1 STATE OF OKLAHOMA
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2 2nd Session of the 59th Legislature (2024)
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3 SENATE BILL 1417 By: Rosino
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6 AS INTRODUCED
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7 An Act relating to the state Medicaid program;
7 amending 56 O.S. 2021, Section 1011.5, which relates
8 to the nursing facility incentive reimbursement rate
8 plan; modifying amount of certain reserved funds;
9 removing certain limitations on deductions and
9 payments; adding certain outcomes metrics; modifying
10 terminology; clarifying language; providing for
10 establishment of certain benchmarks; modifying
11 certain method of reporting; authorizing the Oklahoma
11 Health Care Authority to take certain actions
12 depending on certain factors; amending 63 O.S. 2021,
12 Section 1-1925.2, which relates to reimbursements
13 from the Nursing Facility Quality of Care Fund;
13 modifying and adding components in certain payment
14 methodology; requiring certain adjustments; removing
14 certain provisions relating to payment rates;
15 directing certain allocations; requiring development
15 of certain add-on rate; directing certain transition
16 of payment rate methodology; requiring the Authority
16 to implement certain scholarship program subject to
17 available funding; updating statutory language;
17 providing an effective date; and declaring an
18 emergency.
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19
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20 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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21 SECTION 1. AMENDATORY 56 O.S. 2021, Section 1011.5, is
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22 amended to read as follows:
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23 Section 1011.5. A. 1. The Oklahoma Health Care Authority
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24 shall develop an incentive reimbursement rate plan for nursing
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 1 facilities focused on improving resident outcomes and resident
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2 quality of life.
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3 2. Under the current rate methodology, the The Authority shall
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4 reserve funds above the average of Five Dollars ($5.00) per patient
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5 day designated for incentive payment in the currently approved
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6 Medicaid state plan for the quality assurance component that nursing
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7 facilities can earn for improvement or performance achievement of
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8 resident-centered outcomes metrics. To fund the quality assurance
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9 component, Two Dollars ($2.00) shall be deducted from each nursing
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10 facility’s per diem rate, and matched with Three Dollars ($3.00) per
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11 day funded by the Authority. Payments to nursing facilities that
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12 achieve specific metrics shall be treated as an “add back” to their
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13 net reimbursement per diem. Dollar values assigned to each metric
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14 shall be determined so that an average of the five-dollar-quality
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15 incentive is made to qualifying nursing facilities The Authority
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16 shall determine the dollar amount for each resident-centered
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17 outcomes metric under the incentive reimbursement rate plan.
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18 3. Pay-for-performance payments to contracted nursing
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19 facilities may be earned quarterly and shall be based on the
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20 following outcomes metrics:
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21 a. facility-specific performance achievement of four
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22 equally-weighted equally weighted, Long-Stay Quality
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23 Measures, as defined by the Centers for Medicare and
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 1 Medicaid Services (CMS) and as provided by
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2 subparagraph a of paragraph 6 of this subsection,
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3 b. completion of required hours of a training component
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4 as provided by subparagraph b of paragraph 6 of this
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5 subsection,
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6 c. achievement of staffing retention and direct care
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7 component benchmarks as provided by subparagraph c of
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8 paragraph 6 of this subsection, and
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9 d. achievement of satisfaction survey benchmarks as
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10 provided by subparagraph d of paragraph 6 of this
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11 subsection.
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12 4. Contracted Medicaid long-term care providers may earn
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13 payment by achieving either five percent (5%) relative improvement
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14 each quarter from baseline or by achieving the National Average
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15 Benchmark or better for each individual quality metric.
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16 5. Pursuant to federal Medicaid approval, any funds that remain
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17 as a result of providers failing to meet the quality assurance
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18 benchmarks of the outcomes metrics established by this subsection
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19 shall be pooled and redistributed to those who achieve the quality
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20 assurance metrics benchmarks each quarter. If federal approval is
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21 not received, any remaining funds shall be deposited in the Nursing
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22 Facility Quality of Care Fund authorized in Section 2002 of this
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23 title.
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 1 6. 5. The Authority shall establish an advisory group with
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2 consumer, provider and state agency representation to recommend
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3 quality measures benchmarks for outcomes metrics, other than the
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4 benchmarks specified in paragraph 6 of this subsection, to be
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5 included in the pay-for-performance program and to provide feedback
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6 on program performance and recommendations for improvement. The
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7 quality measures Such benchmarks shall be reviewed annually and
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8 shall be subject to change every three (3) years through the
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9 agency’s promulgation of rules. The Authority shall insure ensure
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10 adherence to the following criteria in determining the quality
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11 measures benchmarks:
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12 a. provides direct benefit to resident care outcomes,
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13 b. applies to long-stay residents, and
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14 c. addresses a need for quality improvement using
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15 criteria including, but not limited to, the Centers
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16 for Medicare and Medicaid Services (CMS) ranking for
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17 Oklahoma.
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18 7. 6. The Authority shall begin administer the pay-for-
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19 performance program focusing on improving the following CMS nursing
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20 home quality measures utilizing the following benchmarks for
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21 outcomes metrics:
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22 a. achievement of either five percent (5%) relative
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23 improvement each quarter from baseline or by achieving
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24 the national average benchmark or better for each of
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 1 the following equally weighted CMS Long-Stay Quality
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2 Measures:
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3 a. percentage of long-stay, high-risk residents with
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4 pressure ulcers
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5 (1) percentage of long-stay, high-risk residents with
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6 falls,
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7 b. (2) percentage of long-stay residents who lose
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8 too much weight,
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9 c. (3) percentage of long-stay residents with a
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10 urinary tract infection, and
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11 d. (4) percentage of long-stay residents who got
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12 an antipsychotic medication,
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13 b. completion of training hours required by the Authority
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14 through distance learning or in-person training on:
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15 (1) fall prevention,
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16 (2) mental health care,
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17 (3) techniques to manage care,
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18 (4) pressure ulcer care, or
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19 (5) any other subject approved by the Authority,
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20 c. achievement of the following staffing retention and
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21 direct care hour benchmarks:
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22 (1) retention of not less than fifty percent (50%) of
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23 registered nurses for twelve (12) months,
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 1 (2) retention of not less than sixty percent (60%) of
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2 certified nurse aides for twelve (12) months, and
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3 (3) provision of direct care hours every three (3)
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4 months in accordance with a benchmark established
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5 by the Authority, and
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6 d. achievement of benchmarks established by the Authority
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7 for satisfaction surveys of:
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8 (1) residents and families of residents, and
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9 (2) staff of the facility.
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10 B. The Oklahoma Health Care Authority shall negotiate with the
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11 Centers for Medicare and Medicaid Services to include the authority
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12 to base provider reimbursement rates for nursing facilities on the
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13 criteria specified in subsection A of this section.
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14 C. The Oklahoma Health Care Authority shall audit the program
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15 to ensure transparency and integrity.
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16 D. The Oklahoma Health Care Authority shall provide
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17 electronically submit an annual report of the incentive
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18 reimbursement rate plan to the Governor, the Speaker of the House of
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19 Representatives, and the President Pro Tempore of the Senate by
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20 December 31 of each year. The report shall include, but not be
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21 limited to, an analysis of the previous fiscal year including
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22 incentive payments, ratings, and notable trends.
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23 E. The Oklahoma Health Care Authority may change, add, or
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24 exclude any outcomes metric from the incentive reimbursement rate
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 1 plan based on availability of funding, changes to metrics made by
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2 the Centers for Medicare and Medicaid Services, and quality needs of
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3 nursing facilities in this state as determined by the Authority.
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4 SECTION 2. AMENDATORY 63 O.S. 2021, Section 1-1925.2, is
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5 amended to read as follows:
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6 Section 1-1925.2. A. The Oklahoma Health Care Authority shall
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7 fully recalculate and reimburse nursing facilities and Intermediate
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8 Care Facilities for Individuals with Intellectual Disabilities
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9 (ICFs/IID) from the Nursing Facility Quality of Care Fund beginning
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10 October 1, 2000, the average actual, audited costs reflected in
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11 previously submitted cost reports for the cost-reporting period that
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12 began July 1, 1998, and ended June 30, 1999, inflated by the
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13 federally published inflationary factors for the two (2) years
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14 appropriate to reflect present-day costs at the midpoint of the July
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15 1, 2000, through June 30, 2001, rate year.
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16 1. The recalculations provided for in this subsection shall be
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17 consistent for both nursing facilities and Intermediate Care
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18 Facilities for Individuals with Intellectual Disabilities
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19 (ICFs/IID).
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20 2. The recalculated reimbursement rate shall be implemented
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21 September 1, 2000.
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22 B. 1. From September 1, 2000, through August 31, 2001, all
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23 nursing facilities subject to the Nursing Home Care Act, in addition
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24 to other state and federal requirements related to the staffing of
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 1 nursing facilities, shall maintain the following minimum direct-
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2 care-staff-to-resident ratios:
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3 a. from 7:00 a.m. to 3:00 p.m., one direct-care staff to
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4 every eight residents, or major fraction thereof,
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5 b. from 3:00 p.m. to 11:00 p.m., one direct-care staff to
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6 every twelve residents, or major fraction thereof, and
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7 c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to
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8 every seventeen residents, or major fraction thereof.
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9 2. From September 1, 2001, through August 31, 2003, nursing
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10 facilities subject to the Nursing Home Care Act and Intermediate
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11 Care Facilities for Individuals with Intellectual Disabilities
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12 (ICFs/IID) with seventeen or more beds shall maintain, in addition
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13 to other state and federal requirements related to the staffing of
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14 nursing facilities, the following minimum direct-care-staff-to-
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15 resident ratios:
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16 a. from 7:00 a.m. to 3:00 p.m., one direct-care staff to
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17 every seven residents, or major fraction thereof,
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18 b. from 3:00 p.m. to 11:00 p.m., one direct-care staff to
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19 every ten residents, or major fraction thereof, and
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20 c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to
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21 every seventeen residents, or major fraction thereof.
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22 3. On and after October 1, 2019, nursing facilities subject to
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23 the Nursing Home Care Act and Intermediate Care Facilities for
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24 Individuals with Intellectual Disabilities (ICFs/IID) with seventeen
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 1 or more beds shall maintain, in addition to other state and federal
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2 requirements related to the staffing of nursing facilities, the
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3 following minimum direct-care-staff-to-resident ratios:
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4 a. from 7:00 a.m. to 3:00 p.m., one direct-care staff to
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5 every six residents, or major fraction thereof,
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6 b. from 3:00 p.m. to 11:00 p.m., one direct-care staff to
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7 every eight residents, or major fraction thereof, and
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8 c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to
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9 every fifteen residents, or major fraction thereof.
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10 4. Effective immediately, facilities shall have the option of
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11 varying the starting times for the eight-hour shifts by one (1) hour
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12 before or one (1) hour after the times designated in this section
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13 without overlapping shifts.
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14 5. a. On and after January 1, 2020, a facility may implement
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15 twenty-four-hour-based staff scheduling; provided,
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16 however, such facility shall continue to maintain a
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17 direct-care service rate of at least two and nine
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18 tenths (2.9) hours of direct-care service per resident
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19 per day, the same to be calculated based on average
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20 direct care staff maintained over a twenty-four-hour
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21 period.
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22 b. At no time shall direct-care staffing ratios in a
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23 facility with twenty-four-hour-based staff-scheduling
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24 privileges fall below one direct-care staff to every
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 1 fifteen residents or major fraction thereof, and at
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2 least two direct-care staff shall be on duty and awake
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3 at all times.
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4 c. As used in this paragraph, “twenty-four-hour-based-
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5 scheduling” means maintaining:
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6 (1) a direct-care-staff-to-resident ratio based on
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7 overall hours of direct-care service per resident
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8 per day rate of not less than two and ninety one-
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9 hundredths (2.90) hours per day,
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10 (2) a direct-care-staff-to-resident ratio of at least
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11 one direct-care staff person on duty to every
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12 fifteen residents or major fraction thereof at
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13 all times, and
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14 (3) at least two direct-care staff persons on duty
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15 and awake at all times.
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16 6. a. On and after January 1, 2004, the State Department of
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17 Health shall require a facility to maintain the shift-
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18 based, staff-to-resident ratios provided in paragraph
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19 3 of this subsection if the facility has been
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20 determined by the Department to be deficient with
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21 regard to:
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