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STATE OF OKLAHOMA
1st Session of the 59th Legislature (2023)
SENATE BILL 351 By: Seifried
AS INTRODUCED
An Act relating to health insurance; amending 36 O.S.
2021, Sections 3624 and 6055, which relate to
assignment of policies and selection of care provider
by an insured; conforming language; expanding health
care providers to be paid a n assigned benefits claim;
requiring insurer failing to p ay assigned benefits
claim to pay certain costs; authorizing Insurance
Commissioner to impose civil fine for certain
violation; requiring fine be deposited in the State
Insurance Commissioner Revolvin g Fund; providing for
terms of assignability; updating statutory reference;
and providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE ST ATE 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 p olicy, whether
heretofore or hereafter issued, under the terms of which the
beneficiary may be chang ed 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 the insurer, whether
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or not the pledgee or assignee is the insurer. Any such assignment
shall entitle the insurer to deal with the assignee as the o wner or
pledgee of the policy in accordance with the terms of the
assignment, until the insurer has rec eived at its home office
written notice of termination of the assignment 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 accident an d 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 parent 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 same.
B. An accident and health insurance policy may:
1. Exclude or limit coverage for a parti cular illness, disease,
injury or condition; but, except for such exclusions or limits,
shall not exclude or limit particular services or procedures that
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
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class of practitioner. However, such services and procedures, in
order to be a covered medical expense, must:
a. be medically necessa ry,
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 any p ractitioner for the
diagnosis and treatment o f 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 copayment provisions between practitioners who, and
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 that may or may not be participating
preferred provider organization providers and practitioners,
hospitals and ambulatory surgical centers who are not participating
in the preferred provider organization, subject to the following
limitations:
a. the amount of any annual ded uctible per covered person
or per family for treatment in a hospital or
ambulatory surgical center that is not a preferred
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provider shall not exceed three times the amount of a
corresponding annual deductible for treatmen t in a
hospital or ambulatory surgi cal center that is a
preferred provider,
b. if the policy has no deductible for treatm ent in a
preferred provider hospital or ambulatory surgical
center, the deductible for treatment in a hospital or
ambulatory surgical c enter that is not a preferred
provider shall not exceed One Thousand D ollars
($1,000.00) per covered -person visit,
c. the amount of any annual deductible per covered person
or per family treatment, other tha n inpatient
treatment, by a practitioner that is not a preferred
practitioner shall not exceed three times the amount
of a corresponding annual deductible for treatment,
other than inpatient treatment, by a preferred
practitioner,
d. if the policy has no d eductible for treatment by a
preferred practition er, the annual deductible for
treatment received from a practitioner t hat is not a
preferred practitioner shall not excee d Five Hundred
Dollars ($500.00) per covered person, and
e. the percentage amount of any c oinsurance to be paid by
an insured to a practiti oner, hospital or ambulatory
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surgical center that is not a preferr ed provider shall
not exceed by more than thirty (3 0) percentage points
the percentage amount of any coinsurance payment to be
paid to a preferred provider.
2. The Insurance Commissioner has discreti on to approve a cost -
sharing arrangement which does not satisfy the limitations imposed
by this subsection if the Commissioner finds that such cost -sharing
arrangement will provide a reduction in premium cos ts.
D. 1. A practitioner who, and a hospital, or ambulatory
surgical center, home care agency, or any other health care provider
or facility licensed or certified by the state that, is not a
preferred provider shall disclose to the insured, in writing, th at
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.
2. When a referral is made to a nonparticipating hospital or
ambulatory surgical center, the referring practitioner must disclose
in writing to the insur ed, any ownership interest in the
nonparticipating hospital or ambulatory surgical center.
E. Upon submission of a claim by a practitioner , or a hospital,
home care agency, or ambulatory surgical center , or other health
care provider or facility licensed and certified by the state to an
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insurer on a uniform health care claim form adopted by the Insurance
Commissioner pursuant to Section 6581 of this title, the insurer
shall provide a timely explanation of benefits to the practitione r,
hospital, home care a gency, or ambulatory surgical center , or other
health care provider or facility licensed and certified by the state
regardless of the network participation status of such person or
entity.
F. Benefits available under a n accident and health insurance
policy, at the option of the insured, shall be assignabl e to a
practitioner who, or a hospital, home care agency , or ambulatory
surgical center, who or other health care provider or facility
licensed and certified by the state that has provided services and
procedures which are covered under the policy. A prac titioner,
hospital, home care agency , or ambulatory surgical center , or other
health care provider or facility licensed and certified by the state
shall be compensated directly by a n insurer for services a nd
procedures which have been provided when the fol lowing conditions
are met:
1. Benefits available under a policy 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 licensed and certified by the state;
2. A copy of the assignment has been provided by the
practitioner, hospital, home care agency , or ambulatory surgical
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center, or other health care provider or facility licensed and
certified by the state to the insurer;
3. A claim has been submitted by the practitioner, hospital,
home care agency, or ambulatory surgical center, or other health
care provider or facility licensed and certified by the state to the
insurer on a uniform health insu rance claim form adopted by the
Insurance Commissioner pursuant to Section 6581 of this title; and
4. A copy of the claim has been provided by the practitioner,
hospital, home care agency , or ambulatory surgical center , or other
health care provider or fa cility licensed and certified by the state
to the insured.
G. When any covered health care b enefits are assigned to an
out-of-network practitioner who, or a hospital, home care agency,
ambulatory surgical center, or other health ca re provider or
facility licensed or certified by the state that, has met all
conditions for compensation required by subsection F o f this
section, an insurer that fails to compensate the practitioner,
hospital, home care agency, a mbulatory surgical center, or o ther
health care provider or facility shall be liable for actual damag es,
any interest charges, court costs , or other legal fees, if
applicable. For any violation of this paragraph, the Insurance
Commissioner may, after notice and hearing, subject an insurer to an
additional civil fine in an amount to be determined by the
Commissioner within fifteen (15) days of a hearin g in which a
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violation is found. The fine shall be deposited into the State
Insurance Commissioner Revolving Fund.
H. The provisions of subsection F of this section shall not
apply to:
1. Any preferred pro vider organization (PPO), as defined by
generally accepted industry standards, that contracts with
practitioners that agree to accept the reimbursement 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 practitioner who, or a hospital, home
care agency, or ambulatory surgical center , or other
health care provider or facility licensed or certified
by the state who that, joins the provider network
shall be compensated dire ctly 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 licensed or certified by the
state except a practitioner who has a prior felony
conviction, to become a network provider if said
hospital or practitioner is willing to comply with the
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terms and conditions of a standa rd network provider
contract, and
d. contracts with practitioners that agree to accept the
reimbursement available under the network agreement as
payment in full and agree not to balance bill the
insured.
The provisions of this section shall not be construed to
prohibit a policyholder from assigning benefits available pursuant
to an accident and health insurance policy ; provided, however, that
the benefits of such policy include out -of-network provisions and
are being assigned to an out-out-network practitioner, hospital,
home care agency, ambulatory surgical center, or ot her health care
provider or facility licensed or certified b y the state. The
assignability of an accident and health insurance policy related to
the out-of-network care shall only be subj ect to the terms and
conditions specified in subsection F of this section.
H. I. A nonparticipating practitioner, hospital or, home care
agency, ambulatory surgical center , or other health care provider or
facility licensed or certified by the s tate may request from an
insurer and the insurer shall supply a good -faith estimate of the
allowable fee for a pr ocedure to be performed upon an insured based
upon information regarding the anticipated medical needs of the
insured provided to the insurer by the nonpa rticipating
practitioner.
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I. J. A practitioner shall be equally c ompensated for covered
services and procedures provided to an insured on the basis of
charges prevailing in the same geographica l area or in similar sized
communities for similar services an d procedures provided to
similarly ill or injured persons regardle ss of the branch of the
healing arts to which the practitioner may belong, if:
1. The practitioner does not authorize or permit false and
fraudulent advertising regarding the services and p rocedures
provided by the pract itioner; and
2. The practitioner d oes not aid or abet the insured to viol ate
the terms of the policy.
J. K. Nothing in the Health Care Freedom of Choice Act shall
prohibit an insurer from establishing a preferred provider
organization and a standard part icipating provider contract
therefor, specifying the terms and conditions, including, but not
limited to, provider qualifications, and alternative levels or
methods of payment that must be met by a practitioner selected by
the insurer as a participating pr eferred provider organization
provider.
K. L. A preferred provider organi zation, in executing a
contract, shall not, by the terms and conditions of the contract or
internal protocol, discriminate within its network of practi tioners
with respect to partici pation and reimbursement as it rela tes to any
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practitioner who is acting w ithin the scope of the practitioner ’s
license under the law solely on the basis of such license .
L. M. Decisions by an insurer or a preferred provider
organization (PPO) to authoriz e or deny coverage for an emergency
service shall be based on the patient presenting symptoms arising
from any injury, illness, or condition manifesting itself by acute
symptoms of sufficient severity, including severe pain, such that a
reasonable and prudent layperson could expect the abse nce of medical
attention to result in s erious:
1. Jeopardy to the health of the patient;
2. Impairment of bodily function; or
3. Dysfunction of any bodily organ or part.
M. N. An insurer or preferred provider organiza tion (PPO) shall
not deny an otherwise covered emergency service based sol ely upon
lack of notification to the insurer or PPO.
N. O. An insurer or a preferred provider organ ization (PPO)
shall compensate a provider for patie nt screening, evaluation, and
examination services that are reason ably calculated to assist the
provider in determining whether the condition of the patient
requires emergency service. If the provider det ermines that the
patient does not require emergency service, coverage for services
rendered subsequent to that determ ination shall be governed by the
policy or PPO contract.
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O. P. Nothing in this act the Health Care Freedom of Choice Act
shall be construed as prohibiting an insurer, preferred provid er
organization or other network from determining the adequacy of the
size of its network.
P. Q. An insurer or a preferred provider organization shall not
unilaterally remove a provider from the network solely because the
provider informs an enrollee of the full range of physicians and
providers available to the enrollee, inc luding out-of-network
providers. Nothing in this act the Health Care Freedom of Cho ice
Act prohibits any insurer from allowing a contract to expire by its
own terms or negotiating a new con tract with the provider 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 provider from ref erring to an out-of-
network provider; provided, the insured signs an acknowledgmen t 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 effe ctive November 1, 2023.
59-1-1576 RD 1/13/2023 4:57:00 PM