Library: Policy

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

Revised 7-1-23

(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.