SECTION 365:40-5-1. Definitions

  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.

[Source: Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04]