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83rd OREGON LEGISLATIVE ASSEMBLY--2025 Regular Session
Senate Bill 822
Printed pursuant to Senate Interim Rule 213.28 by order of the President of the Senate in conformance with pre-
session filing rules, indicating neither advocacy nor opposition on the part of the President (at the request
of Governor Tina Kotek for Department of Consumer and Business Services)
SUMMARY
The following summary is not prepared by the sponsors of the measure and is not a part of the body thereof subject
to consideration by the Legislative Assembly. It is an editor’s brief statement of the essential features of the
measure as introduced.The statement includes a measure digest written in compliance with applicable readability
standards.
Digest: Expands network rules for some health benefit plans.Makes DCBS adopt certain rules.
Allows some health and dental plans to use remote providers to meet network rules. (Flesch Read-
ability Score: 72.3).
Expands network adequacy requirements to health benefit plans offered to large employers and
modifies requirements. Requires the Department of Consumer and Business Services to adopt speci-
fied standards for network adequacy.
Permits a health benefit plan and a dental-only plan to use telemedicine health care providers
to meet network adequacy standards only as permitted by rule adopted by the department.
A BILL FOR AN ACT
Relating to provider networks; amending ORS 743A.058 and 743B.505.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 743B.505 is amended to read:
743B.505. (1) [An insurer] A carrier offering [a] an individual or group health benefit plan in
this state that provides coverage [to individuals or to small employers, as defined in ORS
743B.005,] 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, [and] substance [abuse treatment,] use disorder and reproductive health
care and treatment, are accessible:
(A) To all enrollees for initial and follow-up appointments [without unreasonable delay.]; 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 iden-
tities, 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
BusinessServices;
(B) If the health benefit plan offered through the health insurance exchange offers a majority
of the covered services through physicians employed by the [insurer] 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
NOTE:Matter in boldfaced type in an amended section is new; matter [italic and bracketed] is existing law to be omitted.
New sections are in boldfaced type.
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standards adopted by the department [of Consumer and Business Services]; or
(C) With respect to health benefit plans offered outside of the health insurance exchange, con-
tract 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 [designated by the Health Resources and Services Administration
of the United States Department of Health and Human Services as] health professional shortage areas
or low-income zip codes, as prescribed by the department by rule.
(c) Annually report to the department [of Consumer and Business Services], in the format pre-
scribed by the department, the [insurer’s] carrier’s network of providers for each health benefit
plan.
(2)(a) [An insurer] 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 [an insurer] a carrier to contract with any health care
provider who is willing to abide by the [insurer’s] carrier’s terms and conditions for participation
established by the [insurer] carrier.
(c) This subsection does not prevent [an insurer] a carrier from establishing varying re-
imbursement rates based on quality or performance measures.
(d) Rules adopted by the department [of Consumer and Business Services] to implement this
[section] 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 De-
partment 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, [2017] 2025.
(3) The Department of Consumer and Business Services shall [use one of the following methods
in] conduct an annual evaluation of whether the network of providers available to enrollees in a
health benefit plan meets the requirements of this section[:]
[(a) An approach by which an insurer submits evidence that the insurer is complying with at least
one of the factors prescribed by the department by rule from each of the following categories:]
[(A) Access to care consistent with the needs of the enrollees served by the network;]
[(B) Consumer satisfaction;]
[(C) Transparency; and]
[(D) Quality of care and cost containment; or]
[(b) A] using a nationally recognized standard adopted by the department and adjusted, as nec-
essary, to reflect the age demographics of the enrollees in the plan.
(4)(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. The standards may include but are not limited to:
(A) Standards for geographic access to ensure that specified providers are located within
a reasonable distance of the homes and workplaces of all the enrollees in the carrier’s plans;
(B) Provider-to-patient ratios to ensure that a sufficient number of providers are avail-
able within the carrier’s network to serve all the enrollees in the carrier’s plans; and
(C) Specific limits on the amount of time an enrollee must wait to be seen between re-
questing care and receiving care.
[(4)] (b) [In evaluating an insurer’s] Standards adopted by the department by rule to evalu-
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ate a carrier’s network of mental and behavioral health providers under subsection (3) of this
section[, the department shall] must ensure that the network includes[:]
[(a)] an adequate number and geographic distribution in all geographic areas where the car-
rier offers plans, as prescribed by the department by rule, of licensed professional counselors, li-
censed marriage and family therapists, licensed clinical social workers, psychologists and
psychiatrists who are accepting new patients, based on the needs of the [insureds under the policy
or certificate] enrollees in the carrier’s plans, including but not limited to providers who can ad-
dress 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[; and].
[(b) An adequate number of the providers described in paragraph (a) of this subsection in all ge-
ographic areas where the insurer offers plans.]
(5) This section does not require [an insurer] a carrier to contract with an essential community
provider that refuses to accept the [insurer’s] carrier’s generally applicable payment rates for ser-
vices covered by the plan.
(6) This section does not require [an insurer] a carrier to submit provider contracts to the de-
partment for review.
(7) As used in this section, “carrier” has the meaning given that term in ORS 743B.005.
SECTION 2. ORS 743A.058 is amended to read:
743A.058. (1) As used in this section:
(a)(A) “Audio only” means the use of audio telephone technology, permitting real-time commu-
nication between a health care provider and a patient for the purpose of diagnosis, consultation or
treatment.
(B) “Audio only” does not include:
(i) The use of facsimile, electronic mail or text messages.
(ii) The delivery of health services that are customarily delivered by audio telephone technology
and customarily not billed as separate services by a health care provider, such as the sharing of
laboratoryresults.
(b) “Health benefit plan” has the meaning given that term in ORS 743B.005.
(c) “Health professional” means a person licensed, certified or registered in this state to provide
health care services or supplies.
(d) “Health service” means physical, oral and behavioral health treatment or service provided
by a health professional.
(e) “Originating site” means the physical location of the patient.
(f) “State of emergency” includes:
(A) A state of emergency declared by the Governor under ORS 401.165; or
(B) A state of public health emergency declared by the Governor under ORS 433.441.
(g) “Telemedicine” means the mode of delivering health services using information and tele-
communication technologies to provide consultation and education or to facilitate diagnosis, treat-
ment, care management or self-management of a patient’s health care.
(2) A health benefit plan and a dental-only plan must provide coverage of a health service that
is provided using telemedicine if:
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(a) The plan provides coverage of the health service when provided in person by a health pro-
fessional;
(b) The health service is medically necessary;
(c) The health service is determined to be safely and effectively provided using telemedicine
according to generally accepted health care practices and standards; and
(d) The application and technology used to provide the health service meet all standards re-
quired by state and federal laws governing the privacy and security of protected health information.
(3) Except as provided in subsection (4) of this section, permissible telemedicine applications and
technologiesinclude:
(a) Landlines, wireless communications, the Internet and telephone networks; and
(b) Synchronous or asynchronous transmissions using audio only, video only, audio and video
and transmission of data from remote monitoring devices.
(4) During a state of emergency, a health benefit plan or dental-only plan shall provide coverage
of a telemedicine service delivered to an enrollee residing in the geographic area specified in the
declaration of the state of emergency, if the telemedicine service is delivered using any commonly
available technology, regardless of whether the technology meets all standards required by state and
federal laws governing the privacy and security of protected health information.
(5) A health benefit plan and a dental-only plan may not:
(a) Distinguish between rural and urban originating sites in providing coverage under subsection
(2) of this section or restrict originating sites that qualify for reimbursement.
(b) Restrict a health care provider to delivering services only in person or only via telemedicine.
(c) Use telemedicine health care providers to meet network adequacy standards under ORS
743B.505, except as permitted by the Department of Consumer and Business Services under
criteria prescribed by the department by rule.
(d) Require an enrollee to have an established patient-provider relationship with a provider to
receive telemedicine health services from the provider or require an enrollee to consent to tele-
medicine services in person.
(e) Impose additional certification, location or training requirements for telemedicine providers
or restrict the scope of services that may be provided using telemedicine to less than a provider’s
permissible scope of practice.
(f) Impose more restrictive requirements for telemedicine applications and technologies than
those specified in subsection (3) of this section.
(g) Impose on telemedicine health services different annual dollar maximums or prior authori-
zation requirements than the annual dollar maximums and prior authorization requirements imposed
on the services if provided in person.
(h) Require a medical assistant or other health professional to be present with an enrollee at
the originating site.
(i) Deny an enrollee the choice to receive a health service in person or via telemedicine.
(j) Reimburse an out-of-network provider at a rate for telemedicine health services that is dif-
ferent than the reimbursement paid to the out-of-network provider for health services delivered in
person.
(k) Restrict a provider from providing telemedicine services across state lines if the services are
within the provider’s scope of practice and:
(A) The provider has an established practice within this state;
(B) The provider’s employer operates health clinics or licensed health care facilities in this
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state;
(C) The provider has an established relationship with the patient; or
(D) The patient was referred to the provider by the patient’s primary care or specialty provider
located in this state.
(L) Prevent a provider from prescribing, dispensing or administering drugs or medical supplies
or otherwise providing treatment recommendations to an enrollee after having performed an appro-
priate examination of the enrollee in person, through telemedicine or by the use of instrumentation
and diagnostic equipment through which images and medical records may be transmitted electron-
ically.
(m) Establish standards for determining medical necessity for services delivered using telemedi-
cine that are higher than standards for determining medical necessity for services delivered in per-
son.
(6) A health benefit plan and a dental-only plan shall:
(a) Work with contracted providers to ensure meaningful access to telemedicine services by as-
sessing an enrollee’s capacity to use telemedicine technologies that comply with accessibility stan-
dards, including alternate formats, and providing the optimal quality of care for the enrollee given
the enrollee’s capacity;
(b) Ensure access to auxiliary aids and services to ensure that telemedicine services accommo-
date the needs of enrollees who have difficulty communicating due to a medical condition, who need
an accommodation due to disability or advanced age or who have limited English proficiency;
(c) Ensure access to telemedicine services for enrollees who have limited English proficiency
or who are deaf or hard-of-hearing by providing interpreter services reimbursed at the same rate
as interpreter services provided in person; and
(d) Ensure that telemedicine services are culturally and linguistically appropriate and trauma-
informed.
(7) The coverage under subsection (2) of this section is subject to:
(a) The terms and conditions of the health benefit plan or dental-only plan; and
(b) Subject to subsection (8) of this section, the reimbursement specified in the contract between
the plan and the health professional.
(8)(a) A health benefit plan and dental-only plan must pay the same reimbursement for a health
service regardless of whether the service is provided in person or using any permissible telemedicine
application or technology.
(b) Paragraph (a) of this subsection does not prohibit the use of value-based payment methods,
including capitated, bundled, risk-based or other value-based payment methods, and does not require
that any value-based payment method reimburse telemedicine health services based on an equivalent
fee-for-servicerate.
(9) This section does not require a health benefit plan or dental-only plan to reimburse a health
professional:
(a) For a health service that is not a covered benefit under the plan;
(b) Who has not contracted with the plan; or
(c) For a service that is not included within the Healthcare Procedure Coding System or the
American Medical Association’s Current Procedural Terminology codes or related modifier codes.
(10) This section is exempt from ORS 743A.001.
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