§ 36-6902. Definitions.

As used in the Health Maintenance Organization Act of 2003:

1.  “Basic health care services” means the following medically necessary services:

a.              preventive care,

b.              emergency care,

c.              inpatient and outpatient hospital and physician care,

d.              diagnostic laboratory and diagnostic and therapeutic radiological services,

e.              allopathic, osteopathic, chiropractic, podiatric, optometric, psychological, outpatient diagnostic treatment,

f.              short-term rehabilitation and physical therapy,

g.              emergency, short-term outpatient mental health, substance abuse diagnostic and medical treatment,

h.              home health, and

i.              preventive health services;

provided, however, such term does not include dental services or long-term rehabilitation treatment;

2.  “Capitated basis” means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided.  For purposes of this definition, “capitated basis” includes the cost associated with operating staff model facilities;

3.  “Carrier” means a health maintenance organization, an insurer, a nonprofit hospital and medical service corporation, or other entity responsible for the payment of benefits or provision of services under a group contract;

4.  “Copayment” means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid;

5.  “Deductible” means the amount an enrollee is responsible to pay out-of-pocket before a health maintenance organization begins to pay the costs associated with treatment;

6.  “Enrollee” means an individual who is covered by a health maintenance organization;

7.  “Evidence of coverage” means a statement of the essential features and services of the health maintenance organization coverage which is given to the subscriber by the health maintenance organization or by the group contract holder;

8.  “Extension of benefits” means the continuation of coverage under a particular benefit provided under a contract following termination for an enrollee who is totally disabled on the date of termination;

9.  “Grievance” means a written complaint, submitted in accordance with a health maintenance organization’s formal grievance procedure, by or on behalf of an enrollee regarding any aspect of the health maintenance organization relative to the enrollee;

10.  “Group contract” means a contract for health care services which by its terms limits eligibility to members of a specified group.  The group contract may include coverage for dependents;

11.  “Group contract holder” means the person to which a group contract has been issued;

12.  “Health maintenance organization” or “HMO” means a person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for copayments or deductibles for which the enrollee is responsible, or both;

13.  “Health maintenance organization producer” means a person who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for HMO membership, or who takes or transmits a membership fee or premium for such a policy or contract, other than for the person, or a person who advertises or otherwise holds himself or herself out to the public as a health maintenance organization producer;

14.  “Individual contract” means a contract for health care services issued to and covering an individual.  An individual contract may include the dependents of the subscriber;

15.  “Insolvent” or “insolvency” means a process by which an organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction;

16.  "Insurance Commissioner" means the Insurance Commissioner pursuant to the provisions of Title 36 of the Oklahoma Statutes;

17.  “Managed hospital payment basis” means agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of services;

18.  "NAIC" means the National Association of Insurance Commissioners;

19.  “Net worth” means the excess of total admitted assets over total liabilities, provided, total liabilities shall not include fully subordinated debt;

20.  “Participating provider” means a provider as defined in paragraph 22 of this section who, under an express or implied contract with the health maintenance organization, its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization;

21.  “Person” means a natural or artificial person including, but not limited to, individuals, partnerships, associations, trusts or corporations;

22.  “Provider” means a physician, hospital or other person licensed or otherwise authorized to furnish health care services;

23.  “Replacement coverage” means the benefits provided by a succeeding carrier;

24.  "State Commissioner of Health" means the State Commissioner of Health pursuant to the provisions of Section 1-106 of Title 63 of the Oklahoma Statutes;

25.  “Subscriber” means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued; and

26.  “Uncovered expenditures” means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organization’s insolvency and for which no alternative arrangements have been made that are acceptable to the Insurance Commissioner.

Added by Laws 2003, c. 197, § 2, eff. Nov. 1, 2003.