OAR 836-053-0335: Nationally Recognized Standard for Annual Network Adequacy Evaluation

(1) For purposes of the annual evaluation of network adequacy required by ORS 743B.505, the department adopts the nationally recognized standard for network adequacy, defined as the federal network adequacy standards for Qualified Health Plans set forth in 45 C.F.R. § 156.230, as in effect on January 1, 2025, and as published in annual Centers for Medicare and Medicaid Services (CMS) network adequacy guidance. (2) For purposes of this rule, the department adopts as the default quantitative benchmark the Baseline Time and Distance Standards published by CMS for Plan Year 2025, which are available on the division’s website at https://dfr.oregon.gov/business/reg/health/Pages/annual-network-adequacy.aspx. (3) When CMS publishes Alternative Time and Distance Standards for specific provider types or counties in any plan year, carriers may rely on those alternative benchmarks in their Oregon filings for that year, but only for the provider types and geographic areas identified in the applicable CMS guidance. (4) Carriers must ensure network access for all provider specialties and facility types identified by CMS for Qualified Health Plans, including, at a minimum, primary care, behavioral health care, substance use disorder treatment, and reproductive health care services. (5) Each carrier must submit all network data and documentation necessary for the department’s annual evaluation, using forms, deadlines, and reporting templates prescribed by the department. (6) Compliance with this rule does not exempt a carrier from meeting any other applicable network adequacy requirements under Oregon or federal law.