1| HOUSE OF REPRESENTATIVES - FLOOR VERSION |
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2| STATE OF OKLAHOMA |
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3| 2nd Session of the 59th Legislature (2024) |
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4|COMMITTEE SUBSTITUTE |
|FOR ENGROSSED |
5|SENATE BILL NO. 1675 By: McCortney of the Senate |
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6| and |
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7| McEntire of the House |
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8| |
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9| |
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10| COMMITTEE SUBSTITUTE |
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11| [ Medicaid program capitated contracts entity |
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12| deadlines contracted entities credentialing |
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13| recredentialing authorizations deadlines |
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14| clinical staff claims audits reimbursement |
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15| -deadlines references language |
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16| emergency ] |
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17| |
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18| |
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19|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: |
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20|
1| 1. "Adverse determination" has the same meaning as provided by |
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2|Section 6475.3 of Title 36 of the Oklahoma Statutes; |
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3| 2. "Accountable care organization" means a network of |
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4|physicians, hospitals, and other health care providers that provides |
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5|coordinated care to Medicaid members; |
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6| 3. "Claims denial error rate" means the rate of claims denials |
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7|that are overturned on appeal; |
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8| 4. "Capitated contract" means a contract between the Oklahoma |
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9|Health Care Authority and a contracted entity for delivery of |
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10|services to Medicaid members in which the Authority pays a fixed, |
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11|per-member-per-month rate based on actuarial calculations; |
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12| 5. "Children's Specialty Plan" means a health care plan that |
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13|covers all Medicaid services other than dental services and is |
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14|designed to provide care to: |
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15| a. children in foster care, |
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16| b. former foster care children up to twenty-five (25) |
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17| years of age, |
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18| c. juvenile justice involved juvenile-justice-involved |
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19| children, and |
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20| d. children receiving adoption assistance; |
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21| 6. "Clean claim" means a properly completed billing form with |
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22|Current Procedural Terminology, 4th Edition or a more recent |
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23|edition, the Tenth Revision of the International Classification of |
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24|Diseases coding or a more recent revision, or Healthcare Common |
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1|Procedure Coding System coding where applicable that contains |
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2|information specifically required in the Provider Billing and |
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3|Procedure Manual of the Oklahoma Health Care Authority, as defined |
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4|in 42 C.F.R., Section 447.45(b); |
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5| 7. "Commercial plan" means an organization or entity that |
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6|undertakes to provide or arrange for the delivery of health care |
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7|services to Medicaid members on a prepaid basis and is subject to |
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8|all applicable federal and state laws and regulations; |
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9| 8. "Contracted entity" means an organization or entity that |
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10|enters into or will enter into a capitated contract with the |
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11|Oklahoma Health Care Authority for the delivery of services |
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12|specified in the Ensuring Access to Medicaid Act that will assume |
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13|financial risk, operational accountability, and statewide or |
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14|regional functionality as defined in the Ensuring Access to Medicaid |
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15|Act in managing comprehensive health outcomes of Medicaid members. |
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16|For purposes of the Ensuring Access to Medicaid Act, the term |
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17|contracted entity includes an accountable care organization, a |
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18|provider-led entity, a commercial plan, a dental benefit manager, or |
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19|any other entity as determined by the Authority; |
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20| 9. "Dental benefit manager" means an entity that handles claims |
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21|payment and prior authorizations and coordinates dental care with |
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22|participating providers and Medicaid members; |
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23| 10. "Essential community provider" means: |
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24| a. a Federally Qualified Health Center, |
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1| b. a community mental health center, |
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2| c. an Indian Health Care Provider, |
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3| d. a rural health clinic, |
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4| e. a state-operated mental health hospital, |
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5| f. a long-term care hospital serving children (LTCH-C), |
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6| g. a teaching hospital owned, jointly owned, or |
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7| affiliated with and designated by the University |
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8| Hospitals Authority, University Hospitals Trust, |
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9| Oklahoma State University Medical Authority, or |
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10| Oklahoma State University Medical Trust, |
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11| h. a provider employed by or contracted with, or |
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12| otherwise a member of the faculty practice plan of: |
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13| (1) a public, accredited medical school in this |
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14| state, or |
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15| (2) a hospital or health care entity directly or |
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16| indirectly owned or operated by the University |
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17| Hospitals Trust or the Oklahoma State University |
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18| Medical Trust, |
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19| i. a county department of health or city-county health |
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20| department, |
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21| j. a comprehensive community addiction recovery center, |
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22| k. a hospital licensed by the State of Oklahoma |
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23| including all hospitals participating in the |
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24| Supplemental Hospital Offset Payment Program, |
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1| l. a Certified Community Behavioral Health Clinic |
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2| (CCBHC), |
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3| m. a provider employed by or contracted with a primary |
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4| care residency program accredited by the Accreditation |
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5| Council for Graduate Medical Education, |
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6| n. any additional Medicaid provider as approved by the |
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7| Authority if the provider either offers services that |
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8| are not available from any other provider within a |
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9| reasonable access standard or provides a substantial |
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10| share of the total units of a particular service |
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11| utilized by Medicaid members within the region during |
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12| the last three (3) years, and the combined capacity of |
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13| other service providers in the region is insufficient |
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14| to meet the total needs of the Medicaid members, |
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15| o. a pharmacy or pharmacist, or |
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16| p. any provider not otherwise mentioned in this |
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17| paragraph that meets the definition of "essential |
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18| community provider" under 45 C.F.R., Section 156.235; |
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19| 11. "Material change" includes, but is not limited to, any |
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20|change in overall business operations such as policy, process or |
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21|protocol which affects, or can reasonably be expected to affect, |
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22|more than five percent (5%) of enrollees or participating providers |
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23|of the contracted entity; |
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24| |
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1| 12. "Governing body" means a group of individuals appointed by |
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2|the contracted entity who approve policies, operations, profit/loss |
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3|ratios, executive employment decisions, and who have overall |
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4|responsibility for the operations of the contracted entity of which |
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5|they are appointed; |
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6| 13. "Local Oklahoma provider organization" means any state |
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7|provider association, accountable care organization, Certified |
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8|Community Behavioral Health Clinic, Federally Qualified Health |
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9|Center, Native American tribe or tribal association, hospital or |
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10|health system, academic medical institution, currently practicing |
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11|licensed provider, or other local Oklahoma provider organization as |
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12|approved by the Authority; |
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13| 14. "Medical necessity" has the same meaning as provided by |
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14|rules promulgated by the Oklahoma Health Care Authority Board |
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15|"medically necessary" in Section 6592 of Title 36 of the Oklahoma |
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16|Statutes; |
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17| 15. "Participating provider" means a provider who has a |
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18|contract with or is employed by a contracted entity to provide |
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19|services to Medicaid members as authorized by the Ensuring Access to |
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20|Medicaid Act; |
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21| 16. "Provider" means a health care or dental provider licensed |
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22|or certified in this state or a provider that meets the Authority's |
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23|provider enrollment criteria to contract with the Authority as a |
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24|SoonerCare provider; |
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1| 17. "Provider-led entity" means an organization or entity that |
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2|meets the criteria of at least one of following two subparagraphs: |
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3| a. a majority of the entity's ownership is held by |
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4| Medicaid providers in this state or is held by an |
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5| entity that directly or indirectly owns or is under |
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6| common ownership with Medicaid providers in this |
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7| state, or |
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8| b. a majority of the entity's governing body is composed |
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9| of individuals who: |
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10| (1) A. have Have experience serving Medicaid members |
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11| and: |
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12| (a) 1. are licensed in this state as |
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13| physicians, physician assistants, nurse |
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14| practitioners, certified nurse-midwives, or |
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15| certified registered nurse anesthetists, |
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16| (b) 2. at least one board member is a licensed |
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17| behavioral health provider, or |
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18| (c) 3. are employed by: |
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19| i. (a) a hospital or other medical |
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20| facility licensed by this state and |
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21| operating in this state, or |
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22| ii. (b) an inpatient or outpatient mental |
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23| health or substance abuse treatment |
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24| |
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1| facility or program licensed or |
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2| certified by this state and operating |
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3| in this state, |
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4| (2) B. represent Represent the providers or |
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5| facilities described in division (1) of this |
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6| subparagraph including, but not limited to, |
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7| individuals who are employed by a statewide |
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8| provider association, or |
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9| (3) C. are Are nonclinical administrators of |
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10| clinical practices serving Medicaid members; |
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11| 18. "Provider-owned entity" means an organization or entity |
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12|that a majority of the entity's ownership is held by Medicaid |
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13|providers in this state or is held by an entity that directly or |
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14|indirectly owns or is under common ownership with Medicaid providers |
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15|in this state; |
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16| 19. "Statewide" means all counties of this state including the |
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17|urban region; and |
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18| 19. 20. "Urban region" means: |
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19| a. all counties of this state with a county population |
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20| of not less than five hundred thousand (500,000) |
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21| according to the latest Federal Decennial Census, and |
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22| b. all counties that are contiguous to the counties |
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23| described in subparagraph a of this paragraph, |
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24|combined into one region. |
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1| SECTION 2. AMENDATORY Section 3, Chapter 395, O.S.L. |
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2|2022 (56 O.S. Supp. 2023, Section 4002.3a), is amended to read as |
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3|follows: |
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4| Section 4002.3a A. 1. The Oklahoma Health Care Authority |
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5|(OHCA) shall enter into capitated contracts with contracted entities |
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6|for the delivery of Medicaid services as specified in this act the |
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7|Ensuring Access to Medicaid Act to transform the delivery system of |
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8|the state Medicaid program for the Medicaid populations listed in |
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9|this section. |
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10| 2. Unless expressly authorized by the Legislature, the |
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11|Authority shall not issue any request for proposals or enter into |
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12|any contract to transform the delivery system for the aged, blind, |
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13|and disabled populations eligible for SoonerCare. |
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14| B. 1. The Oklahoma Health Care Authority shall issue a request |
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15|for proposals to enter into public-private partnerships with |
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16|contracted entities other than dental benefit managers to cover all |
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17|Medicaid services other than dental services for the following |
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18|Medicaid populations: |
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19| a. pregnant women, |
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20| b. children, |
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21| c. deemed newborns under 42 C.F.R., Section 435.117, |
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22| d. parents and caretaker relatives, and |
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23| e. the expansion population. |
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24| |
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1| 2. The Authority shall specify the services to be covered in |
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2|the request for proposals referenced in paragraph 1 of this |
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3|subsection. Capitated contracts referenced in this subsection shall |
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4|cover all Medicaid services other than dental services including: |
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5| a. physical health services including, but not limited |
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6| to: |
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7| (1) primary care, |
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8| (2) inpatient and outpatient services, and |
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9| (3) emergency room services, |
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10| b. behavioral health services, and |
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11| c. prescription drug services. |
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12| 3. The Authority shall specify the services not covered in the |
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13|request for proposals referenced in paragraph 1 of this subsection. |
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14| 4. Subject to the requirements and approval of the Centers for |
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15|Medicare and Medicaid Services, the implementation of the program |
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16|shall be no later than October 1, 2023 April 1, 2024. |
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17| C. 1. The Authority shall issue a request for proposals to |
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18|enter into public-private partnerships with dental benefit managers |
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19|to cover dental services for the following Medicaid populations: |
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20| a. pregnant women, |
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21| b. children, |
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22| c. parents and caretaker relatives, |
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23| d. the expansion population, and |
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24| |
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1| e. members of the Children's Specialty Plan as provided |
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2| by subsection D of this section. |
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3| 2. The Authority shall specify the services to be covered in |
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4|the request for proposals referenced in paragraph 1 of this |
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5|subsection. |
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6| 3. Subject to the requirements and approval of the Centers for |
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7|Medicare and Medicaid Services, the implementation of the program |
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8|shall be no later than October 1, 2023 April 1, 2024. |
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9| D. 1. Either as part of the request for proposals referenced |
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10|in subsection B of this section or as a separate request for |
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11|proposals, the Authority shall issue a request for proposals to |
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12|enter into public-private partnerships with one contracted entity to |
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13|administer a Children's Specialty Plan. |
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14| 2. The Authority shall specify the services to be covered in |
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15|the request for proposals referenced in paragraph 1 of this |
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16|subsection. |
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17| 3. The contracted entity for the Children's Specialty Plan |
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18|shall coordinate with the dental benefit managers who cover dental |
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19|services for its members as provided by subsection C of this |
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20|section. |
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21| 4. Subject to the requirements and approval of the Centers for |
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22|Medicare and Medicaid Services, the implementation of the program |
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23|shall be no later than October 1, 2023 April 1, 2024. |
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24| |
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1| E. The Authority shall not implement the transformation of the |
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2|Medicaid delivery system until it receives written confirmation from |
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3|the Centers for Medicare and Medicaid Services that a managed care |
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4|directed payment program utilizing average commercial rate |
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5|methodology for hospital services under the Supplemental Hospital |
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6|Offset Payment Program has been approved for Year 1 of the |
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7|transformation and will be included in the budget neutrality cap |
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8|baseline spending level for purposes of Oklahoma's 1115 waiver |
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9|renewal; provided, however, nothing in this section shall prohibit |
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10|the Authority from exploring alternative opportunities with the |
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11|Centers for Medicare and Medicaid Services to maximize the average |
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12|commercial rate benefit. |
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13| SECTION 3. AMENDATORY Section 4, Chapter 395, O.S.L. |
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14|2022 (56 O.S. Supp. 2023, Section 4002.3b), is amended to read as |
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15|follows: |
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16| Section 4002.3b A. All capitated contracts shall be the result |
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17|of requests for proposals issued by the Oklahoma Health Care |
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18|Authority and submission of competitive bids by contracted entities |
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19|pursuant to the Oklahoma Central Purchasing Act. |
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20| B. Statewide capitated contracts may be awarded to any |
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21|contracted entity including, but not limited to, a provider-led |
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22|entity and a provider-owned entity. |
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23| C. The Authority shall award no less than three four statewide |
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24|capitated contracts to provide comprehensive integrated health |
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1|services including, but not limited to, medical, behavioral health, |
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2|and pharmacy services and no less than two statewide capitated |
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3|contracts to provide dental coverage to Medicaid members as |
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4|specified in Section 3 4002.3a of this act title. At least one |
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5|statewide capitated contract must be a provider-owned entity. |
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6| D. 1. Except as specified in paragraph 2 of this subsection, |
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7|at least one capitated contract to provide statewide coverage to |
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8|Medicaid members shall be awarded to a provider-owned entity and at |
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9|least one capitated contract to provide statewide coverage to |
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10|Medicaid members shall be awarded to a provider-led entity, as long |
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11|as the provider-led entity submits a responsive reply to the |
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12|Authority's request for proposals demonstrating ability to fulfill |
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13|the contract requirements. |
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14| 2. If no provider-led entity or provider-owned entity submits a |
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15|responsive reply to the Authority's request for proposals |
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16|demonstrating ability to fulfill the contract requirements, the |
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17|Authority shall not be required to contract for statewide coverage |
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18|with a provider-led entity or provider-owned entity. |
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19| 3. The Authority shall develop a scoring methodology for the |
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20|request for proposals that affords preferential scoring to |
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21|provider-led entities and provider-owned entities, as long as the |
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22|provider-led entity and provider-owned entity otherwise demonstrates |
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23|ability to fulfill the contract requirements. The preferential |
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24|scoring methodology shall include opportunities to award additional |
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1|points to provider-led entities and provider-owned entities based on |
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2|certain factors including, but not limited to: |
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3| a. broad provider participation in ownership and |
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4| governance structure, |
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5| b. demonstrated experience in care coordination and care |
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6| management for Medicaid members across a variety of |
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7| service types including, but not limited to, primary |
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8| care and behavioral health, |
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9| c. demonstrated experience in Medicare or Medicaid |
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10| accountable care organizations or other Medicare or |
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11| Medicaid alternative payment models, Medicare or |
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12| Medicaid value-based payment arrangements, or Medicare |
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13| or Medicaid risk-sharing arrangements including, but |
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14| not limited to, innovation models of the Center for |
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15| Medicare and Medicaid Innovation of the Centers for |
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16| Medicare and Medicaid Services, or value-based payment |
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17| arrangements or risk-sharing arrangements in the |
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18| commercial health care market, and |
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19| d. other relevant factors identified by the Authority. |
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20| E. The Authority may select at least one provider-led entity or |
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21|one provider-owned entity for the urban region if: |
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22| 1. The provider-led entity or provider-owned entity submits a |
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23|responsive reply to the Authority's request for proposals |
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24|demonstrating ability to fulfill the contract requirements; and |
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1| 2. The provider-led entity or provider-owned entity |
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2|demonstrates the ability, and agrees continually, to expand its |
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3|coverage area throughout the contract term and to develop statewide |
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4|operational readiness within a time frame set by the Authority but |
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5|not mandated before five (5) years. |
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6| F. At the discretion of the Authority, capitated contracts may |
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7|be extended to ensure there are no gaps in coverage that may result |
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8|from termination of a capitated contract; provided, the total |
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9|contracting period for a capitated contract shall not exceed seven |
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10|(7) years. |
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11| G. At the end of the contracting period, the Authority shall |
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12|solicit and award new contracts as provided by this section and |
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13|Section 3 2 of this act. |
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14| H. At the discretion of the Authority, subject to appropriate |
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15|notice to the Legislature and the Centers for Medicare and Medicaid |
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16|Services, the Authority may approve a delay in the implementation of |
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17|one or more capitated contracts to ensure financial and operational |
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18|readiness. |
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19| SECTION 4. AMENDATORY 56 O.S. 2021, Section 4002.4, as |
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20|amended by Section 7, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023, |
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21|Section 4002.4), is amended to read as follows: |
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22| Section 4002.4 A. The Oklahoma Health Care Authority shall |
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23|develop network adequacy standards for all contracted entities that, |
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24|at a minimum, meet the requirements of 42 C.F.R., Sections 438.3 and |
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1|438.68. Network adequacy standards established under this |
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2|subsection shall include distance and time standards and shall be |
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3|designed to ensure members covered by the contracted entities who |
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4|reside in health professional shortage areas (HPSAs) designated |
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5|under Section 332(a)(1) of the Public Health Service Act (42 U.S.C., |
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6|Section 254e(a)(1)) have access to in-person health care and |
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7|telehealth services with providers, especially adult and pediatric |
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8|primary care practitioners. |
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9| B. The Authority shall require all contracted entities to offer |
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10|or extend contracts with all essential community providers, all |
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11|providers who receive directed payments in accordance with 42 |
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12|C.F.R., Part 438 and such other providers as the Authority may |
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13|specify. The Authority shall establish such requirements as may be |
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14|necessary to prohibit contracted entities from excluding essential |
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15|community providers, providers who receive directed payments in |
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16|accordance with 42 C.F.R., Part 438 and such other providers as the |
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17|Authority may specify from contracts with contracted entities. |
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18| C. To ensure models of care are developed to meet the needs of |
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19|Medicaid members, each contracted entity must contract with at least |
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20|one local Oklahoma provider organization for a model of care |
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21|containing care coordination, care management, utilization |
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22|management, disease management, network management, or another model |
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23|of care as approved by the Authority. Such contractual arrangements |
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24|must be in place within twelve (12) months of the effective date of |
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1|the contracts awarded pursuant to the requests for proposals |
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2|authorized by Section 3 of this act Section 4002.3a of this title. |
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3| D. All contracted entities shall formally credential and |
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4|recredential network providers at a frequency required by a single, |
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5|consolidated provider enrollment and credentialing process |
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6|established by the Authority in accordance with 42 C.F.R., Section |
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7|438.214. A contracted entity shall complete credentialing or |
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8|recredentialing of a provider within sixty (60) calendar days of |
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9|receipt of a completed application. |
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10| E. All contracted entities shall be accredited in accordance |
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11|with 45 C.F.R., Section 156.275 by an accrediting entity recognized |
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12|by the United States Department of Health and Human Services. |
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13| F. 1. If the Authority awards a capitated contract to a |
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14|provider-led entity for the urban region under Section 4 of this act |
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15|Section 4002.3b of this title, the provider-led entity shall expand |
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16|its coverage area to every county of this state within the time |
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17|frame set by the Authority under subsection E of Section 4 of this |
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18|act Section 4002.3b of this title. |
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19| 2. The expansion of the provider-led entity's coverage area |
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20|beyond the urban region shall be subject to the approval of the |
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21|Authority. The Authority shall approve expansion to counties for |
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22|which the provider-led entity can demonstrate evidence of network |
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23|adequacy as required under 42 C.F.R., Sections 438.3 and 438.68. |
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24|When approved, the additional county or counties shall be added to |
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1|the provider-led entity's region during the next open enrollment |
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2|period. |
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3| SECTION 5. AMENDATORY 56 O.S. 2021, Section 4002.6, as |
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4|last amended by Section 2, Chapter 331, O.S.L. 2023 (56 O.S. Supp. |
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5|2023, Section 4002.6), is amended to read as follows: |
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6| Section 4002.6 A. A contracted entity shall meet all |
| |
7|requirements established by the Oklahoma Health Care Authority |
| |
8|pertaining to prior authorizations. The Authority shall establish |
| |
9|requirements that ensure timely determinations by contracted |
| |
10|entities when prior authorizations are required including expedited |
| |
11|review in urgent and emergent cases that at a minimum meet the |
| |
12|criteria of this section. |
| |
13| B. A contracted entity shall make a determination on a request |
| |
14|for an authorization of the transfer of a hospital inpatient to a |
| |
15|post-acute care or long-term acute care facility within twenty-four |
| |
16|(24) hours of receipt of the request. |
| |
17| C. A contracted entity shall make a determination on a request |
| |
18|for any member who is not hospitalized at the time of the request |
| |
19|within seventy-two (72) hours of receipt of the request; provided, |
| |
20|that if the request does not include sufficient or adequate |
| |
21|documentation, the review and determination shall occur within a |
| |
22|time frame and in accordance with a process established by the |
| |
23|Authority. The process established by the Authority pursuant to |
| |
24|this subsection shall include a time frame of at least forty-eight |
| |
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1|(48) hours within which a provider may submit the necessary |
| |
2|documentation. |
| |
3| D. A contracted entity shall make a determination on a request |
| |
4|for services for a hospitalized member including, but not limited |
| |
5|to, acute care inpatient services or equipment necessary to |
| |
6|discharge the member from an inpatient facility within one (1) |
| |
7|business day twenty-four (24) hours of receipt of the request. |
| |
8| E. Notwithstanding the provisions of subsection C of this |
| |
9|section, a contracted entity shall make a determination on a request |
| |
10|as expeditiously as necessary and, in any event, within twenty-four |
| |
11|(24) hours of receipt of the request for service if adhering to the |
| |
12|provisions of subsection C or D of this section could jeopardize the |
| |
13|member's life, health or ability to attain, maintain or regain |
| |
14|maximum function. In the event of a medically emergent matter, the |
| |
15|contracted entity shall not impose limitations on providers in |
| |
16|coordination of post-emergent stabilization health care including |
| |
17|pre-certification or prior authorization. |
| |
18| F. Notwithstanding any other provision of this section, a |
| |
19|contracted entity shall make a determination on a request for |
| |
20|inpatient behavioral health services within twenty-four (24) hours |
| |
21|of receipt of the request. |
| |
22| G. A contracted entity shall make a determination on a request |
| |
23|for covered prescription drugs that are required to be prior |
| |
24|authorized by the Authority within twenty-four (24) hours of receipt |
| |
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1|of the request. The contracted entity shall not require prior |
| |
2|authorization on any covered prescription drug for which the |
| |
3|Authority does not require prior authorization. |
| |
4| H. A contracted entity shall make a determination on a request |
| |
5|for coverage of biomarker testing in accordance with Section 3 of |
| |
6|this act Section 4003 of this title. |
| |
7| I. Upon issuance of an adverse determination on a prior |
| |
8|authorization request under subsection B of this section, the |
| |
9|contracted entity shall provide the requesting provider, within |
| |
10|seventy-two (72) hours of receipt of such issuance, with reasonable |
| |
11|opportunity to participate in a peer-to-peer review process with a |
| |
12|provider who practices in the same specialty, but not necessarily |
| |
13|the same sub-specialty, and who has experience treating the same |
| |
14|population as the patient on whose behalf the request is submitted; |
| |
15|provided, however, if the requesting provider determines the |
| |
16|services to be clinically urgent, the contracted entity shall |
| |
17|provide such opportunity within twenty-four (24) hours of receipt of |
| |
18|such issuance. Services not covered under the state Medicaid |
| |
19|program for the particular patient shall not be subject to |
| |
20|peer-to-peer review. |
| |
21| J. The Authority shall ensure that a provider offers to provide |
| |
22|to a member in a timely manner services authorized by a contracted |
| |
23|entity. |
| |
24| |
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1| K. The Authority shall establish requirements for both internal |
| |
2|and external reviews and appeals of adverse determinations on prior |
| |
3|authorization requests or claims that, at a minimum: |
| |
4| 1. Require contracted entities to provide a detailed |
| |
5|explanation of denials to Medicaid providers and members; |
| |
6| 2. Require contracted entities to provide a prompt an |
| |
7|opportunity for peer-to-peer conversations with licensed |
| |
8|Oklahoma-licensed clinical staff of the same or similar specialty |
| |
9|which shall include, but not be limited to, Oklahoma-licensed |
| |
10|clinical staff upon within twenty-four (24) hours of the adverse |
| |
11|determination; and |
| |
12| 3. Establish uniform rules for Medicaid provider or member |
| |
13|appeals across all contracted entities. |
| |
14| SECTION 6. AMENDATORY 56 O.S. 2021, Section 4002.7, as |
| |
15|amended by Section 11, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023, |
| |
16|Section 4002.7), is amended to read as follows: |
| |
17| Section 4002.7 A. The Oklahoma Health Care Authority shall |
| |
18|establish requirements for fair processing and adjudication of |
| |
19|claims that ensure prompt reimbursement of providers by contracted |
| |
20|entities. A contracted entity shall comply with all such |
| |
21|requirements. |
| |
22| B. A contracted entity shall process a clean claim in the time |
| |
23|frame provided by Section 1219 of Title 36 of the Oklahoma Statutes |
| |
24|and no less than ninety percent (90%) of all clean claims shall be |
| |
arsid12452994 SB1675 HFLR Page 21
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1|paid within fourteen (14) days of submission to the contracted |
| |
2|entity. A clean claim that is not processed within the time frame |
| |
3|provided by Section 1219 of Title 36 of the Oklahoma Statutes shall |
| |
4|bear simple interest at the monthly rate of one and one-half percent |
| |
5|(1.5%) payable to the provider. A claim filed by a provider within |
| |
6|six (6) months of the date the item or service was furnished to a |
| |
7|member shall be considered timely. If a claim meets the definition |
| |
8|of a clean claim, the contracted entity shall not request medical |
| |
9|records of the member prior to paying the claim. Once a claim has |
| |
10|been paid, the contracted entity may request medical records if |
| |
11|additional documentation is needed to review the claim for medical |
| |
12|necessity. |
| |
13| C. In the case of a denial of a claim including, but not |
| |
14|limited to, a denial on the basis of the level of emergency care |
| |
15|indicated on the claim, or in the case of a downcoded claim, the |
| |
16|contracted entity shall establish a process by which the provider |
| |
17|may identify and provide such additional information as may be |
| |
18|necessary to substantiate the claim. Any such claim denial or |
| |
19|downcode shall include the following: |
| |
20| 1. A detailed explanation of the basis for the denial; and |
| |
21| 2. A detailed description of the additional information |
| |
22|necessary to substantiate the claim. |
| |
23| D. Postpayment audits by a contracted entity shall be subject |
| |
24|to the following requirements: |
| |
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1| 1. Subject to paragraph 2 of this subsection, insofar as a |
| |
2|contracted entity conducts postpayment audits, the contracted entity |
| |
3|shall employ the postpayment audit process determined by the |
| |
4|Authority; |
| |
5| 2. The Authority shall establish a limit, not to exceed three |
| |
6|percent (3%), on the percentage of claims with respect to which |
| |
7|postpayment audits may be conducted by a contracted entity for |
| |
8|health care items and services furnished by a provider in a plan |
| |
9|year; and |
| |
10| 3. The Authority shall provide for the imposition of financial |
| |
11|penalties under such contract in the case of any contracted entity |
| |
12|with respect to which the Authority determines has a claims denial |
| |
13|error rate of greater than five percent (5%). The Authority shall |
| |
14|establish the amount of financial penalties and the time frame under |
| |
15|which such penalties shall be imposed on contracted entities under |
| |
16|this paragraph, in no case less than annually. |
| |
17| E. A contracted entity may only apply readmission penalties |
| |
18|pursuant to rules promulgated by the Oklahoma Health Care Authority |
| |
19|Board. The Board shall promulgate rules establishing a program to |
| |
20|reduce potentially preventable readmissions. The program shall use |
| |
21|a nationally recognized tool, establish a base measurement year and |
| |
22|a performance year, and provide for risk-adjustment based on the |
| |
23|population of the state Medicaid program covered by the contracted |
| |
24|entities. |
| |
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1| SECTION 7. AMENDATORY 56 O.S. 2021, Section 4002.12, as |
| |
2|last amended by Section 1, Chapter 308, O.S.L. 2023 (56 O.S. Supp. |
| |
3|2023, Section 4002.12), is amended to read as follows: |
| |
4| Section 4002.12 A. Until July 1, 2026, the The Oklahoma Health |
| |
5|Care Authority shall establish minimum rates of reimbursement from |
| |
6|contracted entities to providers who elect not to enter into |
| |
7|value-based payment arrangements under subsection B of this section |
| |
8|or other alternative payment agreements for health care items and |
| |
9|services furnished by such providers to enrollees of the state |
| |
10|Medicaid program. Except as provided by subsection I of this |
| |
11|section until July 1, 2026, such reimbursement rates shall be equal |
| |
12|to or greater than: |
| |
13| 1. For an item or service provided by a participating provider |
| |
14|who is in the network of the contracted entity, one hundred percent |
| |
15|(100%) of the reimbursement rate for the applicable service in the |
| |
16|applicable fee schedule of the Authority; or |
| |
17| 2. For an item or service provided by a non-participating |
| |
18|provider or a provider who is not in the network of the contracted |
| |
19|entity, ninety percent (90%) of the reimbursement rate for the |
| |
20|applicable service in the applicable fee schedule of the Authority |
| |
21|as of January 1, 2021. |
| |
22| B. A contracted entity shall offer value-based payment |
| |
23|arrangements to all providers in its network capable of entering |
| |
24|into value-based payment arrangements. Such arrangements shall be |
| |
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1|optional for the provider but shall be tied to reimbursement |
| |
2|incentives when quality metrics are met. The quality measures used |
| |
3|by a contracted entity to determine reimbursement amounts to |
| |
4|providers in value-based payment arrangements shall align with the |
| |
5|quality measures of the Authority for contracted entities. |
| |
6|Reimbursement under a value-based arrangement will be in addition to |
| |
7|the minimum rate established in Section 4002.3a of this title or one |
| |
8|hundred percent (100%) of minimum rate floor, whichever is greater. |
| |
9| C. Notwithstanding any other provision of this section, the |
| |
10|Authority shall comply with payment methodologies required by |
| |
11|federal law or regulation for specific types of providers including, |
| |
12|but not limited to, Federally Qualified Health Centers, rural health |
| |
13|clinics, pharmacies, Indian Health Care Providers and emergency |
| |
14|services. |
| |
15| D. A contracted entity shall offer all rural health clinics |
| |
16|(RHCs) contracts that reimburse RHCs using the methodology in place |
| |
17|for each specific RHC prior to January 1, 2023, including any and |
| |
18|all annual rate updates. The contracted entity shall comply with |
| |
19|all federal program rules and requirements, and the transformed |
| |
20|Medicaid delivery system shall not interfere with the program as |
| |
21|designed. |
| |
22| E. The Oklahoma Health Care Authority shall establish minimum |
| |
23|rates of reimbursement from contracted entities to Certified |
| |
24|Community Behavioral Health Clinic (CCBHC) providers who elect |
| |
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1|alternative payment arrangements equal to the prospective payment |
| |
2|system rate under the Medicaid State Plan. |
| |
3| F. The Authority shall establish an incentive payment under the |
| |
4|Supplemental Hospital Offset Payment Program that is determined by |
| |
5|value-based outcomes for providers other than hospitals. |
| |
6| G. Psychologist reimbursement shall reflect outcomes. |
| |
7|Reimbursement shall not be limited to therapy and shall include but |
| |
8|not be limited to testing and assessment. |
| |
9| H. Coverage for Medicaid ground transportation services by |
| |
10|licensed Oklahoma emergency medical services shall be reimbursed at |
| |
11|no less than the published Medicaid rates as set by the Authority. |
| |
12|All currently published Medicaid Healthcare Common Procedure Coding |
| |
13|System (HCPCS) codes paid by the Authority shall continue to be paid |
| |
14|by the contracted entity. The contracted entity shall comply with |
| |
15|all reimbursement policies established by the Authority for the |
| |
16|ambulance providers. Contracted entities shall accept the modifiers |
| |
17|established by the Centers for Medicare and Medicaid Services |
| |
18|currently in use by Medicare at the time of the transport of a |
| |
19|member that is dually eligible for Medicare and Medicaid. |
| |
20| I. 1. The rate paid to participating pharmacy providers is |
| |
21|independent of subsection A of this section and shall be the same as |
| |
22|the fee-for-service rate employed by the Authority for the Medicaid |
| |
23|program as stated in the payment methodology at in OAC 317:30-5-78, |
| |
24| |
| |
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1|unless the participating pharmacy provider elects to enter into |
| |
2|other alternative payment agreements. |
| |
3| 2. A pharmacy or pharmacist shall receive direct payment or |
| |
4|reimbursement from the Authority or contracted entity when providing |
| |
5|a health care service to the Medicaid member at a rate no less than |
| |
6|that of other health care providers for providing the same service. |
| |
7| J. Notwithstanding any other provision of this section, |
| |
8|anesthesia shall continue to be reimbursed equal to or greater than |
| |
9|the Anesthesia Fee Schedule anesthesia fee schedule established by |
| |
10|the Authority as of January 1, 2021. Anesthesia providers may also |
| |
11|enter into value-based payment arrangements under this section or |
| |
12|alternative payment arrangements for services furnished to Medicaid |
| |
13|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| |
| |
arsid12452994 SB1675 HFLR Page 27
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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. |
| |
arsid12452994 SB1675 HFLR Page 28
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1| SECTION 8. It being immediately necessary for the preservation |
| |
2|of the public peace, health or safety, an emergency is hereby |
| |
3|declared to exist, by reason whereof this act shall take effect and |
| |
4|be in full force from and after its passage and approval. |
| |
5| |
| |
6|COMMITTEE REPORT BY: COMMITTEE ON APPROPRIATIONS AND BUDGET, dated |
|04/18/2024 - DO PASS, As Amended. |
7| |
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8| |
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9| |
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10| |
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11| |
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12| |
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13| |
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14| |
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15| |
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16| |
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17| |
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18| |
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19| |
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20| |
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21| |
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22| |
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arsid12452994 SB1675 HFLR Page 29
