Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3515 - Network Adequacy

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Managed Care
			 Entities (MCEs) shall maintain and monitor a network of participating providers
			 that is sufficient in number, provider type, and geographic distribution to
			 ensure adequate service capacity and availability to provide available and
			 timely access to medically appropriate and culturally responsive covered
			 services to both current members and those the MCE anticipate shall become
			 enrolled as members.
(2) The MCE
			 shall develop a provider network that enables members to access services within
			 the standards defined in this rule.
(3) The MCE shall meet access-to-care
			 standards that allow for appropriate choice for members. Services and supports
			 shall be as close as possible to where members reside and, to the extent
			 necessary, offered in nontraditional settings that are accessible to families,
			 diverse communities, and underserved populations.
(4) MCEs shall meet quantitative network
			 access standards defined in rule and contract.
(5) MCEs shall ensure access to integrated
			 and coordinated care as outlined in OAR 410-141-3860, which includes access to
			 a primary care provider or primary care team that is responsible for
			 coordination of care and transitions.
(6) In developing its provider network, the
			 MCEs shall anticipate access needs so that the members receive the right care
			 at the right time and place, using a patient-centered, trauma informed
			 approach. The provider network shall support members, especially those with
			 behavioral health conditions, in the most appropriate and independent setting,
			 including in their own home or independent supported living.
(7) In assessing the capacity and adequacy of
			 its provider network, MCEs shall consider, in conjunction with the quantitative
			 standards set forth in this rule, the variety of provider and facility types
			 with the demonstrated ability and expertise to render specific medically or
			 dentally appropriate covered services within the scope of applicable licensing
			 and credentialling. This includes, but is not limited to, the prescribing of
			 Medication-Assisted Treatment and more specialized oral health care
			 services.
(8) All MCEs shall ensure
			 95% of members can access the following provider and facility types, further
			 defined by the Authority in guidance made available on the CCO Contracts Forms
			 webpage
https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx
,
			 within acceptable travel time or distance standards set forth this rule:
(a) Tier one:
(A) Primary care providers serving adults and
			 those serving pediatrics;
(B)
			 Primary care dentists serving adults and those serving pediatrics;
(C) Mental health providers serving adults
			 and those serving pediatrics;
(D)
			 Substance use disorder providers serving adults and those serving
			 pediatrics
(E) Pharmacy;
(F) Additional provider types when it
			 promotes the objectives of the Authority or as required by
			 legislation.