1. (1) Carriers must meet the following minimum quantitative access benchmarks as adopted in OAR 836-053-0335, consistent with the network adequacy standards for Qualified Health Plans set forth in 45 C.F.R. § 156.230, as in effect on January 1, 2025.

   1. (a) Travel time and distance: Carriers must meet the travel time and distance standards to ensure that at least 90 percent of enrollees have access to in-network providers within the applicable time and distance requirements for each provider type and county as defined in OAR 836-053-0310(j). The applicable federal standards, including specific time and distance benchmarks by provider and county type, are published by the Centers for Medicare & Medicaid Services (CMS) in Appendix E of the Network Adequacy Template for Plan Year 2025, which are available on the division’s website at https://dfr.oregon.gov/business/reg/health/Pages/annual-network-adequacy.aspx.
   2. (b) Each carrier is responsible for conducting the geospatial analysis required to demonstrate compliance with travel time and distance standards. Carriers must submit the results of their analysis, showing the number and percentage of enrollees meeting each standard for every required provider and facility type, by county classification, in the format and manner prescribed by the department.

   3. (c) Appointment wait times: For each provider type listed below, carriers must ensure that at least 90 percent of enrollees have access to an in-network provider appointment within the following timeframes:

      1. (A) Primary care: not more than 15 business days.
      2. (B) Behavioral health care: not more than 10 business days.
      3. (C) Specialty care: not more than 30 business days.
2. (2) In areas designated as health professional shortage areas (HPSAs), or low-income ZIP codes as defined in OAR 836-053-0310, carriers may satisfy the quantitative standards in this rule through a justification process as described in OAR 836-053-0325.

3. (3) In meeting the quantitative network adequacy standards in this rule, carriers may use telemedicine providers to satisfy up to:

   1. (a) 10 percent of the access requirements for primary care and specialty care services; and
   2. (b) 30 percent of the access requirements for behavioral health care services.

Statutory/Other Authority

ORS 731.244 & ORS 743B.505

Statutes/Other Implemented

ORS 743B.505

History

ID 6-2026, adopt filed 06/22/2026, effective 06/29/2026
ID 14-2025, temporary adopt filed 12/16/2025, effective 01/01/2026 through 06/29/2026