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28	28	STATE OF OKLAHOMA
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30	30	2nd Session of the 58th Legislature (2022)
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32	32	HOUSE BILL 4098 By: Frix
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38	38	AS INTRODUCED
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40	40	An Act relating to insurance; creating the Oklahoma
41	41	Right to Shop and Transpare ncy Act of 2022; defining
42	42	terms; allowing insurance carriers to offer shared
43	43	savings incentive programs; limiting provider
44	44	participation in certain circumstances; requiring
45	45	enrollees to stay in -network in certain situations;
46	46	providing parameters for out-of-network participation
47	47	in shared savings incentive programs; providing for
48	48	certain construction of provisions; requiring certain
49	49	terms when enrollees receive out -of-network service;
50	50	limiting enrollee and carrier financial liability in
51	51	certain situations; requiring certain features of
52	52	shared savings incentive progra ms; providing for
53	53	calculation and disbursement of savings; limiting
54	54	purpose of savings; requiring Insurance Commissioner
55	55	to create certain form with certain provisions;
56	56	providing for submission of form; providing for
57	57	codification; and providing an effectiv e date.
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62	62	BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
63	63	SECTION 1. NEW LAW A new section of law to be codified
64	64	in the Oklahoma Statutes as Section 6060.40 of Title 36, unless
65	65	there is created a duplication in number ing, reads as follows:
66	66	This act shall be known and may be cited as the "Oklahoma Right
67	67	to Shop and Transparency Act of 2022 ".
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94	94	SECTION 2. NEW LAW A new section of law to be codified
95	95	in the Oklahoma Statutes as Section 6060.41 of Titl e 36, unless
96	96	there is created a duplication in numbering, reads as follows:
97	97	As used in the Oklahoma Right to Shop and Transparency Act of
98	98	2022:
99	99	1. "Allowed amount" means the contractually agreed -upon amount
100	100	paid by a carrier to a provider who has entered into a contract with
101	101	the carrier to provide health care services under the terms and
102	102	conditions established in the contract;
103	103	2. "Average allowed amount " means mean, median, or mode of all
104	104	contractually agreed-upon amounts paid by an enrollee 's health
105	105	benefit plan for comparable health care services as defined by this
106	106	section. The QPA (Qualified Payment Amount) as defined and required
107	107	by the Federal No Surprises Act may be utilized as the average
108	108	allowed amount for the purposes of this act;
109	109	3. "Comparable health care services " means any covered
110	110	nonemergency health care service or bundle of services ;
111	111	4. "Health benefit plan" means any plan as de fined in
112	112	subsection C of Section 6060.4 of Title 36 o f the Oklahoma Statutes;
113	113	5. "Insurance carrier" or "carrier" means an insurance company
114	114	that issues policies of accident and health insurance and is
115	115	licensed to sell insurance in this state;
116	116	6. "Provider" means a health care practitioner, ambulatory
117	117	surgical center, home health care agency, or hospital; and
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144	144	7. "Shared savings incentive program " means an incentive
145	145	program established by an insurance carrier that enables enrollees
146	146	to decrease out-of-pocket costs when a comparable health care
147	147	service is provided by providers who charge less than the average
148	148	allowed amount. If a health benefit plan does not have variation in
149	149	allowed amounts, the amount reimbursed for comparable health care
150	150	services shall be considered the average allowed amount.
151	151	SECTION 3. NEW LAW A new section of law to be co dified
152	152	in the Oklahoma Statutes as Section 6060.42 of Title 36, unless
153	153	there is created a duplication in numbering, reads as follows:
154	154	A. An insurance carrier shall offer a shared savings incentiv e
155	155	program to provide incentives to an enrollee when the enro llee
156	156	obtains a comparable health care service that is covered by the
157	157	health benefit plan from providers that charge less than the average
158	158	allowed amount.
159	159	B. If a provider has entered into a contr act with a carrier to
160	160	provide health care services and the c ontractually agreed-upon
161	161	amount is less than the average allowed amount, the provider shall
162	162	not be allowed to participate in th at carrier's shared savings
163	163	incentive program unless the provider agr ees to charge less than the
164	164	contractually agreed -upon amount.
165	165	C. An enrollee in a health benefit plan that does not include
166	166	out-of-network provisions may only utilize the shared savings
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193	193	incentive program among pr oviders within the health benefit plan
194	194	network.
195	195	SECTION 4. NEW LAW A new sectio n of law to be codified
196	196	in the Oklahoma Statutes as Section 6060.43 of Title 36, unless
197	197	there is created a duplication in numbering, reads as follows:
198	198	A. An insurance carrier shall offer a shared savings incentive
199	199	program to an enrollee when covered compa rable health care services
200	200	are obtained from out -of-network providers that charge less than the
201	201	average allowed amount. Nothing in this act shall be const rued to
202	202	require a health benefit plan to cover a comparable health care
203	203	service from an out-of-network provider if the health benefit plan
204	204	does not include out -of-network benefits.
205	205	B. When an enrollee of a health benefit plan elects to receive
206	206	a covered comparable health care service from an out -of-network
207	207	provider who charges less than the average allow ed amount, a health
208	208	benefit plan shall ensure that:
209	209	1. The enrollee's financial liability is no greater than the
210	210	in-network deductible, copay, and coinsur ance amounts as dictated in
211	211	the health benefit plan contract;
212	212	2. Calculation of coinsurance liabilit y is based on the amount
213	213	charged by the out-of-network provider; and
214	214	3. The enrollee's provider is paid directly.
215	215	C. Nothing in this act shall be constru ed to require a provider
216	216	to participate in a shared savings incentive program. If an out -of-
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243	243	network provider refuses to charge an amount less than the average
244	244	allowed amount, the financial liability for the enrollee and the
245	245	carrier shall be based on the o ut-of-network health benefit plan
246	246	provisions.
247	247	SECTION 5. NEW LAW A new sectio n of law to be codified
248	248	in the Oklahoma Statutes as Section 6060.44 of Title 36, unless
249	249	there is created a duplication in numbering, reads as follows:
250	250	A. A carrier that offers a shared savings in centive program
251	251	shall:
252	252	1. Establish the program as a compon ent part of each health
253	253	benefit policy;
254	254	2. Notify enrollees annually or at the time of renewal of the
255	255	availability of the shared savings incentive program and the
256	256	procedures to participate in the program;
257	257	3. Establish an accessible means by which an enro llee may:
258	258	a. request and obtain from the health benefit plan
259	259	information regarding the payments made by the carrier
260	260	to network providers for comparable hea lth care
261	261	services,
262	262	b. ascertain the average allowed amount as defined in
263	263	this act, and
264	264	c. obtain an estimate of out-of-pocket costs; and
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291	291	4. Ensure that no less than fifty percent (50%) of the savings
292	292	generated by the participation of the enrollee in the s hared savings
293	293	incentive program is applied on the enrollee's behalf.
294	294	B. Savings generated by a share d savings incentive program
295	295	shall be calculated based upon the difference between the average
296	296	allowed amount paid for a comparable health care service and the
297	297	amount charged by the provider. Savi ngs generated by an enrollee 's
298	298	participation in a shared sav ings incentive program shall be
299	299	provided to the enrollee in the form of a cash payment or a credit
300	300	toward the annual in -network deductible and out -of-pocket limit.
301	301	Savings generated by and provided to enrollees who utilize the
302	302	shared savings incentive pro gram shall be made at least quarterly in
303	303	the form of a credit or cash payment to the enrollee.
304	304	C. Savings generated by a shared savings incentive program,
305	305	paid or credited to an enrollee, shall n ot be considered an
306	306	administrative expense for rate developm ent or rate filing purposes.
307	307	SECTION 6. NEW LAW A new section of law to be codified
308	308	in the Oklahoma Statutes as Section 6060.45 of Title 36, unless
309	309	there is created a dupli cation in numbering, reads as follows:
310	310	A. The Insurance Commissioner shall create a shared savings
311	311	incentive program form for enrollees and providers, which shall
312	312	include, but not be limited to:
313	313	1. The enrollee's name;
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340	340	2. The health benefit plan identification number, if
341	341	applicable;
342	342	3. The participating provide r's name;
343	343	4. Network status of the participating provider;
344	344	5. The average allowed amount for comparable health care
345	345	services;
346	346	6. The provider and enroll ee contractually agreed-upon amount;
347	347	and
348	348	7. The amount of savings generated by the shared savings
349	349	incentive program.
350	350	B. A signed copy of the shared savings incentive program form
351	351	shall be submitted to the insurance carrier in conjunction with the
352	352	uniform health care claim forms adopted by the I nsurance
353	353	Commissioner pursuant to Section 6581 of Title 36 o f the Oklahoma
354	354	Statutes and any other health care claim forms required by state and
355	355	federal law.
356	356	C. Nothing in this act shall prohibit an employer of a self -
357	357	funded health benefit plan governed by the Employee Retirement
358	358	Income Security Act of 1974 to volu ntarily elect to be subject to
359	359	the requirements and protections as set forth in this act.
360	360	Employers who voluntarily el ect to be subject to the requirements
361	361	and protections as set forth in this ac t shall only fall under the
362	362	jurisdiction of the Oklahoma Ins urance Department for a period of
363	363	one year. Employers must voluntarily elect to be subject to the
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390	390	provisions of this ac t every year or at renewal of a health benefit
391	391	plan.
392	392	D. The Oklahoma Insurance Commissioner shall set forth an
393	393	appropriate form, proces s by which an employer shall voluntarily
394	394	elect to be subject to the requirements and protections as set forth
395	395	in this act.
396	396	SECTION 7. This act shall become effectiv e November 1, 2022.
397	397
398	398	58-2-10258 KN 01/20/22

Oklahoma 2022 Regular Session

Oklahoma House Bill HB4098 Compare Versions