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STATE OF OKLAHOMA
1st Session of the 60th Legislature (2025)
HOUSE BILL 1119 By: Lepak
AS INTRODUCED
An Act relating to Oklahoma Right to Shop Act;
amending Section 2, Chapter 151, O.S.L. 2022 (36 O.S.
Supp. 2024, Section 6060.41), which r elates to
definitions; adding a term; modifying certain terms;
amending Section 3, Chapter 151, O.S.L. 2022 (36 O.S.
Supp. 2024, Section 6060.42), which relates to shared
savings incentive program and insurance carrier
obligations; clarifying the shared sa vings incentive
program; and providing an effective date .
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY Section 2, Chapter 151, O.S.L.
2022 (36 O.S. Supp. 2024, Section 6060.41), is amende d to read as
follows:
Section 6060.41. As used in the Oklahoma Right to Shop Act:
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;
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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 insurance carrier can demonstrate allowed
amount variation among network providers is less than Fifty Dollars
($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;
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 an insurance carrier may shall provide to
an enrollee for choosing certain health care services under 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.
SECTION 2. AMENDATORY Section 3, Chapter 151, O.S.L.
2022 (36 O.S. Supp. 2024, 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
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that is covered by the carrier from providers that charge less than
the average allowed amount p aid by that carrier to network providers
for that, comparable health care serv ice. If a provider's allowed
amount is less than the average allowed amount paid by the carrier,
the provider shall not participate in the shared savings inventive
program unless the provider agrees to accept an amount less than the
allowed amount.
B. If an enrollee of a health benefit plan elects to receive a
covered comparable health care service from a provider who is not
participating in the carriers network and agrees to ac cept an amount
less than the average allowed amount, the carrier shall ensure that:
1. The enrollee's financial liability 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 liability is based on the amount
negotiated by the enrollee and their provider so long as it is an
amount less than the average allowed amount.
C. Incentives may shall be calculated as a percentage of the
difference in allowed amounts to the average , as a flat dollar
amount, or by any other reasonable me thodology approved by the
Insurance Department allowed amount paid by a carrier for a
comparable health care service . If an enrollee elected to receive a
covered comparable heal th care service from a provider who is not
participating in the carriers network, the incentive shall be
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calculated as a percentage of the difference in average allowed
amount to the amount agreed upon between the enrollee and provider,
so long as the amount is less than the average allowed amount . The
carrier shall provide the inc entive 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 the 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 of the policy or
certificate of insurance provided by the carrier and noti fy 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 Commissioner. The Insurance Department shall review
the filing and determine wh ether the program complies with the
provisions of this section;
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 web site of the insurance carrier, easily
accessible to enrollees and applicants f or insurance, a list of
comparable health care services and health care providers and the
shared savings incentive amount applicable for each service. A
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shared savings incentive shall not 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 comparable 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 Insurance Department
within ninety (90) days after the close of each healt h benefit plan
year. At a minimum, the report shall include the following
information:
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
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toward the annual in -network deductible and out -of-
pocket limit of an enrollee.
D. An enrollee shall not be required to participate in a shared
savings incentive program.
SECTION 3. This act shall become effective November 1, 2025.
60-1-10624 TJ 12/05/24