§36-7201. Definitions.
629 words·~3 min read·
/ok/title-36-insurance/36-7201·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
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: Editorially renumbered from § 7101 of this title to avoid duplication in numbering.