Oklahoma § 36-6060.11 - Benefits required

§ 36-6060.11. Benefits required

A. Subject to the limitations set forth in this section and

Sections 6060.12 and 6060.13 of this title, any health benefit plan

that is offered, issued, or renewed in this state on or after

January 1, 2000, shall provide benefits for treatment of mental

health and substance use disorders.

B. 1. Benefits for mental health and substance use disorders

shall be equal to benefits for treatment of and shall be subject to

the same preauthorization and utilization review mechanisms and

other terms and conditions as all other physical diseases and

disorders including, but not limited to:

a.

coverage of inpatient hospital services for either

twenty-six (26) days or the limit for other covered

illnesses, whichever is greater,

b.

coverage of outpatient services,

c.

coverage of medication,

d.

maximum lifetime benefits,

e.

copayments,

f.

coverage of home health visits,

g.

individual and family deductibles, and

h.

coinsurance.

2. Treatment limitations applicable to mental health or

substance use disorder benefits shall be no more restrictive than

the predominant treatment limitations applied to substantially all

medical and surgical benefits covered by the plan. There shall be

no separate treatment limitations that are applicable only with

respect to mental health or substance abuse disorder benefits.

C. A health benefit plan shall not impose a nonquantitative

treatment limitation with respect to mental health and substance use

disorders in any classification of benefits unless, under the terms

of the health benefit plan as written and in operation, any

processes, strategies, evidentiary standards or other factors used

in applying the nonquantitative treatment limitation to mental

health disorders in the classification are comparable to and applied

Oklahoma Statutes - Title 36. Insurance

no more stringently than to medical and surgical benefits in the

same classification.

D. All health benefit plans must meet the requirements of the

federal Paul Wellstone and Pete Domenici Mental Health Parity and

Addiction Equity Act of 2008, as amended, and federal guidance or

regulations issued under these acts including 45 CFR 146.136, 45 CFR

147.160, 45 CFR 156.115(a)(3), 42 U.S.C. 300gg-26(a), 29 U.S.C.

1185a(a), and 26 U.S.C. 9812.

E. Beginning on or after January 1, 2000, each insurer that

offers, issues or renews any individual or group health benefit plan

providing mental health or substance use disorder benefits shall

submit an annual report to the Insurance Commissioner on or before

April 1 of each year that contains the following:

1. A description of the process used to develop or select the

medical necessity criteria for mental health and substance use

disorder benefits and the process used to develop or select the

medical necessity criteria for medical and surgical benefits;

2. Identification of all nonquantitative treatment limitations

applied to both mental health and substance use disorder benefits

and medical and surgical benefits within each classification of

benefits; and

3. The results of an analysis that demonstrates that for the

medical necessity criteria described in paragraph 1 of this

subsection and for each nonquantitative treatment limitation

identified in paragraph 2 of this subsection, as written and in

operation, the processes, strategies, evidentiary standards or other

factors used in applying the medical necessity criteria and each

nonquantitative treatment limitation to mental health and substance

use disorder benefits within each classification of benefits are

comparable to and are applied no more stringently than to medical

and surgical benefits in the same classification of benefits. At a

minimum, the results of the analysis shall:

a.

identify and clearly define the factors and terms used

to determine that a nonquantitative treatment

limitation will apply to a benefit,

b.

identify and clearly define the specific evidentiary

standards used to define the factors and any other

evidence relied upon in designing each nonquantitative

treatment limitation,

c.

provide the detailed, written, and reasoned

comparative analyses including the results of the

analyses performed to determine that the processes and

strategies used to design each nonquantitative

treatment limitation, as written, and the as written

processes and strategies used to apply the

nonquantitative treatment limitation to mental health

and substance use disorder benefits are comparable to

Oklahoma Statutes - Title 36. Insurance

and applied no more stringently than the processes and

strategies used to design each nonquantitative

treatment limitation, as written, and the as written

processes and strategies used to apply the

nonquantitative treatment limitation to medical and

surgical benefits,

d.

provide the detailed, written, and reasoned

comparative analyses including the results of the

analyses performed to determine that the processes and

strategies used to apply each nonquantitative

treatment limitation, in operation, for mental health

and substance use disorder benefits are comparable to

and applied no more stringently than the processes or

strategies used to apply each nonquantitative

treatment limitation for medical and surgical benefits

in the same classification of benefits, and

e.

disclose the specific findings and conclusions reached

by the insurer that the results of the analyses

required by this subsection indicate whether the

insurer is in compliance with this section and the

Paul Wellstone and Pete Domenici Mental Health Parity

and Addiction Equity Act of 2008, as amended, and its

implementing and related regulations including 45 CFR

146.136, 45 CFR 147.160, 45 CFR 156.115(a)(3), 42

U.S.C. 300gg-26(a), 29 U.S.C. 1185a(a), and 26 U.S.C.

9812.

F. The findings and conclusions shall include sufficient detail

to fully explain such findings including methodologies for the

analyses, detailed descriptions of each treatment limitation for

mental health and substance use disorder benefits compared to each

treatment limitation for medical and surgical benefits, and detailed

descriptions of all criteria involved for approving mental health

and substance use disorder benefits as compared to the criteria

involved for approving medical and surgical benefits.

G. The Commissioner shall implement and enforce any applicable

provisions of the Paul Wellstone and Pete Domenici Mental Health

Parity and Addiction Equity Act of 2008, as amended, and federal

guidance or regulations issued under these acts including 45 CFR

146.136, 45 CFR 147.136, 45 CFR 147.160, 45 CFR 156.115(a)(3), 42

U.S.C. 300gg-26(a), 29 U.S.C. 1185a(a), and 26 U.S.C. 9812.

H. The Commissioner shall issue guidance and standardized

reporting templates to ensure compliance with the provisions of this

section. Guidance shall include examples of non-quantitative

treatment limitations as identified by the Centers for Medicare and

Medicaid Services, the Department of Labor, and the Employee

Benefits Security Administration.

Oklahoma Statutes - Title 36. Insurance

I. No later than December 31, 2021, and by December 31 of each

year thereafter, the Commissioner shall make available to the public

the reports submitted by insurers, as required in subsection E of

this section, during the most recent annual cycle.

1. The Commissioner shall identify insurers that have failed in

whole or in part to comply with the full extent of reporting

required in this section and shall make a reasonable attempt to

obtain missing reports or information by June 1 of the following

year.

2. The reports submitted by insurers and the identification by

the Commissioner of noncompliant insurers shall be made available to

the public by posting on the Internet website of the Insurance

Department. Any information that is confidential or a trade secret

shall be redacted prior to the public posting.

J. The Commissioner may promulgate rules pursuant to the

provisions of this section and any provisions of the Paul Wellstone

and Pete Domenici Mental Health Parity and Addiction Equity Act of

2008, as amended, that relate to the business of insurance.

Added by Laws 1999, c. 153, § 2, eff. Jan. 1, 2000. Amended by Laws

2010, c. 222, § 42, eff. Nov. 1, 2010; Laws 2020, c. 75, § 2, eff.

Nov. 1, 2020; Laws 2021, c. 478, § 28, emerg. eff. May 12, 2021;

Laws 2022, c. 312, § 1, eff. Nov. 1, 2022.

§36-6060.11a. Procedure to assist plan members in accessing out-ofnetwork 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

Oklahoma Statutes - Title 36. Insurance

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 innetwork 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-ofnetwork 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.

§36-6060.11b. Reimbursement for benefits delivered through

behavioral health integration and psychiatric collaborative care

models.

A. For the purposes of this section:

1. “Behavioral health integration” means an approach to

delivering mental health care that improves the ability for primary

care providers to include mental and behavioral health screening,

treatment, and specialty care into their practice pursuant to

Current Procedural Terminology billing code 99484, as established by

the American Medical Association;

Oklahoma Statutes - Title 36. Insurance

2. “Health benefit plan” means a plan as defined pursuant to

Section 6060.4 of Title 36 of the Oklahoma Statutes;

3. “Mental health and substance abuse disorder benefits” means

benefits for the treatment of any condition or disorder that

involves a mental health condition or substance abuse disorder,

including, but not limited to, those that fall under any of the

diagnostic categories listed in the mental disorders section of the

most recent edition of the International Classification of Diseases

or in the mental disorders section of the most recent version of the

Diagnostic and Statistical Manual of Mental Disorders;

4. “Oklahoma Medicaid Program” means the state program

administered by the Oklahoma Health Care Authority pursuant to

Section 1002 of Title 56 of the Oklahoma Statutes; and

5. “Psychiatric collaborative care model” means the evidencebased, integrated behavioral health service delivery method

described pursuant to 81 C.F.R. 80230. The model shall include, but

not be limited to, the following Current Procedural Terminology

billing codes, as established by the American Medical Association:

a.

99492,

b.

99493, and

c.

99494.

B. 1. Any health benefit plan that is offered, issued, or

renewed in this state and that provides mental health or substance

abuse disorder benefits shall provide reimbursement for such

benefits that are delivered through the behavioral health

integration and psychiatric collaborative care models.

2. The Oklahoma Medicaid Program shall provide reimbursement

for such benefits that are delivered through the behavioral health

integration and psychiatric collaborative care models.

3. Plans offered, issued, or renewed in this state that provide

benefits under this subsection may deny reimbursement of any Current

Procedural Terminology code pursuant to paragraph 3 of subsection A

of this section due to medical necessity; provided, such medical

necessity determinations shall be in compliance with the federal

Paul Wellstone and Pete Domenici Mental Health Parity and Addiction

Equity Act of 2008, as amended, and its implementing and related

regulations, and in accordance with the utilization review

requirements pursuant to Section 6551 et seq. of Title 36 of the

Oklahoma Statutes and the review and denial of mental health and

substance abuse disorder treatments and services in Section 1250.5

et seq. of Title 36 of the Oklahoma Statutes.

Added by Laws 2023, c. 374, § 1, eff. Nov. 1, 2023.

NOTE: Editorially renumbered from § 6060.11a of this title to avoid

a duplication in numbering.