Oklahoma medical-plan questions focus on what an Oklahoma health plan must cover and how quickly it must pay. Expect questions on newborn and adopted-child coverage, the state's benefit mandates (mammography, diabetes and insulin, maternity stays, immunizations, autism), prompt-payment deadlines, and the Unfair Claims Settlement Practices Act rules for health claims. The general material (indemnity vs. managed care, HMOs and PPOs, cost sharing, HDHPs and HSAs, the ACA) is in the national Medical Plans guide.

Who regulates and who sells

• Health insurers and HMOs are regulated by the Oklahoma Insurance Department under Title 36.
• People who sell HMO memberships for commission must comply with the Producer Licensing Act (36 O.S. 6917(A)).
• A multiple employer welfare arrangement that isn't fully insured or ERISA-exempt needs a license from the Commissioner. Without one, it is treated as an unauthorized insurer (36 O.S. 634).

Children

Newborns (36 O.S. 6058)

• A policy that covers family members must cover a newborn from the moment of birth.
• If extra premium is required, the insurer may require notice of the birth and payment within 31 days to keep coverage in force.

Adopted children (36 O.S. 6059(A))

• Coverage begins on placement in the insured's custody.

Immunizations (36 O.S. 6060.4)

• Covered from birth through age 18, with no deductible, copay or coinsurance.

Benefit mandates

Mammography (36 O.S. 6060)

• Women 40 and older: one low-dose screening every year, with no deductible, copay or coinsurance.
• Women 35 through 39: one screening every 5 years.

Prostate screening (36 O.S. 6060.8)

• An annual screening (PSA test and digital rectal exam) for men over 50.
• No deductible applies, up to $65 per screening.

Diabetes (36 O.S. 6060.2)

• Medically necessary supplies such as blood glucose monitors and test strips must be covered.
• A plan that covers insulin must cap the covered person's cost at $30 for a 30-day supply of each covered insulin prescription.

Maternity stays (36 O.S. 6060.3)

• At least 48 hours of inpatient care after a vaginal delivery and 96 hours after a cesarean.
• An earlier discharge is allowed if it meets medical criteria and a home visit is covered.

Autism spectrum disorder (36 O.S. 6060.21)

• Treatment coverage may not have any limit on the number of visits.
• The insurer may review the treatment plan annually.

What the mandates don't reach

• A hospital confinement indemnity policy is not a "health benefit plan" for the mandate statutes (6060.4(C)).
• An insurer filing an HSA-qualified high deductible plan isn't required to offer state-mandated benefits (36 O.S. 7003).

Genetic information (36 O.S. 3614.1)

• Under the Genetic Nondiscrimination in Insurance Act, a health insurer may not require an applicant to take a genetic test.
• The Act does not apply to life, disability income or long-term care insurance.

Paying health claims

Prompt payment (36 O.S. 1219)

• A clean claim must be paid within 45 calendar days if filed on paper, or 30 calendar days if filed electronically.
• If the insurer finds a defect, it must notify the insured and the provider in writing within 30 days. Not doing so is prima facie evidence that the claim will be paid.

Unfair Claims Settlement Practices Act rules for health plans (36 O.S. 1250.2, 1250.5)

• Medical necessity: before denying a claim as not medically necessary, the insurer must first get an opinion from a licensed health care provider (1250.5(10)).
• Eligibility verification: a verification of the patient's eligibility stays valid for 4 business days (1250.2(12)).
• Preauthorization: after preauthorizing a service and verifying eligibility, the plan may refuse payment only in limited cases. One is when the premium went unpaid and all grace periods have run out (1250.5(16)).
• Refunds from providers: absent fraud or agreement, an insurer can't ask a provider to refund a claim payment more than 12 months after paying it (1250.5(15)).

Premium after death (36 O.S. 3623.2)

• Premium paid for any period after the insured's death is refunded pro rata by day within 90 days of valid proof of death.

Keeping coverage

Family policies (36 O.S. 4405(B)(11))

• A covered spouse whose coverage would end for a reason other than nonpayment may continue or convert it without new evidence of insurability.

Returning from military service (36 O.S. 1162)

• A resident who dropped individual coverage when activated for military service can be reinstated without medical underwriting.
• The request must reach the plan within 30 days after deactivation or loss of TriCare.

Group coverage

• Group continuation and conversion rules are in the Oklahoma Group Health Insurance guide.

Common exam traps

• Newborns are covered from birth. The 31-day window is only for notice and any extra premium.
• Clean-claim deadlines are 45 days on paper and 30 days electronic, not the other way around.
• Insulin cap: $30 per 30-day supply.
• Mammography: annual at 40 and older. Ages 35-39 get one screening every 5 years.
• HSA-qualified HDHPs are exempt from offering the state mandates.
• Hospital indemnity policies aren't health benefit plans for the mandates.