Or. Admin. Code § 836-053-0340

Current through Register Vol. 63, No. 11, November 1, 2024

Section 836-053-0340 - Factor-Based Evidence of Compliance with Network Adequacy Requirements

(1) An insurer electing to demonstrate compliance with network adequacy requirements required under ORS 743.505B via the factor-based approach shall submit evidence of compliance to the Director by March 31 each year.

(2) The evidence must include a narrative description of how the insurer complies with the factor along with the source and methodology, where applicable, for at least one of the factors listed for each of these categories:

(a) Access to Care Consistent with the Needs of the Enrollees Served by the Network category:

(A) Access to Care Factor #1- The insurer's network ensures all covered services under the health benefit plan are accessible to enrollees without unreasonable delay.

(i) Submit median enrollee wait times for preventive care appointments for the prior calendar year.

(ii) Submit median length of time enrollees waited for access to mental health and substance abuse providers for the prior calendar year.

(iii) Submit median length of time enrollees waited to receive care for mental health conditions following intake evaluation.

(iv) Evidence that the network provides 24-hour access to clinical advice.

(v) Urgent care services outside of regular business hours are available in all covered regions or service areas.

(vi) Submit median enrollee wait times for routine care appointments for the prior calendar year.

(vii) Submit median enrollee wait times for specialist appointments for the prior calendar year.

(B) Access to Care Factor #2 - The network meets special needs of specific populations.

(i) The network has the capacity to accept new patients.

(ii) The network includes a full range of pediatric providers including pediatric subspecialists and providers that offer care to children with special needs.

(iii) Services are made available to enrollees residing in medically underserved areas of the state, if the insurer offers coverage in those areas.

(iv) All plans served by a network are included when determining whether the network is sufficient.

(v) The network provides access to culturally and linguistically appropriate services.

(C) Access to Care Factor #3 - The insurer actively manages the network including oversight of access to care.

(i) Providers who are not accepting new patients are not included when determining whether an adequate number of providers (including specialists) are in the network.

(ii) All plans served by a network are included when determining whether the network is sufficient.

(iii) The network adequacy monitoring process includes specific intervals between formal reviews, reporting of review results to senior management or board of directors, and formal reviews are used to monitor and improve accessibility for enrollees.

(b) Consumer Satisfaction category:

(A) Consumer Satisfaction Factor #1 - Insurer maintains accreditation status and can demonstrate consumers are satisfied with the plan.

(i) Submit insurer accreditation status from either the National Committee for Quality Assurance (NCQA), URAC, or the Accreditation Association for Ambulatory Health Care (AAAHC) including information regarding customer satisfaction rating from accreditation entity; or

(ii) Either of the following:

(I)Global rating of health plan (Enrollee Satisfaction Survey Consumer Assessment of Healthcare Providers and Systems) and

(II) Global rating of health care (Enrollee Satisfaction Survey Consumer Assessment of Healthcare Providers and Systems).

(B) Consumer Satisfaction Factor #2 - Consumers are able to access care when needed without unreasonable delay.

(i) Number of enrollee communications the insurer received during the previous calendar year regarding difficulty in obtaining an appointment with a provider, including but not limited to the inability to find a provider with an open practice or an unreasonable length of time to wait for an appointment.

(ii) Number of consumer complaints the insurer received during the previous calendar year regarding care received out of network due to consumer's inability to receive care in network. Communications under this section include but are not limited to complaints, appeals and grievances from enrollees.

(iii) Median wait times for members to be seen at time of appointment.

(c) Transparency:

(A) Transparency Factor #1 - Insurer maintains an accurate provider directory which is available to the general public.

(i) Provider locations are transparent to the public.

(ii) Provide link to website where provider directory is located and explain how frequently the directory is updated and where this information is disclosed on the provider directory.

(iii) Explain how the insurer keeps information on which providers in the network have open practices and how often this information is updated.

(iv) Provide position and department of individual responsible for establishing and monitoring the network.

(B) Transparency Factor #2 - Consumers, enrollees and providers have access to accurate provider information.

(i) Providers have access to information about other providers in the network.

(ii) Consumers and enrollees are informed on how to locate in-network providers when scheduling medical services.

(iii) Explain how frequently enrollees are specifically notified of changes to the provider network and the method the insurer uses to communicate this information.

(iv) Provider directory discloses which providers are fluent in languages other than English and if so, what languages are available.

(v) Consumers and enrollees are informed of providers in the network with open practices.

(d) Quality of Care and Cost Containment:

(A) Quality of Care and Cost Containment Factor #1 - The insurer engages in provider quality improvement activities.

(i) Submit provider quality data the insurer uses.

(ii) Describe the specific quality designations required of specialists in the network.

(iii) Explain provider accreditation status requirements used by the insurer.

(iv) Provide the percentage of accredited patient-centered primary care homes in the network.

(v) Provide a list of all provider types included in the network and identify those who provide telemedicine services.

(B) Quality of Care and Cost Containment Factor #2 - The insurer is implementing quality improvement activities in addition to provider quality improvement.

(i) The insurer reports quality improvement strategies to the public.

(ii) The provider payment structure supports improved health outcomes, reduction of hospital readmissions, improved patient safety and reduction of medical errors, and reduction of health care disparities.

(iii) The insurer offers health promotion and wellness programs to enrollees.

(iv) Appointments with high volume specialists are available within the network without unreasonable delay.

(C) Quality of Care and Cost Containment Factor #3 - The insurer employs network design strategies to reduce cost and improve quality.

(i) The network design supports improved enrollee health and lower cost.

(ii) The insurer analyzes relevant information to promote good health outcomes.

(iii) The network can be considered a high-value network.

(iv) Electronic health records are used within the network.

Or. Admin. Code § 836-053-0340

ID 10-2016, f. & cert. ef. 9/14/2016

Stat. Auth: ORS 731.244 and 743B.505

Stats. Implemented: ORS 743B.505