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1 STATE OF OKLAHOMA
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2 2nd Session of the 60th Legislature (2026)
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3 SENATE BILL 1646 By: Gollihare
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6 AS INTRODUCED
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7 An Act relating to health insurance; defining terms;
7 requiring health benefit plan to provide coverage for
8 medically necessary treatment of mental health and
8 substance use disorders; prohibiting certain
9 limitations on benefits or coverage; prohibiting
9 certain rescission or modification of authorization;
10 requiring compliance with certain out-of-network care
10 requirements under certain conditions; requiring
11 provision of meaningful benefits under specified
11 conditions; specifying procedures and minimum
12 criteria for certain determination; establishing
12 requirements and procedures related to utilization
13 review; requiring and prohibiting application of
13 certain criteria; specifying requirements for certain
14 authorizations; prohibiting adoption of certain
14 policy terms; authorizing promulgation of certain
15 rules; authorizing certain enforcement by the
15 Insurance Commissioner; specifying applicability of
16 act; providing certain construction; providing for
16 codification; and providing an effective date.
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19 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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20 SECTION 1. NEW LAW A new section of law to be codified
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21 in the Oklahoma Statutes as Section 6060.11c of Title 36, unless
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22 there is created a duplication in numbering, reads as follows:
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23 A. As used in this section:
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1 1. A "core treatment" for a condition or disorder is a standard
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2 treatment or course of treatment, therapy, service, or intervention
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3 indicated by generally accepted standards of mental health and
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4 substance use disorder care;
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5 2. "Generally accepted standards of mental health and substance
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6 use disorder care" means standards of care and clinical practice
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7 that are generally recognized by health care providers practicing in
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8 relevant clinical specialties such as psychiatry, psychology,
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9 addiction medicine and counseling, and behavioral health treatment.
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10 Valid, evidence-based sources reflecting generally accepted
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11 standards of mental health and substance use disorder care include
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12 published peer-reviewed scientific studies and medical literature
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13 and recommendations of nonprofit health care provider professional
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14 associations including, but not limited to, patient placement
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15 criteria and clinical practice guidelines;
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16 3. "Health benefit plan" has the same meaning as provided in
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17 Section 6060.4 of Title 36 of the Oklahoma Statutes;
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18 4. "Medically necessary treatment of a mental health or
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19 substance use disorder" means a service or product addressing the
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20 specific needs of that patient, for the purpose of screening,
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21 preventing, diagnosing, managing, or treating an illness, injury,
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22 condition, or its symptoms, including minimizing the progression of
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23 an illness, injury, condition, or its symptoms, in a manner that is
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24 all of the following:
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1 a. in accordance with the generally accepted standards of
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2 mental health and substance use disorder care,
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3 b. clinically appropriate in terms of type, frequency,
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4 extent, site, and duration, and
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5 c. not primarily for the economic benefit of the health
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6 benefit plan or purchaser or for the convenience of
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7 the patient, treating physician, or other health care
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8 provider;
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9 5. "Mental health and substance use disorder" means a mental
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10 health condition or substance use disorder that falls under any of
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11 the diagnostic categories listed in the mental and behavioral
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12 disorders chapter of the most recent edition of the International
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13 Statistical Classification of Diseases and Related Health Problems,
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14 or that is listed in the most recent version of the American
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15 Psychiatric Association's Diagnostic and Statistical Manual of
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16 Mental Disorders or the Diagnostic Classification of Mental Health
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17 and Developmental Disorders of Infancy and Early Childhood. Changes
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18 in terminology, organization, or classification of mental health and
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19 substance use disorders in future versions of the American
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20 Psychiatric Association's Diagnostic and Statistical Manual of
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21 Mental Disorders or the International Statistical Classification of
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22 Diseases and Related Health Problems shall not affect the conditions
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23 covered by this section as long as a condition is commonly
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1 understood to be a mental health or substance use disorder by health
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2 care providers practicing in relevant clinical specialties;
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3 6. "Nonprofit health care provider professional association"
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4 means a not-for-profit health care provider professional association
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5 or specialty society that is generally recognized by clinicians
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6 practicing in the relevant clinical specialty and that issues peer-
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7 reviewed guidelines, criteria, or other clinical recommendations
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8 developed through a transparent process;
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9 7. "Utilization review" means prospectively, retrospectively,
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10 or concurrently reviewing and approving, modifying, delaying, or
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11 denying, based in whole or in part on medical necessity, requests by
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12 health care providers, insureds, or their authorized representatives
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13 for coverage of health care services prior to, retrospectively, or
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14 concurrent with the provision of health care services to insureds,
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15 or for out-of-network services required pursuant to 6060.11a of
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16 Title 36 of the Oklahoma Statutes; and
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17 8. "Utilization review criteria" means any criteria, standards,
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18 protocols, or guidelines used by a health benefit plan, or any
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19 entity acting on the health benefit plan's behalf, to conduct
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20 utilization review.
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21 B. 1. Every health benefit plan issued, amended, or renewed in
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22 this state that provides hospital, medical, or surgical coverage
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23 shall provide coverage for medically necessary treatment of mental
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24 health and substance use disorders including services that are
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1 consistent with criteria, guidelines, or consensus recommendations
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2 from nationally recognized not-for-profit clinical specialty
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3 associations of the relevant behavioral, mental health, or substance
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4 use disorder specialty.
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5 2. A health benefit plan shall not limit benefits or coverage
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6 for chronic or pervasive mental health and substance use disorders
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7 to short-term or acute treatment at any level of care placement.
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8 3. All utilization review concerning service intensity, level
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9 of care placement, continued stay, and transfer or discharge of
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10 insureds diagnosed with mental health and substance use disorders
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11 shall be conducted in accordance with the requirements of subsection
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12 C of this section.
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13 4. A health benefit plan that authorizes a specific type of
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14 treatment by a provider pursuant to this section shall not rescind
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15 or modify the authorization or payment after the provider renders
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16 the health care service in good faith and pursuant to the
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17 authorization for any reason, including, but not limited to, the
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18 health benefit plan's subsequent rescission, cancellation, or
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19 modification of the insured's or policyholder's contract, or the
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20 health benefit plan's subsequent determination that it did not make
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21 an accurate determination of the insured's or policyholder's
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22 eligibility.
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23 5. If services for the medically necessary treatment of a
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24 mental health or substance use disorder are not available in-
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1 network, the health benefit plan shall comply with the out-of-
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2 network care requirements provided by Section 6060.11a of Title 36
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3 of the Oklahoma Statutes.
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4 6. If a health benefit plan provides any benefits for a mental
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5 health or substance use disorder in any classification of benefits,
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6 it shall provide meaningful benefits for that mental health or
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7 substance use disorder in every classification in which medical or
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8 surgical benefits are provided in accordance with 45 C.F.R., Section
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9 146.136. For purposes of this paragraph, whether the benefits
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10 provided are meaningful benefits shall be determined in comparison
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11 to the benefits provided for medical conditions and surgical
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12 procedures in the classification. At a minimum, the health benefit
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13 plan shall provide coverage of benefits for that condition or
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14 disorder in each classification in which the health benefit plan
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15 provides benefits for one or more medical conditions or surgical
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16 procedures. The health benefit plan shall not be deemed to provide
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17 meaningful benefits unless it provides benefits for a core treatment
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18 for that condition or disorder in each classification in which the
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19 health benefit plan provides benefits for a core treatment for one
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20 or more medical conditions or surgical procedures. If there is no
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21 core treatment for a covered mental health condition or substance
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22 use disorder with respect to a classification, the health benefit
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23 plan is not required to provide benefits for a core treatment for
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24 such condition or disorder in that classification, but shall provide
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1 benefits for such condition or disorder in every classification in
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2 which medical or surgical benefits are provided.
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3 C. 1. In conducting utilization review, a health benefit plan
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4 that provides hospital, medical, or surgical coverage, or an entity
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5 acting on the health benefit plan's behalf, shall not deviate from,
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6 or apply criteria that deviates from, current generally accepted
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7 standards of mental health and substance use disorder care as
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8 defined in subsection A of this section. All denials and appeals
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9 shall be reviewed by a professional with the same level of education
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10 and experience as the provider requesting coverage.
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11 2. In conducting utilization review of all covered health care
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12 services and benefits for the screening, diagnosis, prevention, and
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13 treatment of mental health and substance use disorders in children,
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14 adolescents, and adults, a health benefit plan shall apply the
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15 relevant level of care placement criteria and practice guidelines
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16 set forth in the most recent versions of such criteria and practice
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17 guidelines, developed by the nonprofit health care provider
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18 professional association for the relevant clinical specialty.
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19 3. In conducting utilization review relating to service
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20 intensity or level of care placement, continued stay, transfer or
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21 discharge, or any other patient care decisions that are within the
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22 scope of the sources specified in subsection B of this section, a
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23 health benefit plan shall not apply different, additional,
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24 conflicting, or more restrictive utilization review criteria than
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1 the criteria and guidelines set forth in those sources. For all
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2 service intensity or level of care placement, continued stay, or
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3 transfer or discharge decisions, the health benefit plan shall
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4 authorize placement at the level of care consistent with the
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5 insured's score using the relevant level of care placement criteria
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6 and guidelines as specified in subsection B of this section. If
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7 that level of placement is not available, the health benefit plan
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8 shall authorize the next highest level of care. If the health
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9 benefit plan's application of the relevant age-appropriate criteria
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10 is not consistent with the service intensity or level of care
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11 placement requested by the covered person or his or her provider,
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12 any adverse benefit determination notice shall include full details
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13 of the health benefit plan's assessment under the relevant criteria
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14 to the provider and the covered person.
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15 D. A health benefit plan shall not adopt, impose, or enforce
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16 terms in its policies or provider agreements, in writing or in
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17 operation, that undermine, alter, or conflict with the requirements
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18 of this section.
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19 E. 1. The Insurance Commissioner may promulgate rules to
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20 implement and enforce the provisions of this section including, but
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21 not limited to, rules to:
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22 a. address health benefit plan utilization review
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23 compliance in accordance with subsection C of this
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24 section,
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1 b. specify data testing requirements to determine plan
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2 design and application of parity compliance for
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3 nonquantitative treatment limitations using outcomes
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4 data, and
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5 c. set standard definitions for coverage requirements,
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6 including processes, strategies, evidentiary
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7 standards, and other factors.
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8 2. If the Commissioner determines that a health benefit plan
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9 has violated this section, the Commissioner may, after appropriate
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10 notice and opportunity for hearing by order, assess a civil penalty
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11 not to exceed Five Thousand Dollars ($5,000.00) for each violation
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12 or, if a violation was willful, a civil penalty not to exceed Ten
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13 Thousand Dollars ($10,000.00) for each violation. The civil
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14 penalties authorized under this paragraph are not exclusive and may
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15 be sought and employed in combination with any other remedies
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16 available to the Commissioner under the Oklahoma Insurance Code.
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17 F. 1. This section applies to:
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18 a. all health care services and benefits for the
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19 screening, diagnosis, prevention, and treatment of
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20 mental health and substance use disorders covered by
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21 an insurance policy, and
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22 b. a health benefit plan that covers hospital, medical,
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23 or surgical expenses and conducts utilization review
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24 as defined in this section, and any entity or
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1 contracting provider that performs utilization review
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2 or utilization management functions on a health
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3 benefit plan's behalf.
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4 2. This section applies only to covered benefits. Nothing in
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5 this section shall be construed to expand or alter the benefits
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6 available to the insured or policyholder under an insurance policy.
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7 3. Nothing in this section shall be construed to supersede,
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8 limit, or otherwise affect the provisions of Section 2607.1 of Title
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9 63 of the Oklahoma Statutes.
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10 SECTION 2. This act shall become effective January 1, 2027.
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12 60-2-2893 DC 1/13/2026 7:46:28 PM
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Req. No. 2893 Page 10Every fact on this page links to its source, starting with the official bill record.