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​Rules affected: OAR 836-053-0013

Need for Rules:
ORS 743B.130 requires the Department of Consumer and Business Services (DCBS) to prescribe by rule the form, level of coverage, and benefit design for bronze and silver health benefit plans that must be offered by insurance carriers. These plans must meet federal requirements issued by the Department of Health and Human Services (HHS). Each year, HHS updates the actuarial value (AV) calculator used for determining coverage levels. Changes may include costs, plan designs, populations, developments in the function and operation of the AV calculator and other actuarially relevant factors.

As a result of changes made to the federal AV calculator for 2020, the AV for the standard bronze and silver plans prescribed in OAR 836-053-0013 exceeded federal requirements. Failure to update the rule would result in DCBS requiring carriers to submit plans that are illegal with respect to federal law.

This year, HHS released the AV calculator later than in previous years. As a result, a permanent rulemaking would not have been completed in time for carriers to submit plans in May for review so a temporary rule was adopted. The department is now following the procedures to adopt this temporary rule into a permanent rule.

Filed: May 29, 2019

Public hearing: June 24, 2019, 10:00 a.m.

Last day for public comment: July 1, 2019, 5 p.m.

Documents

​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:

  1. 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.
  2. 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.
  3. 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.

Documents

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Where to send comments on proposed rules

Division of Financial Regulation
ins.rules@oregon.gov

Rulemaking advisory committees

Agency Mailing / Interested Party List:

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This electronic notification service is used to send notifications of all administrative rule changes per ORS 183.335(8). Please note each subscriber must keep their subscription choices and email address up to date to ensure they receive the appropriate notices.

If you have questions or if you need to request hard copy notices, you may contact Karen Winkel via email at Karen.j.winkel@oregon.gov.

Key links

Oregon Revised Statutes
Oregon Administrative Rules​​
Oregon State Legislature​​ ​


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