Oregon’s neighbors to the north and south have strict rules around the number, type and location of providers insurance carriers must include within their policies’ networks. Here, such rules are still in the works.

The Oregon Insurance Division, an agency within the state’s Department of Consumer & Business Services that regulates the insurance marketplace, has for years been working to develop those rules, called network adequacy rules. A bill that outlines the basics of network adequacy earned all but one “yes” vote in the Oregon House and now awaits hearings in the Senate, where it’s likely to be approved. The regulations would take effect Jan. 1, 2017.

The issue of narrow provider networks has become especially visible since the Affordable Care Act’s insurance mandate took effect at the beginning of 2014. Many Americans soon realized buying the cheapest plans possible generally means having the least amount of choice over which doctor they’ll see. In extreme cases, some people found none of those listed by their insurance carrier were accepting new patients, or they had to drive long distances or wait weeks or months for an appointment.

Almost all insurance carriers list the providers they contract with one their websites, but they often aren’t updated when the providers aren’t seeing new patients, said Gayle Woods, a senior policy adviser with the Oregon Insurance Division and a leader on the network adequacy work.

“This is a challenge for carriers, too, because many of them place the responsibility on the provider to update the system to indicate whether they’re accepting new patients,” she said.

The new rules in Oregon, unless they’re changed in the Senate, would require carriers to submit annual reports to the state on their plans for ensuring network adequacy, and their websites must feature lists of in-network providers.

The law would not apply to large group plans, but it would apply to individual policies and small group policies that cover fewer than 100 people. A large proportion of Oregon’s insured are covered under large group plans, usually through employers or associations, but Woods said insurance carriers and business groups had concerns about applying the regulations to large group plans because they’re structured differently from small group and individual plans. The division hopes to develop rules for large group plans in the future, she said.

“We don’t believe we have convincing evidence that people who are enrolled in large group plans shouldn’t have the same level of protection that this bill provides otherwise for individual and small group members,” she said. “But we really didn’t want to compromise the ability to get the bill passed.”

The law’s most crucial details, such as how many providers are covered, where they’re located and whether patients can see them, will be hashed out by the Oregon Insurance Division when it clarifies specific rules after it’s approved by the Legislature.

The division will likely allow carriers to choose one of two methods to prove their networks are adequate. One would be using nationally recognized standards around proving network adequacy, likely those already used with Medicare Advantage plans, because carriers are familiar with those formats, Woods said. The other method would be using a “factor”-based approach using four sets of criteria: access to care, consumer satisfaction, quality and cost containment and transparency. The specifics of those four categories still need to be defined, but Woods said they could include distance to the providers and the time it takes to travel there.

The process is complicated by the fact that certain areas of the state are vastly different from others. Consider a city like Portland, where dozens of doctors could be located within a few miles of one’s home, and Prineville, a city that likely has fewer than a dozen doctors.

“If we were to set prescriptive specific standards and require ratios of specialists in membership, that could force some carriers out of certain areas of the state because they wouldn’t be able to develop networks to comply,” Woods said. “We don’t want to create impossible requirements.”

Moda Health, a prominent insurer in Oregon, and the Oregon Business Association, both took issue with the four “factors,” arguing they’re too open-ended. But Jesse Ellis O’Brien, a health care advocate with the Oregon State Public Interest Research Group Foundation, a Portland-based consumer advocacy group, said the whole idea behind the process was to provide flexibility for rulemaking while not creating burdensome regulations for carriers.

“The intent is for it to still have some teeth, so it won’t be totally flexible,” he said, “but the intent is to provide a different way for insurance companies to show that they are delivering high-value care to people.”

Naturopathic physicians in Oregon hoped the network adequacy regulations would compel insurers to cover them as primary care providers — a move many in the medical community disagreed with — but Woods said the rules do not do that. The division can’t tell insurers who to contract with, she said. There is a federal nondiscrimination law, however, that says insurers can’t exclude certain types of providers so long as they’re licensed in states, they just don’t necessarily need to cover them as primary care providers. Some insurers cover naturopathic physicians under “alternative” or “holistic” sections of their policies.

— Reporter: 541-383-0304,

tbannow@bendbulletin.com