Health Insurance | Oklahoma Insurance Department

Health insurance is important coverage that helps protect you and your family from the devastating financial effects of unexpected health problems or catastrophic illnesses, and as of January 1, 2014, federal law requires that most Americans have health insurance or pay a penalty.

the oklahoma insurance department encourages you to work with insurance professionals in your community to help you determine the right policy for your family or business needs. these insurance professionals can be found on our website at:

Reading: How to get health insurance in oklahoma

Federal Resources for Health Care Reform

You may receive health coverage through an individual insurance policy, through a policy issued to you as a member of an association group, through an employer-sponsored health plan, or through a health plan. government (medicare, soonercare (medicaid), va, etc…). If your employer-sponsored health plan is “self-insured,” it is not subject to regulation by the Oklahoma Department of Insurance, but rather is regulated by the Department of Labor. Additional information about employer-sponsored plans is available below. The three main types of health insurance are:

  • policies that offer traditional health insurance;
  • policies that provide managed care services; and
  • policies that provide limited benefits.
  • affordable care act of 2023 health insurance rate filing

    traditional medical insurance

    With the passage of the Affordable Care Act or health care reform in 2010, most traditional health insurance plans, often called “fee-for-service,” are now more likely to be in “protected plans”, which do not comply with ECA or commonly known as “grandma plans” or medicare supplemental plans. if your plan is a true “free service”:

    • You can use any doctor or hospital.
    • submits your medical bills to the insurance company (the provider can do this for you, but is not required).
    • You will probably have to pay a deductible to your provider before the policy begins to pay and copays to your provider each time you visit your provider or doctor’s office.
    • If the policy pays less than the entire bill, you will most likely be responsible for paying the balance.
    • Individual and group health policies that comply with this are included in the category of comprehensive medical policies. These ACA-compliant policies are expensive because they are required by federal law to provide more benefits than many old or pre-ACA policies. An ACA-compliant policy pays a percentage of covered expenses (for example, 60%, 70%, 80%, or 90%), after you pay the plan’s deductible and applicable copays. the remaining charge (for example, 10%, 20%, 30%, or 40%) is coinsurance and is paid by you. Maximum out-of-pocket limits limit the amount of coinsurance you pay. After the covered individual or family reaches their maximum out-of-pocket limit, your plan will pay 100% for that individual or family for the rest of that year. Pay close attention to the plan’s maximum out-of-pocket limit before you buy a plan, especially if you’re not eligible for cost-sharing reductions on the federal exchange.

      policies that provide managed care services

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      policies that comply with aca will often be tied to a network of care providers. this affects your choice of doctors and hospitals because not all providers are part of the network. In exchange for this limited option, you generally pay less for medical care (ie, doctor visits, prescriptions, surgery, and other covered benefits) than you would with traditional “fee-for-service” health insurance. the managed care network controls health care services in these narrower network options, be sure to review all of the providers available to you in each type of managed care network you choose.

      If your health care provider is out-of-network, you are responsible for the difference between the allowed amount and the provider’s charge, and those amounts will not apply to your out-of-pocket limits. It is imperative that you contact your insurer if you have any questions about whether a healthcare provider is an in-network or out-of-network provider. Out-of-network providers can be much more expensive since they are not subject to your insurer’s provider contracts or discounted rates for services; however, policies that comply with CAA must cover emergency services received from an out-of-network provider as if they were in-network.

      types of managed care networks are:

      • Preferred Provider Organizations (PPOS): PPOS offer a network of providers to meet the health care needs of an insurance company’s members. The insurer contracts with a group of health care providers, or with a PPO network, to control the cost of providing benefits to its policyholders. These providers charge lower rates than usual because they require prompt payment and see a larger number of patients. Members generally choose who will provide their health care, but pay less in coinsurance with a preferred provider than with a non-preferred provider.
      • Health Maintenance Organization (HMO): HMO members pay a fixed monthly dollar amount (similar to an insurance premium), giving them access to a wide range of health care services. in many cases, members also pay a predetermined amount, or copay, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and getting some reimbursement later. members must use the hmo’s provider network, which may include doctors, pharmacies, and hospitals under contract with that particular hmo.
      • Point-of-Service (POS) Plans: In a POS plan, insured members can choose, at the point of service, whether to receive care from a doctor within the plan’s network or leave of the service network. The POS plan provides less coverage for out-of-network health care expenses than for in-network expenses. In addition, the POS plan will generally require you to pay deductibles and coinsurance costs for medical care received out-of-network.
      • limited benefit coverage plans

        Limited benefit health plans are reduced benefit insurance products intended to complement full health insurance plans, not to be an alternative to them. You may have seen these types of plans marketed as short-term limited duration insurance, accident policies, cancer-only policies, heart or specific disease policies, cash for hospitals, or indemnity plans. They can also be discount plans, such as memberships in pharmacies, dental or medical clinics. These plans are not considered CAA-compliant, which could result in you paying additional out-of-pocket costs for non-covered medical services.

        Limited benefit health insurance plans are generally not required to provide the same level of coverage, so they cover fewer types of medical services and expenses than a comprehensive policy. they are not required to cover your pre-existing conditions. These plans generally pay you a fixed amount for a specific service, covered item, or covered condition, or give you a discount for the services, leaving you to pay the rest of the bill yourself. A limited benefit plan may limit the amount of coverage the company will pay per illness or per day, sometimes as low as $50 to $5,000 (not counting coinsurance and deductibles you pay). These policies also provide limited emergency, testing, preventive care, and surgical benefits upon receipt of billing. And with low maximum benefit limits called “caps,” you may be capped quickly, leaving you responsible for the balance of the bill. discount plans still leave you paying for services yourself.

        buyer, be careful when buying limited benefit plans: understand what you are buying!

        click here for more information on limited benefit coverage plans

        • Short Term Limited Duration Insurance: In oklahoma, these state-mandated non-benefit plans currently may cover you for no more than six (6) months and are non-renewable. Some plans sold in Oklahoma may offer more than six (6) months of coverage that must contain all state-mandated benefits. they can exclude pre-existing conditions and even ask health questions on the application; and may have yearly and yearly benefit limits. you’ll want to see the policy’s exclusions and limitations before you buy.
        • all applications and policies must contain prominent language advising consumers that these plans are not major medical or comprehensive major medical plans and do not have the protections normally provided by policies here.
        • Accident Only: Pays only when you receive treatment for accidental injuries or if an accident causes death.
        • disability income: pays a fixed amount for a specified period of time when you are unable to work due to an accident or illness.
        • hospital indemnity: pays a fixed amount (such as $100 per day) when you are hospitalized.
        • Long-Term Care: Pays to care for you for a long time in a nursing home or in your own home. For more information, visit For information on the Oklahoma Long-Term Care Partnership, visit:
        • medicare supplement: pays for some medical expenses not paid by medicare. (see choosing a medigap policy)
        • Special Need: Pays for medical care not covered by typical major medical policies (for example, dental or vision care).
        • Specified Disease: Pays only for treatment of a disease or condition specifically named in the policy, such as cancer.
        • Home Health Care: Pays for health care provided in your home.
        • other types of plans:

          • discount plans: these plans are not considered compatible with aca. Medical discount plans, prescription discount plans, dental discount plans, and vision discount plans are programs in which a consumer pays a fee to join a plan in exchange for discounts on health care products and services. providers and participating providers. Members who join these plans often receive a card similar to an insurance card that identifies them as members. however, these plans are not insurance. Buyer beware!
          • how do i buy health coverage?

            Individual vs. Group Coverage There are two basic ways to buy health coverage: as an individual or through a group. how you buy health coverage affects your rights and responsibilities.

            individual coverage – comprehensive major medical coverage
            • You can buy individual health insurance outside of the oklahoma federal exchange through an agent, broker, or directly from the insurance company or the oklahoma federal exchange at When you buy individual health insurance, you contract directly with an insurance company the same way you insure your home or car.
            • You are the policy holder. however, we may call the contract holder (the person on whose behalf the contract is written) a subscriber, member, or enrollee.
            • Your individual policy may cover your entire family (or only certain people in your family, such as only children or the adult who needs coverage) and each covered family member would be an insured .
            • any premium increase affects everyone with the same type of policy. insurance companies can only rate insurance applicants based on age, tobacco use, zip code, and family composition.
            • Unless you have made false statements on your application, filed fraudulent claims, or failed to pay your premiums on time, the company cannot cancel your policy due to your health, pre-existing conditions, or claims.
            • coverage must include specific minimum benefits as established by the Affordable Care Act and oklahoma state law
            • rates for fully insured individual policies are regulated by the oklahoma insurance department. however, individual policies sold in the federal market or store are also regulated by cms.
            • group coverage

              Group coverage can be purchased outside of the exchange through an agent or broker or directly from the insurance company. small groups of employers (until the end of 2015, those with 50 or fewer employees) can buy through an exchange called the store.

              See also: Business Disability Insurance | W3 Insurance

              A group insurance policy can cover anywhere from two to thousands of people, but it’s still just one policy.

              • your employer or association is the primary policyholder; you and your groupmates are certificate holders.
              • each member of the family covered by your certificate is an insured.
              • the master policyholder (employer or association) negotiates the terms of a group policy with the insurance company.
              • the main holder can:

                • reduce or change benefits and coverage (some exceptions apply to protected plans), including determining to cover only employees and children and to cover or exclude spouses.
                • increase your portion of the premium (some exceptions apply to protected plans),
                • switch to another insurance company, or
                • stop providing cover!
                • in a group contract

                  • rates for fully insured employer groups are negotiable with the insurance carrier and are regulated by the oklahoma insurance department. however, fully insured group plans in the federal or store marketplace are regulated by cms. self-insured large group plans are regulated by the Department of Labor.
                  • the contract must include the specific minimum benefits required by federal and oklahoma state law; the primary policyholder negotiates other benefits.
                  • the owner of the master policy does not need the consent of the certificate holders to change companies or policies, cancel the policy or accept new premiums or benefits.
                  • large and small employer group contracts

                    • may have more generous benefits. however, self-insured plans and association plans may have benefit limits and some services may not be covered. you’ll want to review your benefits carefully.
                    • You may not deny a request for health reasons as long as the request is made during the employer’s eligibility period or during open enrollment. Currently in Oklahoma, large employer groups are defined as those with 51 or more employees. small employer groups are defined as those with 2 to 50 employees.
                    • Other ways you can be covered for health care is through a government-sponsored program like Medicare, SoonerCare (Medicaid), or VA, etc.


                      early attention


                      See also: 2022 Obamacare Open Enrollment Dates by State – eHealth

                      other policy information

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