Oklahoma 2022 Regular Session

Oklahoma House Bill HB2323 Compare Versions

Version 1 (Old)

Version 2 (New)

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1		-	An Act
2		-	ENROLLED HOUSE
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	30	+	March 29, 2021
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3	34		BILL NO. 2323 By: Frix of the House
4	35
5	36		and
6	37
7	38		Pemberton, Bullard, Jett
8	39		and Hamilton of the Senate
9		-
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15	45		An Act relating to insurance; amending 36 O.S. 2011,
16	46		Section 6055, which relates to health insurance;
17	47		prohibiting certain health insurers from removing
18	48		provider from a network for certain reasons;
19	49		providing prohibition shall not apply to certain
20	50		contract expirations; prohibiting restrictions on
21	51		out-of-network referrals; requiring certain signed
22	52		acknowledgement; and providing an effective date.
23	53
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26	56
27		-	SUBJECT: Insurance
28		-
29	57		BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
30		-
31	58		SECTION 1. AMENDATORY 36 O.S. 2011, Section 6055, is
32	59		amended to read as follows:
33		-
34	60		Section 6055. A. Under a ny accident and health insurance
35	61		policy, hereafter renewed or issued for delivery from out of
36	62		Oklahoma or in Oklahoma by any insurer and covering an Oklahoma
37	63		risk, the services and procedures may be performed by any
38	64		practitioner selected by the insured, or the parent or guardian of
39	65		the insured if the insured is a minor, if the services and
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40	93		procedures fall within the licensed scope of practice of the
41	94		practitioner providing the same.
42		-
43	95		B. An accident and health insurance policy may:
44		-
45	96		1. Exclude or limit covera ge for a particular illness, disease,
46		-	injury or condition; but, except for such ~~exclusions~~ or limits, ~~ENR. H. B. NO. 2323 Page 2~~
	97	+	injury or condition; but, except for such e xclusions or limits,
47	98		shall not exclude or limit particular services or procedures that
48	99		can be provided for the diagnosis and treatment of a covered
49	100		illness, disease, injury or condition, if such exclusion or
50	101		limitation has the effect of discriminating agai nst a particular
51	102		class of practitioner. However, such services and procedures, in
52	103		order to be a covered medical expense, must:
53		-
54	104		a. be medically necessary,
55		-
56	105		b. be of proven efficacy, and
57		-
58	106		c. fall within the licensed scope of practice of the
59	107		practitioner providing same; and
60		-
61	108		2. Provide for the application of deductibles and copayment
62	109		provisions, when equally applied to all covered charges for services
63	110		and procedures that can be pro vided by any practitioner for the
64	111		diagnosis and treatment of a covered illness, d isease, injury or
65	112		condition.
66		-
67	113		C. 1. Paragraph 2 of subsection B of this section shall not be
68	114		construed to prohibit differences in cost -sharing provisions such as
69	115		deductibles and copayment provisions between practitioners,
70	116		hospitals and ambulatory surgical centers who are participating
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71	144		preferred provider organization providers and practitioners,
72	145		hospitals and ambulatory surgical centers who are not participating
73	146		in the preferred provider organization, subject to the following
74	147		limitations:
75		-
76	148		a. the amount of any annual deductible per covered person
77	149		or per family for treatment in a hospital or
78	150		ambulatory surgical center that is not a preferred
79	151		provider shall not exceed three times t he amount of a
80	152		corresponding annual deductible for treatment in a
81	153		hospital or ambulatory surgical center that is a
82	154		preferred provider,
83		-
84	155		b. if the policy has no deductible for treatment in a
85	156		preferred provider hospital or ambulatory surgical
86	157		center, the deductible for treatment in a hospital or
87	158		ambulatory surgical center that is not a pr eferred
88	159		provider shall not exceed One Thousand Dollars
89	160		($1,000.00) per covered -person visit,
90		-	ENR. H. B. NO. 2323 Page 3
91	161		c. the amount of any annual deductible per covered person
92	162		or per family treatment, other than inpatient
93	163		treatment, by a practitioner that is not a preferred
94	164		practitioner shall not exceed three times the amount
95	165		of a corresponding annual deductible for treatment,
96	166		other than inpatient treatment, by a preferred
97	167		practitioner,
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99	195		d. if the policy has no deductible for treatment by a
100	196		preferred practitioner, the annual deducti ble for
101	197		treatment received from a practitioner that is not a
102	198		preferred practitioner shall not exceed Five Hundred
103	199		Dollars ($500.00) per covered person,
104		-
105	200		e. the percentage amoun t of any coinsurance to be paid by
106	201		an insured to a practitioner, hospital or ambu latory
107	202		surgical center that is not a preferred provider shall
108	203		not exceed by more than thirty (30) percentage points
109	204		the percentage amount of any coinsurance payment to be
110	205		paid to a preferred provider.
111		-
112	206		2. The Commissioner has discretion to approve a cost -sharing
113	207		arrangement which does not satisfy the limitations imposed by this
114	208		subsection if the Commissioner finds that such cost -sharing
115	209		arrangement will provide a reduction in p remium costs.
116		-
117	210		D. 1. A practitioner, hospital or ambulatory surgical center
118	211		that is not a preferred provider shall disclose to the insured, in
119	212		writing, that the insured may be responsible for:
120		-
121	213		a. higher coinsurance and deductibles, and
122		-
123	214		b. practitioner, hospital or ambulatory surgical center
124	215		charges which exceed the allowable charges o f a
125	216		preferred provider.
126		-
127	217		2. When a referral is made to a nonparticipating hospital or
128	218		ambulatory surgical center, the referring practitioner must disclose
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129	246		in writing to the in sured, any ownership interest in the
130	247		nonparticipating hospital or ambulatory surg ical center.
131		-
132	248		E. Upon submission of a claim by a practitioner, hospital, home
133	249		care agency, or ambulatory surgical center to an insurer on a
134	250		uniform health care claim form adop ted by the Insurance Commissioner
135		-	pursuant to Section 6581 of this title, the ~~insurer~~ shall provide a ~~ENR. H. B. NO. 2323 Page 4~~
	251	+	pursuant to Section 6581 of this title, the ins urer shall provide a
136	252		timely explanation of benefits to the practitioner, hospital, home
137	253		care agency, or ambulatory surgical center regardless of the network
138	254		participation status of such person or entity.
139		-
140	255		F. Benefits available under an accident and health insurance
141	256		policy, at the option of the insured, shall be assignable to a
142	257		practitioner, hospital, home care agency or ambulatory surgical
143	258		center who has provided services and p rocedures which are covered
144	259		under the policy. A practitioner, hospital, home car e agency or
145	260		ambulatory surgical center shall be compensated directly by an
146	261		insurer for services and procedures which have been provided when
147	262		the following conditions are met:
148		-
149	263		1. Benefits available under a policy have been assigned in
150	264		writing by an insured to the practitioner, hospital, home care
151	265		agency or ambulatory surgical center;
152		-
153	266		2. A copy of the assignment has been provided by the
154	267		practitioner, hospital, home care agency or ambulatory surgical
155	268		center to the insurer;
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157	296		3. A claim has been submitted by t he practitioner, hospital,
158	297		home care agency or ambulatory surgical center to the insurer on a
159	298		uniform health insurance claim form adopted by the Insurance
160	299		Commissioner pursuan t to Section 6581 of this title; and
161		-
162	300		4. A copy of the claim has been provided by the practitioner,
163	301		hospital, home care agency or ambulatory surgical center to the
164	302		insured.
165		-
166	303		G. The provisions of subsection F of this section shall not
167	304		apply to:
168		-
169	305		1. Any preferred provider organization (PPO), as defined by
170	306		generally accepted industry stan dards, that contracts with
171	307		practitioners that agree to accept the reimbursement available under
172	308		the PPO agreement as payment in full and agree not to balance bill
173	309		the insured; or
174		-
175	310		2. Any statewide provider network which:
176		-
177	311		a. provides that a practitioner, ho spital, home care
178	312		agency or ambulatory surgical center who joins the
179	313		provider network shall be compensated directly by the
180		-	insurer, ENR. H. B. NO. 2323 Page 5
181		-
	314	+	insurer,
182	315		b. does not have any terms or conditions wh ich have the
183	316		effect of discriminating against a particular class of
184	317		practitioner,
185		-
186	318		c. allows any practitioner, hospital, home care agency or
187	319		ambulatory surgical center, except a practitioner who
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188	347		has a prior felony conviction, to become a network
189	348		provider if said hospital or practitioner is willing
190	349		to comply with the terms and conditions of a standard
191	350		network provider contract, and
192		-
193	351		d. contracts with practitioners that agree to accept the
194	352		reimbursement available under the network agreement as
195	353		payment in full and agree not to balance bill the
196	354		insured.
197		-
198	355		H. A nonparticipating practitioner, ho spital or ambulatory
199	356		surgical center may request from an insurer and the insurer shall
200	357		supply a good-faith estimate of the allowable fee for a procedure to
201	358		be performed upon an insured based upon information regarding the
202	359		anticipated medical needs of the i nsured provided to the insurer by
203	360		the nonparticipating practitioner.
204		-
205	361		I. A practitioner shall be equally compensated for covered
206	362		services and procedures provided to an insured on the basis of
207	363		charges prevailing in the same geographical area or in similar s ized
208	364		communities for similar services and procedures provided to
209	365		similarly ill or injured persons regardless of the branch of the
210	366		healing arts to which the practitioner may be long, if:
211		-
212	367		1. The practitioner does not authorize or permit false and
213	368		fraudulent advertising regarding the services and procedures
214	369		provided by the practitioner; and
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216	397		2. The practitioner does not aid or abet the insured to violate
217	398		the terms of the policy.
218		-
219	399		J. Nothing in the Health Care Freedom of Choice Act shall
220	400		prohibit an insurer fro m establishing a preferred provider
221	401		organization and a standard participating provider contract
222	402		therefor, specifying the terms and conditions , including, but not
223	403		limited to, provider qualifications, and alternative levels or
224		-	methods of payment that must be met by a practitioner selected by ~~ENR. H. B. NO. 2323 Page 6~~
	404	+	methods of payment that must be met by a practitioner selected by
225	405		the insurer as a participating preferred provider organization
226	406		provider.
227		-
228	407		K. A preferred provider organization, in executing a contract,
229	408		shall not, by the terms and conditions of the contract or internal
230	409		protocol, discriminate within its network of practitioners with
231	410		respect to participation and reimbursement as it relates to any
232	411		practitioner who is acting within the sco pe of the practitioner' s
233	412		license under the law solely on the basis of such license.
234		-
235	413		L. Decisions by an insurer or a preferred provider organization
236	414		(PPO) to authorize or deny coverage for an emergency service shall
237	415		be based on the patient presenting symptoms arising from any in jury,
238	416		illness, or condition manifesting itself by acute symptoms of
239	417		sufficient severity, including severe pain, such that a reasonable
240	418		and prudent layperson could expect the absence of medical attention
241	419		to result in serious:
242		-
243	420		1. Jeopardy to the health of t he patient;
244	421
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245	448		2. Impairment of bodily function; or
246		-
247	449		3. Dysfunction of any bodily o rgan or part.
248		-
249	450		M. An insurer or preferred provider organization (PPO) shall
250	451		not deny an otherwise covered emergency service based solely upon
251	452		lack of notification to the insur er or PPO.
252		-
253	453		N. An insurer or a preferred provider organization (PPO) shall
254	454		compensate a provider for patient screening, evaluation, and
255	455		examination services that are reasonably calculated to assist the
256	456		provider in determining whether the condition of the p atient
257	457		requires emergency service. If the provider determines that the
258	458		patient does not require emergency service, coverage for services
259	459		rendered subsequent to that determination shall be governed by the
260	460		policy or PPO contract.
261		-
262	461		O. Nothing in this act sha ll be construed as prohibiting an
263	462		insurer, preferred provider organization or oth er network from
264	463		determining the adequacy of the size of its network.
265		-
266	464		P. An insurer or a preferred provider organization shall not
267	465		unilaterally remove a provider from the net work solely because the
268	466		provider informs an enrollee of the full range of physici ans and
269		-	providers available to the enrollee, including out -of-network ~~ENR. H. B. NO. 2323 Page 7~~
	467	+	providers available to the enrollee including out-of-network
270	468		providers. Nothing in this act prohibits any insurer from allowing
271	469		a contract to expire by its own terms or negotiating a new contract
272	470		with the provider at the end of the contract term. A provider
273	471		agreement shall not, as a condition of the agreement, prohibit,
274		-	penalize, terminate, or otherwise restrict a preferred provider from
275		-	referring to an out-of-network provider; provided, the insured signs
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	499	+	penalize, terminate or otherwise restrict a preferred provider from
	500	+	referring to an out-of-network provider provided the insured signs
276	501		an acknowledgment of referral that the in sured may be responsible
277	502		for:
278		-
279	503		1. Higher coinsurance and deductibles; and
280		-
281	504		2. Charges which exceed the allowable charges of a preferred
282	505		provider.
283		-
284		-	SECTION 2. This act shall become effective November 1, 2021. ENR. H. B. NO. 2323 Page 8
285		-	Passed the House of Representatives the 3rd day of March, 2021.
286		-
287		-
288		-
289		-
290		-	Presiding Officer of the House
291		-	of Representatives
292		-
293		-
294		-	Passed the Senate the 20th day of April, 2021.
295		-
296		-
297		-
298		-
299		-	Presiding Officer of the Senate
300		-
301		-
302		-
303		-	OFFICE OF THE GOVERNOR
304		-	Received by the Office of the Governor this ____________________
305		-	day of ___________________, 20_______, at _______ o'clock _______ M.
306		-	By: _________________________________
307		-	Approved by the Governor of the State of O klahoma this _________
308		-	day of ___________________, 20_______, at _______ o'clock _______ M.
309		-
310		-
311		-	_________________________________
312		-	Governor of the State of Oklahoma
313		-
314		-	OFFICE OF THE SECRETARY OF STATE
315		-	Received by the Office of the Secretary of State this ____ ______
316		-	day of ___________________, 20_______, at _______ o'clock _______ M.
317		-	By: _________________________________
318		-
	506	+	SECTION 2. This act shall become effective November 1, 2021.
	507	+	COMMITTEE REPORT BY: COMMITTEE ON RETIREMENT AND INSURANCE
	508	+	March 29, 2021 - DO PASS