Oklahoma § 36-7201 - Definitions

§ 36-7201. Definitions

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 “payfor-performance” or other incentive compensation

arrangement if the payments are not reflected in the

Oklahoma Statutes - Title 36. Insurance

3.

4.

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, longterm 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;

“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;

“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,

Oklahoma Statutes - Title 36. Insurance

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.