1| STATE OF OKLAHOMA | | | 2| 2nd Session of the 60th Legislature (2026) | | | 3|HOUSE BILL 3626 By: Lawson | | | 4| | | | 5| | | | 6| AS INTRODUCED | | | 7| An Act relating to Medicaid; amending 56 O.S. 2021, | | Section 4002.8, as last amended by Section 3, Chapter | 8| 372, O.S.L. 2025 (56 O.S. Supp. 2025, Section | | 4002.8), which relates to adverse determinations and | 9| procedures; adding to who can review the appeal; | | stating the requirements for a psychologist; amending | 10| 56 O.S. 2021, Section 4002.12, as last amended by | | Section 7, Chapter 448, O.S.L. 2024 (56 O.S. Supp. | 11| 2025, Section 4002.12), which relates to minimum | | rates of reimbursement, value-based payment | 12| arrangements, and payment methodologies; directing | | the Oklahoma Health Care Authority to establish a | 13| reimbursement rate for psychologists upon appeal; and | | providing an effective date. | 14| | | | 15| | | | 16| | | | 17|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 18| SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.8, as | | | 19|last amended by Section 3, Chapter 372, O.S.L. 2025 (56 O.S. Supp. | | | 20|2025, Section 4002.8), is amended to read as follows: | | | 21| Section 4002.8. A. A contracted entity shall utilize uniform | | | 22|procedures established by the Authority under subsection B of this | | | 23|section for the review and appeal of any adverse determination by | | | 24| | | | Req. No. 15156 Page 1 ___________________________________________________________________________
1|the contracted entity sought by any member or provider adversely | | | 2|affected by such determination. | | | 3| B. The Authority shall develop procedures for members or | | | 4|providers to seek review by the contracted entity of any adverse | | | 5|determination made by the contracted entity. | | | 6| C. A provider shall have six (6) months from the receipt of a | | | 7|claim denial to file an appeal. | | | 8| D. A contracted entity shall ensure that all appeals of adverse | | | 9|determinations made by the contracted entity are reviewed by a | | | 10|licensed physician or, if appropriate for the requested service, a | | | 11|licensed mental health professional. The contracted entity shall | | | 12|not use any automated claim review software or other automated | | | 13|functionality for such appeals. | | | 14| E. The physician or mental health professional who reviews the | | | 15|appeal shall: | | | 16| 1. Possess a current and valid unrestricted license in any | | | 17|United States jurisdiction; | | | 18| 2. Be of the same or similar specialty as a physician, | | | 19|psychologist, or mental health professional who typically manages | | | 20|the medical condition or disease. This requirement shall be | | | 21|considered met: | | | 22| a. for a physician, if: | | | 23| | | | 24| | | | Req. No. 15156 Page 2 ___________________________________________________________________________
1| (1) the physician maintains board certification for | | | 2| the same or similar specialty as the medical | | | 3| condition in question, or | | | 4| (2) the physician's training and experience: | | | 5| (a) includes treatment of the condition, | | | 6| (b) includes treatment of complications that | | | 7| may result from the service or procedure, | | | 8| and | | | 9| (c) is sufficient for the physician to | | | 10| determine if the service or procedure is | | | 11| medically necessary or clinically | | | 12| appropriate, or | | | 13| b. for a psychologist, if: | | | 14| (1) the psychologist is currently licensed in | | | 15| accordance with the Psychologists Licensing Act | | | 16| in Title 59 of the Oklahoma Statutes, | | | 17| (2) the psychologist has training and experience in | | | 18| the testing for and treatment of the condition, | | | 19| or | | | 20| (3) the psychologist's training and experience is | | | 21| sufficient to determine if the service is | | | 22| medically necessary or clinically appropriate, or | | | 23| c. foraother mental healthprofessionalprofessionals, | | | 24| | | | Req. No. 15156 Page 3 ___________________________________________________________________________
1| if the mental health professional's training and | | | 2| experience: | | | 3| (1) includes treatment of the condition, and | | | 4| (2) is sufficient for the mental health professional | | | 5| to determine if the service is medically | | | 6| necessary or clinically appropriate; | | | 7| 3. Not have been directly involved in making the adverse | | | 8|determination; | | | 9| 4. Not have any financial interest in the outcome of the | | | 10|appeal; and | | | 11| 5. Consider all known clinical aspects of the health care | | | 12|service under review including, but not limited to, a review of any | | | 13|medical records pertinent to the active condition that are provided | | | 14|to the contracted entity by the member's provider, or a health care | | | 15|facility, and any pertinent medical literature provided to the | | | 16|contracted entity by the provider. | | | 17| F. Upon receipt of notice from the contracted entity that the | | | 18|adverse determination has been upheld on appeal, the member or | | | 19|provider may request a fair hearing from the Authority. The | | | 20|Authority shall develop procedures for fair hearings in accordance | | | 21|with 42 C.F.R., Part 431. | | | 22| SECTION 2. AMENDATORY 56 O.S. 2021, Section 4002.12, as | | | 23|last amended by Section 7, Chapter 448, O.S.L. 2024 (56 O.S. Supp. | | | 24|2025, Section 4002.12), is amended to read as follows: | | | Req. No. 15156 Page 4 ___________________________________________________________________________
1| Section 4002.12. A. Until July 1, 2027, the Oklahoma Health | | | 2|Care Authority shall establish minimum rates of reimbursement from | | | 3|contracted entities to providers who elect not to enter into | | | 4|value-based payment arrangements under subsection B of this section | | | 5|or other alternative payment agreements for health care items and | | | 6|services furnished by such providers to enrollees of the state | | | 7|Medicaid program. Except as provided by subsection I of this | | | 8|section, until July 1, 2027, such reimbursement rates shall be equal | | | 9|to or greater than: | | | 10| 1. For an item or service provided by a participating provider | | | 11|who is in the network of the contracted entity, one hundred percent | | | 12|(100%) of the reimbursement rate for the applicable service in the | | | 13|applicable fee schedule of the Authority; or | | | 14| 2. For an item or service provided by a non-participating | | | 15|provider or a provider who is not in the network of the contracted | | | 16|entity, ninety percent (90%) of the reimbursement rate for the | | | 17|applicable service in the applicable fee schedule of the Authority | | | 18|as of January 1, 2021. | | | 19| B. A contracted entity shall offer value-based payment | | | 20|arrangements to all providers in its network capable of entering | | | 21|into value-based payment arrangements. Such arrangements shall be | | | 22|optional for the provider but shall be tied to reimbursement | | | 23|incentives when quality metrics are met. The quality measures used | | | 24|by a contracted entity to determine reimbursement amounts to | | | Req. No. 15156 Page 5 ___________________________________________________________________________
1|providers in value-based payment arrangements shall align with the | | | 2|quality measures of the Authority for contracted entities. | | | 3| C. Notwithstanding any other provision of this section, the | | | 4|Authority shall comply with payment methodologies required by | | | 5|federal law or regulation for specific types of providers, | | | 6|including, but not limited to, Federally Qualified Health Centers, | | | 7|rural health clinics, pharmacies, Indian Health Care Providers, and | | | 8|emergency services. | | | 9| D. A contracted entity shall offer all rural health clinics | | | 10|(RHCs) contracts that reimburse RHCs using the methodology in place | | | 11|for each specific RHC prior to January 1, 2023, including any and | | | 12|all annual rate updates. The contracted entity shall comply with | | | 13|all federal program rules and requirements, and the transformed | | | 14|Medicaid delivery system shall not interfere with the program as | | | 15|designed. | | | 16| E. The Oklahoma Health Care Authority shall establish minimum | | | 17|rates of reimbursement from contracted entities to Certified | | | 18|Community Behavioral Health Clinic (CCBHC) providers who elect | | | 19|alternative payment arrangements equal to the prospective payment | | | 20|system rate under the Medicaid State Plan. | | | 21| F. The Authority shall establish an incentive payment under the | | | 22|Supplemental Hospital Offset Payment Program that is determined by | | | 23|value-based outcomes for providers other than hospitals. | | | 24| | | | Req. No. 15156 Page 6 ___________________________________________________________________________
1| G. 1. Psychologist reimbursement shall reflect outcomes. | | | 2|Reimbursement shall not be limited to therapy and shall include, but | | | 3|not be limited to, patient intake administration, testing, and | | | 4|assessment. | | | 5| 2. The Authority shall establish a reimbursement rate for | | | 6|psychologists who are successful upon appeal pursuant to section | | | 7|4002.8 of this title that compensates them for the hours spent by | | | 8|the psychologist on the appeal. Such reimbursement shall take into | | | 9|account the hours spent on the administration of the appeal that | | | 10|would have otherwise been spent on providing services to patients. | | | 11| H. Coverage for Medicaid ground transportation services by | | | 12|licensed Oklahoma emergency medical services shall be reimbursed at | | | 13|no less than the published Medicaid rates as set by the Authority. | | | 14|All currently published Medicaid Healthcare Common Procedure Coding | | | 15|System (HCPCS) codes paid by the Authority shall continue to be paid | | | 16|by the contracted entity. The contracted entity shall comply with | | | 17|all reimbursement policies established by the Authority for the | | | 18|ambulance providers. Contracted entities shall accept the modifiers | | | 19|established by the Centers for Medicare and Medicaid Services | | | 20|currently in use by Medicare at the time of the transport of a | | | 21|memberthatwho is dually eligible for Medicare and Medicaid. | | | 22| I. 1. The rate paid to participating pharmacy providers is | | | 23|independent of subsection A of this section and shall be the same as | | | 24|the fee-for-service rate employed by the Authority for the Medicaid | | | Req. No. 15156 Page 7 ___________________________________________________________________________
1|program as stated in the payment methodology in OAC 317:30-5-78, | | | 2|unless the participating pharmacy provider elects to enter into | | | 3|other alternative payment agreements. | | | 4| 2. A pharmacy or pharmacist shall receive direct payment or | | | 5|reimbursement from the Authority or contracted entity when providing | | | 6|a health care service to the Medicaid member at a rate no less than | | | 7|that of other health care providers for providing the same service. | | | 8| J. Notwithstanding any other provision of this section, | | | 9|anesthesia shall continue to be reimbursed equal to or greater than | | | 10|the anesthesia fee schedule established by the Authority as of | | | 11|January 1, 2021. Anesthesia providers may also enter into | | | 12|value-based payment arrangements under this section or alternative | | | 13|payment arrangements for services furnished to Medicaid members. | | | 14| K. The Authority shall specify in the requests for proposals a | | | 15|reasonable time frame in which a contracted entity shall have | | | 16|entered into a certain percentage, as determined by the Authority, | | | 17|of value-based contracts with providers. | | | 18| L. Capitation rates established by the Oklahoma Health Care | | | 19|Authority and paid to contracted entities under capitated contracts | | | 20|shall be updated annually and in accordance with 42 C.F.R., Section | | | 21|438.3. Capitation rates shall be approved as actuarially sound as | | | 22|determined by the Centers for Medicare and Medicaid Services in | | | 23|accordance with 42 C.F.R., Section 438.4 and the following: | | | 24| | | | Req. No. 15156 Page 8 ___________________________________________________________________________
1| 1. Actuarial calculations must include utilization and | | | 2|expenditure assumptions consistent with industry and local | | | 3|standards; and | | | 4| 2. Capitation rates shall be risk-adjusted and shall include a | | | 5|portion that is at risk for achievement of quality and outcomes | | | 6|measures. | | | 7| M. The Authority may establish a symmetric risk corridor for | | | 8|contracted entities. | | | 9| N. The Authority shall establish a process for annual recovery | | | 10|of funds from, or assessment of penalties on, contracted entities | | | 11|that do not meet the medical loss ratio standards stipulated in | | | 12|Section 4002.5 of this title. | | | 13| O. 1. The Authority shall, through the financial reporting | | | 14|required under subsection G of Section 4002.12b of this title, | | | 15|determine the percentage of health care expenses by each contracted | | | 16|entity on primary care services. | | | 17| 2. Not later than the end of the fourth year of the initial | | | 18|contracting period, each contracted entity shall be currently | | | 19|spending not less than eleven percent (11%) of its total health care | | | 20|expenses on primary care services. | | | 21| 3. The Authority shall monitor the primary care spending of | | | 22|each contracted entity and require each contracted entity to | | | 23|maintain the level of spending on primary care services stipulated | | | 24|in paragraph 2 of this subsection. | | | Req. No. 15156 Page 9 ___________________________________________________________________________
1| SECTION 3. This act shall become effective November 1, 2026. | | | 2| | | | 3| 60-2-15156 TJ 12/18/25 | | | 4| | | | 5| | | | 6| | | | 7| | | | 8| | | | 9| | | | 10| | | | 11| | | | 12| | | | 13| | | | 14| | | | 15| | | | 16| | | | 17| | | | 18| | | | 19| | | | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | Req. No. 15156 Page 10