Okla. Admin. Code § 365:10-5-159

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

Section 365:10-5-159 - Qualifying previous and qualifying existing coverage

(a) In determining whether a health benefit plan or other health benefit arrangement (public or private) shall be considered qualifying previous coverage or qualifying existing coverage for the purposes of 36 O.S.Supp.1994, §6512(23) and 36 O.S.Supp.1994, §6519(C)(3)(c), a small employer carrier shall interpret the Act no less favorably to an insured individual than the following:

(1) A health benefit plan, policy, certificate or other health benefit arrangement shall be considered employer-based if an employer sponsors the plan or arrangement or makes a contribution to the plan or arrangement.

(2)Similar or exceeding determination.

(A) A health benefit plan, policy, certificate or other benefit arrangement shall be considered to provide benefits similar to or exceeding the benefits provided under the basic health benefit plan if the policy, certificate or other benefit arrangement provides benefits that:

(i) Have an actuarial value (as considered for a normal distribution of groups) that is not substantially less than the actuarial value of the basic health benefit plan; or

(ii) Provides coverage for hospitalization and physician services that is substantially similar to or exceeds the coverage for such services in the basic health benefit plan.

(B) In making a determination under 365:10-5-159(a), a small employer carrier shall evaluate the previous or existing policy, certificate or other benefit arrangement taken as a whole and shall not base its decision solely on the fact that one portion of the previous or existing policy, certificate or benefit arrangement provides less coverage than the comparable portion of the basic health benefit plan.

(b) An individual will be considered to have qualifying previous coverage with respect to a particular service if the previous policy, certificate or other benefit arrangement covering such individual met the definition of qualifying previous coverage contained in 36 O.S.Supp.1994, §6512(23), and provided any benefit with respect to the service.

(c) A small employer carrier shall ascertain the source of previous or existing coverage of each eligible employee and each dependent of an eligible employee at the time such employee or dependent initially enrolls into the health benefit plan provided by the small employer carrier. The small employer carrier shall have the responsibility to contact the source of such previous or existing coverage to resolve any questions about the benefits or limitations related to such previous or existing coverage.

Okla. Admin. Code § 365:10-5-159

Added at 12 Ok Reg 3137, eff 7-31-95