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 1 - GENERAL PROVISIONS › Section 365:40-5-1 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
When used in this Subchapter, the following words or terms
					 shall have the following meaning unless the context of the sentence requires
					 another meaning:
"Affiliation period"
means a period that must
					 expire before the coverage becomes effective.
"Bona fide association"
means an association
					 which:
(A) Has been actively in existence for at least 5
					 years;
(B) Has been formed and maintained in good faith for
					 purposes other than obtaining insurance;
(C) Does not condition membership in the association on any
					 health-status-related factor that relates to an individual, including an
					 employee of an employer or a dependent of an employee;
(D) Makes health coverage offered through the association
					 available to all members regardless of any health-status related factor that
					 relates to such members or individuals eligible for coverage through a member;
					 and
(E) Does not make health coverage offered through the
					 association available other than in connection with a member of the
					 association.
"Child"
means natural children, stepchildren,
					 adopted children, children placed for adoption, and children under legal
					 guardianship.
"Claim reimbursement"
means repayment from an
					 HMO to a subscriber for services rendered by a noncontracting provider, or
					 direct payment from an HMO to a noncontracting provider.
"Eligible Dependent"
means a spouse, an
					 unmarried child under the age of eighteen (18) years, an unmarried child under
					 the age of twenty-three (23) who is a full-time student and who is financially
					 dependent upon the subscriber, and an unmarried child of any age who is
					 medically certified as disabled and dependent upon the subscriber.
"Grievance"
has the same meaning as in 36 O.S.
					 §
										6902 of
					 the HMO Act.
"Group"
means an employee group or another
					 aggregation of individuals who wish to purchase or who have purchased HMO
					 membership. The group shall be composed of at least two (2) individuals, and
					 shall not be established on the basis of race. Unless specifically exempted in
					 this Chapter, any provision addressed to groups shall apply to small and large
					 groups.
"Health professionals"
means professionals,
					 including physicians, engaged in the delivery of health services who are
					 licensed, certified, or practice under other authority consistent with State
					 law.
"Inquiry"
means an oral or written statement
					 to the Department from a member or other resident of this state expressing
					 misunderstanding, dissatisfaction or disagreement with an activity of an HMO,
					 or reporting a possible violation of this Chapter or the laws of this state by
					 an HMO. Anonymous statements shall be considered as inquiries.
"Large group"
means a group of at least 51
					 employees.
"Late enrollee"
means, with respect to
					 coverage under a group contract, a subscriber or dependent who enrolls under
					 the contract other than during the first effective date in which the subscriber
					 or dependent is eligible to enroll under the contract, or a special enrollment
					 period.
"Non-basic health care services"
means health
					 care services other than basic health care services.
"Noncontracting provider"
means a health
					 service provider not having an HMO contract that includes financial hold
					 harmless language as described in 36 O.S. §
										6913.
"Out-of-area services"
means the health care
					 services that an HMO covers when its enrollees are outside of the service
					 area.
"Physician"
means any person holding a valid
					 license to practice medicine and surgery, osteopathy, chiropractic, podiatry,
					 optometry, or dentistry, pursuant to the state licensing provisions of Title 59
					 of the Oklahoma Statutes.
"Primary care physician"
means a physician who
					 supervises, coordinates, and provides initial and basic care to enrollees, and
					 who initiates their referral for specialist care and maintains continuity of
					 patient care.
"Replacement coverage"
has the same meaning as
					 in 36 O.S. § 6902 of the HMO Act.
"Service area"
means the geographic area as
					 defined through zip codes, census tracts, or other geographic subdivisions,
					 found by the Department to be the area within which the HMO provides or
					 arranges for basic and supplemental health care services that are available and
					 accessible to its enrollees as required by the Act and this Chapter.
"Small group"
means a group composed of not
					 less than two and not more than 50 employees as defined in the Small Employers
					 Health Insurance Reform Act, 36 O.S. §
										6511, et
					 seq.
"Special Enrollment Period"
means a time when
					 a plan shall permit an employee who is eligible, but not enrolled, for coverage
					 under the terms of the plan (or a dependent of such an employee if the
					 dependent is eligible, but not enrolled, for coverage under such terms) to
					 enroll for coverage under the terms of the plan if each of the following
					 conditions is met:
(A) The employee or dependent was covered under a group
					 health plan or had health insurance coverage at the time coverage was
					 previously offered to the employee or dependent.
(B) The employee stated in writing at such time that
					 coverage under a group health plan or health insurance coverage was the reason
					 for declining enrollment, but only if the plan sponsor or issuer required such
					 a statement as such time and provided the employee with notice of such
					 requirement and the consequences of such requirement at such time.
(C) The employee's or dependent's coverage described in
					 subparagraph 1
(i) was under a COBRA continuation provision and the
					 coverage under such provision was exhausted; or
(ii) was not under such a provision and either the coverage
					 was terminated as a result of loss of eligibility for the coverage (including
					 as a result of legal separation, divorce, death, termination of employment, or
					 reduction in the number of hours of employment or employer contributions toward
					 such coverage were terminated.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04