 §4; 2019 c.358 §41; 2021 c.312 §1]