1| SENATE FLOOR VERSION | | March 6, 2025 | 2| AS AMENDED | | | 3|SENATE BILL NO. 1047 By: McIntosh, Bullard, | | Grellner, and Standridge of | 4| the Senate | | | 5| and | | | 6| Newton of the House | | | 7| | | | 8| [ health insurance - billing procedure - | | reimbursement - cost incurrence - rule promulgation - | 9| verification - fines and fees - codification - | | effective date ] | 10| | | | 11| | | | 12|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 13| SECTION 1. NEW LAW A new section of law to be codified | | | 14|in the Oklahoma Statutes as Section 6063 of Title 36, unless there | | | 15|is created a duplication in numbering, reads as follows: | | | 16| This act shall be known and may be cited as the "Oklahoma | | | 17|Surprise Medical Billing Act". | | | 18| SECTION 2. NEW LAW A new section of law to be codified | | | 19|in the Oklahoma Statutes as Section 6063.1 of Title 36, unless there | | | 20|is created a duplication in numbering, reads as follows: | | | 21| As used in this section: | | | 22| 1. "Surprise bill" means a bill issued by an out-of-network | | | 23|provider or out-of-network facility to an enrollee of a health | | | 24|benefit plan for health care services in an amount that exceeds the | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 1 ___________________________________________________________________________
1|enrollee's cost-sharing obligation applicable for the same health | | | 2|care services if the services had been provided by an in-network | | | 3|provider or in-network facility and are rendered in the following | | | 4|circumstances: | | | 5| a. emergency care provided by an out-of-network provider | | | 6| or out-of-network facility, or | | | 7| b. nonemergency health care services rendered by an | | | 8| out-of-network provider at an in-network facility; | | | 9| 2. "Claim" means a request from a provider for payment for | | | 10|health care services rendered to the enrollee of a health benefit | | | 11|plan; | | | 12| 3. "Covered person" means: | | | 13| a. an enrollee, policyholder, or subscriber, | | | 14| b. the enrolled dependent of an enrollee, policyholder, | | | 15| or subscriber, or | | | 16| c. another individual participating in a health benefit | | | 17| plan; | | | 18| 4. "Health benefit plan" means a health benefit plan as defined | | | 19|pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes; | | | 20| 5. "Health care service" means any service, supply, or | | | 21|procedure rendered for the diagnosis, prevention, treatment, cure, | | | 22|or relief of a health condition, illness, injury, or other disease, | | | 23|including physical or behavioral health services, to the extent it | | | 24|is covered by a health benefit plan; | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 2 ___________________________________________________________________________
1| 6. "Emergency care" means a health care procedure, treatment, | | | 2|service, or ambulance transportation service delivered to a covered | | | 3|person after the sudden onset of medical or behavioral health | | | 4|condition symptoms of sufficient severity that, without immediate | | | 5|medical attention, regardless of eventual diagnosis, could be | | | 6|expected by a reasonable layperson to result in impairment of a | | | 7|person's physical or mental health, the health or safety of a fetus | | | 8|or pregnant person, bodily function of a bodily organ or part, or | | | 9|disfigurement to a person; | | | 10| 7. "Minimum benefit standard" means the eightieth percentile of | | | 11|all allowed amounts for the same or similar health care service | | | 12|furnished by an in-network provider or in-network facility as | | | 13|reported in an independent benchmarking database maintained by a | | | 14|nonprofit organization specified by the Insurance Commissioner. The | | | 15|nonprofit organization shall not be financially affiliated with a | | | 16|health benefit plan or provider. The calculation of the eightieth | | | 17|percentile of all allowed amounts shall be reflected by claims paid | | | 18|during the most recent calendar year; | | | 19| 8. "Provider" means a health care professional that is not a | | | 20|facility and is licensed to furnish health care services in this | | | 21|state; | | | 22| 9. "In-network provider" means a provider that is under express | | | 23|contract with a health benefit plan or a health benefit plan's | | | 24| | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 3 ___________________________________________________________________________
1|contractor or subcontractor providing health care services to | | | 2|enrollees of the plan; | | | 3| 10. "Out-of-network provider" means a provider that is not | | | 4|contracted with a health benefit plan for network participation; | | | 5| 11. "Facility" means a licensed entity providing health care | | | 6|services, including: | | | 7| a. a general, special, psychiatric, or rehabilitation | | | 8| hospital, | | | 9| b. an ambulatory surgical center, | | | 10| c. a cancer treatment center, | | | 11| d. a birth center, | | | 12| e. an inpatient, outpatient, or residential drug and | | | 13| alcohol treatment center, | | | 14| f. a laboratory, diagnostic, or other outpatient medical | | | 15| service or testing center, | | | 16| g. a health care provider's office or clinic, | | | 17| h. an urgent care center, or | | | 18| i. any other therapeutic health care setting; | | | 19| 12. "In-network facility" means a facility that is under | | | 20|express contract with a health insurance carrier or a health | | | 21|insurance carrier's contractor or subcontractor to provide health | | | 22|care services to enrollees of a plan; | | | 23| 13. "Out-of-network facility" means a facility that is not | | | 24|contracted with a health benefit plan for network participation; | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 4 ___________________________________________________________________________
1| 14. "Allowed amount" means the contractually agreed-upon amount | | | 2|paid by a health benefit plan to an in-network provider or | | | 3|in-network facility in the health benefit plan network; and | | | 4| 15. "Health insurance carrier" or "carrier" means an entity | | | 5|subject to state insurance laws, including a health insurance | | | 6|company, a health maintenance organization, a hospital and health | | | 7|service corporation, a provider service network, a nonprofit health | | | 8|care plan, or any other entity that contracts or offers to contract, | | | 9|or enters into agreements to provide, deliver, arrange for, pay for, | | | 10|or reimburse any cost of health care services, or that provides, | | | 11|offers, or administers a health benefit policy or managed health | | | 12|care plan in this state. | | | 13| SECTION 3. NEW LAW A new section of law to be codified | | | 14|in the Oklahoma Statutes as Section 6063.2 of Title 36, unless there | | | 15|is created a duplication in numbering, reads as follows: | | | 16| A. An out-of-network provider or out-of-network facility shall | | | 17|not surprise bill a covered person for emergency care. If a covered | | | 18|person pays an out-of-network provider or out-of-network facility an | | | 19|amount that is greater than allowed by this section, the | | | 20|out-of-network provider or out-of-network facility shall render a | | | 21|refund to the covered person within thirty (30) days. | | | 22| B. A health insurance carrier shall directly reimburse an | | | 23|out-of-network provider or out-of-network facility for emergency | | | 24| | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 5 ___________________________________________________________________________
1|care at the minimum benefit standard, or a mutually agreed upon | | | 2|amount, no later than: | | | 3| 1. Thirty (30) days after the date the health benefit plan | | | 4|receives an electronic clean claim for such care that includes all | | | 5|information necessary for the carrier to pay the claim; or | | | 6| 2. Forty-five (45) days after the date the carrier receives a | | | 7|nonelectronic clean claim for such care that includes all | | | 8|information necessary for the carrier to pay the claim. | | | 9| C. A health insurance carrier shall ensure that a covered | | | 10|person who is rendered emergency care by an out-of-network provider | | | 11|or out-of-network facility shall incur no greater cost-sharing | | | 12|obligations than the covered person would have incurred if those | | | 13|health care services were rendered by an in-network provider or | | | 14|in-network facility. | | | 15| D. An out-of-network provider shall not surprise bill a covered | | | 16|person for health care services that are not emergency care and are | | | 17|rendered at an in-network facility. If a covered person pays an | | | 18|out-of-network provider an amount that is greater than allowed by | | | 19|this section, the out-of-network provider shall render a refund to | | | 20|the covered person within thirty (30) days. | | | 21| E. A health insurance carrier shall directly reimburse an | | | 22|out-of-network provider for health care services that are not | | | 23|emergency care and are rendered at an in-network facility the | | | 24| | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 6 ___________________________________________________________________________
1|minimum benefit standard, or mutually agreed to amount, no later | | | 2|than: | | | 3| 1. Thirty (30) days after the date the carrier receives an | | | 4|electronic clean claim for such services that includes all | | | 5|information necessary for the carrier to pay the claim; or | | | 6| 2. Forty-five (45) days after the date the carrier receives a | | | 7|nonelectronic clean claim for such services that includes all | | | 8|information necessary for the carrier to pay the claim. | | | 9| F. A health insurance carrier shall ensure that a covered | | | 10|person who is rendered health care services that are not emergency | | | 11|care by an out-of-network provider at an in-network facility shall | | | 12|incur no greater cost-sharing obligations than the covered person | | | 13|would have incurred if those health care services were rendered by | | | 14|an in-network provider. | | | 15| G. The Insurance Commissioner shall promulgate rules for | | | 16|verifying the minimum benefit standard which may be requested by an | | | 17|out-of-network provider or out-of-network facility that has rendered | | | 18|health care services in accordance with this act. | | | 19| 1. Verification of the minimum benefit standard shall only be | | | 20|requested if reimbursement has been received from a carrier and no | | | 21|more than thirty (30) days have elapsed since the date payment was | | | 22|received. | | | 23| | | | 24| | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 7 ___________________________________________________________________________
1| 2. Request for verification of the minimum benefit standard may | | | 2|be requested for bundled claims provided none of the claims were | | | 3|paid more than thirty (30) days since the date payment was received. | | | 4| 3. The Insurance Commissioner shall ensure that verification of | | | 5|the minimum benefit standard is provided to an out-of-network | | | 6|provider or out-of-network facility no later than fifteen (15) days | | | 7|after a request has been initiated. | | | 8| 4. If the Insurance Commissioner determines that the amount | | | 9|reimbursed by the carrier is less than the minimum benefit standard, | | | 10|the carrier shall be required to compensate the out-of-network | | | 11|provider or out-of-network facility the difference between the | | | 12|amount initially paid and the verified minimum benefit standard no | | | 13|later than fifteen (15) days after the date the Insurance | | | 14|Commissioner has verified the minimum benefit standard. | | | 15| H. A health insurance carrier that fails to reimburse for | | | 16|health care services at the minimum benefit standard shall be | | | 17|subject to a penalty that is calculated as the difference between | | | 18|the minimum benefit standard and the amount billed by the | | | 19|out-of-network provider or out-of-network facility that requested | | | 20|verification of the minimum benefit standard. Fifty percent (50%) | | | 21|of the calculated penalty shall be made payable to the | | | 22|out-of-network provider or out-of-network facility and the remaining | | | 23|fifty percent (50%) shall be made payable to the Oklahoma Health | | | 24|Insurance High Risk Pool. | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 8 ___________________________________________________________________________
1| A carrier may be subject to additional fines and penalties, as | | | 2|determined by the Commissioner, if a pattern of underpayment has | | | 3|been determined. | | | 4| SECTION 4. This act shall become effective November 1, 2025. | | | 5|COMMITTEE REPORT BY: COMMITTEE ON BUSINESS AND INSURANCE | |March 6, 2025 - DO PASS AS AMENDED | 6| | | | 7| | | | 8| | | | 9| | | | 10| | | | 11| | | | 12| | | | 13| | | | 14| | | | 15| | | | 16| | | | 17| | | | 18| | | | 19| | | | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | arsid13924760 SENATE FLOOR VERSION - SB1047 SFLR Page 9