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STATE OF OKLAHOMA
2nd Session of the 58th Legislature (2022)
HOUSE BILL 4098 By: Frix
AS INTRODUCED
An Act relating to insurance; creating the Oklahoma
Right to Shop and Transpare ncy Act of 2022; defining
terms; allowing insurance carriers to offer shared
savings incentive programs; limiting provider
participation in certain circumstances; requiring
enrollees to stay in -network in certain situations;
providing parameters for out-of-network participation
in shared savings incentive programs; providing for
certain construction of provisions; requiring certain
terms when enrollees receive out -of-network service;
limiting enrollee and carrier financial liability in
certain situations; requiring certain features of
shared savings incentive progra ms; providing for
calculation and disbursement of savings; limiting
purpose of savings; requiring Insurance Commissioner
to create certain form with certain provisions;
providing for submission of form; providing for
codification; and providing an effectiv e date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6060.40 of Title 36, unless
there is created a duplication in number ing, reads as follows:
This act shall be known and may be cited as the "Oklahoma Right
to Shop and Transparency Act of 2022 ".
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SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6060.41 of Titl e 36, unless
there is created a duplication in numbering, reads as follows:
As used in the Oklahoma Right to Shop and Transparency Act of
2022:
1. "Allowed amount" means the contractually agreed -upon amount
paid by a carrier to a provider who has entered into a contract with
the carrier to provide health care services under the terms and
conditions established in the contract;
2. "Average allowed amount " means mean, median, or mode of all
contractually agreed-upon amounts paid by an enrollee 's health
benefit plan for comparable health care services as defined by this
section. The QPA (Qualified Payment Amount) as defined and required
by the Federal No Surprises Act may be utilized as the average
allowed amount for the purposes of this act;
3. "Comparable health care services " means any covered
nonemergency health care service or bundle of services ;
4. "Health benefit plan" means any plan as de fined in
subsection C of Section 6060.4 of Title 36 o f the Oklahoma Statutes;
5. "Insurance carrier" or "carrier" means an insurance company
that issues policies of accident and health insurance and is
licensed to sell insurance in this state;
6. "Provider" means a health care practitioner, ambulatory
surgical center, home health care agency, or hospital; and
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7. "Shared savings incentive program " means an incentive
program established by an insurance carrier that enables enrollees
to decrease out-of-pocket costs when a comparable health care
service is provided by providers who charge less than the average
allowed amount. If a health benefit plan does not have variation in
allowed amounts, the amount reimbursed for comparable health care
services shall be considered the average allowed amount.
SECTION 3. NEW LAW A new section of law to be co dified
in the Oklahoma Statutes as Section 6060.42 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. An insurance carrier shall offer a shared savings incentiv e
program to provide incentives to an enrollee when the enro llee
obtains a comparable health care service that is covered by the
health benefit plan from providers that charge less than the average
allowed amount.
B. If a provider has entered into a contr act with a carrier to
provide health care services and the c ontractually agreed-upon
amount is less than the average allowed amount, the provider shall
not be allowed to participate in th at carrier's shared savings
incentive program unless the provider agr ees to charge less than the
contractually agreed -upon amount.
C. An enrollee in a health benefit plan that does not include
out-of-network provisions may only utilize the shared savings
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incentive program among pr oviders within the health benefit plan
network.
SECTION 4. NEW LAW A new sectio n of law to be codified
in the Oklahoma Statutes as Section 6060.43 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. An insurance carrier shall offer a shared savings incentive
program to an enrollee when covered compa rable health care services
are obtained from out -of-network providers that charge less than the
average allowed amount. Nothing in this act shall be const rued to
require a health benefit plan to cover a comparable health care
service from an out-of-network provider if the health benefit plan
does not include out -of-network benefits.
B. When an enrollee of a health benefit plan elects to receive
a covered comparable health care service from an out -of-network
provider who charges less than the average allow ed amount, a health
benefit plan shall ensure that:
1. The enrollee's financial liability is no greater than the
in-network deductible, copay, and coinsur ance amounts as dictated in
the health benefit plan contract;
2. Calculation of coinsurance liabilit y is based on the amount
charged by the out-of-network provider; and
3. The enrollee's provider is paid directly.
C. Nothing in this act shall be constru ed to require a provider
to participate in a shared savings incentive program. If an out -of-
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network provider refuses to charge an amount less than the average
allowed amount, the financial liability for the enrollee and the
carrier shall be based on the o ut-of-network health benefit plan
provisions.
SECTION 5. NEW LAW A new sectio n of law to be codified
in the Oklahoma Statutes as Section 6060.44 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. A carrier that offers a shared savings in centive program
shall:
1. Establish the program as a compon ent part of each health
benefit policy;
2. Notify enrollees annually or at the time of renewal of the
availability of the shared savings incentive program and the
procedures to participate in the program;
3. Establish an accessible means by which an enro llee may:
a. request and obtain from the health benefit plan
information regarding the payments made by the carrier
to network providers for comparable hea lth care
services,
b. ascertain the average allowed amount as defined in
this act, and
c. obtain an estimate of out-of-pocket costs; and
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4. Ensure that no less than fifty percent (50%) of the savings
generated by the participation of the enrollee in the s hared savings
incentive program is applied on the enrollee's behalf.
B. Savings generated by a share d savings incentive program
shall be calculated based upon the difference between the average
allowed amount paid for a comparable health care service and the
amount charged by the provider. Savi ngs generated by an enrollee 's
participation in a shared sav ings incentive program shall be
provided to the enrollee in the form of a cash payment or a credit
toward the annual in -network deductible and out -of-pocket limit.
Savings generated by and provided to enrollees who utilize the
shared savings incentive pro gram shall be made at least quarterly in
the form of a credit or cash payment to the enrollee.
C. Savings generated by a shared savings incentive program,
paid or credited to an enrollee, shall n ot be considered an
administrative expense for rate developm ent or rate filing purposes.
SECTION 6. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6060.45 of Title 36, unless
there is created a dupli cation in numbering, reads as follows:
A. The Insurance Commissioner shall create a shared savings
incentive program form for enrollees and providers, which shall
include, but not be limited to:
1. The enrollee's name;
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2. The health benefit plan identification number, if
applicable;
3. The participating provide r's name;
4. Network status of the participating provider;
5. The average allowed amount for comparable health care
services;
6. The provider and enroll ee contractually agreed-upon amount;
and
7. The amount of savings generated by the shared savings
incentive program.
B. A signed copy of the shared savings incentive program form
shall be submitted to the insurance carrier in conjunction with the
uniform health care claim forms adopted by the I nsurance
Commissioner pursuant to Section 6581 of Title 36 o f the Oklahoma
Statutes and any other health care claim forms required by state and
federal law.
C. Nothing in this act shall prohibit an employer of a self -
funded health benefit plan governed by the Employee Retirement
Income Security Act of 1974 to volu ntarily elect to be subject to
the requirements and protections as set forth in this act.
Employers who voluntarily el ect to be subject to the requirements
and protections as set forth in this ac t shall only fall under the
jurisdiction of the Oklahoma Ins urance Department for a period of
one year. Employers must voluntarily elect to be subject to the
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provisions of this ac t every year or at renewal of a health benefit
plan.
D. The Oklahoma Insurance Commissioner shall set forth an
appropriate form, proces s by which an employer shall voluntarily
elect to be subject to the requirements and protections as set forth
in this act.
SECTION 7. This act shall become effectiv e November 1, 2022.
58-2-10258 KN 01/20/22