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

(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).

[Source: Added at 23 Ok Reg 278, eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 24 Ok Reg 101, eff 8-2-06 (emergency); Amended 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 33 Ok Reg 916, eff 9-1-16; Amended at 35 Ok Reg 1503, eff 9-14-18]