{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6512","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6512","heading":"Definitions","body":"As used in the Small Employer Health Insurance Reform Act:\n\n1. \"Actuarial certification\" means a written statement by a\n\nmember of the American Academy of Actuaries or other individual\n\nacceptable to the Insurance Commissioner that a small employer\n\ncarrier is in compliance with the provisions of Section 6515 of this\n\ntitle, based upon the examination of the person, including a review\n\nof the appropriate records and of the actuarial assumptions and\n\nmethods used by the small employer carrier in establishing premium\n\nrates for applicable health benefit plans;\n\n2. \"Affiliate\" or \"affiliated\" means any entity or person who\n\ndirectly or indirectly through one or more intermediaries, controls\n\nor is controlled by, or is under common control with, a specified\n\nentity or person;\n\n3. \"Base premium rate\" means, for each class of business as to\n\na rating period, the lowest premium rate charged or which could have\n\nbeen charged under a rating system for that class of business, by\n\nthe small employer carrier to small employers with similar case\n\ncharacteristics for health benefit plans with the same or similar\n\ncoverage;\n\n4. \"Basic health benefit plan\" means a lower cost health\n\nbenefit plan adopted by the state for small employer groups;\n\n5. \"Board\" means the board of directors of the program\n\nestablished pursuant to Section 6522 of this title;\n\n6. \"Carrier\" means any entity which provides health insurance\n\nin this state. For the purposes of the Small Employer Health\n\nInsurance Reform Act, carrier includes a licensed insurance company,\n\nnot-for-profit hospital service or medical indemnity corporation, a\n\nfraternal benefit society, a health maintenance organization, a\n\nmultiple employer welfare arrangement or any other entity providing\n\na plan of health insurance or health benefits subject to state\n\ninsurance regulation;\n\n7. \"Case characteristics\" means demographic or other objective\n\ncharacteristics of a small employer that are considered by the small\n\nemployer carrier in the determination of premium rates for the small\n\nemployer, provided that claim experience, health status and duration\n\nof coverage shall not be case characteristics for the purposes of\n\nthe Small Employer Health Insurance Reform Act. A small employer\n\ncarrier shall not use case characteristics, other than age, gender,\n\nindustry, geographic area and family composition, without prior\n\napproval of the Insurance Commissioner. Group size shall not be\n\nused as a case characteristic;\n\n8. \"Class of business\" means all or a separate grouping of\n\nsmall employers established pursuant to Section 6514 of this title.\n\nGroup size shall not be used as a class of business;\n\n9. \"Commissioner\" means the Insurance Commissioner;\n\n10. \"Control\", \"controlling\", \"controlled by\" or \"under common\n\ncontrol with\" means the possession, direct or indirect, of the power\n\nto direct or cause the direction of the management and policies of a\n\nperson, whether through the ownership of voting securities, by\n\ncontract or otherwise, unless the power is the result of an official\n\nposition with or corporate office held by the person. Control shall\n\nbe presumed to exist if any person, directly or indirectly, owns,\n\ncontrols, holds with the power to vote, or holds proxies\n\nrepresenting ten percent (10%) or more of the voting securities of\n\nany other person. This presumption may be rebutted by a showing\n\nthat control does not exist in fact in the manner provided in\n\nSection 1654 of this title. The Commissioner may determine, after\n\nfurnishing all persons in interest notice and opportunity to be\n\nheard and making specific findings of fact to support the\n\ndetermination, that control exists in fact, notwithstanding the\n\nabsence of a presumption to that effect;\n\n11. \"Department\" means the Insurance Department;\n\n12. \"Dependent\" means a spouse, an unmarried child under the\n\nage of eighteen (18), an unmarried child who is a full-time student\nall persons in interest notice and opportunity to be\n\nheard and making specific findings of fact to support the\n\ndetermination, that control exists in fact, notwithstanding the\n\nabsence of a presumption to that effect;\n\n11. \"Department\" means the Insurance Department;\n\n12. \"Dependent\" means a spouse, an unmarried child under the\n\nage of eighteen (18), an unmarried child who is a full-time student\n\nunder the age of twenty-three (23) and who is financially dependent\n\nupon the parent, and an unmarried child of any age who is medically\n\ncertified as disabled and dependent upon the parent;\n\n13. \"Eligible employee\" means an employee who works on a full-\n\ntime basis or, at the option of the employer, an employee who works\n\non a part-time basis with a normal work week of twenty-four (24) or\n\nmore hours. The term includes a sole proprietor, a partner of a\n\npartnership, and associates of a limited liability company, if the\n\nsole proprietor, partner or associate is included as an employee\n\nunder a health benefit plan of a small employer, but does not\n\ninclude an employee who works on a temporary or substitute basis;\n\n14. \"Established geographic service area\" means a geographic\n\narea, as approved by the Commissioner and based on the certificate\n\nof authority of the carrier to transact insurance in this state,\n\nwithin which the carrier is authorized to provide coverage;\n\n15. a. \"Health benefit plan\" means any hospital or medical\n\npolicy or certificate; contract of insurance provided\n\nby a not-for-profit hospital service or medical\n\nindemnity plan; or prepaid health plan or health\n\nmaintenance organization subscriber contract.\n\nb. Health benefit plan does not include accident-only,\n\ncredit, dental, vision, Medicare supplement, long-term\n\ncare, or disability income insurance, coverage issued\n\nas a supplement to liability insurance, workers'\n\ncompensation or similar insurance, or automobile\n\nmedical payment insurance.\n\nc. \"Health benefit plan\" shall not include policies or\n\ncertificates of specified disease, hospital\n\nconfinement indemnity or limited benefit health\n\ninsurance, provided that the carrier offering those\n\npolicies or certificates complies with the following:\n\n(1) the carrier files on or before March 1 of each\n\nyear a certification with the Commissioner that\n\ncontains the statement and information described\n\nin division (2) of this subparagraph,\n\n(2) the certification required in division (1) of\n\nthis subparagraph shall contain the following:\n\n(a) a statement from the carrier certifying that\n\npolicies or certificates described in this\n\nsubparagraph are being offered and marketed\n\nas supplemental health insurance and not as\n\na substitute for hospital or medical expense\n\ninsurance or major medical expense\n\ninsurance, and\nthis subparagraph,\n\n(2) the certification required in division (1) of\n\nthis subparagraph shall contain the following:\n\n(a) a statement from the carrier certifying that\n\npolicies or certificates described in this\n\nsubparagraph are being offered and marketed\n\nas supplemental health insurance and not as\n\na substitute for hospital or medical expense\n\ninsurance or major medical expense\n\ninsurance, and\n\n(b) a summary description of each policy or\n\ncertificate described in this subparagraph,\n\nincluding the average annual premium rates\n\nor range of premium rates in cases where\n\npremiums vary by age, gender or other\n\nfactors charged for such policies and\n\ncertificates in this state, and\n\n(3) in the case of a policy or certificate that is\n\ndescribed in this subparagraph and that is\n\noffered for the first time in this state on or\n\nafter May 20, 1994, the carrier files with the\n\nCommissioner the information and statement\n\nrequired in division (2) of this subparagraph at\n\nleast thirty (30) days prior to the date a policy\n\nor certificate is issued or delivered in this\n\nstate;\n\n16. \"Index rate\" means, for each class of business as to a\n\nrating period for small employers with similar case characteristics,\n\nthe arithmetic average of the applicable base premium rate and the\n\ncorresponding highest premium rate;\n\n17. \"Late enrollee\" means an eligible employee or dependent who\n\nrequests enrollment in a health benefit plan of a small employer\n\nfollowing the initial enrollment period during which the individual\n\nis entitled to enroll under the terms of the health benefit plan,\n\nprovided that the initial enrollment period is a period of at least\n\nthirty-one (31) days. However, an eligible employee or dependent\n\nshall not be considered a late enrollee if:\n\na. the individual meets each of the following:\n\n(1) the individual was covered under qualifying\n\nprevious coverage at the time of the initial\n\nenrollment,\n\n(2) the individual lost coverage under qualifying\n\nprevious coverage as a result of termination of\n\nemployment or eligibility, the involuntary\n\ntermination of the qualifying previous coverage,\n\ndeath of a spouse or divorce, and\n\n(3) the individual requests enrollment within thirty\n\n(30) days after termination of the qualifying\n\nprevious coverage,\n\nb. the individual is employed by an employer which offers\n\nmultiple health benefit plans and the individual\n\nelects a different plan during an open enrollment\n\nperiod, or\n\nc. a court has ordered coverage be provided for a spouse\n\nor minor or dependent child under a health benefit\n\nplan of a covered employee and request for enrollment\n\nis made within thirty (30) days after issuance of the\n\ncourt order;\n\n18. \"New business premium rate\" means, for each class of\n\nbusiness as to a rating period, the lowest premium rate charged or\n\noffered, or which could have been charged or offered, by the small\n\nemployer carrier to small employers with similar case\n\ncharacteristics for newly issued health benefit plans with the same\n\nor similar coverage;\n\n19. \"Premium\" means all monies paid by a small employer and\n\neligible employees as a condition of receiving coverage from a small\n\nemployer carrier, including any fees or other contributions\n\nassociated with the health benefit plan;\n\n20. \"Program\" means the Oklahoma Small Employer Health\n\nReinsurance Program created pursuant to Section 6522 of this title;\n\n21. \"Qualifying previous coverage\" and \"qualifying existing\n\ncoverage\" mean benefits or coverage provided under:\n\na. Medicare or Medicaid,\n\nb. an employer-based health insurance or health benefit\n\narrangement that provides benefits similar to or\n\nexceeding benefits provided under the basic health\n\nbenefit plan, or\n\nc. an individual health insurance policy, including\n\ncoverage issued by a health maintenance organization,\n\nfraternal benefit society and those entities set forth\n\nin Sections 6901 through 6936 of this title, that\nedicaid,\n\nb. an employer-based health insurance or health benefit\n\narrangement that provides benefits similar to or\n\nexceeding benefits provided under the basic health\n\nbenefit plan, or\n\nc. an individual health insurance policy, including\n\ncoverage issued by a health maintenance organization,\n\nfraternal benefit society and those entities set forth\n\nin Sections 6901 through 6936 of this title, that\n\nprovides benefits similar to or exceeding the benefits\n\nprovided under the basic health benefit plan, provided\n\nthat the policy has been in effect for a period of at\n\nleast one (1) year;\n\n22. \"Rating period\" means the calendar period for which premium\n\nrates established by a small employer carrier are assumed to be in\n\neffect;\n\n23. \"Reinsuring carrier\" means a small employer carrier\n\nparticipating in the reinsurance program pursuant to Section 6522 of\n\nthis title;\n\n24. \"Restricted network provision\" means any provision of a\n\nhealth benefit plan that conditions the payment of benefits, in\n\nwhole or in part, on the use of health care providers that have\n\nentered into a contractual arrangement with the carrier pursuant to\n\nSections 6901 through 6963 of this title to provide health care\n\nservices to covered individuals;\n\n25. \"Small employer\" means any person, firm, corporation,\n\npartnership, limited liability company or association that is\n\nactively engaged in business that, on at least fifty percent (50%)\n\nof its working days during the preceding calendar quarter, employed\n\nno more than fifty (50) eligible employees, the majority of whom\n\nwere employed within this state. In determining the number of\n\neligible employees, companies that are affiliated companies, or that\n\nare eligible to file a combined tax return for purposes of state\n\nincome taxation, shall be considered one employer; and\n\n26. \"Small employer carrier\" means a carrier that offers health\n\nbenefit plans covering eligible employees of one or more small\n\nemployers in this state.","path":["OK Code","Title 36"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"b5b76316e31e5e06b06d4ce6a90674013a8c9d2732a0e54adca7fc62dd26eb5d","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6511","next":"us-ok/okla.-stat.-tit.-36-36-6513"},"notice":"GroundRules: Original legal text. Not legal advice."}