Oklahoma § 56-4002.4 - Network adequacy standards for contracted entities

§ 56-4002.4. Network adequacy standards for contracted entities

A. The Oklahoma Health Care Authority shall develop network

adequacy standards for all contracted entities that, at a minimum,

meet the requirements of 42 C.F.R., Sections 438.3 and 438.68.

Network adequacy standards established under this subsection shall

include distance and time standards and shall be designed to ensure

members covered by the contracted entities who reside in health

professional shortage areas (HPSAs) designated under Section

332(a)(1) of the Public Health Service Act (42 U.S.C., Section

254e(a)(1)) have access to in-person health care and telehealth

services with providers, especially adult and pediatric primary care

practitioners.

B. The Authority shall require all contracted entities to offer

or extend contracts with all essential community providers, all

providers who receive directed payments in accordance with 42

C.F.R., Part 438 and such other providers as the Authority may

specify. The Authority shall establish such requirements as may be

necessary to prohibit contracted entities from excluding essential

community providers, providers who receive directed payments in

accordance with 42 C.F.R., Part 438 and such other providers as the

Authority may specify from contracts with contracted entities.

C. To ensure models of care are developed to meet the needs of

Medicaid members, each contracted entity must contract with at least

one local Oklahoma provider organization for a model of care

containing care coordination, care management, utilization

management, disease management, network management, or another model

of care as approved by the Authority. Such contractual arrangements

must be in place within twelve (12) months of the effective date of

the contracts awarded pursuant to the requests for proposals

authorized by Section 4002.3a of this title.

D. All contracted entities shall formally credential and

recredential network providers at a frequency required by a single,

consolidated provider enrollment and credentialing process

established by the Authority in accordance with 42 C.F.R., Section

438.214. A contracted entity shall complete credentialing or

recredentialing of a provider within sixty (60) calendar days of

receipt of a completed application.

Oklahoma Statutes - Title 56. Poor Persons

E. All contracted entities shall be accredited in accordance

with 45 C.F.R., Section 156.275 by an accrediting entity recognized

by the United States Department of Health and Human Services.

F. 1. If the Authority awards a capitated contract to a

provider-led entity or provider-owned entity for the urban region

under Section 4002.3b of this title, the provider-led entity or

provider-owned entity shall expand its coverage area to every county

of this state within the time frame set by the Authority under

subsection E of Section 4002.3b of this title.

2. The expansion of the provider-led entity’s or provider-owned

entity’s coverage area beyond the urban region shall be subject to

the approval of the Authority. The Authority shall approve

expansion to counties for which the provider-led entity or providerowned entity can demonstrate evidence of network adequacy as

required under 42 C.F.R., Sections 438.3 and 438.68. When approved,

the additional county or counties shall be added to the provider-led

entity’s or provider-owned entity’s region during the next open

enrollment period.

Added by Laws 2021, c. 542, § 4, eff. Sept. 1, 2021. Amended by

Laws 2022, c. 395, § 7, eff. July 1, 2022; Laws 2024, c. 448, § 4,

emerg. eff. June 14, 2024.

§56-4002.4a. Standard contract terms.

A. 1. The Oklahoma Health Care Authority shall develop

standard contract terms for contracted entities to include, but not

be limited to, all requirements stipulated by this act. The

Authority shall oversee and monitor performance of contracted

entities and shall enforce the terms of capitated contracts as

required by paragraph 2 of this subsection.

2. The Authority shall require each contracted entity to meet

all contractual and operational requirements as defined in the

requests for proposals issued pursuant to Section 3 of this act.

Such requirements shall include but not be limited to reimbursement

and capitation rates, insurance reserve requirements as specified by

the Insurance Department, acceptance of risk as defined by the

Authority, operational performance expectations including the

assessment of penalties, member marketing guidelines, other

applicable state and federal regulatory requirements, and all

requirements of this act including, but not limited to, the

requirements stipulated in this section.

B. The Authority shall develop methods to ensure program

integrity against provider fraud, waste, and abuse.

C. The Authority shall develop processes for providers and

Medicaid members to report violations by contracted entities of

applicable administrative rules, state laws, or federal laws.

Added by Laws 2022, c. 395, § 8, eff. July 1, 2022.

Oklahoma Statutes - Title 56. Poor Persons