1 STATE OF OKLAHOMA
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2 2nd Session of the 59th Legislature (2024)
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3 SENATE BILL 1675 By: McCortney
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4
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5 AS INTRODUCED
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6 An Act relating to the state Medicaid program;
6 amending Section 3, Chapter 395, O.S.L. 2022 (56 O.S.
7 Supp. 2023, Section 4002.3a), which relates to
7 capitated contracts for delivery of Medicaid
8 services; extending certain deadlines; amending 56
8 O.S. 2021, Section 4002.4, as amended by Section 7,
9 Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023, Section
9 4002.4), which relates to network adequacy standards
10 for contracted entities; imposing certain deadline on
10 credentialing or recredentialing by contracted
11 entities; amending 56 O.S. 2021, Section 4002.6, as
11 last amended by Section 2, Chapter 331, O.S.L. 2023
12 (56 O.S. Supp. 2023, Section 4002.6), which relates
12 to requirements for prior authorizations; modifying
13 and adding deadlines for certain determinations and
13 reviews; requiring certain reviews to be conducted by
14 Oklahoma-licensed clinical staff; amending 56 O.S.
14 2021, Section 4002.7, as amended by Section 11,
15 Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023, Section
15 4002.7), which relates to requirements for processing
16 and adjudicating claims; expanding certain provisions
16 to include downgraded claims; specifying certain
17 limit on claims subject to postpayment audits;
17 updating statutory references; 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 Section 3, Chapter 395, O.S.L.
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22 2022 (56 O.S. Supp. 2023, Section 4002.3a), is amended to read as
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23 follows:
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 1 Section 4002.3a. A. 1. The Oklahoma Health Care Authority
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2 (OHCA) shall enter into capitated contracts with contracted entities
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3 for the delivery of Medicaid services as specified in this act the
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4 Ensuring Access to Medicaid Act to transform the delivery system of
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5 the state Medicaid program for the Medicaid populations listed in
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6 this section.
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7 2. Unless expressly authorized by the Legislature, the
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8 Authority shall not issue any request for proposals or enter into
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9 any contract to transform the delivery system for the aged, blind,
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10 and disabled populations eligible for SoonerCare.
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11 B. 1. The Oklahoma Health Care Authority shall issue a request
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12 for proposals to enter into public-private partnerships with
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13 contracted entities other than dental benefit managers to cover all
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14 Medicaid services other than dental services for the following
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15 Medicaid populations:
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16 a. pregnant women,
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17 b. children,
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18 c. deemed newborns under 42 C.F.R., Section 435.117,
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19 d. parents and caretaker relatives, and
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20 e. the expansion population.
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21 2. The Authority shall specify the services to be covered in
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22 the request for proposals referenced in paragraph 1 of this
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23 subsection. Capitated contracts referenced in this subsection shall
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24 cover all Medicaid services other than dental services including:
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Req. No. 3246 Page 2
 1 a. physical health services including, but not limited
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2 to:
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3 (1) primary care,
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4 (2) inpatient and outpatient services, and
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5 (3) emergency room services,
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6 b. behavioral health services, and
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7 c. prescription drug services.
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8 3. The Authority shall specify the services not covered in the
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9 request for proposals referenced in paragraph 1 of this subsection.
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10 4. Subject to the requirements and approval of the Centers for
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11 Medicare and Medicaid Services, the implementation of the program
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12 shall be no later than October 1, 2023 April 1, 2024.
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13 C. 1. The Authority shall issue a request for proposals to
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14 enter into public-private partnerships with dental benefit managers
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15 to cover dental services for the following Medicaid populations:
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16 a. pregnant women,
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17 b. children,
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18 c. parents and caretaker relatives,
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19 d. the expansion population, and
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20 e. members of the Children’s Specialty Plan as provided
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21 by subsection D of this section.
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22 2. The Authority shall specify the services to be covered in
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23 the request for proposals referenced in paragraph 1 of this
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24 subsection.
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 1 3. Subject to the requirements and approval of the Centers for
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2 Medicare and Medicaid Services, the implementation of the program
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3 shall be no later than October 1, 2023 April 1, 2024.
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4 D. 1. Either as part of the request for proposals referenced
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5 in subsection B of this section or as a separate request for
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6 proposals, the Authority shall issue a request for proposals to
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7 enter into public-private partnerships with one contracted entity to
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8 administer a Children’s Specialty Plan.
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9 2. The Authority shall specify the services to be covered in
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10 the request for proposals referenced in paragraph 1 of this
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11 subsection.
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12 3. The contracted entity for the Children’s Specialty Plan
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13 shall coordinate with the dental benefit managers who cover dental
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14 services for its members as provided by subsection C of this
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15 section.
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16 4. Subject to the requirements and approval of the Centers for
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17 Medicare and Medicaid Services, the implementation of the program
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18 shall be no later than October 1, 2023 April 1, 2024.
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19 E. The Authority shall not implement the transformation of the
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20 Medicaid delivery system until it receives written confirmation from
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21 the Centers for Medicare and Medicaid Services that a managed care
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22 directed payment program utilizing average commercial rate
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23 methodology for hospital services under the Supplemental Hospital
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24 Offset Payment Program has been approved for Year 1 of the
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 1 transformation and will be included in the budget neutrality cap
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2 baseline spending level for purposes of Oklahoma’s 1115 waiver
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3 renewal; provided, however, nothing in this section shall prohibit
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4 the Authority from exploring alternative opportunities with the
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5 Centers for Medicare and Medicaid Services to maximize the average
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6 commercial rate benefit.
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7 SECTION 2. AMENDATORY 56 O.S. 2021, Section 4002.4, as
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8 amended by Section 7, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2023,
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9 Section 4002.4), is amended to read as follows:
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10 Section 4002.4. A. The Oklahoma Health Care Authority shall
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11 develop network adequacy standards for all contracted entities that,
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12 at a minimum, meet the requirements of 42 C.F.R., Sections 438.3 and
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13 438.68. Network adequacy standards established under this
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14 subsection shall include distance and time standards and shall be
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15 designed to ensure members covered by the contracted entities who
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16 reside in health professional shortage areas (HPSAs) designated
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17 under Section 332(a)(1) of the Public Health Service Act (42 U.S.C.,
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18 Section 254e(a)(1)) have access to in-person health care and
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19 telehealth services with providers, especially adult and pediatric
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20 primary care practitioners.
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21 B. The Authority shall require all contracted entities to offer
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22 or extend contracts with all essential community providers, all
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23 providers who receive directed payments in accordance with 42
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24 C.F.R., Part 438 and such other providers as the Authority may
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 1 specify. The Authority shall establish such requirements as may be
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2 necessary to prohibit contracted entities from excluding essential
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3 community providers, providers who receive directed payments in
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4 accordance with 42 C.F.R., Part 438 and such other providers as the
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5 Authority may specify from contracts with contracted entities.
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6 C. To ensure models of care are developed to meet the needs of
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7 Medicaid members, each contracted entity must contract with at least
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8 one local Oklahoma provider organization for a model of care
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9 containing care coordination, care management, utilization
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10 management, disease management, network management, or another model
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11 of care as approved by the Authority. Such contractual arrangements
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12 must be in place within twelve (12) months of the effective date of
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13 the contracts awarded pursuant to the requests for proposals
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14 authorized by Section 3 of this act Section 4002.3a of this title.
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15 D. All contracted entities shall formally credential and
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16 recredential network providers at a frequency required by a single,
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17 consolidated provider enrollment and credentialing process
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18 established by the Authority in accordance with 42 C.F.R., Section
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19 438.214. A contracted entity shall complete credentialing or
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20 recredentialing of a provider within sixty (60) calendar days of
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21 receipt of a completed application.
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22 E. All contracted entities shall be accredited in accordance
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23 with 45 C.F.R., Section 156.275 by an accrediting entity recognized
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24 by the United States Department of Health and Human Services.
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 1 F. 1. If the Authority awards a capitated contract to a
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2 provider-led entity for the urban region under Section 4 of this act
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3 Section 4002.3b of this title, the provider-led entity shall expand
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4 its coverage area to every county of this state within the time
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5 frame set by the Authority under subsection E of Section 4 of this
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6 act Section 4002.3b of this title.
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7 2. The expansion of the provider-led entity’s coverage area
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8 beyond the urban region shall be subject to the approval of the
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9 Authority. The Authority shall approve expansion to counties for
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10 which the provider-led entity can demonstrate evidence of network
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11 adequacy as required under 42 C.F.R., Sections 438.3 and 438.68.
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12 When approved, the additional county or counties shall be added to
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13 the provider-led entity’s region during the next open enrollment
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14 period.
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15 SECTION 3. AMENDATORY 56 O.S. 2021, Section 4002.6, as
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16 last amended by Section 2, Chapter 331, O.S.L. 2023 (56 O.S. Supp.
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17 2023, Section 4002.6), is amended to read as follows:
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18 Section 4002.6. A. A contracted entity shall meet all
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19 requirements established by the Oklahoma Health Care Authority
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20 pertaining to prior authorizations. The Authority shall establish
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21 requirements that ensure timely determinations by contracted
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22 entities when prior authorizations are required including expedited
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23 review in urgent and emergent cases that at a minimum meet the
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24 criteria of this section.
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 1 B. A contracted entity shall make a determination on a request
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2 for an authorization of the transfer of a hospital inpatient to a
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3 post-acute care or long-term acute care facility within twenty-four
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4 (24) hours of receipt of the request.
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5 C. A contracted entity shall make a determination on a request
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6 for any member who is not hospitalized at the time of the request
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7 within seventy-two (72) hours of receipt of the request; provided,
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8 that if the request does not include sufficient or adequate
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9 documentation, the review and determination shall occur within a
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10 time frame and in accordance with a process established by the
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11 Authority. The process established by the Authority pursuant to
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12 this subsection shall include a time frame of at least forty-eight
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13 (48) hours within which a provider may submit the necessary
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14 documentation.
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15 D. A contracted entity shall make a determination on a request
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16 for services for a hospitalized member including, but not limited
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17 to, acute care inpatient services or equipment necessary to
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18 discharge the member from an inpatient facility within one (1)
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19 business day twenty-four (24) hours of receipt of the request.
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20 E. Notwithstanding the provisions of subsection C of this
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21 section, a contracted entity shall make a determination on a request
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22 as expeditiously as necessary and, in any event, within twenty-four
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23 (24) hours of receipt of the request for service if adhering to the
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24 provisions of subsection C or D of this section could jeopardize the
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 1 member’s life, health or ability to attain, maintain or regain
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2 maximum function. In the event of a medically emergent matter, the
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3 contracted entity shall not impose limitations on providers in
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4 coordination of post-emergent stabilization health care including
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5 pre-certification or prior authorization.
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6 F. Notwithstanding any other provision of this section, a
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7 contracted entity shall make a determination on a request for
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8 inpatient behavioral health services within twenty-four (24) hours
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9 of receipt of the request.
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10 G. A contracted entity shall make a determination on a request
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11 for covered prescription drugs that are required to be prior
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12 authorized by the Authority within twenty-four (24) hours of receipt
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13 of the request. The contracted entity shall not require prior
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14 authorization on any covered prescription drug for which the
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15 Authority does not require prior authorization.
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16 H. A contracted entity shall make a determination on a request
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17 for coverage of biomarker testing in accordance with Section 3 of
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18 this act Section 4003 of this title.
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19 I. Upon issuance of an adverse determination on a prior
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20 authorization request under subsection B of this section, the
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21 contracted entity shall provide the requesting provider, within
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22 seventy-two (72) hours of receipt of such issuance, with reasonable
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23 opportunity to participate in a peer-to-peer review process with a
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24 provider who practices in the same specialty, but not necessarily
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 1 the same sub-specialty, and who has experience treating the same
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2 population as the patient on whose behalf the request is submitted;
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3 provided, however, if the requesting provider determines the
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4 services to be clinically urgent, the contracted entity shall
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5 provide such opportunity within twenty-four (24) hours of receipt of
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6 such issuance. Services not covered under the state Medicaid
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7 program for the particular patient shall not be subject to peer-to-
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8 peer review.
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9 J. The Authority shall ensure that a provider offers to provide
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10 to a member in a timely manner services authorized by a contracted
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11 entity.
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12 K. The Authority shall establish requirements for both internal
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13 and external reviews and appeals of adverse determinations on prior
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14 authorization requests or claims that, at a minimum:
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15 1. Require contracted entities to provide a detailed
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16 explanation of denials to Medicaid providers and members;
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17 2. Require contracted entities to provide a prompt an
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18 opportunity for peer-to-peer conversations with licensed Oklahoma-
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19 licensed clinical staff of the same or similar specialty which shall
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20 include, but not be limited to, Oklahoma-licensed clinical staff
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21 upon within twenty-four (24) hours of the adverse determinat