Key Takeaways
- Oklahoma uses the federal HealthCare.gov marketplace for ACA coverage
- The Oklahoma Insurance Department (OID) regulates health insurance
- Pre-existing condition exclusions are prohibited under ACA-compliant plans
- Oklahoma has state-mandated benefits including diabetes care management
- Oklahoma did not expand Medicaid until 2021 (voter-approved)
Oklahoma Health Insurance Policy Requirements
Oklahoma has health insurance regulations that work alongside federal requirements under Title 36 of the Oklahoma Statutes.
Regulatory Structure
Oklahoma health coverage is regulated by the Oklahoma Insurance Department (OID):
| Agency | Role |
|---|---|
| Oklahoma Insurance Department (OID) | Regulates all health insurance, reviews rates and forms |
| Federal CMS | Operates the HealthCare.gov marketplace for Oklahoma |
Health Insurance Marketplace
Oklahoma uses the federal HealthCare.gov marketplace:
- Federally facilitated marketplace
- Provides access to qualified health plans (QHPs)
- Premium tax credits available for eligible residents
- Open enrollment and special enrollment periods apply
Rate Regulation
| Plan Type | Regulator |
|---|---|
| Fully-insured individual policies | Oklahoma Insurance Department |
| Federal exchange/SHOP plans | CMS and OID |
| Fully-insured employer groups | Negotiable with carrier, OID regulated |
| Self-insured large group plans | Department of Labor |
Metal Tier Plans
| Tier | Actuarial Value | Cost Sharing |
|---|---|---|
| Bronze | 60% | Higher out-of-pocket costs |
| Silver | 70% | Moderate cost sharing |
| Gold | 80% | Lower out-of-pocket costs |
| Platinum | 90% | Lowest out-of-pocket costs |
Medicaid Expansion
Oklahoma expanded Medicaid through a 2020 voter initiative:
- State Question 802 approved by voters
- Expansion took effect July 1, 2021
- Covers adults up to 138% of federal poverty level
- SoonerCare (Oklahoma Medicaid) provides coverage
Pre-Existing Condition Protections
Oklahoma prohibits pre-existing condition exclusions in ACA-compliant plans:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited by federal law |
Guaranteed Issue and Renewal
Oklahoma requires:
Guaranteed Issue
- Insurers must accept all applicants for ACA-compliant plans
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with proper notice)
State-Mandated Benefits
Oklahoma mandates specific benefits beyond ACA requirements:
Required Coverage
| Mandate | Applies To |
|---|---|
| Diabetes Care Management | Individual and group plans, HMOs |
| Congenital Anomaly | Including cleft lip and palate |
| Reconstructive Surgery | Group plans and HMOs |
HMO Basic Health Care Services
Oklahoma Administrative Code requires HMOs to provide:
- Physician services including consultant and referral services
- Outpatient services including diagnostic services, treatment services, and x-ray services
- Medically necessary emergency health services
- 20 outpatient visits per enrollee per year for short-term mental health services
- Inpatient and outpatient care for cleft lip or cleft palate treatment
Standard Health Benefit Plans (36 O.S. § 4415)
Oklahoma offers standard health benefit plans for individuals under 40:
- Do not include state-mandated benefits
- Provide creditable coverage
- Must include disclosure statements and acknowledgments
- Rate filings subject to OID review
Exam Tip: Oklahoma uses HealthCare.gov for individual health insurance and has specific state mandates for diabetes care.
Mental Health Parity
Oklahoma requires mental health parity compliance:
Federal MHPAEA Compliance
- Financial requirements must be comparable to medical/surgical
- Treatment limitations must be comparable
- Prior authorization requirements must be comparable
- Out-of-pocket costs must be comparable
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
External Review
Oklahoma provides external review rights:
- Consumers can appeal denied claims
- Independent external review available
- Binding decision on insurer
Which marketplace does Oklahoma use for individual health insurance under the ACA?
Which state-mandated benefit does Oklahoma require for individual and group health plans?
Which agency regulates health insurance in Oklahoma?
When did Oklahoma expand Medicaid under the ACA?
How many outpatient mental health visits must Oklahoma HMOs provide per enrollee per year?