An Act
ENROLLED HOUSE
BILL NO. 2322 By: McEntire, Frix, Sims,
Sneed, and Roberts (Eric)
of the House
and
Taylor, Bullard, Pemberton,
and Garvin of the Senate
An Act relating to the state Medicaid program;
amending 56 O.S. 2021, Section 4002. 2, as amended by
Section 2 of Enrolled Senate Bill No. 1337 of the 2nd
Session of the 58th Oklahoma Legislature , which
relates to definitions used in the Ensuring Access to
Medicaid Act; broadening certain definition; amendi ng
56 O.S. 2021, Section 4002.12 , as amended by Section
15 of Enrolled Senate Bill No. 1337 of the 2nd
Session of the 58th Oklahoma Legislature , which
relates to reimbursement of providers; requiring
certain reimbursement for phar macist; providing an
effective date; declaring an emergenc y; and creating
contingent effectiveness .
SUBJECT: State Medicaid program
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4 002.2, as
amended by Section 2 of Enrolled Senate Bill No. 1337 of the 2nd
Session of the 58th Oklahoma Legislature, is amended to read as
follows:
Section 4002.2 As used in the Ensuring Access to Me dicaid Act:
1. "Adverse determination" has the same meaning as provided by
Section 6475.3 of Tit le 36 of the Oklahoma Statutes; ENR. H. B. NO. 2322 Page 2
2. "Accountable care organization " means a network of
physicians, hospitals, and other health care providers that provides
coordinated care to Medic aid members;
3. "Claims denial error rate" means the rate of claims denial s
that are overturned on appeal;
4. "Capitated contract" means a contract between the Oklahoma
Health Care Authority and a contracted entity for delivery of
services to Medicaid members in which the Authority pays a fixed,
per-member-per-month rate based on actuarial calculations;
5. "Children's Specialty Plan" means a health care plan that
covers all Medicaid services other than den tal services and is
designed to provide care to:
a. children in foster care,
b. former foster care children up to twenty-five (25)
years of age,
c. juvenile justice involved children, and
d. children receiving adoption assistance;
6. "Clean claim" means a properly completed billing form with
Current Procedural Terminology, 4th Edition or a more recent
edition, the Tenth Revision of the International Classification of
Diseases coding or a more recent revision , or Healthcare Common
Procedure Coding Syste m coding where applicable that contains
information specifically required in the Provider Billing and
Procedure Manual of the Oklahoma Health Care Authority, as defined
in 42 C.F.R., Section 447.45 (b);
7. "Commercial plan" means an organization or entity that
undertakes to provide or arrange for the delivery of health care
services to Medicaid members on a prepaid basis and is subject to
all applicable federal a nd state laws and regulations;
8. "Contracted entity" means an organization or entity that
enters into or will ente r into a capitated contract with the
Oklahoma Health Care Authority for the delivery of services
specified in this act the Ensuring Access to Medicai d Act that will
assume financial risk, operational accountability , and statewide or ENR. H. B. NO. 2322 Page 3
regional functionality as defined in this act the Ensuring Access to
Medicaid Act in managing comprehensive health outcomes of Medicaid
members. For purposes of this act the Ensuring Access to Medicai d
Act, the term contracted entit y includes an accountable care
organization, a provider-led entity, a commercial plan, a dental
benefit manager, or any other entity as determined by the Authority;
9. "Dental benefit manager" means an entity that handles claims
payment and prior authorizations and coordinates dental care with
participating provider s and Medicaid members;
10. "Essential community provider" means:
a. a Federally Qualified Health Center,
b. a community mental health center,
c. an Indian Health Care Provider,
d. a rural health clinic,
e. a state-operated mental health hospital,
f. a long-term care hospital ser ving children (LTCH-C),
g. a teaching hospital owned, jointly owned, or
affiliated with and designated by the University
Hospitals Authority, University Hospitals Trust,
Oklahoma State Univers ity Medical Authority, or
Oklahoma State University Medical Trus t,
h. a provider employed by or contracted with, or
otherwise a member of the faculty practice plan of:
(1) a public, accredited medical school in this
state, or
(2) a hospital or health care entity directly or
indirectly owned or operated by the Universit y
Hospitals Trust or the Oklahoma State University
Medical Trust,
i. a county department of health or city-county health
department,
ENR. H. B. NO. 2322 Page 4
j. a comprehensive community addiction recovery center,
k. a hospital licensed by the State of Oklahoma including
all hospitals participating in the Supplemental
Hospital Offset Payment Program,
l. a Certified Community Behavioral Health Clinic
(CCBHC),
m. a provider employed by or contracted with a primary
care residency program accredited by the Accreditation
Council for Graduate Medical Education,
n. any additional Medicaid provider as approved by the
Authority if the provider either offe rs services that
are not available from any other provider within a
reasonable access standard or provides a substantial
share of the total units of a particular service
utilized by Medicaid members within the region during
the last three (3) years, and the combined capacity of
other service providers in the region is insufficient
to meet the total needs of the Medicaid mem bers, or
o. a pharmacy or pharmacist, or
p. any provider not otherwise mentioned in this paragraph
that meets the defini tion of "essential community
provider" under 45 C.F.R., Section 156.235;
11. "Material change" includes, but is not limited to, any
change in overall business operations such as policy, process or
protocol which affects, or can re asonably be expected to affect ,
more than five percent (5%) of enrollees or participating pro viders
of the contracted entity;
12. "Governing body" means a group of individuals appointed by
the contracted entity who approve policies, operations, profit/loss
ratios, executive employment decisio ns, and who have overall
responsibility for the operations of the contracted entity of which
they are appointed;
13. "Local Oklahoma provider organization" means any state
provider association, accountable care organization, Certified
Community Behavioral Health Clinic, Federally Qualified Health
Center, Native American tribe or tribal association, hospital or ENR. H. B. NO. 2322 Page 5
health system, academ ic medical institution, currently practicing
licensed provider, or other local Oklahoma provider organization as
approved by the Authority;
14. "Medical necessity" has the same meaning as provided by
rules promulgated by the Oklahoma Health Care Author ity Board;
15. "Participating provider" means a provider who has a
contract with or is employed by a contracted entity to provide
services to Medicaid members as authorized by this act the Ensuring
Access to Medicaid Act;
16. "Provider" means a health care or dental provider licensed
or certified in this state or a provider that meets the Authority's
provider enrollment criteria to contract with the Authority as a
SoonerCare provider;
17. "Provider-led entity" means an organization or entity that
meets the criteria of at least one of following two subparagraphs:
a. a majority of the entity's ownership is held by
Medicaid providers in this state or is held by an
entity that directly or indirectly owns or is unde r
common ownership with Medicaid providers in thi s
state, or
b. a majority of the entity's governing body is composed
of individuals who:
(1) have experience serving Medicaid members and:
(a) are licensed in this state as physicians,
physician assistants, nurse practitioners,
certified nurse-midwives, or certified
registered nurse anesthetists,
(b) at least one board member is a licensed
behavioral health provider , or
(c) are employed by:
i. a hospital or other medical faci lity
licensed by this state and operating in
this state, or
ENR. H. B. NO. 2322 Page 6
ii. an inpatient or outpatient mental
health or substance abuse treatment
facility or program licensed or
certified by this stat e and operating
in this state,
(2) represent the providers or facili ties described
in division (1) of this subparagraph including ,
but not limited to, individuals who are employed
by a statewide provider association, or
(3) are nonclinical administrators of cl inical
practices serving Medicaid members;
18. "Statewide" means all counties of this state inclu ding the
urban region; and
19. "Urban region" means:
a. all counties of this state with a county population of
not less than five hundred thousand (500,000)
according to the latest Federal Decennial Census, and
b. all counties that are contiguous to the counties
described in subparagraph a of this paragraph ,
combined into one region.
SECTION 2. AMENDATORY 56 O.S. 2021, Section 4002.12, as
amended by Section 15 of Enrolled Senate Bill No. 1337 of the 2nd
Session of the 58th Oklahoma Legislature, is amended to read as
follows:
Section 4002.12 A. Until July 1, 2026, the Oklahoma Health
Care Authority shall establish minimum rates of reimbursement from
contracted entities to providers who elect not to enter into value-
based payment arrangements under subsection B of this section or
other alternative payment agreements for health care items and
services furnished by such providers to enrollees of the state
Medicaid program. Except as provided by subsectio n I of this
section, until July 1, 2026, such reimbursement rates shall be equal
to or greater than:
1. For an item or service provided by a participating provider
who is in the network of the contracted entity, one hundred percent ENR. H. B. NO. 2322 Page 7
(100%) of the reimbursement rate for the applicable service in the
applicable fee schedule of the Authority; or
2. For an item or service provided by a non-participating
provider or a provider who is not in the network of the contracted
entity, ninety percent (90%) of the reimbursement rate for the
applicable service in the applicable fee schedule of the Authority
as of January 1, 2021.
B. A contracted entity shall offer value-based payment
arrangements to all providers in its network capable of entering
into value-based payment arrange ments. Such arrangements shall be
optional for the provider but shall be tied to r eimbursement
incentives when quality metrics are met . The quality measures used
by a contracted entity to determine reimbursement amounts to
providers in value-based payment arrangements shall align with the
quality measures of the Authority for contracted entities.
C. Notwithstanding any other provision of this sec tion, the
Authority shall comply with payment methodologies required by
federal law or regulation for specific types of providers including,
but not limited to, Federally Qualified Health Cente rs, rural health
clinics, pharmacies, Indian Health Care Provid ers and emergency
services.
D. A contracted entity shall offer all rural health clinics
(RHCs) contracts that reimburse RHCs using the methodology in place
for each specific RHC prior to Janua ry 1, 2023, including any and
all annual rate updates. The con tracted entity shall comply with
all federal program rules and requirements, and the transformed
Medicaid delivery system shall not interfere with the program as
designed.
E. The Oklahoma Heal th Care Authority shall establish minimum
rates of reimbursemen t from contracted entities to Certified
Community Behavioral Health Clinic (CCBHC) providers who elect
alternative payment arrangements equal to the prospective payment
system rate under the Me dicaid State Plan.
F. The Authority shall establish an incenti ve payment under the
Supplemental Hospital Offset Payment Program that is determined by
value-based outcomes for providers other than hospitals.
ENR. H. B. NO. 2322 Page 8
G. Psychologist reimbursement shall reflect out comes.
Reimbursement shall not be limited to therapy and shall include but
not be limited to testing and assessment.
H. Coverage for Medicaid ground transportation service s by
licensed Oklahoma emergency medical services shall be reimbursed at
no less than the published Medicaid rates as set by the Authority.
All currently published Medicaid Healthcare Common Procedure Coding
System (HCPCS) codes paid by the Authority shal l continue to be paid
by the contracted entity. The contracted entity shall comply with
all reimbursement policies established by the Authority f or the
ambulance providers. Contracted entities shall accept the modifiers
established by the Centers for Med icare and Medicaid Services
currently in use by Medicare at the time of the transpo rt of a
member that is dually eligible for Medicare and Medicai d.
I. 1. The rate paid to participating pharmacy providers is
independent of subsection A of this section an d shall be the same as
the fee-for-service rate employed by the Authority for th e Medicaid
program as stated in the payment methodology at OAC 317:30 -5-78,
unless the participating pharmacy provider elects to enter into
other alternative payment agreements .
2. A pharmacy or pharmacist shall receive direct payment or
reimbursement from t he Authority or contracted entity when providing
a health care service to the Medicaid member at a rate no less than
that of other health care providers for providing the same service.
J. The Authority shall specify in the requests for proposals a
reasonable time frame in which a contracted entity shall have
entered into a certain percentage , as determined by the Authority,
of value-based contracts with providers.
K. Capitation rates established by the Oklahoma Health Care
Authority and paid to contracted e ntities under capitated contracts
shall be updated annually and in accordance with 42 C.F.R., Section
438.3. Capitation rates shall be approved as actuarially sound as
determined by the Centers for Medicare and Medicaid Services in
accordance with 42 C.F. R., Section 438.4 and the following:
1. Actuarial calculations must include utiliz ation and
expenditure assumptions consistent with industry and local
standards; and
ENR. H. B. NO. 2322 Page 9
2. Capitation rates shall be risk -adjusted and shall include a
portion that is at risk for achievement of quality and outcomes
measures.
L. The Authority may establish a symmetric risk corridor for
contracted entities.
M. The Authority shall establish a proce ss for annual recovery
of funds from, or assessment of penalties on, contracted entities
that do not meet the medical loss ratio standards stipulated in
Section 4002.5 of this title.
N. 1. The Authority shall, through the financial reporting
required under subsection G of Section 17 of this act, determine the
percentage of health care expenses by each contracted entity on
primary care services.
2. Not later than the end of the fourth year of the initial
contracting period, each contracted entity shall be currently
spending not less than eleven percent (11%) o f its total health care
expenses on primary care services.
3. The Authority shall monitor the primary care spending of
each contracted entity and require each contracted entity to
maintain the level of spending on primary care services stipulated
in paragraph 2 of this subsection.
SECTION 3. This act shall become effective July 1, 2022.
SECTION 4. It being immediatel y necessary for the preservation
of the public peace, health or safety, an emergency is hereb y
declared to exist, by reason whereof this act shall take effect and
be in full force from and after its passage and approval.
SECTION 5. The provisions of this act shall be contingent upon
the enactment of Enrolled Senate Bill No. 1337 of the 2nd S ession of
the 58th Oklahoma Legislature and shall not become effective as law
otherwise.
ENR. H. B. NO. 2322 Page 10
Passed the House of Representatives the 19th day of May, 2022.
Presiding Officer of the House
of Representatives
Passed the Senate the 20th day of May, 2022.
Presiding Officer of the Senate
OFFICE OF THE GOVERNOR
Received by the Office of the Governor this ____________________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________
Approved by the Governor of the State of Oklahoma this _________
day of ___________________, 20_______, at _______ o'clock _______ M.
_________________________________
Governor of the State of Oklahoma
OFFICE OF THE SECRETARY OF STATE
Received by the Office of the S ecretary of State this __________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________