OHCA Policies and Rules
317:45-1-3 Definitions
[Revised 09-12-22]
The following words or terms, when used in this Chapter, will have the following meanings unless the context clearly indicates otherwise:
"Carrier" means:
(A) An insurance company, insurance service, insurance organization, or group health service, which is licensed to engage in the business of insurance in the State of Oklahoma and is subject to State law which regulates insurance, or Health Maintenance Organization (HMO) which provides or arranges 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 and is subject to State law which regulates Health Maintenance Organizations (HMOs);
(B) A Multiple Employer Welfare Arrangement (MEWA) licensed by the Oklahoma Insurance Department;
(C) A domestic MEWA exempt from licensing pursuant to Title 36 of the Oklahoma Statutes (O.S.) 634(B) that otherwise meets or exceeds all the licensing and financial requirements of MEWAs as set out in Title 36 O.S.; or
(D) Any entity organized pursuant to the Interlocal Cooperation Act, 74 O.S. 1001 et seq. as authorized by 36 O.S. 607.1 and which is eligible to qualify for and hold a certificate of authority to transact insurance in this State and annually submits on or before March 1st a financial statement to the Oklahoma Insurance Department in a form acceptable to the Insurance Commissioner covering the period ending December 31st of the immediately preceding fiscal year.
"Child care center" means a facility licensed by the Oklahoma Department of Human Services (DHS) which provides care and supervision of children and meets all the requirements in OAC 340:110-3-275 through 340:110-3-311.
"College student" means an Oklahoma resident between the age of nineteen (19) through twenty-two (22) that is a full-time student at an Oklahoma accredited university or college.
"Dependent" means the spouse of the approved applicant and/or child under nineteen (19) years of age or his or her child nineteen (19) years through twenty-two (22) years of age who is attending an Oklahoma qualified institution of higher education and relying upon the insured employee or member for financial support.
"Eligibility period" means the period of eligibility extending from an approval date to an end date.
"Employee" means a person who works for an employer in exchange for earned income. This includes the owners of a business.
"Employer" means the business entity that pays earned income to employees.
"Employer Sponsored Insurance (ESI)" means the program that provides premium assistance to qualified businesses for approved applicants.
"Explanation of Benefit (EOB)" means a statement issued by a carrier that indicates services rendered and financial responsibilities for the carrier and Insure Oklahoma member.
"Full-time employer" means the employer who employs an employee per Federal and State regulations, to perform work in exchange for wages or salary.
"Full-time employment" means a normal work week per Federal and State regulations.
"In-network" means providers or health care facilities that are part of a benefit plan's network of providers with which it has negotiated a discount, and services provided by a physician or other health care provider with a contractual agreement with the insurance company paid at the highest benefit level.
"Insure Oklahoma (IO)" means a benefit plan purchasing strategy in which the State uses public funds to pay for a portion of the costs of benefit plan coverage for eligible populations.
"Member" means an individual enrolled in the Insure Oklahoma ESI program.
"Modified Adjusted Gross Income (MAGI)" means the financial eligibility determination methodology established by the Patient Protection and Affordable Care Act (PPACA) in 2009.
"OAC" means the Oklahoma Administrative Code.
"OESC" means the Oklahoma Employment Security Commission.
"OHCA" means the Oklahoma Health Care Authority.
"OKDHS" means the Oklahoma Department of Human Services which is also referenced in rules as Department of Human Services (DHS) and Office of Human Services (OHS).
"Premium" means a monthly payment to a carrier for benefit plan coverage.
"Primary care provider (PCP)" means a provider under contract with the OHCA to provide primary care services, including all medically necessary referrals.
"Professional employer organization (PEO)" means any person engaged in the business of providing professional employer services shall be subject to registration under the Oklahoma Professional Employer Organization Recognition and Registration Act as provided in 40 O.S. ' 600.1 et. seq.
"Qualified benefit plan (QBP)" means a benefit plan that has been approved by the OHCA for participation in the Insure Oklahoma program.
"Qualifying event" means the occurrence of an event that permits individuals to join a group benefit plan outside of the "open enrollment period" and/or that allows individuals to modify the coverage they have had in effect. Qualifying events are defined by the employer's benefit plan and meet federal requirements under Public Law 104-191 (HIPAA), and 42 U.S.C. 300bb-3.
"State" means the State of Oklahoma, acting by and through the OHCA.
Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.
