Okla. Admin. Code § 365:10-5-161

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

Section 365:10-5-161 - Rules related to fair marketing

(a)Marketing requirements.

(1) A small employer carrier shall actively market each of its health benefit plans to small employers in this state. A small employer carrier may not suspend the marketing or issuance of the basic and standard health benefit plans unless the carrier has good cause and has received the prior approval of the Commissioner.

(2) In marketing the basic and standard health benefit plans to small employers, a small employer carrier shall use at least the same sources and methods of distribution that it uses tomarket other health benefit plans to small employers. Any producer authorized by a small employer carrier to market health benefit plans to small employers in the state shall also be authorized to market the basic and standard health benefit plans.

(b)Mandatory offer.

(1)Offer requirements.

(A) A small employer carrier shall offer at least the basic and standard health benefit plans to any small employer that applies for or makes an inquiry regarding health insurance coverage from the small employer carrier. The offer shall be in writing and shall include at least the following information:

(i) A general description of the benefits contained in the basic and standard health benefit plans and any other health benefit plan being offered to the small employer, and

(ii) Information describing how the small employer may enroll in the plans.

(B) The offer may be provided directly to the small employer or delivered through a producer.

(2)Price quote and application requirements.

(A) A small employer carrier shall provide a price quote to a small employer, either directly or through an authorized producer, within ten (10) working days of receiving a request for a quote and such information as is necessary to provide the quote. A small employer carrier shall notify a small employer, either directly or through an authorized producer, within five (5) working days of receiving a request for a price quote of any additional information needed by the small employer carrier to provide the quote.

(B) A small employer carrier may not apply more stringent or detailed requirements related to the application process for the basic and standard health benefit plans than are applied for other health benefit plans offered by the carrier.

(3)Denial and price quote requirements.

(A)Explanation requirements.

(i) If a small employer carrier denies coverage under a health benefit plan to a small employer on the basis of a risk characteristic, the denial shall be in writing and shall state with specificity the reasons for the denial (subject to any restrictions related to confidentiality of medical information). The written denial shall be accompanied by a written explanation of the availability of the basic and standard health benefit plans from the small employer carrier. The explanation shall include at least the following:

(I) A general description of the benefits contained in each such plan;

(II) A price quote for each such plan; and

(III) Information describing how the small employer may enroll in such plans.

(ii) The written information described in 365:10-5-161(b)(3) may be provided, within the time periods set forth in 365:10-5-161(2), directly to the small employer or delivered through an authorized producer.

(B) The price quote required under 365:10-5-161(b)(3)(A)(ii) shall be for the lowest-priced basic and standard health benefit plan for which the small employer is eligible.

(c) A small employer carrier shall establish and maintain a toll-free telephone service to provide information to small employers regarding the availability of small employer health benefit plans in this state. The service shall provide information to callers on how to apply for coverage from the carrier. The information may include the names and phone numbers of producers located geographically proximate to the caller or such other information that is reasonably designed to assist the caller to locate an authorized producer or to otherwise apply for coverage.

(d) The small group carrier shall not require a small employer to join or contribute to any association or group as a condition of being accepted for coverage by the small employer carrier. However, if membership in an association or other group is a requirement for accepting a small employer into a particular health benefit plan, a small employer carrier may apply such requirement, subject to the requirements of 36 O.S.Supp.1994, §6519(A)(2)(b).

(e) A small employer carrier may not require as a condition to the offer or sale of a health benefit plan to a small employer that the small employer purchase or qualify for any other insurance product or service.

(f)Application requirements.

(1) Carriers offering individual and group health benefit plans in this state shall be responsible for determining whether the plans are subject to the requirements of the Act and this Part. Carriers shall elicit the following information from applicants for such plans at the time of application:

(A) Whether or not any portion of the premium will be paid by or on behalf of a small employer, either directly or through wage adjustments or other means of reimbursement; and

(B) Whether or not the prospective policyholder, certificate holder or any prospective insured individual intends to treat the health benefit plan as part of a plan or program under Section 162 [other than (162(1)], Section 125 or Section 106 of the United States Internal Revenue Code.

(2) If a small employer carrier fails to comply with 365:10-5-161(f)(1), the small employer carrier shall be deemed to be on notice of any information that could reasonably have been attained if the small employer carrier had complied with 365:10-5-161(f)(1).

(g)Filing requirements.

(1) A small employer carrier shall file annually the following information with the Commissioner related to health benefit plans issued by the small employer carrier to small employers in this state:

(A) The number of small employers that were issued health benefit plans in the previous calendar year (separated as to newly issued plans and renewals);

(B) The number of small employers that were issued the basic health benefit plan and the standard health benefit plan in the previous calendar year (separated as to newly issued plans and renewals and as to class of business);

(C) The number of small employer health benefit plans in force in each county (or by zip code) of the state as of December 31 of the previous calendar year;

(D) The number of small employer health benefit plans that were voluntarily not renewed by small employers in the previous calendar year;

(E) The number of small employer health benefit plans that were terminated or nonrenewed (for reasons other than nonpayment of premium) by the carrier in the previous calendar year; and

(F) The number of small employer health benefit plans that were issued to small employer that were uninsured for at least the three (3) months prior to issue.

(2) The information described in 365:10-5-161(g)(1) shall be filed no later than March 15 of each year.

Okla. Admin. Code § 365:10-5-161

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