Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-0340 - Factor-Based Evidence of Compliance with Network Adequacy Requirements
Universal Citation: OR Admin Rules 836-053-0340
Current through Register Vol. 63, No. 9, September 1, 2024
(1) An insurer electing to demonstrate compliance with network adequacy requirements required under ORS 743.505B via the factor-based approach shall submit evidence of compliance to the Director by March 31 each year.
(2) The evidence must include a narrative description of how the insurer complies with the factor along with the source and methodology, where applicable, for at least one of the factors listed for each of these categories:
(a) Access to Care
Consistent with the Needs of the Enrollees Served by the Network category:
(A) Access to Care Factor #1- The insurer's
network ensures all covered services under the health benefit plan are
accessible to enrollees without unreasonable delay.
(i) Submit median enrollee wait times for
preventive care appointments for the prior calendar year.
(ii) Submit median length of time enrollees
waited for access to mental health and substance abuse providers for the prior
calendar year.
(iii) Submit median
length of time enrollees waited to receive care for mental health conditions
following intake evaluation.
(iv)
Evidence that the network provides 24-hour access to clinical advice.
(v) Urgent care services outside
of regular business hours are available in all covered regions or service
areas.
(vi) Submit median enrollee
wait times for routine care appointments for the prior calendar year.
(vii) Submit median enrollee wait
times for specialist appointments for the prior calendar year.
(B) Access to Care Factor #2 - The
network meets special needs of specific populations.
(i) The network has the capacity to accept
new patients.
(ii) The network
includes a full range of pediatric providers including pediatric subspecialists
and providers that offer care to children with special needs.
(iii) Services are made available to
enrollees residing in medically underserved areas of the state, if the insurer
offers coverage in those areas.
(iv) All plans served by a network are
included when determining whether the network is sufficient.
(v) The network provides access to culturally
and linguistically appropriate services.
(C) Access to Care Factor #3 - The insurer
actively manages the network including oversight of access to care.
(i) Providers who are not accepting new
patients are not included when determining whether an adequate number of
providers (including specialists) are in the network.
(ii) All plans served by a network are
included when determining whether the network is sufficient.
(iii) The network adequacy monitoring process
includes specific intervals between formal reviews, reporting of review results
to senior management or board of directors, and formal reviews are used to
monitor and improve accessibility for enrollees.
(b) Consumer Satisfaction category:
(A) Consumer Satisfaction Factor #1 - Insurer
maintains accreditation status and can demonstrate consumers are satisfied with
the plan.
(i) Submit insurer accreditation
status from either the National Committee for Quality Assurance (NCQA), URAC,
or the Accreditation Association for Ambulatory Health Care (AAAHC) including
information regarding customer satisfaction rating from accreditation entity;
or
(ii) Either of the following:
(I)Global rating of health plan (Enrollee
Satisfaction Survey Consumer Assessment of Healthcare Providers and Systems)
and
(II) Global rating of health
care (Enrollee Satisfaction Survey Consumer Assessment of Healthcare Providers
and Systems).
(B) Consumer Satisfaction Factor #2 -
Consumers are able to access care when needed without unreasonable delay.
(i) Number of enrollee communications the
insurer received during the previous calendar year regarding difficulty in
obtaining an appointment with a provider, including but not limited to the
inability to find a provider with an open practice or an unreasonable length of
time to wait for an appointment.
(ii) Number of consumer complaints the
insurer received during the previous calendar year regarding care received out
of network due to consumer's inability to receive care in network.
Communications under this section include but are not limited to complaints,
appeals and grievances from enrollees.
(iii) Median wait times for members to be
seen at time of appointment.
(c) Transparency:
(A) Transparency Factor #1 - Insurer
maintains an accurate provider directory which is available to the general
public.
(i) Provider locations are
transparent to the public.
(ii)
Provide link to website where provider directory is located and explain how
frequently the directory is updated and where this information is disclosed on
the provider directory.
(iii)
Explain how the insurer keeps information on which providers in the network
have open practices and how often this information is updated.
(iv) Provide position and department of
individual responsible for establishing and monitoring the network.
(B) Transparency Factor #2 -
Consumers, enrollees and providers have access to accurate provider
information.
(i) Providers have access to
information about other providers in the network.
(ii) Consumers and enrollees are informed on
how to locate in-network providers when scheduling medical services.
(iii) Explain how frequently enrollees are
specifically notified of changes to the provider network and the method the
insurer uses to communicate this information.
(iv) Provider directory discloses which
providers are fluent in languages other than English and if so, what languages
are available.
(v) Consumers and
enrollees are informed of providers in the network with open practices.
(d) Quality of
Care and Cost Containment:
(A) Quality of
Care and Cost Containment Factor #1 - The insurer engages in provider quality
improvement activities.
(i) Submit provider
quality data the insurer uses.
(ii)
Describe the specific quality designations required of specialists in the
network.
(iii) Explain provider
accreditation status requirements used by the insurer.
(iv) Provide the percentage of accredited
patient-centered primary care homes in the network.
(v) Provide a list of all provider types
included in the network and identify those who provide telemedicine services.
(B) Quality of Care and
Cost Containment Factor #2 - The insurer is implementing quality improvement
activities in addition to provider quality improvement.
(i) The insurer reports quality improvement
strategies to the public.
(ii) The
provider payment structure supports improved health outcomes, reduction of
hospital readmissions, improved patient safety and reduction of medical errors,
and reduction of health care disparities.
(iii) The insurer offers health promotion and
wellness programs to enrollees.
(iv) Appointments with high volume
specialists are available within the network without unreasonable delay.
(C) Quality of Care and
Cost Containment Factor #3 - The insurer employs network design strategies to
reduce cost and improve quality.
(i) The
network design supports improved enrollee health and lower cost.
(ii) The insurer analyzes relevant
information to promote good health outcomes.
(iii) The network can be considered a
high-value network.
(iv) Electronic
health records are used within the network.
Stat. Auth: ORS 731.244 and 743B.505
Stats. Implemented: ORS 743B.505
Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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