Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 5 - BASIC AND SUPPLEMENTAL HEALTH CARE SERVICES › Section 365:40-5-21 - Supplemental health care services

Current through Vol. 41, No. 20,
				  July 1, 2024
Supplemental health care services of an HMO may include the
					 following:
(1) Corrective appliances
				  and artificial aids.
(2) Eyeglasses
				  and hearing care not included as a basic health care service.
(3) Dental services.
(4) Mental health services not included as a
				  basic health care service.
(5)
				  Long-term physical therapy and rehabilitative services.
(6) Cosmetic surgery, unless medically
				  necessary.
(7) Prescribed drugs and
				  medicines incidental to outpatient care. Supplemental coverage for prescription
				  drugs shall also provide coverage of off-label uses of prescription drugs used
				  in the treatment of cancer or the study of oncology. Coverage shall include the
				  approval of oncology (chemotherapeutic) drugs for off-label indications when
				  used for malignant disease, when the safety and effectiveness of use for this
				  indication has been recommended, supported and demonstrated by at least one
				  controlled clinical trial published in a nationally recognized peer reviewed
				  journal or when at least one of the standard pharmacy compendia (United States
				  Pharmacopoeia Dispensing Information [USPDI], American Society of Health-System
				  Pharmacists Drug Information [AHFS Drug Information] or American Medical
				  Association Drug Evaluations [AMADE]) lists the drug to be accepted as safe and
				  effective for this indication. This will not include the off-label use of these
				  agents in the treatment of non-malignant disease.
(8) Ambulance services, unless medically
				  necessary.
(9) Care for military
				  service connected disabilities for which the enrollee is legally entitled to
				  services and for which facilities are reasonably available to this
				  enrollee.
(10) Care for conditions
				  that State or local law requires be treated in a public facility.
(11) Custodial or domiciliary care.
(12) Experimental medical, surgical, or other
				  experimental health care procedures, unless approved as a basic health care
				  service by the policy making body of the HMO.
(13) Personal or comfort items and private
				  rooms, unless necessary during inpatient hospitalization.
(14) Whole blood and blood plasma.
(15) Durable medical equipment for home use
				  (such as wheel chairs, surgical beds, respirators, dialysis and
				  machines).
(16) Health care
				  services which are unusual or infrequently provided and not necessary for the
				  protection of individual health, as approved by the Department upon application
				  by the HMO. "Unusual or infrequently used health services" means those health
				  services which are projected to involve fewer that 1 percent (1%) of the
				  encounters per year for the entire HMO enrollment, or, those health services
				  the provision of which, given the enrollment projection of the HMO and
				  generally accepted staffing patterns, is projected will require less than 0.25
				  full time equivalent health professionals.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04