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
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2 1st Session of the 60th Legislature (2025)
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3 SENATE BILL 1047 By: McIntosh
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6 AS INTRODUCED
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7 An Act relating to health insurance; creating the
7 Oklahoma Surprise Medical Billing Act; providing
8 short title; defining terms; disallowing certain
8 billing procedure; requiring reimbursement for
9 certain health care service; prohibiting cost
9 incurrence greater than certain cost-sharing
10 obligation; directing rule promulgation; requiring
10 certain verification; providing for fines and fees;
11 providing for codification; and providing an
11 effective date.
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14 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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15 SECTION 1. NEW LAW A new section of law to be codified
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16 in the Oklahoma Statutes as Section 6063 of Title 36, unless there
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17 is created a duplication in numbering, reads as follows:
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18 This act shall be known and may be cited as the "Oklahoma
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19 Surprise Medical Billing Act".
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20 SECTION 2. NEW LAW A new section of law to be codified
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21 in the Oklahoma Statutes as Section 6063.1 of Title 36, unless there
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22 is created a duplication in numbering, reads as follows:
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23 As used in this section:
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1 1. "Surprise bill" means a bill issued by an out-of-network
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2 provider or out-of-network facility to an enrollee of a health
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3 benefit plan for health care services in an amount that exceeds the
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4 enrollee's cost-sharing obligation applicable for the same health
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5 care services if the services had been provided by an in-network
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6 provider or in-network facility and are rendered in the following
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7 circumstances:
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8 a. emergency care provided by an out-of-network provider
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9 or out-of-network facility, or
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10 b. nonemergency health care services rendered by an out-
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11 of-network provider at an in-network facility;
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12 2. "Claim" means a request from a provider for payment for
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13 health care services rendered to the enrollee of a health benefit
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14 plan;
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15 3. "Covered person" means:
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16 a. an enrollee, policyholder, or subscriber,
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17 b. the enrolled dependent of an enrollee, policyholder,
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18 or subscriber, or
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19 c. another individual participating in a health benefit
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20 plan;
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21 4. "Health benefit plan" means a health benefit plan as defined
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22 pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes;
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23 5. "Health care service" means any service, supply, or
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24 procedure rendered for the diagnosis, prevention, treatment, cure,
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1 or relief of a health condition, illness, injury, or other disease,
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2 including physical or behavioral health services, to the extent it
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3 is covered by a health benefit plan;
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4 6. "Emergency care" means a health care procedure, treatment,
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5 service, or ambulance transportation service delivered to a covered
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6 person after the sudden onset of medical or behavioral health
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7 condition symptoms of sufficient severity that, without immediate
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8 medical attention, regardless of eventual diagnosis, could be
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9 expected by a reasonable layperson to result in impairment of a
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10 person's physical or mental health, the health or safety of a fetus
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11 or pregnant person, bodily function of a bodily organ or part, or
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12 disfigurement to a person;
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13 7. "Minimum benefit standard" means the eightieth percentile of
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14 all allowed amounts for the same or similar health care service
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15 furnished by an in-network provider or in-network facility as
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16 reported in an independent benchmarking database maintained by a
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17 nonprofit organization specified by the Insurance Commissioner. The
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18 nonprofit organization shall not be financially affiliated with a
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19 health benefit plan or provider. The calculation of the eightieth
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20 percentile of all allowed amounts shall be reflected by claims paid
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21 during the most recent calendar year;
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22 8. "Provider" means a health care professional that is not a
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23 facility and is licensed to furnish health care services in this
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24 state;
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1 9. "In-network provider" means a provider that is under express
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2 contract with a health benefit plan or a health benefit plan's
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3 contractor or subcontractor providing health care services to
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4 enrollees of the plan;
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5 10. "Out-of-network provider" means a provider that is not
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6 contracted with a health benefit plan for network participation;
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7 11. "Facility" means a licensed entity providing health care
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8 services, including:
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9 a. a general, special, psychiatric, or rehabilitation
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10 hospital,
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11 b. an ambulatory surgical center,
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12 c. a cancer treatment center,
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13 d. a birth center,
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14 e. an inpatient, outpatient, or residential drug and
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15 alcohol treatment center,
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16 f. a laboratory, diagnostic, or other outpatient medical
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17 service or testing center,
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18 g. a health care provider's office or clinic,
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19 h. an urgent care center, or
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20 i. any other therapeutic health care setting;
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21 12. "In-network facility" means a facility that is under
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22 express contract with a health insurance carrier or a health
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23 insurance carrier's contractor or subcontractor to provide health
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24 care services to enrollees of a plan;
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1 13. "Out-of-network facility" means a facility that is not
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2 contracted with a health benefit plan for network participation;
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3 14. "Allowed amount" means the contractually agreed-upon amount
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4 paid by a health benefit plan to an in-network provider or in-
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5 network facility in the health benefit plan network; and
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6 15. "Health insurance carrier" or "carrier" means an entity
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7 subject to state insurance laws, including a health insurance
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8 company, a health maintenance organization, a hospital and health
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9 service corporation, a provider service network, a nonprofit health
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10 care plan, or any other entity that contracts or offers to contract,
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11 or enters into agreements to provide, deliver, arrange for, pay for,
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12 or reimburse any cost of health care services, or that provides,
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13 offers, or administers a health benefit policy or managed health
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14 care plan in this state.
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15 SECTION 3. NEW LAW A new section of law to be codified
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16 in the Oklahoma Statutes as Section 6063.2 of Title 36, unless there
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17 is created a duplication in numbering, reads as follows:
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18 A. An out-of-network provider or out-of-network facility shall
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19 not surprise bill a covered person for emergency care. If a covered
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20 person pays an out-of-network provider or out-of-network facility an
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21 amount that is greater than allowed by this section, the out-of-
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22 network provider or out-of-network facility shall render a refund to
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23 the covered person within thirty (30) days.
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1 B. A health insurance carrier shall directly reimburse an out-
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2 of-network provider or out-of-network facility for emergency care at
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3 the minimum benefit standard, or a mutually agreed upon amount, no
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4 later than:
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5 1. Thirty (30) days after the date the health benefit plan
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6 receives an electronic clean claim for such care that includes all
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7 information necessary for the carrier to pay the claim; or
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8 2. Forty-five (45) days after the date the carrier receives a
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9 nonelectronic clean claim for such care that includes all
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10 information necessary for the carrier to pay the claim.
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11 C. A health insurance carrier shall ensure that a covered
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12 person who is rendered emergency care by an out-of-network provider
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13 or out-of-network facility shall incur no greater cost-sharing
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14 obligations than the covered person would have incurred if those
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15 health care services were rendered by an in-network provider or in-
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16 network facility.
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17 D. An out-of-network provider shall not surprise bill a covered
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18 person for health care services that are not emergency care and are
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19 rendered at an in-network facility. If a covered person pays an
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20 out-of-network provider an amount that is greater than allowed by
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21 this section, the out-of-network provider shall render a refund to
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22 the covered person within thirty (30) days.
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23 E. A health insurance carrier shall directly reimburse an out-
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24 of-network provider for health care services that are not emergency
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1 care and are rendered at an in-network facility the minimum benefit
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2 standard, or mutually agreed to amount, no later than:
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3 1. Thirty (30) days after the date the carrier receives an
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4 electronic clean claim for such services that includes all
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5 information necessary for the carrier to pay the claim; or
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6 2. Forty-five (45) days after the date the carrier receives a
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7 nonelectronic clean claim for such services that includes all
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8 information necessary for the carrier to pay the claim.
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9 F. A health insurance carrier shall ensure that a covered
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10 person who is rendered health care services that are not emergency
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11 care by an out-of-network provider at an in-network facility shall
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12 incur no greater cost-sharing obligations than the covered person
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13 would have incurred if those health care services were rendered by
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14 an in-network provider.
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15 G. The Insurance Commissioner shall promulgate rules for
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16 verifying the minimum benefit standard which may be requested by an
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17 out-of-network provider or out-of-network facility that has rendered
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18 health care services in accordance with this act.
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19 1. Verification of the minimum benefit standard shall only be
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20 requested if reimbursement has been received from a carrier and no
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21 more than thirty (30) days have elapsed since the date payment was
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22 received.
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1 2. Request for verification of the minimum benefit standard may
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2 be requested for bundled claims provided none of the claims were
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3 paid more than thirty (30) days since the date payment was received.
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4 3. The Insurance Commissioner shall ensure that verification of
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5 the minimum benefit standard is provided to an out-of-network
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6 provider or out-of-network facility no later than fifteen (15) days
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7 after a request has been initiated.
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8 4. If the Insurance Commissioner determines that the amount
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9 reimbursed by the carrier is less than the minimum benefit standard,
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10 the carrier shall be required to compensate the out-of-network
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11 provider or out-of-network facility the difference between the
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12 amount initially paid and the verified minimum benefit standard no
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13 later than fifteen (15) days after the date the Insurance
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14 Commissioner has verified the minimum benefit standard.
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15 H. A health insurance carrier that fails to reimburse for
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16 health care services at the minimum benefit standard shall be
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17 subject to a penalty that is calculated as the difference between
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18 the minimum benefit standard and the amount billed by the out-of-
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19 network provider or out-of-network facility that requested
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20 verification of the minimum benefit standard. Fifty percent (50%)
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21 of the calculated penalty shall be made payable to the out-of-
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22 network provider or out-of-network facility and the remaining fifty
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23 percent (50%) shall be made payable to the Oklahoma Health Insurance
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24 High Risk Pool.
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1 A carrier may be subject to additional fines and penalties, as
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2 determined by the Commissioner, if a pattern of underpayment has
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3 been determined.
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4 SECTION 4. This act shall become effective November 1, 2025.
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6 60-1-975 CAD 1/16/2025 2:41:22 PM
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Req. No. 975 Page 9Every fact on this page links to its source, starting with the official bill record.