OAR 836-053-0325: Network Adequacy Reporting Requirements

(1) By March 31 of each year, a carrier must submit a network adequacy report for each provider network used in connection with a health benefit plan offered or renewed in this state, demonstrating compliance with the requirements of OAR 836-053-0300 to 836-053-0355. When a single provider network is associated with multiple health benefit plans, the carrier must report once for that network and include all health benefit plans and enrollees for that network. (2) For each provider network, the network adequacy report must include: (a) Identification of the carrier’s provider network and the health benefit plans to which the network applies; (b) A description of how telemedicine or other technology is used to meet network access standards, including a breakdown of the percentage of telemedicine delivered by Oregon-based providers who also provide in-person care versus the percentage delivered by telemedicine-only providers. The report must indicate the percentage of network adequacy standards met through telemedicine for each provider, consistent with the limits in OAR 836-053-0345(3); (c) Evidence of compliance with quantitative access standards in OAR 836-053-0345; (d) For each required provider in the network, including but not limited to behavioral health, substance use disorder, and reproductive health, the report must include the following information: (A) Provider and facility name and unique identifier, if assigned; (B) Specialty or provider type, consistent with department assigned categories; (C) Street address and zip code of the provider or facility location; (D) Contact phone number; (E) Whether the provider is accepting new patients; (F) Whether the provider or facility is located in, or serves, a low-income ZIP code or federally designated health professional shortage area (HPSA); and (G) Network affiliation(s) and tier level, if applicable. (e) Any other information or supporting documentation required by the department to verify compliance, as set forth in reporting templates and instructions published by the department. (3) For any provider network that fails to meet a quantitative travel time and distance or appointment wait time standard established by the department in a HPSA or low-income ZIP code (as defined in OAR 836-053-0310), the annual network adequacy report must include a written justification demonstrating how the carrier ensures that all covered services will be accessible to enrollees without unreasonable delay, consistent with 45 C.F.R. 156.230(a)(2)(ii). The written justification must include, at a minimum, the following mandatory elements for each unmet standard: (a) Identify the specific network inadequacy and the required quantitative standard (e.g., maximum travel distance/time or wait time) that was not met. (b) Provide a clear and concise explanation of the primary reason the provider network failed to meet the standard, such as a lack of available providers, a lack of providers willing to contract, or the recent departure or closure of a key provider or facility. (c) Documentation of specific, recent, good-faith contracting efforts undertaken by the carrier to address the network gap. (d) A description of mitigating measures that ensure enrollees in the affected area have access to care without unreasonable delay. This must detail the carrier’s specific strategy for providing timely access, including: (A) The use of telemedicine (consistent with OAR 836-053-0345(3)). (B) Identification of contracted providers in adjacent counties or service areas who regularly serve the affected population, including the volume or capacity dedicated to serving enrollees in the gap area. (C) Documentation of established case management, referral, or transportation protocols to ensure enrollees are able to access the required services outside the standard time/distance parameters. (4) A carrier may request a waiver from the department for the detailed reporting requirements of this rule for any provider network that has zero enrolled lives in Oregon as of the reporting date. The waiver request must be submitted in writing and certify that the network is not currently marketed or used for any active health benefit plan.