Oklahoma § 56-4002.3

§ 56-4002.3.

Repealed by Laws 2022, c. 395, § 26, eff. July 1, 2022.

§56-4002.3a. Capitated contracts with contracted entities for

delivery of Medicaid services.

A. 1. The Oklahoma Health Care Authority (OHCA) shall enter

into capitated contracts with contracted entities for the delivery

of Medicaid services as specified in the Ensuring Access to Medicaid

Act to transform the delivery system of the state Medicaid program

for the Medicaid populations listed in this section.

2. Unless expressly authorized by the Legislature, the

Authority shall not issue any request for proposals or enter into

any contract to transform the delivery system for the aged, blind,

and disabled populations eligible for SoonerCare.

B. 1. The Oklahoma Health Care Authority shall issue a request

for proposals to enter into public-private partnerships with

contracted entities other than dental benefit managers to cover all

Medicaid services other than dental services for the following

Medicaid populations:

a.

pregnant women,

b.

children,

c.

deemed newborns under 42 C.F.R., Section 435.117,

d.

parents and caretaker relatives, and

e.

the expansion population.

2. The Authority shall specify the services to be covered in

the request for proposals referenced in paragraph 1 of this

subsection. Capitated contracts referenced in this subsection shall

cover all Medicaid services other than dental services including:

a.

physical health services including, but not limited

to:

(1) primary care,

(2) inpatient and outpatient services, and

(3) emergency room services,

Oklahoma Statutes - Title 56. Poor Persons

b.

behavioral health services, and

c.

prescription drug services.

3. The Authority shall specify the services not covered in the

request for proposals referenced in paragraph 1 of this subsection.

4. Subject to the requirements and approval of the Centers for

Medicare and Medicaid Services, the implementation of the program

shall be no later than April 1, 2024.

C. 1. The Authority shall issue a request for proposals to

enter into public-private partnerships with dental benefit managers

to cover dental services for the following Medicaid populations:

a.

pregnant women,

b.

children,

c.

parents and caretaker relatives,

d.

the expansion population, and

e.

members of the Children’s Specialty Plan as provided

by subsection D of this section.

2. The Authority shall specify the services to be covered in

the request for proposals referenced in paragraph 1 of this

subsection.

3. Subject to the requirements and approval of the Centers for

Medicare and Medicaid Services, the implementation of the program

shall be no later than April 1, 2024.

D. 1. Either as part of the request for proposals referenced

in subsection B of this section or as a separate request for

proposals, the Authority shall issue a request for proposals to

enter into public-private partnerships with one contracted entity to

administer a Children’s Specialty Plan.

2. The Authority shall specify the services to be covered in

the request for proposals referenced in paragraph 1 of this

subsection.

3. The contracted entity for the Children’s Specialty Plan

shall coordinate with the dental benefit managers who cover dental

services for its members as provided by subsection C of this

section.

4. Subject to the requirements and approval of the Centers for

Medicare and Medicaid Services, the implementation of the program

shall be no later than April 1, 2024.

E. The Authority shall not implement the transformation of the

Medicaid delivery system until it receives written confirmation from

the Centers for Medicare and Medicaid Services that a managed care

directed payment program utilizing average commercial rate

methodology for hospital services under the Supplemental Hospital

Offset Payment Program has been approved for Year 1 of the

transformation and will be included in the budget neutrality cap

baseline spending level for purposes of Oklahoma’s 1115 waiver

renewal; provided, however, nothing in this section shall prohibit

the Authority from exploring alternative opportunities with the

Oklahoma Statutes - Title 56. Poor Persons

Centers for Medicare and Medicaid Services to maximize the average

commercial rate benefit.

Added by Laws 2022, c. 395, § 3, eff. July 1, 2022. Amended by Laws

2024, c. 448, § 2, emerg. eff. June 14, 2024.

§56-4002.3b. Capitated contracts – Requests for proposals –

Competitive bids.

A. All capitated contracts shall be the result of requests for

proposals issued by the Oklahoma Health Care Authority and

submission of competitive bids by contracted entities pursuant to

the Oklahoma Central Purchasing Act.

B. Statewide capitated contracts may be awarded to any

contracted entity including, but not limited to, any provider-led

entity or provider-owned entity, or both.

C. The Authority shall award no less than three statewide

capitated contracts to provide comprehensive integrated health

services including, but not limited to, medical, behavioral health,

and pharmacy services and no less than two statewide capitated

contracts to provide dental coverage to Medicaid members as

specified in Section 4002.3a of this title.

D. 1. Except as specified in paragraph 3 of this subsection,

at least one capitated contract to provide statewide coverage to

Medicaid members shall be awarded to a provider-led entity, as long

as the provider-led entity submits a responsive reply to the

Authority’s request for proposals demonstrating ability to fulfill

the contract requirements.

2. Effective with the next procurement cycle, and except as

specified in paragraph 3 of this subsection, at least one capitated

contract to provide statewide coverage to Medicaid members shall be

awarded to a provider-owned entity, as long as the provider-owned

entity submits a responsive reply to the Authority’s request for

proposals demonstrating ability to fulfill the contract

requirements.

3. If no provider-led entity or provider-owned entity submits a

responsive reply to the Authority’s request for proposals

demonstrating ability to fulfill the contract requirements, the

Authority shall not be required to contract for statewide coverage

with a provider-led entity or provider-owned entity.

4. The Authority shall develop a scoring methodology for the

request for proposals that affords preferential scoring to providerled entities and provider-owned entities, as long as the providerled entity and provider-owned entity otherwise demonstrate an

ability to fulfill the contract requirements. The preferential

scoring methodology shall include opportunities to award additional

points to provider-led entities and provider-owned entities based on

certain factors including, but not limited to:

Oklahoma Statutes - Title 56. Poor Persons

a.

broad provider participation in ownership and

governance structure,

b.

demonstrated experience in care coordination and care

management for Medicaid members across a variety of

service types including, but not limited to, primary

care and behavioral health,

c.

demonstrated experience in Medicare or Medicaid

accountable care organizations or other Medicare or

Medicaid alternative payment models, Medicare or

Medicaid value-based payment arrangements, or Medicare

or Medicaid risk-sharing arrangements including, but

not limited to, innovation models of the Center for

Medicare and Medicaid Innovation of the Centers for

Medicare and Medicaid Services, or value-based payment

arrangements or risk-sharing arrangements in the

commercial health care market, and

d.

other relevant factors identified by the Authority.

E. The Authority may select at least one provider-led entity or

one provider-owned entity for the urban region if:

1. The provider-led entity or provider-owned entity submits a

responsive reply to the Authority’s request for proposals

demonstrating ability to fulfill the contract requirements; and

2. The provider-led entity or provider-owned entity

demonstrates the ability, and agrees continually, to expand its

coverage area throughout the contract term and to develop statewide

operational readiness within a time frame set by the Authority but

not mandated before five (5) years.

F. At the discretion of the Authority, capitated contracts may

be extended to ensure there are no gaps in coverage that may result

from termination of a capitated contract; provided, the total

contracting period for a capitated contract shall not exceed seven

(7) years.

G. At the end of the contracting period, the Authority shall

solicit and award new contracts as provided by this section and

Section 4002.3a of this title.

H. At the discretion of the Authority, subject to appropriate

notice to the Legislature and the Centers for Medicare and Medicaid

Services, the Authority may approve a delay in the implementation of

one or more capitated contracts to ensure financial and operational

readiness.

Added by Laws 2022, c. 395, § 4, eff. July 1, 2022. Amended by Laws

2024, c. 448, § 3, emerg. eff. June 14, 2024.

§56-4002.3c. Process for assignment of Medicaid members to

contracted entities.

A. The Authority shall develop and implement a process for

assignment of Medicaid members to contracted entities.

Oklahoma Statutes - Title 56. Poor Persons

B. The Authority may only utilize an opt-in enrollment process

for the voluntary enrollment of American Indians and Alaska Natives.

Notwithstanding any other provision of this act, the Authority shall

comply with all Indian provisions associated with Medicaid managed

care including, but not limited to, the Social Security Act,

1932(a)(2)(C), the American Recovery and Reinvestment Act of 2009,

P.L. 111-5 (Feb. 17, 2009), Section 5006, the Children's Health

Insurance Program Reauthorization Act of 2009, P.L. 111-3 (Feb. 4,

2009), and the Centers for Medicare and Medicaid Services (CMS)

managed care protections, 25 C.F.R., 438.14.

C. In the event of the termination of a capitated contract with

a contracted entity during the contract duration, the Authority

shall reassign members to a remaining contracted entity with

demonstrated performance and capability. If no remaining contracted

entity is able to assume management for such members, the Authority

may select another contracted entity by application, as specified in

rules promulgated by the Oklahoma Health Care Authority Board, if

the financial, operation, and performance requirements can be met,

at the discretion of the Authority.

Added by Laws 2022, c. 395, § 5, eff. July 1, 2022.

§56-4002.3d. Selection of primary care provider by members.

A. Every Medicaid member enrolled in a contracted entity shall

have the right to select his or her primary care provider and to

change his or her primary care provider at any time, as long as the

selected primary care provider is a participating provider. Any

parent or guardian of a Medicaid member who is a minor child

enrolled in a contracted entity shall have the right to select the

primary care provider for the member's minor child and to change the

primary care provider at any time, as long as the selected primary

care provider is a participating provider.

B. If a member, or parent or guardian of a member who is a

minor child, does not select a primary care provider, the contracted

entity shall notify the member, parent, or guardian that he or she

needs to select a primary care provider and shall send the member,

parent, or guardian the name, contact information, employer, and any

other applicable information as determined by the Oklahoma Health

Care Authority of the three primary care providers nearest to the

member's home address that are contracted with the contracted

entity.

C. 1. If, after the contracted entity sends the information

described in subsection B of this section, the member, parent, or

guardian does not select a primary care provider within a time

determined by the Authority, the contracted entity shall assign the

member to a primary care provider in accordance with the process

described in paragraph 2 of this subsection.

Oklahoma Statutes - Title 56. Poor Persons

2. The Authority shall develop and implement a process for the

assignment by contracted entities of Medicaid members who do not

select a primary care provider to a primary care provider. The

process shall prioritize existing patient-provider relationships and

geographic proximity of the patient to the provider, and shall

assign families to the same primary care provider to the extent

possible.

Added by Laws 2022, c. 395, § 6, eff. July 1, 2022.