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STATE OF OKLAHOMA
2nd Session of the 59th Legislature (2024 )
HOUSE BILL 3375 By: Fugate
AS INTRODUCED
An Act relating to health insurance policies;
amending 36 O.S. 2021, Section 4502, which relates to
provisions of group accident and heal th policies;
adding pregnancy to the special enrollment period;
providing when coverage begins; and providing an
effective date.
BE IT ENACTED BY THE PEOPLE OF T HE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2021, Section 4502, is
amended to read as follows:
Section 4502. A. Each group accident and health policy shall
contain in substance the following provisions:
1. A provision that, in the absence of fraud, all statements
made by the policyholder or by any in sured person shall be deemed
representations and not warranties, and that no statement made for
the purpose of effecting insurance shall avoid such insurance or
reduce benefits unless contained in a written instrument signed by
the policyholder or the insu red person, a copy of which has been
furnished to such policyholder or to such person or his or her
beneficiary;
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2. A provision that the insurer will furnish to the
policyholder, for delivery to each employee or member of the insured
group, an individual certificate setting forth in summary form a
statement of the essential features of the insurance coverage of
such employee or member and to whom benefits are payable. If
dependents or family members are included in the coverage additional
certificates need not be issued for delivery to such dependents or
family members; and
3. A provision that to the group originally insured may be
added from time to time eligible new employees or members or
dependents, as the case may be, in accordance with the terms of the
policy.
B. Each group health policy certificate subject to the
provisions of the Federal Health Insurance Portability and
Accountability Act, Public Law 104 -191, (HIPAA) laws shall contain
in substance the following provisions, which shall be in addit ion to
the provisions required by subsection A of this section.
1. A provision that a health benefit plan shall not deny,
exclude or limit benefits for a covered individual for losses
incurred more than twelve (12) months following the effective date
of the individual's coverage due to a preexisting condition;
2. A provision that a health benefit plan shall not define a
preexisting condition more restrictively than:
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a. a condition for which medical advice, diagnosis, care
or treatment was recommended or r eceived during the
six (6) months immediately preceding the effective
date of coverage,
b. pregnancy and genetic information shall not be
considered preexisting conditions,
c. a health benefit plan may exclude a preexisting
condition for late enrollees for a period not to
exceed eighteen (18) months from the date the
individual enrolls for coverage,
d. the period of any such preexisting condition exclusion
shall be reduced by the aggregate of the periods of
creditable coverage as defined in the Federal HIPA A
laws,
e. a period of creditable coverage shall not be counted
if after such period and before the enrollment date,
there was a sixty-three-day period during all of which
the individual was not covered under any creditable
coverage,
f. "enrollment date" means the date of enrollment of the
individual in the plan or coverage or, if earlier, the
first day of the waiting period for such enrollment,
and
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g. "late enrollee" means a participant or beneficiary who
enrolls under the plan other than during the first
period in which the individual is eligible to enroll
under the plan or a special enrollment period;
3. A provision that individuals losing other coverage shall be
permitted to enroll for coverage under the terms of the plan if each
of the following condit ions is met:
a. the employee or dependent was covered under a group
health plan or had health insurance coverage at the
time coverage was previously offered to the employee
or dependent,
b. the employee stated in writing at such time that
coverage under a group health plan or health insurance
coverage was the reason for declining enrollment, but
only if the plan sponsor or issuer required such a
statement at such time and provided the employee with
notice of such requirement, and the consequences of
such requirement, at such time,
c. the employee's or dependent's coverage was under a
COBRA continuation provision and the coverage under
such provision was exhausted; or was not under such a
provision and either the coverage was terminated as a
result of loss of eligibility for the coverage,
including as a result of legal separation, divorce,
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death, termination of employment, or reduction in the
number of hours of employment, or employer
contributions toward such coverage were terminated,
and
d. under the terms of the plan, the employee requests
such enrollment not later than thirty (30) days after
the date of exhaustion of coverage;
4. A provision that for any period that an individual is in a
waiting period for any coverage under a group health plan or for
group health insurance coverage or is in an affiliation period, that
period shall not be taken into account in determining the continuous
period of creditable coverage. "Affiliation period" means a period
which, under the terms of the health insurance coverag e offered by a
health maintenance organization, must expire before the health
insurance coverage becomes effective. The organization is not
required to provide health care services or benefits during such
period and no premium shall be charged to the part icipant or
beneficiary for any coverage during the period;
5. A provision that preexisting condition exclusions will not
apply to newborns, who, as the last day of the thirty -day period
beginning with the date of birth, are covered under creditable
coverage;
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6. A provision that preexisting condition exclusions will not
apply to a child who is adopted or placed for adoption before
attaining eighteen (18) years of age;
7. A provision that dependents are eligible for a special
enrollment period if the group health plan makes coverage available
with respect to a dependent of an individual, and the individual is
a participant under the plan, or has met any waiting period
applicable to becoming a participant under the plan and is eligible
to be enrolled under t he plan but for a failure to enroll during a
previous enrollment period, and a person becomes such a dependent of
the individual through marriage, birth or, adoption or, placement
for adoption, or pregnancy. The special enrollment period shall
apply to that person or, if not otherwise enrolled, the individual,
the dependent of the individual, and in the case of the birth or,
adoption of a child, or pregnancy of the indivi dual or dependent of
the individual, the spouse of the individual may be enrolled as a
dependent of the individual if such spouse is otherwise eligible for
coverage.
a. The dependent special enrollment period shall be a
period of not less than thirty (30) days and shall
begin on the later of the date dependent coverage is
made available, or t he date of the marriage, birth, or
adoption or, placement for adoption . The dependent
special enrollment period, for pregnancy, shall be a
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period of not less t han ninety (90) days and shall
begin on the date of the pregnancy.
b. There is no waiting period if an individual seeks to
enroll a dependent during the first thirty (30) days
of such a dependent special enrollment period.
c. The coverage for the d ependent shall become effective
in the case of marriage, not later than the first day
of the first month beginning after the date the
completed request for enrollment is received, in the
case of a dependent's birth, as of the date of such
birth, in the case of a dependent's adoption or
placement for adoption, the date of such adoption o r
placement for adopti on, in the case of pregnancy of
either the individual or dependent of the individual ,
not later than the first day of the first month
beginning after the date the completed request for
enrollment is received ;
8. A provision that eligibility or continued e ligibility of any
individual will not be based on any of the following health -status-
related factors in relation to the individual or a dependent of the
individual: health status, medical condition, including both
physical and mental illnesses, claims exp erience, receipt of health
care, medical history, genetic information, evidence of
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insurability, including conditions arising out of acts of domestic
violence or disability.
a. Carriers are not required to provide particular
benefits other than those provi ded under the terms of
the plan or coverage.
b. Carriers may establish limitations or restrictions on
the amount, level, extent, and nature of the benef its
or coverage for similarly situated individuals
enrolled in the plan or coverage; and
9. A provision that the group health plan is guaranteed
renewable, except as provided pursuant to the federal provisions
found in HIPAA, which are as follows:
a. nonpayment of premium,
b. fraud,
c. violation of participation and/or contribution rules,
d. termination of coverage:
(1) in any case in which an issuer decides to
discontinue offering a particular type of group
health insurance coverage offered in the large o r
small group market, coverage of such type may be
discontinued by the issuer only if: the issuer
provides notice to each plan sponsor provided
coverage of this type in such market, and
participants and beneficiaries covered under such
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coverage, of such discontinuation at least ninety
(90) days prior to the date of the
discontinuation of such coverage and m akes
available the option to purchase all or, in the
case of the large group market, any other health
insurance coverage currently being offered by the
issuer to a group health plan in such market and
in exercising the option to discontinue coverage
of this type and in offering the option of
coverage pursuant to this provision, the issuer
acts uniformly without regard to the claims
experience of those spo nsors or any health-
status-related factor relating to any
participants or beneficiaries covered or new
participants or beneficiaries who may become
eligible for such coverage,
(2) in any case in which an issuer decides to
discontinue offering a particular type of group
health insurance coverage offered in the large or
small group market, coverage of such typ e may be
discontinued by the issuer only if: the issuer
provides notice to the Oklahoma Insurance
Department and to each plan sponsor and
participants and beneficiaries covered under such
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coverage of such discontinuation at least one
hundred eighty (180) days prior to the date of
the discontinuation of such coverage; and all
health insurance issued or delivered for issuance
in the state in such market or markets are
discontinued and coverage under such health
insurance coverage in such market or markets is
not renewed, and
(3) in the case of a discontinuation under division
(2) of this subparagraph in a market, the issuer
shall not provide for the issuanc e of any health
insurance coverage in the market and in this
state during the five -year period beginning on
the date of the discontinuation of the last
health insurance coverage not so renewed,
e. movement outside the service area, and
f. association membership ceases.
SECTION 2. This act shall become effective November 1, 2024.
59-2-9610 TJ 01/17/24