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