reglab/statecodes huggingface dataset:
2023 Oklahoma Statutes › Title 36. Insurance › §36-6919. Examination of affairs, programs, books, and records - Payment of expenses.

A. The Insurance Commissioner may make an examination of the affairs of any health maintenance organization, producers and providers with whom the organization has contracts, agreements or other arrangements pursuant to the provisions of Sections 309.1 through 309.7 of this title.
B. The Insurance Commissioner may require a health maintenance organization to contract for an examination concerning the quality assurance program of the health maintenance organization and of any providers with whom the organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state, but not less frequently than once every three (3) years.
C. Every health maintenance organization and provider shall submit its books and records for examination and in every way facilitate the completion of an examination. For the purpose of an examination, the Insurance Commissioner may administer oaths to, and examine the officers and agents of the health maintenance organization and the principals of the providers concerning their business.
D. Any health maintenance organization examined shall pay the proper charges incurred in such examination, including the actual expense of the Insurance Commissioner or the expenses and compensation of any authorized representative and the expense and compensation of assistants and examiners employed therein. All expenses incurred in such examination shall be verified by affidavit and a copy shall be filed in the office of the Insurance Commissioner.
E. In lieu of an examination, the Insurance Commissioner may accept the report of an examination made by the health maintenance organization regulatory entity of another state.
Added by Laws 2003, c. 197, § 19, eff. Nov. 1, 2003. Amended by Laws 2021, c. 478, § 39, emerg. eff. May 12, 2021.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6922. Order to rectify financial condition or violation - Required actions - Remedies and measures available to Insurance Commissioner.

A. Whenever the Insurance Commissioner determines that the financial condition of a health maintenance organization (HMO) is such that its continued operation might be hazardous to its enrollees, creditors or the general public, or that the HMO has violated any provision of the Health Maintenance Organization Act of 2003, the Insurance Commissioner may, after notice and opportunity for hearing, order the health maintenance organization to take action reasonably necessary to rectify the condition or violation including, but not limited, to one or more of the following:
1. Reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the Insurance Commissioner;
2. Reduce the volume of new business being accepted;
3. Reduce expenses by specified methods;
4. Suspend or limit the writing of new business for a period of time;
5. Increase the health maintenance organization’s capital and surplus by contribution; or
6. Take other steps the Insurance Commissioner may deem appropriate under the circumstances.
B. For purposes of this section, the violation by a health maintenance organization of any law of this state to which the health maintenance organization is subject shall be deemed a violation of this act.
C. Rules of the Insurance Commissioner establishing criteria that the Insurance Commissioner may consider in making a determination that the condition of any insurer is such that continuation of such insurer's business may be hazardous to the public or to holders of its policies or certificates of insurance may be used by the Insurance Commissioner for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors, or the general public and to set standards for evaluating the financial condition of any health maintenance organization.
D. The remedies and measures available to the Insurance Commissioner under this section shall be in addition to, and not in lieu of, the remedies and measures available to the Insurance Commissioner under the provisions of Section 1904 of Title 36 of the Oklahoma Statutes.
Added by Laws 2003, c. 197, § 22, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6926. Provisions of laws not applicable to health maintenance organizations.

A. Except as otherwise provided in the Health Maintenance Organization Act of 2003 or unless expressly made applicable to health maintenance organizations, provisions of the insurance law and provisions of hospital or medical service corporation laws shall not be applicable to a health maintenance organization granted a certificate of authority under the provisions of this act. This provision shall not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance law or the hospital or medical service corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this act.
B. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
C. Any health maintenance organization authorized under this act shall not be deemed to be practicing medicine and shall be exempt from the provisions of Title 59 of the Oklahoma Statutes related to the practice of medicine.
Added by Laws 2003, c. 197, § 26, eff. Nov. 1, 2003. Amended by Laws 2005, c. 129, § 20, eff. Nov. 1, 2005.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6927. Public records - Trade secrets - Privileged or confidential information.

All applications, filings, provider contracts excluding any financial terms and/or reimbursement criteria contained in such contracts, and reports required under the Health Maintenance Organization Act of 2003 shall be treated as public records, except those that are trade secrets or privileged or confidential quality assurance, commercial, financial or other information considered privileged or confidential under state or federal law, including, but not limited to, the Health Insurance Portability and Accountability Act (HIPAA). Annual financial statements that may be required under the provisions of Section 9 of this act shall be treated as public records.
Added by Laws 2003, c. 197, § 27, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6928. Disclosure of diagnostic, treatment or health status information.

A. 1. Any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant obtained from that person or from a provider by a health maintenance organization shall be held in confidence and shall not be disclosed to any person except:
a.
to the extent that it may be necessary to carry out the purposes of the Health Maintenance Organization Act of 2003,
b.
upon the express consent of the enrollee or applicant,
c.
pursuant to statute or court order for the production of evidence or the discovery thereof, or
d.
in the event of claim or litigation between the person and the health maintenance organization wherein the data or information is pertinent.
2. A health maintenance organization shall be entitled to claim any statutory privileges against disclosure that the provider who furnished the information to the health maintenance organization is entitled to claim.
B. A person who, in good faith and without malice, takes an action or makes a decision or recommendation as a member, agent or employee of a health care review committee or who furnishes any records, information or assistance to such a committee shall not be subject to liability for civil damages or any legal action in consequence of the action, nor shall the health maintenance organization that established the committee or the officers, directors, employees or agents of the health maintenance organization be liable for the activities of the person. This section shall not be construed to relieve any person of liability arising from treatment of a patient.
C. 1. The information considered by a health care review committee and the records of the committee’s actions and proceedings shall be confidential and not subject to subpoena or order to produce except in proceedings before the appropriate state licensing or certifying agency, or in an appeal, if permitted, from the committee’s findings or recommendations. No member of a health care review committee, or officer, director or other member of a health maintenance organization or its staff engaged in assisting a committee, or a person assisting or furnishing information to a committee may be subpoenaed to testify in any judicial or quasi-judicial proceeding if the subpoena is based solely on such activities.
2. Information considered by a health care review committee and the records of its actions and proceedings that are used pursuant to the provisions of paragraph 1 of this subsection by a state licensing or certifying agency or in an appeal shall be kept confidential and shall be subject to the same provisions concerning discovery and use in legal actions as the original information and records in the possession and control of a health care review committee.
D. To fulfill its obligations under Section 7 of this act, a health maintenance organization shall have access to treatment records and other information pertaining to the diagnosis, treatment or health status of an enrollee.
Added by Laws 2003, c. 197, § 28, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6929. Contracts by Health Commissioner with qualified persons.

The Insurance Commissioner, in carrying out his or her obligations under the Health Maintenance Organization Act of 2003, may contract with qualified persons to make recommendations concerning the determinations required to be made by the Insurance Commissioner. The recommendations may be accepted in full or in part by the Insurance Commissioner. The Insurance Commissioner shall adopt procedures to ensure that such persons are not subject to a conflict of interest that would impair their ability to make recommendations in an impartial manner.
Added by Laws 2003, c. 197, § 29, eff. Nov. 1, 2003. Amended by Laws 2021, c. 478, § 41, emerg. eff. May 12, 2021.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6930. Acquisition of control of health maintenance organization.

No person other than the issuer may make a tender for or a request or invitation for tenders of, or enter into an agreement to exchange securities for or acquire in the open market or otherwise, any voting security of a health maintenance organization or enter into any other agreement if, after the consummation thereof, that person would, directly or indirectly, or by conversion or by exercise of any right to acquire be in control of the health maintenance organization. No person may enter into an agreement to merge or consolidate with or otherwise to acquire control of a health maintenance organization, unless, at the time any offer, request or invitation is made or any agreement is entered into, or prior to the acquisition of the securities if no offer or agreement is involved, the person complied with the provisions of Article 16A of the Insurance Code.
Added by Laws 2003, c. 197, § 30, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6931. Coordination of benefits provisions.

A. A health maintenance organization is permitted, but not required, to adopt coordination of benefits provisions to avoid over insurance and to provide for the orderly payment of claims when an enrollee is covered by two or more group health insurance or health care plans.
B. If a health maintenance organization adopts coordination of benefits, the provisions thereof shall be consistent with the coordination of benefits provisions that are in general use in the state for coordinating coverage between two or more group health insurance or health care plans.
C. To the extent necessary for a health maintenance organization to meet its obligations as a secondary carrier under the rules for coordination, a health maintenance organization may make payments for services that are:
1. Received from nonparticipating providers;
2. Provided outside its service areas; or
3. Not covered under the terms of its group contract or evidence of coverage.
Added by Laws 2003, c. 197, § 31, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6934. Services permitted to be provided.

Health maintenance organizations may provide any services included in state or federal health care programs, such as state employee benefits, the state basic health benefits program, "Medicare", "Medicaid", "CHAMPUS" and Veterans Administrations and other health programs provided in whole or in part by state or federal funds, in accordance with the laws governing such programs.
Added by Laws 2003, c. 197, § 34, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6935. Services provided to out-of-state enrollees.

Basic health care services as herein provided may be furnished to enrollees of health maintenance organizations outside this state only in accordance with the laws of the state or of the United States that govern the provision of such services in the state or place concerned; provided, that an enrollee may be reimbursed directly for emergency health care expenses incurred by the enrollee while temporarily outside the state, when such expenses would have been provided under the enrollee's program had the enrollee been within the state. Such reimbursement made by a health maintenance organization shall not be construed as an indemnity and no health maintenance organization shall be an insurer or make any contract of insurance of any kind whatsoever.
Added by Laws 2003, c. 197, § 35, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6936. Severability.

If any section, term or provision of this act shall be adjudged invalid for any reason, that judgment shall not affect, impair or invalidate any other section, term or provision of this act; but the remaining sections, terms and provisions shall be and remain in full force and effect.
Added by Laws 2003, c. 197, § 36, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6937. Short title - Risk-based Capital (RBC) for Health Maintenance Organizations Act of 2003.

This act shall be known and may be cited as the "Risk-based Capital (RBC) for Health Maintenance Organizations Act of 2003".
Added by Laws 2003, c. 197, § 37, eff. Nov. 1, 2003. Amended by Laws 2004, c. 146, § 2, eff. Nov. 1, 2004; Laws 2017, c. 287, § 7, eff. Nov. 1, 2017.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6938. Definitions.

As used in the Risk-based Capital (RBC) for Health Maintenance Organizations Act of 2003:
1. “Adjusted Risk-based Capital (RBC) report” means an RBC report which has been adjusted by the Insurance Commissioner in accordance with the provisions of subsection C of Section 39 of this act;
2. “Corrective order” means an order issued by the Commissioner specifying corrective actions which the Insurance Commissioner has determined are required;
3. “Domestic health maintenance organization” means a health maintenance organization domiciled in this state;
4. “Foreign health maintenance organization” means a health maintenance organization that is licensed to do business in this state under the Health Maintenance Organization Act of 2003, but is not domiciled in this state;
5. “NAIC” means the National Association of Insurance Commissioners;
6. “Health maintenance organization” means a health maintenance organization licensed under the Health Maintenance Organization Act of 2003. This definition does not include an organization that is licensed as either a life and health insurer or a property and casualty insurer under Title 36 of the Oklahoma Statutes and that is otherwise subject to either life or property and casualty RBC requirements;
7. “RBC instructions” means the RBC report including risk-based capital instructions adopted by the NAIC, as these RBC instructions may be amended by the NAIC from time to time in accordance with the procedures adopted by the NAIC;
8. “RBC level” means a health maintenance organization’s Company Action Level RBC, Regulatory Action Level RBC, Authorized Control Level RBC, or Mandatory Control Level RBC where:
a.
“Company Action Level RBC” means, with respect to any health maintenance organization, the product of 2.0 and its Authorized Control Level RBC,
b.
“Regulatory Action Level RBC” means the product of 1.5 and its Authorized Control Level RBC,
c.
“Authorized Control Level RBC” means the number determined under the risk-based capital formula in accordance with the RBC instructions, or
d.
“Mandatory Control Level RBC” means the product of .70 and the Authorized Control Level RBC;
9. “RBC plan” means a comprehensive financial plan containing the elements specified in subsection B of Section 40 of this act. If the Insurance Commissioner rejects the RBC plan, and it is revised by the health maintenance organization, with or without the Insurance Commissioner’s recommendation, the plan shall be called the “revised RBC plan”;
10. “RBC report” means the report required in Section 39 of this act; and
11. “Total adjusted capital” means the sum of:
a.
a health maintenance organization’s statutory capital and surplus, or its net worth, as determined in accordance with the statutory accounting applicable to the annual financial statements required to be filed under Section 9 of this act, and
b.
such other items, if any, as the RBC instructions may provide.
Added by Laws 2003, c. 197, § 38, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6939. Report of Risk-based Capital (RBC) levels - Formula - Adjustment by Commissioner.

A. A domestic health maintenance organization shall, on or prior to each March 1 filing date, prepare and submit to the Insurance Commissioner a report of its Risk-based Capital (RBC) levels as of the end of the calendar year just ended, in a form and containing such information as is required by the RBC instructions. In addition, a domestic health maintenance organization shall file its RBC report:
1. With the National Association of Insurance Commissioners (NAIC) in accordance with the RBC instructions; and
2. With the Insurance Commissioner in any state in which the health maintenance organization is authorized to do business, if the Insurance Commissioner has notified the health maintenance organization of its request in writing, in which case the health maintenance organization shall file its RBC report not later than the later of:
a.
fifteen (15) days from the receipt of notice to file its RBC report with that state, or
b.
the filing date.
B. A health maintenance organization’s RBC shall be determined in accordance with the formula set forth in the RBC instructions. The formula shall take the following into account and may adjust for the covariance between, determined in each case by applying the factors in the manner set forth in the RBC instructions:
1. Asset risk;
2. Credit risk;
3. Underwriting risk; and
4. All other business risks and such other relevant risks as are set forth in the RBC instructions.
C. If a domestic health maintenance organization files an RBC report that, in the judgment of the Commissioner, is inaccurate, the Commissioner shall adjust the RBC report to correct the inaccuracy and shall notify the health maintenance organization of the adjustment. The notice shall contain a statement of the reason for the adjustment. An RBC report as so adjusted is referred to as an “adjusted RBC report”.
Added by Laws 2003, c. 197, § 39, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6942. Authorized control level event - Definition - Duties of Insurance Commissioner.

A. “Authorized Control Level Event” means any of the following events:
1. The filing of an RBC report by the health maintenance organization that indicates that the health maintenance organization’s total adjusted capital is greater than or equal to its Mandatory Control Level RBC, but less than its Authorized Control Level RBC;
2. The notification by the Commissioner to the health maintenance organization of an adjusted RBC report that indicates an Authorized Control Level Event as specified in paragraph 1 of this subsection, provided the health maintenance organization does not challenge the adjusted RBC report under Section 44 of this act;
3. If, pursuant to the provisions of Section 44 of this act, the health maintenance organization challenges an adjusted RBC report that indicates the event in paragraph 1 of this subsection, notification by the Commissioner to the health maintenance organization that the commissioner has, after a hearing, rejected the health maintenance organization’s challenge;
4. The failure of the health maintenance organization to respond, in a manner satisfactory to the Commissioner, to a corrective order, provided the health maintenance organization has not challenged the corrective order under Section 44 of this act; or
5. If the health maintenance organization has challenged a corrective order under Section 44 of this act and the Commissioner has, after a hearing, rejected the challenge or modified the corrective order, the failure of the health maintenance organization to respond, in a manner satisfactory to the Commissioner, to the corrective order subsequent to rejection or modification by the Commissioner.
B. In the event of an Authorized Control Level Event with respect to a health maintenance organization, the Commissioner shall:
1. Take such actions as are required under Section 41 of this act regarding a health maintenance organization with respect to which a Regulatory Action Level Event has occurred; or
2. If the Commissioner deems it to be in the best interests of the policyholders and creditors of the health maintenance organization and of the public, take such actions as are necessary to cause the health maintenance organization to be placed under regulatory control pursuant to the provisions of Articles 18 and 19 of the Insurance Code. In the event the Commissioner takes such actions, the Authorized Control Level Event shall be deemed sufficient grounds for the Commissioner to take action pursuant to the provisions of Articles 18 and 19 of the Insurance Code, and the Commissioner shall have the rights, powers and duties with respect to the health maintenance organization as provided in Articles 18 and 19 of the Insurance Code.
Added by Laws 2003, c. 197, § 42, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6943. Mandatory control level event - Definition - Duties of Insurance Commissioner.

A. “Mandatory Control Level Event” means any of the following events:
1. The filing of an RBC report which indicates that the health maintenance organization’s total adjusted capital is less than its Mandatory Control Level RBC;
2. Notification by the Commissioner to the health maintenance organization of an adjusted RBC report that indicates a Mandatory Control Level Event specified in paragraph 1 of this subsection, provided the health maintenance organization does not challenge the adjusted RBC report under Section 44 of this act; or
3. If, pursuant to the provisions of Section 44 of this act, the health maintenance organization challenges an adjusted RBC report that indicates the event in paragraph 1 of this subsection, notification by the Commissioner to the health maintenance organization that the Commissioner has, after a hearing, rejected the health maintenance organization’s challenge.
B. In the event of a Mandatory Control Level Event, the Commissioner shall take such actions as are necessary to place the health maintenance organization under regulatory control pursuant to the provisions of Articles 18 and 19 of the Insurance Code. In that event, the Mandatory Control Level Event shall be deemed sufficient grounds for the Commissioner to take action pursuant to the provisions of Articles 18 and 19 of the Insurance Code, and the Commissioner shall have the rights, powers and duties with respect to the health maintenance organization as provided in Articles 18 and 19 of the Insurance Code. Notwithstanding any of the preceding provisions, the Commissioner may forego action for up to ninety (90) days after the Mandatory Control Level Event if the Commissioner finds there is a reasonable expectation that the Mandatory Control Level Event may be eliminated within the ninety-day period.
Added by Laws 2003, c. 197, § 43, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6944. Challenge of determination or action by Insurance Commissioner - Required events - Hearing.

Upon the occurrence of any of the events specified in this section, the health maintenance organization shall have the right to a confidential departmental hearing, on the record, at which time the health maintenance organization may challenge any determination or action by the Insurance Commissioner. The health maintenance organization shall notify the Commissioner of its request for a hearing within five (5) days after the notification by the Commissioner pursuant to the provisions of paragraph 1, 2, 3 or 4 of this section. Upon receipt of the health maintenance organization’s request for a hearing, the Commissioner shall set a date for the hearing, which shall be not less than ten (10), nor more than thirty (30) days after the date of the health maintenance organization’s request. The events include:
1. Notification to a health maintenance organization by the Commissioner of an adjusted Risk-Based Capital (RBC) report;
2. Notification to a health maintenance organization by the Commissioner that:
a.
the health maintenance organization’s RBC plan or revised RBC plan is unsatisfactory, and
b.
notification constitutes a Regulatory Action Level Event with respect to the health maintenance organization;
3. Notification to a health maintenance organization by the Commissioner that the health maintenance organization has failed to adhere to its RBC plan or revised RBC plan and that the failure has a substantial adverse effect on the ability of the health maintenance organization to eliminate the Company Action Level Event with respect to the health maintenance organization in accordance with its RBC plan or revised RBC plan; or
4. Notification to a health maintenance organization by the Commissioner of a corrective order with respect to the health maintenance organization.
Added by Laws 2003, c. 197, § 44, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6946. Application of act - Rules for implementation of act.

A. The provisions of the Risk-based Capital (RBC) for Health Maintenance Organizations Act of 2003 are supplemental to any other provisions of the laws of this state, and shall not preclude or limit any other powers or duties of the Insurance Commissioner under such laws including, but not limited to, Articles 18 and 19 of the Insurance Code and promulgated rules related to health maintenance organizations in hazardous financial condition.
B. The Commissioner may adopt reasonable rules necessary for the implementation of this act.
C. The Commissioner may exempt from the application of this act a domestic health maintenance organization that:
1. Writes direct business only in this state; and
2. Assumes no reinsurance in excess of five percent (5%) of direct premium written.
Added by Laws 2003, c. 197, § 46, eff. Nov. 1, 2003. Amended by Laws 2004, c. 146, § 3, eff. Nov. 1, 2004.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6947. Foreign health maintenance organizations.

A. 1. A foreign health maintenance organization shall, upon the written request of the Insurance Commissioner, submit to the Commissioner a Risk-Based Capital (RBC) report as of the end of the calendar year just ended the later of:
a.
the date an RBC report would be required to be filed by a domestic health maintenance organization under this act, or
b.
fifteen (15) days after the request is received by the foreign health maintenance organization.
2. A foreign health maintenance organization shall, at the written request of the Commissioner, promptly submit to the Commissioner a copy of any RBC plan that is filed with the Insurance Commissioner of any other state.
B. In the event of a Company Action Level Event, Regulatory Action Level Event or Authorized Control Level Event with respect to a foreign health maintenance organization, as determined under the RBC statute applicable in the state of domicile of the health maintenance organization or, if no RBC statute is in force in that state, under the provisions of this act, if the Insurance Commissioner of the state of domicile of the foreign health maintenance organization fails to require the foreign health maintenance organization to file an RBC plan in the manner specified under that state’s RBC statute or, if no RBC statute is in force in that state, under the provisions of Section 40 of this act, the Commissioner may require the foreign health maintenance organization to file an RBC plan with the Commissioner. In such event, the failure of the foreign health maintenance organization to file an RBC plan with the Commissioner shall be grounds to order the health maintenance organization to cease and desist from writing new insurance business in this state.
C. In the event of a Mandatory Control Level Event with respect to a foreign health maintenance organization, if no domiciliary receiver has been appointed for the foreign health maintenance organization under the rehabilitation and liquidation statute applicable in the state of domicile of the foreign health maintenance organization, the Commissioner may make application to the District Court of Oklahoma County as permitted under Article 19 of the Insurance Code with respect to the liquidation of property of foreign health maintenance organizations found in this state, and the occurrence of the Mandatory Control Level Event shall be considered adequate grounds for the application.
Added by Laws 2003, c. 197, § 47, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6948. Immunity from liability on part of Insurance Commissioner or Insurance Department or its employees or agents.

There shall be no liability on the part of, and no cause of action shall arise against, the Insurance Commissioner or the Insurance Department or its employees or agents for any action taken by them in the performance of their powers and duties under the Risk-based Capital (RBC) for Health Maintenance Organizations Act of 2003.
Added by Laws 2003, c. 197, § 48, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6949. Severability.

If any provision of the Risk-based Capital (RBC) for Health Maintenance Organizations Act of 2003 or its application to any person or circumstance is held invalid, such determination shall not affect the provisions or applications of this act that can be given effect without the invalid provision or application, and to that end the provisions of this act are severable.
Added by Laws 2003, c. 197, § 49, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6950. Effective date of notices by Insurance Commissioner.

All notices by the Insurance Commissioner to a health maintenance organization that may result in regulatory action under this act shall be effective upon the date the notice is postmarked by the United States Postal Service if transmitted by registered or certified mail or, in the case of any other transmission, shall be effective upon the health maintenance organization’s receipt of notice.
Added by Laws 2003, c. 197, § 50, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6951. Requirements for RBC reports filed in 2003.

For Risk-based Capital (RBC) reports required to be filed by health maintenance organizations in 2003, the following requirements shall apply in lieu of the provisions of Sections 40, 41, 42 and 43 of this act:
1. In the event of a Company Action Level Event in a domestic health maintenance organization, the Insurance Commissioner shall take no regulatory action under this act;
2. In the event of a Regulatory Action Level Event under the provisions of paragraphs 1, 2 or 3 of subsection A of Section 41 of this act the Commissioner shall take the actions required under Section 40 of this act;
3. In the event of a Regulatory Action Level Event under paragraphs 4, 5, 6, 7, 8 or 9 of subsection A of Section 41 of this act or an Authorized Control Level Event, the Commissioner shall take the actions required under Section 41 of this act; or
4. In the event of a Mandatory Control Level Event in a health maintenance organization, the Commissioner shall take the actions required under Section 42 of this act.
Added by Laws 2003, c. 197, § 51, eff. Nov. 1, 2003.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6952. Nonprofit health maintenance organizations.

A. Nonprofit charitable and benevolent health maintenance organization corporations may hereafter be organized under the laws of the State of Oklahoma for the purpose of establishing, maintaining and operating a nonprofit health maintenance organization by complying with the provisions of this act.
B. Existing Oklahoma-licensed domestic health maintenance organizations may amend their corporate organizational documents to become nonprofit health maintenance organization corporations pursuant to the provisions of this act, which shall entitle them to all rights, obligations and provisions of this act. Existing Oklahoma-licensed domestic health maintenance organizations that amend their corporate organizational documents to become nonprofit health maintenance organization corporations shall continue to exist without interruption in business, licenses, certifications or other continuity.
C. The Oklahoma Insurance Commissioner may first approve the amended Certificate of Incorporation and the amended Business Plan of an existing Oklahoma-licensed domestic health maintenance organization subject to Section 3 of this act.
Added by Laws 2014, c. 272, § 1, eff. July 1, 2014.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6953. Certificate of authority to issue contracts.

A nonprofit health maintenance organization corporation may issue contracts to its subscribers only when the Insurance Commissioner has, by certificate of authority, authorized it to do so. Application for such certificate of authority shall be made on forms supplied or approved by the Commissioner, containing such information as the Commissioner shall deem necessary. Each application for a certificate of authority shall be accompanied by copies of the documents required by Section 6903 of Title 36 of the Oklahoma Statutes.
Added by Laws 2014, c. 272, § 2, eff. July 1, 2014.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6954. Application for certificate of authority - Requirements.

The Insurance Commissioner may certify nonprofit health maintenance organization corporations by issuing a certificate of authority, authorizing the applicant to issue contracts to its subscribers, when it is shown to the satisfaction of the Commissioner that:
1. The applicant is established as a bona fide nonprofit health maintenance organization corporation;
2. The contracts between the applicant and the participating physicians or other providers of health services obligate each provider executing the same to render service to which each subscriber may be entitled under the terms of the contract to be issued to the subscribers;
3. The amount of required working capital of the corporation is paid into the corporation and, if subject to repayment, can be repaid only out of operating income, without endangering the solvency or financial strength of the nonprofit health maintenance organization corporation; and
4. The nonprofit corporation has met, or will be able to meet, the requirements set forth in the Health Maintenance Organization Act of 2003 and the risk-based capital for the Health Maintenance Organization Act of 2003.
Added by Laws 2014, c. 272, § 3, eff. July 1, 2014.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6955. Transfers for existing health maintenance organizations to nonprofit status.

Any existing Oklahoma licensed domestic health maintenance organization that amends its Certificate of Incorporation and is approved as a nonprofit health maintenance organization corporation by the Insurance Commissioner may utilize its existing contracts, forms and rates already on file with the Commissioner.
Added by Laws 2014, c. 272, § 4, eff. July 1, 2014.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6956. Private or publicly owned nonprofits – Application of Health Maintenance Organization Act of 2003 and rules to nonprofits.

A nonprofit health maintenance organization corporation may be privately or publicly owned. All of the requirements of the Health Maintenance Organization Act of 2003, the risk-based capital for the Health Maintenance Organization Act of 2003 and any rules promulgated thereunder shall be applicable to nonprofit health maintenance organization corporations, except that such corporations shall use their income and profit to further facilitate the providing of health care services to the public after paying expenses of operation and ownership.
Added by Laws 2014, c. 272, § 5, eff. July 1, 2014.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6957. Scope of act.

The provisions of this act shall govern and apply only to nonprofit health maintenance organization corporations. Such corporations shall comply with all other laws applicable to health maintenance organizations under Title 36 of the Oklahoma Statutes and any rules promulgated thereunder.
Added by Laws 2014, c. 272, § 6, eff. July 1, 2014.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6960. Definitions.

For purposes of the Patient's Right to Pharmacy Choice Act:
1. "Health insurer" means any corporation, association, benefit society, exchange, partnership or individual licensed by the Oklahoma Insurance Code;
2. "Health insurer payor" means a health insurance company, health maintenance organization, union, hospital and medical services organization or any entity providing or administering a self-funded health benefit plan;
3. "Mail-order pharmacy" means a pharmacy licensed by this state that primarily dispenses and delivers covered drugs via common carrier;
4. "Pharmacy benefits manager" or "PBM" means a person that performs pharmacy benefits management and any other person acting for such person under a contractual or employment relationship in the performance of pharmacy benefits management for a managed-care company, nonprofit hospital, medical service organization, insurance company, third-party payor or a health program administered by a department of this state;
5. "Provider" means a pharmacy, as defined in Section 353.1 of Title 59 of the Oklahoma Statutes or an agent or representative of a pharmacy;
6. "Retail pharmacy network" means retail pharmacy providers contracted with a PBM in which the pharmacy primarily fills and sells prescriptions via a retail, storefront location;
7. "Rural service area" means a five-digit ZIP code in which the population density is less than one thousand (1,000) individuals per square mile;
8. "Spread pricing" means a prescription drug pricing model utilized by a pharmacy benefits manager in which the PBM charges a health benefit plan a contracted price for prescription drugs that differs from the amount the PBM directly or indirectly pays the pharmacy or pharmacist for providing pharmacy services;
9. "Suburban service area" means a five-digit ZIP code in which the population density is between one thousand (1,000) and three thousand (3,000) individuals per square mile; and
10. "Urban service area" means a five-digit ZIP code in which the population density is greater than three thousand (3,000) individuals per square mile.
Added by Laws 2019, c. 426, § 3, eff. Nov. 1, 2019. Amended by Laws 2022, c. 38, § 1, emerg. eff. April 21, 2022.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6961. Retail pharmacy network access standards.

A. Pharmacy benefits managers (PBMs) shall comply with the following retail pharmacy network access standards:
1. At least ninety percent (90%) of covered individuals residing in an urban service area live within two (2) miles of a retail pharmacy participating in the PBM's retail pharmacy network;
2. At least ninety percent (90%) of covered individuals residing in an urban service area live within five (5) miles of a retail pharmacy designated as a preferred participating pharmacy in the PBM's retail pharmacy network;
3. At least ninety percent (90%) of covered individuals residing in a suburban service area live within five (5) miles of a retail pharmacy participating in the PBM's retail pharmacy network;
4. At least ninety percent (90%) of covered individuals residing in a suburban service area live within seven (7) miles of a retail pharmacy designated as a preferred participating pharmacy in the PBM's retail pharmacy network;
5. At least seventy percent (70%) of covered individuals residing in a rural service area live within fifteen (15) miles of a retail pharmacy participating in the PBM's retail pharmacy network; and
6. At least seventy percent (70%) of covered individuals residing in a rural service area live within eighteen (18) miles of a retail pharmacy designated as a preferred participating pharmacy in the PBM's retail pharmacy network.
B. Mail-order pharmacies shall not be used to meet access standards for retail pharmacy networks.
C. Pharmacy benefits managers shall not require patients to use pharmacies that are directly or indirectly owned by the pharmacy benefits manager, including all regular prescriptions, refills or specialty drugs regardless of day supply.
D. Pharmacy benefits managers shall not in any manner on any material, including but not limited to mail and ID cards, include the name of any pharmacy, hospital or other providers unless it specifically lists all pharmacies, hospitals and providers participating in the preferred and nonpreferred pharmacy and health networks.
Added by Laws 2019, c. 426, § 4, eff. Nov. 1, 2019.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6963. Health insurer to monitor activities and ensure compliance.

A. A health insurer shall be responsible for monitoring all activities carried out by, or on behalf of, the health insurer under the Patient's Right to Pharmacy Choice Act, and for ensuring that all requirements of this act are met.
B. Whenever a health insurer contracts with another person to perform activities required under this act, the health insurer shall be responsible for monitoring the activities of that person with whom the health insurer contracts and for ensuring that the requirements of this act are met.
C. An individual may be notified at the point of sale when the cash price for the purchase of a prescription drug is less than the individual's copayment or coinsurance price for the purchase of the same prescription drug.
D. A health insurer or pharmacy benefits manager (PBM) shall not restrict an individual's choice of in-network provider for prescription drugs.
E. An individual's choice of in-network provider may include a retail pharmacy or a mail-order pharmacy. A health insurer or PBM shall not restrict such choice. Such health insurer or PBM shall not require or incentivize using any discounts in cost-sharing or a reduction in copay or the number of copays to individuals to receive prescription drugs from an individual's choice of in-network pharmacy.
F. A health insurer, pharmacy or PBM shall adhere to all Oklahoma laws, statutes and rules when mailing, shipping and/or causing to be mailed or shipped prescription drugs into the State of Oklahoma.
Added by Laws 2019, c. 426, § 6, eff. Nov. 1, 2019.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6964. Formulary to identify drugs that offer greatest value.

A. A health insurer's pharmacy and therapeutics committee (P&T committee) shall establish a formulary, which shall be a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value.
B. A health insurer shall prohibit conflicts of interest for members of the P&T committee.
1. A person may not serve on a P&T committee if the person is currently employed or was employed within the preceding year by a pharmaceutical manufacturer, developer, labeler, wholesaler or distributor.
2. A health insurer shall require any member of the P&T committee to disclose any compensation or funding from a pharmaceutical manufacturer, developer, labeler, wholesaler or distributor. Such P&T committee member shall be recused from voting on any product manufactured or sold by such pharmaceutical manufacturer, developer, labeler, wholesaler or distributor.
Added by Laws 2019, c. 426, § 7, eff. Nov. 1, 2019.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6965. Power to investigate.

A. The Attorney General shall have power and authority to examine and investigate the affairs of every pharmacy benefits manager (PBM) engaged in pharmacy benefits management in this state in order to determine whether such entity is in compliance with the Patient's Right to Pharmacy Choice Act.
B. All PBM files and records shall be subject to examination by the Attorney General or by duly appointed designees. The Attorney General, authorized employees and examiners shall have access to any of a PBM's files and records that may relate to a particular complaint under investigation or to an inquiry or examination by the Attorney General.
C. Every officer, director, employee or agent of the PBM, upon receipt of any inquiry from the Attorney General shall, within twenty (20) days from the date the inquiry is sent, furnish the Attorney General with an adequate response to the inquiry.
D. When making an examination under this section, the Attorney General may retain subject matter experts, attorneys, appraisers, independent actuaries, independent certified public accountants or an accounting firm or individual holding a permit to practice public accounting, certified financial examiners or other professionals and specialists as examiners, the cost of which shall be borne by the PBM that is the subject of the examination.
Added by Laws 2019, c. 426, § 8, eff. Nov. 1, 2019. Amended by Laws 2021, c. 472, § 9, emerg. eff. May 11, 2021; Laws 2023, c. 293, § 2, eff. Nov. 1, 2023.
2023 Oklahoma Statutes › Title 36. Insurance › §36-6967. Confidentiality and privilege of information.

A. Documents, evidence, materials, records, reports, complaints or other information in the possession or control of the Insurance Department or the Right to Pharmacy Choice Commission that are obtained by, created by or disclosed to the Insurance Commissioner, Pharmacy Choice Commission or any other person in the course of an evaluation, examination, investigation or review made pursuant to the provisions of the Patient's Right to Pharmacy Choice Act, the Pharmacy Integrity Audit Act or Sections 357 through 360 of Title 59 of the Oklahoma Statutes shall be confidential by law and privileged, shall not be subject to open records request, shall not be subject to subpoena and shall not be subject to discovery or admissible in evidence in any private civil action if obtained from the Insurance Commissioner, the Pharmacy Choice Commission or any employees or representatives of the Insurance Commissioner.
B. Nothing in this section shall prevent the disclosure of a final order issued against a pharmacy benefits manager by the Insurance Commissioner or Pharmacy Choice Commission. Such orders shall be open records.
C. In the course of any hearing made pursuant to the provisions of the Patient's Right to Pharmacy Choice Act, the Pharmacy Integrity Audit Act or Sections 357 through 360 of Title 59 of the Oklahoma Statutes, nothing in this section shall be construed to prevent the Insurance Commissioner or any employees or representatives of the Insurance Commissioner from presenting admissible documents, evidence, materials, records, reports or complaints to the adjudicating authority.
Added by Laws 2019, c. 426, § 10, eff. Nov. 1, 2019. Amended by Laws 2021, c. 472, § 11, emerg. eff. May 11, 2021.