Or. Admin. Code § 410-141-5000 - FINANCIAL SOLVENCY REGULATION: Definitions
When used and not otherwise defined in OAR 410-141-5005 through OAR-141-5380, the following terms shall have the meaning given in this section:
(1) "AICPA" means the
American Institute of Certified Public Accountants.
(2) "Assumption Reinsurance Agreement" means
a contract that:
(a) Transfers obligations or
risks of existing or in-force Member Contracts from a cedent CCO to a reinsurer
that acquires the obligations or risks from the cedent; and
(b) Is intended to affect a novation of the
transferred Member Contracts with the result that the reinsurer becomes
directly liable to the Members of the cedent CCO and the cedent CCO's contract
obligations to the Members are extinguished.
(3) "Board" means the board of directors or
other equivalent governing body of a company that is vested by the company's
organizational document(s) with responsibility and authority for the governance
and overall management of the affairs of the company, irrespective of the name
by which the governing body or the members of that governing body are
designated, except that:
(a) An individual or
a group of individuals is not the board of directors because of powers
delegated to the individual or group by provisions in the articles of
incorporation or other equivalent organizational documents authorizing the
individual or group to exercise some or all of the powers which would otherwise
be exercised by a board; and
(b) A
coordinated care organization may have a governing body as required by ORS
414.572 (2)(o)
that is not the board of the CCO entity.
(4) "Capitated Subcontractor" means a
third-party provider that enters into a Sub-capitation Arrangement with a CCO
for any portion of the health care services covered by the CCO's agreement with
the Authority.
(5) "CCO Contract"
means the CCO's agreement to provide managed health care services to a Member
pursuant to the CCO's contract with the Authority.
(6) "CGAD Report" means the corporate
governance annual disclosure report described at OAR
410-141-5045.
(7) "DCBS" means the Department of Consumer
and Business Services.
(8)
"Delinquency proceeding" means any proceeding commenced against a CCO for the
purpose of liquidating, rehabilitating or conserving the CCO.
(9) "Director" means, as the context
requires;
(a) A member of the board of
directors or other equivalent governing body of a company that is vested by the
company's organizational document(s) with the responsibility and authority for
the governance and overall management of the affairs of the company;
or
(b) The Director of the
Authority.
(10)
"Impaired" with respect to a CCO means that the CCO's allowed assets do not
exceed its liabilities plus its required capitalization.
(11) "Loss Protection Program" means a
program or set of arrangements a CCO maintains that are designed to protect the
CCO against catastrophic and unexpected loss or expenses related to capitated
services the CCO is obligated to provide to its Members.
(12) "Member" means an individual covered by,
and entitled to, managed health care services under a CCO's contract with the
Authority.
(13) "NAIC" means the
National Association of Insurance Commissioners.
(14) "NAIC Forms and Instructions" means the
financial statement blanks, forms and instructions for health insurers as
published and as revised by the NAIC from time to time and identified by the
Authority to be applicable for the reporting period. The applicable NAIC Forms
and Instructions prescribed by the Director referred to in this rule are
available for inspection at the office of the Authority. Any person interested
in inspecting the NAIC Forms and Instructions may contact the Authority at
actuarial.services@dhsoha.state.or.us.
(15) "Qualified United States Financial
Institution" means an institution that:
(a) Is
organized, or, in the case of a United States branch or agency office of a
foreign banking organization, is licensed, under the laws of the United States
or any state thereof and has been granted authority to operate with fiduciary
powers; and
(b) Is regulated,
supervised and examined by federal or state authorities having regulatory
authority over banks and trust companies.
(16) "Political subdivision" means,
consistent with ORS 192.005, any city, county,
district or any other municipal or public corporation in the State of
Oregon.
(17) "Primary Reserve"
means the primary Restricted Reserve Fund required by OAR
410-141-5185.
(18) "Receiver" means a receiver,
rehabilitator, liquidator or conservator, as the CCO Contract may
require.
(19) "Restricted Reserve
Account" means the reserve account required by OAR
410-141-5185.
(20) "Restricted Reserve Funds" means the
funds required to be deposited and maintained in the Restricted Reserve Account
under OAR 410-141-5185.
(21) "Restricted Reserve" means the
Restricted Reserve Account, the Primary Reserve, the Secondary Reserve and the
Restricted Reserve Funds required by OAR
410-141-5185.
(22) "Secondary Reserve" means the secondary
Restricted Reserve Fund required by OAR
410-141-5185.
(23) "Statutory Accounting Principles" means
generally accepted statutory accounting principles for health insurers as
prescribed, adopted or otherwise approved by DCBS for the financial and
solvency regulation of health insurers under Oregon law, as supplemented by
generally accepted statutory accounting principles prescribed, adopted or
otherwise approved by the NAIC, including without limitation, those accounting
practices, principles and procedures set forth in the NAIC's Accounting
Practices and Procedures Manual.
(24) "Sub-Capitated Arrangement" means a
contract or other arrangement between the CCO and a Sub-Capitated Counterparty
under which the Sub-Capitated Counterparty agrees to provide, as subcontractor
to the CCO, certain of the health care services required of the CCO under its
CCO Contract in return for a fixed capitation payment, the effect of which is
to transfer claim frequency and utilization risk to the third-party
provider.
(25) "Sub-Capitated
Counterparty" means the third-party provider under a Sub-Capitated Arrangement
with a CCO.
(26) "SVO" means the
Securities Valuation Office of the NAIC.
Notes
Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605
Statutes/Other Implemented: ORS 414.570-414.686 & ORS 415.001-415.430
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