Oklahoma 2025 Regular Session

Oklahoma Senate Bill SB1047 Compare Versions

Version 1 (Old)

Version 2 (New)

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3		-	SENATE FLOOR VERSION - SB1047 SFLR Page 1
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29		-	SENATE FLOOR VERSION
30		-	March 6, 2025
31		-	AS AMENDED
	53	+	STATE OF OKLAHOMA
32	54
33		-	SENATE BILL NO. 1047 By: McIntosh, Bullard,
34		-	Grellner, and Standridge of
35		-	the Senate
	55	+	1st Session of the 60th Legislature (2025)
36	56
37		-	and
38		-
39		-	Newton of the House
	57	+	SENATE BILL 1047 By: McIntosh
40	58
41	59
42	60
43		-	[ health insurance - billing procedure -
44		-	reimbursement - cost incurrence - rule promulgation -
45		-	verification - fines and fees - codification -
46		-	effective date ]
	61	+
	62	+
	63	+	AS INTRODUCED
	64	+
	65	+	An Act relating to health insurance; creating the
	66	+	Oklahoma Surprise Medical Billing Act; providing
	67	+	short title; defining terms ; disallowing certain
	68	+	billing procedure; requiring reimbursement for
	69	+	certain health care service; prohibiting cost
	70	+	incurrence greater than certain cost -sharing
	71	+	obligation; directing rule promulgation; requiring
	72	+	certain verification; providing for fines and fees;
	73	+	providing for codification; and providing an
	74	+	effective date.
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51	79		BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
52	80		SECTION 1. NEW LAW A new section of law to be codified
53	81		in the Oklahoma Statutes as Section 6063 of Title 3 6, unless there
54	82		is created a duplication in numbering, reads as follows:
55	83		This act shall be known and may be cited as the “Oklahoma
56	84		Surprise Medical Billing Act ”.
57	85		SECTION 2. NEW LAW A new section of law to be codified
58	86		in the Oklahoma Statutes as Section 6063.1 of Title 36, unless there
59	87		is created a duplication in numbering, reads as follows:
60	88		As used in this section:
61		-	1. “Surprise bill” means a bill issued by an out -of-network
62		-	provider or out-of-network facility to an enrollee of a heal th
63		-	benefit plan for health care services in an amount that exceeds the
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65		-	SENATE FLOOR VERSION - SB1047 SFLR Page 2
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	140	+	1. “Surprise bill” means a bill issued by an out -of-network
	141	+	provider or out-of-network facility to an enrollee of a hea lth
	142	+	benefit plan for health care services in an amount that exceeds the
91	143		enrollee’s cost-sharing obligation applicable for the same health
92	144		care services if the services had been provided by an in-network
93	145		provider or in-network facility and are rendered in t he following
94	146		circumstances:
95	147		a. emergency care provided by an out -of-network provider
96	148		or out-of-network facility, or
97	149		b. nonemergency health care services rendered by a n out-
98	150		of-network provider at an in-network facility;
99	151		2. “Claim” means a request from a pr ovider for payment for
100	152		health care services rendered to the enrollee of a health benefit
101	153		plan;
102	154		3. “Covered person” means:
103	155		a. an enrollee, policyholder , or subscriber,
104	156		b. the enrolled dependent of an enrollee, policyholder,
105	157		or subscriber, or
106	158		c. another individual participating in a health benefit
107	159		plan;
108	160		4. “Health benefit plan” means a health benefit plan as defined
109	161		pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes ;
110	162		5. “Health care service” means any service, supply, or
111	163		procedure rendered for the diagnosis, prevention, treatment, cure ,
112		-	or relief of a health condition, illness, injury, or other disease,
113		-	including physical or behavioral health services, to the extent it
114		-	is covered by a health benefit plan ;
115	164
116		-	SENATE FLOOR VERSION - SB1047 SFLR Page 3
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	215	+	or relief of a health condition, illness, injury, or other disease,
	216	+	including physical or behavioral health services, to the extent it
	217	+	is covered by a health benefit plan ;
142	218		6. “Emergency care” means a health care procedure, treatment,
143	219		service, or ambulance transportation service delivered to a covered
144	220		person after the sudden onset of medical or behavioral health
145	221		condition symptoms of sufficient severity that, without immediate
146	222		medical attention, regardless of eve ntual diagnosis, could be
147	223		expected by a reasonable layperson to result in impairment of a
148	224		person’s physical or mental health, the health or safety of a fetus
149	225		or pregnant person, bodily function of a bodily organ or part, or
150	226		disfigurement to a person ;
151	227		7. “Minimum benefit standard ” means the eightieth percentile of
152	228		all allowed amounts for the same or similar health care service
153	229		furnished by an in-network provider or in-network facility as
154	230		reported in an independent benchmarking database maintained by a
155	231		nonprofit organization specified by the Insurance Commissioner. The
156	232		nonprofit organization shall not be financially affiliated with a
157	233		health benefit plan or provider. The calculation of the eightieth
158	234		percentile of all allowed amounts shall be reflected by cla ims paid
159	235		during the most recent calendar year ;
160	236		8. “Provider” means a health care professional that is not a
161	237		facility and is licensed to furnish health care services in this
162	238		state;
163		-	9. “In-network provider” means a provider that is under express
164		-	contract with a health benefit plan or a health benefit plan ’s
165	239
166		-	SENATE FLOOR VERSION - SB1047 SFLR Page 4
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	290	+	9. “In-network provider” means a provider that is under express
	291	+	contract with a health benefit plan or a health benefit plan ’s
192	292		contractor or subcontractor providing health care services to
193	293		enrollees of the plan ;
194	294		10. “Out-of-network provider” means a provider that is not
195	295		contracted with a health benefit plan for network particip ation;
196	296		11. “Facility” means a licensed entity providing health care
197	297		services, including:
198	298		a. a general, special, psychiatric, or rehabilitation
199	299		hospital,
200	300		b. an ambulatory surgical center ,
201	301		c. a cancer treatment center ,
202	302		d. a birth center,
203	303		e. an inpatient, outpatient, or residential drug and
204	304		alcohol treatment center ,
205	305		f. a laboratory, diagnostic, or other outpatient medical
206	306		service or testing center ,
207	307		g. a health care provider ’s office or clinic,
208	308		h. an urgent care center , or
209	309		i. any other therapeutic health care setting;
210	310		12. “In-network facility” means a facility that is under
211	311		express contract with a health insurance carrier or a health
212	312		insurance carrier’s contractor or subcontractor to provide health
213	313		care services to enrollees of a plan ;
214		-	13. “Out-of-network facility” means a facility that is not
215		-	contracted with a health benefit plan for network participation ;
216	314
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	365	+	13. “Out-of-network facility” means a facility that is not
	366	+	contracted with a health benefit plan for network participation ;
243	367		14. “Allowed amount” means the contractually agreed -upon amount
244	368		paid by a health benefit plan to an in-network provider or in-
245	369		network facility in the health benefit plan network; and
246	370		15. “Health insurance carrier ” or “carrier” means an entity
247	371		subject to state insurance laws, including a health insurance
248	372		company, a health maintenance organization, a hospital and health
249	373		service corporation, a provider servic e network, a nonprofit health
250	374		care plan, or any other entity that contracts or offers to contract,
251	375		or enters into agreements to provide, deliver, arrange for, pay for,
252	376		or reimburse any cost of health care services, or that provides,
253	377		offers, or administers a health benefit policy or managed health
254	378		care plan in this state .
255	379		SECTION 3. NEW LAW A new section of law to be codified
256	380		in the Oklahoma Statutes as Section 6063.2 of Title 36, unless there
257	381		is created a duplication in numbering, re ads as follows:
258	382		A. An out-of-network provider or out-of-network facility shall
259	383		not surprise bill a covered person for emergency care. If a covered
260	384		person pays an out-of-network provider or out-of-network facility an
261	385		amount that is greater than allowed by this section, the out-of-
262	386		network provider or out-of-network facility shall render a refund to
263	387		the covered person within thirty (30) days.
264		-	B. A health insurance carrier shall directly reimburse a n out-
265		-	of-network provider or out-of-network facility for emergency care at
266	388
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	439	+	B. A health insurance carrier shall directly reimburse a n out-
	440	+	of-network provider or out-of-network facility for emergency care at
293	441		the minimum benefit standard, or a mutually agreed upon amount, no
294	442		later than:
295	443		1. Thirty (30) days after the date the health benefit plan
296	444		receives an electronic clean claim for such care that includes all
297	445		information necessary for the carri er to pay the claim; or
298	446		2. Forty-five (45) days after the date the carrier rec eives a
299	447		nonelectronic clean claim for such care that includes all
300	448		information necessary for the carrier to pay the claim.
301	449		C. A health insurance carrier shall ensure that a cove red
302	450		person who is rendered emergency care by a n out-of-network provider
303	451		or out-of-network facility shall incur no greater cost -sharing
304	452		obligations than the covered person would have incurred if those
305	453		health care services were rendered by a n in-network provider or in-
306	454		network facility.
307	455		D. An out-of-network provider shall not surprise bill a covered
308	456		person for health care services that are not emergency care and are
309	457		rendered at an in-network facility. If a covered person pays a n
310	458		out-of-network provider an amount that is greater than allowed by
311	459		this section, the out-of-network provider shall render a refund to
312	460		the covered person within thirty (30) days.
313	461		E. A health insurance carrier shall directly reimburse a n out-
314	462		of-network provider for health care services that are not emergency
315		-	care and are rendered at an in-network facility the minimum benefit
316		-	standard, or mutually agreed to amount, no later than:
317	463
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	514	+	care and are rendered at an in-network facility the minimum benefit
	515	+	standard, or mutually agreed to amount, no later than:
344	516		1. Thirty (30) days after the date the carrier receives an
345	517		electronic clean claim for such services that includes all
346	518		information necessary for the carrier to pay the claim; or
347	519		2. Forty-five (45) days after the date the carrier receives a
348	520		nonelectronic clean claim for such services that includes all
349	521		information necessary for the carrier to pay the claim.
350	522		F. A health insurance carrier shall ensure that a covered
351	523		person who is rendered heal th care services that are not emergency
352	524		care by an out-of-network provider at an in-network facility shall
353	525		incur no greater cost -sharing obligations than the covered person
354	526		would have incurred if those health care services were rendered by
355	527		an in-network provider.
356	528		G. The Insurance Commissioner shall promulgate rules for
357	529		verifying the minimum benefit standard which may be requested by an
358	530		out-of-network provider or out-of-network facility that has rendered
359	531		health care services in accordance with this act.
360	532		1. Verification of the minimum benefit standard shall only be
361	533		requested if reimbursement has been received from a carrier and no
362	534		more than thirty (30) days have elapsed since the date payment was
363	535		received.
364		-	2. Request for verification of the minimum benefit standard may
365		-	be requested for bundled claims provided none of the claims were
366		-	paid more than thirty (30) days since the date payment was received .
367	536
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	587	+	2. Request for verification of the minimum benefit standard may
	588	+	be requested for bundled claims provided none of the claims were
	589	+	paid more than thirty (30) days since the date payment was received .
394	590		3. The Insurance Commissioner shall ensure that verification of
395	591		the minimum benefit standard is provided to an out-of-network
396	592		provider or out-of-network facility no later than fifteen (15) days
397	593		after a request has been initiated .
398	594		4. If the Insurance Commissioner determines that the a mount
399	595		reimbursed by the carrier is less than the minimum benefit standard,
400	596		the carrier shall be required to compensate the out-of-network
401	597		provider or out-of-network facility the difference between the
402	598		amount initially paid and the verified minimum benefit standard no
403	599		later than fifteen (15) days after the date the Insurance
404	600		Commissioner has verified the minimum benefit standard.
405	601		H. A health insurance carrier that fails to reimburse for
406	602		health care services at the minimum benefit standard shall be
407	603		subject to a penalty that is calculated as the difference between
408	604		the minimum benefit standard and the amount billed by the out-of-
409	605		network provider or out-of-network facility that requested
410	606		verification of the minimum benefit standard. Fifty percent (50%)
411	607		of the calculated penalty shall be made payable to the out-of-
412	608		network provider or out-of-network facility and the remaining fifty
413	609		percent (50%) shall be made payable to the Oklahoma Health Insurance
414	610		High Risk Pool.
415		-	A carrier may be subject to additional fines and p enalties, as
416		-	determined by the Commissioner, if a pattern of underpayment has
417		-	been determined.
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439	656		20
440	657		21
441	658		22
442	659		23
443	660		24
444	661
	662	+	A carrier may be subject to additional fines and penalties, as
	663	+	determined by the Commissioner, if a pattern of underpayment has
	664	+	been determined.
445	665		SECTION 4. This act shall become effective November 1, 2025.
446		-	~~COMMITTEE REPORT BY: COMMITTEE ON BUSINESS AND INSURANCE~~
447		-	~~March 6,~~ 2025 ~~- DO PASS AS AMENDED~~
	666	+
	667	+	60-1-975 CAD 1/16/2025 2:41:22 PM