The following words or terms, when used in this Chapter, will have the following meanings unless the context clearly indicates otherwise:
"Carrier" means:
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(A) an insurance company, insurance service, insurance organization, or group health service, which is licensed to engage in the business of insurance in the State of Oklahoma and is subject to State law which regulates insurance, or Health Maintenance Organization (HMO) which provides or arranges 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 and is subject to State law which regulates Health Maintenance Organizations (HMOs);
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(B) a Multiple Employer Welfare Arrangement (MEWA) licensed by the Oklahoma Insurance Department;
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(D) any entity organized pursuant to the Interlocal Cooperation Act,
Section 1001 et seq. of Title 74 of the Oklahoma Statutes as authorized by
Title 36 Section 607.1 of the Oklahoma Statutes and which is eligible to qualify for and hold a certificate of authority to transact insurance in this State and annually submits on or before March 1st a financial statement to the Oklahoma Insurance Department in a form acceptable to the Insurance Commissioner covering the period ending December 31st of the immediately preceding fiscal year.
"Child Care Center" means a facility licensed by OKDHS which provides care and supervision of children and meets all the requirements in 340:110-3-1 through 340:110-3-33.3.
"College Student" means an Oklahoma resident between the age of 19 through 22 that is a full-time student in an accredited and OHCA approved University or College in the State of Oklahoma.
"Dependent" means the spouse of the approved applicant and/or child under 19 years of age or his or her child 19 years through 22 years of age who is attending an Oklahoma qualified institution of higher education and relying upon the insured employee or member for financial support.
"Eligibility period" means the period of eligibility extending from an approval date to an end date.
"Employee" means a person who works for an employer in exchange for earned income. This includes the owners of a business. All employees and employers must be in compliance with all OESC requirements to be eligible for the program.
"Employer" means the business entity that pays earned income to employees. All employees and employers must be in compliance will all OESC requirements to be eligible for the program.
"Employer Sponsored Insurance" means the program that provides premium assistance to qualified businesses for approved applicants.
"EOB" means an Explanation of Benefit.
"Explanation of Benefit" means a statement issued by a carrier that indicates services rendered and financial responsibilities for the carrier and Insure Oklahoma member.
"Full-time Employment" means a normal work week of 24 or more hours.
"Full-time Employer" means the employer who employs an employee for 24 hours or more per week to perform work in exchange for wages or salary.
"Gross Household Income" or "Annual Gross Household Income" means the countable income (earned or unearned) that is computed pursuant to OHCA's waiver and/or state plan using rules found in 317:35.
"Individual Plan" means the safety net program for those qualified individuals who do not have access to Insure Oklahoma ESI.
"Insure Oklahoma" means a health plan purchasing strategy in which the State uses public funds to pay for a portion of the costs of health plan coverage for eligible populations.
"Insure Oklahoma IP" means the Individual Plan program.
"Insure Oklahoma ESI" means the Employer Sponsored Insurance program.
"Member" means an individual enrolled in the Insure Oklahoma ESI or IP program.
"OESC" means the Oklahoma Employment Security Commission.
"OHCA" means the Oklahoma Health Care Authority.
"OKDHS" means the Oklahoma Department of Human Services.
"PCP" means Primary Care Provider.
"PEO" or "Professional Employer Organization" means any person engaged in the business of providing professional employer services. A person engaged in the business of providing professional employer services shall be subject to registration under the Oklahoma Professional Employer Organization Recognition and Registration Act as provided in Title 40, Chapter 16 of Oklahoma Statutes, Section 600.1 et.seq.
"Primary Care Provider" means a provider under contract with the Oklahoma Health Care Authority to provide primary care services, including all medically necessary referrals.
"Premium" means a monthly payment to a carrier for health plan coverage.
"Qualified Health Plan" means a health plan that has been approved by the OHCA for participation in the Insure Oklahoma program.
"Qualifying Event" means the occurrence of an event that permits individuals to join a group health plan outside of the "open enrollment period" and/or that allows individuals to modify the coverage they have had in effect. Qualifying events are defined by the employer's health plan and meet federal requirements under Public Law 104-191 (HIPAA), and 42 U.S.C. 300bb-3.
"State" means the State of Oklahoma, acting by and through the Oklahoma Health Care Authority.