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1 STATE OF OKLAHOMA
2 1st Session of the 60th Legislature (2025)
3 HOUSE BILL 1808 By: Newton
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5
6 AS INTRODUCED
7 An Act relating to health insurance; providing
definitions; providing cost-sharing requirements;
8 providing enforcement by the Attorney General;
promulgating rules; providing for step-therapy
9 protocols for prescription drugs; providing
requirements for processing claims; providing for
10 downcoding; providing for prior authorization
requests; providing for legislative intent; providing
11 standards for fair contracts; providing for
codification; and providing an effective date.
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14
15 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
16 SECTION 1. NEW LAW A new section of law to be codified
17 in the Oklahoma Statutes as Section 6110 of Title 36, unless there
18 is created a duplication in numbering, reads as follows:
19 As used in this section:
20 1. "Cost sharing" means the share of costs covered by a health
21 plan for which an insured is financially responsible, including
22 deductibles, coinsurance, co-payments, and similar charges. It
23 shall not include premiums, balance billing amount for out-of-
24 network providers, or the cost of noncovered health care services;
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1 2. "Health benefit plan" means any individual or group health
2 insurance policy, any hospital or medical service corporation, or
3 health maintenance organization subscriber contract, or any other
4 plan offered, issued, or renewed for any person in this state by a
5 health plan or other payer. The term does not include benefit plans
6 providing coverage for a specific disease or other limited benefit
7 coverage;
8 3. "Health care services" means services for the diagnosis,
9 prevention, treatment, cure, or relief of a physical, dental,
10 behavioral, or mental health condition or substance use disorder,
11 including procedures, products, devices, and medications; and
12 4. "Readily available" means that the medication is not listed
13 on a national drug shortage list, including lists maintained by the
14 United States Food and Drug Administration and by the American
15 Society of Health-System Pharmacists.
16 SECTION 2. NEW LAW A new section of law to be codified
17 in the Oklahoma Statutes as Section 6110.1 of Title 36, unless there
18 is created a duplication in numbering, reads as follows:
19 A. A health plan or other payer shall:
20 1. Pay a health care provider the full amount due for health
21 care services under the terms of a health benefit plan, including
22 any cost sharing;
23 2. Have the sole responsibility for collecting cost sharing
24 from an insured; and
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1 3. Upon request of an insured, collect cost sharing throughout
2 the plan year in increments defined by the health plan or other
3 payer.
4 B. A health plan or other payer shall not:
5 1. Withhold any amount for cost sharing from the payment to a
6 health care provider; or
7 2. Require a health care provider to offer additional discounts
8 to insureds outside the terms of the health care contract between
9 the health plan or other payer and the health care provider.
10 C. Any value of a co-payment assistance coupon or similar
11 assistance program shall be applied to an enrollee's annual cost-
12 sharing requirement and may be paid directly to the health plan or
13 other payer on the insured's behalf.
14 D. A health plan or other payer shall not cancel the health
15 benefit plan of an insured who does not remit or otherwise pay a
16 cost-sharing amount due for services rendered.
17 E. Any expenses related to implementation of this section by a
18 health plan or other payer shall not be used as justification to
19 increase premiums or decrease payments to a health care provider.
20 F. A violation of this section is an unfair or deceptive act or
21 practice. All remedies, penalties, and authority granted to the
22 Attorney General shall be available to enforce this section.
23 G. The Oklahoma Insurance Department may adopt rules as needed
24 to implement and administer this section.
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1 SECTION 3. NEW LAW A new section of law to be codified
2 in the Oklahoma Statutes as Section 6110.2 of Title 36, unless there
3 is created a duplication in numbering, reads as follows:
4 1. A health insurance or other health benefit plan offered by a
5 health insurer or by a pharmacy benefit manager on behalf of a
6 health insurer that provides coverage for prescription drugs and
7 uses step-therapy protocols shall:
8 a. not require failure, including discontinuation due to
9 lack of efficacy or effectiveness, diminished effect,
10 or an adverse event, on the same medication on more
11 than one occasion for insureds who are continuously
12 enrolled in a plan offered by the insurer or its
13 pharmacy benefit manager, and
14 b. grant an exception to its step-therapy protocols upon
15 request of an insured or the insured's treating health
16 care professional under the same time parameters as
17 set forth for prior authorization requests if any one
18 or more of the following conditions apply:
19 (1) the prescription drug required under the step-
20 therapy protocol is contraindicated or will
21 likely cause an adverse reaction or physical or
22 mental harm to the insured,
23 (2) the prescription drug required under the step-
24 therapy protocol is expected to be ineffective
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1 based on the insured's known clinical history,
2 condition, and prescription drug regimen,
3 (3) the insured has already tried the prescription
4 drugs on the protocol, or other prescription
5 drugs in the same pharmacologic class or with the
6 same mechanism of action, which have been
7 discontinued due to lack of efficacy or
8 effectiveness, diminished effect, or an adverse
9 event, regardless of whether the insured was
10 covered at the time on a plan offered by the
11 current insurer or its pharmacy benefit manager,
12 (4) the insured is stable on a prescription drug
13 selected by the insured's treating health care
14 professional for the medical condition under
15 consideration, or
16 (5) the step-therapy protocol or a prescription drug
17 required under the protocol is not in the
18 patient's best interests because it will:
19 (a) pose a barrier to adherence,
20 (b) likely worsen a comorbid condition, or
21 (c) likely decrease the insured's ability to
22 achieve or maintain reasonable functional
23 ability.
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1 2. Nothing in this subsection shall be construed to prohibit
2 the use of tiered co-payments for members or subscribers not subject
3 to a step-therapy protocol.
4 3. Notwithstanding any provision of paragraph 1 of this
5 subsection to the contrary, a health insurance or other health
6 benefit plan offered by an insurer or by a pharmacy benefit manager
7 on behalf of a health insurer that provides coverage for
8 prescription drugs shall not utilize a step-therapy, "fail first",
9 or other protocol that requires documented trials of a medication,
10 including a trial documented through a "MedWatch", FDA Form 3500,
11 before approving a prescription for the treatment of substance use
12 disorder.
13 SECTION 4. NEW LAW A new section of law to be codified
14 in the Oklahoma Statutes as Section 6110.3 of Title 36, unless there
15 is created a duplication in numbering, reads as follows:
16 A. 1. For urgent prior authorization requests, a health plan
17 shall approve, deny, or inform the insured or health care provider
18 if any information is missing from a prior authorization request
19 from an insured or a prescribing health care provider within twenty-
20 four (24) hours following receipt.
21 2. If a health plan informs an insured or a health care
22 provider that more information is necessary for the health plan to
23 make a determination on the request, the health plan shall have
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1 twenty-four (24) hours to approve or deny the request upon receipt
2 of the necessary information.
3 B. For nonurgent prior authorization requests:
4 1. A health plan shall approve or deny a completed prior
5 authorization request from an insured or a prescribing health care
6 provider within two (2) business days following receipt;
7 2. A health plan shall acknowledge receipt of the prior
8 authorization request within twenty-four (24) hours following
9 receipt and shall inform the insured or health care provider at that
10 time if any information is missing that is necessary for the health
11 plan to make a determination on the request; and
12 3. If a health plan notifies an insured or a health care
13 provider that more information is necessary pursuant to paragraph 2
14 of this subsection, the health plan shall have twenty-four (24)
15 hours to approve or deny the request upon receipt of the necessary
16 information.
17 C. If a health plan does not, within the time limits set forth
18 in this section, respond to a completed prior authorization request,
19 acknowledge receipt of the request for prior authorization, or
20 request missing information, the prior authorization request shall
21 be deemed to have been granted.
22 D. Prior authorization approval for a prescribed treatment,
23 service, or course of medication shall be valid for the duration of
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1 a prescribed or ordered course of treatment or one (1) year,
2 whichever is longer.
3 E. For an insured who is stable on a treatment, service, or
4 course of medication, as determined by a health care provider, that
5 was approved for coverage under a previous health plan, a health
6 plan shall not restrict coverage of that treatment, service, or
7 course of medication for at least ninety (90) days upon the
8 insured's enrollment in the new health plan.
9 F. A health insurance or other health benefit plan offered by a
10 health insurer or by a pharmacy benefit manager on behalf of a
11 health insurer shall cover, without requiring prior authorization,
12 at least one readily available asthma controller medication from
13 each class of medication and mode of administration.
14 G. Prior authorization approval for a prescribed or ordered
15 treatment, service, or course of medication shall be valid for the
16 duration of the prescribed or ordered treatment, service, or course
17 of medication or one (1) year, whichever is longer; provided,
18 however, that for a prescribed or ordered treatment, service, or
19 course of medication that continues for more than one (1) year, a
20 health plan shall not require renewal of the prior authorization
21 approval more frequently than once every five (5) years.
22 SECTION 5. NEW LAW A new section of law to be codified
23 in the Oklahoma Statutes as Section 6110.4 of Title 36, unless there
24 is created a duplication in numbering, reads as follows:
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1 A. The Insurance Department shall adopt rules, bulletins, or
2 other guidance that prohibits carriers from imposing prior
3 authorization requirements for any generic medication or for any
4 admission, item, service, treatment, procedure, or medication, or
5 for any category of these, that have low variation across health
6 care providers and denial rates of less than ten percent (10%)
7 across carriers.
8 B. In developing its rules, bulletins, or other guidance, the
9 Department may rely on prior authorization data submitted by the
10 health plans.
11 C. It is the intent of the Legislature that the rules,
12 bulletins, or other guidance that the Department develops pursuant
13 to this subsection should be designed to apply to frequently used
14 medications and services, especially those ordered by primary care
15 providers, and to achieve consistency in prior authorization
16 exemptions across health plans in order to meaningfully reduce the
17 administrative burden on health care providers.
18 SECTION 6. NEW LAW A new section of law to be codified
19 in the Oklahoma Statutes as Section 6110.5 of Title 36, unless there
20 is created a duplication in numbering, reads as follows:
21 A. Required information.
22 1. Each contracting entity shall provide and each health care
23 contract shall obligate the contracting entity to provide
24 participating health care providers information sufficient for the
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1 participating provider to determine the compensation or payment
2 terms for health care services, including all of the following:
3 a. the manner of payment, such as fee-for-service,
4 capitation, case rate, or risk,
5 b. the fee-for-service dollar amount allowable for each
6 CPT code for those CPT codes that a provider in the
7 same specialty typically uses or that the requesting
8 provider actually bills. Fee schedule information may
9 be provided electronically, at the election of the
10 contracting entity, but a provider may elect to
11 receive a paper copy of the fee schedule information
12 instead of the electronic version, and
13 c. a clearly understandable, readily available mechanism,
14 such as a specific website address, that includes the
15 following information:
16 (1) the name of the commercially available claims
17 editing software product that the health plan,
18 contracting entity, covered entity, or payer
19 uses,
20 (2) the specific standard that the entity uses for
21 claim edits and how those claim edits are
22 supported by those specific standards,
23 (3) payment percentages for modifiers, and
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1 (4) any significant edits, as determined by the
2 health plan, contracting entity, covered entity,
3 or payer, added to the claims software product,
4 which are made at the request of the health plan,
5 contracting entity, covered entity, or payer, and
6 which have been approved by the Commissioner, and
7 d. any policies for prepayment or post-payment audits, or
8 both, including whether the policies include limits on
9 the number of medical records a contracting entity may
10 request for audit in any calendar year.
11 B. If a contracting entity uses policies or manuals to augment
12 the content of the contract with a health care provider, the
13 contracting entity shall ensure that those policies or manuals
14 contain sufficient information to allow providers to understand and
15 comply with the content. The contracting entity shall treat any new
16 policy or manual, and any change to an existing policy or manual, as
17 a contract amendment and shall comply with the requirements for
18 contract amendments.
19 1. For any new policy or manual, or any change to an existing
20 policy or manual, the contracting entity shall do all of the
21 following:
22 a. provide notice of the new policy, manual, or change to
23 each participating provider in writing not fewer than
24 sixty (60) days prior to the effective date of the
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1 policy, manual, or change, which notice shall be
2 conspicuously entitled "Notice of Policy Change" and
3 shall include:
4 (1) a summary of the new policy, manual, or change,
5 (2) an explanation of the policy, manual, or change,
6 (3) the effective date of the policy, manual, or
7 change, and
8 (4) a notice of the right to object in writing to the
9 policy, manual, or change, along with a timeframe
10 for objection and where and how to send the
11 objection.
12 b. provide the participating provider sixty (60) days
13 after receiving the notice and summary to object in
14 writing to the new policy, manual, or change. If the
15 participating provider objects to the new policy,
16 manual, or change, the contracting entity shall
17 provide an initial substantive response to the
18 objection within thirty (30) days following the
19 contracting entity's receipt of the written objection,
20 and the contracting entity shall work together with
21 the provider to achieve a reasonable resolution to the
22 objection within sixty (60) days following the
23 provider's receipt of contracting entity's initial
24 substantive response. If the provider is not
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1 satisfied with the proposed resolution, the provider
2 may pursue any remedy available to the provider under
3 the health care contract or under applicable law.
4 C. For purposes of this section, a health care contract is
5 deemed to be amended when a contracting entity institutes a new
6 policy or manual, or amends an existing policy or manual that is
7 incorporated into a contract by reference, and the new or amended
8 policy or manual impacts the health care provider's reimbursement.
9 SECTION 7. NEW LAW A new section of law to be codified
10 in the Oklahoma Statutes as Section 6110.6 of Title 36, unless there
11 is created a duplication in numbering, reads as follows:
12 For any violation of the provisions of this act or any rule
13 adopted pursuant thereto, the Insurance Commissioner may, upon
14 notice and hearing, subject a person or entity to a civil fine of
15 not less than One Hundred Dollars ($100.00) nor more than One
16 Thousand Dollars ($1,000.00) for each occurrence.
17 SECTION 8. This act shall become effective November 1, 2025.
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19 60-1-10370 TJ 01/15/25
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Req. No. 10370 Page 13Every fact on this page links to its source, starting with the official bill record.