Oklahoma § 56-4002.12 - Minimum rates of reimbursement – Value-based payment

§ 56-4002.12. Minimum rates of reimbursement – Value-based payment

arrangements.

A. Until July 1, 2027, the Oklahoma Health Care Authority shall

establish minimum rates of reimbursement from contracted entities to

providers who elect not to enter into value-based payment

arrangements under subsection B of this section or other alternative

payment agreements for health care items and services furnished by

such providers to enrollees of the state Medicaid program. Except

as provided by subsection I of this section, until July 1, 2027,

such reimbursement rates shall be equal to or greater than:

1. For an item or service provided by a participating provider

who is in the network of the contracted entity, one hundred percent

(100%) of the reimbursement rate for the applicable service in the

applicable fee schedule of the Authority; or

2. For an item or service provided by a non-participating

provider or a provider who is not in the network of the contracted

entity, ninety percent (90%) of the reimbursement rate for the

applicable service in the applicable fee schedule of the Authority

as of January 1, 2021.

B. A contracted entity shall offer value-based payment

arrangements to all providers in its network capable of entering

into value-based payment arrangements. Such arrangements shall be

optional for the provider but shall be tied to reimbursement

incentives when quality metrics are met. The quality measures used

by a contracted entity to determine reimbursement amounts to

providers in value-based payment arrangements shall align with the

quality measures of the Authority for contracted entities.

C. Notwithstanding any other provision of this section, the

Authority shall comply with payment methodologies required by

federal law or regulation for specific types of providers including,

but not limited to, Federally Qualified Health Centers, rural health

clinics, pharmacies, Indian Health Care Providers and emergency

services.

D. A contracted entity shall offer all rural health clinics

(RHCs) contracts that reimburse RHCs using the methodology in place

for each specific RHC prior to January 1, 2023, including any and

all annual rate updates. The contracted entity shall comply with

all federal program rules and requirements, and the transformed

Medicaid delivery system shall not interfere with the program as

designed.

E. The Oklahoma Health Care Authority shall establish minimum

rates of reimbursement from contracted entities to Certified

Community Behavioral Health Clinic (CCBHC) providers who elect

Oklahoma Statutes - Title 56. Poor Persons

alternative payment arrangements equal to the prospective payment

system rate under the Medicaid State Plan.

F. The Authority shall establish an incentive payment under the

Supplemental Hospital Offset Payment Program that is determined by

value-based outcomes for providers other than hospitals.

G. Psychologist reimbursement shall reflect outcomes.

Reimbursement shall not be limited to therapy and shall include but

not be limited to testing and assessment.

H. Coverage for Medicaid ground transportation services by

licensed Oklahoma emergency medical services shall be reimbursed at

no less than the published Medicaid rates as set by the Authority.

All currently published Medicaid Healthcare Common Procedure Coding

System (HCPCS) codes paid by the Authority shall continue to be paid

by the contracted entity. The contracted entity shall comply with

all reimbursement policies established by the Authority for the

ambulance providers. Contracted entities shall accept the modifiers

established by the Centers for Medicare and Medicaid Services

currently in use by Medicare at the time of the transport of a

member that is dually eligible for Medicare and Medicaid.

I. 1. The rate paid to participating pharmacy providers is

independent of subsection A of this section and shall be the same as

the fee-for-service rate employed by the Authority for the Medicaid

program as stated in the payment methodology in OAC 317:30-5-78,

unless the participating pharmacy provider elects to enter into

other alternative payment agreements.

2. A pharmacy or pharmacist shall receive direct payment or

reimbursement from the Authority or contracted entity when providing

a health care service to the Medicaid member at a rate no less than

that of other health care providers for providing the same service.

J. Notwithstanding any other provision of this section,

anesthesia shall continue to be reimbursed equal to or greater than

the anesthesia fee schedule established by the Authority as of

January 1, 2021. Anesthesia providers may also enter into valuebased payment arrangements under this section or alternative payment

arrangements for services furnished to Medicaid members.

K. The Authority shall specify in the requests for proposals a

reasonable time frame in which a contracted entity shall have

entered into a certain percentage, as determined by the Authority,

of value-based contracts with providers.

L. Capitation rates established by the Oklahoma Health Care

Authority and paid to contracted entities under capitated contracts

shall be updated annually and in accordance with 42 C.F.R., Section

438.3. Capitation rates shall be approved as actuarially sound as

determined by the Centers for Medicare and Medicaid Services in

accordance with 42 C.F.R., Section 438.4 and the following:

Oklahoma Statutes - Title 56. Poor Persons

1. Actuarial calculations must include utilization and

expenditure assumptions consistent with industry and local

standards; and

2. Capitation rates shall be risk-adjusted and shall include a

portion that is at risk for achievement of quality and outcomes

measures.

M. The Authority may establish a symmetric risk corridor for

contracted entities.

N. The Authority shall establish a process for annual recovery

of funds from, or assessment of penalties on, contracted entities

that do not meet the medical loss ratio standards stipulated in

Section 4002.5 of this title.

O. 1. The Authority shall, through the financial reporting

required under subsection G of Section 4002.12b of this title,

determine the percentage of health care expenses by each contracted

entity on primary care services.

2. Not later than the end of the fourth year of the initial

contracting period, each contracted entity shall be currently

spending not less than eleven percent (11%) of its total health care

expenses on primary care services.

3. The Authority shall monitor the primary care spending of

each contracted entity and require each contracted entity to

maintain the level of spending on primary care services stipulated

in paragraph 2 of this subsection.

Added by Laws 2021, c. 542, § 12, eff. Sept. 1, 2021. Amended by

Laws 2022, c. 395, § 15, eff. July 1, 2022; Laws 2022, c. 334, § 2,

eff. July 1, 2022; Laws 2023, c. 308, § 1, emerg. eff. May 25, 2023;

Laws 2024, c. 448, § 7, emerg. eff. June 14, 2024.

§56-4002.12a. Dental benefit managers to maintain Medicaid Dental

Advisory Committees.

A. All dental benefit managers shall maintain a Medicaid Dental

Advisory Committee, comprised exclusively of Oklahoma-licensed

dentists and specialists, to advise dental benefit managers

regarding quality measures.

B. Dental providers shall not be required to enter into

capitated contracts with a dental benefit manager.

Added by Laws 2022, c. 395, § 16, eff. July 1, 2022.

§56-4002.12b. Oklahoma Health Care Authority to ensure

sustainability.

A. The Oklahoma Health Care Authority shall ensure the

sustainability of the transformed Medicaid delivery system.

B. The Authority shall ensure that existing revenue sources

designated for the state share of Medicaid expenses are designed to

maximize federal matching funds for the benefit of providers and the

state.

Oklahoma Statutes - Title 56. Poor Persons

C. The Authority shall develop a plan, utilizing waivers or

Medicaid state plan amendments as necessary, to preserve or increase

supplemental payments available to providers with existing revenue

sources as provided in the Oklahoma Statutes including, but not

limited to:

1. Hospitals that participate in the supplemental hospital

offset payment program as provided by Section 3241.3 of Title 63 of

the Oklahoma Statutes;

2. Hospitals in this state that have Level I trauma centers, as

defined by the American College of Surgeons, that provide inpatient

and outpatient services, along with comprehensive pediatric

services, and are owned, operated, or in partnership with the

University Hospitals Trust or the Oklahoma State University Medical

Trust, or affiliates or locations of those hospitals designated by

the University Hospitals Trust or the Oklahoma State University

Medical Trust as part of the hospital trauma system. The qualified

entities in the Oklahoma City metropolitan area shall be a hospital

owned, operated, or in partnership with the University Hospitals

Authority or University Hospitals Trust. The qualified entities in

the Tulsa metropolitan area shall be a hospital owned, operated, or

in partnership with the Oklahoma State University Medical Authority,

or Oklahoma State University Medical Trust; and

3. Providers employed by or contracted with, or otherwise a

member of the faculty practice plan of:

a.

a public, accredited Oklahoma medical school, or

b.

a hospital or health care entity directly or

indirectly owned or operated by the University

Hospitals Trust or the Oklahoma State University

Medical Trust.

D. Subject to approval by the Centers for Medicare and Medicaid

Services, the Authority shall preserve and, to the maximum extent

permissible under federal law, improve existing levels of funding

through directed payments or other mechanisms outside the capitated

rate to contracted entities, including, where applicable, the use of

a directed payment program with an average commercial rate

methodology under the Supplemental Hospital Payment Program Act.

E. On or before January 31, 2023, the Authority shall submit a

report to the Oklahoma Health Care Authority Board, the Chair of the

Appropriations Committee of the Oklahoma State Senate, and the Chair

of the Appropriations and Budget Committee of the Oklahoma House of

Representatives that includes the Authority's plans to continue

supplemental payment programs and implement a managed care directed

payment program for hospital services that complies with the reforms

required by this act. If Medicaid-specific funding cannot be

maintained as currently implemented and authorized by state law, the

Authority shall propose to the Legislature any modifications

Oklahoma Statutes - Title 56. Poor Persons

necessary to preserve supplemental payments and managed care

directed payments to prevent budgetary disruptions to providers.

F. The Authority shall submit a report to the Governor, the

President Pro Tempore of the Oklahoma State Senate and the Speaker

of the Oklahoma House of Representatives that includes at a minimum:

1. A description of the selection process of the contracted

entities;

2. Plans for enrollment of Medicaid members in health plans of

contracted entities;

3. Medicaid member network access standards;

4. Performance and quality metrics;

5. Maintenance of existing funding mechanisms described in this

section;

6. A description of the requirements and other provisions

included in capitated contracts; and

7. A full and complete copy of each executed capitated

contract.

G. 1. Each contracted entity shall report to the Authority in

time intervals determined by the Authority and through a process

determined by the Authority all claims data, expenditures, and such

other financial reporting information as may be required by the

Authority.

2. The Authority shall compile and analyze the information

described in paragraph 1 of this subsection and annually submit a

report summarizing such information, devoid of any personally

identifying information, to the President Pro Tempore of the Senate,

the Speaker of the House of Representatives, and the Oklahoma Health

Care Authority Board.

Added by Laws 2022, c. 395, § 17, eff. July 1, 2022. Amended by

Laws 2025, c. 386, § 3, eff. Sept. 1, 2025.