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STATE OF OKLAHOMA
1st Session of the 60th Legislature (2025)
HOUSE BILL 2805 By: Marti
AS INTRODUCED
An Act relating to dental benefit plans; defining
terms; establishing formula for medical loss ratio;
requiring annual reporting to the Oklahoma Insurance
Department; establishing process for certain data
verification; exempting certain dental plans from
provisions of act; requiring annual rebate for
certain plan years by certain plans; providing for
rebate calculation; prohibiting certain r ate
establishment; directing rule promulgation;
establishing provisions for ra te determination by
Commissioner; requiring certain rate increase notice;
amending 36 O.S. 2021, Section 7301, which relates to
dental plans; modifying definition; providing for
codification; and providing an effective date .
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 7140 of Title 36, unless ther e
is created a duplication in numbering, reads as follows:
A. As used in this act:
1. "Earned premium" means all monies paid by a policyholder or
subscriber as a condition of receiving coverage from the insurer,
including any fees or other contributions associated with the dental
plan;
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2. "Medical loss ratio (MLR) " means the percentage of all
premium funds collected by an insurer each year that shall be spent
on actual patient care rather than overhead costs; and
3. "Unpaid claim reserves " means reserves and liabilities
established to account for claims that were incurred during the MLR
reporting year but were not paid within three (3) months of the end
of the MLR reporting year.
B. The medical loss ratio for a dental plan or the dental
coverage portion of a health benefit plan shall be determined by
dividing the numerator by the denominator as defined in this
section.
C. 1. The numerator shall be the amount spent on care. The
amount spent on care shall include:
a. the amount expended for clinical den tal services which
are services within the code on dental procedures and
nomenclature, provided to enrollees which includes
payments under capitation contracts with dental
providers, whose services are covered by the contract
for dental clinical services o r supplies covered by
the contract; provided, any overpayment that has
already been received from providers shall not be
reported as a paid claim. Overpayment recoveries
received from providers shall be deducted from
incurred claim amounts,
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b. unpaid claim reserves, and
c. claim payments recovered by insurers from providers or
enrollees using utilization management efforts shall
be deducted from incurred claim amounts.
2. Calculation of the numerator shall not include:
a. all administrative costs, includi ng, but not limited
to, infrastructure, personnel costs, or broker
payments,
b. amounts paid to third -party vendors for secondary
network savings,
c. amounts paid to third -party vendors for network
development, administrative fees, claims processing,
and utilization management, and
d. amounts paid to a provider for professional or
administrative services that do not represent
compensation or reimbursement for covered services to
an enrollee, including , but not limited to, dental
record copying costs, attorn ey fees, subrogation
vendor fees, compensation to paraprofessionals,
janitors, quality assurance analysts, administrative
supervisors, secretaries to dental personnel, and
dental record clerks .
D. The denominator shall include the total amount of the earn ed
premium revenues, excluding federal and state taxes and licensing
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and regulatory fees paid after accounting for any payments pursuant
to federal law.
E. 1. A dental benefit plan or the dental portion of a health
benefit plan that issues, sells, renews , or offers a specialized
health benefit plan contract covering dental services on or after
the effective date of this act shall file a medical loss ratio (MLR)
with the Oklahoma Insurance Department that is organized by market
and product type and, where appropriate, contains the same
information required in the 2013 federal Medica l Loss Ratio Annual
Reporting Form (CMS-10418).
2. The MLR reporting year shall be for the calendar year during
which dental coverage is provided by the plan. All terms used in
the MLR annual report shall have the same meaning as used in the
federal Public Health Service Act, 42 U.S.C., Section 300gg -18, Part
158 of Title 45 of the Code of Federal Regulations.
F. 1. If data verification of the dental benefit plan or the
dental portion of a health benefit plan 's representations in the MLR
annual report is deemed necessary, the Insurance Department shall
provide the health benefit plan with a notification thirty (30) days
before the commencement of the financial examination.
2. The dental benefit plan or the dental portion of a health
benefit plan shall have thirty (30) days from the date of
notification to submit to the Department all requested data. The
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Insurance Commissioner may extend the time for a health benefit plan
to comply with this subsection upon a finding of good cause.
G. The Insurance Department shall make available to the public
in a searchable format on a public website all of the data provided
to the Department pursuant to this section which allows members of
the public to compare dental loss ratios among carriers by plan
type.
H. The provisions of this act shall not apply to health benefit
plans under Medicaid.
SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statu tes as Section 7141 of Title 36, unless there
is created a duplication in numb ering, reads as follows:
A. 1. A dental benefit plan or the dental portion of a health
benefit plan that issues, sells, renews, or offers a specialized
health care service plan contract covering dental services on or
after the effective date of this act shall provide an annual rebate
to each enrollee under that coverage, on a pro rata basis , if the
dental loss ratio Formula established in subsections C and D of
Section 1 of this act, is applied and the loss ratio is determined
to be less than, at minimum:
a. eighty-five percent (85%) for large group plans as
defined in 42 U.S.C. , Section 18024(b)(2), and
b. eighty percent (80%) for individual and small group
plans as defined in 4 2 U.S.C., Section 18024(b)(2).
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2. Dental benefit plans shall implement the provisions of
paragraph 1 of this subsection not later than January 1, 2028.
B. The total amount of an annual rebate required under this
section shall be calculated in an amount e qual to the product of the
amount by which the percentage described in subsect ion A of this
section exceeds the insurer 's reported ratio described in
subsections C and D of Section 1 of this act multiplied by the total
amount of premium revenue, excluding federal and state taxes and
licensing or regulatory fees and after accounting for payments or
receipts for risk adjustment, risk corridors, and reinsurance.
C. A dental benefit plan or the dental portion of a health
benefit plan shall provide any rebate o wed to an enrollee no later
than August 1 of the calendar year following the y ear for which the
ratio described in subsection A of this section was calculated.
SECTION 3. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 7142 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A. All carriers offering dental benefit plans shall file group
product base rates and any changes to group rating factors that are
to be effective on January 1 of each year, on or before July 1 of
the preceding year.
B. A dental benefit plan or the dental portion of a health
benefit plan that issues, sells, renews, or offers a specialized
health benefit plan contract covering dental services shall no t
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establish rates for any dental coverage plan issued to any
policyholder that are excessive, inadequate, or unfairly
discriminatory. To assure compliance with the requirements of this
section that rates are not excessive in relation to benefits, the
Insurance Commissioner shall promulgate rules to require rate
filings and shall re quire the submission of adequate documentation
and supporting information, including actuarial opinions or
certifications that the rates proposed by dental plans result in the
MLR meeting or exceeding the ratios described in subsection A of
Section 2 of this act.
C. 1. If a carrier files a base rate change and the
administrative expense loading component, not including taxes and
assessments, increases by more than the most recen t calendar year's
percentage increase in the dental services Consumer Price In dex for
All Urban Consumers, U.S. city average, not seasonally adjusted, the
base rate shall be deemed excessive and presumptively disapproved.
2. If the carrier's rate is presumptively disapproved:
a. the carrier shall communicate to all employers and
individuals covered under a group product that the
proposed increase has been presumptively disapproved
and is subject to a hearing by the Department, and
b. the Insurance Department shall conduct a public
hearing and shall properly advertise the hearing in
compliance with public hearing requirements .
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D. The carrier shall submit expected rate increases to the
Commissioner at least sixty (60) days prior to the proposed
implementation of the rates. If the Commissioner does not approve
or disapprove the rate filings within a sixty -day period, the
carrier may implement and reasonably rely upon the rates provided,
and the Commissioner may require correction of any deficiencies in
the rate filing upon later review if the rate the carrier charged is
excessive, inadequate, or unfairly discriminatory. A prospective
rate adjustment or rebate as described in Section 2 of this act are
the sole remedies for rate deficiencies. If the Commission er finds
deficiencies in the rate filing after a sixty -day period, the
Commissioner shall provide notice to the carrier, and the carrier
shall correct the rate on a prospective basis.
SECTION 4. NEW LAW A new section of law to be co dified
in the Oklahoma Statutes as Section 7143 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A. Beginning July 1, 2026 , and on or before July 1 of each year
thereafter, each dental insurer doing business in this state shall
file with the Insurance Department, in the form and manner
prescribed by the Department, an annual report on the dental loss
ratio for the preceding calendar year. The dental loss ratio annual
report shall include the following:
1. A combined dental loss ratio percentage for all individual
dental policies; and
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2. A combined dental loss ratio percentage for all group dental
policies issued to fully insured groups.
B. Not later than August 1 of each year, the Department shall
post the reported dent al loss ratios for each dental insurer on a
publicly available website in a manner that is easily located and
identifiable to the public. The Department may not post the
underlying claims, premiums and other data used to calculate the
dental loss ratios a nd shall treat all claims, premiums, and other
data as confidential.
SECTION 5. AMENDATORY 36 O.S. 2021, Section 7301, is
amended to read as follows:
Section 7301. A. No contract between a dental plan of a health
benefit plan and a dentist for the provision of services to patients
may require that a dentist provide services to its subscribers at a
fee set by the health benefit plan unless the services are covered
services under the applicable subscriber agreement.
B. As used in this section:
1. "Covered services" means services reimbursable reimbursed
under the applicable subscriber agreement, subject notwithstanding,
and without regard to the contractual limitations on subscriber
benefits as may apply, including, for example, d eductibles, waiting
period or frequency limitations ;
2. "Dental plan" means and shall include any policy of
insurance which is issued by a health benefit plan which provides
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for coverage of dental services not in connection with a medical
plan; and
3. "Health benefit plan" means any plan or arrangement as
defined in subsection C o f Section 6060.4 of this title or any
dental service corporation authorized pursuant to Section 2671 of
this title.
C. A health benefit plan or dental plan shall establish and
maintain appeal procedures for any claim by a dentist or a
subscriber that is denied based on lack of medical necessity. Any
such denial shall be based upon a determination by a dentist who
holds a nonrestricted license in the United States. Any written
communication to a dentist that includes or pertains to a denial of
benefits for all or part of a claim on the basis of a lack of
medical necessity shall include the identifier and license number
together with state of issuance, and a contact telephone numb er of
the licensed dentist making the adverse determination. The dentist
who reviewed the claim shall only be contacted at the telephone
number provided in the written communication about the denial during
business hours.
SECTION 6. This act shall become effective January 1, 2026.
60-1-11307 TJ 01/15/25