Health insurance is an important coverage that helps protect you and your family from the devastating financial effects of unexpected health problems or catastrophic illness and can apply for guaranteed issued health insurance.
The Oklahoma Insurance Department encourages you to work with the insurance professionals in your community to help you determine the appropriate policy for your family or business needs. These insurance professionals can be found on our website under: Tips for Finding an Agent
Federal Health Care Reform Resources
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 government plan (Medicare, SoonerCare (Medicaid), VA, etc.). If your employer sponsored health plan is “self insured” it is not subject to regulation by the Oklahoma Insurance Department but regulated by the Department of Labor. Additional information regarding 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.
2026 Affordable Care Act Health Insurance Rate Filings
Traditional Health Insurance
With the passage for the Affordable Care Act or Healthcare Reform in 2010, most traditional health insurance plans, often called “fee-for-service,” are most likely now to be found in “Grandfathered Plans”, non-compliant ACA plans or commonly known as “Grandmother Plans” or Medicare Supplement Plans. If your plan is a true “free for service”:
- You can use any doctor or hospital.
- You send your medical bills to the insurance company (the provider may do this for you but is not required).
- You will likely have to pay a deductible to your provider before the policy begins to pay and co-payments to your provider each time you visit your provider or doctor’s office.
- If the policy pays less than the full bill, you most likely will be responsible for paying the balance.
ACA compliant group health and individual policies fall under 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 older 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 applicable plan deductible and copays. The remaining expense (for example,10%, 20%, 30% or 40%) is coinsurance and is paid by you. Maximum out-of-pocket limits restrict the amount of coinsurance you pay. After the covered person or family reaches their maximum out-of-pocket limit, your plan will pay 100% for that person or family for the rest of that year. Pay particular attention to the plan’s maximum out of pocket limit before you buy a plan particularly if you are not eligible for cost sharing reductions on the federal exchange.
How do I Purchase 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
- You may buy individual health insurance either outside of the Oklahoma federal exchange through an agent, broker or directly from the insurance carrier or from the Oklahoma federal exchange at www.healthcare.gov. When you buy individual health insurance, you contract directly with a health carrier just like insuring your home or car.
- You are the policyholder. However, HMOs call the contract-holder (the person in whose name the contract is written) a subscriber, member or enrollee.
- Your individual policy can cover your entire family (or only certain individuals in your family, like child/ren only, or the one adult who needs coverage) and each covered family member would be an insured.
- Any premium increase affects everyone who has the same kind of policy. Insurance carriers can only rate applicants for insurance 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 because of your health, pre-existing conditions or claims.
- Coverage must include specific minimum benefits as stated 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 exchange or SHOP 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 carrier. Small employer groups (until the end of 2015, those with 50 or fewer employees) can purchase through an exchange called the SHOP.
A group insurance policy may cover two to thousands of people, but it is still only one policy.
- Your employer or association is the master policyholder; you and your fellow group members are certificate holders.
- Each family member covered under your certificate is an insured.
- The master policyholder (Employer or Association) negotiates the terms of a group policy with the insurance company.
The master policyholder can:
- Reduce or change the benefits and coverage (some exceptions apply to Grandfathered Plans), including determining to cover employees and children only and to cover or exclude spouses.
- Increase your share of the premium (some exceptions apply to Grandfathered Plans),
- Switch to another insurance company, or
- Stop providing any coverage!
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 exchange or SHOP are regulated by CMS. Self-insured large group plans are regulated by the Department of Labor.
- The contract must include specific minimum benefits required by federal and Oklahoma state law —other benefits are negotiated by the master policyholder.
- The master policyholder does not need consent of certificate holders to change companies or policies, cancel the policy or agree to 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 may not cover some services. You will want to review your benefits carefully.
- Cannot reject an application because of health as long as the application is made during the employer’s eligibility period or Open Enrollment. Currently in Oklahoma, large employer groups are defined as having 51 or more employees. Small employer groups are defined as having 2 through 50 employees.
Other ways you can be covered for Health Care is through a government sponsored program like Medicare, SoonerCare (Medicaid) or VA, etc.
Other Policy Information
- Deductibles: This is the amount of covered health care expenses that must be paid for by the insured before the insurance company will begin paying. Choose deductibles that you can afford to pay should you need to use your insurance.
- Co-Insurance: This is the amount stated in the policy that is the insured’s portion of the claim. For instance, the insurance company may pay 60%, 70%, 80% or 90% of the claim and the insured’s share or co-insurance is 40%, 30%, 20% or 10% of the claim. You will pay the co-insurance amount in addition to the deductible. Once your deductible and coinsurance equal your maximum out-of-pocket, then your plan will pay 100%. The individual and family will have a maximum out of pocket amount for the plan they choose.
- Co-Payments: Some policies provide for a set amount paid by the insured for a particular service, usually an office visit, out-patient visit or hospital admission. In that case, the insured pays their co-pay for the visit and the insurer pays the rest of the bill. Amounts you pay for co-payments may or may not go toward the deductible, depending on the policy.
ACA compliant policies have maximum out-of-pocket limits and unlimited lifetime benefits which limits your liability or exposure (how much of the expenses you have to pay yourself). However, out-of-network charges, except in emergency situations, are your responsibility and you may be balanced billed so you must read your policies very carefully and know that your provider is in network before using their services.
When you use an In-Network provider, your provider will file the claim directly with your insurance carrier. You will receive an Explanation of Benefits of how that bill was paid and what your responsibility is, if any. If there is a dispute, contact your insurance carrier customer service department for a resolution, first. Ask for a resolution time frame. If not completed by that time and the explanation seems unreasonable, contact Consumer Assistance at the Oklahoma Insurance Department for help or assistance in appealing.
If your treatment bill has been denied by your insurance carrier, follow these steps to begin the appeal process:
For policies bought on the Exchange:
https://www.healthcare.gov/appeal-insurance-company-decision/appeals/
https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
For policies bought off the Exchange:
Please refer to the How To Appeal sheet enclosed with your Explanation of Benefits received from your insurance carrier on your denied services. For further help, contact your insurance carrier Customer Service Helpline or the Oklahoma Insurance Department Consumer Assistance Department.
Can an Insurance Company Exclude Pre-Existing Conditions?
With the passage of the Affordable Care Act in 2010, eligible children could not be denied insurance coverage due to poor health or prior treatments and beginning January 1, 2014, all eligible persons applying for insurance could not be denied coverage due to poor health or prior treatments.
Click here to see how pre-existing conditions are now protected. This provision applies to ACA comprehensive medical policies sold on and off the exchange.
If you bought a policy on the federal health exchange and you are receiving premium tax credits, you have certain protections when you are late paying your premium. Please contact www.healthcare.gov at 1-800-318-2596.
If you bought a policy outside of the federal health exchange you should contact the insurance carrier’s customer service department who will give you instructions and your options.
- The insurance policy must include a grace period during which the policy must continue to be in force. The length of time for the grace period depends on the frequency of premium payments. If the premium is paid on an annual basis, the grace period cannot be less than 31 days. If the premium is due on a weekly basis, the grace period cannot be less than 7 days and not less than 10 days for premiums due on a monthly basis.
If you have a policy through the federal health exchange, please click here.
If you have a policy outside of the federal exchange, contact your insurance agent or broker who sold you the policy or your insurance carrier’s customer service department who will give you instructions and your options.
You have certain rights and protections both inside and outside of the exchange. However, when an insurance carrier leaves the marketplace, you must follow the instructions you receive from your insurance carrier and take notice of your deadlines to take action.
https://www.healthcare.gov/health-care-law-protections/cancellations/
https://www.healthcare.gov/current-plan-changed-or-cancelled/
You have the option of covering your entire family or not at the time of application or during Open Enrollment.. Read the policy and the schedule page to determine who is insured under the policy.
You will want to refer to your Summary of Benefits and or Policy for your out of pocket limits. Policies can no longer have annual or lifetime limits for essential health benefits. For policies bought through the federal health exchange, please click on the following link:
https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/
Learn more about Employer Health Benefit Plans (ERISA)
