Okla. Stat. tit. 36, § 36-6902

As used in the Health Maintenance Organization Act of 2003:

1. “Basic health care services” means the following medically

necessary services:

a. preventive care,

b. emergency care,

c. inpatient and outpatient hospital and physician care,

d. diagnostic laboratory and diagnostic and therapeutic

radiological services,

e. allopathic, osteopathic, chiropractic, podiatric,

optometric, psychological, outpatient diagnostic

treatment,

f. short-term rehabilitation and physical therapy,

g. emergency, short-term outpatient mental health,

substance abuse diagnostic and medical treatment,

h. home health, and

i. preventive health services;

provided, however, such term does not include dental services or

long-term rehabilitation treatment;

2. “Capitated basis” means fixed per member per month payment

or percentage of premium payment wherein the provider assumes the

full risk for the cost of contracted services without regard to the

type, value or frequency of services provided. For purposes of this

definition, “capitated basis” includes the cost associated with

operating staff model facilities;

3. “Carrier” means a health maintenance organization, an

insurer, a nonprofit hospital and medical service corporation, or

other entity responsible for the payment of benefits or provision of

services under a group contract;

4. “Copayment” means an amount an enrollee must pay in order to

receive a specific service which is not fully prepaid;

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5. “Deductible” means the amount an enrollee is responsible to

pay out-of-pocket before a health maintenance organization begins to

pay the costs associated with treatment;

6. “Enrollee” means an individual who is covered by a health

maintenance organization;

7. “Evidence of coverage” means a statement of the essential

features and services of the health maintenance organization

coverage which is given to the subscriber by the health maintenance

organization or by the group contract holder;

8. “Extension of benefits” means the continuation of coverage

under a particular benefit provided under a contract following

termination for an enrollee who is totally disabled on the date of

termination;

9. “Grievance” means a written complaint, submitted in

accordance with a health maintenance organization’s formal grievance

procedure, by or on behalf of an enrollee regarding any aspect of

the health maintenance organization relative to the enrollee;

10. “Group contract” means a contract for health care services

which by its terms limits eligibility to members of a specified

group. The group contract may include coverage for dependents;

11. “Group contract holder” means the person to which a group

contract has been issued;

12. “Health maintenance organization” or “HMO” means a person

that undertakes to provide or arrange 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;

13. “Health maintenance organization producer” means a person

who solicits, negotiates, effects, procures, delivers, renews or

continues a policy or contract for HMO membership, or who takes or

transmits a membership fee or premium for such a policy or contract,

other than for the person, or a person who advertises or otherwise

holds himself or herself out to the public as a health maintenance

organization producer;

14. “Individual contract” means a contract for health care

services issued to and covering an individual. An individual

contract may include the dependents of the subscriber;

15. “Insolvent” or “insolvency” means a process by which an

organization has been declared insolvent and placed under an order

of liquidation by a court of competent jurisdiction;

16. "Insurance Commissioner" means the Insurance Commissioner

pursuant to the provisions of Title 36 of the Oklahoma Statutes;
ing an individual. An individual

contract may include the dependents of the subscriber;

15. “Insolvent” or “insolvency” means a process by which an

organization has been declared insolvent and placed under an order

of liquidation by a court of competent jurisdiction;

16. "Insurance Commissioner" means the Insurance Commissioner

pursuant to the provisions of Title 36 of the Oklahoma Statutes;

17. “Managed hospital payment basis” means agreements wherein

the financial risk is primarily related to the degree of utilization

rather than to the cost of services;

18. "NAIC" means the National Association of Insurance

Commissioners;

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19. “Net worth” means the excess of total admitted assets over

total liabilities, provided, total liabilities shall not include

fully subordinated debt;

20. “Participating provider” means a provider as defined in

paragraph 22 of this section who, under an express or implied

contract with the health maintenance organization, its contractor or

subcontractor, has agreed to provide health care services to

enrollees with an expectation of receiving payment, other than

copayment or deductible, directly or indirectly from the health

maintenance organization;

21. “Person” means a natural or artificial person including,

but not limited to, individuals, partnerships, associations, trusts

or corporations;

22. “Provider” means a physician, hospital or other person

licensed or otherwise authorized to furnish health care services;

23. “Replacement coverage” means the benefits provided by a

succeeding carrier;

24. "State Commissioner of Health" means the State Commissioner

of Health pursuant to the provisions of Section 1-106 of Title 63 of

the Oklahoma Statutes;

25. “Subscriber” means an individual whose employment or other

status, except family dependency, is the basis for eligibility for

enrollment in the health maintenance organization, or in the case of

an individual contract, the person in whose name the contract is

issued; and

26. “Uncovered expenditures” means the costs to the health

maintenance organization for health care services that are the

obligation of the health maintenance organization, for which an

enrollee may also be liable in the event of the health maintenance

organization’s insolvency and for which no alternative arrangements

have been made that are acceptable to the Insurance Commissioner.