§ 3-106. Limited health benefit plan requirements.
A. The Osage Nation Attorney General is charged with approving a plan or plans which outline the limited health benefit provided for all eligible members which complies with the purpose and provisions of this Act.
B. A plan shall have the following components:
1. An annual benefit for each eligible member of the Osage Nation under age sixty-five (65) not to exceed Five Hundred Dollars ($500.00); and
2. An annual benefit for each eligible member of the Osage Nation age sixty-five (65) and over of One Thousand Dollars ($1,000.00).
C. A plan shall provide for applications, establishment of individual accounts, annual notification to enrolled members of pertinent information including how to access account balances, how to submit claims for processing and appeal the denial of benefits, change of benefit forms and shall be made available throughout the calendar year to the members of the Osage Nation via web access, and upon request by email and mail.
D. The authorized benefits may be reimbursed or paid through a health benefit card issued to eligible recipients.
E. A plan shall provide for administration through a third-party administrator (Plan Administrator), excepting services described in subsection (F)(1) of this section.
F. A plan and any contract entered into with a third-party administrator to administer benefits described in subsection (B) of this section shall provide an Osage member may apply online and access benefits, if desired, via the use of an encoded card. Debit cards issued pursuant to a plan shall offer real-time substantiation by adoption of an Inventory Information Approval System (IIAS) as described in IRS Notice 2006-69, found in Internal Revenue Bulletin 2006-31, published July 31, 2006, and thereby limit approved purchases to those which qualify as medical expenses under current IRS rules. This requirement shall be in addition to other features which limit purchases, including those which restrict purchases to merchants operating under particular MCC codes.
1. All expenses that are otherwise eligible but cannot be processed at the point of purchase will require the member to submit a claim form in order to initiate the reimbursement process.
2. Every plan shall provide for a means of tracking account fund balances and describe how the enrolled member accesses that information.
G. A minor or dependent Osage Nation member may have their health benefit plan balances held in a family account managed by the member’s custodial parent or guardian who shall be authorized to expend funds out of the account for the benefit of the minor or dependent member.
H. Existing health benefit accruals in place as of October 4, 2020, for years 2019 and 2020 will remain in place and expire following their current expiration schedule. Beginning with the 2021 benefit for members under age sixty-five (65), no accrual will be carried forward. Unused benefits for members under age sixty-five (65) in 2021 and going forward during any calendar year are forfeited and shall not accrue to the next calendar year. Members age sixty-five (65) and over at the beginning of the calendar year shall be allowed to accrue up to two years of benefits and carry them over to the next current benefit calendar year. No accrual value shall apply to those individuals receiving the Medicare supplemental coverage.
I. A Plan Administrator is authorized to employ administrative processes to increase convenience for individuals and families with minors, provided such processes do not conflict with the provisions of this Act.
J. Should a Plan Administrator conduct benefits enrollment, the applicant, the parent or legal guardian of a minor child or legal dependent must sign a consent/release form authorizing membership information to be transmitted to an administrator of a health benefit plan by the Osage Nation.
K. The Osage Nation and a Plan Administrator are prohibited from imposing any other eligibility requirements on Osage Nation members applying for benefits according to this Act unless approved by the Osage Nation Congress.
L. A Plan Administrator shall be required to administer a plan in and for the best interest of the beneficiaries, and interpret eligible expenses in a light most favorable to the beneficiaries.
M. Members of the Osage Nation sixty-five (65) years of age and older may opt out of a health benefit plan and elect to participate in the Medicare supplemental coverage benefit provided through the third-party administrator.
N. Changes to a plan document that change the benefit amounts to be made available to members or delay payments for approved claims shall be presented for approval by the Osage Nation Congress.
O. A plan shall contain a description of an appeal process to consider denied claims. Following completion of the appeal process, the decision of a third-party administrator shall be final.
P. A Plan Administrator shall submit quarterly financial and benefit use reports to the Principal Chief and the Osage Nation Congress.
Q. An external audit of a health benefit plan shall be conducted annually through the Treasurer’s office and reported to the Osage Nation Congress by no later than July 15th following the most recent completed calendar year. ONCA 18-70, eff. Apr. 25, 2019; ONCA 20-83, eff. Oct. 5, 2020; ONCA 21-14, eff. Jan. 15, 2021.