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ENGROSSED HOUSE AMENDME NT
TO
ENGROSSED SENATE BILL NO . 1337 By: McCortney of the Senate
and
McEntire of the House
[ 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 adjudicati on of claims
- readiness review - scorecard – provider
reimbursement - capitation rates - supplemental
payments – reports – advisory committee - measures
and goals - federal approval - recodification –
repealers - codification - effective date ]
AMENDMENT NO. 1. Strike the stricken title, enacting clause, and
entire bill and insert:
"An Act relating to the state Medicaid program;
providing legislative intent; amending 56 O.S. 2021,
Section 4002.2, which relates to the Ensuring Access
to Medicaid Act; defining terms; modifying terms;
requiring the Oklahoma Health Care Authority to
enter into certain contracts; requiring legis lative
authorization for certain contracts; requiring the
Oklahoma Health Care Authority to request certain
partnerships; allowing a gency specifications on
covered services; creating compliance deadline;
requiring the Oklahoma Health Care Authority to
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receive certain confirmation from certain federal
agency; requiring certain payment programs;
requiring certain bids; allowing certain entities to
be awarded contracts; requiring a certain number of
contracts to be awarded; req uiring certain
qualifications on certain con tracts; creating
exemption to qualifications requirement ; requiring
the Oklahoma Health Care Authority to develop
certain methodologies ; providing factors for
developed methodologies; allowing exten sion of
contracts in certain situations; requiring new
contracts to be made after the end of the contr act
term; requiring the agency to provide members
certain assistance; amending 56 O.S. 2021, Section
4002.4, which relates to network adequacy standards;
requiring network adequacy standards; removing
certain requirements; modifying terminology; setting
certain timelines; re quiring Oklahoma Health Care
Authority to develop certain contract ter ms;
requiring contracted entities to meet all
requirements; requiring Oklahoma Health Care
Authority to develop certain methods; amending 56
O.S. 2021, Section 4002.5, which relates to
administrative responsibilities; requiring
contracted entities to hold certain administrative
responsibilities; requiring contracted entities to
hold certificates of authority; requiring certain
governance structures; requiring certain
notifications; requiring the use of certain drug
formulary; ensuring broad access to pharmac ies;
requiring the submission of data; amending 56 O.S.
2021, Section 4002.6, which relat es to
authorizations; making certain au thorization
requirements; implementing certain deadlines for
certain requests; requiring agency implementation of
requirements for internal and extern al reviews;
amending 56 O.S. 2021, Section 4002.7, which re lates
to requirements; creating claims adjudica tion
standards; modifying terms; amending 56 O.S. 2021,
Section 4002.8, which relates to procedures;
modifying terms; amending 56 O.S. 2021, Section
4002.10, which relates to re adiness reviews;
updating terms; removing certain requirements;
amending 56 O.S. 2021, Section 4002.11, which
relates to delivery model transition scorecards;
updating timelines; modifying terms; ame nding 56
O.S. 2021, Section 4002.12, which relates t o minimum
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rates; providing deadline for compliance ; modifying
terms; removing certai n requirements; setting
certain requirements for certain services; setting
reimbursement standards; setting dent al contracted
entity standards; requiring agency to en sure
sustainability of system; requiring agency to
preserve funding of certain programs; requiring
agency reporting; amending 56 O.S. 2021, Section
4002.13, which relates to the Quality Advisory
Committee; renaming committee; granting duties and
powers; requesting recommendations from committee;
creating defined measures for program and c apitated
contracts; amending 56 O.S. 2021, Section 4004,
which relates to federal approval; requiring the
seeking of approval for implementation of the
Ensuring Access to Medicaid Act; amending 63 O.S.
2021, Section 5009, which relates to the Oklahoma
Medicaid program; removing cert ain requirements;
updating entity design ation; amending 63 O.S. 2021,
Section 5009.2, which relates to the Advisory
Committee on Medical Care for Public Assistance
Recipients; updating membership requirements;
amending 36 O.S. 2021, Section 312.1, which relates
to the revolving funds ; updating fiscal
apportionment; providing for recodification ;
repealing 56 O.S. 2021, Sections 1010.2, 1010.3,
1010.4, and 1010.5, which relate to the Oklahoma
Medicaid Program Reform Act of 2003 ; repealing 56
O.S. 2021, Sections 4002.3 and 4002.9, which relate
to the Ensuring Access to Medicaid Act ; repealing 63
O.S. 2021, Sections 5009.5, 5011, and 5028, which
relate to the Oklahoma Health Care Authority A ct;
providing for codification; providing an effective
date; declaring an emergency; and providing
contingency effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codif ied
in the Oklahoma Statutes as Section 4002.1a of Title 56, unless
there is created a duplication in numberin g, reads as follows:
It is the intent of the Legislature to transform the state 's
current Medicaid program to provide budget predictability for th e
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taxpayers of this st ate while ensuring quality care to those in
need. The state Medicaid program shall be d esigned to achieve the
following goals:
1. Improve health outcomes for Medicaid members and the state
as a whole;
2. Ensure budget predictabilit y through shared risk and
accountability;
3. Ensure access to care, quality measures, and member
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. 2021, Section 4002.2, is
amended to read as follows:
Section 4002.2 As used in this act the Ensuring Access to
Medicaid Act:
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;
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3. "Claims denial error rate" means the rate of claims denials
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 actuar ial calculations;
5. "Children's Specialty Plan" means a health care plan that
covers all Medicaid services other than den tal services and is
designed to provide care to:
a. children in foster care ,
b. former foster care children up to twenty-five (25)
years of age,
c. juvenile justice involved children, and
d. children receiving adoption assistance ;
6. "Clean claim" means a properly completed billing form with
Current Procedural Terminology, 4th Edition or a more recent
edition, the Tenth Revision of the International Classification of
Diseases coding or a more recent revision, or Healthcare Common
Procedure Coding Syste m coding where applicable that contains
information specifically required in the Provide r Billing and
Procedure Manual of the Oklahoma He alth Care Authority, as defined
in 42 C.F.R., Section 447.45 ;
4. 7. "Commercial plan" means an organization or entity that
undertakes to provide or arrange for the delivery of health care
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services to Medicaid members on a prepaid basis and is subject to
all applicable federal a nd state laws and regulations;
8. "Contracted entity" means an organization or entity that
enters into or will ente r into a capitated contract with the
Oklahoma Health Care Authority for the delivery of services
specified in this ac t that will assume fina ncial risk, operational
accountability, and statewide or regional functionality as defined
in this act in managing c omprehensive health outcomes of Medicaid
members. For purposes of this act, the term contracted entity
includes an accountable care organiza tion, a provider-led entity, a
commercial plan, a dental benefit manager, or any other entity as
determined by the Authority;
9. "Dental benefit manager" means an entity under contract with
the Oklahoma Health Care Authority to man age 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:
a. a Federally Qualified Health Center,
b. a community mental health center,
c. an Indian Health Care Provider ,
d. a rural health clinic,
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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 designated by the University
Hospitals Authority, University Hospitals Trust,
Oklahoma State University Medical Aut hority, or
Oklahoma State University Medical Trust,
h. a provider employed by or contracted with, or
otherwise a member of the f aculty 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 addiction recovery center,
k. any additional Medicaid provider 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
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the last three (3) years, and the combined capacity of
other service providers in the region is insufficient
to meet the total needs of the Medicaid mem bers,
l. a hospital licensed by the State of Oklahoma,
including all hospitals participatin g in Section
3241.1 et. seq. of Title 63 of the Oklahoma Statutes ,
m. Certified Community Behavioral Health Clinics
(CCBHCs), or
n. any provider not otherwise mentioned in this p aragraph
that meets the defini tion 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 Authority to participate in
and deliver benefits and ser vices to enrollees of the capi tated
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 policy, process or
protocol which affects, or can re asonably be expected to affect ,
more than five percent (5%) of enrolle es or participating providers
of the contracted entity, managed care organization or dental
benefit manager;
8. 12. "Governing body" means a group of individuals appointed
by the contracted entity who approve policies, operations,
profit/loss ratios, executive employment decisions, and who have
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overall responsibility for the operations of t he contracted entity
of which they are appointed;
13. "Local Oklahoma provider organization" means any state
provider association, accountable care organization, Certified
Community Behavioral Health Clinic, Federally Qualified Health
Center, Native American tribe or tribal association, hospital or
health system, academ ic medical institution, currently practicing
licensed provider, or other local Oklahoma provider organization as
approved by the Authority;
14. "Medical necessity" has the same meaning as provided by
rules of promulgated by the Oklahoma Health Care Author ity Board;
9. 15. "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. 16. "Provider" means a health care or dental pro vider
licensed or certified in this state or a provider that meets the
Authority's provider enrollment criteria to contract with the
Authority as a SoonerCare provider;
17. "Provider-led entity" means an organization or entity that
meets the 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 unde r
common ownership with Medicaid providers in thi s
state, or
b. a majority of the entity's governing body is composed
of individuals who:
(1) have experience serving Medicaid members and:
(a) are licensed in this state as physicians,
physician assistants, nurse practitioners,
certified nurse-midwives, or certified
registered nurse anesthetists,
(b) at least one board member is a licensed
behavioral health provider , or
(c) are employed by:
i. a hospital or other medical faci lity
licensed by this state and operating in
this state, or
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;
18. "Statewide" means all counties of this state inclu ding the
urban region; and
19. "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 entities 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 i n this section.
2. Unless expressly authorized b y the Legislature, the
Authority shall not issue any request for proposals or enter into
any contract to transform the delivery system for the aged, blind,
and disabled populations eligible for Sooner Care.
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B. 1. The Oklahoma Health Care Authority shall issue a request
for proposals to enter into public-private partnerships with
contracted entities other than dental benefit manage rs to cover all
Medicaid services 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 th e 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 inclu ding, but not limited
to:
(1) primary care,
(2) inpatient and outpatient services, and
(3) emergency room services,
b. behavioral health services, and
c. prescription drug services.
3. The Authority shall specify the services not covered in the
request for proposals referenced in paragraph 1 of this subsection.
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4. The implementation of the program shall be no later than
October 1, 2023.
C. 1. The Authority shall issue a request for proposals to
enter into public-private partnerships with dental benefit managers
to cover dental services for the foll owing Medicaid populations:
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 p rovided
by subsection D of this s ection.
2. The Authority shall specify the se rvices to be covered in
the request for proposals referenced in paragraph 1 of t his
subsection.
3. The implementation of the pr ogram shall be no later than
October 1, 2023.
D. 1. Either as part of the request for proposals referenced
in subsection B of this section or as a separate request for
proposals, the Authority shall issue a request for proposals to
enter into public-private partnerships wi th one contracted entit y to
administer a Children 's Specialty Plan.
2. The Authority shall specify the ser vices to be covered in
the request for proposals referenced in paragraph 1 of th is
subsection.
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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 provid ed by subsection C of this
section.
4. The implementation of the pr ogram shall be no later than
October 1, 2023.
E. The Authority shall not implement the transfo rmation of the
Medicaid delivery system until it recei ves written confirmation from
the Centers for Medicare and Medicaid Services that a managed care
directed payment prog ram utilizing average commercial rate
methodology for hospital service s has been approved for Year 1 of
the transformation and will be inc luded in the budget neutrality cap
baseline spending level for purposes of Oklahoma's 1115 waiver
renewal; provided, however, nothing in this section shall prohib it
the Authority from expl oring alternative opportuniti es with the
Centers for Medicare and Medicaid Services to maximize the average
commercial rate benefit.
SECTION 4. NEW LAW A new sec tion of law to be codified
in the Oklahoma Statutes as Section 4002.3b of Title 56, unless
there is created a duplication in num bering, reads as follows:
A. All capitated cont racts shall be the result of requests for
proposals issued by the Oklahoma Healt h Care Authority and
submission of competitive bids by contracted enti ties pursuant to
the Oklahoma Central Purchasing Act.
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B. Statewide capitated contracts 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 Section
3 of this act.
D. 1. Except as specified in paragraph 2 of this s ubsection,
at least one capitated contract to provide statewide coverage to
Medicaid members shall be awarded to a provider -led entity, as long
as the provider-led entity submits a responsive rep ly 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 requirem ents, 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
demonstrates ability to fulfill the contract requirements. The
preferential scoring methodology shall include opportunities to
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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 coordination 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 organizations 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 Medicaid Innovation of the Centers for
Medicare and Medicaid Services, o r value-based payment
arrangements or risk-sharing arrangements in the
commercial health care m arket, and
d. other relevant factors identified by the Author ity.
E. The Authority may select at least one provider-led entity
for the urban region if:
1. The provider-led entity submits a responsive reply to the
Authority's request for proposals demonst rating ability to fulfill
the contract requirements; and
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2. The provider-led entity demonstrates the abil ity, and agrees
continually, to expand its coverage area throughout the contract
term to develop statewide op erational readiness within a time frame
set by the Authority but not mandated before five (5) years.
F. At the discretion of the Authority, 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 exceed seven
(7) years.
G. At the end of the contract ing 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 Legislature and the Ce nters 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.
SECTION 5. NEW LAW A new section of law to be codifi ed
in the Oklahoma Statutes as Section 4002.3c 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.
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B. The Authority shall develop and implement a process for
assignment of Medicaid members to contracted entities.
C. The Authority may only utilize a n opt-in enrollment process
for the voluntary enrollment of American Indians and Alaska Natives.
Notwithstanding any other provision of this act, the Authority shall
comply with all Indian p rovisions associated with Medicaid managed
care, including, but n ot limited to, the Social Security Act ,
1932(a)(2)(C), the Ameri can Recovery and Reinvestment Act of 2009,
P.L. 111-5 (Feb. 17, 2009), Section 5006, The Children’s Health
Insurance Program Reau thorization Act of 2009, P.L. 111 -3 (Feb. 4,
2009), and the Cente rs for Medicare and Medicaid Services (CMS)
managed care protections, 25 C.F.R., 438.14.
D. In the event of the termination of a capitated con tract with
a contracted entity during the cont ract duration, the Authority
shall reassign members to a remainin g 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 Board, if
the financial, operation , and performance requirements can be met,
at the discretion of the Authority.
SECTION 6. AMENDATORY 5 6 O.S. 2021, Section 4002.4, is
amended to read as follows:
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Section 4002.4 A. The Oklahoma Health Ca re Authority shall
develop network adequacy standards for all managed care
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 standards established under this
subsection shall be designed to ensure enrollees covered by the
managed care organiz ations and dental benef it managers who reside i n
health professional shortage areas (HPSAs) designated under Sec tion
332(a)(1) of the Public Health Service Act (42 U.S.C., Section
254e(a)(1)) have access to in-person health care and telehealth
services with providers, especially adult and pediatric pri mary care
practitioners.
B. All managed care organizations and d ental 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 o f 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 accord ance with 42 C.F.R., Part 438 and suc h
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,
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providers who receive di rected payments in accordance with 42
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 devel oped to meet the needs
of Medicaid members, each contracted entit y must contract with at
least one local Oklahoma provider organization for a model of care
containing care coordination, care management, utilization
management, disease managemen t, network management, or another model
of care as approved by the Authority. Such contractual arrangements
must be in place within twelve (12) months of the effective date of
the contracts awarded pursuant to the requests for proposals
authorized by Section 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 si ngle, 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 dental benefit managers
contracted entities shall be accredited in accordanc e 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 awards a capitated
contract to a provider-led entity for the urban region unde r Section
4 of this act, the provider -led entity may, as provided by the
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contract with the Authority, expand its coverage area beyond the
urban region to counties for which the provider-led entity can
demonstrate evidence of network adequacy as required un der 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 enrollment 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 five (5) years from the date of initial
award of the capitated contract.
SECTION 7. NEW LAW A new section of law to be codified
in the Oklahoma Stat utes as Section 4002.4a of Title 56, unless
there is created a duplication in numbering, 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 enti ty 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
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and capitation rates, insurance reserve requirem ents as specified by
the Insurance Department, acceptance of risk as defined by the
Authority, operational performance expectations including the
assessment of penalties, member marketing guidelines, other
applicable state and federal regulatory requiremen ts, and all
requirements of this act including, but not limited to, the
requirements stipulated in this section.
B. The Authority shall develop methods to ensure pr ogram
integrity against provider fraud, waste, and abuse.
C. The Authority shall develop p rocesses for providers and
Medicaid members to report violations by contracted entities of
applicable administrative rules, state laws, or federal laws.
SECTION 8. AMENDATORY 56 O.S. 2021, Section 4002.5, is
amended to read as follo ws:
Section 4002.5 A. A contracted entity shall be responsible for
all administrative functions for members enrolled in its plan
including, but not limited to, claims processing, authorization of
health services, care and case management, grievances and appeals,
and other necessary administrati ve services.
B. A contracted entity shall hold a ce rtificate 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 Oklahoma Health
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Care Authority under Section 4 of this act, each contracted entity
shall have a shared gove rnance structure that includes:
a. representatives of l ocal Oklahoma provider
organizations who are Medicaid providers,
b. essential community providers , and
c. a representative from a teaching hospital 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 lo cal
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 represent ative of a local Oklahoma provider
organization.
D. A managed care organization or dental benefi t 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.
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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.
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 f ederal or state 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 man ager 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 entities shall:
1. Use the same drug formulary, which shall be established by
the Authority; and
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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,
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 connectivity to
support clinical coordination of care, the 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 timely
determinations by contracte d entities when prior authorizations 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.
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B. Review and issue determinations made by a managed care
organization or, as appropriate, by a dental benefit manag er for
prior authorization for care ordered by primary care or specialist
providers shall be timely and shall occur in accordance with the
following:
1. Within seventy-two (72) hours of receipt of the
C. A contracted entity shall make a determination on a request
for any patient member who is not hospitalize d at the time of the
request within seventy-two (72) hours of receipt of the request ;
provided, that if the request does not inclu de 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 t o 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 h ospitalized 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 reque st.
3. E. Notwithstanding the pro visions of paragraphs 1 or 2 of
this subsection C of this section, a contracted entity shall make a
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determination on a reques t as expeditiously as necessary and, in any
event, within twenty -four (24) hours of receipt of th e request for
service if adhering to the provisions of paragraphs 1 or 2 of this
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 emergent matter, the
managed care organization or dental benefit manager contracted
entity shall not impose limitations on providers in coordination of
post-emergent stabilization health care including pre -certification
or prior authorization ;.
4. F. Notwithstanding any other provision o f this subsection
section, a contracted entity shall make a determination on a request
for inpatient behavioral health servic es 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 tha t 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 prescription
drug for which the Authority does not require prior authorization.
C. H. Upon issuance of an adverse determination on a prior
authorization request under subsecti on B of this section, the
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managed care organization or dental benefit manager shall provide
the requesting provider, withi n seventy-two (72) hours of receipt of
such issuance, with reasonable opportunity to participate in a peer-
to-peer review process with a provider who 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 the
requesting provider determin es 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 partic ular patient shall not be subject to peer-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 denta l benefit manager.
J. The Authority shall establish requirements for both internal
and external reviews and appeals of adverse determinations on prior
authorization requests or claims that, at a minimum:
1. Require contracted entities to provide a detail ed
explanation of denials to Medicaid providers an d members;
2. Require contracted entities to provide a prompt opportunity
for peer-to-peer conversations with licensed clinical staff of the
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same or similar specialty which shall include, but not be limite d
to, Oklahoma-licensed clinical staff upon adverse determination; and
3. Establish uniform rules for Medica id provider or member
appeals across all contracte d entities.
SECTION 10. AMENDATORY 56 O.S. 2021, Sect ion 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 provide rs by contracted entities. A
contracted entity sh all comply with the following requirements with
respect to processing and adjudication of claims for payment
submitted in good faith by providers for health care items and
services furnished by such provide rs to enrollees of the state
Medicaid program: all such requirements.
1. B. A managed care organization or d ental 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 clea n claims shall be paid
within fourteen (14) days of submiss ion to the managed care
organization or dental ben efit manager contracted entity. A clean
claim that is not processed within the time frame provid ed by
Section 1219 of Title 36 of the Oklahoma Sta tutes shall bear simple
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interest at the monthly rate of one and one-half percent (1.5%)
payable to the provid er. A claim filed by a provider within six (6)
months of the date the item or service was furnis hed to an enrollee
a member shall be considered ti mely. If a claim meets the
definition of a clean claim, th e 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 manager
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 p rovide 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 inform ation
necessary to substantiate the claim ;.
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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
manager contracted entity conducts postpayment audits, the managed
care organization or dental benefit manager contracted entity shall
employ the postpayment audit process determi ned by the Authority ,;
b. the
2. The Authority shall establish a limit on the percentage of
claims with respect to which postpayment audits may be conducted by
a managed care organization or dental benefit manager contracted
entity for health care items a nd services furnished by a provider in
a plan year,; and
c. the
3. The Authority shall provide for the imposition of financial
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 denial error
rate of greater than five percent (5%). The Authority shall
establish the amount of financial penalties and the time frame under
which such penalties shall be imposed on managed care organiza tions
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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 promulgate
rules establishing a program to reduce potentially preventable
readmissions. The program shall use a nationally recognized tool,
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 contracted entity sought
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
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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
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 s uch 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
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accordance with 42 C.F.R., Section 438.66. The readiness review
shall assess the ability and capacity of the managed care
organization or dental 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:
1. The managed care organization 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 subsection
offer, but do not require, value -based payment arrangements as
provided by Section 12 of this act; and
3. The managed care organization or dental bene fit manager and
the providers described in paragraph 1 of this subsection have
established and tested data infrastructure such that exchange of
patient data can reasonably be expected to occur within one hundred
twenty (120) calendar days of execution of 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, coordination 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 state Medicaid
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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 organizations and dental benefit
managers following submiss ion of the readiness reviews to the
Centers for Medicare and Medica id Services.
SECTION 13. AMENDATORY 56 O.S. 2021, Section 4002.11, is
amended to read as follows:
Section 4002.11 No later than one (1) year following the
execution of the delivery model transition 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 manner, enrollee member satisfaction survey
results, provider satisfaction survey results, and such other
criteria as the Authority may require. The scorecard shall be
compiled quarterly a nd shall consist of the information specified in
this section from the prior 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 the most recent qua rterly scorecard to all
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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, Section 4002.12, is
amended to read as follows:
Section 4002.12 A. The Until July 1, 2026, the Oklahoma Health
Care Authority shall establish minimum rates of reimbursement from
managed care organizations and dental benefit managers contracted
entities to providers who elect not to enter into value-based
payment arrangements under subsection B of this section or other
alternative payment agreements for health care items and services
furnished by such providers to enrollees of the state Medicaid
program. Until July 1, 2026, such reimbursement 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 applicab le 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 t he
reimbursement rate for the applicable s ervice in the applicable fee
schedule of the Auth ority as of January 1, 2021.
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B. A managed care organization or dental benefit manager
contracted entity shall offer value-based payment arrangement s to
all providers in its network cap able of entering into value-based
payment arrangements. Such arrangements shall be optional for the
provider but shall be tied to reimbursement incentives when quality
metrics are met. The quality measures used by a m anaged care
organization or 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
organizations or dental benefit managers contracted entities.
C. Notwithstanding any other provision of this section, the
Authority shall comply with payment methodologies required by
federal law or regulation for sp ecific types of providers including,
but not limited to, Federally 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 methodology 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 interfere with the program as designed.
E. The Oklahoma Health Care Authority sh all establish minimum
rates of reimbursement from contrac ted entities to Certified
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Community Behavioral Health Clinic (CCBHC) providers who elect
alternative payment arrangements equal to the prospective pa yment
system rate under the Medicaid State Plan .
F. The Authority is given flexibility to work with physic ians
and other providers, not including hospitals, to design an incentive
payment in accordance with paragraph 1 of subsection C of Section
3241.3 of Title 63 of the Oklahoma Statutes that is determined by
value-based outcomes except for anesthesia which shall continue to
be paid at the Medicaid rate as of the passage of this act.
Physicians and providers may contract with multiple contracted
entities.
G. Psychologist reimbursement shall reflect out comes and
include bill codes beyond reimburs ement for therapy to be able to
obtain reimbursement for te sting and assessment.
H. Coverage for Medicaid ground transportation services by
licensed Oklahoma emergency medical services should be reimbursed at
no less than the published Medicaid rates as set by the Authority.
All currently published Medicaid HCPC codes paid by OHCA will
continue to be paid by th e contracted entity. The contracted entity
will continue to follow the reimbursement policies establis hed by
the Authority for the ambulance providers. Such policies shall
include but are not limited to: emergency medical transportation not
being required for prior authorization; and the contracted entities
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will accept the CMS modifiers currently in use b y Medicare at the
time of the transport of a m ember 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
entered into a certain percentage, as determined by t he Authority,
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 accordance 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.
L. The Authority shall create a program for annual recovery by
the state a portion of funds from contracted entities when they
exceed their medical loss ratio.
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:
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Any dental managed care program shall inc lude the following
components:
1. All contracted entities with a dental contract shall be
required to maintain a Medic aid Dental Advisory Committee, comprised
exclusively of Oklahoma-licensed dentists and specialists, to advise
contracted entities regarding quality mea sures in the dental managed
care program; and
2. Dental providers shall not be required to enter into
capitated contracts with a dental contracted entity.
SECTION 16. NEW LAW A new secti on of law to be codified
in the Oklahoma Statutes as Section 4002.12b of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. The Oklahoma Health Care 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 expenses are designed to
maximize federal matching funds for the benefit of providers and the
state.
C. The Authority shall develop a plan , utilizing waivers or
Medicaid state plan amendme nts as necessary, to preserve or increase
supplemental payments available to providers with existing revenue
sources as provided in the Oklahoma Statutes including, but not
limited to:
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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 trauma 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 Me dicare and Medicaid
Services, the Authority sha ll preserve and, to the maximum extent
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, subject to approval by the Centers f or Medicare and
Medicaid Services. The directed payment methodology shall be found
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in Sections 3241.2 through 3241.4 of Title 63 of the Oklah oma
Statutes.
E. On or before January 31, 2023, the Authority shall submit a
report to the Oklahoma Health Care Authority Board, the Chair o f 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 implemented and authorized by state law, the
Authority shall propose to the Legislature any modifications
necessary to preserve supplementa l payments and managed care
directed payments to prevent budgetary disruptions to providers.
F. The Authority shall submit a report to the Governor, the
President Pro Tempore of the Oklahoma State Senate and the Speaker
of the Oklahoma House of Representatives that includes at a mi nimum:
1. A description of the selection process of the contracted
entities;
2. Plans for enrollment of Medicaid members in health plans of
contracted entities;
3. Medicaid member network access standards;
4. Performance and quality metrics;
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5. Maintenance of existing funding mechanisms described in thi s
section;
6. A description of the requirements and other provisions
included in capitated contra cts; 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 Medicaid Delivery System
Quality Advisory Committee for the purpose of pe rforming 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 Administrator of
the Oklahoma Health Care Author ity and the Oklahoma Health Care
Authority Board on quality measures used by managed care
organizations and dental benefit managers contracted entities in the
capitated managed care delivery model of the state Medicaid program .
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 participati ng
in the capitated managed care delivery model of the state M edicaid
program, and such providers may include memb ers of the Advisory
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Committee on Medical Care for Public Assistance Re cipients. Other
members shall include, but not be limited to, represent atives 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 includi ng, but not limited
to, statistics, economics or public policy .
3. The Committee shall select 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.
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 A uthority, the State Department
of Health, the Department of Me ntal Health and Substance Abuse
Services and the Dep artment of Human Services shall as requested
provide technical experti se, statistical information, and any ot her
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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, r eads 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 entitie s 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. Prior to implementation of the transformed Medicaid delivery
system, each contracted entity shall us e nationally recognized,
standardized provider quality metr ics as established by the O klahoma
Health Care Authority and, where applicable, may use additional
quality metrics if the mea sures are mutually agreed upon by the
Authority, the contracted entity , and participating provide rs. The
Authority shall develop p rocesses for determining qu ality metrics
and cascading quality metrics from contracted entities to
subcontractors and provide rs.
C. The Authority may use consultants, organiza tions, or
measures used by health plans, the federal government, or other
states to develop effective measu res for outcomes and quality
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including, but not limited to, the National Committee for Quality
Assurance (NCQA) or the Healthcare Effect iveness 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 application or Medicai d State Plan
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 with an average
commercial rate methodology. The directed payment methodo logy shall
be found in Sections 3241.2 through 324 1.4 of Title 63 of the
Oklahoma Statutes. Dental managed care shall be exempt from the
requirement of CMS approval of the d irected payment program .
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B. The Oklahoma Health Care Authority Board shall promul gate
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 preparation and development for
converting the present delivery of the Oklahoma Medicaid Program to
a managed care syste m. The system shall emphasize:
1. Managed care prin ciples, including a capitated, prepaid
system with either full or partial capitation, provided that highest
priority shall be given to development of prepaid capitated health
plans;
2. Use of primary ca re physicians to establish the appropriate
type of medical care a Medicaid recipient should receive; and
3. Preventative care.
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 Oklahoma Medicaid Program.
1. The Authority shall contract wi th the Department of Human
Services for the determinatio n of Medicaid eligibility and other
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administrative or operational functions related to the Oklahoma
Medicaid Program as necessary and appropriate.
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 Medical Services Division of the
Department of Human Services.
3. The Department of Human Services and the Authority shall
jointly prepare a transition plan for the transfer of the
administration of the Oklahoma Medicaid Program to the Authority.
The transition plan shall include provisions for the retraining and
reassignment of employees of the Department of Human Services
affected by the tran sfer. The transition plan shall be submitted to
the Governor, the President Pro Tempore of the Senate and th e
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
program conducted by the entity described in paragraph 7 of
subsection B of Section 6201 of Title 74 of the Oklahoma Statutes,
and to provide services to persons without regard to their ability
to pay, the Oklahoma Health Care Authority shall analyze the
feasibility of establishing a Medicaid reimbursement methodol ogy for
nursing facilities to provide a separate Medicaid payment rate
sufficient to cover all costs allowable under Medicare principles of
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reimbursement for the facility to be constructed or operated, o r
constructed and operated, by the organization descr ibed in paragraph
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 Me dical 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 representatives of the
health professions who are familiar with the medical needs of low-
income population groups a nd 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
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 limited to:
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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 represen ting one or more
behavioral health professions ;
3. The Director of the Department of Human Services or
designee;
4. The Commissioner of Mental Health 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
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 state .
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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
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.
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3. Members shall not receive any compensation for their
services but shall be reimbursed pursuant to the provisions of the
State Travel Reimbursement Act, Sectio n 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. AMENDATORY 36 O.S. 2021, Section 312.1, is
amended to read as follows:
Section 312.1 A. For the fiscal year ending June 30, 2004, the
Insurance Commissioner shall report and 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 the credit of the
Education Reform Revolving Fund of the State Department of
Education. The Insurance Commissioner 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 Commissioner 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 Section 624 of this title, which shall
be at least One Million Two Hundred Fifty Thousand Dollars
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($1,250,000.00) each year, but which shall also be computed on an
annual basis by the Commissioner as the amount of insurance premi um
tax revenue loss attributable 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 s hall be paid to the Oklahoma
Firefighters Pension and Retirement Fund in the manner provided for
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 t he Oklahoma 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
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FY 2006 through FY 2020 26.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the month ending
August 31, 2020 26.0%
b. for the month beginning September
1, 2020, through the month ending
June 30, 2021 18.2%
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
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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 tax es collected under Section 624 of this title
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 the manner provided f or in Sections
49-119, 49-120 and 49-123 of Title 11 of the Oklahoma 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 Statutes;
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 be paid to the State Treasurer to
the credit of the General Revenue Fund of the state to provide
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revenue for general functions of state govern ment. The Insurance
Commissioner shall keep an ac curate record of all such funds and
make an itemized statement and furnish same to the State Auditor a nd
Inspector, as to all other departments of this state. The report
shall be accompanied by an affidavi t of the Insurance Commissioner
or the Chief Clerk of such office certifying to the correctness
thereof.
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 co llected under Section 624 of this 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 provided 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%
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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
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 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 September
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:
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Fiscal Year Amount
FY 2006 through FY 2020 5.0%
FY 2021 as follows:
a. for the month beginning July 1,
2020, through the mo nth ending
August 31, 2020 5.0%
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 pa ragraphs
1, 2 and 3 of this subsection, of the tax es collected on premiums
the following amounts shall be allocated and disbursed annually for
FY 2023 through FY 2027:
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a. Forty Thousand Six Hundred Twenty-five Dollars
($40,625.00) to the Oklahoma Firefight ers Pension and
Retirement Fund,
b. Sixteen Thousand Two Hundred Fifty Dollars
($16,250.00) to the Oklahoma Police Pension and
Retirement System, and
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 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 t he Insurance 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 t he Governor, the Speaker of the House of
Representatives, the President Pro Tempore of the Senate and the
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State Auditor and Inspector, the amounts colle cted and disbursed
pursuant to this section.
F. Notwithstanding any other provision of law to the contr ary,
no tax credit authorized by law enacted on or after July 1, 2008,
which may be used to reduce any insurance premium tax liability
shall be used to reduce the amount of insurance premium tax revenue
apportioned to the Oklahoma Firefighters Pension and Retirement
System, the Oklahoma Police Pension and Retirement System, the
Oklahoma Law Enforcement Retirement System or the Education Reform
Revolving Fund.
G. For fiscal year 2023, and eac h subsequent fiscal year,
before any other apportionment otherwise required 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 c ontracted entities of the
Ensuring Access to Medic aid program of the Oklahoma Health Care
Authority for funding for the Medicaid Expansion Program .
SECTION 23. RECODIFICATION 56 O.S. 2 021, Section 4004,
as amended by Section 19 of this act, shall be recodified as Section
4002.15 of Title 56 of the Oklahoma Statutes, unless there is
created a duplication in numbering.
SECTION 24. REPEALER 5 6 O.S. 2021, Sections 101 0.2,
1010.3, 1010.4, and 1010.5, are hereby repea led.
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SECTION 25. REPEALER 56 O.S. 2021, Sections 4002.3 and
4002.9, are hereby repealed.
SECTION 26. REPEALER 63 O.S. 2021, Sections 5009.5,
5011, and 5028, are hereby repealed.
SECTION 27. This act shall become effective July 1, 2022.
SECTION 28. 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 ac t shall take effect and
be in full force from and after its passage and approval.
SECTION 29. This act shall become effective only if Engrossed
Senate Bill No. 1396 of the 2nd Session of the 58th Oklahoma
Legislature is enacted into law."
Passed the House of Representatives the 28th day of April, 2022.
Presiding Officer of the House of
Representatives
Passed the Senate the ____ day of _______ ___, 2022.
Presiding Officer of the Senate
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ENGROSSED SENATE
BILL NO. 1337 By: McCortney of the Senate
and
McEntire of the House
[ 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 adjudicati on of claims
- readiness review - scorecard – provider
reimbursement - capitation rates - supplemental
payments – reports – advisory committee - measures
and goals - federal approval - recodification –
repealers - codification - effective date ]
BE IT ENACTED BY THE PEOP LE OF THE STATE OF OKLAHOMA:
SECTION 30. 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 duplication in numbering, reads as follows :
It is the intent of t he Legislature to transform t he state’s
current Medicaid program to provide budget pr edictability for the
taxpayers of this state while ensuring quality care to those in
need. The state Medicaid program shall be designed to achieve the
following goals:
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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 member
satisfaction;
4. Ensure efficient and cost-effective administrative systems
and structures; and
5. Ensure a sustainable delivery syste m that is a provider-led
effort and that is operated and managed by providers to the maximum
extent possible.
SECTION 31. AMENDATORY 56 O.S. 2021, Section 4002.2, is
amended to read as follows:
Section 4002.2. As used in this act the Ensuring Access to
Medicaid Act:
1. “Adverse determination” has the same meaning as provided by
Section 6475.3 of Title 3 6 of the Oklahoma Statutes ;
2. “Claims denial error rate” means the rate of claims denials
that are overturned on a ppeal; “Accountable care organization” means
a network of physicians, hospitals, and other health care providers
that provides coordinated c are to Medicaid members;
2. “Capitated contract” means a contract between the Oklahom a
Health Care Authority and a contracted entity for delivery of
services to Medicaid members in which the Authority pays a fixed,
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per-member-per-month rate based on actuarial calculations as
provided by Section 4002.12 of this title;
3. “Clean claim” means a properly completed billing form with
Current Procedural Terminology, 4th Edition or a more recent
edition, the Tenth R evision of the International Classification of
Diseases coding or a more recent revision, or Hea lthcare Common
Procedure Coding System coding where applicabl e that contains
information specifically required in the Provider Billing and
Procedure Manual of t he Oklahoma Health Care Authority;
4. “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 and state laws and regulations;
5. “Contracted entity” means an organization or entity that
enters into or will enter into a capitated contract with the
Oklahoma Health Care Authority for the delivery of services
specified in this act that will assume financial risk, operational
accountability and state wide or regional functionality as defined in
this act in managing comprehensive health outcom es of Medicaid
members. For purposes of this act, the term contracted entity
includes an accountable care organization, a provider-led entity, a
commercial plan, or a dental benefit manager, or any other entity as
determined by the Authority;
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6. “Dental benefit manager” means an entity under contract with
the Oklahoma Health Care Authority to manage and deliver dental
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. 7. “Essential community provider” has the same meaning as
provided by means:
a. a Federally Qualified Health Ce nter,
b. a community mental health center,
c. an Indian health care provider,
d. a rural health clinic,
e. a state operated mental health hospital ,
f. a long term care hospital serving children (LTCH-C),
g. a teaching hospital owned, jointly owned, or
affiliated with and designated by the Univ ersity
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
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(2) a hospital or health care entity directly or
indirectly owned or operat ed by the University
Hospitals Trust or the Oklahoma State University
Medical Trust,
i. a county department of health, district department of
health, cooperative department of health, or city-
county health department,
j. a comprehensive community addiction recovery center,
k. any additional Medicaid provider as approved by the
Authority if the provid er either offers services that
are not available from any other p rovider 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 t he region is insuffi cient
to meet the total needs of the Medicaid members, or
l. 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 A uthority to participate in
and deliver benefits and services to enrollees of the capitated
managed care delivery model of the state Medicaid program ;
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7. “Material change” includes, but is not limited to, any
change in overall business operations such as p olicy, process or
protocol which affects, or can reasonably be expected to affect,
more than five percent ( 5%) of enrollees or participating provide rs
of the managed care organization or dental benefit manager;
8. “Local Oklahoma provider organization ” means any state
provider association, accountable care organizati on, certified
community behavioral health clinic , federally qualified health
center, Native American tribe or tribal association, hospital or
health system, academic medical institution, licensed provider
currently practicing, foster child or parent associatio ns, or other
local Oklahoma provider organization as approved by Authority;
9. “Medical necessity” has the same meaning as provided by
rules of promulgated by the Oklahoma Health Care Authority Board ;
9. 10. “Participating provider” means a provider who has a
contract with or is employ ed 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. 11. “Provider” means a health care or dental provider
licensed or certified in this state;
12. “Provider-led entity” means an organization or entity that
meets the following criteria:
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a. a majority of the entity’s ownership is held by
Medicaid providers in this state or is held by an
entity that directly or indirectly owns or is under
common ownership with Medicaid providers in this
state, and
b. a majority of the entity ’s governing body is c omposed
of individuals who:
(1) have experience serving Medicaid members and:
(a) are licensed in this state as physicians,
physician assistants, nurse practitio ners,
or licensed behavioral health providers, or
(b) are employed by:
i. a hospital, long-term care facility or
other medical facility licensed 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 state and operating
in this state,
(2) represent the providers or facilities described
in division 1 of this subparagraph including but
not limited to individuals who are employed by a
statewide provider associa tion, or
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(3) are nonclinical administrators of clinical
practices serving Medicaid members;
13. “Statewide” means all counties of this state including the
urban region; and
14. “Urban region” means all counties of this state wi th a
county population of not less than five hu ndred thousand (500,000),
combined into one re gion.
SECTION 32. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.3a of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. 1. The Oklahoma Health Care Authority shall enter into
capitated contracts with contracted entities for the delivery of
Medicaid services as specified in this act to transform the delivery
system of the state Medicaid program for the Medicaid populations
listed in this section.
2. The Authority shall not issue any request for proposals or
enter into any contract to transform the delivery system of the
state Medicaid program for any Medicaid population that is not
expressly included in this section.
B. 1. No later than January 1, 2023, the Oklahoma Health Care
Authority shall issue a request for proposals to enter into public-
private partnerships with contracted entities other than dental
benefit managers to cover all Medicaid services other than dental
services for the following Medicaid populations:
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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
primary care,
b. behavioral health services, and
c. prescription drug services.
C. 1. No later than January 1, 2023, the Authority shall is sue
a request for proposals to enter into public-private partnerships
with dental benefit managers to cover dental services for the
following Medicaid populations:
a. pregnant women,
b. children,
c. parents and caretaker relatives,
d. the expansion population, and
e. members of the Children ’s Specialty Plan as provided
by subsection D of this section.
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2. The Authority shall specify the servic es to be covered in
the request for proposals referenced in paragraph 1 of this
subsection.
D. 1. No later than January 1, 2023, either as part of the
request for proposals referenced in subsection B of this section or
as a separate request for proposals, the Authority shall issue a
request for proposals to enter into public-private partnerships with
one contracted entity to administer a Children’s Specialty Plan that
covers all Medicaid services other than dental services and is
designed to provide care to:
a. children in foster care and former foster c are
children up to age twenty-five (25),
b. juvenile justice involved children, and
c. children receiving adoption assistance.
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 manag ers who cover dental
services for its members as provided by subsection C of this
section.
SECTION 33. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.3b of Title 56, unless
there is created a dup lication in numbering, reads as follows:
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A. All capitated contracts shall be the result of req uests for
proposals issued by the Oklahoma Health Care Authority and
submission of competitive bids by contracted entitie s pursuant to
the Oklahoma Central Purch asing Act.
B. Statewide capitated contracts 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 heal th
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 Section
3 of this act.
D. 1. Except as specified in paragraph 2 of this subsection,
at least one capitated contract to provide statewide coverage to
Medicaid members shall be awarded to a provider-led entity, as long
as the provider-led entity submits a responsive re ply to the
Authority’s request for proposals demonstrating ability 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 n ot be required to
contract for statewide coverage to a provider-led entity.
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3. The Authority shall develop a scori ng methodology for the
request for proposals that affords preferential scoring to provider-
led entities, as long as the provider-led entity otherwise
demonstrates ability to fulfill the contract requirements. The
preferential scoring methodology shall inc lude opportunities to
award additional points to provider-led entities based on certain
factors including but not limited to:
a. broad provider participation in ownership and
governance structure,
b. demonstrated experience in care coordination and care
management for Medicaid members across a variety of
service types including but not limited to primary
care and behavioral health,
c. demonstrated experience in Medicare accountable care
organizations or other Medicare alternative payment
models, Medicare value-based payment arrangements, or
Medicare risk-sharing arrangements including but not
limited to innovation models of t he Center for
Medicare and Medicaid Innovation of the Centers for
Medicare and Medicaid Services, or value-based payment
arrangements or risk-sharing arrangements in the
commercial health care market ,
d. demonstrated experience in improving health outcomes
for Medicaid members, and
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e. other relevant factors identified by the Authority.
E. The Authority may select at least one provider-led entity
for the urban region if:
1. The provider-led entity submits a responsive reply to the
Authority’s request for proposals 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 specified in the request for proposals.
F. At the discretion of the Authority, capitated contracts may
be extended to ensure against gaps in coverage that may result from
termination of a capitated contract; provided, the total contracting
period for a capitated contract shall not exceed seven (7) years.
G. At the end of the contracting 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, subjec t to appropriate
notice to the Legislature 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 fi nancial and operational
readiness.
SECTION 34. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.3c of Title 56, unless
there is created a duplication in numbering, reads as follows:
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A. The Oklahoma Health Care Authority shall require each
contracted entity to ensure that Medicaid members who do not elect a
primary care provider are assigned to a provider, prio ritizing
existing patient-provider relationships.
B. The Authority shall d evelop and implement a process for
assignment of Medicaid members to contracted entities.
C. The Authority may only utilize an opt -in enrollment process
for the voluntary enro llment of American Indians and Alaska Natives.
D. In the event of the termination of a capitated contract with
a contracted entity during the contract d uration, 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 members, the Authority
may select another contracted entity by application, as specified in
rules promulgated by the Okla homa Health Care Authority Board, if
the financial, operation and performance requirements can be met, at
the discretion of the Authori ty.
SECTION 35. 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
organizations and dental benefit managers contracted entities that,
at a minimum, meet the req uirements of 42 C.F.R., Sections 438.14
438.3 and 438.68. Network adequacy standards established under this
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subsection shall be designed to ensure enrollees covered by the
managed care organizations and dental benefit managers who reside in
health professional shortage areas (HPSAs) designated under Section
332(a)(1) of the Public Health Service Act (42 U.S.C., Section
254e(a)(1)) have access to in-person health care and telehealth
services with providers, especially adult and pediatric primary care
practitioners.
B. All managed care organizations and dental benefit managers
shall meet or exceed network adequacy standards established by the
Authority under subsection A of this section to ensure sufficient
access to providers for enrollees of the state Medicaid program.
C. All managed care organizations and dental benefit managers
shall The Authority shall require all contracted entities to
contract to the extent possible and practicable with all essential
community providers, all providers who receive dire cted 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 prohibi t contracted entities
from excluding essential community providers, providers who receive
directed payments in accordance with 42 C.F.R., Part 438 and such
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, each contracted entity must contract with at
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least one essential community provider for a model of care
containing care coordination, care management, utilization
management, disease m anagement, network management, or another mode l
of care as approved by Authority. Such contractual arrangements
must be in place within eighteen (18) months of the effective date
of the contracts awarded pursuant to the requests for proposals
authorized by Section 3 of this act.
D. All managed care organizations and dental benefit managers
contracted entities shall formally credential and recredential
network providers at a frequency required by a single, consolidated
provider enrollment and credentialing process established by the
Authority in accordance with 42 C.F.R., Section 438.214.
E. All managed care organizations and dental benefit managers
contracted entities shall be accredited in accordance wit h 45
C.F.R., Section 156.275 by an accrediting entity recognized by the
United States Department of Health an d Human Services.
F. 1. If the Oklahoma Health Care Authority awards a capitated
contract to a provider-led entity for the urban region under Sec tion
4 of this act, the provider-led entity shall, as provided by the
contract with the Authority, expand its coverage area beyond the
urban region to counties for which the provider-led entity can
demonstrate evidence of network adequacy as required under 42
C.F.R., Sections 438.3 and 438.68 and as approved by Authority. If
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approved, the additional county or counties shall be added to the
urban region during the next open enrollment period.
2. As provided by S ection 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 within the time fr ame
specified by such contract.
3. If the Authority awards a capitated contract to a provider-
led entity for the urban region under Section 4 of this act, the
provider-led entity must include in its network all providers in the
coverage area that are design ated as essential community providers
by the Authority, unless the Authority approves an alternat ive
arrangement for securing the types of services offered by the
essential community providers.
SECTION 36. NEW LAW A new section of la w to be codified
in the Oklahoma Statutes as Section 4002.4a of Title 56, unless
there is created a duplication in numbering, 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 requir ements as defined in the
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requests for proposals issued pursuant to Section 3 of this act.
Such requirements shall include but not be limited to reimbursement
and capitation rates, insurance reserve requirements as specified by
the Insurance Department, ac ceptance of risk as defined by the
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 bu t not limited to the
requirements stipulated in t his section.
B. The Authority shall develop methods to ensure program
integrity against provider fraud, waste, and abuse .
C. The Authority shall develop processes for providers and
Medicaid members to report violations by contracted entities of
applicable administrative rules, state law or federal law.
SECTION 37. AMENDATORY 56 O.S. 2021, Section 4 002.5, is
amended to read as follows:
Section 4002.5. A. A contracted entity shall be responsible
for all administrative functions fo r members enrolled in its plan
including but not lim ited to claims processing, authorization of
health services, care and case management, grievances and appeals,
and other necessary administrati ve services.
B. A contracted entity shall hold a certificate of authority as
a health maintenance organization i ssued by the Insurance
Department.
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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 tha t includes:
a. representatives of local Oklahoma provider
organizations who are Medicaid providers,
b. essential community providers, and
c. a representative from a teaching hospital owne d,
jointly owned, or affiliated with and designated by
the University Hospitals Authority, University
Hospitals Trust, Oklahoma State Univ ersity 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 comprised of representatives of local
Oklahoma provider organizations .
3. No less than two member s of the contracted entity’s clinical
and quality committees shall be representatives of local Oklahoma
provider organizations , and the committees shall be chaired or 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 affecting the delivery of care or the administration of
its program.
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B. E. A managed care organization or dental be nefit manager
contracted entity shall have a medical loss ratio that me ets the
standards provided by 42 C.F.R., Section 438.8.
C. F. A managed care organization or dental be nefit manager
contracted entity shall provide patient data to a provider upon
request to the extent allowed under federal or state laws, rules or
regulations including , but not limited to, the Health Insurance
Portability and Accountability Act of 1996.
D. G. A managed care organizat ion 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 requires 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 accountable 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 establ ished
by the Authority; and
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2. Ensure broad access to pharmacie s including but not limited
to pharmacies contracte d with covered entities under Section 340 B of
the Public Health Service Act. Such access shall, at a minimum,
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 th e state designated entity for health
information exchange to ensure effective systems and connect ivity to
support clinical coordination of care, the exchange of information,
and the availability of data to the Authority to manage the state
Medicaid program.
SECTION 38. 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 authorizations. The
Authority shall establish requirements that ensure timely
determinations by contracted entitie s when prior authorizations are
required including expedited review in urgent and emergent cases
that at a minimum meet the criteria of this section.
B. A contracted entity shall make a determination on a request
for an authorization of the transfer of a hospital inpatient to a
post-acute care or long-term acute care facility within twenty-four
(24) hours of receipt of the request.
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B. Review and issue determinations made by a managed care
organization or, as appropriate, by a dental benefit manager for
prior authorization for care ordered by primary care or specialist
providers shall be timely and shall occur in accordance with the
following:
1. Within seventy-two (72) hours of receipt of the
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 provi der 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 inpatient s ervices 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
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determination on a request as expeditiously as necessary and, in any
event, within twenty -four (24) hours of receipt of the request for
service if adhering to the provisions of paragraphs 1 or 2 of this
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 emergent matter, the
managed care organization or dental benefit manager contracted
entity shall not impose lim itations on providers 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 r equired 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 authorizatio n on any covered prescription
drug for which the Authority does not require prior authorization.
C. Upon issuance of an adverse determination on a prior
authorization request under subsection B of this sectio n, the
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managed care organization or dental bene fit manager shall provide
the requesting provider, within seventy-two (72) hours of receipt of
such issuance, with reasonable opportunity to participate in a peer-
to-peer review process with a provider who pra ctices in the same
specialty, but not necessari ly the same sub-specialty, and who has
experience treating the same population as the patient on whose
behalf the request is submitted; provided, however, if the
requesting provider determines the services to be clinically urgent,
the managed care organiza tion 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 peer-to-
peer review.
D. 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 benefit manager.
H. The Authority shall establish r equirements for both in ternal
and external reviews and appeals of adverse determinations on prior
authorization reques ts 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 entities to provide a prompt opport unity
for peer-to-peer conversations upon adverse de termination; and
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3. Establish uniform rules for Medicaid provider or member
appeals across all contracted entities.
SECTION 39. 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 adju dication of claims that
ensure prompt reimbursement of providers by contracted entities . A
contracted entity shall comply with the following requirements with
respect to processing and adjudication of claims for payment
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 organizati on 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 benefit 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 wi thin six (6)
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months of the date the item or se rvice was furnished to an enrollee
a member shall be considered timely. If a claim meets the
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 manager
contracted entity may request medical records if additional
documentation is needed to review the clai m 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 b y which
the provider may identify and provide such additional informatio n 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
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1. Subject to subparagraph b of this paragraph, in sofar as a
managed care organization or den tal benefit 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 percentage of
claims 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 financial
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 denial error
rate of greater than five percent (5%). The Authority shall
establish the amount of financial penalties and the time frame under
which such penalties sha ll be imposed on managed care organizations
and dental benefit managers contracted entities under this
subparagraph, in no case less than annually; and.
4. E. A managed care organization contracted entity may only
apply readmission penalties pursuant to ru les promulgated by the
Oklahoma Health Care Authority Board. The Board shall promulgate
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rules establishing a program to reduce potentially preventable
readmissions. The program shall use a nationally recognized tool,
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 40. AMENDATORY 56 O.S. 2021, Section 4002.10, is
amended to read as follows:
Section 4002.10. A. The Oklahoma Health Care Authority shall
require a managed care organization or dental benefit manager all
contracted entities to participate in a readiness rev iew in
accordance with 42 C.F.R., Section 4 38.66. The readiness review
shall assess the ability and capacity of the managed care
organization or dental 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 read iness review shall asses s
whether:
1. The managed care organization or dental benefit manager has
entered into contracts with providers to the extent necessary to
meet network adequacy standards prescribed b y Section 4 of this act;
2. The contracts descr ibed in paragraph 1 of t his subsection
offer, but do not require, value-based payment arrangements as
provided by Section 12 of this act; and
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3. The managed care organization or dental benefit manager and
the providers described in paragraph 1 of this sub section have
established and tested data infrastructure such that exchange of
patient data can reasonably be expected to occur within one hundred
twenty (120) calendar days of execution of the transition of the
delivery system described in subsection B of this section. The
Authority shall assess its ability to f acilitate the exchange of
patient data, claims, coordination of benefits and oth er components
of a managed care delivery model.
B. The Oklahoma Health Car e Authority may only execute the
transition of the delivery system of the state Medicaid program to
the capitated managed care delivery model of the state Medicaid
program ninety (90) days after the Centers for Medicare and Medicaid
Services has approved all contracts entered into between the
Authority and all managed care organizations and dental benefit
managers following submission of the readiness reviews to the
Centers for Medicare and Medicaid Services.
SECTION 41. 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 transition 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
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dental benefit managers manager. The scorecard shall report the
average speed of authorizations of services, rates of denials of
Medicaid reimbursable services when a complete authorizatio n request
is submitted in a timely manner, enrollee member 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 prior 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 the most recent quarterly
scorecard to all enrollees members at the beginning of each
enrollment period. The Authority shall publish each quarterly
scorecard on its public Internet website.
SECTION 42. AMENDATORY 56 O.S. 2021, Section 4002.12, is
amended to read as follows:
Section 4002.12. A. The Oklahoma Health Care Authority shall
may establish minimum rates of reimbursement from managed care
organizations and dental benefit managers contracted entities to
providers who elect not to enter into value-based payment
arrangements under subsection B of this section or other alternative
payment agreements for health care items and services furnished by
such providers to enrollees of the state Medicaid program. Until
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July 1, 2026, such reimbursement rates shall be equal to or greater
than:
1. For an item or service provided by a participating provider
who is in the network of the managed care organization or dental
benefit manager, one hundred percent (100%) of t he reimbursement
rate for the applicable service in the applicable fee schedule of
the Authority; or
2. For an item or service provided by a non-participating
provider or a provider who is not in the network of the managed care
organization or dental bene fit manager, ninety percent (90%) of the
reimbursement rate for the applicable service in the applicable fee
schedule of the Authority as of January 1, 2021.
B. A managed care organization or dental benefit manager shall
offer value-based payment arrangements to all providers in its
network capable of entering into value-based payment arrangements.
Such arrangements shall be optional for the provider. The quality
measures used by a managed care organization or dental benefit
manager to determine reimburs ement amounts to providers in value-
based payment arrangements shall align with the quality measures of
the Authority for managed care organizations or dental benefit
managers.
C. Notwithstanding any other provision of this section, the
Authority shall comply with payment methodologies required by
federal law or regulation for specific types of providers including,
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but not limited to, Federally Qualified Health Centers, rural health
clinics, pharmacies, Indian Health Care Providers and emergency
services Medicaid members.
B. The Authority shall specify in the requests for proposals a
reasonable time frame in which a contracted entity shall have
entered into a certain percentage, as determined by the Authority ,
of value-based contracts with providers.
C. Capitation rates established by the Oklahoma Health Care
Authority and paid to contracted entities under capitated contracts
shall be:
1. Actuarily sound. Actuarial calculations must include
assumptions consistent w ith industry and local standards ; and
2. Risk-adjusted and shall include a po rtion that is at risk
for achievement of quality and outcomes measures.
D. The Authority may estab lish a symmetric risk corridor for
contracted entities.
SECTION 43. NEW LAW A new section of law to be codified
in the Oklahoma Statut es as Section 4002.12a of Title 56, unless
there is created a duplication in numbering, reads as follows:
A. The Oklahoma Health Care Authority shall ensure the
sustainability of the transformed Medicaid delivery system.
B. The Authority shall ensure tha t existing revenue sources
designated for the state share of Medicaid expenses are designed to
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maximize federal matching f unds for the benefit of providers and the
state.
C. The Authority shall develop a plan, utilizi ng waivers or
Medicaid state plan amendments as necessary, to preserve or increa se
supplemental payments available to providers with existing revenue
sources as provided in the Oklahoma Statutes including but not
limited to:
1. Hospitals that participate in the Supplemental Hospital
Offset Payment Program as provided by Section 3241.3 of Title 63 of
the Oklahoma Statutes;
2. Hospitals in this state that have Level I trauma centers as
defined by the American College of Surgeo ns that provide inpatient
and outpatient services and are owned or operated by the University
Hospitals Trust, or affiliates 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 otherwise a
member of the faculty practice plan of :
a. a public, accredited Oklahoma medical s chool, or
b. a hospital or health care entity directly or
indirectly owned or op erated by the University
Hospitals Trust or the Oklahoma State University
Medical Trust.
D. Subject to approval by the Centers for Me dicare and Medicaid
Services, the Authority shall preserve and, to the maximum extent
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permissible under federal law, impro ve existing levels of funding
through directed payments or other mechanisms outside the capitate d
rate to contracted entities including where applicable the use of an
average commercial rate methodology.
E. On or before January 31, 2023, the Authority shall submit a
report to the Oklahoma Health Car e Authority Board, the Chair of the
Senate Appropriations Committee, and the Chair of the House
Appropriation and Budget Committee that includes the Authority’s
plans to continue or enhance all suppleme ntal payment programs under
the reforms provided for i n this act. If Medicaid-specific funding
cannot be maintained as current ly implemented and authorized by
state law, the Authority shall propose to the Legislature any
modifications necessary to preserve supplem ental payments and
minimize budgetary disruptions to providers.
F. On or before July 1, 2023, the Authority shall submit a
report to the Governor, the President Pro Tempore o f the Senate and
the Speaker of the House of Representatives that includes at a
minimum:
1. A description of the selection process of the contracted
entities;
2. Plans for enrollment of Medicaid members in health plans of
contracted entities;
3. Medicaid member network access standards;
4. Performance and quality metrics ;
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5. Maintenance of existing funding mechanisms described in this
section;
6. A description of the requir ements and other provisions
included in capitated contracts; and
7. A full and complete copy of each executed capitated
contract.
SECTION 44. 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 Medicaid 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 Ad ministrator of
the Oklahoma Health Care Authori ty and the Oklahoma Health Care
Authority Board on quality measures used by managed care
organizations and dental benefit managers contracted entities in the
capitated managed care delivery model of the state Medicaid program
and to monitor the implementat ion of and adherence to such quality
measures.
C. 1. The Committee shall be comprised of members appointed by
the Administrator of the Oklahoma Health Care Authority. Members
shall serve at the pleasu re of the Administrator.
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2. A majority of the members shall be providers participating
in the capitated managed care delivery model of the state Medicaid
program, and such providers may include members of the Advisory
Committee on Medical Care for Public Assistance Recipients. Other
members shall include, but not be limited to, representatives of
hospitals and integrated health systems, other members of the health
care community, and members of the academic community having
subject-matter expertise in the field of health care or subfields of
health care, or other applicable fields including, but not limited
to, statistics, economics or public policy .
3. The Committee shall select from among its membership a chair
and vice chair.
E. D. 1. The Committee may meet as often as may be required in
order to perform the duties imposed on it.
2. A quorum of the Committee shall be required to approve any
final action recommendations of the Committee. A majority of the
members of the Committee shall constitute a quorum.
3. Meetings of the Committee shall not be subject to the
Oklahoma Open Meeting Act.
F. E. Members of the Committee shall receive no compensation or
travel reimbursement .
G. F. The Oklahoma Health Care Authority shall provide staff
support to the Committee. To the extent allowed under federal or
state law, rules or regulations, the Authority, the State Department
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of Health, the Department of Mental Health and Substance Abuse
Services and the Department of Human Services shall as requested
provide technical expertise, statistical information, and an y other
information deemed necessary by the chair of the Committee to
perform the duties imposed on it.
SECTION 45. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4002.14 of Title 56, unless
there is created a dupli cation in numbering, reads as follows:
A. The transformed delivery system of the state 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 outcom es, quality of care, member
satisfaction, access to care, network adequacy, and cost.
B. Each contracted entity shall use nationally recognized,
standardized provider quality metrics as established by the Oklahoma
Health Care Authority and, where applicab le, may use additional
quality metrics if the measures are mutu ally agreed upon by the
Authority, the contracted entity and participating providers. The
Authority shall develop processes for determining quality metrics
and cascading quality metrics from contracted entities to
subcontractors and providers.
C. The Authority may use consultants, organizations, or
measures used by organizations, health plans, the federal
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government, or other stat es to develop effective measures for
outcomes and quality including but not limited to the National
Committee for Quality Assurance (NCQA) or the Healthcare
Effectiveness Data and Info rmation Set (HEDIS) established by NCQA,
the Physician Consortium for Pe rformance 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 measu res
including but not limited to penalties for noncompliance.
SECTION 46. 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 necess ary to implement this act the Ensuring
Access to Medicaid A ct. This shall include, but not be limited to,
submission to the Centers for Medicare and Medicaid Service s of any
appropriate demonstration waiver application or Medicaid state plan
amendment necessary to accomplish the requirements of this act
within the required timeframes.
B. The Oklahoma Health Care Au thority Board shall promulgate
rules to implement this act the Ensuring Access to Med icaid Act.
SECTION 47. 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
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assume the responsibilities for the preparation and development for
converting the present delivery of the Oklahoma Medicaid Progr am to
a managed care system. The system shall emphasize:
1. Managed care principles, including a capit ated, prepaid
system with either full or partial capitation, provided that highest
priority shall be given to development of prepaid capitated health
plans;
2. Use of primary care physicians to establish the app ropriate
type of medical care a Medicaid rec ipient should receive; and
3. Preventative care.
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 Oklahoma Medicaid Program.
1. The Authority shall contract with the Department of Human
Services for the determination of Medicaid eligibility and othe r
administrative or operational functions re lated to the Oklahoma
Medicaid Program as necessary and appropriate.
2. To the extent pos sible and appropriate, upon the transfer of
the administration of the Oklahoma Medicaid Program, the Authority
shall employ the personnel of the Medical Services Divi sion of the
Department of Human Services.
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3. The Department of Human Services and the Aut hority shall
jointly prepare a transition plan for the transfe r of the
administration of the Oklahoma Medicaid Program to the Authority.
The transition plan shall in clude provisions for the retraining and
reassignment of employees of the Department of Hum an Services
affected by the transfer. The transition plan sha ll be submitted to
the Governor, the President Pro Tempore o f 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
program conducted by the entity described in paragraph 7 of
subsection B of Section 6 201 of Title 74 of the Oklahoma Statutes,
and to provide services to persons without regar d to their ability
to pay, the Oklahoma Health Care Authority shall analyze the
feasibility of establishing a Medicaid rei mbursement methodology for
nursing facilities to provide a separate Medicaid payment rate
sufficient to cover all costs allowable unde r Medicare principles of
reimbursement for the facility to be constructed or operated, or
constructed and operated, by the organization described in paragraph
7 of subsection B of Section 6201 of Title 74 of the Oklahoma
Statutes.
SECTION 48. AMENDATORY 25 O.S. 2021, Section 304, is
amended to read as follows:
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Section 304. As used in the Oklaho ma Open Meeting Act:
1. “Public body” means the governing bodies of all
municipalities located within this state, boards of county
commissioners of the counties in this state, boards of public and
higher education in this state and all boards, bureaus, co mmissions,
agencies, trusteeships, authorities, co uncils, committees, public
trusts or any entity created by a public trust , including any
committee or subcommittee composed of any of the members of a public
trust or other legal entity receiving funds from the Rural Economic
Action Plan Fund as authorized by Section 2007 of Title 62 of the
Oklahoma Statutes, task forces or study groups in this state
supported in whole or in part by public funds or entrusted with the
expending of public funds, or administeri ng public property, and
shall include all committe es or subcommittees of any public body .
Public body shall not include the state judic iary, the Council on
Judicial Complaints when conducting, discussing, or d eliberating any
matter relating to a complaint received or filed with the Council,
the Legislature, or administrative staffs of public bodies,
including, but not limited to, faculty meetings and athletic staff
meetings of institutions of higher education w hen those staffs are
not meeting with the publ ic body, or entry-year assistance
committees. Furthermore, public body shall not includ e the
multidisciplinary teams provided for in Se ction 1-9-102 of Title 10A
of the Oklahoma Statutes and subsection C of Se ction 1-502.2 of
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Title 63 of the Oklahoma Stat utes or any school board meeting for
the sole purpose of considering recommendations of a
multidisciplinary team and deciding the placem ent of any child who
is the subject of the recommendations. Furthermore, public body
shall not include meetings conduct ed by stewards designated by the
Oklahoma Horse Racing Commission pursuant to Section 20 3.4 of Title
3A of the Oklahoma Statutes when th e stewards are officiating at
races or otherwise enforcing rules of the Co mmission. Furthermore,
public body shall not include the board of directors of a Federally
Qualified Health Center. Furthermore, public body shall not include
the Medicaid Delivery System Quality Advisory Committee of the
Oklahoma Health Care Authority created in Section 4002.13 of Title
56 of the Oklahoma Statutes;
2. “Meeting” means the conduct of business of a public body by
a majority of its members being personally together or , as
authorized by Section 307.1 of this title, together pursuant to a
videoconference. Meeting shall not include infor mal gatherings of a
majority of the members of the public body when no business of the
public body is discussed;
3. “Regularly scheduled meeting” means a meeting at which the
regular business of the public bod y is conducted;
4. “Special meeting” means any meeting of a public body other
than a regularly scheduled meeting or emergency meeting ;
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5. “Emergency meeting” means any meeting call ed for the purpose
of dealing with an emergency. For purposes of the Okla homa Open
Meeting Act, an emergency is defined as a situation involving injury
to persons or injury and damage to public or personal p roperty or
immediate financial loss when the tim e requirements for public
notice of a special meeting would make such proc edure impractical
and increase the likelihood of injury or damage or immediate
financial loss;
6. “Continued or reconvened meeting ” means a meeting which is
assembled for the purpos e of finishing business appearing on an
agenda of a previous meeting. For the purposes of the Oklahoma Open
Meeting Act, only matters on the agenda of the previous meeti ng at
which the announcement of the co ntinuance is made may be discussed
at a continued or reconvened meeting;
7. “Videoconference” means a conference among me mbers of a
public body remote from one another who are linked by interactive
telecommunication devices or technology and/or technology permitting
both visual and auditory communicati on between and among members of
the public body and/or between and among m embers of the public body
and members of the p ublic. During any videoconference, both the
visual and auditory communications function s shall attempt to be
utilized; and
8. “Teleconference” means a conference among members of a
public body remote from one another who are linked by
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telecommunication devices and/or technology permitting auditory
communication between and among members of the public body and/or
between and among members of the public body and members of the
public.
SECTION 49. RECODIFICATION 56 O.S. 2021, Section 4004,
as amended by Section 17 of this act, shall be recodified as Section
4002.15 of Title 56 of the Oklahoma Statutes, unless there is
created a duplication in numbering.
SECTION 50. REPEALER 56 O.S. 2021, Sections 1010.2
1010.3, 1010.4, and 1010.5, are hereby repealed.
SECTION 51. REPEALER 56 O.S. 2021, Sections 4002.3,
4002.8, and 4002.9, are hereby repealed.
SECTION 52. REPEALER 63 O.S. 2021, Sections 5009.5,
5011, and 5028, are hereby repealed.
SECTION 53. This act shall become effective November 1, 2022.
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Passed the Senate the 23rd day of March, 2022.
Presiding Officer of the Senate
Passed the House of Representatives the ____ day of __________,
2022.
Presiding Officer of the House
of Representatives