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Library: Policy

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

Revised 9-14-18

(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) office 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).

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