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STATE OF OKLAHOMA
2nd Session of the 59th Legislature (2024)
COMMITTEE SUBSTITUTE
FOR ENGROSSED
SENATE BILL NO. 1675 By: McCortney of the Senate
and
McEntire of the House
COMMITTEE SUBSTITUTE
[ Medicaid program – capitated contracts – entity –
deadlines – contracted entities – credentialing –
recredentialing – authorizations – deadlines –
clinical staff – claims – audits – reimbursement -
deadlines – references – language –
emergency ]
BE IT ENACTED BY THE PEO PLE OF THE STATE OF OKLAHOMA :
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.2, as
last amended by Section 1, Chapter 334, O.S.L. 2022 (56 O.S. Supp.
2023, Section 4002.2) , is amended to read as follows:
Section 4002.2 As used in the Ensuring Access to Me dicaid Act:
1. "Adverse determination" has the same meaning as provided by
Section 6475.3 of Tit le 36 of the Oklahoma Statutes;
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2. "Accountable care organization" means a network of
physicians, hospitals, and other health care providers that provides
coordinated care to Medic aid members;
3. "Claims denial error rate" means the rate of claims denial s
that are overturned on appeal;
4. "Capitated contract" means a contract between the Oklahoma
Health Care Authority and a contracted entity for delivery of
services to Medicaid members in which the Authority pays a fixed,
per-member-per-month rate based on actuarial calculations;
5. "Children's Specialty Plan" means a health care plan that
covers all Medicaid services other than dental 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 involv ed 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 System coding where applicable that contains
information specifically required in the Provider Billing and
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Procedure Manual of the Oklahoma Health Care Authority, as defined
in 42 C.F.R., Section 447.45(b);
7. "Commercial plan" means an organization or entity that
undertakes to provide or arrange for the delivery of health care
services to Medicaid members on a prepaid basis and is subject to
all applicable federal a nd state laws and regulations;
8. "Contracted entity" means an organization or entity that
enters into or will enter into a capitated contract with the
Oklahoma Health Care Authority for the delivery of services
specified in the Ensuring Access to Medicai d Act that will assume
financial risk, operational accountabilit y, and statewide or
regional functionality as defined in the Ensuring Access to Medicaid
Act in managing comprehensive health outcomes of Medicaid members.
For purposes of the Ensuring Access to Medicai d Act, the term
contracted entity includes an accountable care organization, 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 that handles claims
payment and prior authorizations and coordinates dental care with
participating providers and Medicaid members;
10. "Essential community provider" means:
a. a Federally Qualified Health Center,
b. a community mental health center,
c. an Indian Health Care Provider,
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d. a rural health clinic,
e. a state-operated mental health hospital,
f. a long-term care hospital ser ving 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 Authority, or
Oklahoma State University Medical Trus t,
h. a provider employed by or contracted with, or
otherwise a member of the faculty practice plan of:
(1) a public, accredited medical school in this
state, or
(2) a hospital or health care entity directly or
indirectly owned or operated by the Universit y
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. a hospital licensed by the State of Oklahoma including
all hospitals participating in the Supplemental
Hospital Offset Payment Program,
l. a Certified Community Behavioral Health Clinic
(CCBHC),
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m. a provider employed by or contracted with a primary
care residency program accredited by the Accreditation
Council for Graduate Medical Education,
n. any additional Medicaid provider as approved by the
Authority if the provider either offe rs services that
are not available from any other provider within a
reasonable access standard or provides a substantial
share of the total units of a particular service
utilized by Medicaid members within the region during
the last three (3) years, and the combined capacity of
other service providers in the region is insufficient
to meet the total needs of the Medicaid members,
o. a pharmacy or pharmacist, or
p. any provider not otherwise mentioned in this paragraph
that meets the defini tion of "essential community
provider" under 45 C.F.R., Section 156.235;
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 enrollees or participating providers
of the contracted entity;
12. "Governing body" means a group of individuals appointed by
the contracted entity who approve policies, operations, profit/loss
ratios, executive employment decisio ns, and who have overall
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responsibility for the operations of the 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, academic 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 promulgated by the Oklahoma Health Care Authority Board
"medically necessary" in Section 6592 of Title 36 of the Oklahoma
Statutes;
15. "Participating provider" means a provider who has a
contract with or is employed by a contracted entity to provide
services to Medicaid members as authorized by the Ensuring Access to
Medicaid Act;
16. "Provider" means a health care or dental provider 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 criteria of at least one of following two subparagraphs:
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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, or
b. a majority of the entity's governing body is composed
of individuals who:
(1) A. have Have experience serving Medicaid members
and:
(a) 1. are licensed in this state as
physicians, physician assistants, nurse
practitioners, certified nurse-midwives, or
certified registered nurse anesthetists,
(b) 2. at least one board member is a licensed
behavioral health provider, or
(c) 3. are employed by:
i. (a) a hospital or other medical
facility licensed by this state and
operating in this state, or
ii. (b) an inpatient or outpatient mental
health or substance abuse treatment
facility or program licensed or
certified by this state and operating
in this state,
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(2) B. represent 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 association, or
(3) C. are Are nonclinical administrators of
clinical practices serving Medicaid members;
18. "Provider-owned entity" means an organization or entity
that a majority of the entity's ownership is held by Medicaid
providers in this state or i s held by an entity that directly or
indirectly owns or is under common ownership with Medicaid providers
in this state;
19. "Statewide" means all counties of this state inclu ding the
urban region; and
19. 20. "Urban region" means:
a. all counties of this state with a county population of
not less than five hundred thousand (500,000)
according to the late st Federal Decennial Census, and
b. all counties that are contiguous to the counties
described in subparagrap h a of this paragraph ,
combined into one region.
SECTION 2. AMENDATORY Section 3, Chapter 395, O .S.L.
2022 (56 O.S. Supp. 2023, Section 4002.3a), is amended to read as
follows:
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Section 4002.3a A. 1. The Oklahoma Health Care Authority
(OHCA) shall enter into capitated con tracts with contracted entities
for the delivery of Medicaid services as speci fied in this act the
Ensuring Access to Medicaid Act to transform the delivery system of
the state Medicaid progr am for the Medicaid populations listed in
this section.
2. Unless expressly authorized by the Legislature, the
Authority shall not issue any r equest for proposals or enter into
any contract to transform the delivery system for the aged, blind,
and disabled populations eligible for SoonerCare.
B. 1. The Oklahoma Healt h 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:
a. pregnant women,
b. children,
c. deemed newborns under 42 C.F.R., Section 435.1 17,
d. parents and caretaker relatives, and
e. the expansion population.
2. The Authority shall specify the serv ices to be covered in
the request for proposals referenced in par agraph 1 of this
subsection. Capitated contracts referenced in this subsectio n shall
cover all Medicaid services other than dental services including:
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a. physical health services including, but not limited
to:
(1) primary care,
(2) inpatient and outpatien t services, and
(3) emergency room services,
b. behavioral health services, an d
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.
4. Subject to the requirements and approval of the Centers for
Medicare and Medicaid Servi ces, the implementation of the program
shall be no later than October 1, 2023 April 1, 2024.
C. 1. The Authorit y shall issue a request for proposals to
enter into public-private partnerships with dental benefit managers
to cover dental services for the f ollowing Medicaid populations:
a. pregnant women,
b. children,
c. parents and caretaker r elatives,
d. the expansion population, and
e. members of the Children ’s Specialty Plan as provided
by subsection D of this section.
2. The Authority shall specify the services to be covered in
the request for proposals referenced in paragraph 1 of this
subsection.
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3. Subject to the requirements and approval of the Centers for
Medicare and Medicaid Services, the implementation of the program
shall be no later than October 1, 2023 April 1, 2024.
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 sh all issue a request for proposals to
enter into public-private partnerships wi th one contracted entity to
administer a Children ’s Specialty Plan.
2. The Authority sha ll specify the services to be covered in
the request for proposals referenced in paragrap h 1 of this
subsection.
3. The contracted entity for the Children’s Specialty Plan
shall coordinate with the dental benefit managers who cover dental
services for its members as provided by subsection C of this
section.
4. Subject to the requirements and approval of the Centers for
Medicare and Medicaid Services, the implementatio n of the program
shall be no later than October 1, 2023 April 1, 2024.
E. The Authority shall not implement the transformation of the
Medicaid delivery system until it receives written confirmation from
the Centers for Medicare and Medicaid Services that a managed care
directed payment program utilizing average commercial rate
methodology for hospital services under the Supplemental Hospital
Offset Payment Program has been approv ed for Year 1 of the
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transformation and will be included in the budget neutral ity cap
baseline spending level for purposes of Oklahoma ’s 1115 waiver
renewal; provided, however, nothing in thi s section shall prohibit
the Authority from exploring alternative opportunities with the
Centers for Medicare and Medicaid Services to maximize the average
commercial rate benefit.
SECTION 3. AMENDATORY Section 4, Chapter 395, O.S.L.
2022 (56 O.S. Supp. 2023, Section 4002.3b), is amended to rea d as
follows:
Section 4002.3b A. All capitated contracts shall be the result
of requests for proposals issued by the Oklahoma Healt h Care
Authority and submission of competitive bids by contracted entities
pursuant to the Oklahoma Central Purchasing Act.
B. Statewide capitated contracts may be awarded to any
contracted entity including, but not limited to, a provider-led
entity and a provider-owned entity.
C. The Authority shall award no less than three four 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 statewide capitated
contracts to provide dental coverage to Medicaid members as
specified in Section 3 4002.3a of this act title. At least one
statewide capitated contract must be a provider-owned entity.
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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-owned entity and at
least one capitated contract to provide stat ewide coverage to
Medicaid members shall be awarded to a provider-led entity, as long
as the provider-led entity submits a responsive reply to the
Authority's request for proposals demonstrating ability to fulfill
the contract requirements.
2. If no provider-led entity or provider-owned entity submits a
responsive reply to the Authority 's request for proposals
demonstrating ability to fulfill th e contract requirements, the
Authority shall not be required to contract for statewide coverage
with a provider-led entity or provider-owned entity.
3. The Authority shall develop a scoring methodology for the
request for proposals that affords preferential scoring to provider -
led entities and provider-owned entities, as long as the provider-
led entity and provider-owned entity otherwise demonstrates ability
to fulfill the contract requirements. The preferential scoring
methodology shall include opportunities to award additio nal points
to provider-led entities and provider-owned entities based on
certain factors including, but not limited to:
a. broad provider participation in ownership and
governance structure,
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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 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 market, and
d. other relevant factors identified by the Authority.
E. The Authority may select at least one provider-led entity or
one provider-owned entity for the urban region if:
1. The provider-led entity or provider-owned 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 or provider-owned entity
demonstrates the ability, and agrees continually, to expand its
coverage area throughout the contract term and to develop statewide
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operational 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 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 2 of this act.
H. At the discretion of the Authority, subject 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 financia l and operational
readiness.
SECTION 4. AMENDATORY 56 O.S. 2021, Section 4002. 4, as
amended by Section 7, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023,
Section 4002.4), is am ended to read as follows:
Section 4002.4 A. The Oklahoma Health Care Authority shall
develop network adequacy standards for all contr acted entities that,
at a minimum, meet the requirements of 42 C.F.R., Sections 438.3 and
438.68. Network adequacy stand ards established under this
subsection shall include distance and time standards and shall be
designed to ensure members covered by the contracted entities who
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reside in health professional shortage areas (HPSAs) designated
under Section 332(a)(1) of the P ublic Health Service Act (42 U.S.C.,
Section 254e(a)(1)) have access to in -person health care and
telehealth services with providers, e specially adult and pedi atric
primary care practitioners.
B. The Authority shall require all contracted entities to offe r
or extend contracts with all essential community providers, all
providers who receive directed payments in accordance with 42
C.F.R., Part 438 and such other providers as the Authority may
specify. The Authority shall establish such requirements as may be
necessary to prohibit contracted entities from excluding essential
community providers, providers who receive directed payments in
accordance with 42 C.F.R. , Part 438 and such other providers as the
Authority may specify from contracts with contracted e ntities.
C. To ensure models of care are developed to meet the needs of
Medicaid members, each contracted entity must contract with at least
one local Oklahoma provider organization for a model of care
containing care coordination, care management, utiliz ation
management, disease management, network management, or another model
of care as approved by the Authority. Such contractual arra ngements
must be in place within twelve (12) months of the effective date of
the contracts awarded pursuant to the reques ts for proposals
authorized by Section 3 of this act Section 4002.3a of this title .
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D. All contracted entities shall formally credenti al and
recredential network providers at a frequency required by a single,
consolidated provider enrollment and credentia ling process
established by the Authority in accordance with 42 C.F.R., Section
438.214. A contracted entity shall complete credential ing or
recredentialing of a provider within sixty (60) calendar days of
receipt of a completed application.
E. All contracted entities shall be accredited in accordance
with 45 C.F.R., Section 156.275 by an accrediting entity recognized
by the United States Department of Health and Human Services.
F. 1. If the Authority awards a capitated contract to a
provider-led entity for the urban region under Section 4 of this act
Section 4002.3b of this title , the provider-led entity shall expand
its coverage area to every county of this state within the time
frame set by the Authority under subsection E of Section 4 of this
act Section 4002.3b of this title .
2. The expansion of the provider -led entity’s coverage area
beyond the urban region shall be subject to th e approval of the
Authority. The Authority shall approve expansion 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.
When approved, the additional county or counties shall be added to
the provider-led entity’s region during the next open enrollment
period.
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SECTION 5. AMENDATORY 56 O.S. 2021, Section 4002.6, as
last amended by Section 2, Chapter 331, O.S.L. 2023 (56 O.S. Supp.
2023, Section 4002.6), is amende d to read as follows:
Section 4002.6 A. A contracted entity shall meet all
requirements establi shed by the Oklahoma Health Care Authority
pertaining to prior authorizations. The Authority shall establish
requirements that ensure timely determinations b y contracted
entities 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 reques t
for an authorization o f the transfer of a hospital inpatient to a
post-acute care or long-term acute care facility withi n twenty-four
(24) hours of receipt of the request.
C. A contracted entity shall make a determination on a request
for any 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 determination shall occur within a
time frame and in accordance with a proc ess established by t he
Authority. The process established by the Authority pursuant to
this subsection shall include a time frame of at least forty -eight
(48) hours within which a provider may submit the necessary
documentation.
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D. A contracted entity sh all make a determination on a request
for services for a hospitalized member including, but not li mited
to, acute care inpatient services or equipment necessary to
discharge the member from an inpatient facility within one (1)
business day twenty-four (24) hours of receipt of the request.
E. Notwithstanding the provisions of subsection C of this
section, a contracted entity shall make a determination on a request
as expeditiously as necessary and, in any event, within twenty -four
(24) hours of receipt of t he request for service if adhering to the
provisions of subsection C or D of this section could je opardize the
member’s life, health or ability to attain, maintain or regain
maximum function. In the event of a medically emergent ma tter, the
contracted entity shall not impose limitations on providers in
coordination of post-emergent stabilization healt h care including
pre-certification or prior authorization.
F. Notwithstanding any other provision of this section, a
contracted entity shall make a determina tion on a request for
inpatient behavioral health services within twenty-four (24) hours
of receipt of the request.
G. A contracted entity shall make a determination on a request
for covered prescription drugs that are required to be prior
authorized by the Authority within twenty-four (24) hours of receipt
of the request. The contracted entity shall not require prior
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authorization on any covered prescription drug for which the
Authority does not require prior authorization.
H. A contracted entity shall make a determination on a request
for coverage of biomarker testing in accordance with Section 3 of
this act Section 4003 of this title .
I. Upon issuance of an adverse determination on a prior
authorization request under subsection B of this section, the
contracted entity sh all 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 practices in the sam e specialty, but not nec essarily
the same sub-specialty, and who has experience treating the same
population as the patien t on whose behalf the request is submitted;
provided, however, if the requesting provider determines the
services to be clinically urg ent, the contracted enti ty shall
provide such opportunity within twenty-four (24) hours of receipt of
such issuance. Serv ices not covered under the state Medicaid
program for the particular patient shall not be subject to peer -to-
peer review.
J. The Authority shall ensure that a provider offers to provide
to a member in a timely manner services authorized by a contracted
entity.
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K. The Authority shall establish requirements for both internal
and external reviews and appeals of adverse determinations on p rior
authorization requests 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 an
opportunity for peer -to-peer conversations with licensed Oklahoma-
licensed clinical staff of the same or similar specialty which shall
include, but not be limited to, Oklahoma-licensed clinical staff
upon within twenty-four (24) hours of the adverse determination; and
3. Establish uniform rules for Medicaid p rovider or member
appeals across all contracted entities.
SECTION 6. AMENDATORY 56 O.S. 2021, Section 4002.7, as
amended by Section 11, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023,
Section 4002.7), is amen ded to read as follows:
Section 4002.7 A. The Oklahoma Health Care Authority shall
establish requirements for fair proce ssing and adjudication of
claims that ensure prompt reimbursement of providers by contracted
entities. A contracted entity shall com ply with all such
requirements.
B. A contracted entity shall process a clean claim in the time
frame provided by Section 1 219 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 t he contracted
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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 cla im filed by a provide r within
six (6) months of the date the item or service was furnished to a
member shall be considered timely. If a claim meets the definition
of a clean claim, the contracted entity shall not request medical
records of the member prio r to paying the claim. Once a claim has
been paid, the contracted entity may request medical recor ds if
additional documentation is needed to review the claim for medical
necessity.
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, or in the case of a down coded claim, the
contracted entity shall establish a process by which the provider
may identify and provide such additional informati on as may be
necessary to substantiate the claim. Any such claim denial or
downcode shall include the following:
1. A detailed explanation of the basis for the denial; and
2. A detailed description of the additional information
necessary to substantiat e the claim.
D. Postpayment audits by a contra cted entity shall be subject
to the following requirements:
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1. Subject to paragraph 2 of this subsection, insofar as a
contracted entity conducts postpayment audits, the contracted entity
shall employ the pos tpayment audit process det ermined by the
Authority;
2. The Authority shall establish a limit, not to exceed three
percent (3%), on the percentage of claims with respect to which
postpayment audits may be conducted by a contracted entity for
health care items and services furnished by a provider in a p lan
year; and
3. The Authority shall provide for the imposition of financial
penalties under such contract in the case of any contracted entity
with respect to which the Authority determines has a claims deni al
error rate of greater t han five percent (5%). The Authority shall
establish the amount of financial penalties and the tim e frame under
which such penalties shall be imposed on contracted entities under
this paragraph, in no case less than annually.
E. A contracted entity may o nly 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 recogniz ed 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 contracted
entities.
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SECTION 7. AMENDATORY 56 O.S. 2021, Secti on 4002.12, as
last amended by Section 1, Chapter 308, O.S.L. 2023 (56 O.S. Supp.
2023, Section 4002.12), is amended to read as follows:
Section 4002.12 A. Until July 1, 2026, the The Oklahoma Health
Care Authority shall estab lish minimum rates of reimbu rsement from
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 b y such providers to enrollee s of the state
Medicaid program. Except as provided by subsection I of this
section until July 1, 2026, such reimbursement rates shall be equal
to or greater than:
1. For an item or service provided by a participating pr ovider
who is in the network of t he contracted entity, one hundred percent
(100%) of the reimbursement rate for the applicable servic e 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 netw ork of the contracte d
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. A contracted entity shall offer value -based payment
arrangements to all pro viders in its network capable of entering
into value-based payment arrangements. Such arrangements shall be
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optional for the provider but shall be tied to reimbursement
incentives when quality metrics are met. The quality measures used
by a contracted enti ty to determine reim bursement amounts to
providers in value-based payment arrangements shall align with the
quality measures of the Authority for contracted entities.
Reimbursement under a value -based arrangement will be in addition to
the minimum rate established in Section 4002.3a of this title or one
hundred percent (100%) of minimum rate floor, whi chever is greater.
C. Notwithstanding any other provision of this sectio n, the
Authority shall comply wit h payment methodologies required by
federal law or regulation for specif ic types of providers including,
but not limited to, Federally Qualified Healt h Centers, rural health
clinics, pharmacies, Indian Health Care Providers and emergency
services.
D. A contracted entity shall offer all rural health clinics
(RHCs) contracts that reimburse RHCs using the methodology in place
for each specific RHC prior t o January 1, 2023, including any and
all annual rate updates. The contra cted 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. The Oklahoma Health Care Authority shall establish minimum
rates of reimbursement f rom contracted entities to Certified
Community Behavioral Health Clinic (CCBHC) providers who elect
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alternative payment arrangements equal to the prospective payment
system rate under the Medicaid State Plan.
F. The Authority shall establish an incentive payment under the
Supplemental Hospital Offset Payment Program that is determined by
value-based outcomes for providers other than hospitals.
G. Psychologist reimbursement shall refl ect outcomes.
Reimbursement shall not be limited to therapy and shall in clude but
not be limited to testing and assessment.
H. Coverage for Medicaid ground transportation servi ces by
licensed Oklahoma emergency medical services shall be reimbursed at
no less than the published Medicaid rates as set by the Authority.
All currently published Medicaid Healthca re Common Procedure Coding
System (HCPCS) codes paid by the Authority sh all continue to be paid
by the contracted entity. The contracted entity shall comply with
all reimbursement policies established by the Authority for the
ambulance providers. Contracted entities shall accept the modifiers
established by the Centers for M edicare and Medicaid Services
currently in use by Medicare at the time of the transport of a
member that is dually eligible for Medicare and Medicaid.
I. 1. The rate paid to particip ating 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 fo r the Medicaid
program as stated in the payment methodology at in OAC 317:30-5-78,
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unless the participating pharmacy provider elects to enter into
other alternative payment agree ments.
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 t he same service.
J. Notwithstanding any other provision of this section,
anesthesia shall continue to be reimbursed equal to or greater than
the Anesthesia Fee Schedule anesthesia fee schedule established by
the Authority as of January 1, 2021. Anesthesi a providers may also
enter into value-based payment arrangements under this se ction or
alternative payment arrangements for services furnished to Medic aid
members.
K. The Authority sh all specify in the requests for proposals a
reasonable time frame in whi ch a contracted entity shall have
entered into a certain percentage, as determ ined by the Authority,
of value-based contracts with providers.
L. Capitation rates established by the Oklahoma Health Care
Authority and paid to contracted entities under capit ated contracts
shall be updated annually and in accordance with 42 C.F.R., Sec tion
438.3. Capitation rates shall be approved as actuarially sound as
determined by the Centers for Medi care and Medicaid Services in
accordance with 42 C.F.R., Section 438.4 a nd the following:
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1. Actuarial calculations must include utilization and
expenditure assumptions consistent with industry and local
standards; and
2. Capitation rates shall be risk -adjusted and shall include a
portion that is at risk for achievement of q uality and outcomes
measures.
M. The Authority may establish a symmetric risk corridor for
contracted entities.
N. The Authority shall establish a pr ocess for annual recovery
of funds from, or assessment of penalties on, contracted entities
that do not meet the medical loss ratio standards stipulated in
Section 4002.5 of this titl e.
O. 1. The Authority shall, through the financial reporting
required under subsection G of Section 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 o f the fourth year of the initial
contracting period, each contracted enti ty shall be currently
spending not less than eleven percent (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 stipulated
in paragraph 2 of this subsection.
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SECTION 8. It being immediately necessary for the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, b y reason whereof this act shall t ake effect and
be in full force from and after its passage and approval.
59-2-11006 JM 04/18/24