Rules affected: OAR 836-053-0320, 836-053-0330
Need for Rules:
Oregon adopted its network adequacy requirements through House Bill 2468 in 2015 and adoption of related administrative rules in 2016. The Oregon process allows insurers to demonstrate its networks are adequate by submitting to the department evidence of compliance with a nationally-recognized standard. Acceptable nationally-recognized standards were established in administrative rule and included federal network adequacy standards applicable to Medicare Advantage plans, adjusted to reflect the age demographics of the enrollees in the plan or federal network adequacy standards applicable to Qualified Health Benefit Plans as outlined in the Final United States Department of Health and Human Services Notice of Benefit and Payment Parameters and Letter to Issuers in the Federally-facilitated Marketplaces.
The Centers for Medicare and Medicaid Services (CMS) no longer conducts network adequacy compliance reviews for Qualified Health Plans (QHPs) and now defers to state processes to determine compliance. CMS relies on insurers’ accreditation with an HS-recognized accrediting entity for states without authority and means to conduct network adequacy reviews.
At the time Oregon’s current network adequacy rules were adopted, the rulemaking advisory committee considered whether accreditation with an HHS-recognized accrediting entity would be an acceptable nationally-recognized standard and determined the accreditation process would not provide sufficient evidence that networks are adequate.
The proposed amendments to the rules remove the federal network adequacy standards applicable to QHPs as an acceptable nationally-recognized standard to use in demonstrating network adequacy. The proposed rules also provide clarification requested by the external rulemaking advisory committee on:
- The applicability of the annual report required in OAR 836-053-0320 to networks associated with health benefit plans currently in force and to those health benefit plans currently being sold.
- The evidence of compliance with a nationally-recognized standard should be based on compliance as of December 31 of the calendar year immediately preceding the March 31 reporting date.
- How the Medicare Advantage network adequacy standards must be adjusted to reflect the age demographics of the enrollees in the plan.
Filed: April 5, 2019
Public hearing: May 23, 2019, 10:00 a.m.
Last day for public comment: May 31, 2019, 5 p.m.