Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-51 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms, when used in this Part, shall
					 have the following meaning, unless the context clearly indicates
					 otherwise:
"Allowable expense"
means, unless otherwise
					 mandated by law, any necessary, reasonable, and customary item of expense at
					 least a portion of which is covered under at least one of the Plans covering
					 the person for whom claim is made except where a statute requires a different
					 definition. However, items of expense under coverage such as dental care,
					 vision care, prescription drug or hearing aid programs may be excluded from the
					 definition of allowable expense. A plan which provides benefits only for any
					 such items of expense may limit its definition of allowable expense to like
					 items of expense. When a Plan provides benefits in the form of services rather
					 than cash payments, the reasonable cash value of each service rendered shall be
					 deemed to be both an Allowable Expense and a benefit paid. The difference
					 between the cost of a private hospital room and the cost of a semi-private
					 hospital room shall not be deemed to be an "Allowable Expense," except for the
					 period of time during which the patient's confinement to a private hospital
					 room is deemed medically necessary in terms of generally accepted medical
					 practice.
"Plan"
includes the following:
(A) Group and nongroup insurance contracts and subscriber
					 contracts;
(B) Uninsured arrangements of group or group-type
					 coverage;
(C) Group and nongroup coverage through closed panel
					 plans;
(D) Group-type contracts;
(E) The medical care components of long-term care
					 contracts, such as skilled nursing care;
(F) The medical benefits coverage in automobile "no fault"
					 and traditional automobile "fault" type contracts;
(G) Medicare or other governmental benefits, as permitted
					 by law, except as provided in a state plan under Medicaid. That part of the
					 definition of plan may be limited to the hospital, medical and surgical
					 benefits of the governmental program; and
(H) Group and nongroup insurance contracts and subscriber
					 contracts that pay or reimburse for the cost of dental care.
"Plan"
does not include:
(A) Hospital indemnity coverage benefits or other fixed
					 indemnity coverage;
(B) Accident only coverage;
(C) Specified disease or specified accident
					 coverage;
(D) Limited benefit health coverage;
(E) School accident-type coverages that cover students for
					 accidents only, including athletic injuries, either on a twenty-four-hour basis
					 or on a "to and from school" basis;
(F) Benefits provided in long-term care insurance policies
					 for non-medical services, for example, personal care, adult day care, homemaker
					 services, assistance with activities of daily living, respite care and
					 custodial care or for contracts that pay a fixed daily benefit without regard
					 to expenses incurred or the receipt of services;
(G) Medicare supplement policies;
(H) A state plan under Medicaid; or
(I) A governmental plan, which, by law, provides benefits
					 that are in excess of those of any private insurance plan or other
					 non-governmental plan.
"This plan"
means that portion of the policy
					 which provides the benefits that are subject to this
					 subchapter.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04