Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 11 - Coordination of Benefit Guidelines › Section 365:10-11-2 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms, when used in this subchapter,
				  shall have the following meaning, unless the context clearly indicates
				  otherwise:
"Allowable expense"
means 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; or
(J) Disability income protection coverage.
"This plan"
means that portion of the policy
				  which provides the benefits that are subject to this
				  subchapter.