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STATE OF OKLAHOMA
1st Session of the 58th Legislature (2021)
COMMITTEE SUBSTITUTE
FOR
HOUSE BILL NO. 2323 By: Frix
COMMITTEE SUBSTITUTE
An Act relating to insurance; amending 36 O.S. 2011,
Section 6055, which relates to health insurance;
prohibiting certain health insurers from removing
provider from a network for certain reasons;
providing prohibition shall not apply to certain
contract expirations; prohibiting restrictions on
out-of-network referrals; requiring certain signed
acknowledgement; and providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2011, Section 6055, is
amended to read as follows:
Section 6055. A. Under any accident and he alth 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 gua rdian of
the insured if the insured is a minor, if the services and
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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 particula r 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 suc h 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:
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 pract itioner for the
diagnosis and treatment of 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 prov isions between practitioners,
hospitals and ambulatory surgical centers who are participating
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preferred provider organization providers and practitioners,
hospitals and ambulatory surgical centers who are not participating
in the preferred provider organiz ation, 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 treatment 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 treatme nt in a hospital or
ambulatory surgical center 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 inpati ent
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,
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d. if the policy has no deductibl e for treatment by a
preferred practitioner, 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 coinsuran ce to be paid by
an insured to a practitioner, 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 pr ovider.
2. The Commissioner has discretion 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
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 ambulato ry surgical center
charges which exceed the 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
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in writing to the insured, any ownersh ip interest in the
nonparticipating hospital 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 Insuran ce 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 an 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 who has provided services and procedures which ar e covered
under the policy. A practitioner, 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 surg ical
center to the insurer;
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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 claim has been provided by the practitioner,
hospital, home care agency or ambulatory surgical center to the
insured.
G. The provisions of subsection F of this section shall not
apply to:
1. Any preferred provider org anization (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 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, except a practitioner who
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has a prior felony conviction, to become a network
provider if said hospital or p ractitioner 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 bal ance bill the
insured.
H. 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 upo n information regarding the
anticipated medical needs of the insured provided to the insurer by
the nonparticipating practitioner.
I. A practitioner shall be equally compensated for covered
services and procedures provided to an insured 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
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2. The practitioner does not aid or abet the insured to violate
the terms of the policy.
J. Nothing in the H ealth 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 qualificati ons, 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. A preferred provider organization, in executing a contract,
shall not, by the term s 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
practitioner who is acting within the scope of the practitioner’s
license under the law solely on the basis of such license.
L. 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 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;
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2. Impairment of bodily function; or
3. Dysfunction of any bodily organ or part.
M. 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. 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 the 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.
O. Nothing in this 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. An insurer or a preferred provider organization shall not
unilaterally remove a provider from the network, solely becaus e 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,
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penalize, terminate, or otherwise restrict a preferred provider from
referring to an out-of-network provider, provid ed 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 2. This act shall become effective November 1, 2021.
58-1-7758 AMM 02/24/21