Okla. Stat. tit. 36 § 6972

Current through Laws 2024, c. 453.

Section 6972

As used in this act:

1. "Contractual discount" means a reduction from a provider's usual and customary rate for covered services and materials required under a prepaid vision plan agreement with a provider;

2. "Covered materials" means materials for which reimbursement from the insurer, vision plan, or vision care discount plan is provided to a vision care provider by an enrollee's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance;

3. "Covered services" means services eligible for reimbursement from the insurer or vision plan to a provider, or services that would be eligible for reimbursement but for the application of the enrollee's contractual plan limitations of deductibles, copayments, or coinsurance, regardless of how the benefits are listed in the explanation of benefits provided in the vision plan of the enrollee;

4. "Enrollee" means any individual enrolled in a health care plan, vision plan, or vision care discount plan provided by a group, employer, or other entity that purchases or supplies coverage for a vision plan;

5. "Extrapolation" means a mathematical process or technique used by a vision plan in the process of auditing a vision care provider to estimate audit results for a larger batch of group claims not reviewed in the audit by the plan;

6. "Health benefit plan" means a health benefit plan as defined pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes;

7. "Materials" means ophthalmic devices including but not limited to lenses, devices containing lenses, artificial intraocular lenses, ophthalmic frames and other lens mounting apparatus, prisms, lens treatments and coatings, contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa, or any material allowed to be utilized by the Board of Examiners in Optometry and optometry's scope of practice as provided by law;

8. "Net equity" means the excess of total assets over total liabilities, excluding liabilities which have been subordinated in a manner acceptable to the Insurance Commissioner;

9. "Prepaid vision plan" means any contractual agreement whereby any prepaid vision plan organization undertakes to provide full payment or a discount of vision services directly, to arrange for prepaid vision services, or to pay or make reimbursement for any vision service not provided for by other insurance;

10. "Prepaid vision plan organization" means any person who, or organization or entity that, undertakes to conduct one or more prepaid vision plans providing only vision services;

11. "Services" means the professional work performed by a vision care provider;

12. "Subcontractor" means any company, group, or third-party entity including agents, servants, partially or wholly owned subsidiaries, and controlled organizations contracted by the insurer, vision plan, or vision care discount plan to supply services or materials for a vision care provider or enrollee to fulfill the benefit plan of an insurer, vision plan, or vision care discount plan;

13. "Tangible net equity" means net equity reduced by the value assigned to intangible assets including, but not limited to, goodwill, going concern value, organizational expenses, start-up costs, long-term prepayments of deferred charges, nonreturnable deposits, and obligations of officers, directors, owners, or affiliates, except short-term obligations of affiliates for goods or services arising in the normal course of business that are payable on the same term as equivalent transactions with nonaffiliates and that are not past due;

14. "Uncovered expense" means the cost of health care services that are the obligation of a prepaid vision plan organization for which:

a. an enrollee may be liable in the event of the insolvency of the organization, and

b. alternative arrangements acceptable to the Commissioner have not been made to cover the costs; and

15. "Vision care provider" or "provider" means a licensed doctor of optometry or a licensed medical or osteopathic doctor practicing under the authority of the applicable provisions of Title 59 of the Oklahoma Statutes.

Okla. Stat. tit. 36, § 6972

Added by Laws 2024, c. 360,s. 1, eff. 5/30/2024.