STATE OF OKLAHOMA

1st Session of the 53rd Legislature (2011)

HOUSE BILL 1250	By:	Rousselot

AS INTRODUCED

An Act relating to insurance; creating the Oklahoma Any Willing Institute Act; stating legislative findings; stating purpose; defining terms; prohibiting certain acts by health care insurers; providing that insurance providers may continue certain efficiency and cost-control programs; specifying that participation in a health plan is not mandatory for certain institutes; specifying that insurers may establish terms and conditions for participation in certain programs; specifying applicability to various insurance providers; requiring compliance with federal Employee Retirement Income Security Act of 1974; specifying that the Oklahoma Any Willing Institute Act shall not apply to certain self-insured businesses; authorizing the creation of certain networks by certain noninsurers; providing that the Oklahoma Any Willing Institute Act shall apply to state and education employees; specifying violations of act; providing for cause of action in the event of certain violations; providing that the Oklahoma Any Willing Institute Act shall be applicable to certain contracts arising after certain date; providing duties and powers of the Insurance Commissioner; providing for codification; and providing an 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 7005.1 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 Any Willing Institute Act”. 
SECTION 2.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.2 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  The Legislature finds that as the state’s insurance sector becomes increasingly dominated by managed care features that include decisions regarding coverage and appropriateness of health care, there is a vital need to protect patients in this environment.
B.  The purpose of the Oklahoma Any Willing Institute Act is to prohibit discrimination against a provider institute willing to meet the terms and conditions for participation established by a health insurer and to preclude an insurer from prohibiting or limiting participation in the provision of services through a health benefit plan.
SECTION 3.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.3 of Title 36, unless there is created a duplication in numbering, reads as follows:
As used in the Oklahoma Any Willing Institute Act:
1.  “Copayment” means a type of cost-sharing whereby insured or covered persons pay a specified predetermined amount per unit of service or percentage of health care costs with their insurer paying the remainder of the charge.  Further:
a.	the copayment is incurred at the time the service is rendered, and
b.	the copayment may be a fixed or variable amount; 
2.  “Gatekeeper system” means a system of administration used by any health benefit plan in which a primary care provider furnishes basic patient care and coordinates diagnostic testing, indicated treatment, and specialty referral for persons covered by the health benefit plan;
3.  “Health benefit plan” means any entity or program that provides reimbursement, including capitation, for health care services;
4.  “Health care institute” means those entities or institutions licensed by the State of Oklahoma to provide health care, limited to the following:
a.	community mental health centers or clinics,
b.	hospitals,
c.	licensed ambulatory surgery centers, and
d.	rural health clinics;
5.  “Health care services” means services and products provided by a health care institute within the scope of the institute's license; and
6.  “Health care insurer” means any entity including, but not limited to:
a.	insurance companies,
b.	hospital and medical service corporations,
c.	health maintenance organizations,
d.	preferred provider organizations,
e.	physician hospital organizations, 
f.	third-party administrators, and 
g.	prescription benefit management companies authorized to administer, offer, or provide health benefit plans.
SECTION 4.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.4 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  A health care insurer shall not, directly or indirectly:
1.   a.	Impose a monetary advantage or penalty under a health benefit plan that would affect the choice of a beneficiary to select among those health care institutes participating in the health benefit plan according to the terms offered. 
b.	"Monetary advantage" or "penalty" includes:
(1)	a higher copayment,
(2)	a reduction in reimbursement for services, or
(3)	promotion of one health care provider over another by these methods;  
2.  Impose upon a beneficiary of health care services under a health benefit plan any copayment, fee, or condition that is not equally imposed upon all beneficiaries in the same benefit category, class, or copayment level under that health benefit plan when the beneficiary is receiving services from a participating health care institute pursuant to that health benefit plan; or
3.  Prohibit or limit a health care institute, as defined in Section 3 of this act, willing to accept the health benefit plan’s operating terms and conditions, schedule of fees, covered expenses, and utilization regulations and quality standards from the opportunity to participate in that plan.  
B.  Nothing in this section shall prevent a health benefit plan from instituting measures designed to maintain quality and to control costs, including, but not limited to, the utilization of a gatekeeper system, as long as such measures are imposed equally on all institutes in the same class. 
SECTION 5.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.5 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  The Oklahoma Any Willing Institute Act shall not be construed:
1.  To require all institutes or a percentage of institutes in the state or a locale to participate in the provision of services for a health maintenance organization; or
2.  To take away the authority of health maintenance organizations that provide coverage of physician services to set the terms and conditions for participation by institutes, though health maintenance organizations shall apply the terms and conditions in a nondiscriminatory manner.  
B.  1.  The Oklahoma Any Willing Institute Act shall apply to: 
a.	all health insurers, regardless of whether they are providing coverage, including prepaid coverage, or administering or contracting to provide provider networks, and
b.	all multiple-employer welfare arrangements and multiple-employer trusts.  
2.  This subsection shall apply only to the extent permitted by the federal Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C., Sections 1001 through 1461. 
C.  1.  Nothing in the Oklahoma Any Willing Institute Act shall be construed to cover or regulate health care provider networks offered by noninsurers.
2.  If an employer sponsoring a self-insured health benefit plan contracts directly with providers or contracts for a health care provider network, the Oklahoma Any Willing Institute Act shall not apply.
3.  If a health insurer subcontracts with a noninsurer whose health care network does not meet the requirements of the Oklahoma Any Willing Institute Act, then the noninsurer may create a separate health care provider network that meets the requirements of the Oklahoma Any Willing Institute Act. 
4.  If the noninsurer chooses not to create the separate health care provider network, then the responsibility for compliance with the Oklahoma Any Willing Institute Act shall be the obligation of the health insurer to the extent permitted by the federal Employee Retirement Income Security Act of 1974, as amended.
D.  Notwithstanding the provisions of subsection C of this section, the Oklahoma Any Willing Institute Act applies to a health benefit plan provided by the state to state employees and education employees, as defined by Section 1303 of Title 74 of the Oklahoma Statutes, whether the health benefit plan is self-funded or insured. 
SECTION 6.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.6 of Title 36, unless there is created a duplication in numbering, reads as follows:
It is a violation of the Oklahoma Any Willing Institute Act for any health care insurer or other person or entity to provide any health benefit plan providing for health care services to residents of this state that does not conform to the Oklahoma Any Willing Institute Act, but nothing in the Oklahoma Any Willing Institute Act shall constitute a violation on the basis of actions taken by the health benefit plan to maintain quality, enforce utilization regulations, and to control costs.  
SECTION 7.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.7 of Title 36, unless there is created a duplication in numbering, reads as follows:
To the extent permitted by ERISA, the federal Employee Retirement Income Security Act of 1974, 29 U.S.C., Sections 1001 through 1461, any institute adversely affected by a violation of the Oklahoma Any Willing Institute Act may sue in district court only for injunctive relief against the health care insurer, but not for damages.  The prevailing party shall be allowed a reasonable attorney fee and costs.
SECTION 8.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.8 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  To avoid impairment of existing contracts the Oklahoma Any Willing Institute Act shall only apply to contracts issued or renewed after November 1, 2011. 
B.  Any provision in a health benefit plan which is executed, delivered, or renewed, or otherwise contracts for provision of services in this state that is contrary to the Oklahoma Any Willing Institute Act, shall, to the extent of the conflict, be void.  
SECTION 9.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.9 of Title 36, unless there is created a duplication in numbering, reads as follows:
The provisions of the Oklahoma Any Willing Institute Act shall not apply to self-funded or other health benefit plans that are exempt from state regulation by virtue of the federal Employee Retirement Income Security Act of 1974, as amended. 
SECTION 10.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 7005.10 of Title 36, unless there is created a duplication in numbering, reads as follows:
The Insurance Commissioner shall:
1.  Enforce the Oklahoma Any Willing Institute Act using powers granted to the Commissioner in Title 36 of the Oklahoma Statutes; and
2.  Be entitled to seek an injunction against a health insurer in a court of competent jurisdiction.
SECTION 11.  This act shall become effective November 1, 2011.

53-1-5116	SDR	01/17/11