As used in OAR 836-053-0300 to 836-053-0355:

1. (1) “Enrollee” means an employee, dependent of the employee or an individual otherwise eligible for a group or individual health benefit plan who has enrolled for coverage under the terms of the plan.
2. (2) “Carrier” has the meaning given that term in ORS 743B.005.

3. (3) “Health benefit plan” means any:

   1. (a) Hospital expense, medical expense or hospital or medical expense policy or certificate;
   2. (b) Subscriber contract of a health care service contractor as defined in ORS 750.005; or
   3. (c) Plan provided by a multiple employer welfare arrangement or by another benefit arrangement defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent that the plan is subject to state regulation.
4. (4) “Network plan” means a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use health care providers managed, owned, under contract with or employed by the carrier.
5. (5) “Marketplace” means health insurance exchange as defined in OAR 945-001-0002(23).
6. (6) “Low-income zip code” means a ZIP code included in the Centers for Medicare and Medicaid Services (CMS) Marketplace Low-Income ZIP Code list for the applicable plan year, as published by CMS as of January 1, 2025 and thereafter as published by the department in a bulletin made available on the division’s website at https://dfr.oregon.gov/laws-rules/Pages/bulletins.aspx, or its successor.
7. (7) “Health professional shortage area” or HPSA means a geographic area, population group, or facility designated as such by the Department of Health and Human Services under 42 U.S.C. § 254e. For purposes of network adequacy, a provider or facility will be considered to be located in or serving an HPSA if it is located in, or serves a population group designated as an HPSA by the Health Resources and Services Administration (HRSA), updated annually as of January 1, 2025 and thereafter as published by the department in a bulletin made available on the division’s website at https://dfr.oregon.gov/laws-rules/Pages/bulletins.aspx, or its successor.
8. (8) “Telemedicine” has the meaning given that term in ORS 743A.058.
9. (9) “Nationally recognized standard” means the federal network adequacy standard for Qualified Health Plans, as set forth in 45 C.F.R. § 156.230, as in effect on January 1, 2025, unless otherwise specified in these rules.

10. (10) “County" means the designation assigned by the Centers for Medicare & Medicaid Services (CMS) for purposes of applying network adequacy standards for Qualified Health Plans (QHPs). The following county classifications are defined in 42 C.F.R § 156.230, as in effect on January 1, 2025, unless otherwise specified in these rules:

    1. (a) Large Metro – Counties with a population size and population density meeting the CMS thresholds for large metropolitan areas;
    2. (b) Metro – Counties with a population size and population density meeting the CMS thresholds for metropolitan areas;
    3. (c) Micro – Counties with a population size and population density meeting the CMS thresholds for micropolitan areas;
    4. (d) Rural – Counties with a population size and population density meeting the CMS thresholds for rural areas; and
    5. (e) Counties with Extreme Access Considerations (CEAC) – Counties with a population density of fewer than 10 persons per square mile, as determined by CMS.

Statutory/Other Authority

ORS 731.244 & ORS 743B.505

Statutes/Other Implemented

ORS 743B.505

History

ID 6-2026, amend filed 06/22/2026, effective 06/29/2026
ID 14-2025, temporary amend filed 12/16/2025, effective 01/01/2026 through 06/29/2026
ID 10-2016, f. & cert. ef. 9-14-16