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STATE OF OKLAHOMA
1st Session of the 60th Legislature (2025)
HOUSE BILL 2055 By: Stinson
AS INTRODUCED
An Act relating to poor persons; amending 56 O.S.
2021, Section 4002.2, as last amended by Section 1,
Chapter 448, O.S.L. 2024 (56 O.S. Supp. 2024, Section
4002.2), which relates to ensuring access to Medicaid
Act; clarifying definition; and providing an
effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.2, as
last amended by Section 1, Chapter 448, O.S.L. 2024 ( 56 O.S. Supp.
2024, 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;
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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-involved children, and
d. children receiving adoption assistance ,
e. children involved in a Family Centered Services (FCS)
case through the Child Welfare Services division of
the Department of Human Services,
f. children in the custody of the Department of Human
Services and placed at home under court supervision,
g. children who are placed at home in a trial
reunification plan administered by the Department of
Human Services, and
h. Medicaid enrolled parents and guardians whose children
are in an FCS case, are in trial reunification, or are
in the custody of the Department of Human Services in
Foster Care or under court supervision ;
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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 applicabl e 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 the 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 in to a capitated contract with the
Oklahoma Health Care Authority for the delive ry of services
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 Access 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 commerc ial plan, a dental benefit manager, or
any other entity as determined by the A uthority;
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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 Me dical Trust,
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 University
Hospitals Trust or the Oklahoma State University
Medical Trust,
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i. a county department of health or city -county health
department,
j. a comprehensive community addiction recovery center,
k. a hospital licensed by this state including all
hospitals 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 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 definition of "essential community
provider" under 45 C.F.R., Section 156.235;
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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 appoint ed 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 org anization" 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 instit ution, currently practicing
licensed provider, or other local Oklahoma provide r organization as
approved by the Authority;
14. "Medical necessity" has the same meaning as "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;
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16. "Provider" means a health care or dental provider licens ed
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, a
majority of whose governing body is c omposed of individuals who:
a. have experience serving Medicaid members and:
(1) are licensed in this state as physicians,
physician assistants, or Advanced Practice
Registered Nurses,
(2) at least one board member is a licensed
behavioral health provider, or
(3) are employed by:
(a) a hospital or other medical facility
licensed by this state and operating in this
state, or
(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,
b. represent the providers or facilities described in
subparagraph a of this paragraph including, but not
limited to, individuals who are employed by a
statewide provider association, or
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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 ownersh ip with Medicaid providers in this state;
19. "Statewide" means all counties of this state including the
urban region; and
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 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. This act shall become effective July 1, 2026.
60-1-10140 TJ 01/06/25