§ 36-6060.52 — Choice to pay out of pocket — Documentation to carrier

Oklahoma § 36-6060.52

• Jurisdiction: Oklahoma
• Title 36: Insurance

Text

— Deductible and out of pocket apportionment. A. An enrollee may choose to pay out of pocket for a health care service from a health care provider. If an enrollee obtains a medically necessary health care service covered by his or her health benefit plan and negotiates for a price lower than the average allowed amount established by the benefit plan and provided to the enrollee upon request, and the enrollee pays out of pocket for the health care service, the enrollee may electronically send documentation to the carrier that provides the following: 1. The health care service the enrollee or patient received and the name of the health care provider and contact information; 2. If an order by the health care provider is required by the policy, the order from the health care provider given to the enrollee or patient and the final bill or statement for the health care service; and 3. The negotiated cost of the health care service that the enrollee received and that: a. the enrollee paid out of pocket for the health care services received, and b. the health care entity is not making a claim against the carrier for payment for the health care service provided to the enrollee or patient. B. The health care provider shall accept the payment from the enrollee as payment in full and shall not bill the enrollee or the health benefit plan for any balance between the amount collected from the enrollee and the billed charge for the service by the provider. C. A carrier that receives the documentation described in subsection A of this section shall count the full amount that the enrollee paid out of pocket toward the deductible and annual maximum out-of-pocket expense if: 1. The health care service is covered under the health benefit plan of the enrollee; and 2. The enrollee negotiated for a lower cost for the health care service than the average allowed amount established by his or her health benefit plan for that covered health care service. D. The amount of the out-of-pocket cost shall be attributed to the in-network deductible and annual maximum out-of-pocket expense if the provider was an in-network provider, and to the out-of- network deductible and annual maximum out-of-pocket expense if the provider was an out-of-network provider. E. The amount counted toward an applicable out-of-pocket deductible and annual maximum out-of-pocket expense shall not exceed the total amount that the enrollee is required to pay out of pocket during a contractually agreed upon period of time for health care services that are included under the health benefit plan of the enrollee, and shall not carry over once a new contract or agreement period for the plan begins.

Legislative History

Added by Laws 2025, c. 131, § 2, eff. Nov. 1, 2025.