Shown verbatim: the complete text as captured from the official PDF posted by the Oklahoma Legislature, fetched 2026-07-23. Page and line markers are part of the official record; nothing is edited or removed. The official bill page.
1 STATE OF OKLAHOMA
2 1st Session of the 60th Legislature (2025)
3 HOUSE BILL 2805 By: Marti
4
5
6 AS INTRODUCED
7 An Act relating to dental benefit plans; defining
terms; establishing formula for medical loss ratio;
8 requiring annual reporting to the Oklahoma Insurance
Department; establishing process for certain data
9 verification; exempting certain dental plans from
provisions of act; requiring annual rebate for
10 certain plan years by certain plans; providing for
rebate calculation; prohibiting certain rate
11 establishment; directing rule promulgation;
establishing provisions for rate determination by
12 Commissioner; requiring certain rate increase notice;
amending 36 O.S. 2021, Section 7301, which relates to
13 dental plans; modifying definition; providing for
codification; and providing an effective date.
14
15
16 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
17 SECTION 1. NEW LAW A new section of law to be codified
18 in the Oklahoma Statutes as Section 7140 of Title 36, unless there
19 is created a duplication in numbering, reads as follows:
20 A. As used in this act:
21 1. "Earned premium" means all monies paid by a policyholder or
22 subscriber as a condition of receiving coverage from the insurer,
23 including any fees or other contributions associated with the dental
24 plan;
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1 2. "Medical loss ratio (MLR)" means the percentage of all
2 premium funds collected by an insurer each year that shall be spent
3 on actual patient care rather than overhead costs; and
4 3. "Unpaid claim reserves" means reserves and liabilities
5 established to account for claims that were incurred during the MLR
6 reporting year but were not paid within three (3) months of the end
7 of the MLR reporting year.
8 B. The medical loss ratio for a dental plan or the dental
9 coverage portion of a health benefit plan shall be determined by
10 dividing the numerator by the denominator as defined in this
11 section.
12 C. 1. The numerator shall be the amount spent on care. The
13 amount spent on care shall include:
14 a. the amount expended for clinical dental services which
15 are services within the code on dental procedures and
16 nomenclature, provided to enrollees which includes
17 payments under capitation contracts with dental
18 providers, whose services are covered by the contract
19 for dental clinical services or supplies covered by
20 the contract; provided, any overpayment that has
21 already been received from providers shall not be
22 reported as a paid claim. Overpayment recoveries
23 received from providers shall be deducted from
24 incurred claim amounts,
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1 b. unpaid claim reserves, and
2 c. claim payments recovered by insurers from providers or
3 enrollees using utilization management efforts shall
4 be deducted from incurred claim amounts.
5 2. Calculation of the numerator shall not include:
6 a. all administrative costs, including, but not limited
7 to, infrastructure, personnel costs, or broker
8 payments,
9 b. amounts paid to third-party vendors for secondary
10 network savings,
11 c. amounts paid to third-party vendors for network
12 development, administrative fees, claims processing,
13 and utilization management, and
14 d. amounts paid to a provider for professional or
15 administrative services that do not represent
16 compensation or reimbursement for covered services to
17 an enrollee, including, but not limited to, dental
18 record copying costs, attorney fees, subrogation
19 vendor fees, compensation to paraprofessionals,
20 janitors, quality assurance analysts, administrative
21 supervisors, secretaries to dental personnel, and
22 dental record clerks.
23 D. The denominator shall include the total amount of the earned
24 premium revenues, excluding federal and state taxes and licensing
Req. No. 11307 Page 3
1 and regulatory fees paid after accounting for any payments pursuant
2 to federal law.
3 E. 1. A dental benefit plan or the dental portion of a health
4 benefit plan that issues, sells, renews, or offers a specialized
5 health benefit plan contract covering dental services on or after
6 the effective date of this act shall file a medical loss ratio (MLR)
7 with the Oklahoma Insurance Department that is organized by market
8 and product type and, where appropriate, contains the same
9 information required in the 2013 federal Medical Loss Ratio Annual
10 Reporting Form (CMS-10418).
11 2. The MLR reporting year shall be for the calendar year during
12 which dental coverage is provided by the plan. All terms used in
13 the MLR annual report shall have the same meaning as used in the
14 federal Public Health Service Act, 42 U.S.C., Section 300gg-18, Part
15 158 of Title 45 of the Code of Federal Regulations.
16 F. 1. If data verification of the dental benefit plan or the
17 dental portion of a health benefit plan's representations in the MLR
18 annual report is deemed necessary, the Insurance Department shall
19 provide the health benefit plan with a notification thirty (30) days
20 before the commencement of the financial examination.
21 2. The dental benefit plan or the dental portion of a health
22 benefit plan shall have thirty (30) days from the date of
23 notification to submit to the Department all requested data. The
24
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1 Insurance Commissioner may extend the time for a health benefit plan
2 to comply with this subsection upon a finding of good cause.
3 G. The Insurance Department shall make available to the public
4 in a searchable format on a public website all of the data provided
5 to the Department pursuant to this section which allows members of
6 the public to compare dental loss ratios among carriers by plan
7 type.
8 H. The provisions of this act shall not apply to health benefit
9 plans under Medicaid.
10 SECTION 2. NEW LAW A new section of law to be codified
11 in the Oklahoma Statutes as Section 7141 of Title 36, unless there
12 is created a duplication in numbering, reads as follows:
13 A. 1. A dental benefit plan or the dental portion of a health
14 benefit plan that issues, sells, renews, or offers a specialized
15 health care service plan contract covering dental services on or
16 after the effective date of this act shall provide an annual rebate
17 to each enrollee under that coverage, on a pro rata basis, if the
18 dental loss ratio Formula established in subsections C and D of
19 Section 1 of this act, is applied and the loss ratio is determined
20 to be less than, at minimum:
21 a. eighty-five percent (85%) for large group plans as
22 defined in 42 U.S.C., Section 18024(b)(2), and
23 b. eighty percent (80%) for individual and small group
24 plans as defined in 42 U.S.C., Section 18024(b)(2).
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1 2. Dental benefit plans shall implement the provisions of
2 paragraph 1 of this subsection not later than January 1, 2028.
3 B. The total amount of an annual rebate required under this
4 section shall be calculated in an amount equal to the product of the
5 amount by which the percentage described in subsection A of this
6 section exceeds the insurer's reported ratio described in
7 subsections C and D of Section 1 of this act multiplied by the total
8 amount of premium revenue, excluding federal and state taxes and
9 licensing or regulatory fees and after accounting for payments or
10 receipts for risk adjustment, risk corridors, and reinsurance.
11 C. A dental benefit plan or the dental portion of a health
12 benefit plan shall provide any rebate owed to an enrollee no later
13 than August 1 of the calendar year following the year for which the
14 ratio described in subsection A of this section was calculated.
15 SECTION 3. NEW LAW A new section of law to be codified
16 in the Oklahoma Statutes as Section 7142 of Title 36, unless there
17 is created a duplication in numbering, reads as follows:
18 A. All carriers offering dental benefit plans shall file group
19 product base rates and any changes to group rating factors that are
20 to be effective on January 1 of each year, on or before July 1 of
21 the preceding year.
22 B. A dental benefit plan or the dental portion of a health
23 benefit plan that issues, sells, renews, or offers a specialized
24 health benefit plan contract covering dental services shall not
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1 establish rates for any dental coverage plan issued to any
2 policyholder that are excessive, inadequate, or unfairly
3 discriminatory. To assure compliance with the requirements of this
4 section that rates are not excessive in relation to benefits, the
5 Insurance Commissioner shall promulgate rules to require rate
6 filings and shall require the submission of adequate documentation
7 and supporting information, including actuarial opinions or
8 certifications that the rates proposed by dental plans result in the
9 MLR meeting or exceeding the ratios described in subsection A of
10 Section 2 of this act.
11 C. 1. If a carrier files a base rate change and the
12 administrative expense loading component, not including taxes and
13 assessments, increases by more than the most recent calendar year's
14 percentage increase in the dental services Consumer Price Index for
15 All Urban Consumers, U.S. city average, not seasonally adjusted, the
16 base rate shall be deemed excessive and presumptively disapproved.
17 2. If the carrier's rate is presumptively disapproved:
18 a. the carrier shall communicate to all employers and
19 individuals covered under a group product that the
20 proposed increase has been presumptively disapproved
21 and is subject to a hearing by the Department, and
22 b. the Insurance Department shall conduct a public
23 hearing and shall properly advertise the hearing in
24 compliance with public hearing requirements.
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1 D. The carrier shall submit expected rate increases to the
2 Commissioner at least sixty (60) days prior to the proposed
3 implementation of the rates. If the Commissioner does not approve
4 or disapprove the rate filings within a sixty-day period, the
5 carrier may implement and reasonably rely upon the rates provided,
6 and the Commissioner may require correction of any deficiencies in
7 the rate filing upon later review if the rate the carrier charged is
8 excessive, inadequate, or unfairly discriminatory. A prospective
9 rate adjustment or rebate as described in Section 2 of this act are
10 the sole remedies for rate deficiencies. If the Commissioner finds
11 deficiencies in the rate filing after a sixty-day period, the
12 Commissioner shall provide notice to the carrier, and the carrier
13 shall correct the rate on a prospective basis.
14 SECTION 4. NEW LAW A new section of law to be codified
15 in the Oklahoma Statutes as Section 7143 of Title 36, unless there
16 is created a duplication in numbering, reads as follows:
17 A. Beginning July 1, 2026, and on or before July 1 of each year
18 thereafter, each dental insurer doing business in this state shall
19 file with the Insurance Department, in the form and manner
20 prescribed by the Department, an annual report on the dental loss
21 ratio for the preceding calendar year. The dental loss ratio annual
22 report shall include the following:
23 1. A combined dental loss ratio percentage for all individual
24 dental policies; and
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1 2. A combined dental loss ratio percentage for all group dental
2 policies issued to fully insured groups.
3 B. Not later than August 1 of each year, the Department shall
4 post the reported dental loss ratios for each dental insurer on a
5 publicly available website in a manner that is easily located and
6 identifiable to the public. The Department may not post the
7 underlying claims, premiums and other data used to calculate the
8 dental loss ratios and shall treat all claims, premiums, and other
9 data as confidential.
10 SECTION 5. AMENDATORY 36 O.S. 2021, Section 7301, is
11 amended to read as follows:
12 Section 7301. A. No contract between a dental plan of a health
13 benefit plan and a dentist for the provision of services to patients
14 may require that a dentist provide services to its subscribers at a
15 fee set by the health benefit plan unless the services are covered
16 services under the applicable subscriber agreement.
17 B. As used in this section:
18 1. "Covered services" means services reimbursable reimbursed
19 under the applicable subscriber agreement, subject notwithstanding,
20 and without regard to the contractual limitations on subscriber
21 benefits as may apply, including, for example, deductibles, waiting
22 period or frequency limitations;
23 2. "Dental plan" means and shall include any policy of
24 insurance which is issued by a health benefit plan which provides
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1 for coverage of dental services not in connection with a medical
2 plan; and
3 3. "Health benefit plan" means any plan or arrangement as
4 defined in subsection C of Section 6060.4 of this title or any
5 dental service corporation authorized pursuant to Section 2671 of
6 this title.
7 C. A health benefit plan or dental plan shall establish and
8 maintain appeal procedures for any claim by a dentist or a
9 subscriber that is denied based on lack of medical necessity. Any
10 such denial shall be based upon a determination by a dentist who
11 holds a nonrestricted license in the United States. Any written
12 communication to a dentist that includes or pertains to a denial of
13 benefits for all or part of a claim on the basis of a lack of
14 medical necessity shall include the identifier and license number
15 together with state of issuance, and a contact telephone number of
16 the licensed dentist making the adverse determination. The dentist
17 who reviewed the claim shall only be contacted at the telephone
18 number provided in the written communication about the denial during
19 business hours.
20 SECTION 6. This act shall become effective January 1, 2026.
21
22 60-1-11307 TJ 01/15/25
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Req. No. 11307 Page 10Every fact on this page links to its source, starting with the official bill record.