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ENGROSSED HOUSE
BILL NO. 3508 By: Sneed of the House
and
McCortney of the Senate
An Act relating to the Employee Group Insurance
Division; transferring the Employee Group Ins urance
Division from the Office of Management and Enterprise
Services to the Oklahoma Health Care Authority ;
amending 36 O.S. 2021, Section 6802, which relates to
definitions for the Oklahoma Telemedicine A ct;
transferring the Employee Group Insur ance Division
from the Office of Managemen t and Enterprise Services
to the Oklahoma Health Care Authority; amending 63
O.S. 2021, Section 2-309I, as amended by Section 1,
Chapter 257, O.S.L. 2022 (63 O.S . Supp. 2023, Section
2-309I), which relates to prescription r equirements
for opioids and benzodiazepines ; transferring the
Employee Group Insurance Division from the Office of
Management and Enterprise Services to the Oklahoma
Health Care Authority ; amending 74 O.S. 2021, Section
1304.1, which relates to Okla homa Employees Insurance
and Benefits Board; transferring the Emplo yee Group
Insurance Division from the Office of Management and
Enterprise Services to the Oklahoma Health Care
Authority; amending 85A O.S. 2021, Secti on 50, which
relates to employer required to provide prompt
medical treatment and fee schedule; transferring the
Employee Group Insurance Division from the Office of
Management and Enterprise Services to the Oklahoma
Health Care Authority ; providing for codification;
providing an effective date; and declaring an
emergency.
BE IT ENACTED BY THE PEOP LE OF THE STATE OF OKLAHOMA:
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SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Sec tion 1304.2 of Title 74, unless there
is created a duplication in numbering, reads as follows:
Effective July 1, 2024 , the Employee Group Insurance Division of
the Office of Management and Enterprise Services shal l be
transferred to the Oklahoma Health Care Authority . All unexpended
funds, property, records, p ersonnel, and any outstanding financial
obligations or encumbrances of the Office of Management and
Enterprise Services which relate to the Emplo yee Group Division
Insurance Division are hereby transferred to the Oklahoma Health
Care Authority.
SECTION 2. AMENDATORY 36 O.S. 2021, Section 68 02, is
amended to read as follows:
Section 6802. As used in the Oklahoma Telemedicine Act:
1. "Distant site" means a site at which a health care
professional licensed to practice in this state is located while
providing health care services by means of t elemedicine;
2. a. "Health benefits plan" means any plan or arrangement
that:
(1) provides benefits for medical or surgical
expenses incurred as a resu lt of a health
condition, accident or illn ess, and
(2) is offered by any insurance company, group
hospital service corporation or health
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maintenance organiza tion that delivers or issues
for delivery an individual, gr oup, blanket or
franchise insurance poli cy or insurance
agreement, a group hospita l service contract or
an evidence of coverage, or, to the ext ent
permitted by the Employee Retirement Income
Security Act of 1974, 29 U.S.C., Section 1001 et
seq., by a multiple employer welfare arrangement
as defined in Section 3 of the Employee
Retirement Income Security Act of 1974, or any
other analogous benefit arrangement, whether the
payment is fixed or by indem nity,
b. Health benefits plan shall not include:
(1) a plan that provides coverage:
(a) only for a specified disease or diseases or
under an individual limited benefit policy,
(b) only for accidental de ath or dismemberment,
(c) only for dental or visi on care,
(d) for a hospital confinement indemnity policy,
(e) for disability income insurance or a
combination of accident-only and disability
income insurance, or
(f) as a supplement to liability insurance,
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(2) a Medicare supplemental policy as defined by
Section 1882(g)(1) of the Social Security Act (42
U.S.C., Section 1395ss),
(3) workers' compensation insurance coverage,
(4) medical payment insu rance issued as part of a
motor vehicle insurance policy,
(5) a long-term care policy including a nursing home
fixed indemnity polic y, unless a determination is
made that the policy provides benefit coverage so
comprehensive that the policy meets the
definition of a health benefits plan,
(6) short-term health insurance issued on a
nonrenewable basis with a duration of six (6)
months or less, or
(7) a plan offered by the Employ ees Group Insurance
Division of the Office of Management and
Enterprise Services Oklahoma Health Care
Authority;
3. "Health care professional " means a physician or other health
care practitioner licensed, accredited or certified to perform
specified health care services consistent with state law;
4. "Insurer" means any entity providin g an accident and health
insurance policy in this state inclu ding, but not limited to, a
licensed insurance company, a not-for-profit hospital service and
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medical indemnity corporation, a fraternal ben efit society, a
multiple employer welfare arrangement o r any other entity subject to
regulation by the Insurance Com missioner;
5. "Originating site" means a site at which a patient is
located at the time health care services are provided to him or her
by means of telemedicine, which may include, but shall not be
restricted to, a patient 's home, workplace or school;
6. "Remote patient monitoring services" means the delivery of
home health services using telecommunica tions technology to enhance
the delivery of home health care including monitoring of clinical
patient data such as weight, blood pressure, pulse, pulse oxim etry,
blood glucose and other condition-specific data, medication
adherence monitoring and interacti ve video conferencing with or
without digital image upload;
7. "Store and forward transfer " means the transmission of a
patient's medical information eithe r to or from an originating site
or to or from the health care professional at the distant site, but
does not require the patient being pres ent nor must it be in real
time; and
8. "Telemedicine" or "telehealth" means technology-enabled
health and care management and delivery systems that extend capacity
and access, which includes:
a. synchronous mechanisms, which may include live
audiovisual interaction between a patient and a health
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care professional or real-time provider-to-provider
consultation through live interactive audiovisual
means,
b. asynchronous mechanisms, which include store and
forward transfers, online exchange of health
information between a patient and a health care
professional and online exchange of health information
between health care professionals, but shall not
include the use of automated text messages or
automated mobile applicat ions that serve as the sole
interaction between a patient and a health care
professional,
c. remote patient monitoring, and
d. other electronic means that s upport clinical health
care, professional consultation, patient and
professional health-related education, public health
and health administration.
SECTION 3. AMENDATORY 63 O.S. 2021, Section 2-309I, as
amended by Section 1, Chapt er 257, O.S.L. 2022 (63 O.S. Supp. 2023,
Section 2-309I), is amended to read as follows:
Section 2-309I. A. A practitioner shall not issue an initial
prescription for an opioid drug in a quanti ty exceeding a seven-day
supply for treatment of acute pain . Any opioid prescription for
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acute pain shall be for th e lowest effective dose of an immed iate-
release drug.
B. Prior to issuing an initial prescription for an opioid drug
in a course of treatme nt for acute or chronic pain, a practitioner
shall:
1. Take and document the results of a thorough medical histor y,
including the experience of the pa tient with nonopioid medication
and nonpharmacological pain-management approaches and substance
abuse history;
2. Conduct, as appropriate, and document the results of a
physical examination;
3. Develop a treatment plan with particular attention focused
on determining the cause of pain of the patient;
4. Access relevant prescription monitoring information f rom the
central repository pursuant to Section 2-309D of this title;
5. Limit the supply of any opioid drug prescribed for acute
pain to a duration of no more than seven (7) days as determined by
the directed dosage and frequency of dosage; provided, howe ver, upon
issuing an initial prescription for acute pain pu rsuant to this
section, the practitioner may issue one (1) subsequent prescription
for an opioid drug in a quantity not to exceed seven (7) da ys if:
a. the subsequent prescription is due to a major surgical
procedure or "confined to home" status as defined in
42 U.S.C., Section 1395n(a),
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b. the practitioner provides the subsequent prescription
on the same day as the initial prescription,
c. the practitioner provides written instructions on the
subsequent prescription indicating the ea rliest date
on which the prescription may be filled, otherwise
known as a "do not fill until" date, and
d. the subsequent prescription is dispensed no more than
five (5) days after the "do not fill until" date
indicated on the prescription;
6. In the case of a patient under the age of eighteen (18)
years, enter into a patient-provider agreement with a parent or
guardian of the patient; and
7. In the case of a patien t who is a pregnant woman, enter into
a patient-provider agreement with the patient.
C. No less than seven (7) days after issuing the initial
prescription pursuant to subsection A of this section, the
practitioner, after consultation with the patient, may issue a
subsequent prescription for the drug to the patient in a quantity
not to exceed seven (7) days, provided that:
1. The subsequent prescription would not be deemed an initial
prescription under this section;
2. The practitioner determines the pres cription is necessary
and appropriate to the treatm ent needs of the patient and documents
the rationale for the issuance of the subsequent prescription; and
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3. The practitioner determines that issuance of the subsequent
prescription does not present an un due risk of abuse, addiction or
diversion and documents that determination.
D. Prior to issuing the initial prescription of an opioid drug
in a course of treatment for acute or chronic pain and again prior
to issuing the third prescription of the course o f treatment, a
practitioner shall discuss with th e patient or the parent or
guardian of the patient if the patient is under eighteen (18) years
of age and is not an emancipated minor, the risks associated w ith
the drugs being prescribed, including but not limited to:
1. The risks of addiction and overd ose associated with opioid
drugs and the dangers of taking opioid drugs with alcohol,
benzodiazepines and other central nervous system depressants;
2. The reasons why the prescription is necessary;
3. Alternative treatments that may be available; and
4. Risks associated with the use of the drugs being prescribed,
specifically that opioids are highly addictive, even when tak en as
prescribed, that there is a r isk of developing a physical or
psychological dependence on the controlled dangerous substance, and
that the risks of taking more opioids tha n prescribed or mixing
sedatives, benzodiazepines or alcohol with opioids can re sult in
fatal respiratory depressio n.
The practitioner shall include a note in the me dical record of
the patient that the patient or the parent or guardian of the
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patient, as applicable, has discussed with the practitioner the
risks of developing a physica l or psychological dependence on th e
controlled dangerous substance and alternative t reatments that may
be available. The applicable state licensing board of the
practitioner shall develop and make available to practitioners
guidelines for the discussion required pursuant to this subsectio n.
E. At the time of the issuance of the third pr escription for an
opioid drug, the practiti oner shall enter into a patient-provider
agreement with the patient.
F. When an opioid drug is continuously prescribed for thre e (3)
months or more for chronic pa in, the practitioner shall:
1. Review, at a minimum of every three (3) months, the course
of treatment, any new information about the etiolo gy of the pain,
and the progress of the patient toward treatment objectives and
document the results of that review ;
2. In the first year of the patient-provider agreement, assess
the patient prior to every renewal to determine whether the patient
is experiencing problems associated with an opioid use disorder as
defined by the Ameri can Psychiatric Association and document the
results of that assessment. Following one (1) year of compliance
with the patient-provider agreement, the practitioner shall asses s
the patient at a minimum of every six (6) months;
3. Periodically make reason able efforts, unless clinically
contraindicated, to either stop the use of the contro lled substance,
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decrease the dosage, try other drugs or treatment modalities in an
effort to reduce the potential for abuse or the development of an
opioid use disorder as defined by the American Psychiatri c
Association and document with specificity the ef forts undertaken;
4. Review the central repository information in accordance with
Section 2-309D of this title; and
5. Monitor compliance with the patient-provider agreement and
any recommendations that t he patient seek a referral.
G. 1. Any prescription for acute pain pursuant to this section
shall have the words "acute pain" notated on the face of the
prescription by the practitioner.
2. Any prescription for chronic pain pursuant to this section
shall have the words "chronic pain" notated on the face of the
prescription by the practitioner.
H. This section shall not apply to a prescriptio n for a
patient:
1. Who has sickle cell disease;
2. Who is in treatment for cancer or receiving aftercare cancer
treatment;
3. Who is receiving hospice care from a licensed hospice;
4. Who is receiving palliative care in conjunction with a
serious illness;
5. Who is a resident of a long-term care facility; or
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6. For any medications that are being prescribed for u se in the
treatment of substance abuse or opioid d ependence.
I. Every policy, contract or plan delive red, issued, executed
or renewed in this state, or approved for issuance or renewal in
this state by the Insurance Commissioner, and every contract
purchased by the Employees Group Insurance Division of t he Office of
Management and Enterprise Services Oklahoma Health Care Authority ,
on or after November 1, 2018, that provides coverage for
prescription drugs subject to a copayment, coinsurance or deductible
shall charge a copayment, coinsurance or deductible for an initial
prescription of an opioid drug prescri bed pursuant to this sect ion
that is either:
1. Proportional between the cost sharing for a thirty-day
supply and the amount of drugs the patient was prescribed; or
2. Equivalent to the cost sharing for a full thirty-day supply
of the drug, provided that no additional cost shari ng may be charged
for any additional prescriptions for the remainder of the thirty-day
supply.
J. Any practitioner authorized to prescribe an opioid drug
shall adopt and maintain a written policy or policies that include
execution of a written agreement t o engage in an informed consent
process between the prescribing practitioner and qualifying opioid
therapy patient. For the purposes of this section, "qualifying
opioid therapy patient" means:
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1. A patient requiring opioid trea tment for more than three ( 3)
months;
2. A patient who is prescribed benzodiazepines and opioids
together for more than one twenty-four-hour period; or
3. A patient who is prescribed a dos e of opioids that exceeds
one hundred (100) morphine equivalent doses.
K. Nothing in the Anti-Drug Diversion Act shall be construed to
require a practitioner to limit or forcibly taper a patient on
opioid therapy. The standard of care requires effective and
individualized treatment for each patient as deemed appropr iate by
the prescribing practi tioner without an administrative or codified
limit on dose or quantity that is more restrictive than approved by
the Food and Drug Administration (FDA).
SECTION 4. AMENDATORY 74 O.S. 2021, Section 1304.1, is
amended to read as follows:
Section 1304.1 A. The State and Education Employees Group
Insurance Board and the Oklahoma State Employees Benefits Council
are hereby abolished. Wherever the State and Education Employees
Group Insurance Board and the Oklahoma State Employees Benefits
Council are referenced in la w, that reference shall be construed to
mean the Oklahoma Employees Insurance and Benefit s Board.
B. There is hereby created the Oklahoma Employees Insurance and
Benefits Board.
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C. The chair and vice-chair shall be elected by the Board
members at the first meeting of the Board and shall preside over
meetings of the Board and perform other du ties as may be required by
the Board. Upon the resignation or expiration o f the term of the
chair or vice-chair, the members shall elect a chair or vice -chair.
The Board shall elect one of its members to serve as secretary.
D. The Board shall consist of seven (7) members to be appointed
as follows:
1. The State Insurance Comm issioner, or designee;
2. Four members shall be appointed by the Governor;
3. One member shall be appointed by the Speaker of the Oklahoma
House of Representatives; and
4. One member shall be appointed by the President Pro Tempore
of the Oklahoma State Senate.
E. The appointed members shall:
1. Have demonstrated professional experience in inve stment or
funds management, public funds management, p ublic or private group
health or pension fund management, or group health insuranc e
management;
2. Be licensed to practice law in this state and have
demonstrated professional experience in commercial matters; or
3. Be licensed by the Oklahoma Accountanc y Board to practice in
this state as a public accountant or a certified public acc ountant.
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In making appointments that conform to the requirements of this
subsection, at least one but not more than thre e members shall be
appointed each from paragraphs 2 an d 3 of this subsection by the
combined appointing authorities.
F. Each member of the Board shall serve a ter m of four (4)
years from the date of appointment.
G. Members of the Board shall be subject t o the following:
1. The appointed members shall each receive compensation of
Five Hundred Dollars ($500.00) per month. Appointed membe rs who
fail to attend a reg ularly scheduled meeting of the Board shall not
receive the related compensation;
2. The appointed members shall be reimbursed for their
expenses, according to the State Travel Reimburseme nt Act, as are
incurred in the performan ce of their duties, which s hall be paid
from the Health Insurance Reserve Fund;
3. In the event an appointed member doe s not attend at least
seventy-five percent (75%) of th e regularly scheduled meetings of
the Board during a calendar year, the appointing authority may
remove the member;
4. A member may also be removed for any other cause as provided
by law;
5. No Board member shall be individually or personally liable
for any action of the Board; and
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6. Participation on the Board is contingent upon mai ntaining
all necessary annual training as may be required through the Health
Insurance Portability and Accountability Ac t of 1996, Medicare
contracting requirements or other statutory or regulatory
guidelines.
H. The Board shall meet as often as necessary to conduct
business but shall meet no less than four times a year, with an
organizational meeting to be held prior to D ecember 1, 2012. The
organizational meeting shall be called by the Insurance
Commissioner. A majority of the members of the Board shal l
constitute a quorum for t he transaction of business, and any
official action of the Board must have a favorable vote b y a
majority of the members of the Board present.
I. Except as otherwise provided in this subse ction, no member
of the Board shall be a lobbyist registered in thi s state as
provided by law, or be employed directly or indirectly by any firm
or health care provider under contract to the State and Education
Employees Group Insurance Board, the Oklahoma State Employees
Benefits Council, or th e Oklahoma Employees Insura nce and Benefits
Board, or any benefit program under its jurisdiction, for any goods
or services whatsoever. Any physician member of the Board sha ll not
be subject to the provisions of thi s subsection.
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J. Any vacancy occurring on the Board shall be fille d for the
unexpired term of office in the same manner as provided for in
subsection D of this section.
K. The Board shall act in accordance with t he provisions of the
Oklahoma Open Meeting Act, the Oklahoma Open Records Act and the
Administrative Procedur es Act.
L. The Administrative Director of the Courts shall designate
grievance panel members as shall be necessary. The members of the
grievance panel shall consist of two attorneys licen sed to practice
law in this state and on e state licensed health car e professional or
health care administrator who has at least three (3) years practical
experience, has had or has admitting privileges to a hospita l in
this state, has a working knowledge o f prescription medication, or
has worked in an administrative capac ity at some point in their
career. The state health care professional shall be appointed by
the Governor. At the Governor's discretion, one or mo re qualified
individuals may also be appoi nted as an alternate to serve on the
grievance panel in the event t he Governor's primary appointee
becomes unable to serve.
M. The Office of Management and Ent erprise Services Oklahoma
Health Care Authority shall have the following duties,
responsibilities and authority with respec t to the administration of
the flexible benefits plan authorized pursuan t to the State
Employees Flexible Benefits Act:
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1. To construe and interpret the plan, and decide all questions
of eligibility in accordance wi th the Oklahoma State Employees
Benefits Act and 26 U.S.C.A., Section 1 et seq.;
2. To select those benefits wh ich shall be made availa ble to
participants under the p lan, according to the Oklahoma State
Employees Benefits Act, and other applicable laws an d rules;
3. To prescribe procedures to be followed by participants in
making elections and filing claims under the plan;
4. Beginning with the plan year which begins on January 1,
2013, to select and contract with one or more providers to offer a
group TRICARE Supplement product to eligible em ployees who are
eligible TRICARE benefic iaries. Any membership dues req uired to
participate in a group TRICARE Supplement prod uct offered pursuant
to this paragraph shall be paid by the employee. As used in this
paragraph, "TRICARE" means the Department of Defense health care
program for active duty and retired service membe rs and their
families;
5. To prepare and distribute in formation communicating and
explaining the plan to participating employers and participan ts.
Health Maintenance Organizations or other third-party insurance
vendors may be directly or indirectly involv ed in the distribution
of communicated information to p articipating state agency employers
and state employee participants subject to the follow ing condition:
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the Board shall verify a ll marketing and communications informat ion
for factual accuracy prior t o distribution;
6. To receive from participating emplo yers and participants
such information as shall be necessary for the proper administratio n
of the plan, and any of the benefits o ffered thereunder;
7. To furnish the pa rticipating employers and partic ipants such
annual reports with respect to the administ ration of the plan as are
reasonable and appropriate;
8. To keep reports of benefit elec tions, claims and
disbursements for clai ms under the plan;
9. To negotiate for best and final offer through com petitive
negotiation with the assistance and through th e purchasing
procedures adopted by the Office of Management and Enterprise
Services Oklahoma Health Care Authority and contract with federally
qualified health maintenance organizations under the provi sions of
42 U.S.C., Section 300e et seq., or with Health Maintenance
Organizations granted a certificate of authority by the Insura nce
Commissioner pursuant to the Health Maintenance Reform Act of 2003
for consideration by participants as an alternative to the health
plans offered by the Oklahoma Employees Insurance and Benefits
Board, and to transfer to the health maintenance organiz ations such
funds as may be approved for a participant electing health
maintenance organization alternative services. The Bo ard may also
select and contract with a ve ndor to offer a point-of-service plan.
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An HMO may offer coverage through a point -of-service plan, subject
to the guidelines esta blished by the Board. However, if the Board
chooses to offer a point-of-service plan, then a vendor that offers
both an HMO plan and a point-of-service plan may choose to offer
only its point-of-service plan in lieu of offering its HMO plan.
The Board may, however, renegotiate rates with successful bidders
after contracts have been award ed if there is an extraordinary
circumstance. An extraordinary circumstance shall be limited to
insolvency of a participating heal th maintenance organization or
point-of-service plan, dissolution of a participating health
maintenance organization or point -of-service plan or withdrawal of
another participating health maintenance organization or point-of-
service plan at any time during the calendar year. Nothing in this
section of law shall be construed to permit eith er party to
unilaterally alter the terms of the contract;
10. To retain as confid ential information the initial Request
For Proposal offers as well as any subsequent bid offers made by the
health plans prior to final contract awards as a part of the best
and final offer negotiations process for the benefit plan;
11. To promulgate admi nistrative rules for the competitive
negotiation process;
12. To require vendors offerin g coverage to provide such
enrollment and claims data as is determined by the Board. The Board
shall be authorized to retain as confidential any proprietary
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information submitted in response to the Board's Request For
Proposal. Provided, however, that an y such information requested by
the Board from the vendors shall only be subject to t he
confidentiality provision of this par agraph if it is clearly
designated in the Request For Proposal as being protected under this
provision. All requested information lacking such a designation in
the Request For Proposal shall be subject to Section 24 A.1 et seq.
of Title 51 of the Oklahoma Statutes. From health maintenance
organizations, data provided shall include the current Health Plan
Employer Data and Information Set (HEDIS);
13. To authorize the purc hase of any insurance deemed necessary
for providing benefits under the plan includin g indemnity dental
plans, provided that th e only indemnity health plan selected by the
Board shall be the indemnity plan offered by the Board, and to
transfer to the Board such funds as may be approved for a
participant electing a benefit plan offered by t he Board. All
indemnity dental plans shal l meet or exceed the following
requirements:
a. they shall have a statewide provider netw ork,
b. they shall provide benefits whic h shall reimburse the
expense for the followi ng types of dental procedures:
(1) diagnostic,
(2) preventative,
(3) restorative,
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(4) endodontic,
(5) periodontic,
(6) prosthodontics,
(7) oral surgery,
(8) dental implants,
(9) dental prosthetics, and
(10) orthodontics, and
c. they shall provide an annual benefit of not less than
One Thousand Five Hundred Dollars ($1,500.00) for all
services other than orthodontic services, and a
lifetime benefit of not less than One Thous and Five
Hundred Dollars ($1,500.00) for orthodontic services;
14. To communicate de ferred compensation programs as provided
in Section 1701 of Title 74 of the Oklaho ma Statutes;
15. To assess and collect reasonable fees from contracted
health maintenance organizations and third-party insurance vendors
to offset the costs of administrati on;
16. To accept, modify or reject ele ctions under the plan in
accordance with the Oklahoma State Employees Benefits Act and 26
U.S.C.A., Section 1 et seq.;
17. To promulgate election and claim forms to be us ed by
participants;
18. To adopt rules requi ring payment for medical and dental
services and treatment rendered by duly licens ed hospitals,
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physicians and dentists. Unless the Board has otherwise contracted
with the out-of-state health care provider, the Board shall
reimburse for medical services a nd treatment rendered and charged by
an out-of-state health care provider at least at the same percentage
level as the network percentage level of the fee schedule
established by the Oklahoma Employees Insurance and Benefits Board
if the insured employee w as referred to the out-of-state health care
provider by a physician or it was an e mergency situation and the
out-of-state provider was the closest in proximity to the plac e of
residence of the employee which off ers the type of health care
services needed. For purposes of this paragraph, health care
providers shall include, but not be l imited to, physicians,
dentists, hospitals and special care facilities;
19. To enter into a contract with out-of-state providers in
connection with any PPO or hospital or me dical network plan which
shall include, but not be limited to, special care facili ties and
hospitals outside the borders of the State of Oklahoma. The
contract for out-of-state providers shall be identical to t he in-
state provider contracts. The Board ma y negotiate for discounts
from billed charges when the out-of-state provider is no t a network
provider and the member sought services in an emergency situation,
when the services were not otherwise available in the State of
Oklahoma or when the Administrat or appointed by the Board approved
the service as an exceptional circumstance;
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20. To create the establishment of a grievance procedure by
which a three-member grievance panel shall act as an appeals body
for complaints by insured employees regarding the allowance and
payment of claims, eligibi lity, and other matters. Except for
grievances settled to the satisfaction of both parties prior to a
hearing, any person who requ ests in writing a hearing before the
grievance panel shall receive a hearing before t he panel. The
grievance procedure provi ded by this paragraph shall be the
exclusive remedy available to insured employees having complaints
against the insurer. Such gri evance procedure shall be subject to
the Oklahoma Administrative Procedures Act, incl uding provisions
thereof for review of a gency decisions by the district court. Th e
grievance panel shall schedule a hearing regarding the allowance and
payment of claims, eligibility and other matters within s ixty (60)
days from the date the grievance pa nel receives a written request
for a hearing unless the panel orders a continuance for good cause
shown. Upon written request by the insured employee to the
grievance panel and received not less than ten (10) d ays before the
hearing date, the grievance pa nel shall cause a full stenographic
record of the proceedings to be made by a comp etent court reporter
at the insured employee's expense; and
21. To intercept monies owin g to plan participants from other
state agencies, when those participants in turn owe money to the
Office of Management and E nterprise Services Oklahoma Health Care
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Authority, and to ensure that the participants are afforded due
process of law.
N. Except for a breach of fiduciary o bligation, a Board member
shall not be individually or personally responsible for any action
of the Board.
O. The Board shall operate in an advisory capacity to the
Office of Management and Enterprise Services Oklahoma Health Care
Authority.
P. The members of the Board shall not accept gifts or
gratuities from an indiv idual organization with a value in excess of
Ten Dollars ($10.00) per year. The provisions o f this section shall
not be construed to prevent the members of the Board from atten ding
educational seminars, conferences, meeti ngs or similar functions.
SECTION 5. AMENDATORY 85A O.S. 2021, Section 50, is
amended to read as foll ows:
Section 50. A. The employer shall promptly provide an injured
employee with medical, surgical, hospital, optometric, podiatric,
chiropractic and nursing ser vices, along with any medicine,
crutches, ambulatory devices, artificial limbs, eyeglasses, c ontact
lenses, hearing aids, and other apparatus as may be reasonably
necessary in connection with the injury r eceived by the employee.
The employer shall have th e right to choose the treating physician
or chiropractor.
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B. If the employer fails or neglec ts to provide medical
treatment within five (5) days after actual knowledge is recei ved of
an injury, the injur ed employee may select a physician or
chiropractor to provide medical treatment at the expense of the
employer; provided, however, that the injur ed employee, or another
in the employee's behalf, may obtain emergency treatment at the
expense of the employer where such emergency treatment is not
provided by the employer.
C. Diagnostic tests shall not be repeated sooner than six (6)
months from the date of the test unless agreed to by the parties or
ordered by the Commission for goo d cause shown.
D. Unless recommended by the treating doctor or chiropractor at
the time claimant reaches maximum medical improvement or by an
independent medical examiner, continuing medical maintenance shall
not be awarded by the Commission. The employe r or insurance carrier
shall not be responsible for continuing medical maintena nce or pain
management treatment that is outside the parameters established by
the Physician Advisory Committee or ODG. The employer or insurance
carrier shall not be responsib le for continuing medical m aintenance
or pain management treatment not previous ly ordered by the
Commission or approved in advance by the employer or insurance
carrier.
E. An employee claiming or entitled to benefits under the
Administrative Workers' Compensation Act, shall, if ord ered by the
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Commission or requested by the employer or insurance carrier, submit
himself or herself for medical examination. If an employee refu ses
to submit himself or herself to examination, his or her right to
prosecute any proceeding under the Adminis trative Workers'
Compensation Act shall be suspended , and no compensation shall be
payable for the period of such refusal.
F. For compensable in juries resulting in the use of a medical
device, ongoing service for the medical device shall be provided in
situations including, but not limited to, medical devi ce battery
replacement, ongoing medication refills related to the medical
device, medical device repair, or medical device replacement.
G. The employer shall reimburse the empl oyee for the actual
mileage in excess of twenty (20) miles round trip to and from the
employee's home to the location of a medical service provider for
all reasonable and n ecessary treatment, for an evaluation of an
independent medical examiner and for any evaluation made at the
request of the employer or insurance carrier. The rate of
reimbursement for such travel expense shall be the official
reimbursement rate as establi shed by the State Travel Reimbursement
Act. In no event shall the reimbursement of travel for medical
treatment or evaluation exceed six hundred (600) miles round trip.
H. Fee Schedule.
1. The Commission shall conduct a review and update of the
Current Procedural Terminology (CPT) in the Fee Schedule every two
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(2) years pursuant to the provisions of paragraph 14 of this
subsection. The Fee Schedule shall establi sh the maximum rates that
medical providers shall be reimbursed for medical care provided to
injured employees including, but not limited to, charges by
physicians, chiropractor s, dentists, counselors, ho spitals,
ambulatory and outpatient facilities, clini cal laboratory services,
diagnostic testing services, and ambulance services, and charges for
durable medical equipment, prosthetics, orthotics, and supplies.
The most current Fee Schedule established by the Administrator of
the Workers' Compensation Court prior to February 1, 2014, shall
remain in effect, unless or until the Legislature approves the
Commission's proposed Fee Schedule.
2. Reimbursement for medical care shall be prescribed and
limited by the Fee Schedule. The director of the Employees Gro up
Insurance Division of the Office of Management and Enterprise
Services Oklahoma Health Care Authority shall provide the Commission
such information as may be rel evant for the development o f the Fee
Schedule. The Commission shall develop the Fee Schedul e in a manner
in which quality of medical care is assured and maintained for
injured employees. The Commission shall give due consideration to
additional requireme nts for physicians treating an injured worker
under the Administrative Workers ' Compensation Act, including, but
not limited to, communication with claims representatives, ca se
managers, attorneys, and representatives of employers, and the
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additional time required to complete forms for the Commission,
insurance carriers, and employers.
3. In making adjustments to the Fee Sched ule, the Commission
shall use, as a benchmark, the reimbursement rate for each Current
Procedural Terminology (CPT) code provided fo r in the fee schedule
published by the Centers for Medicare and Medicaid Services of the
U.S. Department of Health and Human Services for use in Oklahoma
(Medicare Fee Schedu le) on the effective date of this section,
workers' compensation fee schedules emp loyed by neighboring states ,
the latest edition of "Relative Values for Physicians " (RVP), usual,
customary and reasonable m edical payments to workers' compensation
health care providers in the same trade area for comparable
treatment of a person with simi lar injuries, and all other data the
Commission deems relevant. For services not valued by CMS, the
Commission shall establ ish values based on the usual, customary and
reasonable medical payments to health care providers in the same
trade area for compara ble treatment of a person w ith similar
injuries.
a. No reimbursement shall be allowed for an y magnetic
resonance imaging (MR I) unless the MRI is provided by
an entity that meets Medicare requirements for the
payment of MRI services or is accredited by the
American College of Radiolo gy, the Intersocietal
Accreditation Commission or the Joint Commi ssion on
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Accreditation of Health care Organizations. For all
other radiology proce dures, the reimbursement rate
shall be the lesser of the reimbursement rate allowe d
by the 2010 Oklahoma Fee Schedule and two hundred
seven percent (207%) of the Medicare Fee Schedule.
b. For reimbursement of medical services for Evaluation
and Management of injured employees as defined in the
Fee Schedule adopted by the Commission, the
reimbursement rate shall n ot be less than one hundred
fifty percent (150%) of the Medicare Fee Schedule.
c. Any entity providing durable medical equipment,
prosthetics, orthotics or supplies shall be accredited
by a CMS-approved accreditation organization . If a
physician provides durable medical equipment,
prosthetics, orthotics, prescription d rugs, or
supplies to a patient a ncillary to the patient's
visit, reimbursement sha ll be no more than ten percent
(10%) above cost.
d. The Commission shall develop a reasonable stop-loss
provision of the Fee Schedule to provide for adequate
reimbursement for treatment for major burns, sev ere
head and neurological injuries, multiple syste m
injuries, and other catastrophic injuries requiring
extended periods of intensive care. An employer or
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insurance carrier shall have the right to audit the
charges and question the reasonableness and nece ssity
of medical treatment contained in a bill for treatment
covered by the stop-loss provision.
4. The right to recover charges fo r every type of medical car e
for injuries arising out of and in the course of covered employ ment
as defined in the Administr ative Workers' Compensation Act shall lie
solely with the Commission. When a medical care provider has
brought a claim to the Commi ssion to obtain payment for services, a
party who prevails in full on the claim shall be ent itled to
reasonable attorney fee s.
5. Nothing in this section shall prevent an em ployer, insurance
carrier, group self-insurance association, or certified workplac e
medical plan from contrac ting with a provider of medical care for a
reimbursement rate tha t is greater than or less than l imits
established by the Fee Schedule.
6. A treating physician may not charge more than Four Hundred
Dollars ($400.00) per hour for preparation for or testimo ny at a
deposition or appearance before the Commission in connect ion with a
claim covered by the Administrative Workers' Compensation Act.
7. The Commission's review of medical and treatment charges
pursuant to this section shal l be conducted pursuant to the Fee
Schedule in existence at the time the medical care or tre atment was
provided. The judgme nt approving the medical and treatment charges
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pursuant to this section shall be enforceable by the Commission in
the same manner as provided in the Administra tive Workers'
Compensation Act for the enforcement of other compe nsation payments.
8. Charges for prescription drugs dispensed by a pharmacy shall
be limited to ninety percent (90%) of the average wholesale price of
the prescription, plus a dispensing fee of Five Dollars ($5.00) per
prescription. "Average wholesale pr ice" means the amount determined
from the latest publication designated by the Com mission.
Physicians shall prescribe and pharmacies shall dispense generic
equivalent drugs when available. If the National Drug Code, or
"NDC", for the drug product dispens ed is for a repackaged drug, the n
the maximum reimbursement shall be the lesser of the original
labeler's NDC and the lowest-cost therapeutic equivalent drug
product. Compounded medications shall be billed by the compounding
pharmacy at the ingredient lev el, with each ingredient identif ied
using the applicable NDC of the drug product, and the corresponding
quantity. Ingredients with no NDC area are not separately
reimbursable. Payment shall be based on a sum of the allowable fee
for each ingredient plus a dispensing fee of Five Dollars ($5.00)
per prescription.
9. When medical care i ncludes prescription drugs dispensed by a
physician or other medical care provider and the NDC for the drug
product dispensed is for a repackaged drug, then the maximum
reimbursement shall be the lesser of the original labeler's NDC and
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the lowest-cost therapeutic equivalent drug product. Payment shall
be based upon a sum of the allowable fee for each ingredient plus a
dispensing fee of Five Dollars ($5.00) per prescription. Compounded
medications shall be billed by the compounding pharmacy.
10. Implantables are paid in addition to procedural
reimbursement paid for medical or surgical services. A
manufacturer's invoice for the actual cost to a physician, hospital
or other entity of an implantable device s hall be adjusted by the
physician, hospital or oth er entity to reflect, at the time
implanted, all applicable discounts, rebates, co nsiderations and
product replacement programs and shall be provided to the payer by
the physician or hospital as a condition of payment for the
implantable device. If the ph ysician, or an entity in which the
physician has a financial interest other than a n ownership interest
of less than five percent (5%) in a publically traded company,
provides implantable devices, this relat ionship shall be disclosed
to patient, employer, i nsurance company, third-party commission,
certified workplace medical plan, case m anagers, and attorneys
representing claimant and defendant. If the physician, or an entity
in which the physician has a fin ancial interest other than an
ownership interest o f less than five percent (5%) in a publicly
traded company, buys and resells impla ntable devices to a hospita l
or another physician, the markup shall be limited to ten percen t
(10%) above cost.
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11. Payment for medical care as required by the Administrativ e
Workers' Compensation Act shall be due within forty-five (45) days
of the receipt by the employer or insura nce carrier of a complete
and accurate invoice, unless the employ er or insurance carrier has a
good-faith reason to request additional information about such
invoice. Thereafter, the Commission may assess a penalty up to
twenty-five percent (25%) for any amount due under the Fee Schedule
that remains unpaid on the find ing by the Commission that no go od-
faith reason existed for the delay in payment. If the Commission
finds a pattern of an employer or insurance carrier willfully and
knowingly delaying payme nts for medical care, the Commission may
assess a civil penalty o f not more than Five Thousand Do llars
($5,000.00) per occurrence.
12. If an employee fails to appear for a scheduled appointment
with a physician or chiropractor, the employer or insurance c ompany
shall pay to the physician or chiropractor a reasonable ch arge, to
be determined by the Co mmission, for the missed appointment. In the
absence of a good-faith reason for missing the appointment, the
Commission shall order the employee to reimburse the employer or
insurance company for the charge.
13. Physicians or chiropractors providing trea tment under the
Administrative Workers ' Compensation Act shall disclose under
penalty of perjury to the Commission, on a form prescr ibed by the
Commission, any ownership or interest in any health care facility,
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business, or diagnostic center that is not th e physician's or
chiropractor's primary place of b usiness. The disclosure shall
include any employee leasing arrangement between th e physician or
chiropractor and any health care facility that is not the
physician's or chiropractor's primary place of busi ness. A
physician's or chiropractor's failure to disclose as required by
this section shall be grounds for the Commission to disqua lify the
physician or chiropractor from providing treatment under the
Administrative Workers ' Compensation Act.
14. a. Beginning on May 28, 2019, the Commission shall
conduct an evaluation of the Fee Schedule, which shall
include an update of the list of C urrent Procedural
Terminology (CPT) codes, a line item adjustment or
renewal of all rates, a nd amendment as needed to the
rules applicable to the Fee Schedule.
b. The Commission shall contract with an external
consultant with knowledge of workers' compensation fee
schedules to review regional and nationwide
comparisons of Oklahoma 's Fee Schedule rates and date
and market for medical services. The consultant shall
receive written and oral comment from employers,
workers' compensation medical service and ins urance
providers, self-insureds, group self-insurance
associations of this state and the pub lic. The
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consultant shall submi t a report of its findings and a
proposed amended Fee Schedule to the Commission.
c. The Commission shall adopt the proposed amended Fee
Schedule in whole or i n part and make any additional
updates or adjustments. The Commi ssion shall submit a
proposed updated and adjusted Fee Schedule to the
President Pro Tempore of the Senate, the Speaker of
the House of Representatives and the Gove rnor. The
proposed Fee Schedule shall become effective on July 1
following the legislative session, if approved by
Joint Resolution of the Legislature during the session
in which a proposed Fee Schedule is submitted.
d. Beginning on May 28, 2019, an exter nal evaluation
shall be conducted and a proposed amended Fee Schedule
shall be submitted to the Legislature for approval
during the 2020 legislative session. Thereafter, an
external evaluation shall be conducted and a proposed
amended Fee Schedule shall b e submitted to the
Legislature for approval every two (2) years.
I. Formulary. The Commiss ion by rule shall adopt a closed
formulary. Rules adopted by the Commission shall allow an appeals
process for claims in which a treating doctor determines and
documents that a drug not incl uded in the formulary is necessary to
treat an injured employee 's compensable injury. The Commis sion by
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rule shall require the use of generic phar maceutical medications and
clinically appropriate over-the-counter alternatives to prescription
medications unless otherwise specified by the prescribing doctor, in
accordance with applicable state law.
SECTION 6. This act shall become eff ective July 1, 2024.
SECTION 7. It being immediately necessary fo r the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, by reason whereof thi s act shall take effect and
be in full force from and after its passage and approval.
Passed the House of Representatives the 13th day of March, 2024.
Presiding Officer of the House
of Representatives
Passed the Senate the ___ day of __________, 2024.
Presiding Officer of the Senate