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HOUSE OF REPRESENTATIVES - FLOOR VERSION
STATE OF OKLAHOMA
1st Session of the 59th Legislature (2023)
ENGROSSED SENATE
BILL NO. 563 By: Haste of the Senate
and
McEntire of the House
An Act relating to the state Medicaid program;
amending 56 O.S. 2021, Section 4002.12, as amended by
Section 2, Chapter 334, O.S.L. 2022 (56 O.S. Supp.
2022, Section 4002.12), which relates to m inimum
rates of reimbursement ; requiring certain
reimbursement of anes thesia; clarifying authority of
anesthesia providers to enter into value-based
payment arrangements; updating statut ory reference;
and declaring an emergency.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.12, as
amended by Section 2, Chapter 334, O.S.L. 2022 (56 O.S. Supp. 20 22,
Section 4002.12), is amended to read as follows:
Section 4002.12. A. Until July 1, 2026, the Oklahoma Health
Care Authority shall establish minimum rates of reimbursement from
contracted entities to providers who elect not to enter into value-
based payment arrangements under subsec tion B of this section or
other alternative payment agreements for health care items and
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services furnished by such providers to enrollees of the state
Medicaid program. Except as provided by subsection I of this
section, until July 1, 2026, such reimburs ement 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 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 applic able fee schedule of the Authority
as of January 1, 2021.
B. A contracted entity shall offer value-based payment
arrangements to all providers in its network capable o f 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
providers in value-based payment arrangements shall align with the
quality measures of the Authority for contracted entities.
C. Notwithstanding any other provision of this sec tion, the
Authority shall comply with payment methodologies require d by
federal law or regulation for specific types of providers including,
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but not limited to, Federally Qualified Health Cent ers, rural health
clinics, pharmacies, Indian Health Care Provid ers and emergency
services.
D. A contracted entity shall offer all rural health clinics
(RHCs) contracts that reimburse RHCs using the methodology in plac e
for each specific RHC prior to Janu ary 1, 2023, including any and
all annual rate updates . The contracted entity shall comply with
all federal program rules and requ irements, and the transformed
Medicaid delivery system shall not interfere with the prog ram as
designed.
E. The Oklahoma Health Care Authority shall establish minimum
rates of reimbursemen t from contracted entities to Certified
Community Behavioral Health Clinic (CCBHC) providers who elect
alternative payment arrangements equal to the prospe ctive payment
system rate under the M edicaid State Plan.
F. The Authority shall establish an incenti ve payment under the
Supplemental Hospital Offset Payment Program t hat is determined by
value-based outcomes for providers other than hospitals.
G. Psychologist reimbursement shall reflect ou tcomes.
Reimbursement shall not be limited to therapy and shall include but
not be limited to testing and assessment.
H. Coverage for Medicaid ground transportation services by
licensed Oklahoma emergency medical serv ices shall be reimbursed at
no less than the published Medicaid rates as set by the Authority .
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All currently published Medicaid Healthcare Common Procedure Coding
System (HCPCS) codes paid by the Authority shall continue to be paid
by the contracted entit y. The contracted entity shall compl y with
all reimbursement policies established by the Authority f or the
ambulance providers. Contracted entities shall accept the m odifiers
established by the Centers for Medicare and Medicaid Services
currently in use by Medicare at the time of the transp ort of a
member that is dually eligible for Medicare and Medicai d.
I. 1. The rate paid to participating pharmacy providers is
independent of subsection A of 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 methodology at OAC 317:30 -5-78,
unless the participating pharmacy provider elects to ente r into
other alternative payment agreements.
2. A pharmacy or pharmacist shall receive direct payment or
reimbursement from the Authority or contracted entity when providing
a health care service to the Medicaid member at a rate no less than
that of other health care providers for providing the same service.
J. Notwithstanding any other pro vision of this section,
anesthesia shall continue to be rei mbursed equal to or greater than
the Anesthesia Fee Schedule established by the Authority as of
January 1, 2021. Anesthesia providers may also enter into value -
based payment arrangements under this section or alternative payment
arrangements for services furnished to Medicaid members.
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K. 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 pr oviders.
K. L. Capitation rates established by the Oklahoma Health Care
Authority and paid to contracte d entities under capitated contracts
shall be updated annuall y and in accordance with 42 C.F.R., Section
438.3. Capitation rates shall be approved as a ctuarially sound as
determined by the Centers for Medicare and Medicaid Services in
accordance with 42 C .F.R., Section 438.4 and the following:
1. Actuarial calculations must include utiliz ation and
expenditure assumptions consistent with industry and loc al
standards; and
2. Capitation rates shall be risk -adjusted and shall include a
portion that is at ris k 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 assessment of penalties on, contracted
entities that do not meet the medical loss ratio standa rds
stipulated in Section 4002.5 of this title.
N. O. 1. The Authority shall, through the financial reporting
required under subsection G of Section 17 of this act Section
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4002.12b of this title , determine the percentage of health care
expenses by each contracted entity on primary 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 perc ent (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 stipulat ed
in paragraph 2 of this subsection.
SECTION 2. It being immediately n ecessary for the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, by reason whereof this act shall take effect and
be in full force from and after its passage and approval.
COMMITTEE REPORT BY: COMMITTEE ON APPROPRIATIONS AND BUDGET , dated
04/13/2023 - DO PASS.