Or. Rev. Stat. § 743B.505

      743B.505 Provider networks; rules. (1) A carrier offering an individual or group health benefit plan in this state that provides coverage through a specified network of health care providers shall:

      (a) Contract with or employ a network of providers that is sufficient in number, geographic distribution and types of providers to ensure that all covered services under the health benefit plan, including mental health, substance use disorder and reproductive health care and treatment, are accessible:

      (A) To all enrollees for initial and follow-up appointments; and

      (B) In an appropriate and culturally competent manner to all enrollees, including those with diverse cultural and ethnic backgrounds, varying sexual orientations and gender identities, disabilities or physical or mental health conditions.

      (b)(A) With respect to health benefit plans offered through the health insurance exchange under ORS 741.310, contract with a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of essential community providers for low-income, medically underserved individuals in the plan’s service area in accordance with the network adequacy standards established by the Department of Consumer and Business Services;

      (B) If the health benefit plan offered through the health insurance exchange offers a majority of the covered services through physicians employed by the carrier or through a single contracted medical group, have a sufficient number and geographic distribution of employed or contracted providers and hospital facilities to ensure reasonable and timely access for low-income, medically underserved enrollees in the plan’s service area, in accordance with network adequacy standards adopted by the department; or

      (C) With respect to health benefit plans offered outside of the health insurance exchange, contract with or employ a network of providers that is sufficient in number, geographic distribution and types of providers to ensure access to care by enrollees who reside in locations within the health benefit plan’s service area that are health professional shortage areas or low-income zip codes, as prescribed by the department by rule.

      (c) Annually report to the department, in the format prescribed by the department, the carrier’s network of providers for each health benefit plan.

      (2)(a) A carrier may not discriminate with respect to participation under a health benefit plan or coverage under the plan against any health care provider who is acting within the scope of the provider’s license or certification in this state.

      (b) This subsection does not require a carrier to contract with any health care provider who is willing to abide by the carrier’s terms and conditions for participation established by the carrier.

      (c) This subsection does not prevent a carrier from establishing varying reimbursement rates based on quality or performance measures.

      (d) Rules adopted by the department to implement this subsection shall be consistent with the provisions of 42 U.S.C. 300gg-5 and the rules adopted by the United States Department of Health and Human Services, the United States Department of the Treasury or the United States Department of Labor to carry out 42 U.S.C. 300gg-5 that are in effect on January 1, 2025.

      (3) The Department of Consumer and Business Services shall conduct an annual evaluation of whether the network of providers available to enrollees in a health benefit plan meets the requirements of this section using a nationally recognized standard adopted by the department and adjusted, as necessary, to reflect the age demographics of the enrollees in the plan.

      (4)(a)(A) The department shall adopt by rule standards for evaluating, under subsection (3) of this section, the adequacy of a carrier’s network of providers in meeting the requirements of subsection (1) of this section and ensuring access by enrollees to initial and follow-up care without unreasonable delay. Standards shall be consistent with federal standards, including 45 C.F.R. 156.230, as in effect on January 1, 2025, but may incorporate flexibility to address issues specific to this state. Standards shall account for designations of a health professional shortage area and access to services based on provider and specialist availability in a geographic area.

      (B) The standards may include but are not limited to:

      (i) Standards for geographic access to ensure that specified providers are located within a reasonable distance of the homes or workplaces of all the enrollees in the carrier’s plans; and

      (ii) Specific limits on the amount of time an enrollee must wait to be seen between requesting care and receiving care.

      (C) The standards shall include standards for the scope and extent of telemedicine services, including behavioral health services that carriers may use to demonstrate compliance with network adequacy standards described in this section. As used in this subparagraph, “telemedicine” has the meaning given that term in ORS 743A.058.

      (b) Standards adopted by the department by rule to evaluate a carrier’s network of mental and behavioral health providers under subsection (3) of this section must ensure that the network includes an adequate number and geographic distribution in all geographic areas where the carrier offers plans, as prescribed by the department by rule, of licensed professional counselors, licensed marriage and family therapists, licensed clinical social workers, psychologists and psychiatrists who are accepting new patients, based on the needs of the enrollees in the carrier’s plans, including but not limited to providers who can address the needs of:

      (A) Children and adults;

      (B) Individuals with limited English proficiency or who are illiterate;

      (C) Individuals with diverse cultural or ethnic backgrounds;

      (D) Individuals with chronic or complex behavioral health conditions; and

      (E) Other groups specified by the department by rule.

      (5) This section does not require a carrier to contract with an essential community provider that refuses to accept the carrier’s generally applicable payment rates for services covered by the plan.

      (6) This section does not require a carrier to submit provider contracts to the department for review.

      (7) As used in this section:

      (a) “Carrier” has the meaning given that term in ORS 743B.005.

      (b) “Health professional shortage area” has the meaning given that term in 42 U.S.C. 254e. [2015 c.59 §2; 2017 c.152 §13; 2021 c.629 §6; 2025 c.541 §1]

      Note: 743B.505 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.

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