Current through Vol. 41, No. 13, March 15, 2024
(a) Participating
qualified benefit plans must offer, at a minimum, benefits that include:
(1) Hospital services;
(2) Physician services;
(3) Clinical laboratory and
radiology;
(4) Pharmacy;
(5) visits;
(6) Well baby/well child exams;
(7) Age appropriate immunizations as required
by law; and
(8) Emergency services
as required by law.
(b)
The benefit plan, if required, must be approved by the Oklahoma Insurance
Department for participation in the Oklahoma market. All benefit plans must
share in the cost of covered services and pharmacy products in addition to any
negotiated discounts with network providers, pharmacies, or pharmaceutical
manufacturers. If the benefit plan requires co-payments or deductibles, the
co-payments or deductibles cannot exceed the limits described in this
subsection.
(1) An annual in-network
out-of-pocket maximum cannot exceed $3,000 per individual, excluding separate
pharmacy deductibles.
(2) Office
visits cannot require a co-payment exceeding $50 per visit.
(3) Annual in-network pharmacy deductibles
cannot exceed $500 per individual.
(c) Qualified benefit plans will provide an
EOB, an expense summary, or required documentation for paid and/or denied
claims subject to member co-insurance or member deductible calculations. The
required documentation must contain, at a minimum, the:
(1) Provider's name;
(2) Patient's name;
(3) Date(s) of service;
(4) Code(s) and/or description(s) indicating
the service(s) rendered, the amount(s) paid or the denied status of the
claim(s);
(5) Reason code(s) and
description(s) for any denied service(s);
(6) Amount due and/or paid from the patient
or responsible party; and
(7)
Provider network status (in-network or out-of-network provider).
(d) A qualified benefit plan that
is participating in the Insure Oklahoma (IO) program as of November 1, 2022 may
become a self-funded or self-insured benefit plan if the following conditions
are met:
(1) The qualified benefit plan has
continuously participated in the premium assistance program without
interruption up to the date it becomes a self-funded or self-insured health
care plan;
(2) The self-funded or
self-insured benefit plan continues to be recognized as a benefit plan by the
Oklahoma Insurance Department;
(3)
The self-funded or self-insured benefit plan continues to cover all essential
health benefits listed in (a) of this section in addition to all other health
benefits that are required under applicable federal laws; and
(4) The self-funded or self-inured benefit
plan must have a monthly premium assessed and a rate schedule in order to be an
approved business with the IO program.
