SECTION 317:45-11-10. Insure Oklahoma IP adult benefits

(a)   All IP adult benefits are subject to rules delineated in OAC 317:30 except as specifically set out in this Section. The scope of IP adult benefits described in this Section is subject to specific non-covered services listed in OAC 317:45-11-11.

(b)   A PCP referral is required to see any other provider with the exception of the following services:

(1)   behavioral health services;

(2)   prenatal and obstetrical supplies and services, meaning prenatal care, delivery and 60 days of postpartum care;

(3)   family planning supplies and services, meaning an office visit for a comprehensive family planning evaluation, including obtaining a Pap smear;

(4)   women's routine and preventive health care services;

(5)   emergency medical condition as defined in OAC 317:30-3-1; and

(6)   services delivered to American Indians at Indian Health Service, tribal, or urban Indian clinics.

(c)   IP covered adult benefits for in-network services and limits are listed in this subsection. Member cost sharing related to premium and co-payments cannot exceed federal maximums with the exception of emergency room visits, in which case the State establishes the maximum for member cost share. Native American adults providing documentation of ethnicity who receive items and services furnished by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services are exempt from co-payments. Coverage for IP services includes:

(1)   Anesthesia/Anesthesiologist Standby. Covered in accordance with OAC 317:30-5-7. Eligible services are covered for covered illness or surgery including services provided by a Certified Registered Nurse Anesthetist (CRNA) or Anesthesiologist Assistant (AA).

(2)   Blood and Blood Products. Processing, storage, and administration of blood and blood products in inpatient and outpatient settings.

(3)   Chelation Therapy. Covered for heavy metal poisoning only.

(4)   Diagnostic X-ray, including Ultrasound. Covered in accordance with OAC 317:30-5-22(b)(2). PCP referral is required.

(5)   Emergency Room Treatment, services and supplies for treatment in an emergency. Contracted provider services are subject to a $30 co-pay per occurrence. The emergency room co-pay will be waived if the member is admitted to the hospital or death occurs before admission.

(6)   Inpatient Hospital Benefits. Covered in accordance with OAC 317:30-5-41, OAC 317:30-5-47 and OAC 317:30-5-95.

(7)   Preventive Office Visit. For services of evaluation and medical management (wellness exam); one visit per year. This visit counts as an office visit.

(8)   Office Visits/Specialist Visits. Covered in accordance with OAC 317:30-5-9, OAC 317:30-5-10, and OAC 317:30-5-11. For services of evaluation and medical management; up to four visits are covered per month; PCP referral required for specialist visits.

(9)   Outpatient Hospital/Facility Services.

(A)   Includes hospital surgery services in an approved outpatient facility including outpatient services and diagnostic services. Prior authorization required for certain procedures.

(B)   Therapeutic radiology or chemotherapy on an outpatient basis without limitation to the number of treatments per month for persons with proven malignancies or opportunistic infections.

(C)   Physical, Occupational and Speech Therapy services. Coverage is limited to one evaluation/re-evaluation visit (unit) per discipline per calendar year and 15 visits (units) per discipline per date of service per calendar year. Must be hospital based.

(10)   Maternity (Obstetric). Covered in accordance with OAC 317:30-5-22.

(11)   Laboratory/Pathology. Covered in accordance with OAC 317:30-5-20.

(12)   Mammogram (Radiological or Digital). Covered in accordance with OAC 317:30-5-901.

(13)   Immunizations. Covered in accordance with OAC 317:30-5-2.

(14)   Assistant Surgeon. Covered in accordance with OAC 317:30-5-8.

(15)   Dialysis, Kidney dialysis, and services and supplies, either at home or in a facility.

(16)   Oral Surgery. Services are limited to the removal of tumors or cysts.

(17)   Behavioral Health (Mental Health and Substance Abuse) Treatment (Inpatient). Covered in accordance with OAC 317:30-5-95.1.

(18)   Behavioral Health (Mental Health and Substance Abuse) Treatment (Outpatient). Outpatient benefits are limited to 48 visits per calendar year. Additional visits may be approved as medically necessary.

(A)   Agency services. Covered in accordance with OAC 317:30-5-241 and OAC 317:30-5-596.

(B)   Individual provider services. Licensed Behavioral Health Professionals (LBHPs) are defined as follows for the purpose of Outpatient Behavioral Health Services and Outpatient Substance Abuse Treatment:

(i)   Allopathic or Osteopathic Physicians with a current license and board certification in psychiatry or board eligible in the state in which services are provided, or a current resident in psychiatry practicing as described in OAC 317:30-5-2.

(ii)   Practitioners with a license to practice in the state in which services are provided.

(I)   Psychology,

(II)   Social Work (clinical specialty only),

(III)   Professional Counselor,

(IV)   Marriage and Family Therapist,

(V)   Behavioral Practitioner, or

(VI)   Alcohol and Drug Counselor.

(iii)   Advanced Practice Nurse (certified in a psychiatric mental health specialty), licensed as a registered nurse with a current certification of recognition from the board of nursing in the state in which services are provided.

(iv)   A Physician's Assistant who is licensed in good standing in this state and has received specific training for and is experienced in performing mental health therapeutic, diagnostic, or counseling functions.

(v)   LBHPs must have a valid Insure Oklahoma contract in order to bill for services rendered.

(vi)   LBHP services require prior authorization and are limited to four (4) therapy services per month per member and eight (8) testing units per year per member.

(19)   Durable Medical Equipment and Supplies. Covered in accordance with OAC 317:30-5-210 through OAC 317:30-5-218. A PCP referral and prior authorization is required for certain items.

(20)   Diabetic Supplies. Covered in accordance with OAC 317:30-5-211.15.

(21)   Oxygen. Covered in accordance with OAC 317:30-5-211.11 through OAC 317:30-5-211.12.

(22)   Pharmacy. Covered in accordance with OAC 317:30-5-72.1 and OAC 317:30-5-72. Prenatal vitamins and smoking cessation products do not count against monthly prescription limits.

(23)   Smoking Cessation Products. Products do not count against monthly prescription limits. Covered in accordance with OAC 317:30-5-72.1.

(24)   Nutrition Services. Covered in accordance with OAC 317:30-5-1076.

(25)   External Breast Prosthesis, Bras and Prosthetic Garments. Covered in accordance with OAC 317:30-5-211.13.

(26)   Surgery. Covered in accordance with OAC 317:30-5-8.

(27)   Home Dialysis. Covered in accordance with OAC 317:30-5-211.13.

(28)   Parenteral Therapy. Covered in accordance with OAC 317:30-5-211.14.

(29)   Family Planning Services and Supplies, including Sterilizations. Covered in accordance with OAC 317:30-3-57.

(30)   Home Health and Medications, Intravenous (IV) Therapy and Supplies. Covered in accordance with OAC 317:30-5-211.15 and OAC 317:30-5-42.16(b)(3).

(31)   Fundus photography.

(32)   Emergency ground ambulance transportation. Covered in accordance with OAC 317:30-5-336.

[Source: Added at 24 Ok Reg 101, eff 8-2-06 (emergency); Added at 24 Ok Reg 700, eff 2-1-07 (emergency); Added at 24 Ok Reg 811, eff 4-1-07 (emergency); Added at 24 Ok Reg 2162, eff 6-25-07; Amended at 26 Ok Reg 409, eff 1-1-09 (emergency); Amended at 26 Ok Reg 2175, 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 28 Ok Reg 2335, eff 7-13-11 (emergency); Amended at 29 Ok Reg 484, eff 5-11-12; Amended at 30 Ok Reg 1274, eff 7-1-13; Amended at 31 Ok Reg 147, eff 10-15-13 (emergency); Amended at 31 Ok Reg 1751, eff 9-12-14; Amended at 34 Ok Reg 760, eff 9-1-17; Amended at 35 Ok Reg 1503, eff 9-14-18]