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STATE OF OKLAHOMA
1st Session of the 59th Legislature (2023)
HOUSE BILL 1658 By: McEntire
AS INTRODUCED
An Act relating to poor persons; 56 O.S. 2021,
Section 4002.5, as amended by Section 9, Chapter 395,
O.S.L. 2022 (56 O.S. Supp. 2022, S ection 4002.5),
which relates to ensuring access to Medicaid Act ;
adding when an entity shall obtain a certificate of
authority; health maintenance organization; a ccident
and health insurer; prepaid dental plan organization ;
and providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.5, as
amended by Section 9, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2022,
Section 4002.5), is amended to read as follows:
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 administrative services.
B. A contracted entity selected by the Oklahoma Health Care
Authority under Section 4 of this act shall obtain a certificate of
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authority as a health maintenance organization issued by the
Insurance Department prior Prior to the execution of the a contract
between the a contracted entity and the Oklahoma Health Care
Authority, the contracted entity shall obtain the appropriate
certificate of authority issued by the In surance Department.
1. A contracted entity shall obtain a certificate of authority
issued by the Insurance Department to operate as a health
maintenance organization when the contracted services to be
delivered include physical health services, behav ioral health
services, and prescription drug services.
2. A contracted entity shall obtain a certificate of authority
issued by the Insurance Department to operate as an a ccident and
health insurer or as a prepai d dental plan organization when the
contracted services to be deliver ed include dental services.
C. 1. To ensure providers have a voice in the direction and
operation of the contracted entities selected by the Oklahoma Health
Care Authority under Section 4 4002.3b of this act title, each
contracted entity shall have a shared governance 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 affiliated with and designated by
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the University Hospitals Authority, University
Hospitals Trust, Oklahoma State University Med ical
Authority, or Oklahoma State University Medical Trust.
2. No less than one-third (1/3) of the contracted entity's
local governing body shall be comprised of representatives of local
Oklahoma provider organizations.
3. No less than two members of the contracted entity's clinical
and quality committees shall be representatives of local Oklahoma
provider organizations, and the committees shall be chaired or co-
chaired by a representative of a local Oklahoma provider
organization.
D. A contracted entity shall promptly notify the Authority of
all material changes affecting the delivery of care or the
administration of its program.
E. A contracted entity shall have a medical loss ratio that
meets the standards provided by 42 C.F.R., Section 438.8.
F. A contracted entity shall provide patient data to a provider
upon request to the extent al lowed under federal or state laws,
rules or regulations including, but not limited to, the Health
Insurance Portability an d Accountability Act of 1996.
G. A contracted entity or a subcontractor of 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
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currently offered or that may be offered in the future by the
contracted entity or subcontractor.
H. Nothing in this act or in a contract between the Authority
and a contracted entity shall prohibit the contracted entity from
contracting with a statewide or regional accounta ble care
organization.
I. Nothing in this act, in a contract between the Authority and
a contracted entity, or in a contract between a contracted entity
and a provider shall prohibit any provider from contracting with
more than one contracted entity.
J. A contracted entity shall not withhold, fail to offer, or
make impracticable a contract with a provider on the basis of
independent practice or lack of hospital system affiliation.
K. All contracted entities shall:
1. Use the same drug formulary, which shall be established by
the Authority; and
2. Ensure broad access to pharmacies including, but not limited
to, pharmacies contracted with covered entities under Section 340B
of the Public Health Service Act. Such access shall, at a minimum,
meet the requirements of the Patient's Right to Pharmacy Choice Act,
Section 6958 et seq. of Title 36 of the Oklahoma Statutes.
L. 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
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support clinical coordination of care, the exchange of information,
and the availability of data to the Authority to manage the state
Medicaid program.
SECTION 2. This act shall become effectiv e November 1, 2023.
59-1-5506 TJ 12/02/22