SECTION 317:45-1-4. Reimbursement for out-of-pocket expenses

(a)   Out-of-pocket expenses for all approved and eligible members (and/or their approved and eligible dependents) will be limited to five (5) percent of their annual gross household income. The OHCA will provide reimbursement for out-of-pocket expenses in excess of the five (5) percent annual gross household income. An expense must be for an allowed and covered service by a qualified benefit plan (QBP) to be eligible for reimbursement. For the purpose of this Section, an allowed and covered service is defined as an in-network service covered in accordance with a QBPs benefit summary and policies. For instance, if a QBP has multiple in-network reimbursement percentage methodologies (80% for level 1 provider and 70% for level 2 provider) the OHCA will only reimburse expenses related to the highest percentage network.

(b)   For all eligible expenses as defined above in OAC 317:45-1-4(a), the member must submit the OHCA required form and all OHCA required documentation to support that the member incurred and paid the out-of-pocket expense. The OHCA required documentation must substantiate that the member actually incurred and paid the eligible out-of-pocket expense. The OHCA may request additional documentation at any time to support a member's request for reimbursement of eligible out-of-pocket expenses.

[Source: Added at 24 Ok Reg 101, eff 8-2-06 (emergency); Added at 24 Ok Reg 963, eff 5-11-07; Amended at 26 Ok Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff 6-25-11; Amended at 29 Ok Reg 1210, eff 6-25-12; Amended at 33 Ok Reg 916, eff 9-1-16; Amended at 35 Ok Reg 1503, eff 9-14-18]