Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 13 - Coordination of Health and Dental Benefits › Section 260:50-5-45 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this part, shall
				  have the following meaning, unless the context clearly indicates
				  otherwise:
"Allowable expense"
means any medically
				  necessary item of expense at least a portion of which is covered under at least
				  one of the plans covering the person for whom the claim is made except where a
				  statute requires a different definition. An expense or service, or a portion of
				  an expense or service that is not covered by EGID's medical and or dental plan
				  is not an allowable expense. The maximum liability under EGID's medical and or
				  dental plan as a secondary or subordinate payor is the member's actual
				  liability under any coordinating plan or EGID's standard benefit, whichever is
				  less. However, items of expense under coverage such as, but not limited to
				  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"
means the following:
(A) "Plan" means any plan providing benefits or services for
				  or by reason of medical or dental care or treatment, which benefits or services
				  are provided by:
(i) group, blanket or franchise insurance coverage,
(ii) service plan contracts, group practice, individual
				  practice and other prepayment coverage,
(iii) any coverage under labor-management trustee plans,
				  union welfare plans, employer organization plans, or employee benefit
				  organization plans, and
(iv) any coverage under governmental programs, and any
				  coverage required or provided by any statute.
(B) The term "Plan" shall be construed separately with
				  respect to each policy, contract, or other arrangement for benefits or services
				  and separately with respect to that portion of any such policy, contract, or
				  other arrangement which reserves the right to take the benefits or services of
				  other plans into consideration in determining its benefits and that portion
				  which does not.
(C) Individually underwritten and issued contracts which
				  provide a contractual right to renewal regardless of membership in or
				  connection with any particular organization or group shall not be considered
				  group-type contracts, irrespective of the mode or channel of premium payment
				  and regardless of any reduction in premium the covered person may receive by
				  virtue of such method of premium collection.
(D) The definition of a "Plan" within the coordination of
				  benefits provision of group contracts enumerates the types of coverage which
				  the insurer may consider in determining whether other insurance exists with
				  respect to a specific claim. Such definition:
(i) May not include individual or family policies, or
				  individual or family subscriber contracts, except as provided in (ii) of this
				  part and in (E) of this definition.
(ii) May include all group or group subscriber contracts as
				  well as such group-type contracts as are not available to the general public
				  and can be obtained and maintained only because of the covered person's
				  membership in or connection with a particular organization or group. Group-type
				  contracts answering this description may be included in the definition, at the
				  option of the insurer and its policyholder client, whether or not individual
				  policy forms are utilized and whether the group-type coverage is designated as
				  "franchise" or "blanket" or in some other fashion.
(E) The definition of "Plan" may include both group and
				  individual automobile "no fault" contracts but, as to the traditional
				  automobile "fault" contracts, only the medical benefits written on a group or
				  group-type basis may be included.
(F) Interpretation of the definition of a "Plan" may not
				  include group or group-type hospital indemnity benefits (written on a
				  non-expense incurred basis) of thirty dollars [$30] per day or less unless they
				  are characterized as reimbursement type benefits but are designed to administer
				  so as to give the insured the right to elect indemnity type benefits, in lieu
				  of such reimbursement type benefits at the time of the claim. In any event, the
				  amount of group and group-type hospital indemnity benefits which exceed thirty
				  dollars [$30] per day may be construed as being included under the definition
				  of "Plan".
(G) School accident type coverages, written on either an
				  individual, blanket, group or franchise basis should not be taken into
				  consideration in coordination of benefits. In this context, school accident
				  type coverages are defined to mean coverage covering grammar school, middle
				  school, and high school students for accidents only, including athletic
				  injuries, either on a twenty-four [24] hour basis or "to and from school" for
				  which the parent pays the entire premium.
(H) If "Medicare" or similar governmental benefits are
				  included in the definition of "Plan", such benefits may be taken into
				  consideration without expanding any of the definitions of this provision beyond
				  the hospital, medical, and surgical benefits which may be provided by the
				  governmental program.
(I) A plan may not coordinate or design benefits so that the
				  benefits payable are altered solely on the basis that:
(i) another plan exists; or
(ii) except with respect to Part B of Medicare, that the
				  claimant is or could have been covered under another plan; or
(iii) the claimant has elected an option under another plan
				  providing a lower level of benefits than another option for which the claimant
				  was eligible.
(J) With regard to plans offered by EGID an eligible person
				  shall not be insured as a primary insured and also as a dependent for any
				  benefit options except dependent life, nor can any dependent be covered
				  simultaneously by more than one primary insured. Double enrollment, whether it
				  occurs intentionally or by error, shall be deemed void from the inception, and
				  EGID reserves the right to decide which form of single enrollment coverage to
				  allow, whether primary or dependent. "
This Plan
"means that portion
				  of the benefits that are subject to this part.
Amended by
				  Oklahoma
				  Register, Volume 34, Issue 24, September 1, 2017, eff.
				  1/1/2018
Revoked by
				  Oklahoma
				  Register, Volume 36, Issue 24, September 3, 2019, eff.
				  1/20/2020