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ENGROSSED HOUSE
BILL NO. 2322 By: Frix and Sims of the House
and
Bullard of the Senate
[ health insurance - requiring insurer failing to
pay assigned benefits claim to pay certain costs -
effective date ]
BE IT ENACTED BY THE PEOPLE O F THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2011, Section 3624, is
amended to read as follows:
Section 3624. Except as provided in subsection D of Section
6055 of this title, a policy may be assignable or not assignabl e, as
provided by its terms. Subject to its terms relating to
assignability, any life or accident and health policy, whether
heretofore or hereafter issued, under the terms of which the
beneficiary may be changed upon the sole request of the insured, may
be assigned either by pledge or transfer of title, by an assignment
executed by the insured alone and delivered to the insurer, whether
or not the pledgee or assignee is the insurer. Any such assignment
shall entitle the insurer to deal with the assignee as the owner or
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pledgee of the policy in accordance with the terms of the
assignment, until the insurer has received at its home office
written notice of termination of the assignment or pledge, or
written notice by or on behalf of some other person claimi ng some
interest in the policy in conflict with the assignment.
SECTION 2. AMENDATORY 36 O.S. 2011, Section 6055, is
amended to read as follows:
Section 6055. A. Under any accident and health insurance
policy, hereafter renewed or issued for delivery from out of
Oklahoma or in Oklahoma by any insurer and covering an Oklahoma
risk, the services and procedures may be performed by any
practitioner selected by the insured, or the parent or guardian of
the insured if the insured is a minor, if the services and
procedures fall within the licensed scope of practice of the
practitioner providing the same.
B. An accident and health insurance policy may:
1. Exclude or limit coverage for a particular illness, disease,
injury or condition; but, except for such exclusions or limits,
shall not exclude or limit particular services or procedures that
can be provided for the diagnosis and treatment of a covered
illness, disease, injury or condition, if such exclusion or
limitation has the effect of discriminating against a particular
class of practitioner. However, such services and procedures, in
order to be a covered medical expense, must:
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a. be medically necessary,
b. be of proven efficacy, and
c. fall within the licensed scope of practice of the
practitioner providing same; and
2. Provide for the application of deductibles and copayment
provisions, when equally applied to all covered charges for services
and procedures that can be provided by any practitioner for the
diagnosis and treatment o f a covered illness, disease, injury or
condition.
C. 1. Paragraph 2 of subsection B of this section shall not be
construed to prohibit differences in cost -sharing provisions such as
deductibles and copayment provisions between practitioners,
hospitals and ambulatory surgical centers who are participating
preferred provider organization providers and practitioners,
hospitals and ambulatory surgical centers who are not participating
in the preferred provider organization, subject to the following
limitations:
a. the amount of any annual deductible per covered person
or per family for treatment in a hospital or
ambulatory surgical center that is not a preferred
provider shall not exceed three times the amount of a
corresponding annual deductible for treatmen t in a
hospital or ambulatory surgical center that is a
preferred provider,
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b. if the policy has no deductible for treatment in a
preferred provider hospital or ambulatory surgical
center, the deductible for treatment in a hospital or
ambulatory surgical c enter that is not a preferred
provider shall not exceed One Thousand Dollars
($1,000.00) per covered -person visit,
c. the amount of any annual deductible per covered person
or per family treatment, other than inpatient
treatment, by a practitioner that is not a preferred
practitioner shall not exceed three times the amount
of a corresponding annual deductible for treatment,
other than inpatient treatment, by a preferred
practitioner,
d. if the policy has no deductible for treatment by a
preferred practition er, the annual deductible for
treatment received from a practitioner that is not a
preferred practitioner shall not exceed Five Hundred
Dollars ($500.00) per covered person,
e. the percentage amount of any coinsurance to be paid by
an insured to a practiti oner, hospital or ambulatory
surgical center that is not a preferred provider shall
not exceed by more than thirty (30) percentage points
the percentage amount of any coinsurance payment to be
paid to a preferred provider.
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2. The Commissioner has discreti on to approve a cost-sharing
arrangement which does not satisfy the limitations imposed by this
subsection if the Commissioner finds that such cost -sharing
arrangement will provide a reduction in premium costs.
D. 1. A practitioner, hospital or ambulator y surgical center
that is not a preferred provider shall disclose to the insured, in
writing, that the insured may be responsible for:
a. higher coinsurance and deductibles, and
b. practitioner, hospital or ambulatory surgical center
charges which exceed t he allowable charges of a
preferred provider.
2. When a referral is made to a nonparticipating hospital or
ambulatory surgical center, the referring practitioner must disclose
in writing to the insured , any ownership interest in the
nonparticipating hospi tal or ambulatory surgical center.
E. Upon submission of a claim by a practitioner, hospital, home
care agency, or ambulatory surgical center to an insurer on a
uniform health care claim form adopted by the Insurance Commissioner
pursuant to Section 6581 of this title, the insurer shall provide a
timely explanation of benefits to the practitioner, hospital, home
care agency, or ambulatory surgical center regardless of the network
participation status of such person or entity.
F. Benefits available under a n accident and health insurance
policy, at the option of the insured, shall be assignable to a
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practitioner, hospital, home care agency or ambulatory surgical
center who has provided services and procedures which are covered
under the policy. A practition er, hospital, home care agency or
ambulatory surgical center shall be compensated directly by an
insurer for services and procedures which have been provided when
the following conditions are met:
1. Benefits available under a policy have been assigned in
writing by an insured to the practitioner, hospital, home care
agency or ambulatory surgical center;
2. A copy of the assignment has been provided by the
practitioner, hospital, home care agency or ambulatory surgical
center to the insurer;
3. A claim has been submitted by the practitioner, hospital,
home care agency or ambulatory surgical center to the insurer on a
uniform health insurance claim form adopted by the Insurance
Commissioner pursuant to Section 6581 of this title; and
4. A copy of the clai m has been provided by the practitioner,
hospital, home care agency or ambulatory surgical center to the
insured.
G. When any covered health care benefits are assigned to an
out-of-network practitioner, hospital, home care agency or
ambulatory surgical ce nter and have met all conditions for
compensation required by subsection F of this section, an insurer
that fails to compensate the practitioner, hospital, home care
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agency or ambulatory surgical center shall be liable for actual
damages, any interest charges, court costs or other legal fees, if
applicable. For any violation of this paragraph, the Insurance
Commissioner may, after notice and a hearing, subject an insurer to
an additional civil fine in an amount to be determined by the
Commissioner within f ifteen (15) days of a hearing in which a
violation is found. The fine will be placed in the State Insurance
Commissioner Revolving Fund.
H. The provisions of subsection F of this section shall not
apply to:
1. Any preferred provider organization (PPO) , as defined by
generally accepted industry standards, that contracts with
practitioners that agree to accept the reimbursement available under
the PPO agreement as payment in full and agree not to balance bill
the insured; or
2. Any statewide provider netw ork which:
a. provides that a practitioner, hospital, home care
agency or ambulatory surgical center who joins the
provider network shall be compensated directly by the
insurer,
b. does not have any terms or conditions which have the
effect of discriminati ng against a particular class of
practitioner,
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c. allows any practitioner, hospital, home care agency or
ambulatory surgical center, except a practitioner who
has a prior felony conviction, to become a network
provider if said the hospital or practitioner is
willing to comply with the terms and conditions of a
standard network provider contract, and
d. contracts with practitioners that agree to accept the
reimbursement available under the network agreement as
payment in full and agree not to balance bill th e
insured.
H. The provisions of this section shall not be deemed to
prohibit a policyholder from assigning benefits available pursuant
to an accident and health insurance policy provid ed that the
benefits of such policy include out -of-network provisions a nd are
being assigned to an out-of-network practitioner, hospital, home
care agency or ambulatory surgical center. The assignability of an
accident and health insurance policy related to out -of-network care
shall only be subject to the terms and condition s specified in
subsection F of this section .
I. A nonparticipating practitioner, hospital or ambulatory
surgical center may request from an insurer and the insurer shall
supply a good-faith estimate of the allowable fee for a procedure to
be performed upon an insured based upon information regarding the
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anticipated medical needs of the insured provided to the insurer by
the nonparticipating practitioner.
I. J. A practitioner shall be equally compensated for covered
services and procedures provided to an i nsured on the basis of
charges prevailing in the same geographical area or in similar sized
communities for similar services and procedures provided to
similarly ill or injured persons regardless of the branch of the
healing arts to which the practitioner may belong, if:
1. The practitioner does not authorize or permit false and
fraudulent advertising regarding the services and procedures
provided by the practitioner; and
2. The practitioner does not aid or abet the insured to violate
the terms of the pol icy.
J. K. Nothing in the Health Care Freedom of Choice Act shall
prohibit an insurer from establishing a preferred provider
organization and a standard participating provider contract
therefor, specifying the terms and conditions, including, but not
limited to, provider qualifications, and alternative levels or
methods of payment that must be met by a practitioner selected by
the insurer as a participating preferred provider organization
provider.
K. L. A preferred provider organization, in executing a
contract, shall not, by the terms and conditions of the contract or
internal protocol, discriminate within its network of practitioners
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with respect to participation and reimbursement as it relates to any
practitioner who is acting within the scope of the p ractitioner's
license under the law solely on the basis of such license.
L. M. Decisions by an insurer or a preferred provider
organization (PPO) to authorize or deny coverage for an emergency
service shall be based on the patient presenting symptoms aris ing
from any injury, illness, or condition manifesting itself by acute
symptoms of sufficient severity, including severe pain, such that a
reasonable and prudent layperson could expect the absence of medical
attention to result in serious:
1. Jeopardy to the health of the patient;
2. Impairment of bodily function; or
3. Dysfunction of any bodily organ or part.
M. N. An insurer or preferred provider organization (PPO) shall
not deny an otherwise covered emergency service based solely upon
lack of notification to the insurer or PPO.
N. O. An insurer or a preferred provider organization (PPO)
shall compensate a provider for patient screening, evaluation, and
examination services that are reasonably calculated to assist the
provider in determining whether t he condition of the patient
requires emergency service. If the provider determines that the
patient does not require emergency service, coverage for services
rendered subsequent to that determination shall be governed by the
policy or PPO contract.
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O. P. Nothing in this act the Health Care Freedom of Choice Act
shall be construed as prohibiting an insurer, preferred provider
organization or other network from determining the adequacy of the
size of its network.
P. Q. An insurer or a preferred provider or ganization shall not
unilaterally remove a provider from the network solely because the
provider informs an enrollee of the full range of physicians and
providers available to the enrollee, including out -of-network
providers. Nothing in this act prohibits any insurer from allowing
a contract to expire by its own terms or negotiating a new contract
with the provider at the end of the contract term. A provider
agreement shall not, as a condition of the agreement, prohibit,
penalize, terminate, or otherwise restrict a preferred provider from
referring to an out-of-network provider; provided, the insured signs
an acknowledgment of referral that the insured may be responsible
for:
1. Higher coinsurance and deductibles; and
2. Charges which exceed the allowabl e charges of a preferred
provider.
SECTION 3. This act shall bec ome effective November 1, 20 22.
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Passed the House of Representatives the 22nd day of March, 2022.
Presiding Officer of the House
of Representatives
Passed the Senate the ___ day of __________, 2022.
Presiding Officer of the Senate