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The report must be submitted to the Insurance Department within ninety days after each health benefit plan year closes and include required participation counts, instances, service costs, and the value of shared-savings incentive payments distributed as cash or credited toward annual in-network deductible and out-of-pocket limits. 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[36 § 6060.42(C)(6)] The form must be complete and accompanied by an officer’s [signature. Forms should be submitted to](signature. Forms should be submitted to data.call@oid.ok.gov)[ ](signature. Forms should be submitted to data.call@oid.ok.gov)[data.call@oid.ok.gov](signature. Forms should be submitted to data.call@oid.ok.gov).  \nCOMPANY NAME:   NAIC CO. CODE:    \nPOLICY / PLAN NAME:   HEALTH BENEFIT PLAN YEAR:    \n\n| Number of enrollees who participated in the program during the health benefit plan year: |  |\n| --- | --- |\n| Number of instances of participation: |  |\n| Total cost of services provided as part of the program: | $ |\n| Total value of the shared savings incentive payments made to enrollees participating in the program: | $ |\n| Total value distributed as cash: | $ |\n| Total value distributed as a credit toward enrollees’annual in-network deductible and out-of-pocket limit: | $ |\n\nBy signing, I am attesting to the accuracy of the above information and full compliance with 36 § 6060 .42(C)(6) .  \nOfficer’s Name & Title:    \nOfficer’s Signature:","cbCaiqUn9S48KvSN","https://ap.wps.com/l/cbCaiqUn9S48KvSN","pdf",82205,"English","# Reporting Requirement\n## Submission Deadline\n## Required Information\n# Company and Plan Details\n# Participation and Financial Fields\n## Enrollees and Instances\n## Service Costs\n## Incentive Payment Values\n# Attestation and Officer Signature","[{\"question\":\"Who must submit the annual report for the Oklahoma Shared Savings Incentive Program?\",\"answer\":\"Insurance carriers that created a Shared Savings Incentive Program under 36 § 6060.40 et. seq. and offered enrollment within a policy or certificate of insurance must submit the report.\"},{\"question\":\"When is the annual report due after the end of the health benefit plan year?\",\"answer\":\"The report must be submitted to the Insurance Department within ninety (90) days after the close of each health benefit plan year.\"},{\"question\":\"What key data fields must be included in the report?\",\"answer\":\"The report includes the number of enrollees who participated, number of participation instances, total service cost, total value of shared savings incentive payments, and how the incentive value was distributed (cash and/or credits toward annual deductible and out-of-pocket limits).\"}]","Oklahoma Shared Savings Incentive Program - Annual Report | PDF",1789160362]