Okla. Admin. Code § 365:40-5-31

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

Section 365:40-5-31 - Purpose/scope

(a) The provisions of this Part do not apply to emergency care.

(b) Each HMO shall submit this benefit for the Department's approval before offering the benefit to members.

(c) This benefit is optional, and the HMO has the following flexibility:

(1) The HMO is not required to offer this benefit;

(2) The HMO may decide which services will be offered or excluded;

(3) The HMO may limit the groups to whom this benefit is offered, but the benefit must be offered to all persons within the group;

(4) If individual contracts are offered, the HMO may limit the individuals to whom this benefit is offered;

(5) The HMO may set annual dollar limits on services provided through this benefit;

(6) The HMO may use enrollee cost-sharing for this benefit. This cost-sharing may be accomplished through premium, copayment or deductible; and,

(7) The HMO may require precertification of services provided through this benefit.

(d) Under no circumstances shall the member be required to pay for any portion of these services, other than as provided in the member's contract.

(e) The marketing materials of any HMO offering this benefit must be written in a manner so that the enrollee will easily understand the services included, the procedures to be followed, and the costs.

(f) This benefit may be supplemented by a reasonable deductible. The deductible should be set to discourage excessive use but must not be prohibitively high. Copayments cannot exceed 50% of the HMO's allowable charge for any single service.

(g) The offering of this benefit does not relieve the HMO of the duty to ensure that all basic health care services are available and accessible.

(h) The requirements of Part 23 of this Subchapter shall apply to any claims for payment or reimbursement submitted under this benefit.

Okla. Admin. Code § 365:40-5-31

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