Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0320 - Annual Report Requirements for Network Adequacy

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer offering individual or small
			 group health benefits plans must submit its annual report for each network
			 required under ORS 743B.505 no later than March 31
			 of each year.
(2) Beginning March
			 31, 2020, the annual report shall include at least the following information
			 for networks associated with health benefit plans currently in force and
			 networks associated with health benefit plans being marketed at the time the
			 report is submitted:
(a) Identification of
			 the insurer's network, including plans to which the network applies, how the
			 use of telemedicine or telehealth or other technology may be used to meet
			 network access standards;
(b) The
			 insurer's procedures for making and authorizing referrals within and outside
			 its network, if applicable;
(c) The
			 insurer's procedures for monitoring and assuring on an ongoing basis the
			 sufficiency of the network to meet the health care needs of populations that
			 enroll in network plans;
(d) The
			 factors used by the insurer to build its provider network, including a
			 description of the network and the criteria used to select or tier
			 providers;
(e) The insurer's
			 efforts to address the needs of enrollees, including, but not limited to
			 children and adults, including those with limited English proficiency or
			 illiteracy, diverse cultural or ethnic backgrounds, gay, lesbian, bisexual,
			 transgender, and any other minority gender identity or sexual orientation,
			 physical or mental disabilities, and serious, chronic, complex medical or
			 behavioral health conditions. This information must include the insurer's
			 efforts, when appropriate, to include various types of essential community
			 providers in its network;
(f) The
			 insurer's process for ensuring networks for plans sold outside of the
			 marketplace provide enrollees who reside in low-income zip code areas or who
			 reside in health professional shortage areas with adequate access to care
			 without delay;
(g) The insurer's
			 methods for assessing the health care needs of enrollees and their satisfaction
			 with services;
(h) The insurer's
			 method of informing enrollees of the plan's covered services and features,
			 including but not limited to:
(A) The plan's
			 grievance and appeals procedures;
(B) Its process for choosing and changing
			 providers;
(C) Its process for
			 updating its provider directories for each of its network plans;
(D) A statement of health care services
			 offered, including those services offered through the preventive care benefit,
			 if applicable; and
(E) Its
			 procedures for covering and approving emergency, urgent and specialty care, if
			 applicable.
(i) The
			 insurer's system for ensuring the coordination and continuity of care:
(A) For enrollees referred to specialty
			 physicians; and
(B) For enrollees
			 using ancillary services, including social services and other community
			 resources, and for ensuring appropriate discharge planning.
(j) The insurer's process for
			 enabling enrollees to change primary care professionals, if
			 applicable;
(k) The insurer's
			 proposed plan for providing continuity of care in the event of contract
			 termination between the insurer and any of its participating providers, or in
			 the event of the insurer's insolvency or other inability to continue
			 operations. The description shall explain how enrollees will be notified of the
			 contract termination, or the insurer's insolvency or other cessation of
			 operations, and transitioned to other providers in a timely manner;
			 and
(l) The insurer's process for
			 monitoring access to physician specialist services in emergency room care,
			 anesthesiology, radiology, hospitalist care and pathology/laboratory services
			 at their participating hospitals.