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STATE OF OKLAHOMA
1st Session of the 59th Legislature (2023)
COMMITTEE SUBSTITUTE
FOR
HOUSE BILL NO. 1504 By: Sneed
COMMITTEE SUBSTITUTE
An Act relating to health insurance; amending 36 O.S.
2021, Section 3624, which relates to ass ignability of
policies; updating statutory reference; amending 36
O.S. 2021, Section 6055, which relates to insurance
policies; modifying entities subject to cert ain
policies; requiring compensation of certain entities
in certain situations; creating liabi lity for damages
in certain cases; providing for certain
administrative fines; providing for an opportunity
for hearing; directing administrative fees to certain
funds; creating certain policyholder rights; updating
statutory references; and providing an e ffective
date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2021, Section 3624, is
amended to read as follows:
Section 3624. Except as provided in subsection D of Section
6055 of this title, a policy may be assignable or not assignable, as
provided by its terms. Subject to its terms relating to
assignability, any life or accident and health policy , whether
heretofore or hereafter issued, under the terms of which the
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beneficiary may be c hanged upon the sole request of the insured, may
be assigned either by pledge or transfer of title, by an assignment
executed by the insured alone and delivered to t he insurer, whether
or not the pledgee or assignee is the insurer. Any such assignment
shall entitle the insurer to deal with the assignee as the owner or
pledgee of the policy in accordance with the terms of the
assignment, until the insurer has received at its home office
written notice of termination of the a ssignment or pledge, or
written notice by or on behalf of some other person claiming some
interest in the policy in conflict with the assignment.
SECTION 2. AMENDATORY 36 O .S. 2021, Section 6055, is
amended to read as follows:
Section 6055. A. Under any acciden t and health 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 paren t or guardian of
the insured if the insured is a minor, if the services and
procedures fall within the licensed scope of practice of the
practitioner providing the s ame.
B. An accident and health insurance policy may:
1. Exclude or limit coverage for a p articular illness, disease,
injury or condition; but, except for such exclusions or limits,
shall not exclude or limit particular services or procedures that
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can be provided for the diagnosis and treatment of a covered
illness, disease, injury or condition , if such 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 necessar y,
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 a ny practitioner 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 copaym ent provisions between practitioners,
hospitals and, ambulatory surgical centers , home care agencies, or
other health care providers or facilities that are licensed or
certified by the state who are participating preferred provider
organization providers a nd practitioners, hospitals and, ambulatory
surgical centers, home care agencies, or other health care providers
or facilities that are licensed or certified by the state who are
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not participating in the preferred provider organization, 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 pr eferred
provider shall not exceed three times the amount o f a
corresponding annual deductib le 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 h ospital or ambulatory surgical
center, the deductible for treatment 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 deducti ble per covered person
or per family treatment, other than inpatient
treatment, by a practi tioner that is not a preferred
practitioner shall not exceed three times the amount
of a corresponding annual deductible for treatment,
other than inpatient treatmen t, by a preferred
practitioner,
d. if the policy has no de ductible for treatment by a
preferred practitioner, the annual deductible for
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treatment received from a practitioner that is not a
preferred practitioner shall not exceed Five Hundred
Dollars ($500.00) per covered person, and
e. the percentage amount of an y coinsurance 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 provider.
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 cos t-sharing
arrangement will provide a reduction in premium costs.
D. 1. A practitioner, ho spital or, ambulatory surgical center,
home care agency, or other health care provider or facility that is
licensed or certified by the state 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 ambulatory surgical center
charges which exceed the allowable charges of a
preferred provider, and
c. a good-faith estimate of the total cost to the
insured.
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2. When a referral is made to a nonparticipating hospital or
ambulatory surgical center, the referring practitioner must disclose
in writing to the insured, any ownership interest in the
nonparticipating hospital or ambulatory surgical center.
E. Upon submission of a clai m by a practitioner, hospital, home
care agency, or ambulatory surgical center , or other health care
provider or facility that is licensed or certified by the state to
an insurer on a uniform health care claim form adopted by th e
Insurance Commissioner pur suant 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, or other health care provider or facility that is li censed
or certified by the s tate 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, h ome care agency or, ambulatory surgical
center, or other health care provider or facility that is licensed
or certified by the state who has provided services and procedures
which are covered under the policy. A practitioner, hospital, home
care agency or, ambulatory surgical center , or other health care
provider or facility that is licensed or certified by the state
shall be compensated directly by an insurer for services and
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procedures which have been provided when the following conditions
are met:
1. Benefits available under a po licy have been assigned in
writing by an insured to the practitioner, hospital, home care
agency or, ambulatory surgical center , or other health care provider
or facility that is licensed or certified by the state ;
2. A copy of the assignment has been pro vided by the
practitioner, hospital, home care agency or, ambulatory surgical
center, or other health care provider or facility that is licensed
or certified by the state to the insurer;
3. A claim has been submitted by the pra ctitioner, hospital,
home care agency, or ambulatory surgical center, or other health
care provider or facility that is licensed or certified by the state
to the insurer on a uniform health ins urance claim form adopted by
the Insurance Commissioner pursuan t to Section 6581 of this ti tle;
and
4. A copy of the claim has and the estimate required in
subparagraph c of paragraph 1 of subsection D of this section have
been provided by the practitioner, hospital, home care agency or,
ambulatory surgical center, or other health care provider or
facility that is licensed or certified by the s tate to the insured.
G. The provisions of subsection F of this section shall not
apply to:
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1. Any preferred provider organization (PPO), as defined by
generally accepted indus try standards, that contracts with
practitioners that agree to accept the reimb ursement 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 practiti oner, hospital, home care
agency or, ambulatory surgical center, or other health
care provider or facility that is licensed or
certified by the state who joins the provider ne twork
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, or other health care
provider or facility that is licensed or certified b y
the state, except a practitioner who has a prior
felony conviction, to become a network provider if
said the hospital or practitioner is willing to comply
with the terms and conditions of a standard network
provider contract, and
d. contracts with practi tioners that agree to accept the
reimbursement available under the network agre ement as
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payment in full and agree not to balance bill the
insured.
The provisions of this secti on shall not be deemed to prohibit a
policyholder from assigning benefits availab le pursuant to an
accident and health insurance policy, provided that the benefi ts of
such policy include out -of-network provisions and are being assigned
to an out-of-network practitioner, hospital, home care agency,
ambulatory surgical center, or other h ealth care provider or
facility that is licensed or certified by the state. The
assignability of an accident and health insurance policy related to
out-of-network care shall o nly be subject to the terms and
conditions specified in subsection F of this sec tion.
H. A nonparticipating p ractitioner, hospital or ambulatory
surgical center may request from an insurer and the insurer shall
supply a good-faith estimate of the allow able fee for a procedure to
be performed upon an insured based upon information reg arding the
anticipated medical needs of the insured provided to the insurer by
the nonparticipating practitioner.
I. A practitioner shall be equally compensated for cove red
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 servic es and procedures provided to
similarly ill or injured persons regardless of the branch of the
healing arts to which the practitioner may belong, if:
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1. The practitioner does not authorize or permit false and
fraudulent advertising regarding the services and procedures
provided by the practitioner; and
2. The practitioner does not aid or abet the insured to violate
the terms of the policy.
J. Nothing in the Health Care Freedo m of Choice Act shall
prohibit an insurer from establishing a preferred provider
organization and a standard participating provider contract
therefor, specifying the t erms and conditions, including, but not
limited to, provider qualifications, and alternat ive 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 terms and conditions of the contract or internal
protocol, discriminate within its network of practit ioners 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 th e basis of such license.
L. Decisions by an insurer or a preferred provider org anization
(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 manifest ing itself by acute symptoms o f
sufficient severity, including severe pain, such that a reasonable
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and prudent layperson could expect the absence of medical atte ntion
to result in serious:
1. Jeopardy to the health of the patient;
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 emergen cy service based solely upon
lack of notification to the insurer or PPO.
N. An insurer or a prefe rred provider organization (PP O) shall
compensate a provider for patient screeni ng, 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 tha t the
patient does not require emergency service, coverage for services
rendered subsequent to that determination shall be go verned by the
policy or PPO contract.
O. Nothing in this act the Health Care Freedom of Choice Act
shall be construed as prohib iting 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 ne twork solely because the
provider informs an enrollee of the full range of physi cians and
providers available to the enrollee , including out-of-network
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providers. Nothing in this act the Health Care Freedom of Choice
Act prohibits any insurer from allowin g a contract to expire b y its
own terms or negotiating a new contract with the p rovider at the end
of the contract term. A provider agreement shall not, as a
condition of the agreement, prohibit, penalize, terminate, or
otherwise restrict a preferred prov ider from referring to an out-of-
network provider; provided, the insured signs a n 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 3. This act shall become effective November 1, 2023.
59-1-7660 MJ 02/22/23