Oklahoma § 36-6972 - Definitions

§ 36-6972. Definitions

As used in this act:

1. “Contractual discount” means a reduction from a provider’s

usual and customary rate for covered services and materials required

under a prepaid vision plan agreement with a provider;

2. “Covered materials” means materials for which reimbursement

from the insurer, vision plan, or vision care discount plan is

provided to a vision care provider by an enrollee’s plan contract,

or for which a reimbursement would be available but for the

application of the enrollee’s contractual limitations of

deductibles, copayments, or coinsurance;

3. “Covered services” means services eligible for reimbursement

from the insurer or vision plan to a provider, or services that

would be eligible for reimbursement but for the application of the

enrollee’s contractual plan limitations of deductibles, copayments,

or coinsurance, regardless of how the benefits are listed in the

explanation of benefits provided in the vision plan of the enrollee;

4. “Enrollee” means any individual enrolled in a health care

plan, vision plan, or vision care discount plan provided by a group,

employer, or other entity that purchases or supplies coverage for a

vision plan;

Oklahoma Statutes - Title 36. Insurance

5. “Extrapolation” means a mathematical process or technique

used by a vision plan in the process of auditing a vision care

provider to estimate audit results for a larger batch of group

claims not reviewed in the audit by the plan;

6. “Health benefit plan” means a health benefit plan as defined

pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes;

7. “Materials” means ophthalmic devices including but not

limited to lenses, devices containing lenses, artificial intraocular

lenses, ophthalmic frames and other lens mounting apparatus, prisms,

lens treatments and coatings, contact lenses, and prosthetic devices

to correct, relieve, or treat defects or abnormal conditions of the

human eye or its adnexa, or any material allowed to be utilized by

the Board of Examiners in Optometry and optometry’s scope of

practice as provided by law;

8. “Net equity” means the excess of total assets over total

liabilities, excluding liabilities which have been subordinated in a

manner acceptable to the Insurance Commissioner;

9. “Prepaid vision plan” means any contractual agreement

whereby any prepaid vision plan organization undertakes to provide

full payment or a discount of vision services directly, to arrange

for prepaid vision services, or to pay or make reimbursement for any

vision service not provided for by other insurance;

10. “Prepaid vision plan organization” means any person who, or

organization or entity that, undertakes to conduct one or more

prepaid vision plans providing only vision services;

11. “Services” means the professional work performed by a

vision care provider;

12. “Subcontractor” means any company, group, or third-party

entity including agents, servants, partially or wholly owned

subsidiaries, and controlled organizations contracted by the

insurer, vision plan, or vision care discount plan to supply

services or materials for a vision care provider or enrollee to

fulfill the benefit plan of an insurer, vision plan, or vision care

discount plan;

13. “Tangible net equity” means net equity reduced by the value

assigned to intangible assets including, but not limited to,

goodwill, going concern value, organizational expenses, start-up

costs, long-term prepayments of deferred charges, nonreturnable

deposits, and obligations of officers, directors, owners, or

affiliates, except short-term obligations of affiliates for goods or

services arising in the normal course of business that are payable

on the same term as equivalent transactions with nonaffiliates and

that are not past due;

14. “Uncovered expense” means the cost of health care services

that are the obligation of a prepaid vision plan organization for

which:

Oklahoma Statutes - Title 36. Insurance

a.

an enrollee may be liable in the event of the

insolvency of the organization, and

b.

alternative arrangements acceptable to the

Commissioner have not been made to cover the costs;

and

15. “Vision care provider” or “provider” means a licensed

doctor of optometry or a licensed medical or osteopathic doctor

practicing under the authority of the applicable provisions of Title

59 of the Oklahoma Statutes.

Added by Laws 2024, c. 360, § 1, emerg. eff. May 30, 2024.