Oklahoma Senate Bill SB1337 Amended / Bill

                     
 
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HOUSE OF REPRESENTATIVES - FLOOR VERSION 
 
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 ] 
   
 
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BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: 
SECTION 1.     NEW LAW     A new section of law to be cod ified 
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 predictabil ity 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 deliver y 
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 assistanc e; 
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 Commo n 
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 e nter 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 managin g 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 th e 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 Oklah oma 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 d elivery 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 i s 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 duplicat ion 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 requ est 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 se rvices, 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 shal l 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 th e 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 financi al 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 Hea lth 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 co ntract 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 membe rs, 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 organizations 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 ensur e 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 a n 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 operational 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 provide rs 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 al lowed 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 organization 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 entitie s 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 shall, 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 entity 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 pert aining to prior authorizations.  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 c riteria of this section. 
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 requ est. 
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 re quest; 
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 mak e 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 re ceipt 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 ev ent 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 behavi oral 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 determ ination 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 
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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 d etailed 
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 determinati on; 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 organizati on 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 shal l 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 b ear 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 c laim 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 organiza tion 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 subst antiate 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 d ental 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 p rovider 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 d etermines 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 man agers 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 B oard.  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 this 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 Auth ority 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 con tracts 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 b e 
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 i ts 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 Authorit y 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 se rvices 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 t he 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 transpor tation 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 deletion s 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 
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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, Secti on 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 Oklahoma 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 administer 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 Department 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 tr ansfer 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 tra nsition plan 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 transf er.  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 purposes 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 Health 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 medical 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 Indian 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 Authority 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 Authority 
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 make 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 shall 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 
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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 Statutes, 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 immediately 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. 
 
COMMITTEE REPORT BY: COMMITTEE ON APPROPRIATIONS AND BUDGET, dated 
04/21/2022 - DO PASS, As Amended.