1| STATE OF OKLAHOMA | | | 2| 1st Session of the 60th Legislature (2025) | | | 3|HOUSE BILL 2055 By: Stinson | | | 4| | | | 5| | | | 6| AS INTRODUCED | | | 7| An Act relating to poor persons; amending 56 O.S. | | 2021, Section 4002.2, as last amended by Section 1, | 8| Chapter 448, O.S.L. 2024 (56 O.S. Supp. 2024, Section | | 4002.2), which relates to ensuring access to Medicaid | 9| Act; clarifying definition; and providing an | | effective date. | 10| | | | 11| | | | 12|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 13| SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.2, as | | | 14|last amended by Section 1, Chapter 448, O.S.L. 2024 (56 O.S. Supp. | | | 15|2024, Section 4002.2), is amended to read as follows: | | | 16| Section 4002.2. As used in the Ensuring Access to Medicaid Act: | | | 17| 1. "Adverse determination" has the same meaning as provided by | | | 18|Section 6475.3 of Title 36 of the Oklahoma Statutes; | | | 19| 2. "Accountable care organization" means a network of | | | 20|physicians, hospitals, and other health care providers that provides | | | 21|coordinated care to Medicaid members; | | | 22| 3. "Claims denial error rate" means the rate of claims denials | | | 23|that are overturned on appeal; | | | 24| | | | Req. No. 10140 Page 1 ___________________________________________________________________________
1| 4. "Capitated contract" means a contract between the Oklahoma | | | 2|Health Care Authority and a contracted entity for delivery of | | | 3|services to Medicaid members in which the Authority pays a fixed, | | | 4|per-member-per-month rate based on actuarial calculations; | | | 5| 5. "Children's Specialty Plan" means a health care plan that | | | 6|covers all Medicaid services other than dental services and is | | | 7|designed to provide care to: | | | 8| a. children in foster care, | | | 9| b. former foster care children up to twenty-five (25) | | | 10| years of age, | | | 11| c. juvenile-justice-involved children,and| | | 12|d. children receiving adoption assistance, | | | 13| e. children involved in a Family Centered Services (FCS) | | | 14| case through the Child Welfare Services division of | | | 15| the Department of Human Services, | | | 16| f. children in the custody of the Department of Human | | | 17| Services and placed at home under court supervision, | | | 18| g. children who are placed at home in a trial | | | 19| reunification plan administered by the Department of | | | 20| Human Services, and | | | 21| h. Medicaid enrolled parents and guardians whose | | | 22| children are in an FCS case, are in trial | | | 23| reunification, or are in the custody of the Department | | | 24| | | | Req. No. 10140 Page 2 ___________________________________________________________________________
1| of Human Services in Foster Care or under court | | | 2| supervision; | | | 3| 6. "Clean claim" means a properly completed billing form with | | | 4|Current Procedural Terminology, 4th Edition or a more recent | | | 5|edition, the Tenth Revision of the International Classification of | | | 6|Diseases coding or a more recent revision, or Healthcare Common | | | 7|Procedure Coding System coding where applicable that contains | | | 8|information specifically required in the Provider Billing and | | | 9|Procedure Manual of the Oklahoma Health Care Authority, as defined | | | 10|in 42 C.F.R., Section 447.45(b); | | | 11| 7. "Commercial plan" means an organization or entity that | | | 12|undertakes to provide or arrange for the delivery of health care | | | 13|services to Medicaid members on a prepaid basis and is subject to | | | 14|all applicable federal and state laws and regulations; | | | 15| 8. "Contracted entity" means an organization or entity that | | | 16|enters into or will enter into a capitated contract with the | | | 17|Oklahoma Health Care Authority for the delivery of services | | | 18|specified in the Ensuring Access to Medicaid Act that will assume | | | 19|financial risk, operational accountability, and statewide or | | | 20|regional functionality as defined in the Ensuring Access to Medicaid | | | 21|Act in managing comprehensive health outcomes of Medicaid members. | | | 22|For purposes of the Ensuring Access to Medicaid Act, the term | | | 23|contracted entity includes an accountable care organization, a | | | 24| | | | Req. No. 10140 Page 3 ___________________________________________________________________________
1|provider-led entity, a commercial plan, a dental benefit manager, or | | | 2|any other entity as determined by the Authority; | | | 3| 9. "Dental benefit manager" means an entity that handles claims | | | 4|payment and prior authorizations and coordinates dental care with | | | 5|participating providers and Medicaid members; | | | 6| 10. "Essential community provider" means: | | | 7| a. a Federally Qualified Health Center, | | | 8| b. a community mental health center, | | | 9| c. an Indian Health Care Provider, | | | 10| d. a rural health clinic, | | | 11| e. a state-operated mental health hospital, | | | 12| f. a long-term care hospital serving children (LTCH-C), | | | 13| g. a teaching hospital owned, jointly owned, or | | | 14| affiliated with and designated by the University | | | 15| Hospitals Authority, University Hospitals Trust, | | | 16| Oklahoma State University Medical Authority, or | | | 17| Oklahoma State University Medical Trust, | | | 18| h. a provider employed by or contracted with, or | | | 19| otherwise a member of the faculty practice plan of: | | | 20| (1) a public, accredited medical school in this | | | 21| state, or | | | 22| (2) a hospital or health care entity directly or | | | 23| indirectly owned or operated by the University | | | 24| | | | Req. No. 10140 Page 4 ___________________________________________________________________________
1| Hospitals Trust or the Oklahoma State University | | | 2| Medical Trust, | | | 3| i. a county department of health or city-county health | | | 4| department, | | | 5| j. a comprehensive community addiction recovery center, | | | 6| k. a hospital licensed by this state including all | | | 7| hospitals participating in the Supplemental Hospital | | | 8| Offset Payment Program, | | | 9| l. a Certified Community Behavioral Health Clinic | | | 10| (CCBHC), | | | 11| m. a provider employed by or contracted with a primary | | | 12| care residency program accredited by the Accreditation | | | 13| Council for Graduate Medical Education, | | | 14| n. any additional Medicaid provider as approved by the | | | 15| Authority if the provider either offers services that | | | 16| are not available from any other provider within a | | | 17| reasonable access standard or provides a substantial | | | 18| share of the total units of a particular service | | | 19| utilized by Medicaid members within the region during | | | 20| the last three (3) years, and the combined capacity of | | | 21| other service providers in the region is insufficient | | | 22| to meet the total needs of the Medicaid members, | | | 23| o. a pharmacy or pharmacist, or | | | 24| | | | Req. No. 10140 Page 5 ___________________________________________________________________________
1| p. any provider not otherwise mentioned in this | | | 2| paragraph that meets the definition of "essential | | | 3| community provider" under 45 C.F.R., Section 156.235; | | | 4| 11. "Material change" includes, but is not limited to, any | | | 5|change in overall business operations such as policy, process or | | | 6|protocol which affects, or can reasonably be expected to affect, | | | 7|more than five percent (5%) of enrollees or participating providers | | | 8|of the contracted entity; | | | 9| 12. "Governing body" means a group of individuals appointed by | | | 10|the contracted entity who approve policies, operations, profit/loss | | | 11|ratios, executive employment decisions, and who have overall | | | 12|responsibility for the operations of the contracted entity of which | | | 13|they are appointed; | | | 14| 13. "Local Oklahoma provider organization" means any state | | | 15|provider association, accountable care organization, Certified | | | 16|Community Behavioral Health Clinic, Federally Qualified Health | | | 17|Center, Native American tribe or tribal association, hospital or | | | 18|health system, academic medical institution, currently practicing | | | 19|licensed provider, or other local Oklahoma provider organization as | | | 20|approved by the Authority; | | | 21| 14. "Medical necessity" has the same meaning as "medically | | | 22|necessary" in Section 6592 of Title 36 of the Oklahoma Statutes; | | | 23| 15. "Participating provider" means a provider who has a | | | 24|contract with or is employed by a contracted entity to provide | | | Req. No. 10140 Page 6 ___________________________________________________________________________
1|services to Medicaid members as authorized by the Ensuring Access to | | | 2|Medicaid Act; | | | 3| 16. "Provider" means a health care or dental provider licensed | | | 4|or certified in this state or a provider that meets the Authority's | | | 5|provider enrollment criteria to contract with the Authority as a | | | 6|SoonerCare provider; | | | 7| 17. "Provider-led entity" means an organization or entity, a | | | 8|majority of whose governing body is composed of individuals who: | | | 9| a. have experience serving Medicaid members and: | | | 10| (1) are licensed in this state as physicians, | | | 11| physician assistants, or Advanced Practice | | | 12| Registered Nurses, | | | 13| (2) at least one board member is a licensed | | | 14| behavioral health provider, or | | | 15| (3) are employed by: | | | 16| (a) a hospital or other medical facility | | | 17| licensed by this state and operating in this | | | 18| state, or | | | 19| (b) an inpatient or outpatient mental health or | | | 20| substance abuse treatment facility or | | | 21| program licensed or certified by this state | | | 22| and operating in this state, | | | 23| | | | 24| | | | Req. No. 10140 Page 7 ___________________________________________________________________________
1| b. represent the providers or facilities described in | | | 2| subparagraph a of this paragraph including, but not | | | 3| limited to, individuals who are employed by a | | | 4| statewide provider association, or | | | 5| c. are nonclinical administrators of clinical practices | | | 6| serving Medicaid members; | | | 7| 18. "Provider-owned entity" means an organization or entity, a | | | 8|majority of whose ownership is held by Medicaid providers in this | | | 9|state or is held by an entity that directly or indirectly owns or is | | | 10|under common ownership with Medicaid providers in this state; | | | 11| 19. "Statewide" means all counties of this state including the | | | 12|urban region; and | | | 13| 20. "Urban region" means: | | | 14| a. all counties of this state with a county population | | | 15| of not less than five hundred thousand (500,000) | | | 16| according to the latest Federal Decennial Census, and | | | 17| b. all counties that are contiguous to the counties | | | 18| described in subparagraph a of this paragraph, | | | 19| combined into one region. | | | 20| SECTION 2. This act shall become effective July 1, 2026. | | | 21| | | | 22| 60-1-10140 TJ 01/06/25 | | | 23| | | | 24| | | | Req. No. 10140 Page 8