1| STATE OF OKLAHOMA | | | 2| 2nd Session of the 60th Legislature (2026) | | | 3|SENATE BILL 1646 By: Gollihare | | | 4| | | | 5| | | | 6| AS INTRODUCED | | | 7| An Act relating to health insurance; defining terms; | | requiring health benefit plan to provide coverage for | 8| medically necessary treatment of mental health and | | substance use disorders; prohibiting certain | 9| limitations on benefits or coverage; prohibiting | | certain rescission or modification of authorization; | 10| requiring compliance with certain out-of-network care | | requirements under certain conditions; requiring | 11| provision of meaningful benefits under specified | | conditions; specifying procedures and minimum | 12| criteria for certain determination; establishing | | requirements and procedures related to utilization | 13| review; requiring and prohibiting application of | | certain criteria; specifying requirements for certain | 14| authorizations; prohibiting adoption of certain | | policy terms; authorizing promulgation of certain | 15| rules; authorizing certain enforcement by the | | Insurance Commissioner; specifying applicability of | 16| act; providing certain construction; providing for | | codification; and providing an effective date. | 17| | | | 18| | | | 19|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 20| SECTION 1. NEW LAW A new section of law to be codified | | | 21|in the Oklahoma Statutes as Section 6060.11c of Title 36, unless | | | 22|there is created a duplication in numbering, reads as follows: | | | 23| A. As used in this section: | | | 24| | | | Req. No. 2893 Page 1 ___________________________________________________________________________
1| 1. A "core treatment" for a condition or disorder is a standard | | | 2|treatment or course of treatment, therapy, service, or intervention | | | 3|indicated by generally accepted standards of mental health and | | | 4|substance use disorder care; | | | 5| 2. "Generally accepted standards of mental health and substance | | | 6|use disorder care" means standards of care and clinical practice | | | 7|that are generally recognized by health care providers practicing in | | | 8|relevant clinical specialties such as psychiatry, psychology, | | | 9|addiction medicine and counseling, and behavioral health treatment. | | | 10|Valid, evidence-based sources reflecting generally accepted | | | 11|standards of mental health and substance use disorder care include | | | 12|published peer-reviewed scientific studies and medical literature | | | 13|and recommendations of nonprofit health care provider professional | | | 14|associations including, but not limited to, patient placement | | | 15|criteria and clinical practice guidelines; | | | 16| 3. "Health benefit plan" has the same meaning as provided in | | | 17|Section 6060.4 of Title 36 of the Oklahoma Statutes; | | | 18| 4. "Medically necessary treatment of a mental health or | | | 19|substance use disorder" means a service or product addressing the | | | 20|specific needs of that patient, for the purpose of screening, | | | 21|preventing, diagnosing, managing, or treating an illness, injury, | | | 22|condition, or its symptoms, including minimizing the progression of | | | 23|an illness, injury, condition, or its symptoms, in a manner that is | | | 24|all of the following: | | | Req. No. 2893 Page 2 ___________________________________________________________________________
1| a. in accordance with the generally accepted standards | | | 2| of mental health and substance use disorder care, | | | 3| b. clinically appropriate in terms of type, frequency, | | | 4| extent, site, and duration, and | | | 5| c. not primarily for the economic benefit of the health | | | 6| benefit plan or purchaser or for the convenience of | | | 7| the patient, treating physician, or other health care | | | 8| provider; | | | 9| 5. "Mental health and substance use disorder" means a mental | | | 10|health condition or substance use disorder that falls under any of | | | 11|the diagnostic categories listed in the mental and behavioral | | | 12|disorders chapter of the most recent edition of the International | | | 13|Statistical Classification of Diseases and Related Health Problems, | | | 14|or that is listed in the most recent version of the American | | | 15|Psychiatric Association's Diagnostic and Statistical Manual of | | | 16|Mental Disorders or the Diagnostic Classification of Mental Health | | | 17|and Developmental Disorders of Infancy and Early Childhood. Changes | | | 18|in terminology, organization, or classification of mental health and | | | 19|substance use disorders in future versions of the American | | | 20|Psychiatric Association's Diagnostic and Statistical Manual of | | | 21|Mental Disorders or the International Statistical Classification of | | | 22|Diseases and Related Health Problems shall not affect the conditions | | | 23|covered by this section as long as a condition is commonly | | | 24| | | | Req. No. 2893 Page 3 ___________________________________________________________________________
1|understood to be a mental health or substance use disorder by health | | | 2|care providers practicing in relevant clinical specialties; | | | 3| 6. "Nonprofit health care provider professional association" | | | 4|means a not-for-profit health care provider professional association | | | 5|or specialty society that is generally recognized by clinicians | | | 6|practicing in the relevant clinical specialty and that issues | | | 7|peer-reviewed guidelines, criteria, or other clinical | | | 8|recommendations developed through a transparent process; | | | 9| 7. "Utilization review" means prospectively, retrospectively, | | | 10|or concurrently reviewing and approving, modifying, delaying, or | | | 11|denying, based in whole or in part on medical necessity, requests by | | | 12|health care providers, insureds, or their authorized representatives | | | 13|for coverage of health care services prior to, retrospectively, or | | | 14|concurrent with the provision of health care services to insureds, | | | 15|or for out-of-network services required pursuant to 6060.11a of | | | 16|Title 36 of the Oklahoma Statutes; and | | | 17| 8. "Utilization review criteria" means any criteria, standards, | | | 18|protocols, or guidelines used by a health benefit plan, or any | | | 19|entity acting on the health benefit plan's behalf, to conduct | | | 20|utilization review. | | | 21| B. 1. Every health benefit plan issued, amended, or renewed in | | | 22|this state that provides hospital, medical, or surgical coverage | | | 23|shall provide coverage for medically necessary treatment of mental | | | 24|health and substance use disorders including services that are | | | Req. No. 2893 Page 4 ___________________________________________________________________________
1|consistent with criteria, guidelines, or consensus recommendations | | | 2|from nationally recognized not-for-profit clinical specialty | | | 3|associations of the relevant behavioral, mental health, or substance | | | 4|use disorder specialty. | | | 5| 2. A health benefit plan shall not limit benefits or coverage | | | 6|for chronic or pervasive mental health and substance use disorders | | | 7|to short-term or acute treatment at any level of care placement. | | | 8| 3. All utilization review concerning service intensity, level | | | 9|of care placement, continued stay, and transfer or discharge of | | | 10|insureds diagnosed with mental health and substance use disorders | | | 11|shall be conducted in accordance with the requirements of subsection | | | 12|C of this section. | | | 13| 4. A health benefit plan that authorizes a specific type of | | | 14|treatment by a provider pursuant to this section shall not rescind | | | 15|or modify the authorization or payment after the provider renders | | | 16|the health care service in good faith and pursuant to the | | | 17|authorization for any reason, including, but not limited to, the | | | 18|health benefit plan's subsequent rescission, cancellation, or | | | 19|modification of the insured's or policyholder's contract, or the | | | 20|health benefit plan's subsequent determination that it did not make | | | 21|an accurate determination of the insured's or policyholder's | | | 22|eligibility. | | | 23| 5. If services for the medically necessary treatment of a | | | 24|mental health or substance use disorder are not available | | | Req. No. 2893 Page 5 ___________________________________________________________________________
1|in-network, the health benefit plan shall comply with the | | | 2|out-of-network care requirements provided by Section 6060.11a of | | | 3|Title 36 of the Oklahoma Statutes. | | | 4| 6. If a health benefit plan provides any benefits for a mental | | | 5|health or substance use disorder in any classification of benefits, | | | 6|it shall provide meaningful benefits for that mental health or | | | 7|substance use disorder in every classification in which medical or | | | 8|surgical benefits are provided in accordance with 45 C.F.R., Section | | | 9|146.136. For purposes of this paragraph, whether the benefits | | | 10|provided are meaningful benefits shall be determined in comparison | | | 11|to the benefits provided for medical conditions and surgical | | | 12|procedures in the classification. At a minimum, the health benefit | | | 13|plan shall provide coverage of benefits for that condition or | | | 14|disorder in each classification in which the health benefit plan | | | 15|provides benefits for one or more medical conditions or surgical | | | 16|procedures. The health benefit plan shall not be deemed to provide | | | 17|meaningful benefits unless it provides benefits for a core treatment | | | 18|for that condition or disorder in each classification in which the | | | 19|health benefit plan provides benefits for a core treatment for one | | | 20|or more medical conditions or surgical procedures. If there is no | | | 21|core treatment for a covered mental health condition or substance | | | 22|use disorder with respect to a classification, the health benefit | | | 23|plan is not required to provide benefits for a core treatment for | | | 24|such condition or disorder in that classification, but shall provide | | | Req. No. 2893 Page 6 ___________________________________________________________________________
1|benefits for such condition or disorder in every classification in | | | 2|which medical or surgical benefits are provided. | | | 3| C. 1. In conducting utilization review, a health benefit plan | | | 4|that provides hospital, medical, or surgical coverage, or an entity | | | 5|acting on the health benefit plan's behalf, shall not deviate from, | | | 6|or apply criteria that deviates from, current generally accepted | | | 7|standards of mental health and substance use disorder care as | | | 8|defined in subsection A of this section. All denials and appeals | | | 9|shall be reviewed by a professional with the same level of education | | | 10|and experience as the provider requesting coverage. | | | 11| 2. In conducting utilization review of all covered health care | | | 12|services and benefits for the screening, diagnosis, prevention, and | | | 13|treatment of mental health and substance use disorders in children, | | | 14|adolescents, and adults, a health benefit plan shall apply the | | | 15|relevant level of care placement criteria and practice guidelines | | | 16|set forth in the most recent versions of such criteria and practice | | | 17|guidelines, developed by the nonprofit health care provider | | | 18|professional association for the relevant clinical specialty. | | | 19| 3. In conducting utilization review relating to service | | | 20|intensity or level of care placement, continued stay, transfer or | | | 21|discharge, or any other patient care decisions that are within the | | | 22|scope of the sources specified in subsection B of this section, a | | | 23|health benefit plan shall not apply different, additional, | | | 24|conflicting, or more restrictive utilization review criteria than | | | Req. No. 2893 Page 7 ___________________________________________________________________________
1|the criteria and guidelines set forth in those sources. For all | | | 2|service intensity or level of care placement, continued stay, or | | | 3|transfer or discharge decisions, the health benefit plan shall | | | 4|authorize placement at the level of care consistent with the | | | 5|insured's score using the relevant level of care placement criteria | | | 6|and guidelines as specified in subsection B of this section. If | | | 7|that level of placement is not available, the health benefit plan | | | 8|shall authorize the next highest level of care. If the health | | | 9|benefit plan's application of the relevant age-appropriate criteria | | | 10|is not consistent with the service intensity or level of care | | | 11|placement requested by the covered person or his or her provider, | | | 12|any adverse benefit determination notice shall include full details | | | 13|of the health benefit plan's assessment under the relevant criteria | | | 14|to the provider and the covered person. | | | 15| D. A health benefit plan shall not adopt, impose, or enforce | | | 16|terms in its policies or provider agreements, in writing or in | | | 17|operation, that undermine, alter, or conflict with the requirements | | | 18|of this section. | | | 19| E. 1. The Insurance Commissioner may promulgate rules to | | | 20|implement and enforce the provisions of this section including, but | | | 21|not limited to, rules to: | | | 22| a. address health benefit plan utilization review | | | 23| compliance in accordance with subsection C of this | | | 24| section, | | | Req. No. 2893 Page 8 ___________________________________________________________________________
1| b. specify data testing requirements to determine plan | | | 2| design and application of parity compliance for | | | 3| nonquantitative treatment limitations using outcomes | | | 4| data, and | | | 5| c. set standard definitions for coverage requirements, | | | 6| including processes, strategies, evidentiary | | | 7| standards, and other factors. | | | 8| 2. If the Commissioner determines that a health benefit plan | | | 9|has violated this section, the Commissioner may, after appropriate | | | 10|notice and opportunity for hearing by order, assess a civil penalty | | | 11|not to exceed Five Thousand Dollars ($5,000.00) for each violation | | | 12|or, if a violation was willful, a civil penalty not to exceed Ten | | | 13|Thousand Dollars ($10,000.00) for each violation. The civil | | | 14|penalties authorized under this paragraph are not exclusive and may | | | 15|be sought and employed in combination with any other remedies | | | 16|available to the Commissioner under the Oklahoma Insurance Code. | | | 17| F. 1. This section applies to: | | | 18| a. all health care services and benefits for the | | | 19| screening, diagnosis, prevention, and treatment of | | | 20| mental health and substance use disorders covered by | | | 21| an insurance policy, and | | | 22| b. a health benefit plan that covers hospital, medical, | | | 23| or surgical expenses and conducts utilization review | | | 24| as defined in this section, and any entity or | | | Req. No. 2893 Page 9 ___________________________________________________________________________
1| contracting provider that performs utilization review | | | 2| or utilization management functions on a health | | | 3| benefit plan's behalf. | | | 4| 2. This section applies only to covered benefits. Nothing in | | | 5|this section shall be construed to expand or alter the benefits | | | 6|available to the insured or policyholder under an insurance policy. | | | 7| 3. Nothing in this section shall be construed to supersede, | | | 8|limit, or otherwise affect the provisions of Section 2607.1 of Title | | | 9|63 of the Oklahoma Statutes. | | | 10| SECTION 2. This act shall become effective January 1, 2027. | | | 11| | | | 12| 60-2-2893 DC 1/14/2026 6:43:58 AM | | | 13| | | | 14| | | | 15| | | | 16| | | | 17| | | | 18| | | | 19| | | | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | Req. No. 2893 Page 10