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STATE OF OKLAHOMA
1st Session of the 58th Legislature (2021)
CONFERENCE COMMITTEE SUBSTITUTE
FOR ENGROSSED
SENATE BILL 131 By: McCortney, Garvin and Treat
of the Senate
and
McEntire, Newton, Bush,
Fugate, Pae, McDugle, Roe,
Moore, Talley, Cornwell,
Marti, Fetgatter, Culver,
Lawson, Humphrey and
Waldron of the House
CONFERENCE COMMITTEE SUBSTITUTE
An Act relating to the state Medicaid program;
creating the "Ensuring Access to Medicaid Act ";
defining terms; authorizing Oklahoma Hea lth Care
Authority to require enrollment in certain delivery
model for certain individuals; providing for
voluntary enrollment by certain individuals;
specifying enrollment process for certain
individuals; prohibit ing requirement or offer of
enrollment for certain individuals; directing
Authority to develop certain network adequacy
standards; requiring managed care organizations and
dental benefit managers to meet or exceed network
adequacy requirements; requiring c ontracting with
certain providers; requiring certain credentialing
and recredentialing process for providers; requiring
accreditation for managed care organizations and
dental benefit managers; requiring certain
notification for material change; requiring medical
loss ratio to meet certain standar ds; requiring
certain provision of patient data upon request;
prohibiting enforcement of certain policy or contract
term; prohibiting contract from disallowing certain
contract with accountable care organization;
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stipulating timeframes for certain authoriz ations;
providing for peer-to-peer review; requiring
Authority to ensure timely offering of authorized
services; setting certain requirements for processing
and adjudication of claims ; requiring managed care
organizations and dental benefit managers to uti lize
certain procedures for review and appeal; directing
Authority to develop certain procedures; providing
requirements for appeal of adverse determination
based on medical necessity; providing for fair
hearing; providing for non-compliance remedies;
requiring managed care organization or dental benefit
manager to participate in readiness review;
specifying criteria of readiness review; allowing
execution of transition of certain delivery system
under certain condition; directing Authority to
create certain quarterly scorecard; specifying
criteria of scorecard; requiring Authority to provide
scorecard to enrollees and publish on its Internet
website; directing Authority to establish minimum
rates of reimbursement for certain providers; setting
minimum rates for certain time period; requiring
managed care organization or dental benefit manager
to offer value-based payment arrangements to certain
providers; requiring use of certain quality measures
for value-based payments; directing Authority to
comply with federally required payment methodologies;
creating the MC Quality Advisory Committee; providing
for duties, membership, selection of chair and vice
chair, meetings, quorum and staff support;
prohibiting compensation; 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 4002.1 of Title 56, unless there
is created a duplicat ion in numbering, reads as follows:
This act shall be known and may be cited as the "Ensuring Access
to Medicaid Act".
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SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.2 of Title 56, un less there
is created a duplication in numbering, reads as follows:
As used in this act:
1. "Adverse determination " has the same meaning as provided by
Section 6475.3 of Title 36 of the Oklahoma Statutes ;
2. "Claims denial error rate " means the rate of claims denials
that are overturned on appeal ;
3. "Clean claim" means a properly completed billing form with
Current Procedural Te rminology, 4th Editi on 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 System coding where applicabl e that contains
information specificall y required in the Pr ovider Billing and
Procedure Manual of the Oklahoma Health Care Authority;
4. "Dental benefit manager" means an entity under contract with
the Oklahoma Health Care Authority to manage and deliver dental
benefits and services to enrolle es of the capitated managed care
delivery model of the state Medicaid program ;
5. "Essential community pr ovider" has the same meaning as
provided by 45 C.F.R., Section 156.235;
6. "Managed care organization " means a health plan under
contract with the Ok lahoma Health Care A uthority to participate in
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and deliver benefits and services to enrollees of the capit ated
managed care delivery model of the state Medicaid program ;
7. "Material change" includes, but is not lim ited to, any
change in overall business operations such as p olicy, process or
protocol which affects, or can reasonably be expected to affect,
more than five percent ( 5%) of enrollees or participating providers
of the managed care organization or dental be nefit manager;
8. "Medical necessity" has the same meaning as provided by
rules of the Oklahoma Health Care Authority Board ;
9. "Participating provider" means a provider who has a contract
with or is employed by a managed care organization or dental benef it
manager to provide services to enrollees under the capitated managed
care delivery model of the state Medicaid program; and
10. "Provider" means a health care or dental provider licensed
or certified in this state .
SECTION 3. NEW LAW A new section of law to be codifi ed
in the Oklahoma Statutes as Section 4002. 3 of Title 56, unless there
is created a duplication in numbering, reads as follows:
A. Unless expressly authorized by the Legislature, the Oklahoma
Health Care Authority may only require enrollment in a capitated
managed care delivery model of the state Medicaid program for
eligible individuals from an enrollee population of the state
Medicaid program delineated as a mandatory enrollment population in
the SoonerSelect Reques t for Proposals awarded in January of 2021 or
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the SoonerSelect Dental Program Request for Proposals awarded in
February of 2021.
B. 1. Unless expressly authorized by the Legislature,
enrollment in a capitated managed care delivery model of the state
Medicaid program shall be voluntary for eligible individuals from an
enrollee population of the state Medicaid program delineated as a
voluntary enrollment population in the SoonerSelect Request for
Proposals awarded in January of 2021 or the SoonerSelect Dent al
Program Request for Proposals award ed in February of 20 21.
2. The Authority may only utilize an opt -in enrollment process
for the voluntary enrollment of individ uals in the American
Indian/Alaska Native population .
C. Unless expressly authorized by th e Legislature, the
Authority shall not:
1. Require enrollment in a capitated managed care delivery
model of the state Medicaid program for eligible individuals from
any enrollee population of the state Medicaid program delineated as
an excluded population in or omitted entirely from the SoonerSelect
Request for Proposals awarded in January of 2021 or the SoonerSelect
Dental Program Request for Proposals awarded in Fe bruary of 2021; or
2. Offer voluntary enrollment in a capitated managed care
delivery model of the state Medicaid program to eligible individuals
from any enrollee population of the state Medicaid program
delineated as an excluded population in or omitted entirely from the
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SoonerSelect Request for Proposals awarded in January of 2021 or the
SoonerSelect Dental Program Request for P roposals awarded in
February of 2021.
SECTION 4. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002. 4 of Title 56, unless there
is created a duplication in numb ering, reads as follows:
A. The Oklahoma Health Care Authority shall develop networ k
adequacy standards for all managed care organizations and dental
benefit managers that, at a minimum, meet the requirements of 42
C.F.R., Sections 438.14 and 438.68. Network adequacy standards
established under this subsection shall be designed to ensur e
enrollees covered by the managed care organizations and dental
benefit managers who reside in health professional shortage areas
(HPSAs) designated under Section 332(a)(1 ) of the Public Health
Service Act (42 U.S.C., Section 254e(a)(1)) have access to in -person
health care and telehealth services with providers, especially adult
and pediatric primary care practitioners.
B. All managed care organizations and dental benefit managers
shall meet or exceed network adequacy standards established by the
Authority under subsection A of this section to ensure sufficient
access to providers fo r enrollees of the state Medicaid program.
C. All managed care organizations and dental be nefit managers
shall contract to the extent possible and p racticable with all
essential community providers, all providers who receive directed
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payments in accordanc e with 42 C.F.R., Part 438 and such other
providers as the Authority may specify .
D. All managed care organizations and dental b enefit managers
shall formally credential and recredential network providers at a
frequency required by a single, consolidated provider enrollment and
credentialing process established by the Authority in accordance
with 42 C.F.R., Section 438.214.
E. All managed care organizations and dental benefit managers
shall be accredited in accordance with 45 C.F.R., Section 156.275 by
an accrediting entity recognized by the United States Department of
Health and Human Service s.
SECTION 5. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002. 5 of Title 56, unless there
is created a duplication in numbering, reads as follows:
A. A managed care organization or dental benefi t manager shall
promptly notify the Aut hority of all change s materially affecting
the delivery of care or the administration of its program .
B. A managed care organi zation or dental benefit manager shall
have a medical loss ratio that meets the standards provided by 42
C.F.R., Section 438.8.
C. A managed care or ganization or dental benefit manager shall
provide patient data to a provider upon request to the extent
allowed under federal or state laws, rules or regulations including,
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but not limited to, the Health Insurance Portability and
Accountability Act of 1996.
D. A managed care organization or dental benefit manager or a
subcontractor of such managed care organi zation or dental benefit
manager shall not enforce a policy or contract term with a provide r
that requires the provider to contra ct for all products that are
currently offered or that may be offered in the future by the
managed care organization or dental benefit manager or
subcontractor.
E. Nothing in a contract between the Authority and a man aged
care organization or dental benef it manager shall pro hibit the
managed care organization or dental benefit manager from contracting
with a statewide or regional accountable care organization to
implement the capitated managed care delivery model of the state
Medicaid program.
SECTION 6. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002. 6 of Title 56, unless there
is created a duplication in numbering, reads as follows:
A. A managed care organization shall make a determination on a
request for an authorization of the transfer of a hospital inpatient
to a post-acute care or long-term acute care facility within twenty-
four (24) hours of receipt of the request .
B. Review and issue determinations made by a managed care
organization or, as appropriate, by a dental benefit manager for
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prior authorization for care ordered by primary care or specialist
providers shall be timely and shall occur in accordance with the
following:
1. Within seventy-two (72) hours of receipt of the request for
any patient who is n ot hospitalized at the time of the request ;
provided, that if the request does not include sufficient or
adequate documentation, the review and issue determination shall
occur within a time frame an d in accordance with a process
established by the Authority. The process established by the
Authority pursuant to this paragraph shall include a time frame of
at least forty-eight (48) hours within which a provider may submit
the necessary documentation;
2. Within one (1) business day of receipt of the request for
services for a hospitalized patient including, but not limited to,
acute care inpatient services or equ ipment necessary to discharge
the patient from an inpatient facility;
3. Notwithstanding the provisions of paragraphs 1 or 2 of this
subsection, as expeditiously as necessary and, in any event, within
twenty-four (24) hours of receipt of the request for s ervice if
adhering to the provisions of paragraphs 1 or 2 of this subsection
could jeopardize the enrollee's life, health or abil ity to attain,
maintain or regain maximum function . In the event of a medically
emergent matter, the managed care organization or dental benefit
manager shall not impose limitations on providers in coordination of
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post-emergent stabilization health care i ncluding pre-certification
or prior authorization ;
4. Notwithstanding any other provision of this subsection,
within twenty-four (24) hours of receipt of the request for
inpatient behavioral health services; and
5. Within twenty-four (24) hours of receip t of the request for
covered prescription drugs that are required to be prior authorized
by the Authority. The managed care or ganization shall not require
prior authorization on any covered prescription drug for which the
Authority does not require prior authorization.
C. Upon issuance of an adverse determination on a prior
authorization request under subsection B of this sectio n, the
managed care organization or dental benefit manager shall provide
the requesting provider, within seventy-two (72) hours of receipt of
such issuance, with reasonable opportunity to participate in a peer -
to-peer review process with a provider who pra ctices in the same
specialty, but not necessarily the same sub -specialty, and who has
experience treating the same population as the patient on whose
behalf the request is submitted ; provided, however, if the
requesting provider determines the services to be clinically urgent,
the managed care organization or dental benefit manager shall
provide such opportunity within twenty-four (24) hours of receipt of
such issuance. Services not covered under the state Medicaid
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program for the particular patient shall not be subject to peer-to-
peer review.
D. The Authority shall ensure that a provider offers to provide
to an enrollee in a timely manner services au thorized by a managed
care organization or dental benefit manager .
SECTION 7. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002. 7 of Title 56, unless there
is created a duplicat ion in numbering, re ads as follows:
A managed care organization or dental benefit manager shall
comply with the following requi rements with respect to processing
and adjudication of claims for payment submitted in good faith by
providers for health care it ems and services fur nished by such
providers to enrollees of the state Medicaid program :
1. A managed care organization or den tal benefit manager shall
process a clean claim in the time frame provided by Section 1219 of
Title 36 of the Oklahoma Statutes and no less than ninety percent
(90%) of all clean claims shall be paid within fourteen (14) days of
submission to the managed care organization or dental benefit
manager. A clean claim that is not processed within the time frame
provided by Section 1219 of Title 36 of the Ok lahoma Statutes shall
bear simple interest at the monthly rate of one and one-half percent
(1.5%) payable to the provider. A claim filed by a provider within
six (6) months of the date the item or se rvice was furnished to an
enrollee shall be considered tim ely. If a claim meets the
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definition of a clean claim, the managed care organization or dental
benefit manager shall not request medical records of the enrollee
prior to paying the claim. Once a c laim has been paid, the managed
care organization or denta l benefit manager may request medical
records if additional documentation is needed to review the claim
for medical necessity;
2. In the case of a denial of a claim including, but not
limited to, a denial on the basis of the level of e mergency care
indicated on the claim, the managed care organization or dental
benefit manager shall establish a process by wh ich the provider may
identify and provide such additional information as may be necessary
to substantiate the claim. Any such clai m denial shall inclu de the
following:
a. a detailed explanation of the basis for the denial,
and
b. a detailed description of the additional information
necessary to substantiate the claim;
3. Postpayment audits by a managed care organization or dental
benefit manager shall be subject to the following requirements:
a. subject to subparagraph b of this paragraph, insofar
as a managed care organization or dental benefit
manager conducts postpayment audits, the managed care
organization or dental benefit manager shall employ
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the postpayment audit process determined by the
Authority,
b. the Authority shall establish a limit on the
percentage of claims with respect to which postpayment
audits may be conducted by a managed care organization
or dental benefit manager for health care items and
services furnished by a provider in a plan year, and
c. the Authority shall provide for the imp osition of
financial penalties under such contract in the case of
any managed care organizati on or dental benefit
manager with respect to which the Authority determines
has a claims denial error rate of greater than five
percent (5%). The Authority shall establish the
amount of financial penalties and the time frame under
which such penalties sha ll be imposed on managed care
organizations and dental ben efit managers under this
subparagraph, in no case less than annually; and
4. A managed care organization may only apply readmission
penalties pursuant to rules promulgated by the Oklahoma Health Ca re
Authority Board. The Board shall promulgate rules establishing a
program to reduce potentially preventable readmissions. The program
shall use a nationally re cognized tool, establish a base measurement
year and a performance year, and provide for risk -adjustment based
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on the population of the state Medicaid program covered by the
managed care organizations and dental benefit managers .
SECTION 8. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002 .8 of Title 56, unless there
is created a duplication in numbering, reads as follows:
A. A managed care organization or dental benefit manager shall
utilize uniform procedures established by the Authority under
subsection B of this section for the review and appeal of any
adverse determinatio n by the managed care organization or dental
benefit manager sought by any enrollee or provider adversely
affected by such determination.
B. The Authority shall develop procedures for enrollee or
providers to seek rev iew by the managed care organization or dental
benefit manager of any adverse determination made by the managed
care organization or dental benefit manager . A provider shall have
six (6) months from the receipt of a claim denial t o file an appeal.
With respect to appeals of adverse determina tions made by a managed
care organization or dental benefit manager on the basis of medical
necessity, the following requirem ents shall apply:
1. Medical review staff of the managed care organization or
dental benefit manager shall be licensed or credenti aled health care
clinicians with relevant clinical training or experience ; and
2. All managed care organizations and dental benefit managers
shall use medical review staff for such appeals and shall not use
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any automated claim review software or other aut omated functionality
for such appeals.
C. Upon receipt of notice from the managed care organization or
dental benefit manage r that the adverse determination has been
upheld on appeal, the enro llee or provider may request a fair
hearing from the Authority. The Authority shall develop procedures
for fair hearings in accordance with 42 C.F.R., Part 431.
SECTION 9. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002 .9 of Title 56, unless there
is created a duplication in n umbering, reads as follows:
In addition to such other remedies or penalties as may be
prescribed by law, a managed care organization or dental benefit
manager found to be in violation of the provisi ons of or rules
promulgated under this act or of the terms and conditions of the
contract entered into between the managed care organization or
dental benefit manager and the Oklahoma Health Care Authority shall
be subject to one or more non-compliance remedies of the Authority.
SECTION 10. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002. 10 of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. The Oklahoma Health Ca re Authority shall require a managed
care organization or dental benefit manager to participate in a
readiness review in accordance with 42 C.F.R., Section 438.66. The
readiness review shall assess the ability and capacity of the
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managed care organization or dental benefit manager to perform
satisfactorily in su ch areas as may be specified in 42 C.F.R.,
Section 438.66. In addition, the readiness review shall asses s
whether:
1. The managed care organization or dental benefit manag er has
entered into contracts with providers to the extent necessary to
meet network adequacy standards prescribed b y Section 4 of this act;
2. The contracts described in paragraph 1 of t his subsection
offer, but do not require, value-based payment arrangements as
provided by Section 12 of this act; and
3. The managed care organization or dental benefit manager and
the providers described in paragraph 1 of this subsection have
established and tested data infrastructure such that exchange of
patient data can reasonably be expected to occur within one hundred
twenty (120) calendar days of execution of the transition of the
delivery system described in subsection B of this section . The
Authority shall assess its ability to facilitate the exchange of
patient data, claims, coordinatio n of benefits and other components
of a managed care deliv ery model.
B. The Oklahoma Health Care Authority may only execute the
transition of the delivery sys tem of the state Medicaid program to
the capitated managed care delivery model of the state Medicaid
program ninety (90) days after the Centers for Medicare and Medicaid
Services has approved all contracts ent ered into between the
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Authority and all managed care organizations and dental benefit
managers following submission of the readiness review s to the
Centers for Medicare and Medicaid Services.
SECTION 11. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.11 of Title 56, unless
there is created a duplication in numbering, reads as follows:
No later than one year following th e execution of the delive ry
model transition described in Section 10 of this act, the Oklahoma
Health Care Authority shall create a scorecard that compares managed
care organizations and dental benefit managers . The scorecard shal l
report the average spee d of authorizations of se rvices, rates of
denials of services, enrollee satisfaction survey results a nd such
other criteria as the Authority may require. The scorecard shall be
compiled quarterly and shall consist of the informati on specified in
this section from the prior year. The Authority shall provide the
most recent quarterly scorecard to all init ial enrollees during
enrollment choice counseling following the eligibility determination
and prior to initial enrollment. The Au thority shall provide the
most recent quarterly scorecard to all enrollees at the b eginning of
each enrollment period. The Au thority shall publish each quarterly
scorecard on its Internet website.
SECTION 12. NEW LAW A new section o f law to be codified
in the Oklahoma Statutes as S ection 4002.12 of Title 56, unless
there is created a duplication in numbering, reads as follows:
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A. The Oklahoma Health Care Authority shall establish minimum
rates of reimbursement from managed care orga nizations and dental
benefit managers to providers who elect not to enter into value-
based payment arrangements under subsection B of this section for
health care items and services furnished by such providers to
enrollees of the state Medicaid program . 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 managed care organization or dental
benefit manager, one hundred percent (100%) of t he reimbursement
rate for the applicable service i n 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 managed care
organization or dental bene fit manager, ninety percent (90%) of the
reimbursement rate for the applicable serv ice in the applicable fee
schedule of the Authority as of January 1, 202 1.
B. A managed care organization or dental benefit manager shall
offer value-based payment arrangements to all providers in its
network capable of entering into value-based payment arrangements.
Such arrangements shall be optional for the provider. The quality
measures used by a managed care organization or dental benefit
manager to determine reimburs ement amounts to providers in value-
based payment arrangements shall align with the quality measures of
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the Authority for managed care organization s or dental benefit
managers.
C. Notwithstanding any other provision of this section, the
Authority shall comply with payment methodo logies required by
federal law or regulation for specific types of providers including,
but not limited to, Federally Qualified He alth Centers, rural health
clinics, pharmacies, Indian Health Care Providers and emergency
services.
SECTION 13. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.1 3 of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. There is hereby created the MC Quality Advisory Committee
for the purpose of performing the duties specified in subsection B
of this section.
B. The primary power and duty of the Committee shall be to make
recommendations to the Administrator of the Oklahoma Health Care
Authority and the Oklahoma Hea lth Care Authority Board on quality
measures used by managed care organizations and dental benefit
managers in the capitated managed care deliver y model of the state
Medicaid program.
C. 1. The Committee shall be comprised of members appointed by
the Administrator of the Oklahoma Health Care Authority. Members
shall serve at the pleasu re of the Administrator.
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2. A majority of the members shall be provide rs participating
in the capitated managed care delivery model of the state Medicaid
program, and such providers may include members of the Advisory
Committee on Medical Care for Public Assistance Recipients . Other
members shall include, but not be limited to, representatives of
hospitals and integrated health systems , other members of the health
care community, and members of the academic community havi ng
subject-matter expertise in the field of health care or subfields of
health care, or other applicable fields including, but not limited
to, statistics, economics or public policy .
3. The Committee shall select from among its membership a chair
and vice chair.
E. 1. The Committee may meet as often as may be required in
order to perform the duties imposed on it.
2. A quorum of the Committee shall be required to approve any
final action of the Committee. A majority of the members of the
Committee shall constitute a quorum.
3. Meetings of the Committee shall be subject to the Oklahoma
Open Meeting Act.
F. Members of the Committee shall receive no compensation or
travel reimbursement.
G. The Oklahoma Health Care Authority shall provide staff
support to the Committee. To the extent allowed under federal or
state law, rules or regulations, t he Authority, the State Department
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of Health, the Department of Mental Health and Substance Abuse
Services and the Department of Human Servi ces shall as requested
provide technical expertise, statis tical information, and an y other
information deemed necessary by the chair of the Committee to
perform the duties imposed on it.
SECTION 14. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4004 of Title 56, unless there
is created a duplication in numbering, reads as follow s:
A. The Oklahoma Health Care Authority shall seek any federal
approval necessary to implement this act.
B. The Oklahoma Health Care Au thority Board shall promulgate
rules to implement this act.
SECTION 15. This act shall become effectiv e September 1, 2021.
58-1-2217 DC 5/18/2021 6:39:38 PM