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ENGROSSED HOUSE
BILL NO. 1650 By: McEntire of the House
and
Haste of the Senate
An Act relating to managed care; amending 56 O.S.
2021, Section 4002.12, as last amended by Section 2,
Chapter 334, O.S.L. 2022 (56 O.S . Supp. 2022, Section
4002.12), which relates to minimum rates of
reimbursement; extending the date the Oklahoma Health
Care Authority shall e stablish minimum rates of
reimbursement; adding reimbursement fee schedule
relating to anesthesia; and providing an effective
date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.12, as
last amended by Section 2, Chapter 334, O.S.L. 2022 (56 O.S. Supp.
2022, Section 4002.12), is amended to read as follows:
Section 4002.12 A. Until July 1, 2026 2031, the Oklahoma
Health Care Authority shall establish minimum rat es of reimbursement
from contracted entities to providers who elect not to ente r into
value-based payment arrangemen ts under subsection B C of this
section or other alternative payment agreements for health care
items and services furnished by such provide rs to enrollees of the
state Medicaid program. Except as provided by subsectio n I J of
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this section, until July 1, 2026 2031, such reimbursement rates
shall be equal to or grea ter than:
1. For an item or service provided by a participating provider
who is in the network of the contracted entity, one hundred percent
(100%) of the reimbursement rate for the applicable service in the
applicable fee schedule of the Authority; or
2. For an item or service provided by a non-participating
provider or a provider who is not in the network of the contracted
entity, ninety percent (90%) of the reimbursement rate for the
applicable service in the applicable fee schedule of the Authority
as of January 1, 2021.
B. Notwithstanding any other provision in this section,
anesthesia will continue to be reimbursed equal to or greater than
the anesthesia fee schedule established by the Aut hority as of
January 1, 2021. Anesthesia providers m ay also enter into value -
based payment arrangements for services furnished to enrollees t o
the state Medicaid progra m.
C. A contracted entity shall offer value-based payment
arrangements to all provider s in its network capable 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 contracted entity to determine reimbursement amounts to
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providers in value-based payment arrangements shall align with the
quality measures of the Authority f or contracted entities.
C. D. Notwithstanding any other provision of this sec tion, the
Authority shall comply with payment methodologies required by
federal law or regulation f or specific types of providers including,
but not limited to, Federally Qualifie d Health Centers, rural health
clinics, pharmacies, Indian Health Care Provid ers and emergency
services.
D. E. A contracted entity shall offer all rural health clinics
(RHCs) contracts that reimburse RHCs using the methodology in place
for each specific RH C prior to January 1, 2023, including any and
all annual rate updates . The contracted entity shall comply with
all federal program rules and requirements, and the transformed
Medicaid delivery system shall not interfere with the program as
designed.
E. F. The Oklahoma Health Care Authority shall establish
minimum rates of reimburse ment from contracted entities to Ce rtified
Community Behavioral Health Clinic (CCBHC) providers who elect
alternative payment arrangements equal to the prospective payment
system rate under the Medicaid State Plan.
F. G. The Authority shall establish an i ncentive payment under
the Supplemental Hospital Offset Payment Program that is determined
by value-based outcomes for providers other than hospitals.
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G. H. Psychologist reimburse ment shall reflect ou tcomes.
Reimbursement shall not be limited to therapy and shall include, but
not be limited to, testing and assessment.
H. I. Coverage for Medicaid ground transp ortation services by
licensed Oklahoma emergency medical services shall be reimbursed at
no less than the published Medicaid rates as set by the Aut hority.
All currently published Me dicaid Healthcare Common Procedure Coding
System (HCPCS) codes paid by th e Authority shall continue to be paid
by the contracted entity . The contracted entity shall com ply with
all reimbursement policies established by t he Authority for the
ambulance providers. Contracted entities shall accept the modifiers
established by the Centers for Medicare and Medicaid Services
currently in use by Medicare at the time of the tran sport of a
member that is dually eligible for Medica re and Medicaid.
I. J. 1. The rate paid to participating pharmacy providers is
independent of subsection A o f this section and shall be the same as
the fee-for-service rate employed by the Authority for the Medicaid
program as stated in the payment metho dology at OAC 317:30-5-78,
unless the participating pharmacy provider elects to enter into
other alternative payment agreements.
2. A pharmacy or pharmacist shall receive direct payme nt or
reimbursement from the Authority or contracted entity when providing
a health care service to the Me dicaid member at a rate no less than
that of other health care providers for providing the same service.
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J. K. The Authority shall specify in the requ ests 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 pr oviders.
K. L. Capitation rates established by the Oklahoma Health Care
Authority and paid to contracted entities under capitated contracts
shall be updated annually and in accor dance with 42 C.F.R., Section
438.3. Capitation rates shall be approved as act uarially sound as
determined by the Centers for Medicare and Medicaid Ser vices in
accordance with 42 C.F.R., Section 438.4 and the following:
1. Actuarial calculations must inc lude utilization and
expenditure assumptions consistent with industry and loca l
standards; and
2. Capitation rates shall be risk -adjusted and shall inc lude a
portion that is at risk for achievement of quality and outcomes
measures.
L. M. The Authority may establish a symmetric risk corridor for
contracted entities.
M. N. The Authority shall establish a proce ss for annual
recovery of funds from, or assess ment of penalties on, contracted
entities that do not meet the medical loss ratio standards
stipulated in Section 4002.5 of this title.
N. O. 1. The Authority shall, through the finan cial reporting
required under subsection G of Section 17 4002.12b of this act
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title, determine the percentage of health care expenses by each
contracted entity on primar y care services.
2. Not later than the end of the fourth year of the initial
contracting period, eac h contracted entity shall be currently
spending not less than eleven per cent (11%) of its total health care
expenses on primary care services.
3. The Authority shall monitor the primary care spending of
each contracted entity and require each contracted entity to
maintain the level of spending on primary care services stipula ted
in paragraph 2 of this subsection.
SECTION 2. This act shall become effective November 1, 2023.
Passed the House of Representatives the 9th day of March, 2023.
Presiding Officer of the House
of Representatives
Passed the Senate the ____ day of __________, 2023.
Presiding Officer of the Senate