Library: Policy

317:55-5-20. Financial standards and third-party liability

Revised 7-1-23

(a) Financial standards. The CE or DBM shall comply with Oklahoma Insurance Department requirements for minimum net worth and risk- based capital in accordance with applicable Oklahoma Statutes found in Title 36 Insurance.

(b) Insolvency protection. In accordance with the requirements found at 42 C.F.R. §§ 438.106, 438.116, 36 O.S. § 6901, et seq., and all contractual requirements, the CE and DBM will provide satisfactory assurances to the OHCA to ensure that neither Enrollees nor the OHCA is held liable or responsible for any of the following:

(1) Any debts obtained by the CE or DBM;

(2) Covered services that are provided to the Enrollee for which the OHCA does not pay the CE or DBM; or

(3) Payment for covered services that are in excess of the amount that the Enrollee would owe the CE or DBM if those services were covered directly.

(c) Medical loss ratio. A CE or DBM will have a medical loss ratio that, at minimum, meets the standards provided by 42 C.F.R. §§ 438.8, 438.74, and applicable Contract. OHCA will monitor compliance with this requirement. If CE or DBM are not compliant with submission of MLR reporting, OHCA will evaluate the CE's or DBM's status for penalties or termination. Monitoring procedures to ensure compliance with MLR reporting include review of timeliness and completeness of reporting requirement and audit of date contained within the report.

(d) Third-party liability. Medicaid should be the payer of last resort for all covered services pursuant to federal regulations including but not limited to 42 C.F.R. 433 Subpart D and 42 C.F.R. § 447.20. The OHCA will notify the CE and DBM for any known third-party resources identified or made available to OHCA at the time of an Applicant's or Eligible's eligibility determination or re-determination. The CE or DBM shall make every reasonable effort to:

(1) Determine the liability of third parties to pay for services rendered to Enrollees;

(2) Avoid costs which may be the responsibility of third parties;

(3) Reduce payments based on payments by a third-party for any part of a service;

(4) Recover any liability from responsible third-party sources, except for estate recovery and third-party subrogation which will remain OHCA's responsibility;

(5) Treat funds recovered from third parties as reductions to claims payments as required in the Contract; and

(6) Report all third-party liability collections as specified by the OHCA, the Contract, and reporting manual.