Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 1 - Purpose and Definitions › Section 260:50-1-2 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms as defined by EGID, when used
				  in this chapter, shall have the following meaning, unless the content clearly
				  indicates otherwise:
"Administrative error"
occurs when the coverage
				  elections the member makes are not the same as those entered into payroll for
				  deduction from the member's paycheck. This does not include untimely member
				  coverage elections or member misrepresentation. When such an administrative
				  error results in underpaid premiums, full payment to EGID shall be required
				  before coverage elected by the member can be made effective. If overpayment
				  occurs, EGID shall refund overpaid funds to the appropriate party.
"Administrator"
means the Administrator of the
				  Employees Group Insurance Division or a designee.
"Allowable fee"
means the maximum allowed amount
				  based on the HealthChoice Network Provider Contracts payable to a provider by
				  EGID and the member for covered services.
"Attorney representing EGID"
means any attorney
				  designated by the Administrator to appear on behalf of EGID.
"The Board"
means the seven [7] Oklahoma
				  Employees Insurance and Benefits Board members designated by statute [74 O.S.
				  §1303(1)].
"Business Associate"
shall have the meaning
				  given to "Business Associate" under the Health Insurance Portability and
				  Accountability Act of 1996, Privacy Rule, including, but not limited to,
				  45 CFR §
										160.103.
"Carrier"
means the State of Oklahoma.
"Comprehensive benefits"
means benefits which
				  reimburse the expense of facility room and board, other hospital services,
				  certain out-patient expenses, maternity benefits, surgical expense, including
				  obstetrical care, in-hospital medical care expense, diagnostic radiological and
				  laboratory benefits, providers' services provided by house and office calls,
				  treatments administered in providers' office, prescription drugs, psychiatric
				  services, Christian Science practitioners' services, Christian Science nurses'
				  services, optometric medical services for injury or illness of the eye, home
				  health care, home nursing service, hospice care and such other benefits as may
				  be determined by EGID. Such benefits shall be provided on a copayment or
				  coinsurance basis, the insured to pay a proportion of the cost of such
				  benefits, and may be subject to a deductible that applies to all or part of the
				  benefits as determined by EGID. [74 O.S. §1303 (14)]
"Cosmetic procedure"
means a procedure that
				  primarily serves to improve appearance.
"Current employee"
means an employee in the
				  service of a participating entity who receives compensation for services
				  actually rendered and is listed on the payrolls and personnel records of said
				  employer, as a current and present employee, including employees who are
				  otherwise eligible who are on approved leave without pay, not to exceed
				  twenty-four [24] months. A person elected by popular vote will be considered an
				  eligible employee during his tenure of office. Eligible employees are defined
				  by statute. [74 O.S. §1303 and §1315]
"Custodial care"
means treatment or services
				  regardless of who recommends them or where they are provided, that could be
				  given safely and reasonably by a person not medically skilled. These services
				  are designed mainly to help the patient with daily living activities. These
				  activities include but are not limited to: personal care as in walking, getting
				  in and out of bed, bathing, eating by spoon, tube or gastrostomy, exercising,
				  dressing, using toilet, preparing meals or special diets, moving the patient,
				  acting as companion or sitter, and supervising medication which can usually be
				  self-administered.
"Dependent"
means the primary member's spouse
				  (if not legally separated by court order), including common-law. Dependents
				  also include a member's daughter, son, stepdaughter, stepson, eligible foster
				  child, adopted child, child for whom the member has been granted legal
				  guardianship or child legally placed with the primary member for adoption up to
				  the child's twenty-sixth [26th ] birthday. In
				  addition, other unmarried children up to age twenty-six [26] may be considered
				  dependents if the child lives with the member and the member is primarily
				  responsible for the child's support. A child that meets the definition of a
				  disabled dependent in this section and also all requirements in
				  260:50-3-18, may also be covered
				  regardless of age if the child is incapable of self-support because of mental
				  or physical incapacity that existed prior to reaching age twenty-six [26].
				  Coverage is not automatic and must be approved with a review of medical
				  information. A disabled dependent deemed disabled by Social Security does not
				  automatically mean that this disabled dependent will meet the Plan
				  requirements. [74 O.S. §1303(14)]. See additional eligibility criteria for
				  disabled dependents over the age of twenty-six [26] at
				  260:50-3-18. Participating
				  employer groups may have a more restrictive definition of Dependent.
"Durable medical equipment"
means medically
				  necessary equipment, prescribed by a provider, which serves a therapeutic
				  purpose in the treatment of an illness or an injury. Durable medical equipment
				  is for the exclusive use of the afflicted member and is designed for prolonged
				  use. Specific criteria and limitations apply.
"Eligible Provider"
means a practitioner who or
				  a facility that is recognized by EGID as eligible for reimbursement. EGID
				  reserves the right to determine provider eligibility for network and
				  non-Network reimbursement.
"Emergency"
means a medical condition
				  manifesting itself by acute symptoms of sufficient severity (including severe
				  pain) so that a prudent layperson, who possesses an average knowledge of health
				  and medicine, could reasonably expect the absence of immediate medical
				  attention to result in a condition described in clause (i), (ii), or (iii) of
				  section 1867(e)(1)(A) of the Social Security Act (42 U.S.C.
				  1395dd(e)(1)(A)) . (In that
				  provision of the Social Security Act, clause (i) refers to placing the health
				  of the individual (or, with respect to a pregnant woman, the health of the
				  woman or her unborn child) in serious jeopardy; clause (ii) refers to serious
				  impairment to bodily functions; and clause (iii) refers to serious dysfunction
				  of any bodily organ or part.)
"Enrollment period"
means the time period in
				  which an individual may make an election of coverage or changes to coverage in
				  effect.
"Excepted Benefits"
means the four categories of
				  benefits as established in section 2791 of the PHS Act, section 733 of ERISA
				  and section 9832 of the Internal Revenue Code, as summarized in IRS Bulletin
				  2015-14 and subsequent regulatory guidance. These Excepted Benefits include but
				  are not limited to vision coverage, dental coverage, long-term care insurance,
				  Medicare supplement coverage, automobile liability insurance, workers
				  compensation, accidental death and dismemberment insurance and specific disease
				  coverage (such as cancer).
"Facility"
means any organization as defined by
				  EGID which is duly licensed under the laws of the state of operation and meets
				  credentialing criteria established by EGID.
"Fee schedule"
means a listing of one or more
				  allowable fees.
"Former participating employees and dependents"
means eligible former employees who have elected benefits within thirty [30]
				  days of termination of service and includes those who have retired, or vested
				  through an eligible State of Oklahoma retirement system, or who have completed
				  the statutory required years of service, or who have other coverage rights
				  through Consolidated Omnibus Budget Reconciliation Act (COBRA) or the Oklahoma
				  Personnel Act. An eligible dependent is covered through the participating
				  former employee or the dependent is eligible as a survivor or has coverage
				  rights through COBRA.
"Health information"
means any information,
				  whether oral or recorded in any form or medium:
(1) that relates to the past, present or
				future physical or mental condition of a member; the provision of health care
				to a member; or the past, present or future payment for the provision of health
				care to a member; and
(2) that
				identifies the member or with respect to which there is a reasonable basis to
				believe the information can be used to identify the member.
"Home health care"
means a plan of continued
				  care of an insured person who is under the care of a provider who certifies
				  that without the Home health care, confinement in a hospital or skilled nursing
				  facility would be required. Specific criteria and limitations apply.
"Hospice care"
means a concept of supportive
				  care for terminally ill patients. Treatment focuses on the relief of pain and
				  suffering associated with a terminal illness. Specific criteria and limitations
				  apply.
"Inaccurate or erroneous information"
means
				  materially erroneous, false, inaccurate, or misleading information that was
				  intentionally submitted in order to obtain a specific coverage.
"Initial enrollment period"
means the first
				  thirty [30] days following the employee's entry-on-duty date. A group initial
				  enrollment period is defined as the thirty [30] days following the enrollment
				  date of the participating entity.
"Insurance Coordinator"
means Insurance/Benefits
				  Coordinator for Education, Local Government, and State Employees.
"Insured(s)"
means both the Primary insured and
				  covered Dependents.
"Maintenance care"
means there is no measurable
				  progress of goals achieved, no skilled care required, no measurable improvement
				  in daily function or self-care, or no change in basic treatment or
				  outcome.
"Medically necessary"
means services or supplies
				  which are provided for the diagnosis and treatment of the medical and/or mental
				  health/substance abuse condition and complies with criteria adopted by EGID.
				  Direct care and treatment are within standards of good medical practice within
				  the community, and are appropriate and necessary for the symptoms, diagnosis or
				  treatment of the condition. The services or supplies must be the most
				  appropriate supply or level of service, which can safely be provided. For
				  hospital stays, this means that inpatient acute care is necessary due to the
				  intensity of services the member is receiving or the severity of the member's
				  condition, and that safe and adequate care cannot be received as an outpatient
				  or in a less intensified medical setting. The services or supplies cannot be
				  primarily for the convenience of the member, caregiver, or provider. The fact
				  that services or supplies are medically necessary does not, in itself, assure
				  that the services or supplies are covered by the Plan.
"Members"
means all persons covered by one or
				  more of the group insurance plans offered by EGID including eligible current
				  and qualified former employees of participating entities and their eligible
				  covered dependents.
"Mental health and substance abuse"
means
				  conditions including a mental or emotional disorder of any kind, organic or
				  inorganic, and/or alcoholism and drug dependency.
"Network provider"
means a practitioner who or
				  facility that is duly licensed or operates under the laws of the state,
				  satisfies credentialing criteria as established by EGID, and has entered into a
				  contract with EGID to accept scheduled reimbursement for covered health care
				  services and supplies provided to members.
"Non-Network out-of-pocket"
means the member's
				  expenses include the total of the member's deductibles and co-insurance costs
				  plus all amounts that continue to be charged by the non-Network provider after
				  the HealthChoice allowable fees have been paid.
"OEIBB"
means Oklahoma Employees Insurance and
				  Benefits Board.
"Open enrollment period"
means a limited period
				  of time as approved by either EGID or the Legislature in which a specified
				  group of individuals are permitted to enroll.
"Option period"
means the time set aside at
				  least annually by EGID in which enrolled plan members may make changes to their
				  enrollments. Eligible but not enrolled employees may also make application for
				  enrollment during this time. Enrollment is subject to approval by EGID.
"Orthodontic limitation"
means an individual who
				  enrolls in the Dental Plan will not be eligible for any orthodontic benefits
				  for services occurring within the first twelve [12] months after the effective
				  date of coverage. Continuing orthodontic services for newly hired employees who
				  had previous group dental coverage will be paid by prorating or according to
				  plan benefits.
"Other hospital services and supplies"
means
				  services and supplies rendered by the hospital that are required for treatment,
				  but not including room and board nor the professional services of any provider,
				  nor any private duty, special or intensive nursing services, by whatever name
				  called, regardless of whatever such services are rendered under the direction
				  of the hospital or otherwise.
"Participating entity"
means any employer or
				  organization whose employees or members are eligible to be participants in any
				  plan authorized by or through the Oklahoma Employees Insurance and Benefits'
				  Act.
"The Plan or Plans"
means the self-insured Plans
				  by the State of Oklahoma for the purpose of providing health benefits to
				  eligible members and may include such other benefits as may be determined by
				  EGID. Such benefits shall be provided on a coinsurance basis and the insured
				  pays a proportion of the cost of such benefits.
"Primary insured"
means the member who first
				  became eligible for the insurance coverage creating eligibility rights for
				  dependents.
"Prosthetic appliance"
means an artificial
				  appliance that replaces body parts that may be missing or defective as a result
				  of surgical intervention, trauma, disease, or developmental anomaly. Said
				  appliance must be medically necessary.
"Provider"
means a practitioner who or facility
				  that is duly licensed or operates under the laws of the state in which the
				  Provider practices and is recognized by this Plan, to render health and dental
				  care services and/or supplies.
"Qualifying Event"
means an event that changes a
				  member's family or health insurance situation and qualifies the member and/or
				  dependent for a special enrollment period. The most common qualifying life
				  events are the loss of health care coverage, a change in household (such as
				  marriage or birth of a child), or a change of residence or other federally
				  required mandates. A complete summary of qualifying events are set out in Title
				  26, Treasury Regulations, Section
				  125.
"Schedule of benefits"
means the EGID plan
				  description of one or more covered services.
"Skilled care"
means treatment or services
				  provided by licensed medical personnel as prescribed by a provider. Treatment
				  or services that could not be given safely or reasonably by a person who is not
				  medically skilled and would need continuous supervision of the effectiveness of
				  the treatment and progress of the condition. Specific criteria and limitations
				  are applied.