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28	28	STATE OF OKLAHOMA
29	29
30	30	1st Session of the 60th Legislature (2025)
31	31
32	32	HOUSE BILL 2055 By: Stinson
33	33
34	34
35	35
36	36
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38	38	AS INTRODUCED
39	39
40	40	An Act relating to poor persons; amending 56 O.S.
41	41	2021, Section 4002.2, as last amended by Section 1,
42	42	Chapter 448, O.S.L. 2024 (56 O.S. Supp. 2024, Section
43	43	4002.2), which relates to ensuring access to Medicaid
44	44	Act; clarifying definition; and providing an
45	45	effective date.
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48	48
49	49
50	50	BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
51	51	SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.2, as
52	52	last amended by Section 1, Chapter 448, O.S.L. 2024 ( 56 O.S. Supp.
53	53	2024, Section 4002.2), is amended to read as follows:
54	54	Section 4002.2. As used in the Ensuring Access to Medicaid Act:
55	55	1. "Adverse determination " has the same meaning as provided by
56	56	Section 6475.3 of Title 36 of the Oklahoma Statutes;
57	57	2. "Accountable care organization " means a network of
58	58	physicians, hospitals, and other health care providers that provides
59	59	coordinated care to Medicaid members;
60	60	3. "Claims denial error rate" means the rate of claims denials
61	61	that are overturned on appeal;
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88	88	4. "Capitated contract" means a contract between the Oklahoma
89	89	Health Care Authority and a contracted entity for delivery of
90	90	services to Medicaid members in which the Authority pays a fixed,
91	91	per-member-per-month rate based on actuarial calculations;
92	92	5. "Children's Specialty Plan" means a health care plan that
93	93	covers all Medicaid services other than dental services and is
94	94	designed to provide care to:
95	95	a. children in foster care,
96	96	b. former foster care children up to twenty -five (25)
97	97	years of age,
98	98	c. juvenile-justice-involved children, and
99	99	d. children receiving adoption assistance ,
100	100	e. children involved in a Family Centered Services (FCS)
101	101	case through the Child Welfare Services division of
102	102	the Department of Human Services,
103	103	f. children in the custody of the Department of Human
104	104	Services and placed at home under court supervision,
105	105	g. children who are placed at home in a trial
106	106	reunification plan administered by the Department of
107	107	Human Services, and
108	108	h. Medicaid enrolled parents and guardians whose children
109	109	are in an FCS case, are in trial reunification, or are
110	110	in the custody of the Department of Human Services in
111	111	Foster Care or under court supervision ;
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138	138	6. "Clean claim" means a properly completed billing form with
139	139	Current Procedural Terminology, 4th Edition or a more recent
140	140	edition, the Tenth Revision of the International Classification of
141	141	Diseases coding or a more recent revision, or Healthcare Common
142	142	Procedure Coding System coding where applicabl e that contains
143	143	information specifically required in the Provider Billing and
144	144	Procedure Manual of the Oklahoma Health Care Authority, as defined
145	145	in 42 C.F.R., Section 447.45(b);
146	146	7. "Commercial plan" means an organization or entity that
147	147	undertakes to provide or arrange for the delivery of health care
148	148	services to Medicaid members on a prepaid basis and is subject to
149	149	all applicable federal and state laws and regulations;
150	150	8. "Contracted entity" means an organization or entity that
151	151	enters into or will enter in to a capitated contract with the
152	152	Oklahoma Health Care Authority for the delive ry of services
153	153	specified in the Ensuring Access to Medicaid Act that will assume
154	154	financial risk, operational accountability, and statewide or
155	155	regional functionality as defined in the Ensuring Access to Medicaid
156	156	Act in managing comprehensive health outcomes of Medicaid members.
157	157	For purposes of the Ensuring Access to Medicaid Act, the term
158	158	contracted entity includes an accountable care organization, a
159	159	provider-led entity, a commerc ial plan, a dental benefit manager, or
160	160	any other entity as determined by the A uthority;
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187	187	9. "Dental benefit manager " means an entity that handles claims
188	188	payment and prior authorizations and coordinates dental care with
189	189	participating providers and Medicaid members;
190	190	10. "Essential community provider " means:
191	191	a. a Federally Qualified Health Center,
192	192	b. a community mental health center,
193	193	c. an Indian Health Care Provider,
194	194	d. a rural health clinic,
195	195	e. a state-operated mental health hospital,
196	196	f. a long-term care hospital serving children (LTCH -C),
197	197	g. a teaching hospital owned, jointly owned, or
198	198	affiliated with and designated by the University
199	199	Hospitals Authority, University Hospitals Trust,
200	200	Oklahoma State University Medical Authority, or
201	201	Oklahoma State University Me dical Trust,
202	202	h. a provider employed by or contracted with, or
203	203	otherwise a member of the faculty practice plan of:
204	204	(1) a public, accredited medical school in this
205	205	state, or
206	206	(2) a hospital or health care entity directly or
207	207	indirectly owned or operated by the University
208	208	Hospitals Trust or the Oklahoma State University
209	209	Medical Trust,
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236	236	i. a county department of health or city -county health
237	237	department,
238	238	j. a comprehensive community addiction recovery center,
239	239	k. a hospital licensed by this state including all
240	240	hospitals participating in the Supplemental Hospital
241	241	Offset Payment Program,
242	242	l. a Certified Community Behavioral Health Clinic
243	243	(CCBHC),
244	244	m. a provider employed by or contracted with a primary
245	245	care residency program accredited by the Accreditation
246	246	Council for Graduate Medical Education,
247	247	n. any additional Medicaid provider as approved by the
248	248	Authority if the provider either offers services that
249	249	are not available from any other provider within a
250	250	reasonable access standard or provides a substantial
251	251	share of the total units of a particular service
252	252	utilized by Medicaid members within the region during
253	253	the last three (3) years, and the combined capacity of
254	254	other service providers in the region is insufficient
255	255	to meet the total needs of the Medicaid members,
256	256	o. a pharmacy or pharmacist, or
257	257	p. any provider not otherwise mentioned in this paragraph
258	258	that meets the definition of "essential community
259	259	provider" under 45 C.F.R., Section 156.235;
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286	286	11. "Material change" includes, but is not limited to, any
287	287	change in overall business operations such as policy, process or
288	288	protocol which affects, or can reasonably be expected to affect,
289	289	more than five percent (5%) of enrollees or participating providers
290	290	of the contracted entity;
291	291	12. "Governing body" means a group of individuals appoint ed by
292	292	the contracted entity who approve policies, operations, profit/loss
293	293	ratios, executive employment decisions, and who have overall
294	294	responsibility for the operations of the contracted entity of which
295	295	they are appointed;
296	296	13. "Local Oklahoma provider org anization" means any state
297	297	provider association, accountable care organization, Certified
298	298	Community Behavioral Health Clinic, Federally Qualified Health
299	299	Center, Native American tribe or tribal association, hospital or
300	300	health system, academic medical instit ution, currently practicing
301	301	licensed provider, or other local Oklahoma provide r organization as
302	302	approved by the Authority;
303	303	14. "Medical necessity" has the same meaning as "medically
304	304	necessary" in Section 6592 of Title 36 of the Oklahoma Statutes;
305	305	15. "Participating provider " means a provider who has a
306	306	contract with or is employed by a contracted entity to provide
307	307	services to Medicaid members as authorized by the Ensuring Access to
308	308	Medicaid Act;
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335	335	16. "Provider" means a health care or dental provider licens ed
336	336	or certified in this state or a provider that meets the Authority 's
337	337	provider enrollment criteria to contract with the Authority as a
338	338	SoonerCare provider;
339	339	17. "Provider-led entity" means an organization or entity, a
340	340	majority of whose governing body is c omposed of individuals who:
341	341	a. have experience serving Medicaid members and:
342	342	(1) are licensed in this state as physicians,
343	343	physician assistants, or Advanced Practice
344	344	Registered Nurses,
345	345	(2) at least one board member is a licensed
346	346	behavioral health provider, or
347	347	(3) are employed by:
348	348	(a) a hospital or other medical facility
349	349	licensed by this state and operating in this
350	350	state, or
351	351	(b) an inpatient or outpatient mental health or
352	352	substance abuse treatment facility or
353	353	program licensed or certified by this state
354	354	and operating in this state,
355	355	b. represent the providers or facilities described in
356	356	subparagraph a of this paragraph including, but not
357	357	limited to, individuals who are employed by a
358	358	statewide provider association, or
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385	385	c. are nonclinical administrators of clinical practices
386	386	serving Medicaid members;
387	387	18. "Provider-owned entity" means an organization or entity, a
388	388	majority of whose ownership is held by Medicaid providers in this
389	389	state or is held by an entity that directly or indirectly owns or is
390	390	under common ownersh ip with Medicaid providers in this state;
391	391	19. "Statewide" means all counties of this state including the
392	392	urban region; and
393	393	20. "Urban region" means:
394	394	a. all counties of this state with a county population of
395	395	not less than five hundred thousand (500,000)
396	396	according to the latest Federal Decennial Census, and
397	397	b. all counties that are contiguous to the counties
398	398	described in subparagraph a of this paragraph,
399	399	combined into one region.
400	400	SECTION 2. This act shall become effective July 1, 2026.
401	401
402	402	60-1-10140 TJ 01/06/25

Oklahoma 2025 Regular Session

Oklahoma House Bill HB2055 Compare Versions