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SENATE FLOOR VERSION
April 11, 2022
COMMITTEE SUBSTITUTE
FOR ENGROSSED
HOUSE BILL NO. 2322 By: Frix, Sims, Sneed, and
Roberts (Eric) of the House
and
Bullard and Pemberton 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 OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2021, 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 assignable, as
provided by its terms. Subject to its terms relating to
assignability, any life or accident and health p olicy, 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 rec eived at its home office
written notice of termination of the assignment or pledge, or
written notice by or on behalf of some other person claiming some
interest in the policy in conflict with the assignment.
SECTION 2. AMENDATORY 36 O.S. 2021, 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 b e 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 diagn osis 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 exp ense, 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 , home care agencies, or
other health care pr oviders or facilities that are licensed or
certified by the state who are participating preferred provider
organization providers and practitioners, hospitals , and ambulatory
surgical centers, home care agencies, or other health care pr oviders
or facilities that are licensed or certified by the state who are
not participating in the preferred provider organization, subject to
the following limitatio ns:
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
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corresponding annual deductible for treatmen t in a
hospital or ambulatory surgical center that is a
preferred provider,
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 , and
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
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not exceed by more than thirty (30) percentage points
the percentage amount of any c oinsurance payment to be
paid to a preferred provider.
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 ambulatory surgical center,
home care agency, or other health care pr oviders or facilities that
are licensed or certified by the state 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, or other health care
provider or facility that is licensed or certified by the state to
an insurer on a uniform health care claim form adopted by the
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Insurance Commissione r 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, or other health care provider or facility that is licensed
or certified by the state 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
practitioner, hospital, home care agency , or ambulatory surgical
center, or other health care provider or facility that is licensed
or certified by the state who has provided services and procedures
which are covered under the policy. A practition er, hospital, home
care agency, or ambulatory surgical c enter, or other health care
provider or facility that is licensed or certified by the state
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 , or other health care provider
or facility that is licensed or certified by the state ;
2. A copy of the assignment has bee n provided by the
practitioner, hospital, home care agency , or ambulatory surgical
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center, or other health care provider or facility that is licensed
or certified by the state to the insurer;
3. A claim has been submitted by the practitioner, hospital,
home care agency, or ambulatory surgical center, or other health
care provider or facility that is licensed or certified by the state
to the insurer on a uniform health insurance claim form adopted by
the Insurance Commissioner pursuant to Section 6581 of th is title;
and
4. A copy of the claim has been provided by the practitioner,
hospital, home care agency , or ambulatory surgical center , or other
health care provider or facility that is licensed or certified by
the state to the insured.
G. When any covered health care benefits are assigned to an
out-of-network practitioner, hospital, home care agency , ambulatory
surgical center, or other health care provider or facility that is
licensed or certified by the state , 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
agency, ambulatory surgical center , or other health care provider or
facility that is licensed or certified by the state 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 de termined by
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the Commissioner within fifteen (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 network which:
a. provides that a practitioner, hospital, home care
agency, or ambulatory surgical center , or other health
care provider or facility that is licensed or
certified by the state 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 discriminating against a particular class of
practitioner,
c. allows any practitioner, hospital, home care agency ,
or ambulatory surgical center , or other health care
provider or facility that is licensed or certified by
the state, except a practitioner who has a prior
felony conviction, to become a network provider if
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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 the
insured.
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 provided that the benefits of
such policy include out -of-network provisions and are being assigned
to an out-of-network practitioner, hospital, home care agency,
ambulatory surgical center , or other health care provider or
facility that is licensed or certified by the state . The
assignability of an accident and health insurance policy related to
out-of-network care shall only be subject to the terms and
conditions specified in subsection F of this section.
H. 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 f ee for a procedure to
be performed upon an insured based upon information regarding the
anticipated medical needs of the insured provided to the insurer by
the nonparticipating practitioner.
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I. J. A practitioner shall be equally compensated for covered
services and procedures provided to an insured on the basis of
charges prevailing in the same geographica l 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 i nsured to violate
the terms of the policy.
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 a nd 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
with respect to participation and reimbursement as it relates to any
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practitioner who is acting within the scope of the practitioner '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 o n the patient presenting symptoms arising
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 ser vice based solely upon
lack of notification to the insurer or PPO.
N. O. An insurer or a preferred provider organizat ion (PPO)
shall compensate a provider for patient screening, evaluation, and
examination services that are reasonably calculated to assist the
provider in determining whether the condition of the patient
requires emergency service. If the provider determi nes 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 provid er
organization or other network from determining the adequacy of the
size of its network.
P. Q. An insurer or a preferred provider organization 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 the Health Care Freedom of Choice
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, a s 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 allowable charges of a preferred
provider.
SECTION 3. This act shall become effective November 1, 2022.
COMMITTEE REPORT BY: COMMITTEE ON RETIREMENT AND INSURANCE
April 11, 2022 - DO PASS AS AMENDED