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STATE OF OKLAHOMA
1st Session of the 60th Legislature (2025)
SENATE BILL 1060 By: Thompson
AS INTRODUCED
An Act relating to dental benefit plans; defining
terms; establishing formula for medical loss ratio;
requiring annual reporting to th e 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 rate
establishment; directing rule promulgation;
establishing provisions for rate det ermination by
Insurance Commissioner; requiring certain rate
increase notice; amending 36 O.S. 2021, Section 7301,
which relates to dental plan fee regulation;
modifying definitions; 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 7011 of Title 36, unless there
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,
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including any fees o r other contributions associated with the dental
plan;
2. “Medical loss ratio” (MLR) means the minimum percentage of
all premium funds collected by an insurer each year that shall be
spent on actual patient care rather than overhead costs. The funds
to be spent on actual patient ca re under this subsection shall be
refunded to individuals and groups in the form of a rebate; 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 denominato r as defined in this
section.
C. 1. The numerator shall be the amount spent o n care. The
amount spent on care shall include:
a. the amount expended for clinical dental services ,
which are services within the code on dental
procedures and nomenclature, p rovided to enrollees
which includes payments under capitation contracts
with dental providers, whose services are covered by
the contract for dental clinical services or supplies
covered by the contract; provided, any overpayment
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that has already been rece ived from providers shall
not be reported as a paid claim. Overpayment
recoveries received from providers shall be deducted
from incurred claim amounts,
b. unpaid claim reserves, and
c. claim payments recovered by insurers from providers or
enrollees using utilization management efforts,
deducted from claim amounts .
2. Calculation of the numerator shall not include:
a. all administrative costs, including , 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, attorney fees, subrogation
vendor fees, and compensation to paraprofessionals,
janitors, quality assurance anal ysts, administrative
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supervisors, secretaries to dental personnel, and
dental record clerks.
D. The denominator shall include the total amount of the earned
premium revenues, excluding federal and state taxes and licensing
and regulatory fees paid after a ccounting 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 Insurance Department that is organized by market and
product type and, where appropriate, contains the same information
required in the 2013 federal Medical 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, and
Part 158 of Title 45 of the Code of Federal Regulations .
F. 1. If data verification of the dental benefit plan ’s or the
dental portion of a health benefit plan ’s representations in the MLR
annual report is deemed necessary, the De partment shall notify the
benefit plan thirty (30) days before the commencement of the
financial examination.
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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
Insurance Commissioner may extend the t ime period for a health
benefit plan to comply with this subsection upon a finding of good
cause.
G. The Department shall make available to the public all of the
data provided to the Department pursuant to this section.
H. The provisions of this act shall not apply to health benefit
plans under the state Medicaid program or plans offered to the
state-sponsored health benefit plans.
SECTION 2. NEW LAW A n ew section of law to be codified
in the Oklahoma Statutes as Section 7012 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A. 1. A dental benefit plan or the dental portion of a health
benefit plan that issues, sells, re news, 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
ratio of the amount of prem ium revenue expended by the dental
benefit plan or the dental portion of a heal th benefit plan on the
costs for reimbursement for services provided to enrollees under
that coverage and for activities that improve dental care quality to
the total amount of premium revenue, excluding federal and state
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taxes and licensing or regulatory fees, and after accounting for
payments or receipts for risk adjustment, risk corridors, and
reinsurance, subsections C and D Section 1 of this act, is less
than, at minimum:
a. eighty percent (80%) for large group plans as defined
in 42 U.S.C., Section 18024(b)(1), and
b. seventy-five percent (75%) for individual and small
group plans as defined in 42 U.S.C. , Section
18024(b)(2).
2. Dental benefit plans shall implement the prov isions 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 equal to the product of the
amount by which the percentage described in subsectio n 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 fo r 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 owed to an enrollee no later
than August 1 of the calendar year following the yea r for which the
ratio described in subsection A of this section was calculated.
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SECTION 3. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 7013 of Title 36, unless there
is created a duplication in nu mbering, reads as follows:
A. On or before July 1 of the preceding year , 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.
B. A dental benefit plan or the dental portion of a health
benefit plan that issues, sell s, renews, or offers a specialized
health benefit plan contract covering dental services shall not
establish rates for any dental coverage plan issued to any
policyholder that are excessive, inadequate, or unfairly
discriminatory. To assure compliance with the requirement s of this
section that rates are not excessive in relation to benefits, the
Insurance Commissioner shall promulgate rules to require rate
filings and shall requ ire the submission of adequate documentation
and supporting information, includ ing actuarial opinions or
certifications that the rates proposed by dental plans do not result
in the MLR 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 recent calendar year ’s
percentage increase in the dental services Consumer Price Index fo r
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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 base 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 Insurance
Department, and
b. the Department shall conduct a public hearing and
shall properly advertise the hearing in c ompliance
with public hearing requirements .
D. The carrier shall submit expect ed 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 fi lings within a sixty -day period, the
carrier may implement and reasonably rely upon the rates provided.
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 des cribed in Section 2 of this act is
the sole remedy for rate deficiencies. If the Commissioner 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.
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SECTION 4. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 7014 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
2. A combined dental loss ratio percentage for all group dental
policies issued to fully insured g roups.
B. Not later than August 1 of each year, the Department shall
post the reported dental loss ratios for each dental insurer on a
publicly available website in a manner th at 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 and 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
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may require that a dentist pro vide 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, deductibles, 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
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 of Secti on 6060.4 of this title or any
dental service corporation authorized pursuant t o 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 b ased 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
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medical necessity shall include the identifier and license number
together with state of issuance, and a contact telephone number 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 November 1, 2025.
60-1-367 CAD 1/16/2025 2:58:35 PM