Oregon has made changes to the network adequacy rules for OHP with a focus on standards for how long it should take most CCO members to get to different types of providers or services.
These changes were made using considerable feedback from members, community partners, and health plans. OHA made changes based on this feedback and a variety of data sources (for example: claims and encounter data).
You can see the results of the feedback survey that closed April 3, 2023 in the menu to the right.
To help those interested in tracking the changes over time, OHA has posted its slides from network standards presentations. Also available is a description of changes to the proposed standards. See documents below.
Changes as of 01/01/2024 are:
New area types
OHA expanded the rules from two area types: urban and rural, to four area types. OHA thought that two area types are not enough to describe Oregon's geography. Here is our new list of area types:
-
County with Extreme Access Considerations
(orange) - Counties with 10 or fewer people per square mile.
-
Rural (blue) - More than 10 miles from the center of an urban area.
-
Urban(green) - More than 40,000 people in a 10 mile radius.
-
Large Urban Areas(purple) - Connected urban areas with 1 million people or with more than 1,000 people per square mile.
Tiers
The rules are different based on the provider you need to see and the area you live in. OHA is created tighter time and distance standards for providers that members usually see more often. These providers are "Tier 1" providers. Primary Care Providers are considered “Tier 1". A specialty provider that not all members need is a "Tier 2" or "Tier 3" provider. A Dermatologist, for example, is in "Tier 3".
The charts below lists the time and distance tiers in minutes or miles and the provider or service types by tier.
|
Large Urban |
Urban |
Rural |
County with Extreme Access Considerations |
Tier 1
|
10 mins or
5 miles |
25 mins or
15 miles |
30 mins or
20 miles
|
40 mins or
30 miles |
Tier 2
|
20 mins or
10 miles |
30 mins or
20 miles |
75 mins or
60 miles |
95 mins or
85 miles |
Tier 3
|
30 mins or
15 miles |
45 mins or
30 miles |
110 mins or
90 miles |
140 mins or
125 miles |
|
Tier 1 |
Primary Care, Primary Care Dentistry, Mental Health, Pharmacy, SUD Treatment |
|
Tier 2 |
Cardiology, Durable Medical Equipment, Hospital, Methadone Clinic, Neurology, Obstetrics and
Gynecology, Occupational Therapy, Medical Oncology, Radiation Oncology, Ophthalmology, Optometry, Physical Therapy, Podiatry, Psychiatry, Speech Language Pathology |
|
Tier 3 |
Allergy & Immunology, Dermatology, Endocrinology, Gastroenterology, Hematology, Nephrology,
Otolaryngology, Pulmonology, Rheumatology, Skilled Nursing Facility, Urology |
Heath plans serving OHP members are responsible for helping members get the care they need. That means that even if the provider or service is not listed in the chart above, your health plan should still help you get access to covered benefits and services.