Okla. Admin. Code § 365:40-5-11

Current through Vol. 42, No. 8, January 2, 2025

Section 365:40-5-11 - Community rating

Under community rating, rates of payments may be determined on a per-person or per-family basis and may vary with the number of persons in a family, but except as otherwise authorized in this paragraph, such rates must be equivalent for all individuals and for all families of similar composition. This does not preclude changes in the rates of payments for health services based on a community rating system which are established for new enrollments or re-enrollments and which changes do not apply to existing contracts until the renewal of such contracts. Only the following differentials in rates of payments may be established under such system:

(1) Nominal differentials in such rates may be established to reflect differences in marketing costs and the different administrative costs of collecting payments from the following categories of subscribers:

(A) Individual (non-group) subscribers (including their families).

(B) Small groups of subscribers.

(C) Large groups of subscribers.

(2) Nominal differentials in such rates may be established to reflect the compositing of the rates of payment in a systematic manner to accommodate group purchasing practices of the various employers.

(3) Differentials in such rates may be established for subscribers enrolled under any governmental authority or program authorized by United States Code, or under any health benefits program for employees of States, political subdivisions of States, and other public entities.

(4) An HMO may establish a separate community rate for separate regional components of the organization upon satisfactory demonstration of the following:

(A) Each such regional component is geographically distinct and separate from any other regional component.

(B) Enrollment is established with respect to the individual regional component, rather than with respect to the parent HMO.

(C) Each such regional component provides substantially the full range of basic health care services to its enrollees without extensive referral between components of the organization for such services, and without substantial utilization by any two such components of the same health care facilities. The separate community rate for each such regional component of the HMO must be based on the different costs of providing health services in such regions.

Okla. Admin. Code § 365:40-5-11

Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04