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OAC 365:10

INSURANCE DEPARTMENT

communicated within ten working days of the issuer receiving notification of disenrollment.

[Source: Added at 15 Ok Reg 3569, eff 5-29-98 (emergency); Added at 16 Ok Reg 1088, eff 4-26- 99; Amended at 20 Ok Reg 1667, eff 7-14-03; Amended at 22 Ok Reg 1954, eff 7-14-05; Amended at 26 Ok Reg 1529, eff 7-1-2009]

365:10-5-130. Standards for claims payment (a) An issuer shall comply with section 1882(c)(3) of the Social Security Act (as enacted by section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-

  • 203)

    by:

    • (1)

      Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

    • (2)

      Notifying the participating physician or supplier and the beneficiary of the payment determination;

    • (3)

      Paying the participating physician or supplier directly;

    • (4)

      Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent;

    • (5)

      Paying user fees for claim notices that are transmitted electronically or otherwise; and

    • (6)

      Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.

(b) Compliance with the requirements set forth in (a) of this section shall be certified on the Medicare supplement insurance experience reporting form.

[Source: Added at 9 Ok Reg 2499, eff 6-26-92]

365:10-5-131. Loss ratio standards and refund or credit of premium

  • (a)

    Loss ratio standards.

    • (1)

      A Medicare Supplement policy form or certificate form shall not be delivered or issued for delivery unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to policyholders and certificate holders in the form of aggregate benefits (not including anticipated refunds or credits) provided under the policy form or certificate form:

      • (A)

        At least seventy-five percent (75%) of the aggregate amount of premiums earned in the case of group policies, or

      • (B)

        At least sixty-five percent (65%) of the aggregate amount of premiums earned in the case of individual policies.

    • (2)

      Calculated on the basis of incurred claims experience or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for such period and in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a helath maintenance organization shall not include:

      • (A)

        Home office and overhead costs;

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