Oklahoma § 36-6915 - Insolvency - Replacement coverage - Reduction or

§ 36-6915. Insolvency - Replacement coverage - Reduction or

exclusion of benefits.

A. 1. In the event of an insolvency of a commercial health

maintenance organization, upon order of the Insurance Commissioner,

all other carriers that participated in the enrollment process with

the insolvent health maintenance organization at a group’s last

regular enrollment period shall offer the group’s enrollees of the

insolvent health maintenance organization a thirty-day enrollment

period commencing upon the date of insolvency. Each carrier shall

offer the enrollees of the insolvent health maintenance organization

the same coverages and rates offered to the enrollees of the group

at its last regular enrollment period.

2. If no other carrier had been offered to some groups enrolled

in the insolvent health maintenance organization, or if the

Insurance Commissioner determines that the other health benefit

plans lack sufficient health care delivery resources to ensure that

health care services will be available and accessible to all of the

group enrollees of the insolvent health maintenance organization,

the Insurance Commissioner shall equitably allocate the insolvent

health maintenance organization’s group contracts for these groups

among all health maintenance organizations that operate within a

portion of the insolvent health maintenance organization’s service

area, taking into consideration the health care delivery resources

of each health maintenance organization. Each health maintenance

organization to which a group or groups are so allocated shall offer

the group or groups the health maintenance organization’s existing

coverage that is most similar to each group’s coverage with the

insolvent health maintenance organization, at rates determined in

accordance with the successor health maintenance organization’s

existing rating methodology.

B. 1. “Discontinuance” means the termination of the contract

between the group contract holder and a health maintenance

organization due to the insolvency of the health maintenance

organization, and does not refer to the termination of any agreement

Oklahoma Statutes - Title 36. Insurance

between any individual enrollee and the health maintenance

organization.

2. Any carrier providing replacement coverage with respect to

group hospital, medical or surgical expense or service benefits

within a period of sixty-three (63) days from the date of

discontinuance of a prior health maintenance organization contract

or policy providing hospital, medical or surgical expense or service

benefits shall, as of the effective date of the replacement

coverage, cover all enrollees who were validly covered under the

previous health maintenance organization contract or policy at the

date of discontinuance and who would otherwise be eligible for

coverage under the succeeding carrier’s contract, regardless of any

provisions of the contract relating to active employment, hospital

confinement or pregnancy.

3. Except to the extent benefits for the condition would have

been reduced or excluded under the prior carrier’s contract or

policy, no provision in a succeeding carrier’s contract of

replacement coverage that would operate to reduce or exclude

benefits on the basis that the condition giving rise to benefits

preexisted the effective date of the succeeding carrier’s contract

shall be applied with respect to those enrollees validly covered

under the prior carrier’s contract or policy on the date of

discontinuance.

4.

a.

Upon being declared insolvent, a health maintenance

organization shall provide to the Insurance

Commissioner:

(1) the names of all known enrollees who were validly

enrolled under the insolvent HMO’s contract, or

(2) policy information on validly enrolled enrollees

who are hospitalized or whose health conditions

require continuity of care.

b.

The insolvent HMO shall continue to provide such

information to the Insurance Commissioner throughout

the period of time required to provide replacement

coverage to the validly covered enrollees of the

insolvent HMO.

Added by Laws 2003, c. 197, § 15, eff. Nov. 1, 2003.