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STATE OF OKLAHOMA
2nd Session of the 58th Legislature (2022)
COMMITTEE SUBSTITUTE
FOR ENGROSSED
SENATE BILL NO. 1337 By: McCortney of the Senate
and
McEntire of the House
COMMITTEE SUBSTITUTE
[ state Medicaid program - legislative intent -
definitions - capitated contracts - requests for
proposals - award of contracts to provider -led
entities – enrollment and assignment of Medicaid
members - network adequacy standards - essential
community providers – Oklahoma Health Care
Authority monitoring, oversight, and enforcement –
duties of contracted entities - determination and
review requirements - processing and adjudication
of claims - readiness review - scorecard – provider
reimbursement - capitation rates - supplemental
payments – reports – advisory committee - measures
and goals - federal approval - effective date -
emergency ]
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.1a of Title 56, unless
there is created a dupli cation in numbering, reads as follows:
It is the intent of the Legislature to transform the state 's
current Medicaid program to provide budget predictability for the
taxpayers of this st ate while ensuring quality care to those in
need. The state Medicaid program shall be designed to achieve the
following goals:
1. Improve health outcomes for Medicaid members and the state
as a whole;
2. Ensure budget predictability through shared risk and
accountability;
3. Ensure access to care, quality measures, and m ember
satisfaction;
4. Ensure efficient and cost -effective administrative systems
and structures; and
5. Ensure a sustainable delivery system that is a provider -led
effort and that is operated and managed by providers to the maximum
extent possible.
SECTION 2. AMENDATORY 56 O.S. 20 21, Section 4002.2, is
amended to read as follows:
Section 4002.2 As used in this act the Ensuring Access to
Medicaid Act:
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1. "Adverse determination" has the same meaning as provided by
Section 6475.3 of Title 36 of the Oklahoma Statutes;
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 d enials
that are overturned on appeal;
3. 4. "Capitated contract" means a contract between the
Oklahoma Health Care Authority and a contracted entity for delivery
of services to Medicai d members in which the Authority pays a fixed,
per-member-per-month rate based on actuarial calculations as
provided by Section 4002.12 of this title;
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 and former foster care ,
b. 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 Terminolo gy, 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
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information specifically requi red in the Provider Billing and
Procedure Manual of the Oklahoma Health Care Authority;
4. 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 enter into a capitated co ntract with the
Oklahoma Health Care Authority for the delivery of ser vices
specified in this act that will assume fina ncial risk, operational
accountability, and statewide or regional functionality as defined
in this act in managing comprehensive health o utcomes of Medicaid
members. For purposes of this act, the term contr acted entity
includes an accountable care organiza tion, a provider-led entity, a
commercial plan, or a dental benefit manager, or any other entity as
determined by the Authority;
9. "Dental benefit manager" means an entity under contract with
the Oklahoma Health Care Authority to manage and deliver denta l
benefits and services to enrollees of the capitated managed care
delivery model of the state Medicaid program that handles claims
payment and prior authorizations and coordinates dental care with
participating providers and Medicaid members ;
5. 10. "Essential community provider" has the same meaning as
provided by means:
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a. a Federally Qualified Health Center,
b. a community mental heal th center,
c. a Native American health care provider,
d. a rural health clinic,
e. a state-operated mental health hospital ,
f. a long-term care hospital serving children (LTCH -C),
g. a teaching hospital owned, jointly owned, or
affiliated with and designat ed by the University
Hospitals Authority, University Hospitals Trust,
Oklahoma State University Medical Authority, or
Oklahoma State University Medical Trust,
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 University
Hospitals Trust or the Oklahoma State University
Medical Trust,
i. a county department of health or city-county health
department,
j. a comprehensive community recovery center,
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k. any additional Medicaid provide r as approved by the
Authority if the provider either offers 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 re gion is insufficient
to meet the total needs of the Medicaid members,
l. a hospital licensed by the State of Oklahoma,
including all hospitals partici pating in Section
3241.1 et. seq. of Title 63 of the Oklahoma Statutes ,
m. Certified Community Behavioral Health Clinics (CCBHC),
or
n. any provider not otherwise mentioned in this paragraph
that meets the definition of "essential community
provider" under 45 C.F.R., Section 156.235;
6. "Managed care organization " means a health plan under
contract with the Oklahoma Health Care Authorit y to participate in
and deliver benefits and services to enrollees of the capitated
managed care delivery model of the state Medicaid program;
7. 11. "Material change" includes, but is not limited to, any
change in overall business operations such as poli cy, process or
protocol which affects, or can reasonably be expected t o affect,
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more than five percent (5%) of enrolle es or participating providers
of the contracted entity, managed care organization or dental
benefit manager;
8. 12. "Local Oklahoma provi der organization" means any state
provider association, accountable ca re organization, Certified
Community Behavioral Health Clinic, Federally Qualified Health
Center, Native American tribe or tribal association, hospital or
health system, academic medical institution, currently practicing
licensed provider, or other local Oklahoma provider organization as
approved by the Authority;
13. "Medical necessity" has the same meaning as provided by
rules of promulgated by the Oklahoma Health Care Authority Boa rd;
9. 14. "Participating provider" means a provider who has a
contract with or is employed by a managed care organization
contracted entity or dental benefit manager to provide services to
enrollees under the capitated managed care delivery model of the
state Medicaid program Medicaid members as authorized by this act ;
and
10. 15. "Provider" means a health care or dental pro vider
licensed or certified in this state or an enrolled provider of
SoonerCare services as of the time of passage of this act;
16. "Provider-led entity" means an organization or entity that
meets the following criteria:
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a. a majority of the en tity's ownership is held by
Medicaid providers in this state or is held by an
entity that directly or indirectly owns or is under
common ownership with Medicaid providers in this state
and is a not-for-profit or tax-exempt organization, 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
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,
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(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;
17. "Statewide" means all counties of this state including the
urban region; and
18. "Urban region" means 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, combined into one
region and the counties that are contiguous to the urban region.
SECTION 3. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Sect ion 4002.3a of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. 1. The Oklahoma Health Care Authority (OHCA) shall enter
into capitated contracts with contracted entitie s for the delivery
of Medicaid services as specified in th is act to transform the
delivery system of the state Medicaid program for t he Medicaid
populations listed in this section.
2. Unless expressly authorized by the Legislature, the
Authority shall not issue any request for proposals or enter into
any contract to transform the delivery syste m for the aged, blind,
and disabled populations eligible for SoonerCare.
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3. If the state seeks to e xpand this program in the future to
include other populations, it must obtain stakeholder input from
providers who serve these populations at leas t twelve (12) months
prior to issuing a request for proposals and such input should
include, but not be limited to, listening sessions, meetings , and/or
opportunities to provi de written feedback.
B. 1. No later than July 1, 2022, the Oklahoma Health Care
Authority shall issue a request for proposals to en ter into public-
private partnerships with contracted entitie s other than dental
benefit managers to cover all Medicaid serv ices other than dental
services for the followi ng Medicaid populations:
a. pregnant women,
b. children,
c. deemed newborns,
d. parents and caretaker relatives, and
e. the expansion population.
2. The Authority shall specify the services to be covered in
the request for proposals referenced in paragraph 1 of this
subsection. Capitated contracts referenced in this subsection shall
cover all Medicaid services other than dental services including:
a. physical health services including , but not limited
to:
(1) primary care,
(2) inpatient and outpatient services, and
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(3) emergency room services,
b. behavioral health services, and
c. prescription drug services.
3. The Authority shall specify the services not co vered in the
request for proposals referenced in p aragraph 1 of this subsection.
Capitated contracts referenced in this subsect ion shall not cover
providers of Durable Medical Equipmen t or Complex Rehabilitation
Technology as defined in 317:30-5-211.1 of the Oklahoma
Administrative Code.
C. 1. No later than January 1, 2023, the Authority shall is sue
a request for proposals to en ter into public-private partnerships
with dental benefit managers to cover dental services for the
following Medicaid population s:
a. pregnant women,
b. children,
c. parents and caretaker relatives,
d. the expansion populat ion, and
e. members of the Childr en's Specialty Plan as provi ded
by subsection D of this s ection.
2. The Authority shall specify the services to be covered in
the request for proposals referenced in paragraph 1 o f this
subsection.
D. 1. No later than July 1, 2022, either as part of the
request for proposals re ferenced in subsection B of this section or
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as a separate request for proposals, the Authority shall is sue a
request for proposals to enter into public -private partnerships with
one contracted entit y to administer a Children 's Specialty Plan.
2. The Authority shall specify the services to be covered in
the request for proposals referenced in paragraph 1 of this
subsection.
3. The contracted entity for the Children's Specialty Plan
shall coordinate with the dental benefit managers who cover dental
services for its members as provided by subsection C of this
section.
E. The Authority shall not implement the transformation of the
Medicaid delivery system until it receives written con firmation from
the Centers for Medicare and Medicaid Services that a managed care
directed payment program e qual to ninety percent (90%) of the
average commercial rate methodology for hospital services has been
approved for Year 1 of the transformation and will be included in
the budget neutrality cap baseline spending level for purposes of
Oklahoma's 1115 waiver renewal.
SECTION 4. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Secti on 4002.3b of Title 56, unless
there is created a duplication in num bering, reads as follows:
A. All capitated contracts shall be th e result of requests for
proposals issued by the Oklahoma Health Care A uthority and
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submission of competitive bids by contr acted entities pursuant to
the Oklahoma Central Purchasing Act.
B. Statewide capitated contrac ts may be awarded to any
contracted entity including, but not limited to, a provider-led
entity.
C. The Authority shall award no less than three statewide
capitated contracts to provide comprehensive integrated health
services including, but not limited to, medical, behavioral health,
and pharmacy services and no less than two capitated contracts to
provide dental coverage to Medicaid members as specified in Sect ion
3 of this act.
D. 1. Except as specified in paragraph 2 of this s ubsection,
at least one capitated contract to provide statewid e coverage to
Medicaid members shall be awarded to a provider -led entity, as long
as the provider-led entity submits a resp onsive reply to the
Authority's request for proposals demonstrating abi lity to fulfill
the contract requirements.
2. If no provider-led entity submits a responsive reply to the
Authority's request for proposals demonstrating ability to fulfill
the contract requirements, the Authority shall not be required to
contract for statewide coverage with a provider-led entity.
3. The Authority shall develop a scoring methodology for the
request for proposals that affords preferential scoring to provider -
led entities, as long as the provider -led entity otherwise
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demonstrates ability to fulfill the contract requirem ents. The
preferential scoring methodology shall include opportunities to
award additional points to provider-led entities based on certain
factors including, but not limited to:
a. broad provider participation in ownership a nd
governance structure,
b. demonstrated experience in care co ordination and care
management for Medicaid members acros s a variety of
service types including , but not limited to, primary
care and behavioral health,
c. demonstrated experience in Medicare or Medicaid
accountable care organi zations or other Medicare or
Medicaid alternative payment models, Medicare or
Medicaid value-based payment arrangements, or Medicare
or Medicaid risk-sharing arrangements including , but
not limited to, innovation models of the Center for
Medicare and Medicai d Innovation of the Centers for
Medicare and Medicaid Services, o r value-based payment
arrangements or risk-sharing arrangements in the
commercial health care market, and
d. other relevant factors identified by the Author ity.
E. The Authority may select a t least one provider -led entity
for the urban region if:
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1. The provider-led entity submits a res ponsive reply to the
Authority's request for proposa ls demonstrating ability to fulfill
the contract requirements; and
2. The provider-led entity demonstrates the ability, and
agrees, to expand its coverage area to the entire state within a
time frame set by the Authority but not mandated before se ven (7)
years.
F. At the discretion of the Authori ty, capitated contracts may
be extended to ensure there are no gaps in coverage that may r esult
from termination of a capitated contract; provided, the total
contracting period for a capitated contract shall not e xceed five
(5) years. During the five-year initial term, OHCA shall open
another request for proposal at year three (3) for a provider-led
entity to place bids and begin enrollment prior to the next open
enrollment period.
G. At the end of the contractin g period, the Authority shall
solicit and award new contracts as provided by this section and
Section 3 of this act.
H. At the discretion of the Authority, subject to appropriate
notice to the Legislatur e and the Centers for Medicare and Medicaid
Services, the Authority may approve a delay in the implementation of
one or more capitated contracts to ensure financia l and operational
readiness.
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SECTION 5. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4 002.3c of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. The Oklahoma Heal th Care Authority shall require each
contracted entity to ensure that Medicaid members who do not elect a
primary care provider are assigned to a provider, prioritizing
existing patient-provider relationships.
B. The Authority shall develop and implement a process for
assignment of Medicaid members to contracted entities.
C. The Authority may on ly utilize an opt-in enrollment process
for the voluntary enrollment of American Indians and Alaska Natives.
D. In the event of the termination of a capitated con tract with
a contracted entity during the contract duration, the Authority
shall reassign members to a remaining contracted entity with
demonstrated performance and capability. If no remaining contracted
entity is able to assume management for such member s, the Authority
may select another contracted entity by application, as specified in
rules promulgated by the Oklahoma Health Care Authority Boa rd, if
the financial, operation , and performance requirements can be met,
at the discretion of the Authority.
SECTION 6. AMENDATORY 56 O.S. 2021, Section 4002.4, is
amended to read as follows:
Section 4002.4 A. The Oklahoma Health Care Authority shall
develop network adequacy standards for all managed care
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organizations and dental benefit managers contracted entities that,
at a minimum, meet the requirements of 42 C.F.R., Sections 438.14,
438.3, and 438.68. Network adequacy standa rds established under
this subsection shall be designed to ensure enrollees covered by the
managed care organiz ations and dental benef it managers who reside in
health professional shortage areas (HPSAs) d esignated under Section
332(a)(1) of the Public Heal th 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 for enrollees of the state Medicaid program.
C. All managed care organizations and dental benefit managers
shall contract to the extent possible and practicable The Authority
shall require all contracted entities to offer or extend contracts
with all essential community providers, all providers who receive
directed payments in accordance with 42 C.F.R., Part 438 and such
other providers as the Authority may specify. The Authority shall
establish such requirements as may be necessary to prohibit
contracted entities from excluding essential community providers,
providers who receive directed payments in accordance wit h 42
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C.F.R., Part 438 and suc h other providers as the Authority may
specify from contracts with contracted entities.
D. C. To ensure models of care are developed to meet the needs
of Medicaid members, ea ch contracted entity must contract with local
Oklahoma provider organizations for a model of care containing care
coordination, care management, utilization management, disease
management, network management, or another model of care as approved
by the Authority. Such contractual arrangements must be in pl ace
within twelve (12) months of the effective date of the contracts
awarded pursuant to the requests for proposals authorized by Sect ion
3 of this act.
D. All managed care organizations and dental be nefit managers
contracted entities shall formally credential and recredential
network providers at a frequency required by a single, consolidated
provider enrollment and credentialing proce ss established by the
Authority in accordance with 42 C.F.R., Secti on 438.214.
E. All managed care organizations and den tal benefit managers
contracted entities shall be accredited in accordance with 45
C.F.R., Section 156.275 by an accrediting entity rec ognized by the
United States Department of Health and Human Serv ices.
F. 1. If the Oklahoma Health Care Authority award s a capitated
contract to a provider -led entity for the urban region under Section
4 of this act, the provider -led entity may, as provided by the
contract with the Authority, expand its coverage area beyond the
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urban region to counties for which the provid er-led entity can
demonstrate evidence of net work adequacy as required under 42
C.F.R., Sections 438.3 and 438.68 and as approved by Au thority. If
approved, the additional county or counties shall b e added to the
urban region during the next open enrollme nt period.
2. As provided by Section 4 of this act and by the contract
with the Authority, the provider -led entity shall expand its
coverage area to every county of this state on a timeline set by the
Authority but no sooner than seven (7) years.
SECTION 7. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.4a of Title 56, unless
there is created a duplication in numberi ng, reads as follows:
A. 1. The Oklahoma Health Care Authority shall develop
standard contract terms for contracted entities to include but not
be limited to all requirements stipulated by this act. The
Authority shall oversee and monitor performance of contracted
entities and shall enforce the terms of capitated contracts as
required by paragraph 2 of this subsection.
2. The Authority shall require each contracted entity to meet
all contractual and operat ional requirements as defined in the
requests for proposals issued pursuant to Section 3 of this act.
Such requirements shall i nclude but not be limited to reimbursement
and capitation rates, insurance reserve requirements as specified by
the Insurance Department, acceptance of risk as defined by the
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Authority, operational performance expectations including the
assessment of penalties, member marketing guidelines, other
applicable state and federal regulatory requirements, and all
requirements of this act including, but not limited to, the
requirements stipulated in this s ection.
B. The Authority shall deve lop methods to ensure pr ogram
integrity against provider fraud, waste, and abuse.
C. The Authority shall develop processes for providers and
Medicaid members to report violations by contracted entiti es of
applicable administrative rules, state laws, or federal laws.
SECTION 8. AMENDATORY 56 O.S. 2021, Section 4002.5, is
amended to read as follows:
Section 4002.5 A. A contracted entity shall be responsible for
all administrative functions for member s enrolled in its plan
including, but not limited to, claims processing, authorization of
health services, care and case management, and other necessary
administrative services.
B. A contracted entity shall hold a certificate of authority as
a health maintenance organization issued by the Insurance
Department.
C. 1. To ensure providers have a voice in the direction and
operation of the contracted entities selected by the Authority under
Section 4 of this act, each contracted entity shall have a shared
governance structure that includes:
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a. representatives of l ocal Oklahoma provider
organizations who are Medicaid providers,
b. essential community providers , including Certified
Community Behavioral Health Clinics, and
c. a representative from a teaching hospi tal owned,
jointly owned, or aff iliated with and design ated by
the University Hospitals Authority, University
Hospitals Trust, Oklahoma State University Medical
Authority, or Oklahoma State University Medical Trust.
2. No less than one-third (1/3) of the contracted entity's
board of directors shall be compris ed of representatives of local
Oklahoma provider organizations.
3. No less than two members of the contracted entity 's clinical
and quality committees shall be representatives of local Oklahoma
provider organizations, and the commit tees shall be chaired o r co-
chaired by a representative of a local Oklahoma provider
organization.
D. A managed care organization or dental benefit manager
contracted entity shall promptly notify the Authority of all changes
materially material changes affecting the delivery of care or the
administration of its program.
B. E. A managed care organization or dental benefit manager
contracted entity shall have a medical loss ratio that meets the
standards provided by 42 C.F.R., Section 438.8.
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C. F. A managed care organization or dental benefit manager
contracted entity shall provide patient data to a provider upon
request to the extent allowed under federal or s tate laws, rules or
regulations including, but not limited to, the Health Insurance
Portability and Accountability Act of 1996.
D. G. A managed care organization or dental benefit manager
contracted entity or a subcontractor of such managed care
organization or dental benefit manager a contracted entity shall not
enforce a policy or contract term with a provider that requir es the
provider to contract for all products that are currently offered or
that may be offered in the future by the managed care organization
or dental benefit manager contracted entity or subcontractor.
E. H. Nothing in this act or in a contract between the
Authority and a managed care organization or dental benefit manager
contracted entity shall prohibit the managed care organiz ation or
dental benefit manager contracted entity from contracting with a
statewide or regional accounta ble care organization to implement the
capitated managed care delivery model of the state Medicaid program .
I. All contracted entities shall:
1. Use the same open drug formulary, which shall be established
by the Authority; and
2. Ensure broad access to pharmacies including , but not limited
to, pharmacies contracted with covered entities under Section 340B
of the Public Health Service Act. Such access s hall, at a minimum,
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meet the requirements of the Patient's Right to Pharmacy Choice Act,
Section 6958 et seq. of Title 36 of the Oklahoma Statutes.
J. Each contracted entity and each participating provider shall
submit data through the state designated en tity for health
information exchange to ensure effective systems and con nectivity to
support clinical coordination of care, t he exchange of information,
and the availability of data to the Authority to manage the state
Medicaid program.
SECTION 9. AMENDATORY 56 O.S. 2021, Section 4002.6, is
amended to read as follows:
Section 4002.6 A. A managed care organization contracted
entity shall meet all requirements established by the Oklahoma
Health Care Authority pertaining to prior a uthorizations. The
Authority shall establish requirements that ensure time ly
determinations by contracte d entities when prior a uthorizations are
required including expedited review in urgent and emergent cases
that at a minimum meet the criteria of this s ection.
B. A contracted entity shall make a determination on a request
for an authorization of the trans fer 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 appropri ate, by a dental benefit manag er for
prior authorization for care ordered by primary care or specialist
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providers shall be timely and shall occur in accordance with the
following:
1. Within seventy-two (72) hours of receipt of the
C. A contracted entity shall make a determination on a request
for any patient member who is not hospitalized at the time of the
request within seventy-two (72) hours of receipt 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 and in accordance with a process
established by the Authority. The process established by the
Authority pursuant to this paragraph subsection 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 .
D. A contracted entity shall make a determination on a request
for services for a hospitalized patient member including, but not
limited to, acute care in patient services or equipment necessary to
discharge the patient member from an inpatient facility ;, within one
(1) business day of receipt of the request.
3. E. Notwithstanding the provisions of paragraphs 1 or 2 of
this subsection C of this section, a contracted entity shall make a
determination on a request as expeditiously as necessary and, in any
event, within twenty -four (24) hours of receipt of the requ est for
service if adhering to the provisions of paragraphs 1 or 2 of this
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subsection C or D of this section could jeopardize the enrollee's
member's life, health or ability to attain, maintain or regain
maximum function. In the event of a medically emerg ent matter, the
managed care organization or dental benefit manager contracted
entity shall not impose limitations on pro viders in coordination of
post-emergent stabilization health care including pre -certification
or prior authorization ;.
4. F. Notwithstanding any other provision of this subsection
section, a contracted entity shall make a determination on a request
for inpatient behavioral health services within twenty-four (24)
hours of receipt of the request for inpatient behavioral health
services; and
5. Within twenty-four (24) hours of receipt of the.
G. A contracted entity shall make a determination on a request
for covered prescription drugs that are required to be prior
authorized by the Authority within twenty-four (24) hours of receipt
of the request. The managed care organization contracted entity
shall not require prior authorization on any covered prescripti on
drug for which the Authority does not require prior authorization.
C. H. Upon issuance of an adverse determination on a prior
authorization request under subsection B of this section, 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 p eer-
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to-peer review process with a provider who practices 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 t he
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
program for the particular patient shall not be subject to pe er-to-
peer review.
D. I. The Authority shall ensure that a provider offers to
provide to an enrollee in a timely manner services authorized by a
managed care organization or dental bene fit manager.
J. The Authority shall establish requirements for both i nternal
reviews and appeals of adverse determinations on prior authorization
requests or claims that, at a minimum:
1. Require contracted entities to provide a detailed
explanation of denials to Medicaid providers and members;
2. Require contracted entit ies to provide a prompt opportunity
for peer-to-peer conversations with Oklahoma licensed clinical staff
of the same or similar specialty upon adverse determination; and
3. Establish uniform rules for Medicaid provider or member
appeals across all contrac ted entities.
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SECTION 10. AMENDATORY 56 O.S. 2021, Section 4002.7, is
amended to read as follows:
Section 4002.7 A managed care organization or dental benefit
manager shall
A. The Oklahoma Health Care Authority shall establish
requirements for fair processing and adjudication of claims that
ensure prompt reimbursement of providers by contracted entities. A
contracted entity shall comply with the following require ments with
respect to processing and adjudication of claims for paymen t
submitted in good faith by providers for health care items and
services furnished by such providers to enrollees of the state
Medicaid program: all such requirements.
1. B. A managed care organization or dental benefit manager
contracted entity 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 b enefit manager contracted entity. A clean
claim that is not processed within the time frame provided by
Section 1219 of Title 36 of the Oklahoma 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 service was furnished to an enrollee
a member shall be considered timely. If a claim meets the
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definition of a clean claim, the managed care organization or dental
benefit manager contracted entity shall not request medical records
of the enrollee member prior to paying the claim. Once a claim has
been paid, the managed care organization or dental benefit m anager
contracted entity may request medical records if additional
documentation is needed to review the claim for medical necessity;.
2. C. In the case of a denial of a claim including, but not
limited to, a denial on the basis of the level of emergency care
indicated on the claim, the managed care organization or dental
benefit manager contracted entity shall establish a process by which
the provider may identify and provide such additional information as
may be necessary to substantiate the claim. Any such claim denial
shall include the following:
a. a
1. A detailed explanation of the basis for the denial,; and
b. a
2. A detailed description of the additional information
necessary to substantiate the claim ;.
3. D. Postpayment audits by a managed care organization or
dental benefit manager contracted entity shall be subject to the
following requirements:
a. subject
1. Subject to subparagraph b paragraph 2 of this paragraph
subsection, insofar as a managed care organization or dental benefit
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manager contracted entity conducts postpayment audits, the managed
care organization or dental benefit manager contracted entity shall
employ the postpayment audit process determined by the Authority ,;
b. the
2. The Authority shall establish a limit on the percenta ge of
claims, not to exceed three percent (3%), with respect to which
postpayment audits may be conducted by a managed care organization
or dental benefit manager contracted entity for health care items
and services furnished by a provider in a plan year ,; and
c. the
3. The Authority shall provide for the imposition of fina ncial
penalties under such contract in the case of any managed care
organization or dental benefit manager contracted entity with
respect to which the Authority determines has a claims d enial error
rate of greater than five percent (5%). The Authority sha ll
establish the amount of financial penalties and the time frame under
which such penalties shall be imposed on managed care organizations
and dental benefit managers contracted entities under this
subparagraph paragraph, in no case less than annually ; and.
4. E. A managed care organization contracted entity may only
apply readmission penalties pursuant to rules promulgated by the
Oklahoma Health Care Authority Board. The Board shall p romulgate
rules establishing a program to reduce potentially preventab le
readmissions. The program shall use a nationally recognized tool,
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establish a base measurement year and a performance year, and
provide for risk-adjustment based on the population of the state
Medicaid program covered by the managed care organizations and
dental benefit managers contracted entities.
SECTION 11. AMENDATORY 56 O.S. 2021, Section 4002.8, is
amended to read as follows :
Section 4002.8 A. A managed care organization or dental
benefit manager contracted entity shall utilize uniform procedures
established by the Authority under subsection B of this section for
the review and appeal of any adverse determination by the managed
care organization or dental benefit manager sought contracted entity
by any enrollee or provider adversely affected by such
determination.
B. The Authority shall develop procedures fo r enrollee
enrollees or providers to seek rev iew by the managed care
organization or dental benefit manager contracted entity of any
adverse determination made by the managed care organization or
dental benefit manager contracted entity. A provider shall have six
(6) months from the receipt of a clai m denial to file an appeal.
With respect to appeals of adverse determinations made by a managed
care organization or dental benefit manager contracted entity 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 contracted entity shall be licensed or
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credentialed health care clinicians with relevant clinical training
or experience; and
2. All managed care organizations and dental benefit managers
contracted entities shall use medical review staff for suc h appeals
and shall not use any automated claim review software or other
automated functionality for such appeals.
C. Upon receipt of notice from the managed care organization or
dental benefit manage r contracted entity that the adverse
determination has been upheld on appeal, the enrollee 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 12. AMENDATORY 56 O.S. 2021, Section 4002.10, is
amended to read as follows:
Section 4002.10 A. The Oklahoma Health Care Authori ty shall
require a managed care organization or dental benefit mana ger all
contracted entities 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 managed care
organization or denta l benefit manager contracted entity to perform
satisfactorily in such areas as may be specified in 42 C.F.R.,
Section 438.66. In addition, the readiness review shall assess
whether:
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1. The managed care o rganization or dental benefi t manager has
entered into contracts with providers to the extent n ecessary to
meet network adequacy stan dards prescribed by Section 4 of t his act;
2. The contracts described in paragraph 1 of this sub section
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 bene fit manager and
the providers described in paragraph 1 of this subsection have
established and tested data infrastructure s uch that exchange of
patient data can reasonably be expected to occur within one hundred
twenty (120) calendar days of execution of t he 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, co ordination of benefits and other components
of a managed care delivery model.
B. The Oklahoma Health Care Authority may only execute the
transition of the delivery system of the state Medicaid program to
the capitated managed care d elivery model of the st ate Medicaid
program ninety (90) days after the Centers for Medicare and Medicaid
Services has approved all contract s entered into between the
Authority and all managed care organ izations and dental benefi t
managers following submiss ion of the readiness re views to the
Centers for Medicare and Medica id Services.
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SECTION 13. AMENDATORY 56 O.S. 2021, Section 4002.11, is
amended to read as follows:
Section 4002.11 No later than one year following the execution
of the delivery model trans ition described in Section 10 of this act
the Ensuring Access to Medicaid Act , the Oklahoma Health Care
Authority shall create a scorecard that compares managed care
organizations each contracted entity and separately compares each
dental benefit managers manager. The scorecard shall report the
average speed of authorizations of servic es, rates of denials of
Medicaid reimbursable services when a complete authorization request
is submitted in a timely manne r, enrollee member satisfaction survey
results, provider satisfaction survey results, and such other
criteria as the Authority may require. The scorecard shall be
compiled quarterly and shall consist of the information specified in
this section from the p rior year quarter. The Authority shall
provide the most recent quarterly scorecard to all initial enrollees
members during enrollment choice counseling following the
eligibility determination and prior to initial enrollment. The
Authority shall provide t he most recent quarterly scorecard to all
enrollees members at the beginning of each enrollment peri od. The
Authority shall publish each quarterly scorecard on its public
Internet website.
SECTION 14. AMENDATORY 56 O.S. 2021, Sectio n 4002.12, is
amended to read as follows:
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Section 4002.12 A. The Oklahoma Health Care Authority shall
establish minimum rate s of reimbursement from managed care
organizations and denta l benefit managers contracted entities to
providers who elect not to e nter 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. Unti l
July 1, 2026, such reimb ursement rates shall be equal to or greater
than:
1. For an item or service provided by a participa ting provider
who is in the network of the managed care organization or dental
benefit manager, one hundred percent (100%) of the reimbursement
rate for the applicable service in the applicable fee schedule of
the Authority; or
2. For an item or service p rovided by a non-participating
provider or a provider who is not in the network of the managed care
organization or dental benefit manager, ninety percent ( 90%) of the
reimbursement rate for the applicable s ervice in the applicable fee
schedule of the Auth ority as of January 1, 202 1.
B. A managed care organization or dental benefit manager shall
offer value-based payment arrangement s to all providers in its
network capable of entering into value-based payment arrangements.
Such arrangements shall be optio nal for the provider but shall be
tied to reimbursement incentives when quality metric s are met. The
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quality measures used by a m anaged care organization o r dental
benefit manager to determine reimbursement amounts to providers in
value-based payment arrangements shall align with the quality
measures of the Authority for managed care organ izations or dental
benefit managers.
C. Notwithstanding any other pro vision of this section, the
Authority shall comply with payment methodologies required by
federal law or regulation for specif ic types of providers including,
but not limited to, Federal ly Qualified Health Centers, rural health
clinics, pharmacies, Indian Health Care Providers and em ergency
services.
D. All rural health clinics (RHCs) shall be offered contracts
that will reimburse them using the metho dology in place for each
specific RHC prior to January 1, 2023, including any and all annual
rate updates. Future RHC developments wil l be based on the feder al
program rules and requirements, and this new commercially managed
Medicaid program will not inter fere with the program as designed.
E. The Oklahoma Health Care Authority shall establish minimum
rates of reimbursement from contrac ted entities to Certified
Community Behavioral Health Clinic (CCBHC) providers who elect
alternative payment arrangements equal to the prospective payment
system rate under the Medicaid State Plan .
F. The Authority is given fle xibility to work with physic ians
and other providers not including hospitals to design a
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reimbursement rate not to exceed the purpose of paragraph 1 of
subsection C of Section 3241.3 of Title 63 of the Oklahoma Statutes
with two components: a base rate no less than one hundred percent
(100%) of the Medicare rate; and an incentive payment that is
determined by value-based outcomes. Physicians and providers may
contract with multiple contr acted entities.
G. Psychologist reimbursement shall reflect outcomes and
include bill codes beyond reimburs ement for therapy to be able to
obtain reimbursement for testing and assessment.
H. Coverage for Medicaid transportation services by licensed
Oklahoma emergency medical services should be reimbursed at no less
than the published Medicaid rates in effect o n the date of enactment
of this act. All currently published Medicaid HCPC codes paid by
OHCA will continue to be paid by the contracted entity. The
contracted entity will continue to follow the reimbursement policie s
established OHCA for the ambulance p roviders at the time of passage
of this act. Such policies shall include but are not limited to:
emergency medical transportation not being require d for prior
authorization; and the contracted entities will accept the CMS
modifiers currently in use by Medicare at the time of the transport
of a member that is a dual -eligible.
I. The Authority shall specify in the requests for proposals a
reasonable time frame in which a contracted entity shall have
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entered into a certa in percentage, as determined by the Auth ority,
of value-based contracts with pr oviders.
J. Capitation rates established by the Oklah oma Health Care
Authority and paid to contracted enti ties under capitated contracts
shall be updated annually and in accord ance with 42 C.F.R. Section
438.36(c) and approved as actuarially sound as dete rmined by CMS in
accordance with 42 C.F.R. Section 438.4 and the following :
1. Actuarial calculations must include utilization and
expenditure assumptions consistent with industry and local
standards; and
2. Risk-adjusted and shall include a portion tha t is at risk
for achievement of quality and outco mes measures.
K. The Authority may establish a symmetric r isk corridor for
contracted entities.
SECTION 15. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Sect ion 4002.12a of Title 56, unless
there is created a duplication in numbering, reads as follows:
Any dental managed care program shall include the following
components:
1. All dental claims reviewed, and r eimbursements made with in
fourteen (14) days following a clean claim submission to a
contracted entity;
2. There shall be no deletions to the list of covered dental
procedures as of the date of this act, as well as those that d o or
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do not require pre-authorization, including in-office sedation or
anesthesia;
3. At least two ODA-appointed representatives to provide input
during the request for proposal process , as well as any negotiating
and structuring of contracts with any con tracted entity;
4. The Authority shall award a contract to more than one
contracted entity for dental ;
5. The Authority shall not require a dentist to enroll
exclusively with one contr acted entity;
6. All contracted entities with a dental contract shall be
required to maintain a Medicai d Dental Advisory Committee, comprised
exclusively of Oklahoma -licensed dentists and specialists, to
conduct all pre-authorizations and claims reviews a nd appeals; and
7. The state shall employ an Oklahoma-licensed dentist to serve
as the Medicaid Dental Direct or overseeing all contracted entities
with a dental contract.
SECTION 16. NEW LAW A new secti on of law to be codified
in the Oklahoma Statutes as Section 4002.12 b of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. The Oklahoma Health Car e Authority shall ensure the
sustainability of the transformed Medicaid deli very system.
B. The Authority shall ensure that existing revenue sources
designated for the stat e share of Medicaid exp enses are designed to
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maximize federal matching funds for th e benefit of providers and the
state.
C. The Authority shall develop a plan , utilizing waivers or
Medicaid state plan amendments as necessary, to preserve or increase
supplemental payments availa ble to providers with existing revenue
sources as provided i n the Oklahoma Statutes including , but not
limited to:
1. Hospitals that par ticipate in the supplemental hospital
offset payment program as provided by Section 3241.3 of Ti tle 63 of
the Oklahoma Statutes;
2. Hospitals in this state that have Level I trau ma centers, as
defined by the American College of Surgeons , that provide inpatient
and outpatient services and are owned or operated by the University
Hospitals Trust, or af filiates or locations of those hospitals
designated by the Trust as part of the hospital trauma system; and
3. Providers employed by or contracted with, or other wise a
member of the faculty practice plan of:
a. a public, accredited Oklahoma medical school , or
b. a hospital or health care entity directly or
indirectly owned or operated by the University
Hospitals Trust or the Oklahoma State University
Medical Trust.
D. Subject to approval by the Centers for Medicare and Medicaid
Services, the Authority sha ll preserve and, to the maximum extent
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permissible under federal law, improve existing levels of funding
through directed payments or other mechanisms outside the capitated
rate to contracted entities, including, where applicable, the use of
a directed payment program with an average commercial rate
methodology equal to ninety percent (9 0%) of the average commercial
rate methodology for hospital services , subject to approval by the
Centers for Medicare and Medicaid Services. The directed payment
methodology shall be found in Sections 3241.2 through 3241.4 of
Title 63 of the Oklahoma Statutes.
E. On or before January 31, 2023, the Authority shall submit a
report to the Oklahoma Health Care Authority Board, the Chair of the
Appropriations Committee of the Oklahoma State Senate, and the Chair
of the Appropriations and Budget Committee of the Oklahoma House of
Representatives that includes the Authority's plans to continue
supplemental payment programs and implement a managed care directed
payment program for hospital services that complies with the reforms
required by this act. If Medicaid-specific funding cannot be
maintained as currently im plemented and authorized by state law, the
Authority shall propose to the Legislature any modifications
necessary to preserve supplemental payments and managed care
directed payments to prevent budgetary disruptions to providers.
F. On or before January 1, 2023, the Authority shall submit a
report to the Governor, the President Pro Tempore of the Oklahoma
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State Senate and the Speaker of the Oklahoma House of
Representatives that includes at a minimum:
1. A description of the selection process of the contr acted
entities;
2. Plans for enrollment of Medicaid members in health plans of
contracted entities;
3. Medicaid member n etwork access standards;
4. Performance and quality metrics;
5. Maintenance of existing funding mechanisms described in this
section;
6. A description of the r equirements and other provisions
included in capitated contracts; and
7. A full and complete copy of each executed capitated
contract.
SECTION 17. AMENDATORY 56 O.S. 2021, Section 4002.13, is
amended to read as follows:
Section 4002.13 A. There is hereby created the MC The Oklahoma
Health Care Authority shall establish a M edicaid Delivery System
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 have
the power and duty to make recommendations to the Administr ator of
the Oklahoma Health Care Author ity and the Oklahoma Health Care
Authority Board on quality measures used by managed care
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organizations and dental benefit managers contracted entities in the
capitated managed care delivery model of the state Medicai d program
and to monitor the implementa tion of and adherence to such quality
measures.
C. 1. The Committee shall be comprised of mem bers appointed by
the Administrator of the Oklahoma Health Care Authority. Members
shall serve at the pleasure of the Adm inistrator.
2. A majority of the membe rs shall be providers participating
in the capitated managed care delivery model of the state M edicaid
program, and such pr oviders may include memb ers of the Advisory
Committee on Medical Care for Public Assistance Re cipients. Other
members shall include, but not be limited to, representatives of
hospitals and integrated health systems, other membe rs of the health
care community, and members of the academic community having
subject-matter expertise in the field of hea lth care or subfields of
health care, or other applicable fields including, but not limited
to, statistics, economics or public policy .
3. The Committee shall se lect from among its memb ership a chair
and vice chair.
E. D. 1. The Committee may meet as of ten 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 recommendations of the Committee. A majo rity of the
members of the Committee shall constitute a quorum.
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3. Meetings of the Committee shall be subject to the Oklahoma
Open Meeting Act.
F. E. Members of the Committee shall receive no compensati on or
travel reimbursement.
G. F. The Oklahoma Health Care Authority shall provide staff
support to the Committee. To th e extent allowed under federal or
state law, rules or regulations, the Authority, the State Department
of Health, the Department of Me ntal Health and Substance Ab use
Services and the Dep artment of Human Services shall as req uested
provide technical experti se, statistical information, and any ot her
information deemed necessary by the chair of the Committee to
perform the duties imposed on it.
SECTION 18. NEW LAW A ne w section of law to be codified
in the Oklahoma Statutes as Section 40 02.14 of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. The transformed delivery system of the st ate Medicaid
program and capitated contracts awarded under the transformed
delivery system shall be designed with uniform defined measures and
goals that are consistent across contracted entities including, but
not limited to, adjusted health outcomes, social determinants of
health, quality of care, member satisfaction, provider satisfaction,
access to care, network adequacy, and cost.
B. Each contracted entity shall us e nationally recognized,
standardized provider quality metr ics as established by the Oklahoma
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Health Care Authority and, where applicable, may use additional
quality metrics if the measures are mutually agreed upon by the
Authority, the contracted entity , and participating providers. The
Authority shall develop p rocesses for determining quality metrics
and cascading quality metrics from contracted entities to
subcontractors and providers.
C. The Authority may use consultants, organiza tions, or
measures used by health plans, the federal government, or other
states to develop effective measures for outcomes and quality
including, but not limited to, the National Committee for Quality
Assurance (NCQA) or the Healt hcare Effectiveness Data and
Information Set (HEDIS) established by NCQA, the Physician
Consortium for Performance Improvement (PCPI) or any measures
developed by PCPI.
D. Each component of the quality metrics established by the
Authority shall be subject to specific accountability measures
including, but not limited to, penalties for noncompliance.
SECTION 19. AMENDATORY 56 O.S. 2021, Section 4004, is
amended to read as follows:
Section 4004. A. The Oklahoma Health Care Authority shall seek
any federal approval necessary to i mplement this act the Ensuring
Access to Medicaid Act. This sh all include, but not be limited to,
submission to the Centers for Medicare and Medicaid Services of any
appropriate demonstration waiver applicatio n or Medicaid State Plan
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amendment necessary t o accomplish the requirements of this act
within the required time frames. Prior to implementation of the
managed care contracts, the Authority shall obtain federal approval
of a managed care directed payment program equal to ninety percent
(90%) of the average commercial rate methodology for hospital
services. Dental managed care shall be exempt from the requirement
of CMS approval of the d irected payment program.
B. The Oklahoma Health Care Authority Board shall promulgate
rules to implement this act the Ensuring Access to Medicaid Act.
SECTION 20. AMENDATORY 63 O.S. 2021, Section 5009, is
amended to read as follows:
Section 5009. A. On and after July 1, 1993, the Oklahoma
Health Care Authority shall be the state entity designated by law to
assume the responsibilities for the prepar ation and development for
converting the present delivery of the Okla homa Medicaid Program to
a managed care system. The system shall emphasize:
1. Managed care principles, i ncluding a capitated, prepaid
system with either full or partial capitation, pro vided that highest
priority shall be given to development of prepaid capitated health
plans;
2. Use of primary care physicians to establish the appropria te
type of medical care a Medicaid recipient should receive; and
3. Preventative care.
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The Authority shall also study the feasibility of allowing a
private entity to admi nister all or part of the managed care system.
B. On and after January 1, 1995, the Oklahoma Health Care
Authority shall be the designated state agency for the
administration of the Okla homa Medicaid Program.
1. The Authority shall contract with the Depa rtment of Human
Services for the determination of Medicaid eligibility and other
administrative or operatio nal functions related to the Oklahoma
Medicaid Program as necessary and appropri ate.
2. To the extent possible and appropriate, upon the transfer of
the administration of the Oklahoma Medicaid Program, the Authority
shall employ the personnel of the Medic al Services Division of the
Department of Human Services.
3. The Department of Human Services and the Authority shall
jointly prepare a transition p lan for the transfer of the
administration of the Oklahoma Medicaid Program to the Au thority.
The transition plan shall include provisions for the retraining and
reassignment of employee s of the Department of Human Services
affected by the transfer. The transition plan shall be submitted to
the Governor, the President Pro Tempore of the Senate and the
Speaker of the House of Representatives on or before January 1,
1995.
C. B. In order to provide adequate funding for the unique
training and research purpo ses associated with the demonstration
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program conducted by the entity described in pa ragraph 7 of
subsection B of Section 6201 of Title 74 of the Oklahoma Statutes,
and to provide service s to persons without regard to their ability
to pay, the Oklahoma Hea lth Care Authority shall analyze the
feasibility of establishing a Medicaid reimburse ment methodology for
nursing facilities to provide a separate Medicaid payment rate
sufficient to cover all costs allowable under Medicare principles of
reimbursement for the facility to be constructed or operated, or
constructed and operated, by the organ ization described in p aragraph
7 of subsection B of Section 6201 of Title 74 of the Oklahoma
Statutes.
SECTION 21. AMENDATORY 63 O.S. 2021, Section 5009.2, is
amended to read as follows:
Section 5009.2 A. The Advisory Committee on Medical Care for
Public Assistance Recipients, created by the Oklahoma Health Care
Authority pursuant to 42 Code of Federal Regulations, Section
431.12, for the purpose of advising the Authority about health and
medical care services, shall include among its membership of no more
than fifteen (15) the following:
1. Board-certified physicians and other represen tatives of the
health professions who are familiar with the medi cal needs of low-
income population groups and with the resources available and
required for their care. The Advisory Committee shall, at all
times, include at least one physician from each of the six classes
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of physicians listed in Section 725.2 of Title 59 of the Oklahoma
Statutes. The Advisory Committee shall at all times include at
least one pharmacist and one psychologist licensed in this state.
All such physicians and other representatives of the health
professions shall be participating providers in the State Medicaid
Plan;
2. Members of consumers' groups, including, but not limit ed to:
a. Medicaid recipients, and
b. representatives from consumer organizations including
a member representing nursing homes, a member
representing individuals with developmental
disabilities and a member representing one or more
behavioral health professions;
3. The Director of the Department of Human Services or
designee;
4. The Commissioner of Mental Hea lth and Substance Abuse
Services or designee;
5. A member approved and appointed by a state organization or
state chapter of a national organization of pediatricians dedicated
to the health, safety and well-being of infants, children,
adolescents and young adults, who shall:
a. monitor provider relations with the Oklahoma Health
Care Authority, and
b. create a forum to address grievances; and
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6. Members who are representatives of a statewide a ssociation
representing rural and urban hospitals; and
7. A member who is a member or citizen of a federally
recognized American In dian tribe or nation whose primary tribal
headquarters is located in this stat e.
Beginning on January 1, 2022, appointments made to the Advisory
Committee shall be for a duration not to exceed four (4) consecutive
calendar years.
B. The Advisory Committee shall meet bimonthly to review and
make recommendations related to:
1. Policy development and program administration;
2. Policy changes proposed by the Authority prior to
consideration of such changes by the Authority;
3. Financial concerns related to the Authority and the
administration of the programs under the Authority; and
4. Other pertinent information related to the management and
operation of the Authority and the delivery of health and medical
care services.
C. 1. The Administrator of the Au thority shall provide such
staff support and independent technical assist ance as needed by the
Advisory Committee to enable the Advisory Committee to make
effective recommendations.
2. The Advisory Committee shall elect from among its members a
chair and a vice-chair who shall serve one-year terms. A member may
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serve more than one (1), but not more than four (4), consecutive
one-year terms as chair or vice-chair. A majority of the members of
the Advisory Committee shall constitute a quorum to transact
business, but no vacancy shall impair the right of the remaining
members to exercise all of the powers of the Advisory Committ ee.
3. Members shall not receive any compensation for their
services but shall be reimbursed pursuant to the provisions of the
State Travel Reimbursement Act, Section 500.1 et seq. of Title 74 of
the Oklahoma Statutes.
D. The Authority shall give due con sideration to the comments
and recommendations of the Advisory Committee in the Authority's
deliberations on policies, administration, management and operation
of the Authority.
SECTION 22. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 307.1 of Title 36, unless there
is created a duplication in numb ering, reads as follows:
The Insurance Department shall develop methods to ensure program
integrity against fraud, waste, and abuse by any contracted entit y
as defined by Section 4002.2 of Title 56 of the Oklahoma Statut es.
The Insurance Department and the O klahoma Health Care Authorit y
shall establish a provider grievance committee to advise the
Oklahoma Health Care Authority and Insurance Department on
imposition of penalties on the contracted entities that do not
comply with established statutes and regulations .
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SECTION 23. AMENDATORY 36 O.S. 2021, Section 312.1, is
amended to read as f ollows:
Section 312.1 A. For the fiscal year ending June 30, 2004, the
Insurance Commissioner shall report an d disburse one hundred percent
(100%) of the fees and taxes collected under Section 624 of this
title to the State Treasurer to be deposited to t he credit of the
Education Reform Revolving Fund of the State Department of
Education. The Insurance Commissio ner shall keep an accurate record
of all such funds and m ake an itemized statement and furnish same to
the State Auditor and Inspector, as to all other departments of this
state. The report shall be accompanied by an affidavit of the
Insurance Commissione r or the Chief Clerk of such office c ertifying
to the correctness thereof.
B. The Insurance Commissioner shall apportion an amount of the
taxes and fees received from Sec tion 624 of this title, which shall
be at least One Million Two Hundred Fifty Thousan d Dollars
($1,250,000.00) each year, but which shall also be computed on an
annual basis by the Commissioner as the amount of insurance premium
tax revenue loss attributab le to the provisions of subsection H of
Section 625.1 of this title and increased if necessary to reflect
the annual computation, and which sh all be apportioned before any
other amounts, as follows:
1. The following amounts shall be paid to the Oklahoma
Firefighters Pension and Retirement Fund in the manner provided for
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in Sections 49-119, 49-120 and 49-123 of Title 11 of th e Oklahoma
Statutes:
Fiscal Year Amount
FY 2006 through FY 2020 65.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month ending
August 31, 2020 65.0%
b. for the month beginning September
1, 2020, through the month ending
June 30, 2021 45.5%
FY 2022 and each fiscal year thereafter 65.0%;
2. The following amounts shall be paid to the O klahoma Police
Pension and Retirement System pursuant to the provisions of Sections
50-101 through 50-136 of Title 11 of the Oklahoma Statutes:
Fiscal Year Amount
FY 2006 through FY 2020 26.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month endi ng
August 31, 2020 26.0%
b. for the month beginning September
1, 2020, through the month en ding
June 30, 2021 18.2%
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FY 2022 and each fiscal year thereafter 26.0%;
3. The following amounts shall be paid to the Law Enforcement
Retirement Fund:
Fiscal Year Amount
FY 2006 through FY 2 020 9.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month ending
August 31, 2020 9.0%
b. for the month beginning September
1, 2020, through the month ending
June 30, 2021 6.3%
FY 2022 and each fiscal year thereafter 9.0%; and
4. The following amounts shall be paid to the Education Reform
Revolving Fund of the State Department of Education:
Fiscal Year Amount
FY 2021 as follows:
for the month beginning September 1,
2020, through the month ending June 30,
2021 30.0%.
C. After the apportionment required by subsection B of this
section, for the fiscal years beginning July 1, 2004 , and ending
June 30, 2009, the Insurance Commissioner shall report and disburse
all of the fees and taxes c ollected under Section 624 of this title
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and Section 2204 of this title, and the same are hereby apportioned
as follows:
1. Thirty-four percent (34%) of the taxes collected on premiums
shall be allocated and disbursed for the Oklahoma Firefighters
Pension and Retirement Fund, in t he manner provided f or in Sections
49-119, 49-120 and 49-123 of Title 11 of the Oklah oma Statutes;
2. Seventeen percent (17%) of the taxes collected on premiums
shall be allocated and disbursed to the Oklahoma Police Pension and
Retirement System pursuant to the provisions of Sections 50-101
through 50-136 of Title 11 of the Oklahoma Stat utes;
3. Six and one-tenth percent (6.1%) of the taxes collected on
premiums shall be allocated and disbursed to the Law Enforcement
Retirement Fund; and
4. All the balance and remainder of the taxes and fees provided
in Section 624 of this title shall b e paid to the State Treasurer to
the credit of the General Revenue Fund of the state to provide
revenue for general functions of state government . The Insurance
Commissioner shall keep an ac curate record of all such funds and
make an itemized statement an d furnish same to the State Auditor a nd
Inspector, as to all other departments of this state. The report
shall be accompanied by an affidavit of the Insurance Commissione r
or the Chief Clerk of such office certifying to the correctness
thereof.
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D. After the apportionment required by subsect ion B of this
section, the Insurance Commissioner shall report and disburse all of
the fees and taxes colle cted under Section 624 of t his title and
Section 2204 of this title, and the same are hereby apportioned as
follows:
1. Of the taxes collected on pr emiums the following shall be
allocated and disbursed for the Oklahoma Firefighters Pension and
Retirement Fund, in the manner provide d for in Sections 49 -119, 49-
120 and 49-123 of Title 11 of the Oklahoma Statutes:
Fiscal Year Amount
FY 2006 through FY 20 20 36.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month ending
August 31, 2020 36.0%
b. for the month beginning September
1, 2020, through the month ending
June 30, 2021 25.2%
FY 2022 36.0%
FY 2023 through FY 2027 37.8%
FY 2028 and each fiscal year thereafter 36.0%;
2. Of the taxes collected on premiums the following shall be
allocated and disbursed to the Oklahoma Police Pension and
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Retirement System pursuant to the provisions of Secti ons 50-101
through 50-136 of Title 11 of the Oklahoma Statutes:
Fiscal Year Amount
FY 2006 through FY 2020 14.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month ending
August 31, 2020 14.0%
b. for the month beginning Septembe r
1, 2020, through the month ending
June 30, 2021 9.8%
FY 2022 14.0%
FY 2023 through FY 2027 14.7%
FY 2028 and each fiscal year thereafter 14.0%;
3. Of the taxes collected on premiums the following shall be
allocated and disbursed to the Law Enforcement Retirement Fund:
Fiscal Year Amount
FY 2006 through FY 2020 5.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month ending
August 31, 2020 5.0%
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b. for the month beginning September
1, 2020, through the month ending
June 30, 2021 3.5%
FY 2022 5.0%
FY 2023 through FY 2027 5.25%
FY 2028 and each fiscal year thereafter 5.0%;
4. The following amounts shall be paid to the Education Reform
Revolving Fund of the State Department of Education:
Fiscal Year Amount
FY 2021 as follows:
for the month beginning September 1,
2020, through the month ending June 30,
2021 16.5%;
5. In addition to the allocations made pursuant to paragr aphs
1, 2 and 3 of this su bsection, of the tax es collected on premiums
the following amounts shall be allocated and disbursed annually for
FY 2023 through FY 2027:
a. Forty Thousand Six Hundred Twenty-five Dollars
($40,625.00) to the Oklahoma Firefighters Pension and
Retirement Fund,
b. Sixteen Thousand Two Hundred Fifty Dollars
($16,250.00) to the Oklahoma Police Pension and
Retirement System, and
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c. Five Thousand Six Hundred Twenty-five Dollars
($5,625.00) to the Oklahoma Law Enforcement Retirement
Fund; and
6. All the balance and remainder of the t axes and fees provided
in Section 624 of this title shall be paid to the State Treasurer to
the credit of the General Revenue Fund of the state to provide
revenue for general functions of state government . The Insurance
Commissioner shall keep an accurate record of all such funds and
make an itemized statement and furn ish same to the State Auditor and
Inspector, as to all other departments of this state. The report
shall be accompanied by an affidavit of the I nsurance Commissioner
or the Chief Clerk of su ch office certifying to the correctness
thereof.
E. The disbursements provided for in subsections A, B, C and D
of this section shall be made monthly. The Insurance Commissioner
shall report annually to the G overnor, the Speaker of th e House of
Representatives, the President Pro Tempore of the Senate and the
State Auditor and Inspector, the amounts colle cted and disbursed
pursuant to this section.
F. Notwithstanding any other provision of law to the contrary,
no tax credit authorized by law enacted on or after July 1, 2008,
which may be used to reduce any insurance pr emium tax liability
shall be used to reduce the amount of insurance premium tax revenue
apportioned to the Oklahoma Firefighters Pension and Reti rement
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System, the Oklahoma Police Pension and Retirement System, the
Oklahoma Law Enforcement Retirement Syste m or the Education Reform
Revolving Fund.
G. For fiscal year 2023, and eac h subsequent fiscal year,
before any other apportionment otherwise req uired by this section is
made, there shall be apportioned to the Medicaid Contingency
Revolving Fund, created in Section 1010.8 of Title 56 of the
Oklahoma Statutes, the portion of premi um taxes and fees collected
under Section 624 of this title from contr acted entities of the
Ensuring Access to Medic aid program of the Oklahoma Health Care
Authority and to provide the state share of Medica id expansion costs
as outlined in Section 1 et seq. of Article XXV-A of the Oklahoma
Constitution.
SECTION 24. RECODIFICATION 56 O.S. 2021, Sec tion 4004,
as amended by Section 20 of this act, shall be recodified as S ection
4002.15 of Title 56 of the Oklahoma S tatutes, unless there is
created a duplication in numbering.
SECTION 25. REPEALER 56 O.S. 2021, Sections 1010.2 ,
1010.3, 1010.4, and 1010.5, are hereby repealed.
SECTION 26. REPEALER 56 O.S. 2021, Section s 4002.3 and
4002.9, are hereby repealed.
SECTION 27. REPEALER 63 O.S. 2021, Sections 5009.5,
5011, and 5028, are hereby repeale d.
SECTION 28. This act shall become effect ive July 1, 2022.
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SECTION 29. It being immediatel y necessary for the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, by reason whereof this act shall take effect and
be in full force from and af ter its passage and approval.
SECTION 30. NEW LAW A new section of law not to be
codified in the Oklahoma Statutes reads a s follows:
This act shall become effective only if Senate Bill No. 1396 of
the 2nd Session of the 58th Oklahoma Legislature is enacted into
law.
58-2-11428 JM 04/21/22