1| STATE OF OKLAHOMA | | | 2| 1st Session of the 60th Legislature (2025) | | | 3|SENATE BILL 787 By: Weaver | | | 4| | | | 5| | | | 6| | | | 7| AS INTRODUCED | | | 8| An Act relating to health care costs; creating the | | Oklahoma Health Care Cost Containment and | 9| Affordability Act; providing short title; defining | | terms; placing limitations on certain payment rates; | 10| prohibiting collections from exceeding certain | | authorized amounts; providing alternative payment | 11| methods; providing exceptions; requiring provision of | | certain information; exempting certain confidential | 12| information; requiring report to certain officials; | | requiring promulgation of rules; constituting certain | 13| violations as unfair trade practices; authorizing | | enforcement by certain entities; establishing | 14| penalties for certain violations; authorizing certain | | audits; stipulating certain duties; requiring certain | 15| filings; requiring certain notice; establishing | | procedures for approval of certain filings; requiring | 16| consideration of certain factors; providing for | | codification; and providing an effective date. | 17| | | | 18| | | | 19| | | | 20|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 21| SECTION 1. NEW LAW A new section of law to be codified | | | 22|in the Oklahoma Statutes as Section 6013 of Title 36, unless there | | | 23|is created a duplication in numbering, reads as follows: | | | 24| | | | Req. No. 1236 Page 1 ___________________________________________________________________________
1| This act shall be known and may be cited as the "Oklahoma Health | | | 2|Care Cost Containment and Affordability Act". | | | 3| SECTION 2. NEW LAW A new section of law to be codified | | | 4|in the Oklahoma Statutes as Section 6013.1 of Title 36, unless there | | | 5|is created a duplication in numbering, reads as follows: | | | 6| As used in the Oklahoma Health Care Cost Containment and | | | 7|Affordability Act: | | | 8| 1. "Health insurance carrier" means an entity subject to the | | | 9|insurance laws and regulations of this state or subject to the | | | 10|jurisdiction of the Insurance Department that offers health | | | 11|insurance, health benefits, or contracts for health care services, | | | 12|including prescription drug coverage, to large groups, small groups, | | | 13|or individuals on or outside the Patient Protection and Affordable | | | 14|Care Act Health Insurance mandate; | | | 15| 2. "Health benefit plan" means a plan, policy, contract, | | | 16|certificate, or agreement entered into, offered, or issued by a | | | 17|health insurance carrier or health plan administrator acting on | | | 18|behalf of a plan sponsor to provide, deliver, arrange for, pay for, | | | 19|or reimburse any of the costs of health care services, including | | | 20|nonfederal governmental plans as defined in 29 U.S.C., Section | | | 21|1002(32), but excludes any coverage by Medicare, Medicaid, TRICARE, | | | 22|the Veterans Health Administration, the Indian Health Service, and | | | 23|the Federal Employees Health Benefit Program; | | | 24| | | | Req. No. 1236 Page 2 ___________________________________________________________________________
1| 3. "Health plan administrator" means a third-party | | | 2|administrator who acts on behalf of a plan sponsor to administer a | | | 3|health benefit plan; | | | 4| 4. "Health system" means: | | | 5| a. a parent corporation of one or more hospitals and any | | | 6| entity affiliated with such parent corporation through | | | 7| ownership, governance, membership or other means, or | | | 8| b. a hospital and any entity affiliated with such | | | 9| hospital through ownership, governance, membership or | | | 10| other means; | | | 11| 5. "Hospital" means a hospital licensed by the State Department | | | 12|of Health; | | | 13| 6. "Hospital-based facility" means a facility that is owned or | | | 14|operated, in whole or in part, by a hospital where hospital or | | | 15|professional medical services are provided; | | | 16| 7. "Health care provider" means an individual, entity, | | | 17|corporation, person, or organization, whether for profit or | | | 18|nonprofit, that furnishes, bills, or is paid for health care service | | | 19|delivery in the normal course of business, and includes, without | | | 20|limitation, health systems, hospitals, and hospital-based | | | 21|facilities; | | | 22| 8. "Price transparency laws" means Section 2718(e) of the | | | 23|Public Health Service Act (PHSA), as amended, and rules adopted by | | | 24|the U.S. Department of Health and Human Services implementing | | | Req. No. 1236 Page 3 ___________________________________________________________________________
1|Section 2718(e) of such act and the Transparency in Health Care | | | 2|Prices Act; and | | | 3| 9. "Transparency in coverage laws" means Section 2715A of the | | | 4|Public Health Service Act, as amended; Section 715 of the Employee | | | 5|Retirement Income Security Act of 1974 (ERISA); Section 9815 of the | | | 6|Internal Revenue Code of 1986, as amended (IRC); and rules adopted | | | 7|by the U.S. Department of Health and Human Services, the U.S. | | | 8|Department of the Treasury, and the U.S. Department of Labor | | | 9|implementing Section 2715A of the PHSA, Section 715 of ERISA, and | | | 10|Section 9815 of the IRC. | | | 11| SECTION 3. NEW LAW A new section of law to be codified | | | 12|in the Oklahoma Statutes as Section 6013.2 of Title 36, unless there | | | 13|is created a duplication in numbering, reads as follows: | | | 14| A. Total payments to any health care provider for inpatient or | | | 15|outpatient hospital services furnished to persons covered by a | | | 16|health benefit plan shall not exceed the lesser of: | | | 17| 1. Two hundred percent (200%) of the amount paid by Medicare | | | 18|for the item or service. If there is no allowable amount in | | | 19|Medicare for this item or service, then two hundred percent (200%) | | | 20|of the amount paid by Medicaid for the same item or service; or | | | 21| 2. The median amount paid by health benefit plans for the same | | | 22|item or service. | | | 23| B. A health care provider who is reimbursed in accordance with | | | 24|subsection A of this section may not charge or collect from the | | | Req. No. 1236 Page 4 ___________________________________________________________________________
1|patient any amount greater than cost-sharing amounts authorized by | | | 2|the terms of the health benefit plan and allowed under applicable | | | 3|law. The total payment, including amounts paid by the health | | | 4|benefit plan and individual cost-sharing, shall not exceed the | | | 5|amounts stated in subsection A of this section. | | | 6| C. If a health benefit plan does not reimburse claims on a | | | 7|fee-for-service basis, the payment method used shall conform to the | | | 8|limits specified in subsection A of this section. Such payment | | | 9|methods include, but are not limited to, value-based payments, | | | 10|capitation payments, or bundled payments. | | | 11| D. The provisions of this section shall not apply to: | | | 12| 1. Critical access hospitals; | | | 13| 2. Federally Qualified Health Centers; or | | | 14| 3. Rural health clinics. | | | 15| SECTION 4. NEW LAW A new section of law to be codified | | | 16|in the Oklahoma Statutes as Section 6013.3 of Title 36, unless there | | | 17|is created a duplication in numbering, reads as follows: | | | 18| A. Health care providers shall provide the State Department of | | | 19|Health the information required by price transparency laws and any | | | 20|such data as the State Department of Health determines is necessary | | | 21|to calculate the growth rates of health care services and to monitor | | | 22|compliance with the payment limits established in this act. | | | 23| B. Health insurance carriers and the health plan administrator | | | 24|of the state public employee health benefit plan shall provide the | | | Req. No. 1236 Page 5 ___________________________________________________________________________
1|Insurance Department the information required by transparency in | | | 2|coverage laws and any such data as the Insurance Department | | | 3|determines is necessary to calculate the growth rates of health care | | | 4|services, to monitor compliance with the payment limits established | | | 5|in this act, to evaluate compliance with medical loss ratio | | | 6|requirements under applicable federal or state laws, and to review | | | 7|and approve premium rates and growth. | | | 8| C. The State Department of Health and the Insurance Department | | | 9|shall keep confidential all nonpublic information and documents | | | 10|obtained under this act and shall not disclose the confidential | | | 11|information or documents to any person without the consent of the | | | 12|party that produced the confidential information or documents, | | | 13|except that the information may be disclosed to experts or | | | 14|consultants under contract with the State Department of Health or | | | 15|the Insurance Department, provided that the expert or consultant is | | | 16|bound by the same confidentiality requirements as the state | | | 17|officials. The confidential information and documents shall not be | | | 18|public records and shall be exempt from the Oklahoma Open Records | | | 19|Act. | | | 20| D. By the last day of February every year, the State Department | | | 21|of Health and the Insurance Department shall each provide an | | | 22|electronic report to the President Pro Tempore of the Senate, the | | | 23|Speaker of the House of Representatives, and the Governor on trends | | | 24|for providers, health insurance premiums, patient access to | | | Req. No. 1236 Page 6 ___________________________________________________________________________
1|providers, and compliance with this act. The departments may | | | 2|include recommendations for further actions to make health care more | | | 3|affordable and accessible to residents of the state. | | | 4| E. The State Department of Health may promulgate regulations | | | 5|necessary to implement the requirements of this act, alter or reduce | | | 6|the rate limits set forth in this act, specify the format and | | | 7|content of reports established in this act, and impose penalties for | | | 8|noncompliance consistent with the State Department of Health's | | | 9|authority to regulate health care providers. | | | 10| F. The Insurance Department and the Insurance Commissioner may | | | 11|promulgate regulations necessary to evaluate the growth or reduction | | | 12|of health insurance premiums, ensure that savings from reductions in | | | 13|provider payments are passed on to consumers, ensure compliance with | | | 14|applicable medical loss ratio requirements under federal and state | | | 15|laws, specify the format and content of reports under this act, and | | | 16|impose penalties for noncompliance consistent with the Insurance | | | 17|Department's and Commissioner's authority to regulate health | | | 18|insurance carriers. | | | 19| SECTION 5. NEW LAW A new section of law to be codified | | | 20|in the Oklahoma Statutes as Section 6013.4 of Title 36, unless there | | | 21|is created a duplication in numbering, reads as follows: | | | 22| A. Any violation of this act shall constitute an unfair trade | | | 23|practice pursuant to Section 1201 et seq. of Title 36 of the | | | 24| | | | Req. No. 1236 Page 7 ___________________________________________________________________________
1|Oklahoma Statutes, which may be enforced by the Insurance | | | 2|Department, the Attorney General, or an aggrieved individual. | | | 3| B. A health care provider that violates any provision of this | | | 4|act or the rules and regulations adopted pursuant to this act shall: | | | 5| 1. Refund any amount received that is more than the amount set | | | 6|forth in this act to the health benefit plan; and | | | 7| 2. Pay the patient or individual responsible for the patient a | | | 8|penalty of the greater of One Thousand Dollars ($1,000.00) or the | | | 9|amount the health care provider received that is more than the | | | 10|amount set forth in this act. | | | 11| C. The State Department of Health may audit any health care | | | 12|provider, and the Insurance Department, the Insurance Commissioner, | | | 13|or their designee may audit any health insurance carrier or health | | | 14|plan administrator, for compliance with the requirements of this | | | 15|act. Until the expiration of four (4) years after the furnishing of | | | 16|any services for which an out-of-network payment was charged, | | | 17|billed, or collected, each health care provider, health insurance | | | 18|carrier, or health plan administrator shall make available, upon | | | 19|written request of the State Department of Health, the Insurance | | | 20|Department, the Insurance Commissioner, or their designee, copies of | | | 21|any books, documents, records, or data that are necessary for the | | | 22|purposes of completing the audit. | | | 23| | | | 24| | | | Req. No. 1236 Page 8 ___________________________________________________________________________
1| SECTION 6. NEW LAW A new section of law to be codified | | | 2|in the Oklahoma Statutes as Section 1613.5 of Title 36, unless there | | | 3|is created a duplication in numbering, reads as follows: | | | 4| A. In addition to the purposes pertaining to rates set forth in | | | 5|Section 901.1 of Title 36 of the Oklahoma Statutes, the Insurance | | | 6|Department and Insurance Commissioner shall discharge their powers | | | 7|and duties to: | | | 8| 1. Protect the public interest and the interests of consumers; | | | 9| 2. Encourage the fair treatment of health care providers; and | | | 10| 3. View the health care system as a comprehensive entity, and | | | 11|encourage and direct insurers towards policies that advance the | | | 12|welfare of the public through overall efficiency, affordability, | | | 13|improved health care quality, and appropriate access. | | | 14| B. 1. Every health benefit plan shall file with the Insurance | | | 15|Department, either directly or through a licensed rating | | | 16|organization of which it is a member or subscriber, all rates and | | | 17|rating plans, classifications, class rates, rating schedules, loss | | | 18|cost, all other supplementary rate information, and every | | | 19|modification of all such information, which it uses or proposes to | | | 20|use in this state except as otherwise provided in this act. | | | 21| 2. The Insurance Department shall send a notification of filing | | | 22|of rates to any person who submits a written request to be notified | | | 23|of filings pursuant to regulation of the Board. | | | 24| | | | Req. No. 1236 Page 9 ___________________________________________________________________________
1| 3. The Attorney General shall be notified in writing within ten | | | 2|(10) days of: | | | 3| a. filing of rates, whether for prior approval or for | | | 4| immediate use, and | | | 5| b. certification of completion of a filing. | | | 6| C. Rates, rating plans, classifications, schedules, loss cost, | | | 7|and other information shall be deemed approved ninety (90) calendar | | | 8|days following certification of completion of the filing as provided | | | 9|in this act unless, within the ninety-calendar-day period: | | | 10| 1. The Insurance Department approves, disapproves, or approves | | | 11|with modification, the filing; | | | 12| 2. The Insurance Department orders a formal hearing on the | | | 13|filing; or | | | 14| 3. The Insurance Commissioner extends such period for one | | | 15|additional ninety-calendar-day period. | | | 16| D. Any formal hearing ordered by the Insurance Department shall | | | 17|be completed and a written order on the filing issued within one | | | 18|hundred twenty (120) calendar days from the date of the order | | | 19|setting the formal hearing, or the filing shall be deemed approved | | | 20|at the expiration of this period. | | | 21| E. In discharging the duties to approve, disapprove, modify, or | | | 22|take any other action authorized by law with respect to a health | | | 23|benefit plan's filing of health insurance rates or rate formulas | | | 24|under this act, the Insurance Department and Insurance Commissioner | | | Req. No. 1236 Page 10 ___________________________________________________________________________
1|shall consider whether the health benefit plan's products are | | | 2|affordable and whether the carrier has implemented effective | | | 3|strategies to enhance the affordability of its products. | | | 4| F. The Insurance Department and Insurance Commissioner may | | | 5|promulgate regulations to carry out the powers and duties of this | | | 6|section, including without limitation, to implement rate filing | | | 7|requirements, establish affordability standards, impose penalties, | | | 8|and ensure compliance with this section. | | | 9| G. When investigating rates to determine whether they comply | | | 10|with the provisions of this act, the previously approved filing | | | 11|shall not be changed, altered, amended, or held in abeyance until | | | 12|after completion of the investigation and an opportunity for hearing | | | 13|in accordance with the provisions of this article. Following such | | | 14|hearing, the Insurance Department shall enter its order in | | | 15|accordance with the provisions of this act. The effective date of | | | 16|such order shall not be fewer than thirty (30) days nor more than | | | 17|sixty (60) days after the date of the order unless the Insurance | | | 18|Department determines that, in the public interest, a shorter or | | | 19|longer period is appropriate, provided the filer has adequate time | | | 20|to implement such rate change. Any such order shall apply | | | 21|prospectively only and shall not affect premiums collected on new or | | | 22|renewal policies issued prior to the effective date of the order. | | | 23| H. If the Department finds that a filing does not meet the | | | 24|requirements of this act, it shall send to the insurer or rating | | | Req. No. 1236 Page 11 ___________________________________________________________________________
1|organization which made such filing, written notice of disapproval | | | 2|of such filing, specifying in what respects it finds that such | | | 3|filing fails to meet the requirements of this act and stating that | | | 4|such filing shall not become effective to the extent disapproved. | | | 5| I. In determining whether a heath benefit plan's health | | | 6|insurance products are affordable, the Department and Commissioner | | | 7|may consider the following factors: | | | 8| 1. Historical rates of trends for existing products; | | | 9| 2. National medical and health insurance trends, including | | | 10|Medicare trends; | | | 11| 3. Regional medical and health insurance trends; | | | 12| 4. Inflation indices, such as the Consumer Price Index and the | | | 13|medical care component of the Consumer Price Index; | | | 14| 5. Price comparison to other market rates for similar products | | | 15|such as consideration of rate differentials, if any, between | | | 16|not-for-profit and for-profit insurers in other markets; | | | 17| 6. The ability of lower-income individuals to pay for health | | | 18|insurance; | | | 19| 7. Efforts of the health benefit plan to maintain close control | | | 20|over its administrative costs; | | | 21| 8. Implementation of effective strategies by the health benefit | | | 22|plan to enhance the affordability of its products; or | | | 23| | | | 24| | | | Req. No. 1236 Page 12 ___________________________________________________________________________
1| 9. Any other relevant affordability factor, measurement, or | | | 2|analysis determined by the Commissioner to be necessary or desirable | | | 3|to carry out the purposes of this act. | | | 4| SECTION 7. This act shall become effective November 1, 2025. | | | 5| | | | 6| 60-1-1236 CAD 1/15/2025 7:03:30 PM | | | 7| | | | 8| | | | 9| | | | 10| | | | 11| | | | 12| | | | 13| | | | 14| | | | 15| | | | 16| | | | 17| | | | 18| | | | 19| | | | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | Req. No. 1236 Page 13