1 STATE OF OKLAHOMA
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2 2nd Session of the 59th Legislature (2024)
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3 HOUSE BILL 3367 By: McEntire
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6 AS INTRODUCED
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7 An Act relating to poor persons; amending 56 O.S.
7 2021, Section 4002.2, as last amended by Section 1,
8 Chapter 334, O.S.L. 2022 (56 O.S. Supp. 2023, Section
8 4002.2), which relates to ensuring access to Medicaid
9 Act; clarifying definition; and providing an
9 effective date.
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12 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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13 SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.2, as
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14 last amended by Section 1, Chapter 334, O.S.L. 2022 (56 O.S. Supp.
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15 2023, Section 4002.2), is amended to read as follows:
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16 Section 4002.2 As used in the Ensuring Access to Medicaid Act:
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17 1. "Adverse determination" has the same meaning as provided by
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18 Section 6475.3 of Title 36 of the Oklahoma Statutes;
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19 2. "Accountable care organization" means a network of
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20 physicians, hospitals, and other health care providers that provides
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21 coordinated care to Medicaid members;
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22 3. "Claims denial error rate" means the rate of claims denials
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23 that are overturned on appeal;
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 1 4. "Capitated contract" means a contract between the Oklahoma
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2 Health Care Authority and a contracted entity for delivery of
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3 services to Medicaid members in which the Authority pays a fixed,
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4 per-member-per-month rate based on actuarial calculations;
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5 5. "Children's Specialty Plan" means a health care plan that
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6 covers all Medicaid services other than dental services and is
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7 designed to provide care to:
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8 a. children in foster care,
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9 b. former foster care children up to twenty-five (25)
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10 years of age,
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11 c. juvenile justice involved children, and
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12 d. children receiving adoption assistance,
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13 e. children involved in a Family Centered Services (FCS)
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14 case through the Child Welfare Services division of
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15 the Department of Human Services,
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16 f. children in the custody of the Department of Human
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17 Services and placed at home under court supervision,
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18 g. children who are placed at home in a trial
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19 reunification plan administered by the Department of
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20 Human Services, and
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21 h. Medicaid enrolled parents and guardians whose children
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22 are in a Family Centered Services case, are in trial
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23 reunification, or are in the custody of the Department
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 1 of Human Services in Foster Care or under court
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2 supervision;
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3 6. "Clean claim" means a properly completed billing form with
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4 Current Procedural Terminology, 4th Edition or a more recent
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5 edition, the Tenth Revision of the International Classification of
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6 Diseases coding or a more recent revision, or Healthcare Common
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7 Procedure Coding System coding where applicable that contains
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8 information specifically required in the Provider Billing and
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9 Procedure Manual of the Oklahoma Health Care Authority, as defined
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10 in 42 C.F.R., Section 447.45(b);
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11 7. "Commercial plan" means an organization or entity that
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12 undertakes to provide or arrange for the delivery of health care
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13 services to Medicaid members on a prepaid basis and is subject to
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14 all applicable federal and state laws and regulations;
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15 8. "Contracted entity" means an organization or entity that
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16 enters into or will enter into a capitated contract with the
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17 Oklahoma Health Care Authority for the delivery of services
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18 specified in the Ensuring Access to Medicaid Act that will assume
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19 financial risk, operational accountability, and statewide or
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20 regional functionality as defined in the Ensuring Access to Medicaid
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21 Act in managing comprehensive health outcomes of Medicaid members.
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22 For purposes of the Ensuring Access to Medicaid Act, the term
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23 contracted entity includes an accountable care organization, a
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 1 provider-led entity, a commercial plan, a dental benefit manager, or
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2 any other entity as determined by the Authority;
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3 9. "Dental benefit manager" means an entity that handles claims
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4 payment and prior authorizations and coordinates dental care with
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5 participating providers and Medicaid members;
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6 10. "Essential community provider" means:
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7 a. a Federally Qualified Health Center,
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8 b. a community mental health center,
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9 c. an Indian Health Care Provider,
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10 d. a rural health clinic,
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11 e. a state-operated mental health hospital,
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12 f. a long-term care hospital serving children (LTCH-C),
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13 g. a teaching hospital owned, jointly owned, or
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14 affiliated with and designated by the University
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15 Hospitals Authority, University Hospitals Trust,
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16 Oklahoma State University Medical Authority, or
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17 Oklahoma State University Medical Trust,
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18 h. a provider employed by or contracted with, or
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19 otherwise a member of the faculty practice plan of:
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20 (1) a public, accredited medical school in this
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21 state, or
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22 (2) a hospital or health care entity directly or
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23 indirectly owned or operated by the University
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 1 Hospitals Trust or the Oklahoma State University
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2 Medical Trust,
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3 i. a county department of health or city-county health
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4 department,
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5 j. a comprehensive community addiction recovery center,
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6 k. a hospital licensed by the State of Oklahoma including
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7 all hospitals participating in the Supplemental
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8 Hospital Offset Payment Program,
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9 l. a Certified Community Behavioral Health Clinic
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10 (CCBHC),
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11 m. a provider employed by or contracted with a primary
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12 care residency program accredited by the Accreditation
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13 Council for Graduate Medical Education,
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14 n. any additional Medicaid provider as approved by the
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15 Authority if the provider either offers services that
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16 are not available from any other provider within a
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17 reasonable access standard or provides a substantial
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18 share of the total units of a particular service
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19 utilized by Medicaid members within the region during
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20 the last three (3) years, and the combined capacity of
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21 other service providers in the region is insufficient
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22 to meet the total needs of the Medicaid members,
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23 o. a pharmacy or pharmacist, or
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 1 p. any provider not otherwise mentioned in this paragraph
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2 that meets the definition of "essential community
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3 provider" under 45 C.F.R., Section 156.235;
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4 11. "Material change" includes, but is not limited to, any
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5 change in overall business operations such as policy, process or
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6 protocol which affects, or can reasonably be expected to affect,
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7 more than five percent (5%) of enrollees or participating providers
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8 of the contracted entity;
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9 12. "Governing body" means a group of individuals appointed by
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10 the contracted entity who approve policies, operations, profit/loss
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11 ratios, executive employment decisions, and who have overall
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12 responsibility for the operations of the contracted entity of which
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13 they are appointed;
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14 13. "Local Oklahoma provider organization" means any state
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15 provider association, accountable care organization, Certified
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16 Community Behavioral Health Clinic, Federally Qualified Health
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17 Center, Native American tribe or tribal association, hospital or
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18 health system, academic medical institution, currently practicing
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19 licensed provider, or other local Oklahoma provider organization as
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20 approved by the Authority;
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21 14. "Medical necessity" has the same meaning as provided by
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22 rules promulgated by the Oklahoma Health Care Authority Board;
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23 15. "Participating provider" means a provider who has a
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24 contract with or is employed by a contracted entity to provide
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 1 services to Medicaid members as authorized by the Ensuring Access to
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2 Medicaid Act;
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3 16. "Provider" means a health care or dental provider licensed
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4 or certified in this state or a provider that meets the Authority's
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5 provider enrollment criteria to contract with the Authority as a
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6 SoonerCare provider;
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7 17. "Provider-led entity" means an organization or entity that
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8 meets the criteria of at least one of the following two
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9 subparagraphs:
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10 a. a majority of the entity's ownership is held by
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11 Medicaid providers in this state or is held by an
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12 entity that directly or indirectly owns or is under
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13 common ownership with Medicaid providers in this
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14 state, or
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15 b. a majority of the entity's governing body is composed
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16 of individuals who:
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17 (1) have experience serving Medicaid members and:
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18 (a) are licensed in this state as physicians,
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19 physician assistants, nurse practitioners,
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20 certified nurse-midwives, or certified
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21 registered nurse anesthetists,
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22 (b) at least one board member is a licensed
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23 behavioral health provider, or
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24 (c) are employed by:
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 1 i. a hospital or other medical facility
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2 licensed by this state and operating in
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3 this state, or
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4 ii. an inpatient or outpatient mental
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5 health or substance abuse treatment
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6 facility or program licensed or
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7 certified by this state and operating
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8 in this state,
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9 (2) represent the providers or facilities described
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10 in division (1) of this subparagraph including,
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11 but not limited to, individuals who are employed
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12 by a statewide provider association, or
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13 (3) are nonclinical administrators of clinical
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14 practices serving Medicaid members;
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15 18. "Statewide" means all counties of this state including the
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16 urban region; and
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17 19. "Urban region" means:
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18 a. all counties of this state with a county population of
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19 not less than five hundred thousand (500,000)
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20 according to the latest Federal Decennial Census, and
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21 b. all counties that are contiguous to the counties
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22 described in subparagraph a of this paragraph,
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23 combined into one region.
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 1 SECTION 2. This act shall become effective November 1, 2024.
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3 59-2-9183 TJ 12/29/23
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Statutes affected:
Introduced: 56-4002.2
Floor (House): 56-4002.2
Floor (Senate): 56-4002.2
Engrossed: 56-4002.2
Enrolled (final version): 56-4002.2