{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6902","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6902","heading":"Definitions","body":"As used in the Health Maintenance Organization Act of 2003:\n\n1. “Basic health care services” means the following medically\n\nnecessary services:\n\na. preventive care,\n\nb. emergency care,\n\nc. inpatient and outpatient hospital and physician care,\n\nd. diagnostic laboratory and diagnostic and therapeutic\n\nradiological services,\n\ne. allopathic, osteopathic, chiropractic, podiatric,\n\noptometric, psychological, outpatient diagnostic\n\ntreatment,\n\nf. short-term rehabilitation and physical therapy,\n\ng. emergency, short-term outpatient mental health,\n\nsubstance abuse diagnostic and medical treatment,\n\nh. home health, and\n\ni. preventive health services;\n\nprovided, however, such term does not include dental services or\n\nlong-term rehabilitation treatment;\n\n2. “Capitated basis” means fixed per member per month payment\n\nor percentage of premium payment wherein the provider assumes the\n\nfull risk for the cost of contracted services without regard to the\n\ntype, value or frequency of services provided. For purposes of this\n\ndefinition, “capitated basis” includes the cost associated with\n\noperating staff model facilities;\n\n3. “Carrier” means a health maintenance organization, an\n\ninsurer, a nonprofit hospital and medical service corporation, or\n\nother entity responsible for the payment of benefits or provision of\n\nservices under a group contract;\n\n4. “Copayment” means an amount an enrollee must pay in order to\n\nreceive a specific service which is not fully prepaid;\n\n5. “Deductible” means the amount an enrollee is responsible to\n\npay out-of-pocket before a health maintenance organization begins to\n\npay the costs associated with treatment;\n\n6. “Enrollee” means an individual who is covered by a health\n\nmaintenance organization;\n\n7. “Evidence of coverage” means a statement of the essential\n\nfeatures and services of the health maintenance organization\n\ncoverage which is given to the subscriber by the health maintenance\n\norganization or by the group contract holder;\n\n8. “Extension of benefits” means the continuation of coverage\n\nunder a particular benefit provided under a contract following\n\ntermination for an enrollee who is totally disabled on the date of\n\ntermination;\n\n9. “Grievance” means a written complaint, submitted in\n\naccordance with a health maintenance organization’s formal grievance\n\nprocedure, by or on behalf of an enrollee regarding any aspect of\n\nthe health maintenance organization relative to the enrollee;\n\n10. “Group contract” means a contract for health care services\n\nwhich by its terms limits eligibility to members of a specified\n\ngroup. The group contract may include coverage for dependents;\n\n11. “Group contract holder” means the person to which a group\n\ncontract has been issued;\n\n12. “Health maintenance organization” or “HMO” means a person\n\nthat undertakes to provide or arrange for the delivery of basic\n\nhealth care services to enrollees on a prepaid basis, except for\n\ncopayments or deductibles for which the enrollee is responsible, or\n\nboth;\n\n13. “Health maintenance organization producer” means a person\n\nwho solicits, negotiates, effects, procures, delivers, renews or\n\ncontinues a policy or contract for HMO membership, or who takes or\n\ntransmits a membership fee or premium for such a policy or contract,\n\nother than for the person, or a person who advertises or otherwise\n\nholds himself or herself out to the public as a health maintenance\n\norganization producer;\n\n14. “Individual contract” means a contract for health care\n\nservices issued to and covering an individual. An individual\n\ncontract may include the dependents of the subscriber;\n\n15. “Insolvent” or “insolvency” means a process by which an\n\norganization has been declared insolvent and placed under an order\n\nof liquidation by a court of competent jurisdiction;\n\n16. \"Insurance Commissioner\" means the Insurance Commissioner\n\npursuant to the provisions of Title 36 of the Oklahoma Statutes;\ning an individual. An individual\n\ncontract may include the dependents of the subscriber;\n\n15. “Insolvent” or “insolvency” means a process by which an\n\norganization has been declared insolvent and placed under an order\n\nof liquidation by a court of competent jurisdiction;\n\n16. \"Insurance Commissioner\" means the Insurance Commissioner\n\npursuant to the provisions of Title 36 of the Oklahoma Statutes;\n\n17. “Managed hospital payment basis” means agreements wherein\n\nthe financial risk is primarily related to the degree of utilization\n\nrather than to the cost of services;\n\n18. \"NAIC\" means the National Association of Insurance\n\nCommissioners;\n\n19. “Net worth” means the excess of total admitted assets over\n\ntotal liabilities, provided, total liabilities shall not include\n\nfully subordinated debt;\n\n20. “Participating provider” means a provider as defined in\n\nparagraph 22 of this section who, under an express or implied\n\ncontract with the health maintenance organization, its contractor or\n\nsubcontractor, has agreed to provide health care services to\n\nenrollees with an expectation of receiving payment, other than\n\ncopayment or deductible, directly or indirectly from the health\n\nmaintenance organization;\n\n21. “Person” means a natural or artificial person including,\n\nbut not limited to, individuals, partnerships, associations, trusts\n\nor corporations;\n\n22. “Provider” means a physician, hospital or other person\n\nlicensed or otherwise authorized to furnish health care services;\n\n23. “Replacement coverage” means the benefits provided by a\n\nsucceeding carrier;\n\n24. \"State Commissioner of Health\" means the State Commissioner\n\nof Health pursuant to the provisions of Section 1-106 of Title 63 of\n\nthe Oklahoma Statutes;\n\n25. “Subscriber” means an individual whose employment or other\n\nstatus, except family dependency, is the basis for eligibility for\n\nenrollment in the health maintenance organization, or in the case of\n\nan individual contract, the person in whose name the contract is\n\nissued; and\n\n26. “Uncovered expenditures” means the costs to the health\n\nmaintenance organization for health care services that are the\n\nobligation of the health maintenance organization, for which an\n\nenrollee may also be liable in the event of the health maintenance\n\norganization’s insolvency and for which no alternative arrangements\n\nhave been made that are acceptable to the Insurance Commissioner.","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":"45c77387cee94d3ef812a8a1a42b1d39be9ba8a0b9c26d1545f77fdd73c12c20","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6901","next":"us-ok/okla.-stat.-tit.-36-36-6903"},"notice":"GroundRules: Original legal text. Not legal advice."}