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ENGROSSED HOUSE
BILL NO. 1398 By: Lepak, Sims, Sneed, Olsen,
Caldwell (Trey), Humphrey,
Randleman, Sterling, and
Wolfley of the House
and
Jett of the Senate
An Act relating to emergency medical services;
defining term; defining certain actions as unfair
methods of competition or unfair or deceptive act s or
practices for certain purposes; prohibiting
distinction in health care coverage related to
network status of emergency care providers or
facilities; prohibiting construction of st atutory
provisions with respect to cost-sharing amounts;
imposing requirements re lated to emergency care
claims; prescribing procedures for utilization review
process; providing for statutory construction with
respect to utilization review; providing for
codification; and providing an effective date.
BE IT ENACTED BY THE PE OPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4420 of Title 36, unless th ere
is created a duplication in numberi ng, reads as follows:
A. As used in this section, "emergency care" means health care
services provided in a general medical surgical hospita l, critical
access hospital, or emergency hospital, as such terms are defined in
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Section 1-701 of Title 63 of the O klahoma Statutes, that is licensed
by the State Department of Health, to evaluate and stabilize medical
conditions of a recent and onset seve rity, including severe pain,
regardless of the final diagnosis that is given , that would lead a
prudent layperson possessing an average knowledge of medicine and
health to believe that the individual 's condition, sickness, or
injury is of such a nature tha t failure to get immediate medical
care could:
1. Place the individual 's health in serious jeopardy;
2. Result in serious impairment to bodily function;
3. Result in serious disfunction of a bodily organ or part;
4. Result in serious disfigurement; or
5. For pregnant women, result in serious jeopardy to the health
of the fetus.
Nothing in this section shall be con strued as providing licensure
of, or applying to, facilities providing emergency care that are not
licensed as, or affiliated with, a hospita l as defined in Section 1-
701 of Title 63 of the Oklahoma Statutes.
B. It shall be an unfair method of competition or an unfair or
deceptive act or practice in the business of insurance for an
insurer or an individual or entity acting on behalf of an insu rer
to:
1. Deter enrollees from seeking care consistent with the
prudent layperson standard for emergency care; or
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2. Engage in a pattern of wrongful denia ls of claims for
emergency care.
C. If an individual's health insurance coverage includes any
benefits for emergency care, there shall be no distinction made in
regard to network status of an emergency care provid er or facility.
An enrollee's cost-sharing amount shall not be greater tha n that
which would be imposed if the services were pro vided in-network for
emergency care.
D. This section shall not be construed to prohibit an insurer
from imposing a different cost-sharing amount for out -of-network
services so long as the services provided are not related to the
evaluation and stabilization of an emer gency medical care situation.
E. Utilization review of an emergency care cl aim must be
performed by a physician bo ard-certified in emergency medicine . A
utilization review agent:
1. May not make an adverse determin ation for the emergency care
claim based on the final diagnosis that is given, including the
classification under a Current Procedural Terminology or
International Classification of Diseases co de; and
2. Must review the enrollee 's medical records before making an
adverse determination.
F. Nothing in this section may be co nstrued as authorizing
utilization review of e mergency care when otherwise prohibited by
law.
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SECTION 2. This act shall become effective November 1, 2023.
Passed the House of Representatives the 22nd day of March, 2023.
Presiding Officer of the House
of Representatives
Passed the Senate the ___ day of __________, 2023.
Presiding Officer of the Senate