Or. Admin. Code § 836-053-1190

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-1190 - Annual Summary, Uniform Indicators of Network Adequacy

An insurer offering managed health insurance or preferred provider organization insurance shall submit its annual summary required under ORS 743.817 on March 1 of each year. The annual summary shall include the following matters for the immediately preceding calendar year as of December 31, according to the following uniform indicators:

(1) Whether the insurer has established a requirement or goal for accessibility that providers must meet, in terms of hours, days or weeks, or in the alternative an indication that the insurer does not establish and maintain such a requirement or goal, for the following categories:

(a) Preventive care;

(b) Routine primary care; and

(c) Urgent care.

(2) Whether accessibility to urgent care services outside of regular business hours differs by region or geographical area of the state that the insurer serves, and if so, a description of the differences among the regions or areas.

(3) The number of communications expressing a concern regarding difficulty in obtaining an appointment with a provider, including but not limited to the inability to find a provider with a open practice or to an unreasonable length of time to wait for an appointment. Communications under this section include but are not limited to complaints, grievances and appeals from enrollees.

(4) Whether the insurer has a process for ensuring network adequacy that includes oversight, communication and monitoring, and the following information about the process:

(a) The position and department of the individual with the responsibility of ensuring and monitoring the network;

(b) The phone number, address or website that enrollees are requested to use in order to express concerns regarding network adequacy;

(c) The website at which enrollees can locate the provider directory, and the frequency with which the website is updated.

(d) How often an enrollee is specifically notified of changes to the insurer's provider network and the medium or media by which an enrollee is informed.

(e) Information regarding the insurer's monitoring of its network adequacy, including:

(A) The intervals between formal reviews (monthly, quarterly, annually or other);

(B) Whether the results of the reviews are reported to senior management or the board of directors, or both, or neither; and

(C) How the insurer uses its formal reviews to monitor and improve accessibility for clients.

(5) Whether the insurer's provider directory and updates to the directory disclose which providers are fluent in languages other than English and, if so, what languages are available.

(6) Whether the insurer keeps information on which of the physicians in its network have open practices, and if so:

(a) How often does the insurer update the information; and

(b) Whether enrollees have access to the information. If enrollees have access, please explain how enrollees may seek access.

(7) Any other information that the insurer determines to be significant in documenting the scope of its network or its monitoring of access to services.

Or. Admin. Code § 836-053-1190

ID 1-1998, f. & cert. ef. 1-15-98; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02

Stat. Auth.: ORS 731.244 & ORS 743.819

Stats. Implemented: ORS 743.817