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STATE OF OKLAHOMA
2nd Session of the 59th Legislature (2024)
CONFERENCE COMMITTEE SUBSTITUTE
FOR ENGROSSED
SENATE BILL 1675 By: McCortney of the Senate
and
McEntire of the House
CONFERENCE COMMITTEE SUBSTITUTE
An Act relating to the state Medicaid program;
amending 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), which relates to
definitions in the Ensuring Access to Medicaid Act;
adding and modifying defin itions; amending Section 3,
Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023, Section
4002.3a), which relates to capitated contracts f or
delivery of Medicaid services; extending certain
deadlines; amending Section 4, Chapter 395, O.S.L.
2022 (56 O.S. Supp. 2023, S ection 4002.3b), which
relates to capitated contracts; broadening certain
provisions to cover provider -owned entities;
requiring selection of provider -owned entity under
certain conditions; amending 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), which
relates to network adequacy standards for contracted
entities; imposing certain deadline on credentialing
or recredentialing by contracted entities; broadening
certain provisions to cover p rovider-owned entities;
amending 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), which relates to
requirements for prior authorizations; modifying and
adding deadlines for certa in determinations and
reviews; requiring certain reviews to be conducted by
Oklahoma-licensed clinical staff; amending 56 O.S.
2021, Section 4002.7, as amended by Section 11,
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Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023, Section
4002.7), which relates to requi rements for processing
and adjudicating claims; expanding certain provisions
to include downcoded claims; amending 56 O.S. 2021,
Section 4002.12, as last amended by Section 1,
Chapter 308, O.S.L. 2023 (56 O.S. Supp. 2023, Section
4002.12), which relate s to minimum rates of
reimbursement; extending certain deadline; updating
statutory references; updating statutory language;
and declaring an emergency .
BE IT ENACTED BY THE PEOPLE 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 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 Medicaid members;
3. “Claims denial error rate ” means the rate of claims denials
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 t he Authority pays a fixed,
per-member-per-month rate based on actuarial calculations;
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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 involved 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
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 t he delivery of health care
services to Medicaid members on a prepaid basis and is subject to
all applicable federal and 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
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specified in the Ensuring Access to Medicaid Act that will assume
financial risk, operational accountability, and statewide or
regional functionality as defined in the Ensuring Acces s to Medicaid
Act in managing comprehensive health outcomes of Medicaid members.
For purposes of the Ensuring Access to Medicaid Act, the term
contracted entity includes an accountable care organization, a
provider-led entity, a commercial plan, a dental bene fit 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,
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 University
Hospitals Authority, University Hospitals Trust,
Oklahoma State University Medical Authority, or
Oklahoma State University Medical Trust,
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h. a provider employed by or contracted with, or
otherwise a member of the faculty practice plan of:
(1) a public, accredited medical sc hool 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. a hospital licensed by the State of Oklahoma this
state including all hospita ls participating in the
Supplemental Hospital Offset Payment Program,
l. a Certified Community Behavioral Health Clinic
(CCBHC),
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 offers services that
are not available from any other provider within a
reasonable access standard or provides a substantial
share of the total u nits of a particular service
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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 definition 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 reasonably 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 appointe d by
the contracted entity who approve policies, operations, profit/loss
ratios, executive employment decisions, and who have overall
responsibility for the operations of the contracted entity of which
they are appointed;
13. “Local Oklahoma provider orga nization” means any state
provider association, accountable care organization, Certified
Community Behavioral Health Clinic, F ederally Qualified Health
Center, Native American tribe or tribal association, hospital or
health system, academic medical institu tion, currently practicing
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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 Author ity 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:
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 unde r
common ownership with Medicaid providers in this
state, or,
b. a majority of the entity’s whose governing body is
composed of individuals who:
(1)
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a. 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 or Advanced Practice
Registered Nurses,
(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 sta te,
(2)
b. represent the providers or facilities described in
division (1) of this subparagraph a of this paragraph
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including, but not limited to, individuals who are
employed by a statewide provider association, or
(3)
c. are nonclinical administrators of clinical practices
serving Medicaid members;
18. “Provider-owned entity” means an organization or entity , a
majority of whose 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;
19. “Statewide” means all counties of this state including 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 thous and (500,000)
according to the latest Federal Decennial Census, and
b. all counties that are contiguous to the counties
described in subparagraph a of this paragraph,
combined into one region.
SECTION 2. AMENDATORY Section 3, Chap ter 395, O.S.L.
2022 (56 O.S. Supp. 2023, Section 4002.3a), is amended to read as
follows:
Section 4002.3a. A. 1. The Oklahoma Health Care Authority
(OHCA) shall enter into capitated contracts with contracted entities
for the delivery of Medicaid servic es as specified in this act the
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Ensuring Access to Medicaid Act to transform the delivery system of
the state Medicaid program for the Medicaid populations listed in
this section.
2. Unless expressly authorized by 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 SoonerCare.
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 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., Se ction 435.117,
d. parents and caretaker relatives, and
e. the expansion population.
2. The Authority shall specify the servic es to be covered in
the request for proposals referenced in paragraph 1 of this
subsection. Capitated contracts referenced in thi s subsection shall
cover all Medicaid services other than dental services including:
a. physical health services including, but not limited
to:
(1) primary care,
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(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.
4. 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.
C. 1. The Authority shall issue a request for proposals to
enter into public-private partnerships with dental benefit managers
to cover dental service s 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.
2. The Authority shall specify the services to be covered in
the request for proposals referenced in paragraph 1 of this
subsection.
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.
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D. 1. Either as part of the request for proposals referenced
in subsection B of this s ection 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.
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 managers who cover dental
services for its members as provided by su bsection C of this
section.
4. Subject to the requirements and approval of the Centers for
Medicare and Medicaid Services, the im plementation 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 Ser vices that a managed care
directed payment program utilizing average commercial rate
methodology for hospital services under t he Supplemental Hospital
Offset Payment Program has been approved for Year 1 of the
transformation and will be included in the bud get neutrality cap
baseline spending level for purposes of Oklahoma ’s 1115 waiver
renewal; provided, however, nothing in this section shall prohibit
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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 read as
follows:
Section 4002.3b. A. All capitated contracts shall b e the
result of requests for proposals issued by the Oklahoma Health 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 any provider-led
entity or provider-owned entity, or both.
C. The Authority shall award no less than three statewide
capitated contracts to provide comprehensive integrated health
services including, but not limit ed 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.
D. 1. Except as specified in paragraph 2 3 of this subsection,
at least one capitated contract to provide statewide coverage to
Medicaid members shall be awarded to a provi der-led entity, as long
as the provider-led entity submits a responsive reply to the
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Authority’s request for proposals demonstrati ng ability to fulfill
the contract requirements.
2. Effective with the next procurement cycle, and except as
specified in paragraph 3 of this subsection, at least one capitated
contract to provide statewide coverage to Medicaid members shall be
awarded to a provider-owned entity, as long as the provider -owned
entity submits a responsive reply to the Authority ’s request for
proposals demonstrating ability to fulfill the contract
requirements.
3. If no 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, the
Authority shall not be required to contract for statewide coverage
with a provider-led entity or provider-owned entity.
3. 4. 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
demonstrate an ability to fulfill the contract requirements. The
preferential scoring methodology shall include opportunities to
award additional 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, or 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 Author ity’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 sev en
(7) years.
G. At the end of the contracting period, the Authority shall
solicit and award new contracts as provided by this se ction and
Section 3 of this act Section 4002.3a of this title .
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 implementat ion of
one or more capitated contracts to ensure financial 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 a mended to read as follows:
Section 4002.4. A. The Oklahoma Health Care Authority shall
develop network adequacy standards for all contracted entities that,
at a minimum, meet the requirements of 42 C.F.R., Sections 438.3 and
438.68. Network adequacy sta ndards established under this
subsection shall include distance and time standards and shall be
designed to ensure members cov ered by the contracted entities who
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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. The Authority shall require all contracted entities to of fer
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 ma y 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 entities.
C. To ensure models of care are developed to meet the needs of
Medicaid members, each contracted entity must contr act with at least
one local Oklahoma provider organization for a model of care
containing care coordination, care management, util ization
management, disease management, 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 requ ests for proposals
authorized by Section 3 of this act Section 4002.3a of this title .
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D. All contracted entities shall formal ly credential and
recredential network providers at a frequency required by a single,
consolidated provider enrollment and credent ialing process
established by the Authority in accordance with 42 C.F.R., Section
438.214. A contracted entity shall complete credentialing 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 or provider-owned entity for the urban region
under Section 4 of this act Section 4002.3b of this title , the
provider-led entity or provider-owned 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 or provider-owned
entity’s coverage area beyond the urban region shall be subject to
the approval of the Authority. The Authorit y shall approve
expansion to counties for which the provider -led entity or provider-
owned 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
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entity’s or provider-owned entity’s region during the next open
enrollment period.
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 amended to read as follows:
Section 4002.6. A. A 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
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 o n 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.
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 process established by the
Authority. The process established by the Authority pursuant to
this subsection shall include a time frame of at least forty -eight
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(48) hours within which a provider may submit the necessary
documentation.
D. A contracted entity shall make a determination on a request
for services for a hospitalized member including, but not limited
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 twen ty-four
(24) hours of receipt of the request for service if adhering to the
provisions of subsection C or D of this section co uld jeopardize the
member’s life, health or ability to attain, maintain or regain
maximum function. In the event of a medically e mergent matter, the
contracted entity shall not impose limitations on providers in
coordination of post -emergent stabilization health care including
pre-certification or prior authorization.
F. Notwithstanding any other provision of this 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.
G. A contracted entity shall make a determination on a request
for covered prescription drugs that are re quired to be prior
authorized by the Authority within twenty -four (24) hours of receipt
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of the request. The contracted entity shall not require prior
authorization on any covered prescription drug for which the
Authority does not require prior authorizati on.
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 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 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 determines the
services to be clinically urgent, the contracted entity 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.
J. The Authority shall ensure that a provider offers to provide
to a member in a timely manner services authorized by a contrac ted
entity.
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K. The Authority shall establish requirements for both internal
and external reviews and appeals of adverse determina tions on prior
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 provider 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 amended to read as follows:
Section 4002.7. A. The Oklahoma Health Care Authority shall
establish requirements for fai r processing and adjudication of
claims that ensure prompt reimbursement of providers by contracted
entities. A contracted entity shall comply with all such
requirements.
B. A 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 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 claim filed by a provider 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 prior to paying the claim. Once a claim has
been paid, the contracted entity may request medica l records 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 downcoded claim , the
contracted entity shall establish a process by which the provider
may identify and provide such additional information 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 substantiate the claim.
D. Postpayment audits by a contracted 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 postpayment audit process determined by the
Authority;
2. The Authority shall establish a limit 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 plan 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 denial
error rate of greater th an five percent (5%). The Authority shall
establish the amount of financial penalties and the time 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 on ly 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 recognize d 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, Sectio n 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 2027, the Oklahoma
Health Care Authority shall establish minimum rates of reimb ursement
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 by such providers to enrolle es of the state
Medicaid program. Except as provided by subsection I of this
section, until July 1, 2026 2027, 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 networ k 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. A contracted entity shall offer value -based payment
arrangements to all providers 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 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 section, the
Authority shall comp ly with payment methodologies required by
federal law or regulation for specific types of providers including,
but not limited to, Federally Qualified Health 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 to January 1, 2023, including any and
all annual rate updates. The contracted entity shall comply wi th
all federal program rules and requirements, and the transformed
Medicaid delivery system shall not interfere with the progr am as
designed.
E. The Oklahoma Health Care Authority shall establish minimum
rates of reimbursement from contracted entities to Certified
Community Behavioral Health Clinic (CCBHC) providers who elect
alternative payment arrangements equal to the prospective payment
system rate under the Medicaid State Plan.
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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 reflect outcomes.
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 services shall be reimbursed at
no less than the published Medicaid rates as set by the Authority.
All currently published Medicaid He althcare Common Procedure Coding
System (HCPCS) codes paid by the Authority shall 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. C ontracted entities shall accept the modifiers
established by the Centers for Medicare 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 pa rticipating 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 in OAC 317:30-5-78,
unless the participating pharmacy provider elects to enter into
other alternative payment agreements.
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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 mem ber at a rate no less than
that of other health care providers for providing the same service.
J. Notwithstanding any other p rovision 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. Anesthesia providers may also
enter into value-based payment arrangements under this section or
alternative payment arrangements for services furnished to Medicaid
members.
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 providers.
L. Capitation rates established by the Oklahoma Health Care
Authority and paid to contracted entities under capitated contracts
shall be updated annually and in accordance with 42 C.F.R., Section
438.3. Capitation rates shall be approved as actuarially sound as
determined by the Centers fo r Medicare and Medicaid Services in
accordance with 42 C.F.R., Section 438.4 and the following:
1. Actuarial calculations mus t include utilization and
expenditure assumptions consistent with industry and local
standards; and
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2. Capitation rates shall be risk-adjusted and shall include a
portion that is at risk for achievement of quality and outcomes
measures.
M. The Authority may establish a symmetric risk corridor for
contracted entities.
N. The Authority shall establish a process 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 title.
O. 1. The Authority shall, through the financial reporting
required under subsection G of Secti on 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, each contracted entity shall be currently
spending not less than eleven percent (11%) of its total health care
expenses on primary care services.
3. The Authority shall mon itor the primary care spending of
each contracted entity and require each contracted entity to
maintain the level of spending on p rimary care services stipulated
in paragraph 2 of this subsection.
SECTION 8. It being immediately necessary for the preservation
of the public peace, health or safety, an emergency is hereby
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declared to exist, by reason whereof this act s hall take effect and
be in full force from and after its passage and approval.
59-2-3813 DC 5/28/2024 1:39:44 PM