Oregon Senate Bill (SB) 1529 recently passed by the state legislature brings new requirements for employer sponsored health plans. Effective January 1, 2024, individual and fully insured group health insurance policies written in Oregon are required to provide 3 primary care visits (PCP) per covered individual with a limited copay and the deductible waived. The bill also requires carriers to assign a PCP to enrollees within 90 days of enrollment. Sponsors of the bill advocate that improving access to preventive care will lower the cost of health care in the long run.
Primary Care Benefit Enhancements
The original ruling required a $0 copay but was amended in June 2023 to allow a $5 copay. Carriers were required to file small group (<50 employees) plan designs and rates with the Oregon Division of Financial Regulation by June 5th which was prior to the amendment. Because of the timing, we are seeing some small group policies with a $0 copay and most large employer policies with a $5 copay. We anticipate that carriers will remedy this in 2025 and move to a $5 copay for all policies.
- The 3 visits are in addition to the one annual wellness visit that is already covered at 100% under ACA preventive care requirements.
- Includes Behavioral health services provided by the PCP.
- HSA eligible high deductible health plans are exempt from the deductible waiver requirement. Limited copay requirements apply. Carriers are offering HDHP plans with limited copay PCP visits after the deductible.
- The following plans are exempt from this new requirement: self-funded and level-funded plans, Public Employees’ Benefit Board (PEBB) and the Oregon Educators Benefit Board (OEBB) plans.
Primary Care Provider Assignment
SB 1529 also includes a requirement that carriers assign a PCP within 90 days of enrollment and notify the enrollee when the PCP is assigned. Enrollees have the option to elect a PCP when enrolling or one will be assigned. Enrollees are allowed to change their PCP at any time by contacting the carrier.
The PCP assignment requirement applies to all individual and fully insured plans. Level-funded and self-funded plans, PEBB and OEBB plans are exempt.
Carriers are taking a variety of approaches to comply with the carrier PCP assignment requirement. The state has issued draft rules that outline the PCP assignment methodology. The draft rules require plans to assign the PCP based on the following:
- Enrollees’ election during enrollment;
- Claims history, if the member does not designate a PCP;
- When neither of the above exist, the carrier must assign a provider.
For employers with Oregon based plans that are collecting PCP elections, we encourage communicating the PCP election requirement during open enrollment. Reach out to your IMA benefits team if you have questions regarding your carrier’s PCP assignment process.
This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.