SECTION 365:10-5-152. Applicability and scope

(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.

(2)   The provisions of the Act and this Part shall not apply to an individual health benefit plan delivered or issued for delivery prior to the effective date of the Act.

(b)   Applicability to carriers that provide individual health benefit plans.

(1)   A carrier that provides individual health benefit plans to three (3) or more of the employees of a small employer shall be considered a small employer carrier and shall be subject to the provisions of the Act and this Part with respect to such policies if the small employer contributes directly or indirectly to the premiums for the policies and the carrier is aware or should have been aware of such contribution.

(2)   In the case of a carrier that provides individual health benefit plans to three (3) or more employees of a small employer, the small employer shall be considered to be an eligible small employer as defined in 36 O.S.Supp.1994, §6512(28), and the small employer carrier shall be subject to 36 O.S.Supp.1994, §6519(A)(1) (relating to guaranteed issue of coverage), if:

(A)   The small employer has at least three (3) employees;

(B)   The small employer contributes directly or indirectly to the premiums charged by the carrier; and

(C)   The carrier is aware or should have been aware of the contribution by the employer.

(c)   The provisions of the Act and this Part shall apply to a health benefit plan provided to a small employer or to the employees of a small employer pursuant to 36 O.S.Supp.1994, §6513(A), without regard to whether the health benefit plan is offered under or provided through a group policy or trust arrangement for any eligible employer with two (2) to fifty (50) employees sponsored by an association or discretionary group regardless of the size of the association or discretionary group.

(d)   An individual health benefit plan shall not be subject to the provisions of the Act and this Part solely because the policyholder elects a deduction under Section 162(1) of the Internal Revenue Code.

(e)   Continuation of coverage and notification requirement.

(1)   If a small employer is issued a health benefit plan under the terms of the Act, the provisions of the Act and this Part shall continue to apply to the health benefit plan in the case that the small employer subsequently employs more than fifty (50) eligible employees. A carrier providing coverage to such an employer shall, within sixty (60) days of becoming aware that the employer has more than fifty (50) eligible employees but no later than the anniversary date of the employer's health benefit plan, notify the employer that the protections provided under the Act and this Part shall cease to apply to the employer if such employer fails to renew its current health benefit plan or elects to enroll in a different health benefit plan.

(2)   Plans issued to a non-small employer that subsequently becomes a small employer and requirements.

(A)   If a health benefit plan is issued to an employer that is not a small employer as defined in the Act, but subsequently the employer becomes a small employer due to the loss or change of work status of one or more employees, the terms of the Act shall not apply to the health benefit plan. The carrier providing a health benefit plan to such an employer shall not become a small employer carrier under the terms of the Act solely because the carrier continues to provide coverage under the health benefit plan to the employer.

(B)   A carrier providing coverage to an employer described in 365:10-5-152(e)(2)(A) shall, within sixty (60) days of becoming aware that the employer has fifty (50) or fewer eligible employees, notify the employer of the options and protections available to the employer under the Act, including the employer's option to purchase a small employer health benefit plan from any small employer carrier.

(f)   Employers with employees in more than one state.

(1)   Application.

(A)   If a small employer has employees in more than one state, the provisions of the Act and this Part shall apply to a health benefit plan issued to the small employer if:

(i)   The majority of eligible employees of such small employer are employed in this state; or

(ii)   If no state contains a majority of the eligible employees of the small employer, the primary business location of the small employer is in this state.

(B)   In determining whether the laws of this state or another state apply to a health benefit plan issued to a small employer described in 365:10-5-152(f)(1)(A), the provisions of the paragraph shall be applied as of the date the health benefit plan was issued to the small employer for the period that the health benefit plan remains in effect.

(2)   If a health benefit plan is subject to the Act and this Part, the provisions of the Act and this Part shall apply to all individuals covered under the health benefit plan, whether they reside in this state or in another state.

(g)   A carrier that is not operating as a small employer carrier in this state shall not become subject to the provisions of the Act and this Part solely because a small employer that was issued a health benefit plan in another state by that carrier moves to this state.

[Source: Added at 12 Ok Reg 3137, eff 7-31-95]