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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 787 By: Weaver
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7 AS INTRODUCED
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8 An Act relating to health care costs; creating the
8 Oklahoma Health Care Cost Containment and
9 Affordability Act; providing short title; defining
9 terms; placing limitations on certain payment rates;
10 prohibiting collections from exceeding certain
10 authorized amounts; providing alternative payment
11 methods; providing exceptions; requiring provision of
11 certain information; exempting certain confidential
12 information; requiring report to certain officials;
12 requiring promulgation of rules; constituting certain
13 violations as unfair trade practices; authorizing
13 enforcement by certain entities; establishing
14 penalties for certain violations; authorizing certain
14 audits; stipulating certain duties; requiring certain
15 filings; requiring certain notice; establishing
15 procedures for approval of certain filings; requiring
16 consideration of certain factors; providing for
16 codification; and providing an effective date.
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20 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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21 SECTION 1. NEW LAW A new section of law to be codified
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22 in the Oklahoma Statutes as Section 6013 of Title 36, unless there
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23 is created a duplication in numbering, reads as follows:
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1 This act shall be known and may be cited as the "Oklahoma Health
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2 Care Cost Containment and Affordability Act".
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3 SECTION 2. NEW LAW A new section of law to be codified
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4 in the Oklahoma Statutes as Section 6013.1 of Title 36, unless there
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5 is created a duplication in numbering, reads as follows:
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6 As used in the Oklahoma Health Care Cost Containment and
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7 Affordability Act:
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8 1. "Health insurance carrier" means an entity subject to the
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9 insurance laws and regulations of this state or subject to the
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10 jurisdiction of the Insurance Department that offers health
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11 insurance, health benefits, or contracts for health care services,
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12 including prescription drug coverage, to large groups, small groups,
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13 or individuals on or outside the Patient Protection and Affordable
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14 Care Act Health Insurance mandate;
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15 2. "Health benefit plan" means a plan, policy, contract,
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16 certificate, or agreement entered into, offered, or issued by a
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17 health insurance carrier or health plan administrator acting on
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18 behalf of a plan sponsor to provide, deliver, arrange for, pay for,
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19 or reimburse any of the costs of health care services, including
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20 nonfederal governmental plans as defined in 29 U.S.C., Section
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21 1002(32), but excludes any coverage by Medicare, Medicaid, TRICARE,
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22 the Veterans Health Administration, the Indian Health Service, and
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23 the Federal Employees Health Benefit Program;
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1 3. "Health plan administrator" means a third-party
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2 administrator who acts on behalf of a plan sponsor to administer a
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3 health benefit plan;
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4 4. "Health system" means:
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5 a. a parent corporation of one or more hospitals and any
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6 entity affiliated with such parent corporation through
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7 ownership, governance, membership or other means, or
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8 b. a hospital and any entity affiliated with such
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9 hospital through ownership, governance, membership or
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10 other means;
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11 5. "Hospital" means a hospital licensed by the State Department
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12 of Health;
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13 6. "Hospital-based facility" means a facility that is owned or
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14 operated, in whole or in part, by a hospital where hospital or
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15 professional medical services are provided;
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16 7. "Health care provider" means an individual, entity,
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17 corporation, person, or organization, whether for profit or
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18 nonprofit, that furnishes, bills, or is paid for health care service
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19 delivery in the normal course of business, and includes, without
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20 limitation, health systems, hospitals, and hospital-based
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21 facilities;
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22 8. "Price transparency laws" means Section 2718(e) of the
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23 Public Health Service Act (PHSA), as amended, and rules adopted by
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24 the U.S. Department of Health and Human Services implementing
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1 Section 2718(e) of such act and the Transparency in Health Care
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2 Prices Act; and
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3 9. "Transparency in coverage laws" means Section 2715A of the
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4 Public Health Service Act, as amended; Section 715 of the Employee
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5 Retirement Income Security Act of 1974 (ERISA); Section 9815 of the
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6 Internal Revenue Code of 1986, as amended (IRC); and rules adopted
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7 by the U.S. Department of Health and Human Services, the U.S.
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8 Department of the Treasury, and the U.S. Department of Labor
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9 implementing Section 2715A of the PHSA, Section 715 of ERISA, and
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10 Section 9815 of the IRC.
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11 SECTION 3. NEW LAW A new section of law to be codified
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12 in the Oklahoma Statutes as Section 6013.2 of Title 36, unless there
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13 is created a duplication in numbering, reads as follows:
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14 A. Total payments to any health care provider for inpatient or
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15 outpatient hospital services furnished to persons covered by a
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16 health benefit plan shall not exceed the lesser of:
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17 1. Two hundred percent (200%) of the amount paid by Medicare
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18 for the item or service. If there is no allowable amount in
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19 Medicare for this item or service, then two hundred percent (200%)
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20 of the amount paid by Medicaid for the same item or service; or
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21 2. The median amount paid by health benefit plans for the same
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22 item or service.
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23 B. A health care provider who is reimbursed in accordance with
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24 subsection A of this section may not charge or collect from the
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1 patient any amount greater than cost-sharing amounts authorized by
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2 the terms of the health benefit plan and allowed under applicable
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3 law. The total payment, including amounts paid by the health
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4 benefit plan and individual cost-sharing, shall not exceed the
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5 amounts stated in subsection A of this section.
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6 C. If a health benefit plan does not reimburse claims on a fee-
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7 for-service basis, the payment method used shall conform to the
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8 limits specified in subsection A of this section. Such payment
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9 methods include, but are not limited to, value-based payments,
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10 capitation payments, or bundled payments.
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11 D. The provisions of this section shall not apply to:
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12 1. Critical access hospitals;
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13 2. Federally Qualified Health Centers; or
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14 3. Rural health clinics.
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15 SECTION 4. NEW LAW A new section of law to be codified
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16 in the Oklahoma Statutes as Section 6013.3 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. Health care providers shall provide the State Department of
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19 Health the information required by price transparency laws and any
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20 such data as the State Department of Health determines is necessary
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21 to calculate the growth rates of health care services and to monitor
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22 compliance with the payment limits established in this act.
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23 B. Health insurance carriers and the health plan administrator
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24 of the state public employee health benefit plan shall provide the
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1 Insurance Department the information required by transparency in
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2 coverage laws and any such data as the Insurance Department
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3 determines is necessary to calculate the growth rates of health care
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4 services, to monitor compliance with the payment limits established
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5 in this act, to evaluate compliance with medical loss ratio
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6 requirements under applicable federal or state laws, and to review
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7 and approve premium rates and growth.
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8 C. The State Department of Health and the Insurance Department
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9 shall keep confidential all nonpublic information and documents
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10 obtained under this act and shall not disclose the confidential
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11 information or documents to any person without the consent of the
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12 party that produced the confidential information or documents,
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13 except that the information may be disclosed to experts or
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14 consultants under contract with the State Department of Health or
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15 the Insurance Department, provided that the expert or consultant is
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16 bound by the same confidentiality requirements as the state
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17 officials. The confidential information and documents shall not be
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18 public records and shall be exempt from the Oklahoma Open Records
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19 Act.
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20 D. By the last day of February every year, the State Department
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21 of Health and the Insurance Department shall each provide an
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22 electronic report to the President Pro Tempore of the Senate, the
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23 Speaker of the House of Representatives, and the Governor on trends
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24 for providers, health insurance premiums, patient access to
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1 providers, and compliance with this act. The departments may
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2 include recommendations for further actions to make health care more
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3 affordable and accessible to residents of the state.
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4 E. The State Department of Health may promulgate regulations
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5 necessary to implement the requirements of this act, alter or reduce
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6 the rate limits set forth in this act, specify the format and
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7 content of reports established in this act, and impose penalties for
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8 noncompliance consistent with the State Department of Health's
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9 authority to regulate health care providers.
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10 F. The Insurance Department and the Insurance Commissioner may
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11 promulgate regulations necessary to evaluate the growth or reduction
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12 of health insurance premiums, ensure that savings from reductions in
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13 provider payments are passed on to consumers, ensure compliance with
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14 applicable medical loss ratio requirements under federal and state
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15 laws, specify the format and content of reports under this act, and
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16 impose penalties for noncompliance consistent with the Insurance
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17 Department's and Commissioner's authority to regulate health
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18 insurance carriers.
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19 SECTION 5. NEW LAW A new section of law to be codified
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20 in the Oklahoma Statutes as Section 6013.4 of Title 36, unless there
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21 is created a duplication in numbering, reads as follows:
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22 A. Any violation of this act shall constitute an unfair trade
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23 practice pursuant to Section 1201 et seq. of Title 36 of the
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1 Oklahoma Statutes, which may be enforced by the Insurance
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2 Department, the Attorney General, or an aggrieved individual.
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3 B. A health care provider that violates any provision of this
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4 act or the rules and regulations adopted pursuant to this act shall:
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5 1. Refund any amount received that is more than the amount set
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6 forth in this act to the health benefit plan; and
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7 2. Pay the patient or individual responsible for the patient a
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8 penalty of the greater of One Thousand Dollars ($1,000.00) or the
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9 amount the health care provider received that is more than the
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10 amount set forth in this act.
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11 C. The State Department of Health may audit any health care
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12 provider, and the Insurance Department, the Insurance Commissioner,
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13 or their designee may audit any health insurance carrier or health
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14 plan administrator, for compliance with the requirements of this
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15 act. Until the expiration of four (4) years after the furnishing of
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16 any services for which an out-of-network payment was charged,
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17 billed, or collected, each health care provider, health insurance
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18 carrier, or health plan administrator shall make available, upon
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19 written request of the State Department of Health, the Insurance
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20 Department, the Insurance Commissioner, or their designee, copies of
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21 any books, documents, records, or data that are necessary for the
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22 purposes of completing the audit.
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1 SECTION 6. NEW LAW A new section of law to be codified
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2 in the Oklahoma Statutes as Section 1613.5 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. In addition to the purposes pertaining to rates set forth in
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5 Section 901.1 of Title 36 of the Oklahoma Statutes, the Insurance
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6 Department and Insurance Commissioner shall discharge their powers
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7 and duties to:
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8 1. Protect the public interest and the interests of consumers;
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9 2. Encourage the fair treatment of health care providers; and
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10 3. View the health care system as a comprehensive entity, and
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11 encourage and direct insurers towards policies that advance the
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12 welfare of the public through overall efficiency, affordability,
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13 improved health care quality, and appropriate access.
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14 B. 1. Every health benefit plan shall file with the Insurance
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15 Department, either directly or through a licensed rating
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16 organization of which it is a member or subscriber, all rates and
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17 rating plans, classifications, class rates, rating schedules, loss
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18 cost, all other supplementary rate information, and every
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19 modification of all such information, which it uses or proposes to
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20 use in this state except as otherwise provided in this act.
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21 2. The Insurance Department shall send a notification of filing
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22 of rates to any person who submits a written request to be notified
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23 of filings pursuant to regulation of the Board.
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1 3. The Attorney General shall be notified in writing within ten
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2 (10) days of:
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3 a. filing of rates, whether for prior approval or for
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4 immediate use, and
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5 b. certification of completion of a filing.
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6 C. Rates, rating plans, classifications, schedules, loss cost,
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7 and other information shall be deemed approved ninety (90) calendar
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8 days following certification of completion of the filing as provided
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9 in this act unless, within the ninety-calendar-day period:
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10 1. The Insurance Department approves, disapproves, or approves
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11 with modification, the filing;
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12 2. The Insurance Department orders a formal hearing on the
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13 filing; or
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14 3. The Insurance Commissioner extends such period for one
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15 additional ninety-calendar-day period.
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16 D. Any formal hearing ordered by the Insurance Department shall
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17 be completed and a written order on the filing issued within one
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18 hundred twenty (120) calendar days from the date of the order
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19 setting the formal hearing, or the filing shall be deemed approved
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20 at the expiration of this period.
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21 E. In discharging the duties to approve, disapprove, modify, or
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22 take any other action authorized by law with respect to a health
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23 benefit plan's filing of health insurance rates or rate formulas
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24 under this act, the Insurance Department and Insurance Commissioner
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1 shall consider whether the health benefit plan's products are
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2 affordable and whether the carrier has implemented effective
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3 strategies to enhance the affordability of its products.
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4 F. The Insurance Department and Insurance Commissioner may
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5 promulgate regulations to carry out the powers and duties of this
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6 section, including without limitation, to implement rate filing
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7 requirements, establish affordability standards, impose penalties,
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8 and ensure compliance with this section.
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9 G. When investigating rates to determine whether they comply
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10 with the provisions of this act, the previously approved filing
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11 shall not be changed, altered, amended, or held in abeyance until
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12 after completion of the investigation and an opportunity for hearing
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13 in accordance with the provisions of this article. Following such
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14 hearing, the Insurance Department shall enter its order in
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15 accordance with the provisions of this act. The effective date of
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16 such order shall not be fewer than thirty (30) days nor more than
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17 sixty (60) days after the date of the order unless the Insurance
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18 Department determines that, in the public interest, a shorter or
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19 longer period is appropriate, provided the filer has adequate time
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20 to implement such rate change. Any such order shall apply
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21 prospectively only and shall not affect premiums collected on new or
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22 renewal policies issued prior to the effective date of the order.
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23 H. If the Department finds that a filing does not meet the
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24 requirements of this act, it shall send to the insurer or rating
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1 organization which made such filing, written notice of disapproval
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2 of such filing, specifying in what respects it finds that such
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3 filing fails to meet the requirements of this act and stating that
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4 such filing shall not become effective to the extent disapproved.
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5 I. In determining whether a heath benefit plan's health
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6 insurance products are affordable, the Department and Commissioner
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7 may consider the following factors:
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8 1. Historical rates of trends for existing products;
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9 2. National medical and health insurance trends, including
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10 Medicare trends;
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11 3. Regional medical and health insurance trends;
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12 4. Inflation indices, such as the Consumer Price Index and the
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13 medical care component of the Consumer Price Index;
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14 5. Price comparison to other market rates for similar products
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15 such as consideration of rate differentials, if any, between not-
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16 for-profit and for-profit insurers in other markets;
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17 6. The ability of lower-income individuals to pay for health
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18 insurance;
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19 7. Efforts of the health benefit plan to maintain close control
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20 over its administrative costs;
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21 8. Implementation of effective strategies by the health benefit
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22 plan to enhance the affordability of its products; or
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1 9. Any other relevant affordability factor, measurement, or
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2 analysis determined by the Commissioner to be necessary or desirable
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3 to carry out the purposes of this act.
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4 SECTION 7. This act shall become effective November 1, 2025.
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Req. No. 1236 Page 13Every fact on this page links to its source, starting with the official bill record.