2023 Oklahoma Statutes › Title 36. Insurance › §36-6060.11a. Procedure to assist plan members in accessing out-of- network behavioral health care providers.

A. For the purposes of this act:
1. “Health benefit plan” means a health benefit plan as defined pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes;
2. “Health care provider” or “provider” means a health care provider as defined pursuant to Section 6571 of Title 36 of the Oklahoma Statutes; and
3. “Timely manner” means:
a.
for a request for a routine appointment, a provider’s referral for services, the start of a new treatment or medication, or other maintenance services, as determined by the Insurance Department, thirty (30) days from the date that the insured requests the appointment, service, or care,
b.
for residential care or hospitalization, seven (7) days from the date that the insured first attempts to receive care, and
c.
for urgent, emergency, or crisis care, twenty-four (24) hours from the date and time that the insured first attempts to receive care.
B. A health benefit plan must establish a documented procedure to assist a plan member in accessing an out-of-network behavioral health care provider when no in-network behavioral health care provider is available within a timely manner.
C. If the beneficiary of a health benefit plan is unable to obtain covered behavioral health services from an in-network provider in a timely manner as defined in subsection A of this section, including medically appropriate telehealth services, such plan shall ensure coverage of the behavioral health services from an out-of-network provider by arranging a network exception with a negotiated rate from an out-of-network provider. Such an agreement between the health benefit plan and the out-of-network provider shall hold the beneficiary harmless for any amount greater than the in-network cost-sharing amount, including copayment, coinsurance, and deductible, that the beneficiary would have paid had the same services been rendered by an in-network provider. The negotiated rate in the network exception, in addition to the beneficiary's in-network cost-sharing amount, shall be accepted as payment in full for the provided behavioral health services. In no instance shall the beneficiary pay more than the in-network cost-sharing amount for such services.
D. A plan shall not be held responsible if behavioral health services are available within a timely manner, as defined in this section, but the beneficiary chooses to schedule services outside the timely access standard.
E. A health benefit plan that makes a payment to an out-of-network provider pursuant to this section shall document the details of the payment to be made available to the Department upon request not later than twenty (20) days from the date requested.
F. The Department may promulgate rules to ensure compliance with and effectuate the provisions of this section.
G. The Insurance Department shall have the authority to investigate when an insurer has failed to ensure coverage as required by this section. After the conclusion of an investigation, the Department may use all available tools to levy fees or fines for noncompliance.
Added by Laws 2023, c. 284, § 1, eff. Nov. 1, 2023.