reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 11 - ACCELERATED BENEFITS › Section 365:10-5-106 - Effective date of the accelerated benefits

Current through Vol.
				  41, No. 20, July 1, 2024
The accelerated benefit provision shall be effective for
					 accidents on the effective date of the policy or rider. The accelerated benefit
					 provision shall be effective for illness no more than thirty (30) days
					 following the effective date of the policy or rider.
Added at 9 Ok Reg
					 2493, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 11 - ACCELERATED BENEFITS › Section 365:10-5-107 - Waiver of premiums

Current through Vol. 41, No. 20, July 1,
				  2024
The insurer may offer a waiver of premium for the
					 accelerated benefit provision in the absence of a regular waiver of premium
					 provision being in effect. At the time the benefit is claimed, the insurer
					 shall explain any continuing premium requirement to keep the policy in
					 force.
Added at 9 Ok Reg
					 2493, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 11 - ACCELERATED BENEFITS › Section 365:10-5-108 - Discrimination

Current through Vol. 41, No. 20, July 1, 2024
Insurers shall not unfairly discriminate among insureds
					 with differing qualifying events covered under the policy or among insureds
					 with similar qualifying events covered under the policy. Insurers shall not
					 apply further conditions on the payment of the accelerated benefits other than
					 those conditions specified in the policy or rider.
Added at 9 Ok Reg
					 2493, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 11 - ACCELERATED BENEFITS › Section 365:10-5-109 - Actuarial standards

Current through Vol. 41, No. 20, July 1,
				  2024
(a)
Financing
				  options.
(1) The insurer may require a
				  premium charge or cost of insurance charge for the accelerated benefit. These
				  charges shall be based on sound actuarial principles. In the case of group
				  insurance, the additional cost may also be reflected in the experience
				  rating.
(2) The insurer may pay a
				  present value of the face amount. The calculation shall be based on any
				  applicable actuarial discount appropriate to the policy design. The interest
				  rate or interest rate methodology used in the calculation shall be based on
				  sound actuarial principles and disclosed in the contract or actuarial
				  memorandum. The maximum interest rate used shall be no greater than the greater
				  of:
(A) The current yield on 90 day treasury
				  bills; or
(B) The current maximum
				  statutory adjustable policy loan interest rate.
(3) The insurer may accrue an interest charge
				  on the amount of the accelerated benefits. The interest rate or interest rate
				  methodology used in the calculation shall be -based on sound actuarial
				  principles and disclosed in the contract or actuarial memorandum. The maximum
				  interest rate used shall be no greater than the greater of:
(A) The current yield on 90 day treasury
				  bills; or
(B) The current maximum
				  statutory adjustable policy loan interest rate. The interest rate accrued on
				  the portion of the lien which is equal in amount to the cash value of the
				  contract at the time of the benefit acceleration shall be no more than the
				  policy loan interest rate stated in the contract.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 11 - ACCELERATED BENEFITS › Section 365:10-5-110 - Actuarial disclosure and reserves

Current through Vol. 41, No.
				  20, July 1, 2024
(a)
Actuarial memorandum.
A qualified actuary should describe the
				  accelerated benefits, the risks, the expected costs and the calculation of
				  statutory reserves in an actuarial memorandum accompanying each state filing.
				  The insurer shall maintain in its files descriptions of the bases and
				  procedures used to calculate benefits payable under these provisions. These
				  descriptions shall be made available for examination by the Commissioner upon
				  request.
(b)
Reserves.
(1) When benefits are provided through the
				  acceleration of benefits under group or individual life policies or riders to
				  such policies, policy reserves shall be determined in accordance with the
				  Standard Valuation Law. All valuation assumptions used in constructing the
				  reserves shall be determined as appropriate for statutory valuation purposes by
				  a member in good standing of the American Academy of Actuaries. Mortality
				  tables and interest currently recognized for life insurance reserves by the
				  NAIC may be used as well as appropriate assumptions for the other provisions
				  incorporated in the policy form. The actuary must follow-both actuarial
				  standards and certification for good and sufficient reserves. Reserves in the
				  aggregate should be sufficient to cover:
(A)
				  Policies upon which no claim has yet arisen.
(B) Policies upon which an accelerated claim
				  has arisen.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-120 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Part is to provide for the reasonable
					 standardization of coverage and simplification of terms and benefits of
					 Medicare supplement policies; to facilitate public understanding and comparison
					 of such policies; to eliminate provisions contained in such policies which may
					 be misleading or confusing in connection with the purchase of such policies or
					 with the settlement of claims; and to provide for full disclosures in the sale
					 of accident and health insurance coverages to persons eligible for
					 Medicare.
Added at 9 Ok Reg 549,
					 eff 12-13-91 (emergency); Added at 9 Ok Reg 2499, eff 6-26-92; Amended at 9 Ok
					 Reg 3899, eff 8-24-92 (emergency); Amended at 10 Ok Reg 1475, eff
					 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-121 - Authority

Current through Vol. 41, No. 20, July 1, 2024
This Part is issued pursuant to the authority vested in the
					 Commissioner under 36 O.S. §
										3611.1.
Added at 9 Ok Reg
					 2499, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-122 - Applicability and scope

Current through Vol. 41, No. 20, July 1,
				  2024
(a) Except as
				  otherwise specifically provided in Sections
				  365:10-5-126,
				  365:10-5-130,
				  365:10-5-131
				  and
				  365:10-5-139,
				  this Part shall apply to:
(1) All Medicare
				  supplement policies delivered or issued for delivery in this state on or after
				  the effective date hereof, and
(2)
				  All certificates issued under group Medicare supplement policies which
				  certificates have been delivered or issued for delivery in this
				  state.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-124 - Policy definitions and terms

Current through Vol. 41, No. 20,
				  July 1, 2024
No policy or certificate may be advertised, solicited or
					 issued for delivery in this state as a Medicare supplement policy or
					 certificate unless such policy or certificate contains definitions or terms
					 which conform to the requirements of this section.
(1)
"Accident," "Accidental
				  Injury,"
or
"Accidental Means"
shall be defined to employ
				  "result" language and shall not include words which establish an accidental
				  means test or use words such as "external, violent, visible wounds" or similar
				  words of description or characterization.
(A)
				  The definition shall not be more restrictive than the following: "Injury or
				  injuries for which benefits are provided means accidental bodily injury
				  sustained by the insured person which is the direct result of an accident,
				  independent of disease or bodily infirmity or any other cause, and occurs while
				  insurance coverage is in force."
(B) Such definition may provide that injuries
				  shall not include injuries for which benefits are provided or available under
				  any workers' compensation, employer's liability or similar law, or motor
				  vehicle no-fault plan, unless prohibited by law.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-125 - Policy provisions

Current through Vol. 41, No. 20, July 1,
				  2024
(a)
Limitations and exclusions.
Except for permitted preexisting
				  condition clauses as described in
				  365:10-5-126(b)(1)
				  and
				  365:10-5-127(b)(1),
				  no policy or certificate may be advertised, solicited or issued for delivery in
				  this state as a Medicare supplement policy if such policy or certificate
				  contains limitations or exclusions on coverage that are more restrictive than
				  those of Medicare.
(b)
Waivers.
No Medicare supplement policy or certificate may use
				  waivers to exclude, limit or reduce coverage or benefits for specifically named
				  or described preexisting diseases or physical conditions.
(c)
Duplication of benefits.
No
				  Medicare supplement policy or certificate in force in the state shall contain
				  benefits which duplicate benefits provided by Medicare.
(d)
Outpatient prescription
				  drugs.
(1) Subject to sections
				  365:10-5-126(b)(4),(5),
				  and (7) and
				  365:10-5-127(b)
				  (4) and (5), a Medicare supplement policy with benefits for outpatient
				  prescription drugs in existence prior to January 1, 2006 shall be renewed for
				  current policyholders who do not enroll in Part D at the option of the
				  policyholder.
(2) A Medicare
				  Supplement policy with benefits for outpatient prescription drugs shall not be
				  issued after December 31, 2005.
(3)
				  After December 31, 2005, a Medicare supplement policy with benefits for
				  outpatient prescription drugs may not be renewed after the policyholder enrolls
				  in Medicare Part D unless:
(A) The policy is
				  modified to eliminate outpatient prescription coverage for expenses of
				  outpatient prescription drugs incurred after the effective date of the
				  individual's coverage under a Part D plan and;
(B) Premiums are adjusted to reflect the
				  elimination of outpatient prescription drug coverage at the time of Medicare
				  Part D enrollment, accounting for any claims paid, if applicable.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-128.1 - Medicare Select Policies and Certificates [AMENDED AND RENUMBERED TO 365:10-5-128.3]

Current through Vol. 41, No. 20, July
				  1, 2024
Added at 15 Ok Reg
					 3569, eff 5-29-98 (emergency); Added at 16 Ok Reg 1088, eff 4-26-99; Amended at
					 20 Ok Reg 1667, eff 7-14-03; Amended at 22 Ok Reg 1954, eff 7-14-05; Amended
					 and renumbered to 365:10-5-128.3 at 26 Ok Reg 1551, eff
					 7-1-09
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-128.3 - Medicare select policies and certificates

Current through Vol.
				  41, No. 20, July 1, 2024
(a)
Application.
This section
				  shall apply to Medicare Select policies and certificates, as defined in this
				  section. No policy or certificate may be advertised as a Medicare Select policy
				  or certificate unless it meets the requirements of this section.
(b)
Definitions.
For the
				  purposes of this section:
(1) "Complaint"
				  means any dissatisfaction expressed by an individual concerning a Medicare
				  Select issuer or its network providers.
(2) "Grievance" means dissatisfaction
				  expressed in writing by an individual insured under a Medicare Select policy or
				  certificate with the administration, claims practices, or provision of services
				  concerning a Medicare Select issuer or its network providers.
(3) "Medicare Select issuer" means an issuer
				  offering, or seeking to offer, a Medicare Select policy or
				  certificate.
(4) "Medicare Select
				  policy" or "Medicare Select certificate" mean respectively a Medicare
				  supplement policy or certificate that contains restricted network
				  provisions.
(5) "Network provider"
				  means a provider of health care, or a group of providers of health care, which
				  has entered into a written agreement with the issuer to provide benefits
				  insured under a Medicare Select policy.
(6) "Restricted network provision" means any
				  provision which conditions the payment of benefits, in whole or in part, on the
				  use of network providers.
(7)
				  "Service area" means the geographic area approved by the Commissioner within
				  which an issuer is authorized to offer a Medicare Select policy.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-129 - Open enrollment

Current through Vol. 41, No. 20, July 1,
				  2024
(a) An issuer shall
				  not deny or condition the issuance or effectiveness of any Medicare supplement
				  policy or certificate available for sale in this State, nor discriminate in the
				  pricing of such a policy or certificate because of the health status, claims
				  experience, receipt of health care, or medical condition of an applicant in the
				  case of an application for a policy or certificate that is submitted prior to
				  or during the six (6) month period beginning with the first day of the first
				  month in which an individual is both sixty-five (65) years of age or older and
				  is enrolled for benefits under Medicare Part B. Each Medicare supplement policy
				  and certificate currently available from an issuer shall be made available to
				  all applicants who qualify under this subsection without regard to
				  age.
(b) If an applicant qualifies
				  under subsection (a) or subsection (d) of this Section and submits an
				  application during the time period referenced in said subsection (a) or
				  subsection (d), and
(1) as of the date of
				  application, has had a continuous period of creditable coverage of at least six
				  (6) months, the issuer shall not exclude benefits based on a preexisting
				  condition; or
(2) as of the date of
				  application, has had a continuous period of creditable coverage that is less
				  than six (6) months, the issuer shall reduce the period of any preexisting
				  condition exclusion by the aggregate of the period of creditable coverage
				  applicable to the applicant as of the enrollment date. The Secretary shall
				  specify the manner of the reduction under this subsection.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-129.1 - Guaranteed Issue for Eligible Persons

Current through Vol. 41,
				  No. 20, July 1, 2024
(a)
Guaranteed Issue.
(1) Eligible
				  persons are those individuals described in subsection (b) who apply to enroll
				  under the policy not later than sixty-three (63) days after the date of the
				  termination of enrollment described in subsection (b), and who submit evidence
				  of the date of termination, disenrollment or Medicare Part D enrollment with
				  the application for a Medicare supplement policy.
(2) With respect to eligible persons, an
				  issuer shall not deny or condition the issuance or effectiveness of a Medicare
				  supplement policy described in subsection (c) that is offered and is available
				  for issuance to new enrollees by the issuer, shall not discriminate in the
				  pricing of such a Medicare supplement policy because of health status, claims
				  experience, receipt of health care, or medical condition, and shall not impose
				  an exclusion of benefits based on a preexisting condition under such a Medicare
				  supplement policy.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-129.2 - Special enrollment period for Medicare supplement policies

Current through Vol. 41, No. 20, July 1,
				  2024
(a) An issuer of
				  Medicare supplement policies in this State shall issue any Medicare supplement
				  policy the carrier sells in this State to an individual eligible for Medicare
				  if the individual:
(1) Is enrolled in
				  SoonerCare (Oklahoma Medicaid) and remained enrolled in SoonerCare due to a
				  suspension of terminations by the Oklahoma Health Care Authority during the
				  COVID-19 Public Health Emergency;
(2) Enrolled in Medicare Parts A and B within
				  six (6) months of the later date of termination or disenrollment of SoonerCare
				  benefits (or, if a notice is not received, notice that a claim has been denied
				  because of such a termination or disenrollment); or the date that the
				  SoonerCare benefits terminate or cease;
(3) Applies for a Medicare supplement policy
				  during the 63-day period following the date of enrollment in Medicare Part
				  B;
(4) Submits evidence of the date
				  of termination or disenrollment from SoonerCare with the application for a
				  Medicare supplement policy.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-130 - Standards for claims payment

Current through Vol. 41, No. 20,
				  July 1, 2024
(a) An
				  issuer shall comply with section 1882(c) (3) of the Social Security Act (as
				  enacted by section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of
				  1987 (OBRA) 1987, Pub. L. No. 100-203 ) by:
(1) Accepting a notice from a Medicare
				  carrier on dually assigned claims submitted by participating physicians and
				  suppliers as a claim for benefits in place of any other claim form otherwise
				  required and making a payment determination on the basis of the information
				  contained in that notice;
(2)
				  Notifying the participating physician or supplier and the beneficiary of the
				  payment determination;
(3) Paying
				  the participating physician or supplier directly;
(4) Furnishing, at the time of enrollment,
				  each enrollee with a card listing the policy name, number and a central mailing
				  address to which notices from a Medicare carrier may be sent;
(5) Paying user fees for claim notices that
				  are transmitted electronically or otherwise; and
(6) Providing to the Secretary of Health and
				  Human Services, at least annually, a central mailing address to which all
				  claims may be sent by Medicare carriers.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-131 - Loss ratio standards and refund or credit of premium

Current through Vol. 41, No. 20, July 1, 2024
(a)
Loss ratio standards.
(1) A Medicare Supplement policy form or
				  certificate form shall not be delivered or issued for delivery unless the
				  policy form or certificate form can be expected, as estimated for the entire
				  period for which rates are computed to provide coverage, to return to
				  policyholders and certificate holders in the form of aggregate benefits (not
				  including anticipated refunds or credits) provided under the policy form or
				  certificate form:
(A) At least seventy-five
				  percent (75%) of the aggregate amount of premiums earned in the case of group
				  policies, or
(B) At least
				  sixty-five percent (65%) of the aggregate amount of premiums earned in the case
				  of individual policies.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-132 - Filing and approval of policies and certificates and premium rates

Current through Vol. 41, No. 20, July 1, 2024
(a)
Policy forms and certificates
				  filing and approval requirements.
An issuer shall not deliver or issue
				  for delivery a policy or certificate to a resident of this state unless the
				  policy form or certificate form has been filed with and approved by the
				  Commissioner in accordance with filing requirements and procedures prescribed
				  by the Commissioner.
(b)
Removal of Prescription Drug benefit.
An issuer shall file any
				  rider or amendments to policy and certificate forms to delete outpatient
				  prescription drug benefits as required by the Medicare Prescription Drug,
				  improvement, and Modernization Act of 2003 only with the commissioner in the
				  state in which the policy or certificate was issued.
(c)
Premium rates and rating schedule
				  filing and approval requirements.
An issuer shall not use or change
				  premium rates for a Medicare supplement policy or certificate unless the rates,
				  rating schedule and supporting documentation have been filed with and approved
				  by the Commissioner in accordance with the filing requirements and procedures
				  prescribed by the Commissioner.
(d)
Additional policy or certificate forms.
(1) Except as provided in paragraph (2) of
				  this subsection, an issuer shall not file for approval more than one form of a
				  policy or certificate of each type for each standard Medicare supplement
				  benefit plan.
(2) An issuer may
				  offer, with the approval of the Commissioner, up to four (4) additional policy
				  forms or certificate forms of the same type for the same standard Medicare
				  supplement benefit plan, one for each of the following cases:
(A) The inclusion of new or innovative
				  benefits;
(B) The addition of
				  either direct response or agent marketing methods;
(C) The addition of either guaranteed issue
				  or underwritten coverage;
(D) The
				  offering of coverage to individuals eligible for Medicare by reason of
				  disability.
(3) For the
				  purposes of this section, a "type" means an individual policy, a group policy,
				  an individual Medicare Select policy, or a group Medicare Select
				  policy.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-133 - Permitted compensation arrangements

Current through Vol. 41, No.
				  20, July 1, 2024
(a) An
				  issuer or other entity may provide commission or other compensation to an agent
				  or other representative for the sale of a Medicare supplement policy or
				  certificate only if the first year commission or other first year compensation
				  is no more than two hundred percent (200%) of the commission or other
				  compensation paid for selling or servicing the policy or certificate in the
				  second year or period.
(b) The
				  commission or other compensation provided in subsequent (renewal) years must be
				  the same as that provided in the second year or period and must be provided for
				  no fewer than five (5) renewal years.
(c) No issuer or other entity shall provide
				  compensation to its agents or other producers and no agent or producer shall
				  receive compensation greater than the renewal compensation payable by the
				  replacing issuer on renewal policies or certificates if an existing policy or
				  certificate is replaced.
(d) For
				  purposes of this section, "compensation" includes pecuniary or non-pecuniary
				  remuneration of any kind relating to the sale or renewal of the policy or
				  certificate including but not limited to bonuses, gifts, prizes, awards and
				  finders fees.
Added at 9 Ok Reg
					 2499, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-136 - Filing requirements for advertising

Current through Vol. 41,
				  No. 20, July 1, 2024
An issuer shall provide a copy of any Medicare supplement
					 advertisement intended for use in this state whether through written, radio or
					 television medium to the Commissioner of Insurance of this state for review or
					 approval by the Commissioner to the extent it may be required under state
					 law.
Added at 9 Ok Reg
					 2499, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-137 - Standards for marketing

Current through Vol. 41, No. 20, July 1,
				  2024
(a) An issuer,
				  directly or through its producers, shall:
(1)
				  Establish marketing procedures to assure that any comparison of policies by its
				  agents or other producers will be fair and accurate.
(2) Establish marketing procedures to assure
				  excessive insurance is not sold or issued.
(3) Display prominently by type, stamp or
				  other appropriate means, on the first page of the policy the following:
"Notice to buyer: This policy may not cover all of your medical
				  expenses."
(4) Inquire and
				  otherwise make every reasonable effort to identify whether a prospective
				  applicant or enrollee for Medicare supplement insurance already has accident
				  and health insurance and the types and amounts of any such insurance.
(5) Establish auditable procedures for
				  verifying compliance with (a) of this section.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-138 - Appropriateness of recommended purchase and excessive insurance

Current through Vol. 41, No. 20, July 1, 2024
(a) In recommending the purchase or
				  replacement of any Medicare supplement policy or certificate an agent shall
				  make reasonable efforts to determine the appropriateness of a recommended
				  purchase or replacement.
(b) Any
				  sale of Medicare supplement coverage that will provide an individual more than
				  one Medicare supplement policy or certificate is prohibited.
(c) An issuer shall not issue a Medicare
				  supplement policy or certificate to an individual enrolled in Medicare Part C
				  unless the effective date of the coverage is after the termination of the
				  individual's Part C coverage.
Added at 9 Ok Reg
					 2499, eff 6-26-92; Amended at 22 Ok Reg 1954, eff
					 7-14-05
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-139 - Reporting of multiple policies

Current through Vol. 41, No. 20,
				  July 1, 2024
(a) On or
				  before March 1 of each year, an issuer shall report the following information
				  for every individual resident of this State for which the issuer has in force
				  more than one Medicare supplement policy or certificate:
(1) Policy and certificate number,
				  and
(2) Date of issuance.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-140 - Prohibition against preexisting conditions, waiting periods, elimination periods and probationary periods in replacement policies or certificates

Current through Vol. 41, No. 20, July 1, 2024
(a) If a Medicare supplement policy or
				  certificate replaces another Medicare supplement policy or certificate, the
				  replacing issuer shall waive any time periods applicable to preexisting
				  conditions, waiting periods, elimination periods and probationary periods in
				  the new Medicare supplement policy or certificate to the extent such time was
				  spent under the original policy.
(b) If a Medicare supplement policy or
				  certificate replaces another Medicare supplement policy or certificate which
				  has been in effect for at least six (6) months, the replacing policy shall not
				  provide any time period applicable to preexisting conditions, waiting periods,
				  elimination periods and probationary periods.
Added at 9 Ok Reg
					 2499, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-141 - Separability

Current through Vol. 41, No. 20, July 1, 2024
If any provision of this Part or the application thereof to
					 any person or circumstance is for any reason held to be invalid, the remainder
					 of the Part and the application of such provision to other persons or
					 circumstances shall not be affected thereby.
Added at 9 Ok Reg
					 2499, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-142 - Effective date

Current through Vol. 41, No. 20, July 1,
				  2024
Medicare Supplement policy forms that were approved prior
					 to the adoption of this Part, shall not be used for issuance of new policies
					 and/or certificates on or after July 1,1992.
Added at 9 Ok Reg
					 2499, eff 6-26-92
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-143 - Prohibition against use of genetic information and requests for genetic testing

Current through Vol. 41, No. 20, July 1,
				  2024
(a) This Section
				  applies to all policies with policy years beginning on or after May 21,
				  2009.
(b) An issuer of a Medicare
				  supplement policy or certificate:
(1) Shall
				  not deny or condition the issuance or effectiveness of the policy or
				  certificate (including the imposition of any exclusion of benefits under the
				  policy based on a pre-existing condition) on the basis of the genetic
				  information with respect to such individual; and
(2) Shall not discriminate in the pricing of
				  the policy or certificate (including the adjustment of premium rates) of an
				  individual on the basis of the genetic information with respect to such
				  individual.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-150 - Statement of purpose

Current through Vol. 41, No. 20, July 1,
				  2024
(a) This Part is
				  intended to implement the provisions of the Small Employer Health Insurance
				  Reform Act. The general purposes of the Act and this Part are to provide for
				  the availability of health insurance coverage to small employers, regardless of
				  their health status or claims experience; to regulate insurer rating practices
				  and establish limits on differences in rates between health benefit plans; to
				  ensure renewability of coverage; to establish limitations on underwriting
				  practices, eligibility requirements and the use of preexisting condition
				  exclusions; to provide for development of "basic" and "standard" health
				  insurance plans to be offered to all small employers; to direct the basis of
				  market competition away from risk selection and toward the efficient management
				  of health care; and to improve the overall fairness and efficiency of the small
				  group health insurance market.
(b)
				  The Act and this Part are intended to promote broader spreading of risk in the
				  small employer marketplace. The Act and Part are intended to regulate all
				  health benefit plans sold to small employers, whether sold directly or through
				  associations or other groupings of small employers. Carriers that provide
				  health benefit plans to small employers are intended to be subject to all of
				  the provisions of the Act and this Part.
Added at 12 Ok Reg
					 3137, eff 7-31-95; Amended at 29 Ok Reg 1254, eff
					 7-14-12
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-151 - 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:
"Act"
means the Small Employer Health
					 Insurance Reform Act, 36 O.S.Supp.1994, §6511 et seq.
"Associate member of an employee organization"
means any individual who participates in an employee benefit plan [as defined
					 in 29 U.S.C.
					 §1002(1) ] that is a
					 multi-employer plan [as defined in
					 29
					 U.S.C. §1002(37A) ],
					 other than the following:
(A) An individual or the beneficiary of such individual who
					 is employed by a participating employer within a bargaining unit covered by at
					 least one of the collective bargaining agreements under or pursuant to which
					 the employee benefit plan is established or maintained; or
(B) An individual who is a present or former employee (or a
					 beneficiary of such employee) of the sponsoring employee organization, of an
					 employer who is or was a party to at least one of the collective bargaining
					 agreements under or pursuant to which the employee benefit plan is established
					 or maintained, or of the employee benefit plan (or of a related plan).
"New entrant"
means an eligible employee, or
					 the dependent of an eligible employee, who becomes part of an employer group
					 after the initial period for enrollment in a health benefit plan.
"Risk characteristic"
means the health status,
					 claims experience, duration of coverage, or any similar characteristic related
					 to the health status or experience of a small employer group or of any member
					 of a small employer group.
"Risk load"
means the percentage above the
					 applicable base premium rate that is charged by a small employer carrier to a
					 small employer to reflect the risk characteristics of the small employer
					 group.
Added at 12 Ok Reg
					 3137, eff 7-31-95
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-152 - Applicability and scope

Current through Vol. 41, No. 20, July 1,
				  2024
(a)
Exceptions.
(1) Except as
				  provided in
				  365:10-5-163(A)(2),
				  this Part shall apply to any health benefit plan, whether provided on a group
				  or individual basis, which:
(A) Meets one or
				  more of the conditions set forth in 36 O.S.Supp.1994, §6513(A),
(B)(1) and (B)(2), of the Act;
(B) Provides coverage to employees of a small
				  employer located in this state as set forth in 36 O.S.Supp.1994, §6513(A),
				  without regard to whether the policy or certificate was issued in this state;
				  and
(C) Is in effect on or after
				  the effective date of the Act.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-153 - Establishment of classes of business

Current through Vol. 41, No.
				  20, July 1, 2024
(a) A
				  small employer carrier that establishes more than one class of business
				  pursuant to the provisions of 36 O.S.Supp.1994, §6514, shall maintain on
				  file for inspection by the Commissioner the following information with respect
				  to each class of business so established:
(1)
				  A description of each criterion employed by the carrier (or any of its agents)
				  for determining membership in the class of business;
(2) A statement describing the justification
				  for establishing the class as a separate class of business and documentation
				  that the establishment of the class of business is intended to reflect
				  substantial differences in expected claims experience or administrative costs
				  related to the reasons set forth in 36 O.S.Supp.1994, §6514; and
(3) A statement disclosing which, if any,
				  health benefit plans are currently available for purchase in the class and any
				  significant limitations related to the purchase of such plans.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-154 - Transaction for assumptions of business from another carrier

Current through Vol. 41, No. 20, July 1, 2024
(a)
Requirements for transfer or
				  assumption of business.
(1) A small
				  employer carrier shall not transfer or assume the entire insurance obligation
				  and/or risk of a health benefit plan covering a small employer in this state
				  unless:
(A) The transaction has been approved
				  by the Commissioner of the state of domicile of the assuming carrier;
(B) The transaction has been approved by the
				  Commissioner of the state of domicile of the ceding carrier; and
(C) The transaction otherwise meets the
				  requirements of 365:10-5-154.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-156 - Requirement to insure entire groups

Current through Vol. 41, No.
				  20, July 1, 2024
(a)
Offer and option requirements.
(1) A small employer carrier that offers
				  coverage to a small employer shall offer to provide coverage to each eligible
				  employee and to each dependent of an eligible employee. Except as provided in
				  Paragraph (2), the small employer carrier shall provide the same health benefit
				  plan to each such employee and dependent.
(2) A small employer carrier may offer the
				  employees of a small employer the option of choosing among one or more health
				  benefit plans, provided that each employee may choose any of the offered plans.
				  Except as provided in 36 O.S.Supp.1994, §6519(C) (exclusions for
				  preexisting conditions), the choice among benefit plans may not be limited,
				  restricted or conditioned based upon the risk characteristics of the employees
				  or their dependents.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-157 - Consideration of industry

Current through Vol. 41, No. 20, July 1,
				  2024
(a) Except as
				  provided in Subsections (b) and (c), a small employer carrier may not consider
				  the trade or occupation of the employees of a small employer or the industry or
				  type of business in which the small employer is engaged in determining whether
				  to issue or continue to provide coverage to the small employer.
(b) A small employer carrier may use industry
				  as a case characteristic in establishing premium rates, subject to 36
				  O.S.Supp.1994, §6515(A)(6).
(c) A small employer carrier may consider
				  trade, occupation or industry as part of the eligibility criteria for a class
				  of business, subject to 36 O.S.Supp.1994, §6519(A)(2)(b).
Added at 12 Ok Reg
					 3137, eff 7-31-95
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-158 - Application to reenter state

Current through Vol. 41, No. 20, July
				  1, 2024
(a) A carrier
				  that has been prohibited from writing coverage for small employers in this
				  state for five (5) years pursuant to 36 O.S.Supp.1994, §6516(B), may not
				  resume offering health benefit plans to small employers in this state until the
				  carrier has made a petition to the Commissioner to be reinstated as a small
				  employer carrier and the petition has been approved by the Commissioner. In
				  reviewing a petition, the Commissioner may ask for such information and
				  assurances as the Commissioner finds reasonable and appropriate.
(b) In the case of a small employer carrier
				  doing business in only one established geographical service area of the state,
				  if the small employer carrier elects to nonrenew a health benefit plan under 36
				  O.S.Supp.1994, §6516(A)(6), the small employer carrier shall be prohibited
				  from offering health benefit plans to small employers in any part of the
				  service area for a period of five (5) years. In addition, the small employer
				  carrier shall not offer health benefit plans to small employers in any other
				  geographic area of the state without the prior approval of the Commissioner. In
				  considering whether to grant approval, the Commissioner may ask for such
				  information and assurances as the Commissioner finds reasonable and
				  appropriate.
Added at 12 Ok Reg
					 3137, eff 7-31-95
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-159 - Qualifying previous and qualifying existing coverage

Current
				  through Vol. 41, No. 20, July 1, 2024
(a) In determining whether a health benefit
				  plan or other health benefit arrangement (public or private) shall be
				  considered qualifying previous coverage or qualifying existing coverage for the
				  purposes of 36 O.S.Supp.1994, §6512(23) and 36 O.S.Supp.1994,
				  §6519(C)(3)(c), a small employer carrier shall interpret the Act no less
				  favorably to an insured individual than the following:
(1) A health benefit plan, policy,
				  certificate or other health benefit arrangement shall be considered
				  employer-based if an employer sponsors the plan or arrangement or makes a
				  contribution to the plan or arrangement.
(2)
Similar or exceeding
				  determination.
(A) A health benefit
				  plan, policy, certificate or other benefit arrangement shall be considered to
				  provide benefits similar to or exceeding the benefits provided under the basic
				  health benefit plan if the policy, certificate or other benefit arrangement
				  provides benefits that:
(i) Have an actuarial
				  value (as considered for a normal distribution of groups) that is not
				  substantially less than the actuarial value of the basic health benefit plan;
				  or
(ii) Provides coverage for
				  hospitalization and physician services that is substantially similar to or
				  exceeds the coverage for such services in the basic health benefit
				  plan.
(B) In making a
				  determination under 365:10-5-159(a), a small employer carrier shall evaluate
				  the previous or existing policy, certificate or other benefit arrangement taken
				  as a whole and shall not base its decision solely on the fact that one portion
				  of the previous or existing policy, certificate or benefit arrangement provides
				  less coverage than the comparable portion of the basic health benefit
				  plan.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-160 - Restrictive riders

Current through Vol. 41, No. 20, July 1,
				  2024
A restrictive rider, endorsement or other provision that
					 would violate the provisions of 36 O.S.Supp.1994, §6519(C)(4)(b), and that
					 was in force on the effective date of this Part may not remain in force beyond
					 the first anniversary date of the health benefit plan subject to the
					 restrictive provision that follows the effective date of this Part. A small
					 employer carrier shall provide written notice to those small employers whose
					 coverage will be changed pursuant to 365:10-5-160(a) at least thirty (30) days
					 prior to the required change to the health benefit plan.
Added at 12 Ok Reg
					 3137, eff 7-31-95
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 15 - SMALL EMPLOYER HEALTH INSURANCE REFORM REGULATION › Section 365:10-5-161 - Rules related to fair marketing

Current through Vol. 41, No.
				  20, July 1, 2024
(a)
Marketing requirements.
(1) A
				  small employer carrier shall actively market each of its health benefit plans
				  to small employers in this state. A small employer carrier may not suspend the
				  marketing or issuance of the basic and standard health benefit plans unless the
				  carrier has good cause and has received the prior approval of the
				  Commissioner.
(2) In marketing the
				  basic and standard health benefit plans to small employers, a small employer
				  carrier shall use at least the same sources and methods of distribution that it
				  uses tomarket other health benefit plans to small employers. Any producer
				  authorized by a small employer carrier to market health benefit plans to small
				  employers in the state shall also be authorized to market the basic and
				  standard health benefit plans.