Oregon Senate Bill requirement enhances access to care and may improve health outcomes

The Oregon Senate Bill (SB) 1529 has introduced new requirements for the administration of health care benefits, which impacts all new and renewing fully insured businesses issued in the state of Oregon. It is effective for new groups Jan. 1, 2024, and existing groups upon their renewal after Jan. 1, 2024, for both Small Business (groups up to size 50) and Large Group (51+) inclusive of all medical plans.

Under this bill, issuers for all employer sponsored health plans in Oregon must apply a primary care copay of no more than $5 for the first three visits (including behavioral health). UnitedHealthcare will waive the cost-share for the first 3 primary care visits for Small Business only; $5 for Large Group. A Primary Care Physician (PCP) must be assigned for each plan member. This requirement applies to all fully insured plans across all segments filed in the state of Oregon. Where applicable, members have been moved to a PCP-enabled plan that complies with the PCP selection, assignment and notification rules of SB 1529.

Telehealth services provided by the in-person provider virtually, as well as virtual primary care services performed by national providers, are in-scope and will also be included in this benefit.

Oregon Senate Bill 1529 impacts all new and renewing fully insured business in the state of Oregon. The legislation affects cost-share for primary care visits and requires the assignment of a PCP to members. Care providers and members will be informed when a PCP is assigned, and benefit summaries and other plan materials will include language specific to these new benefits and member cost-share information.

Under this bill, issuers for all employer sponsored health plans in Oregon must apply a primary care physician (PCP) copay of no more than $5 for the first three visits (including behavioral health) and a PCP must be assigned for their members. This requirement applies to all PCP-centered and open-access fully insured plans across all segments filed in the state of Oregon.

New health care benefit requirements for all employer sponsored health plans in Oregon include:

• Waiving the cost-share for the first three PCP visits for Small Business; $5 for Large Group: All payers must cover the cost of the first three primary care physician (PCP) visits, including visits for behavioral health provided by the PCP:
  • Small Business (2–50) plans have been updated to include $0 for the first three PCP visits. This is in addition to the annual wellness visits that are already covered at 100%. This $0 PCP benefit will come into effect on Jan. 1, 2024. We will target the 2025 portfolio cycle to update our plans to reflect the amended ruling released in June 2023 and apply the $5 PCP copay (first three visits) at that time.
  • For Large Group (51+), plans have been updated to include $5 for the first three PCP visits. This is in addition to the annual wellness visits that are already covered at 100%. This requirement will come into effect on Jan. 1, 2024.

Telehealth services provided by the in-person PCP virtually, as well as Virtual Primary Care services performed by National providers is in-scope and will also be included in this benefit.

• PCP assignment: Under this bill, all payers must assign a PCP for their members. This requirement applies to all PCP-centered and open-access fully insured plans across all segments filed in the state of Oregon.
  • UnitedHealthcare will do their part to inform members and their care providers when a PCP has been assigned. Members can change their designated PCP at any time. Benefit Summaries and other Plan Materials will include language specific to these new benefits and member cost-share information.

If you have any questions about the initiative, please read this flier or visit the site.

For more information on the amendment clarifying mental health parity $5 copay, please visit the site.