Oklahoma § 36-6512 - Definitions

§ 36-6512. Definitions

As used in the Small Employer Health Insurance Reform Act:

1. "Actuarial certification" means a written statement by a

member of the American Academy of Actuaries or other individual

acceptable to the Insurance Commissioner that a small employer

carrier is in compliance with the provisions of Section 6515 of this

title, based upon the examination of the person, including a review

of the appropriate records and of the actuarial assumptions and

methods used by the small employer carrier in establishing premium

rates for applicable health benefit plans;

2. "Affiliate" or "affiliated" means any entity or person who

directly or indirectly through one or more intermediaries, controls

or is controlled by, or is under common control with, a specified

entity or person;

3. "Base premium rate" means, for each class of business as to

a rating period, the lowest premium rate charged or which could have

been charged under a rating system for that class of business, by

the small employer carrier to small employers with similar case

characteristics for health benefit plans with the same or similar

coverage;

4. "Basic health benefit plan" means a lower cost health

benefit plan adopted by the state for small employer groups;

5. "Board" means the board of directors of the program

established pursuant to Section 6522 of this title;

6. "Carrier" means any entity which provides health insurance

in this state. For the purposes of the Small Employer Health

Insurance Reform Act, carrier includes a licensed insurance company,

not-for-profit hospital service or medical indemnity corporation, a

fraternal benefit society, a health maintenance organization, a

multiple employer welfare arrangement or any other entity providing

a plan of health insurance or health benefits subject to state

insurance regulation;

7. "Case characteristics" means demographic or other objective

characteristics of a small employer that are considered by the small

employer carrier in the determination of premium rates for the small

employer, provided that claim experience, health status and duration

of coverage shall not be case characteristics for the purposes of

the Small Employer Health Insurance Reform Act. A small employer

carrier shall not use case characteristics, other than age, gender,

industry, geographic area and family composition, without prior

approval of the Insurance Commissioner. Group size shall not be

used as a case characteristic;

Oklahoma Statutes - Title 36. Insurance

8. "Class of business" means all or a separate grouping of

small employers established pursuant to Section 6514 of this title.

Group size shall not be used as a class of business;

9. "Commissioner" means the Insurance Commissioner;

10. "Control", "controlling", "controlled by" or "under common

control with" means the possession, direct or indirect, of the power

to direct or cause the direction of the management and policies of a

person, whether through the ownership of voting securities, by

contract or otherwise, unless the power is the result of an official

position with or corporate office held by the person. Control shall

be presumed to exist if any person, directly or indirectly, owns,

controls, holds with the power to vote, or holds proxies

representing ten percent (10%) or more of the voting securities of

any other person. This presumption may be rebutted by a showing

that control does not exist in fact in the manner provided in

Section 1654 of this title. The Commissioner may determine, after

furnishing all persons in interest notice and opportunity to be

heard and making specific findings of fact to support the

determination, that control exists in fact, notwithstanding the

absence of a presumption to that effect;

11. "Department" means the Insurance Department;

12. "Dependent" means a spouse, an unmarried child under the

age of eighteen (18), an unmarried child who is a full-time student

under the age of twenty-three (23) and who is financially dependent

upon the parent, and an unmarried child of any age who is medically

certified as disabled and dependent upon the parent;

13. "Eligible employee" means an employee who works on a fulltime basis or, at the option of the employer, an employee who works

on a part-time basis with a normal work week of twenty-four (24) or

more hours. The term includes a sole proprietor, a partner of a

partnership, and associates of a limited liability company, if the

sole proprietor, partner or associate is included as an employee

under a health benefit plan of a small employer, but does not

include an employee who works on a temporary or substitute basis;

14. "Established geographic service area" means a geographic

area, as approved by the Commissioner and based on the certificate

of authority of the carrier to transact insurance in this state,

within which the carrier is authorized to provide coverage;

15. a.

"Health benefit plan" means any hospital or medical

policy or certificate; contract of insurance provided

by a not-for-profit hospital service or medical

indemnity plan; or prepaid health plan or health

maintenance organization subscriber contract.

b.

Health benefit plan does not include accident-only,

credit, dental, vision, Medicare supplement, long-term

care, or disability income insurance, coverage issued

as a supplement to liability insurance, workers'

Oklahoma Statutes - Title 36. Insurance

compensation or similar insurance, or automobile

medical payment insurance.

c.

"Health benefit plan" shall not include policies or

certificates of specified disease, hospital

confinement indemnity or limited benefit health

insurance, provided that the carrier offering those

policies or certificates complies with the following:

(1) the carrier files on or before March 1 of each

year a certification with the Commissioner that

contains the statement and information described

in division (2) of this subparagraph,

(2) the certification required in division (1) of

this subparagraph shall contain the following:

(a) a statement from the carrier certifying that

policies or certificates described in this

subparagraph are being offered and marketed

as supplemental health insurance and not as

a substitute for hospital or medical expense

insurance or major medical expense

insurance, and

(b) a summary description of each policy or

certificate described in this subparagraph,

including the average annual premium rates

or range of premium rates in cases where

premiums vary by age, gender or other

factors charged for such policies and

certificates in this state, and

(3) in the case of a policy or certificate that is

described in this subparagraph and that is

offered for the first time in this state on or

after May 20, 1994, the carrier files with the

Commissioner the information and statement

required in division (2) of this subparagraph at

least thirty (30) days prior to the date a policy

or certificate is issued or delivered in this

state;

16. "Index rate" means, for each class of business as to a

rating period for small employers with similar case characteristics,

the arithmetic average of the applicable base premium rate and the

corresponding highest premium rate;

17. "Late enrollee" means an eligible employee or dependent who

requests enrollment in a health benefit plan of a small employer

following the initial enrollment period during which the individual

is entitled to enroll under the terms of the health benefit plan,

provided that the initial enrollment period is a period of at least

thirty-one (31) days. However, an eligible employee or dependent

shall not be considered a late enrollee if:

Oklahoma Statutes - Title 36. Insurance

a.

the individual meets each of the following:

(1) the individual was covered under qualifying

previous coverage at the time of the initial

enrollment,

(2) the individual lost coverage under qualifying

previous coverage as a result of termination of

employment or eligibility, the involuntary

termination of the qualifying previous coverage,

death of a spouse or divorce, and

(3) the individual requests enrollment within thirty

(30) days after termination of the qualifying

previous coverage,

b.

the individual is employed by an employer which offers

multiple health benefit plans and the individual

elects a different plan during an open enrollment

period, or

c.

a court has ordered coverage be provided for a spouse

or minor or dependent child under a health benefit

plan of a covered employee and request for enrollment

is made within thirty (30) days after issuance of the

court order;

18. "New business premium rate" means, for each class of

business as to a rating period, the lowest premium rate charged or

offered, or which could have been charged or offered, by the small

employer carrier to small employers with similar case

characteristics for newly issued health benefit plans with the same

or similar coverage;

19. "Premium" means all monies paid by a small employer and

eligible employees as a condition of receiving coverage from a small

employer carrier, including any fees or other contributions

associated with the health benefit plan;

20. "Program" means the Oklahoma Small Employer Health

Reinsurance Program created pursuant to Section 6522 of this title;

21. "Qualifying previous coverage" and "qualifying existing

coverage" mean benefits or coverage provided under:

a.

Medicare or Medicaid,

b.

an employer-based health insurance or health benefit

arrangement that provides benefits similar to or

exceeding benefits provided under the basic health

benefit plan, or

c.

an individual health insurance policy, including

coverage issued by a health maintenance organization,

fraternal benefit society and those entities set forth

in Sections 6901 through 6936 of this title, that

provides benefits similar to or exceeding the benefits

provided under the basic health benefit plan, provided

Oklahoma Statutes - Title 36. Insurance

that the policy has been in effect for a period of at

least one (1) year;

22. "Rating period" means the calendar period for which premium

rates established by a small employer carrier are assumed to be in

effect;

23. "Reinsuring carrier" means a small employer carrier

participating in the reinsurance program pursuant to Section 6522 of

this title;

24. "Restricted network provision" means any provision of a

health benefit plan that conditions the payment of benefits, in

whole or in part, on the use of health care providers that have

entered into a contractual arrangement with the carrier pursuant to

Sections 6901 through 6963 of this title to provide health care

services to covered individuals;

25. "Small employer" means any person, firm, corporation,

partnership, limited liability company or association that is

actively engaged in business that, on at least fifty percent (50%)

of its working days during the preceding calendar quarter, employed

no more than fifty (50) eligible employees, the majority of whom

were employed within this state. In determining the number of

eligible employees, companies that are affiliated companies, or that

are eligible to file a combined tax return for purposes of state

income taxation, shall be considered one employer; and

26. "Small employer carrier" means a carrier that offers health

benefit plans covering eligible employees of one or more small

employers in this state.

Added by Laws 1992, c. 329, § 2, eff. Sept. 1, 1992. Amended by

Laws 1994, c. 211, § 2, eff. July 1, 1994; Laws 1998, c. 304, § 2,

eff. July 1, 1998; Laws 2000, c. 353, § 47, eff. Nov. 1, 2000; Laws

2001, c. 363, § 25, eff. July 1, 2001; Laws 2009, c. 176, § 50, eff.

Nov. 1, 2009; Laws 2010, c. 222, § 43, eff. Nov. 1, 2010; Laws 2012,

c. 151, § 1, eff. Nov. 1, 2012; Laws 2019, c. 265, § 1, eff. Nov. 1,

2019.