STATE OF OKLAHOMA

1st Session of the 53rd Legislature (2011)

SENATE BILL 43	By:	Wilson

AS INTRODUCED

An Act relating to the coverage of medically necessary procedures by a health benefit plan; requiring a health benefit plan to fully cover certain health care services; providing exception; defining terms; requiring the Insurance Commissioner to promulgate certain rules; 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 6060.19 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  Any health benefit plan that is offered, issued or renewed in this state on or after January 1, 2012, shall fully cover any health care services of the insured that is deemed by a health care professional to be medically necessary in order to treat a health condition, illness, injury or disease.
B.  The provisions of subsection A of this section shall not apply to any elective procedures that would result in the termination of a pregnancy.
C.  As used in this section:
1.  “Health benefit plan” means any plan or arrangement as defined in subsection C of Section 6060.4 of Title 36 of the Oklahoma Statutes;
2.  “Health care professional” means a physician or other health care practitioner providing health care services;
3.  “Health care services” means services for the diagnosis, prevention or treatment of a health condition, illness, injury or disease; and
4.  “Medically necessary” means health care services that a health care professional, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating a health condition, illness, injury or its symptoms, and that are:
a.	in accordance with generally accepted standards of medical practice,
b.	clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s health condition, illness, injury or disease,
c.	not primarily for the convenience of the patient or health care professional, and
d.	not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s health condition, illness, injury or disease.
D.  The Insurance Commissioner shall promulgate rules necessary to implement the provisions of this section.
SECTION 2.  This act shall become effective November 1, 2011.

53-1-64	ARE	1/16/2004 6:58:40 AM