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1 STATE OF OKLAHOMA
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2 1st Session of the 60th Legislature (2025)
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3 SENATE BILL 1060 By: Thompson
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6 AS INTRODUCED
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7 An Act relating to dental benefit plans; defining
7 terms; establishing formula for medical loss ratio;
8 requiring annual reporting to the Insurance
8 Department; establishing process for certain data
9 verification; exempting certain dental plans from
9 provisions of act; requiring annual rebate for
10 certain plan years by certain plans; providing for
10 rebate calculation; prohibiting certain rate
11 establishment; directing rule promulgation;
11 establishing provisions for rate determination by
12 Insurance Commissioner; requiring certain rate
12 increase notice; amending 36 O.S. 2021, Section 7301,
13 which relates to dental plan fee regulation;
13 modifying definitions; providing for codification;
14 and providing an effective date.
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17 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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18 SECTION 1. NEW LAW A new section of law to be codified
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19 in the Oklahoma Statutes as Section 7011 of Title 36, unless there
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20 is created a duplication in numbering, reads as follows:
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21 A. As used in this act:
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22 1. "Earned premium" means all monies paid by a policyholder or
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23 subscriber as a condition of receiving coverage from the insurer,
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1 including any fees or other contributions associated with the dental
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2 plan;
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3 2. "Medical loss ratio" (MLR) means the minimum percentage of
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4 all premium funds collected by an insurer each year that shall be
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5 spent on actual patient care rather than overhead costs. The funds
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6 to be spent on actual patient care under this subsection shall be
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7 refunded to individuals and groups in the form of a rebate; and
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8 3. "Unpaid claim reserves" means reserves and liabilities
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9 established to account for claims that were incurred during the MLR
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10 reporting year but were not paid within three (3) months of the end
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11 of the MLR reporting year.
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12 B. The medical loss ratio for a dental plan or the dental
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13 coverage portion of a health benefit plan shall be determined by
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14 dividing the numerator by the denominator as defined in this
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15 section.
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16 C. 1. The numerator shall be the amount spent on care. The
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17 amount spent on care shall include:
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18 a. the amount expended for clinical dental services,
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19 which are services within the code on dental
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20 procedures and nomenclature, provided to enrollees
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21 which includes payments under capitation contracts
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22 with dental providers, whose services are covered by
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23 the contract for dental clinical services or supplies
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24 covered by the contract; provided, any overpayment
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1 that has already been received from providers shall
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2 not be reported as a paid claim. Overpayment
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3 recoveries received from providers shall be deducted
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4 from incurred claim amounts,
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5 b. unpaid claim reserves, and
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6 c. claim payments recovered by insurers from providers or
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7 enrollees using utilization management efforts,
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8 deducted from claim amounts.
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9 2. Calculation of the numerator shall not include:
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10 a. all administrative costs, including, but not limited
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11 to, infrastructure, personnel costs, or broker
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12 payments,
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13 b. amounts paid to third-party vendors for secondary
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14 network savings,
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15 c. amounts paid to third-party vendors for network
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16 development, administrative fees, claims processing,
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17 and utilization management, and
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18 d. amounts paid to a provider for professional or
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19 administrative services that do not represent
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20 compensation or reimbursement for covered services to
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21 an enrollee, including, but not limited to, dental
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22 record copying costs, attorney fees, subrogation
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23 vendor fees, and compensation to paraprofessionals,
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24 janitors, quality assurance analysts, administrative
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Req. No. 367 Page 3
1 supervisors, secretaries to dental personnel, and
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2 dental record clerks.
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3 D. The denominator shall include the total amount of the earned
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4 premium revenues, excluding federal and state taxes and licensing
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5 and regulatory fees paid after accounting for any payments pursuant
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6 to federal law.
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7 E. 1. A dental benefit plan or the dental portion of a health
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8 benefit plan that issues, sells, renews, or offers a specialized
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9 health benefit plan contract covering dental services on or after
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10 the effective date of this act shall file a medical loss ratio (MLR)
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11 with the Insurance Department that is organized by market and
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12 product type and, where appropriate, contains the same information
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13 required in the 2013 federal Medical Loss Ratio Annual Reporting
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14 Form (CMS-10418).
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15 2. The MLR reporting year shall be for the calendar year during
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16 which dental coverage is provided by the plan. All terms used in
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17 the MLR annual report shall have the same meaning as used in the
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18 federal Public Health Service Act, 42 U.S.C., Section 300gg-18, and
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19 Part 158 of Title 45 of the Code of Federal Regulations.
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20 F. 1. If data verification of the dental benefit plan's or the
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21 dental portion of a health benefit plan's representations in the MLR
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22 annual report is deemed necessary, the Department shall notify the
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23 benefit plan thirty (30) days before the commencement of the
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24 financial examination.
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1 2. The dental benefit plan or the dental portion of a health
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2 benefit plan shall have thirty (30) days from the date of
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3 notification to submit to the Department all requested data. The
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4 Insurance Commissioner may extend the time period for a health
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5 benefit plan to comply with this subsection upon a finding of good
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6 cause.
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7 G. The Department shall make available to the public all of the
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8 data provided to the Department pursuant to this section.
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9 H. The provisions of this act shall not apply to health benefit
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10 plans under the state Medicaid program or plans offered to the
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11 state-sponsored health benefit plans.
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12 SECTION 2. NEW LAW A new section of law to be codified
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13 in the Oklahoma Statutes as Section 7012 of Title 36, unless there
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14 is created a duplication in numbering, reads as follows:
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15 A. 1. A dental benefit plan or the dental portion of a health
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16 benefit plan that issues, sells, renews, or offers a specialized
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17 health care service plan contract covering dental services on or
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18 after the effective date of this act shall provide an annual rebate
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19 to each enrollee under that coverage, on a pro rata basis, if the
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20 ratio of the amount of premium revenue expended by the dental
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21 benefit plan or the dental portion of a health benefit plan on the
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22 costs for reimbursement for services provided to enrollees under
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23 that coverage and for activities that improve dental care quality to
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24 the total amount of premium revenue, excluding federal and state
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1 taxes and licensing or regulatory fees, and after accounting for
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2 payments or receipts for risk adjustment, risk corridors, and
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3 reinsurance, subsections C and D Section 1 of this act, is less
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4 than, at minimum:
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5 a. eighty percent (80%) for large group plans as defined
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6 in 42 U.S.C., Section 18024(b)(1), and
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7 b. seventy-five percent (75%) for individual and small
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8 group plans as defined in 42 U.S.C., Section
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9 18024(b)(2).
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10 2. Dental benefit plans shall implement the provisions of
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11 paragraph 1 of this subsection not later than January 1, 2028.
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12 B. The total amount of an annual rebate required under this
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13 section shall be calculated in an amount equal to the product of the
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14 amount by which the percentage described in subsection A of this
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15 section exceeds the insurer's reported ratio described in
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16 subsections C and D of Section 1 of this act multiplied by the total
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17 amount of premium revenue, excluding federal and state taxes and
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18 licensing or regulatory fees and after accounting for payments or
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19 receipts for risk adjustment, risk corridors, and reinsurance.
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20 C. A dental benefit plan or the dental portion of a health
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21 benefit plan shall provide any rebate owed to an enrollee no later
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22 than August 1 of the calendar year following the year for which the
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23 ratio described in subsection A of this section was calculated.
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1 SECTION 3. NEW LAW A new section of law to be codified
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2 in the Oklahoma Statutes as Section 7013 of Title 36, unless there
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3 is created a duplication in numbering, reads as follows:
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4 A. On or before July 1 of the preceding year, all carriers
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5 offering dental benefit plans shall file group product base rates
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6 and any changes to group rating factors that are to be effective on
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7 January 1 of each year.
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8 B. A dental benefit plan or the dental portion of a health
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9 benefit plan that issues, sells, renews, or offers a specialized
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10 health benefit plan contract covering dental services shall not
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11 establish rates for any dental coverage plan issued to any
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12 policyholder that are excessive, inadequate, or unfairly
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13 discriminatory. To assure compliance with the requirements of this
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14 section that rates are not excessive in relation to benefits, the
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15 Insurance Commissioner shall promulgate rules to require rate
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16 filings and shall require the submission of adequate documentation
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17 and supporting information, including actuarial opinions or
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18 certifications that the rates proposed by dental plans do not result
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19 in the MLR exceeding the ratios described in subsection A of Section
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20 2 of this act.
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21 C. 1. If a carrier files a base rate change and the
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22 administrative expense loading component, not including taxes and
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23 assessments, increases by more than the most recent calendar year's
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24 percentage increase in the dental services Consumer Price Index for
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1 All Urban Consumers, U.S. city average, not seasonally adjusted, the
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2 base rate shall be deemed excessive and presumptively disapproved.
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3 2. If the carrier's base rate is presumptively disapproved:
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4 a. the carrier shall communicate to all employers and
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5 individuals covered under a group product that the
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6 proposed increase has been presumptively disapproved
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7 and is subject to a hearing by the Insurance
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8 Department, and
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9 b. the Department shall conduct a public hearing and
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10 shall properly advertise the hearing in compliance
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11 with public hearing requirements.
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12 D. The carrier shall submit expected rate increases to the
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13 Commissioner at least sixty (60) days prior to the proposed
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14 implementation of the rates. If the Commissioner does not approve
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15 or disapprove the rate filings within a sixty-day period, the
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16 carrier may implement and reasonably rely upon the rates provided.
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17 The Commissioner may require correction of any deficiencies in the
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18 rate filing upon later review if the rate the carrier charged is
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19 excessive, inadequate, or unfairly discriminatory. A prospective
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20 rate adjustment or rebate as described in Section 2 of this act is
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21 the sole remedy for rate deficiencies. If the Commissioner finds
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22 deficiencies in the rate filing after a sixty-day period, the
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23 Commissioner shall provide notice to the carrier, and the carrier
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24 shall correct the rate on a prospective basis.
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1 SECTION 4. NEW LAW A new section of law to be codified
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2 in the Oklahoma Statutes as Section 7014 of Title 36, unless there
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3 is created a duplication in numbering, reads as follows:
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4 A. Beginning July 1, 2026, and on or before July 1 of each year
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5 thereafter, each dental insurer doing business in this state shall
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6 file with the Insurance Department, in the form and manner
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7 prescribed by the Department, an annual report on the dental loss
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8 ratio for the preceding calendar year. The dental loss ratio annual
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9 report shall include the following:
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10 1. A combined dental loss ratio percentage for all individual
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11 dental policies; and
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12 2. A combined dental loss ratio percentage for all group dental
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13 policies issued to fully insured groups.
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14 B. Not later than August 1 of each year, the Department shall
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15 post the reported dental loss ratios for each dental insurer on a
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16 publicly available website in a manner that is easily located and
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17 identifiable to the public. The Department may not post the
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18 underlying claims, premiums, and other data used to calculate the
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19 dental loss ratios and shall treat all claims, premiums, and other
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20 data as confidential.
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21 SECTION 5. AMENDATORY 36 O.S. 2021, Section 7301, is
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22 amended to read as follows:
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23 Section 7301. A. No contract between a dental plan of a health
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24 benefit plan and a dentist for the provision of services to patients
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1 may require that a dentist provide services to its subscribers at a
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2 fee set by the health benefit plan unless the services are covered
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3 services under the applicable subscriber agreement.
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4 B. As used in this section:
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5 1. "Covered services" means services reimbursable reimbursed
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6 under the applicable subscriber agreement, subject notwithstanding
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7 and without regard to the contractual limitations on subscriber
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8 benefits as may apply, including, for example, deductibles, waiting
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9 period or frequency limitations;
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10 2. "Dental plan" means and shall include any policy of
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11 insurance which is issued by a health benefit plan which provides
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12 for coverage of dental services not in connection with a medical
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13 plan; and
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14 3. "Health benefit plan" means any plan or arrangement as
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15 defined in subsection C of Section 6060.4 of this title or any
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16 dental service corporation authorized pursuant to Section 2671 of
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17 this title.
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18 C. A health benefit plan or dental plan shall establish and
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19 maintain appeal procedures for any claim by a dentist or a
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20 subscriber that is denied based on lack of medical necessity. Any
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21 such denial shall be based upon a determination by a dentist who
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22 holds a nonrestricted license in the United States. Any written
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23 communication to a dentist that includes or pertains to a denial of
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24 benefits for all or part of a claim on the basis of a lack of
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1 medical necessity shall include the identifier and license number
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2 together with state of issuance, and a contact telephone number of
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3 the licensed dentist making the adverse determination. The dentist
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4 who reviewed the claim shall only be contacted at the telephone
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5 number provided in the written communication about the denial during
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6 business hours.
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7 SECTION 6. This act shall become effective November 1, 2025.
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Req. No. 367 Page 11Every fact on this page links to its source, starting with the official bill record.