Okla. Admin. Code § 317:45-5-1

Current through Vol. 42, No. 7, December 16, 2024

Section 317:45-5-1 - Qualified Benefit Plan requirements

(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 copayments 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.

Okla. Admin. Code § 317:45-5-1

Added at 23 Ok Reg 278, eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 24 Ok Reg 101, eff 8-2-06 (emergency); Amended at 24 Ok Reg 963, eff 5-11-07; Amended at 26 Ok Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff 6-25-11

Amended by Oklahome Register, Volume 33, Issue 23, August 15, 2016, eff. 9/1/2016

Amended by Oklahoma Register, Volume 35, Issue 24, September 4, 2018, eff. 9/14/2018

Amended by Oklahoma Register, Volume 40, Issue 23, August 15, 2023, eff. 7/6/2023 (emergency)

Amended by Oklahoma Register, Volume 41, Issue 23, August 15, 2024, eff. 9/1/2024