Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 1 - General Provisions › Section 317:45-1-3 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms, when used in this Chapter,
				  will have the following meanings unless the context clearly indicates
				  otherwise:
"Carrier"
means:
(A) An insurance company, insurance service, insurance
				  organization, or group health service, which is licensed to engage in the
				  business of insurance in the State of Oklahoma and is subject to State law
				  which regulates insurance, or Health Maintenance Organization (HMO) which
				  provides or arranges for the delivery of basic health care services to
				  enrollees on a prepaid basis, except for copayments or deductibles for which
				  the enrollee is responsible, or both and is subject to State law which
				  regulates Health Maintenance Organizations (HMOs);
(B) A Multiple Employer Welfare Arrangement (MEWA) licensed
				  by the Oklahoma Insurance Department;
(C) A domestic MEWA exempt from licensing pursuant to Title
				  36 of the Oklahoma Statutes (O.S.) §
									634(B)
				  that otherwise meets or exceeds all the licensing and financial requirements of
				  MEWAs as set out in Title 36 O.S.; or
(D) Any entity organized pursuant to the Interlocal
				  Cooperation Act, 74 O.S. §
									1001
				  et seq. as authorized by 36 O.S. § 607.1 and which is eligible to qualify
				  for and hold a certificate of authority to transact insurance in this State and
				  annually submits on or before March 1st a financial statement to the Oklahoma
				  Insurance Department in a form acceptable to the Insurance Commissioner
				  covering the period ending December 31st of the immediately preceding fiscal
				  year.
"Child care center"
means a facility licensed by
				  the Oklahoma Department of Human Services (DHS) which provides care and
				  supervision of children and meets all the requirements in OAC
				  340:110-3-275 through
				  340:110-3-311.
"College student"
means an Oklahoma resident
				  between the age of nineteen (19) through twenty-two (22) that is a full-time
				  student at an Oklahoma accredited university or college.
"Dependent"
means the spouse of the approved
				  applicant and/or child under nineteen (19) years of age or his or her child
				  nineteen (19) years through twenty-two (22) years of age who is attending an
				  Oklahoma qualified institution of higher education and relying upon the insured
				  employee or member for financial support.
"Eligibility period"
means the period of
				  eligibility extending from an approval date to an end date.
"Employee"
means a person who works for an
				  employer in exchange for earned income. This includes the owners of a business.
"Employer"
means the business entity that pays
				  earned income to employees.
"Employer Sponsored Insurance (ESI)"
means the
				  program that provides premium assistance to qualified businesses for approved
				  applicants.
"Explanation of Benefit (EOB)"
means a statement
				  issued by a carrier that indicates services rendered and financial
				  responsibilities for the carrier and Insure Oklahoma member.
"Full-time employer"
means the employer who
				  employs an employee per Federal and State regulations, to perform work in
				  exchange for wages or salary.
"Full-time employment"
means a normal work week
				  per Federal and State regulations.
"In-network"
means providers or health care
				  facilities that are part of a benefit plan's network of providers with which it
				  has negotiated a discount, and services provided by a physician or other health
				  care provider with a contractual agreement with the insurance company paid at
				  the highest benefit level.
"Insure Oklahoma (IO)"
means a benefit plan
				  purchasing strategy in which the State uses public funds to pay for a portion
				  of the costs of benefit plan coverage for eligible populations.
"Member"
means an individual enrolled in the
				  Insure Oklahoma ESI program.
"Modified Adjusted Gross Income (MAGI)"
means
				  the financial eligibility determination methodology established by the Patient
				  Protection and Affordable Care Act (PPACA) in 2009.
"OAC"
means the Oklahoma Administrative
				  Code.
"OESC"
means the Oklahoma Employment Security
				  Commission.
"OHCA"
means the Oklahoma Health Care
				  Authority.
"OKDHS"
means the Oklahoma Department of Human
				  Services which is also referenced in rules as Department of Human Services
				  (DHS) and Office of Human Services (OHS).
"Premium"
means a monthly payment to a carrier
				  for benefit plan coverage.
"Primary care provider (PCP)"
means a provider
				  under contract with the OHCA to provide primary care services, including all
				  medically necessary referrals.
"Professional employer organization (PEO)"
means
				  any person engaged in the business of providing professional employer services
				  shall be subject to registration under the Oklahoma Professional Employer
				  Organization Recognition and Registration Act as provided in 40 O.S. §
				  600.1 et. seq.
"Qualified benefit plan (QBP)"
means a benefit
				  plan that has been approved by the OHCA for participation in the Insure
				  Oklahoma program.
"Qualifying event"
means the occurrence of an
				  event that permits individuals to join a group benefit plan outside of the
				  "open enrollment period" and/or that allows individuals to modify the coverage
				  they have had in effect. Qualifying events are defined by the employer's
				  benefit plan and meet federal requirements under
				  Public
				  Law 104-191 (HIPAA), and
				  42 U.S.C.
				  300bb-3.
"
State"
means the State of Oklahoma, acting by
				  and through the OHCA.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 24 Ok
				  Reg 101, eff 8-2-06 (emergency); Amended at 24 Ok Reg 963, eff 5-11-07; Amended
				  at 25 Ok Reg 2770, eff 6-1-08 (emergency); Amended at 26 Ok Reg 621, eff 3-1-09
				  (emergency); Amended at 26 Ok Reg 2165, eff 6-25-09; Amended at 27 Ok Reg 2391,
				  eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff 6-25-11; Amended at 29
				  Ok Reg 1210, eff 6-25-12