§ 36-7201. Definitions.

As used in this act:

1.  “Access payments” means an amount paid to the Insurance Commissioner based upon a percentage of claims paid by a health carrier to be used to fund the state’s Medicaid program and make full use of any federal matching funds available to the state;

2.  “Claims paid” means all payments made by a health carrier for health and medical services for residents of this state.  “Claims paid” shall not include:

a.claims-related expenses and general administrative expenses,

b.payments made to qualifying providers under a “pay-for-performance” or other incentive compensation arrangement if the payments are not reflected in the processing of claims submitted for services rendered to specific covered individuals,

c.claims paid by health carriers with respect to accidental injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care, Medicare supplement or other limited benefit health insurance, except claims paid for dental services covered under a medical policy,

d.claims paid for services rendered to nonresidents of this state,

e.claims paid under retiree health benefit plans that are separate from and not included within benefit plans for existing employees,

f.claims paid by an employee benefit excess insurance carrier that have been counted by a third-party administrator for determining an access payment,

g.claims paid for services rendered to a person covered under a benefit plan for federal employees,

h.claims paid for services rendered outside of this state to a person who is a resident of this state, and

i.claims paid pursuant to Medicare or Medicaid;

3.  “Claims-related expenses” means:

a.payments for utilization review, care management, disease management, risk assessment and similar administrative services intended to reduce the claims paid for health and medical services rendered to cover individuals for the purposes of attempting to ensure that needed services are delivered in an efficacious manner or by helping to maintain or improve the health of a covered individual, and

b.payments made to or by organized groups of providers of health and medical services in accordance with managed care risk arrangements or network access agreements that are unrelated to the provision of services to specific covered individuals;

4.  “Health and medical services” means, but is not limited to:

a.any services included in the furnishing of medical care,

b.dental care to the extent covered under a medical insurance policy,

c.pharmaceutical benefits or hospitalization, including, but not limited to, services provided in a hospital or other medical facility,

d.ancillary services, including, but not limited to, ambulatory services,

e.physician and other practitioner services, including, but not limited to, services provided by an assistant to a physician, nurse practitioner or midwife, and

f.behavioral health services, including, but not limited to, mental health and substance abuse services;

5.  “Health carrier” means any entity or insurer authorized to provide health insurance or health benefits pursuant to the laws of this state and any entity or person engaged in the business of making contracts of accident or health insurance.  “Health carrier” includes, but is not limited to:

a.third-party administrators as provided for in Sections 1441 through 1452 of Title 36 of the Oklahoma Statutes,

b.health maintenance organizations as provided for in Sections 6901 through 6936 of Title 36 of the Oklahoma Statutes,

c.self-insured employer welfare arrangements,

d.excess carriers,

e.stop loss carriers,

f.multiple employer welfare arrangements (MEWA) as provided for in Sections 633 through 650 of Title 36 of the Oklahoma Statutes,

g.professional employer organizations (PEO), and

h.the Oklahoma State and Education Employees Group Insurance Board (OSEEGIB); and

6.  “Insurance Commissioner” or “Commissioner” means the Oklahoma Insurance Commissioner.

Added by Laws 2010, c. 300, § 1.

Note

NOTE:  Editorially renumbered from § 7101 of this title to avoid duplication in numbering.