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ENGROSSED HOUSE
BILL NO. 1522 By: Sims, Randleman, Sneed, and
Sterling of the House
and
Bullard of the Senate
[ insurance - definitions - shared savings incentive
programs - short title - savings incentive program -
effective date ]
BE IT ENACTED BY THE PEOPLE OF THE S TATE OF OKLAHOMA:
SECTION 1. AMENDATORY Section 1, Chapter 151, O.S.L.
2022 (36 O.S. Supp. 2023, Section 6060.40), is amended to read as
follows:
Section 6060.40 This act shall be known and may be c ited as the
"Oklahoma Right to Shop Consumer Health Choice Empowerment Act".
SECTION 2. AMENDATORY Section 2, Chapter 151, O.S.L.
2022 (36 O.S. Supp. 2023, Section 6060.41 ), is amended to read as
follows:
Section 6060.41 As used in the Oklahoma Right to Shop Consumer
Health Choice Empowerment Act:
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1. "Allowed amount" means the contractually agreed -upon amount
paid by a carrier to a health care entity participating in the
network of the carrier;
2. "Average allowed amount" means the mean of all allowed
amounts paid for a comparable health care service;
3. "Comparable health care service " means any covered
nonemergency health care service or bundle of services. The
Insurance Commissioner may limit what is considered a comparable
health care service if an insuran ce carrier can demonstrate allowed
amount variation among network providers is less than Fifty Dol lars
($50.00);
3. 4. "Health benefit plan" means any plan as defined in
subsection C of Section 6060 .4 of Title 36 of the Oklahoma Statutes
this title;
4. 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;
5. 6. "Shared savings incentive " means a voluntary and optional
financial incentive that a n insurance carrier may shall provide to
an enrollee for choosing certain health care services und er a shared
savings incentive program; and
6. 7. "Shared savings incentive program " means a voluntary and
optional an incentive program established by an insurance carrier
pursuant to this act the Consumer Health Choice Empowerment Act.
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SECTION 3. AMENDATORY Section 3, Chapter 151, O.S.L.
2022 (36 O.S. Supp. 2023, Section 6060.42), is amended to read as
follows:
Section 6060.42 A. An insurance carrier may shall offer a
shared savings incentive program to provide incentives to an
enrollee when the enrollee obtains a comparable health care service
that is covered by the carrier from providers that charge le ss than
the average allowed amount paid by that carrier to network providers
for that, comparable health care service. If the allowed amount of
a provider is less than the average allowed amount paid by the
carrier, the provider shall not participate in t he shared savings
incentive program unless the provider agrees to accept an amoun t
less than the allowed amount.
B. If an enrollee of a h ealth benefit plan elects to receive a
covered comparable health care service from a provider who is not
participating in the network of the carrier and agrees to accept an
amount less than the avera ge allowed amount, the carrier shall
ensure that:
1. The financial liability of the enrollee is no greater than
the in-network deductible, copay, and coinsurance amounts as
dictated in the health benefit plan contract; and
2. Calculation of coinsurance l iability is based on the amount
negotiated by the enrolle e and his or her provider, provided that it
is an amount less than the average allowed amount.
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C. Incentives may shall be calculated as a percentage of the
difference in allowed amounts to the avera ge, as a flat dollar
amount, or by any other reasonable m ethodology approved by the
Insurance Department allowed amount paid by a carrier for a
comparable health care service . If an enrollee elects to receive a
covered comparable health care service from a provider who is not
participating in the network of the carrier, the incentive shall be
calculated as a percentage of the difference in the average allowed
amount to the amount agreed upon between the enrollee and provider,
provided that the amount is le ss than the average allowed amount .
The carrier shall pr ovide the incentive as a cash payment to the
enrollee or credit toward the annual in -network deductible and out -
of-pocket limit of the enrollee. Carriers may allow enrollees to
select which method t he enrollee prefers to receive the incentive.
C. D. An insurance carrier that offers a shared savings
incentive program shall:
1. Establish the program as a component part o f the policy or
certificate of insurance provided by the carrier and notify the
enrollees and the Insurance Department at least thirty (30 ) days
before program termination;
2. File a description of the program on a form prescribed by
the Insurance Commiss ioner. The Insurance Department shall review
the filing and determine whether th e program complies with the
provisions of this section;
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3. Notify an enrollee, annually or at the time of renewal, of
the availability of the shared savings incentive program and the
procedures to participate in the program;
4. Publish on the website of the insurance carrier, easily
accessible to enrollees and applicants for insurance, a list of
comparable health care services and health care providers and the
shared savings incentive amount applicable for each service. A
shared savings incentive shall n ot be less than twenty -five percent
(25%) of the savings generated by the participation of the enrollee
in any shared savings incentive program offered by the insurance
carrier. The baseline for the savings calculation shall be the
average in-network amount paid for that service in the most recent
twelve-month period or any other methodology established by the
insurance carrier and approved by the Insurance Department ;
5. Upon request by an enrollee, provide the average allowed
amount for a covered compar able health care service;
6. At least quarterly, credit, deposit or make a cash payment
to an enrollee of the shared savings incentive amount pursuant to
participation in the shared savings incentive program; and
6. 7. Submit an annual report to the Insu rance Department
within ninety (90) days after the close of each health benefit plan
year. At a minimum, the report shall include the following
information:
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a. the number of enrollees who participated in the
program during the health benefit plan year and the
number of instances of participation,
b. the total cost of services provided as a part of the
program, and
c. the total value of the shared savings incentive
payments made to enrollees participating in the
program and the values distributed as cash or credit
toward the annual in -network deductible and out -of-
pocket limit of an enrollee.
D. E. An enrollee shall not be required to participate in a
shared savings incentive p rogram.
SECTION 4. This act shall become effective November 1, 2024.
Passed the House of Representatives the 14th day of March, 2024.
Presiding Officer of the House
of Representatives
Passed the Senate the ___ day of __________, 2024.
Presiding Officer of the Senate