reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 50 - Home and Community-Based Waiver Services › Subchapter 5 - Sooner Seniors [REVOKED] › Section 317:50-5-12

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 148,
				  eff 10-14-10 (emergency); Added at 28 Ok Reg 1630, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 50 - Home and Community-Based Waiver Services › Subchapter 5 - Sooner Seniors [REVOKED] › Section 317:50-5-13

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 148,
				  eff 10-14-10 (emergency); Added at 28 Ok Reg 1630, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 50 - Home and Community-Based Waiver Services › Subchapter 5 - Sooner Seniors [REVOKED] › Section 317:50-5-14

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 148, eff 10-14-10 (emergency) ; Added
					 at 28 Ok Reg 1630, eff 6-25-11 ; Amended at 30 Ok Reg 1307, eff
					 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 50 - Home and Community-Based Waiver Services › Subchapter 5 - Sooner Seniors [REVOKED] › Section 317:50-5-15

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 148,
				  eff 10-14-10 (emergency); Added at 28 Ok Reg 1630, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 50 - Home and Community-Based Waiver Services › Subchapter 5 - Sooner Seniors [REVOKED] › Section 317:50-5-16

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 148,
				  eff 10-14-10 (emergency); Added at 28 Ok Reg 1630, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 1 - General Provisions › Section 317:55-1-1 - Purpose; use of manuals

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Chapter is to provide detailed rules
				  which govern the delivery of health care services provided by managed care
				  organizations or dental benefits managers as required by the "Ensuring Access
				  to Medicaid Act", 2021 Okla. Sess. Law Serv. Ch. 542 (S.B. 131), Title 56 of
				  the Oklahoma Statutes, Sections 4002-4004 and
				  42
				  Code of Federal Regulations (C.F.R.), Part 438 . The Oklahoma Health Care
				  Authority may also develop manuals and medical guidelines that formalize terms,
				  conditions, and applicable policy of awarded contracts.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 1 - General Provisions › Section 317:55-1-1 - Purpose; use of manuals

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Chapter is to provide detailed rules
				  which govern the delivery of health care services provided by contracted
				  entities or dental benefits managers as required by the "Ensuring Access to
				  Medicaid Act", Title 56 of the Oklahoma Statutes, Sections
				  4002-4004 and
				  42 Code of Federal Regulations
				  (C.F.R.), Part 438 . The Oklahoma Health Care Authority may also develop
				  manuals and medical guidelines that formalize terms, conditions, and applicable
				  policy of awarded contracts.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 1 - General Provisions › Section 317:55-1-4 - Eligible entities

Current through Vol. 41, No. 20, July 1, 2024
Eligible entities.
The OHCA shall enter into a
				  capitated contract for the delivery of statewide Medicaid services. Eligible
				  entities include an accountable care organization, a provider-led entity, a
				  commercial plan, or any other entity as determined by OHCA. The CE or DBM shall
				  meet the following requirements:
(1)
Licensure and certificate of authority.
(A) The CE must be licensed as a Health
				Maintenance Organization (HMO) pursuant to 36 O.S. § 6901 et seq.
(B) The CE must furnish OHCA with
				a certificate of authority, to operate as an HMO, prior to contract
				implementation.
(C) The DBM must be
				licensed and authorized, as prepaid dental health plan, and able to transact
				dental business in the State of Oklahoma in accordance with 36 O.S. § 6141
				et seq.
(D) The DBM must furnish
				OHCA with a certificate of authority for accident and health insurance or
				pre-paid dental prior to contract implementation in accordance with 36 O.S.
				§ 703.
(E) Any changes to the
				certificate of authority, for CE and DBM, must be reported immediately to the
				OHCA.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 1 - General Provisions › Section 317:55-1-5 - Program administration requirements

Current through Vol. 41, No. 20, July 1, 2024
(a)
Compliance.
The CE or DBM shall comply with all applicable state
				and federal laws and regulations, including, but not limited to, 42 C.F.R. Part
				438 , and HIPAA privacy and security law, as defined in Section 3009 of the
				Public Health Service Act.
(b)
Subcontracting.
The CE or DBM shall seek approval from the OHCA
				prior to the effective date of any subcontract for performance of certain
				Contract responsibilities.
(1) The CE or DBM
				shall maintain ultimate responsibility for adhering to and otherwise fully
				complying with all terms and conditions of its Contract with OHCA,
				notwithstanding any relationship(s) with any subcontractors. The CE or DBM
				shall actively monitor subcontractors to ensure their compliance with the
				Contract and verify the quality of their services.
(2) The CE or DBM is prohibited from entering
				into any subcontract for the performance of any duty under the Contract in
				which such services are to be transmitted or performed outside of the United
				States.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 1 - ELIGIBILITY, ENROLLMENT AND CONTINUITY OF CARE › Section 317:55-3-1 - Mandatory populations

Current through Vol. 41, No. 20, July 1, 2024
(a)
Mandatory
				  MCO enrollment.
Per 56 O.S. § 4002.3, eligibles in the following
				  categories will be mandatorily enrolled in the MCP and with an MCO:
(1) Expansion adults;
(2) Parents and caretaker
				  relatives;
(3) Pregnant
				  women;
(4) Deemed
				  newborns;
(5) Children;
				  and
(6) All other populations
				  requiring mandatory coverage pursuant to in 42 C.F.R. Part 435 , Subpart B
				  (§§ 435.100 435.172), unless otherwise covered by
				  SoonerCare.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 1 - ELIGIBILITY, ENROLLMENT AND CONTINUITY OF CARE › Section 317:55-3-1 - Mandatory, voluntary, and excluded populations

Current through Vol. 41, No. 20, July 1, 2024
(a)
Mandatory
				  populations.
The following SoonerCare Eligibles will be mandatorily
				  enrolled with a CE and DBM under the SoonerSelect Dental and Medical program:
(1) Expansion adults;
(2) Parents and caretaker
				  relatives;
(3) Pregnant
				  women;
(4) Deemed
				  newborns;
(5) Former foster
				  children;
(6) Juvenile justice
				  involved children;
(7) Foster care
				  children;
(8) Children receiving
				  adoption assistance; and
(9)
				  Children.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 1 - ELIGIBILITY, ENROLLMENT AND CONTINUITY OF CARE › Section 317:55-3-2 - Excluded populations

Current through Vol. 41, No. 20, July 1, 2024
(a) Per 56 O.S.
				  § 4002.3, individuals in the following categories will be excluded from
				  enrollment in a MCP contracted with one (1) or more MCOs:
(1) Dual eligible individuals;
(2) Individuals enrolled in the Medicare
				  Savings Program, including Qualified Medicare Beneficiaries (QMB), Specified
				  Low Income Medicare Beneficiaries (SLMB), Qualified Disabled Workers (QDW) and
				  Qualified Individuals (QI);
(3)
				  Persons with a nursing facility or intermediate care facility for individuals
				  with intellectual disabilities (ICF/IID) level of care, except that enrollees
				  who are transitioning into long-term care will remain enrolled in any MCO for
				  up to sixty (60) days while the enrollee's level of care determination is
				  pending. Prior to disenrollment from an MCO, such excepted enrollees will
				  receive a facility's pre-admission screening and resident review (PASRR)
				  process. If OHCA approves the PASRR and designates the nursing facility or
				  ICF/IID level of care, reimbursement will be made to the facility and the
				  enrollee will be disenrolled from their MCO;
(4) Individuals during a period of
				  presumptive eligibility;
(5)
				  Individuals infected with tuberculosis eligible for tuberculosis-related
				  services under
				  42 C.F.R. §
												435.215;
(6) Individuals determined eligible for
				  SoonerCare on the basis of needing treatment for breast or cervical cancer
				  under
				  42
				  C.F.R. §
												435.213;
(7) Individuals enrolled in a 1915(c)
				  waiver;
(8) Undocumented persons
				  eligible for emergency services only in accordance with
				  42 C.F.R. §
												435.139;
(9) Insure Oklahoma employee sponsored
				  insurance (ESI) dependent children in accordance with the Oklahoma Title XXI
				  State Plan;
(10) Coverage of
				  pregnancy-related services under Title XXI for the benefit of unborn children
				  (Soon- to-be-Sooners), as allowed by
				  42 C.F.R. §
												457.10; and
(11) Individuals determined eligible for
				  Medicaid on the basis of age, blindness or disability.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 1 - ELIGIBILITY, ENROLLMENT AND CONTINUITY OF CARE › Section 317:55-3-3 - Voluntary enrollment and disenrollment

Current through Vol. 41, No. 20, July 1, 2024
(a) Per 56 O.S.
				  § 4002.3, AI/AN populations that are eligible for SoonerCare will have the
				  option to:
(1) Voluntarily enroll in the MCP
				  through an opt-in process;
(2)
				  Enroll in an MCO or DBM at each open enrollment period, regardless of initial
				  selection or past disenrollment from the MCP;
(3) Receive services from an IHCP;
(4) Choose the IHCP as the enrollee's PCMH
				  provider or DH provider, if the provider has the capacity to provide such
				  services;
(5) Obtain services
				  covered under the contract from out-of-network IHCPs when the enrollee is
				  otherwise eligible to receive the IHCP's services;
(6) Self-refer for services provided by IHCPs
				  to AI/AN enrollees;
(7) Obtain
				  services covered under the contract from out-of-network IHCPs when the AI/AN
				  enrollee is otherwise eligible to receive the IHCP's services; and
(8) Disenroll from any MCO or DBM at any time
				  without cause.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 1 - ELIGIBILITY, ENROLLMENT AND CONTINUITY OF CARE › Section 317:55-3-3 - Enrollee rights

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				  with 42 C.F.R. §
											438.100, state and federal regulations, and
				  all contractual requirements, the CE and DBM shall allow the Enrollee the right
				  to:
(1) Receive information on the
				  SoonerSelect program and the CE or DBM;
(2) Receive information on all available
				  treatment options and alternatives;
(3) Participate in decisions regarding their
				  healthcare;
(4) Free from any form
				  of restraint or seclusion used as a means of coercion, discipline, convenience,
				  or retaliation; and
(5) Request and
				  receive a copy of their medical records in accordance with all HIPAA rules.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-10 - Grievances and appeals

Current through Vol. 41, No. 20, July 1, 2024
(a)
Filing.
Grievances and appeals are to be initially filed with each
				  enrollee's MCO or DBM. Grievances may be filed with the enrollee's MCO or DBM
				  at any time, either orally or in writing. A provider or an authorized
				  representative may file an appeal, grievance, or request for a State fair
				  hearing on behalf of an enrollee, provided that the provider or authorized
				  representative has obtained the enrollee's written consent.
(b)
Levels of appeal.
Pursuant
				  to
				  42 C.F.R. §
											438.402, MCOs and DBMs will only have one (1)
				  level of appeal. Enrollees and providers may file an appeal to OHCA seeking the
				  review of a final adverse benefit determination rendered by an MCO or
				  DBM.
(c)
Governing
				  rules.
The provisions at OAC
				  317:2-1-1
				  et seq. will govern any enrollee or provider right to file a grievance,
				  complaint, appeal or request for a State fair hearing pursuant to 56 O.S.
				  § 4002-4004, 42 C.F.R. Parts 431 or 438, or the managed care
				  contract.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-10 - Covered services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Amount,
				  duration, and scope of services.
The CE or DBM must ensure members have
				  timely access to all medically necessary services, as applicable, covered by
				  SoonerCare under the Medicaid State Plan, the Alternative Benefit Plan (ABP),
				  and the 1115 IMD Waiver. The CE or DBM must ensure:
(1) Services are sufficient in amount,
				  duration, and scope to reasonably be expected to achieve the purpose for which
				  the services are provided;
(2) The
				  amount, duration, and scope of a required service is not arbitrarily denied or
				  reduced solely because of the diagnosis, type of illness, or condition;
(3) PA is available for services
				  on which the CE or DBM has placed a pre-identified limitation to ensure the
				  limitation may be exceeded when medically necessary.
(A) The CE or DBM may propose to impose
				  alternative PA requirements, subject to OHCA's review and approval, except for
				  those benefits identified as exempt from PA. The CE or DBM may be less
				  restrictive on the requirements of a PA than OHCA but may not impose greater
				  restrictions.
(B) PA shall be
				  processed in accordance with timeliness requirements specified in the Contract.
(4) Coverage decisions
				  are based on the coverage and medical necessity criteria published in Title 317
				  of the Oklahoma Administrative Code and practice guidelines/manual; and
(5) If a member is unable to
				  obtain medically necessary services offered by SoonerCare from a CE or DBM
				  network provider, the CE or DBM must adequately and timely cover the services
				  out of network, until the CE or DBM is able to provide the services from a
				  network provider.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-11 - Cost sharing

Current through Vol. 41, No. 20, July 1, 2024
The CE or DBM shall ensure that all Enrollees are held
					 harmless by providers for payment for any existing covered services, other than
					 required cost sharing, during the continuity of care period. The CE or DBM
					 shall not impose premiums or charges on Enrollees that are in excess of those
					 permitted in the SoonerCare program in accordance with OAC
					 317:30-3-5 and the Oklahoma
					 Medicaid State Plan. If the CE or DBM fails to comply with OAC
					 317:55-3-11, the OHCA may impose
					 any or all the CE intermediate sanctions, found at OAC
					 317:55-5-10 and the CE Contract,
					 or DBM administrative remedies, found at OAC
					 317:55-5-11 and the DBM
					 Contract.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-12 - Non-compliance damages and remedies

Current through Vol. 41, No. 20, July 1, 2024
If OHCA finds an MCO or DBM to be in violation of the
					 provisions of 56 O.S. §§ 4002-4004, rules promulgated thereto, or the
					 terms and conditions of the contract, OHCA may enforce any damages or remedies
					 for non-compliance as required by CMS, as provided for in the contract, or as
					 permitted by State or Federal law.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-12 - Provider contracting and network requirements

Current through Vol. 41, No. 20, July 1, 2024
(a)
Provider
				  contracts.
A CE or DBM must provide or arrange for the delivery of
				  covered health care services described in OAC
				  317:55-3-5 through a provider
				  agreement with SoonerCare-contracted providers. All provider agreements must be
				  in writing and in accordance with the Contract and
				  42 C.F.R. §§
											434.6 and
				  438.6. The CE's or DBM's execution
				  of a provider agreement does not terminate the CE's or DBM's legal
				  responsibility to the OHCA to ensure all the CE's and DBM's activities and
				  obligations are performed in accordance with Okla. Admin. Code § 317, as
				  applicable, the CE's or DBM's Contract with the OHCA, and all applicable
				  federal, state, and local regulations. The CE or DBM shall maintain, and have
				  available, written policies and procedures on:
(1) Participating provider
				  selection;
(2) Retention and
				  termination of a provider's participation with the CE or DBM;
(3) Responding to changes in the CE'S or
				  DBM'S network of participating providers that affect access and ability to
				  deliver services in a timely manner; and
(4) Access standards.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-13 - Termination of managed care contract

Current through Vol. 41, No. 20, July 1, 2024
(a)
Termination of an MCO, permitted by 42 C. F.R. § 438.708.
Members impacted by the contract termination of an MCO will be enrolled with a
				  different MCO or be provided Medicaid benefits through options as prescribed in
				  the Oklahoma Medicaid State Plan. OHCA may terminate a contract with an MCO if
				  OHCA determines that the MCO:
(1) Failed to
				  carry out the substantive terms of the contract; or
(2) Failed to meet applicable requirements of
				  sections 1903(m), 1905(t), or 1932 of the Act.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-13 - Time, distance, and access standards

Current through Vol. 41, No. 20, July 1, 2024
(a) The CE and DBM
				  must meet all time and distance standards as established by the OHCA in
				  accordance with 42 C.F.R.
				  §
											438.68. The time and distance
				  standards will apply to all geographic areas in which the CE or DBM operates,
				  with standards varying for urban and rural areas, which will include, at a
				  minimum:
(1) Anticipated
				  enrollment;
(2) Expected
				  utilization of services;
(3)
				  Characteristics and health care needs of all covered populations;
(4) Provider-to-Enrollee ratios;
(5) Travel time or distance to providers;
(6) Percentage of contracted
				  providers that are accepting new patients;
(7) Ability to communicate with limited
				  English proficiency Enrollees;
(8)
				  Ability to ensure physical access, reasonable accommodations, and accessible
				  equipment for Enrollees with physical or mental disabilities;
(9) Maximum wait times; and
(10) Hours of operations.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-14 - Record retention

Current through Vol. 41, No. 20, July 1, 2024
In addition to the requirements found at OAC
					 317:30-3-15 and
					 317:30-5-70.2,
					 the MCO or DBM and its affiliates, subcontractors, and employees must retain
					 records in compliance with the provisions and spirit of
					 42 C.F.R. §§
											438.3(h) and (u), to the
					 extent applicable.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-14 - Primary care requirements

Current through Vol. 41, No. 20, July 1, 2024
(a)
Primary
				  care spending/expenses.
No later than the end of the fourth (4 th) year
				  of the initial contracting period, each CE shall be currently spending not less
				  than eleven percent (11%) of its total health care expenses on primary care
				  services.
(b)
Primary care
				  expenditure reporting requirements.
(1) The CEs must submit a primary care
				  implementation plan which describes the CEs strategies for increasing the
				  percentage of total medical expenditures allocated to primary care over the
				  initial four (4) year contract period.
(2) The plan shall include target annual
				  percentage increases over the previous year baseline data that demonstrate the
				  CEs ability to achieve eleven percent (11%) by the end of year four (4).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-15 - Provider agreement/contract termination

Current through Vol. 41, No. 20, July 1, 2024
(a) The CE and DBM
				  and all participating providers have the right to terminate the Contract
				  entered into with each other via a provider agreement.
(b) The CE and DBM and all participating
				  providers may terminate the provider agreement for cause with thirty (30) days
				  advance written notice and without cause with sixty (60) days advance written
				  notice to the other party.
(c) The
				  CE and DBM shall terminate its provider agreement with a participating provider
				  immediately if any of the following circumstances occur:
(1) In order to protect the health and safety
				  of all Enrollees;
(2) If a credible
				  allegation of fraud results in a conviction of credible allegation on the
				  participating provider;
(3) When
				  the participating provider's licenses, certifications and/or accreditations are
				  modified, revoked or in any other way making it unlawful for the provider to
				  provide services under the Contract; or
(4) If requested by the
				  OHCA.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 3 - ACCESS TO COVERED SERVICES AND PROVIDER NETWORK STANDARDS › Section 317:55-3-16 - Non-licensed providers

Current through Vol. 41, No. 20, July 1, 2024
(a) The CE and DBM
				  must ensure that all non-licensed providers are educated, trained, and
				  qualified to perform all job responsibilities.
(b) Background checks and database screening
				  in accordance with state and federal laws must be completed to ensure the
				  non-licensed provider has not been excluded or debarred from participation in
				  Medicare, Medicaid, or any federal health care program.
(c) All applicable state and federal
				  regulations and contractual requirements must be followed when employing
				  non-licensed providers.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 5 - GRIEVANCE, APPEAL AND PROVIDER COMPLAINT SYSTEM › Section 317:55-3-20 - Authorizations

Current through Vol. 41, No. 20, July 1, 2024
Prior to the implementation of any MCP authorized under 42
					 C.F.R. Part 438 , OHCA will receive the following authorizations:
(1) Federal authority through a State Plan
				  Amendment or waiver of the Act;
(2)
				  CMS approval of each contract in relation to the MCP;
(3) CMS approval of all contract rates
				  authorized under the MCP; and
(4)
				  CMS approval of direct payment arrangements authorized under the MCP.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 5 - GRIEVANCE, APPEAL AND PROVIDER COMPLAINT SYSTEM › Section 317:55-3-20 - SoonerSelect enrollee grievance and appeal system

Current through Vol. 41, No. 20, July 1, 2024
(a) The CE or DBM
				  shall have written grievance and appeal policies and procedures for an
				  Enrollee, or an Enrollee's authorized representative, to appeal a CE's or DBM's
				  action and/or file a grievance. The policies must address contractual
				  requirements, including performance standards, and federal funding
				  requirements, including 42
				  C.F.R. §
											438 Subpart F and OAC
				  317:2-3-3.
(1) Timeframes, pursuant to OAC
				  317:2-3-2;
(2) Grievances, pursuant to OAC
				  317:2-3-4;
(3) Appeals, pursuant to OAC
				  317:2-3-5;
(4) Grievance and appeal notices, pursuant to
				  OAC 317:2-3-8;
(5) State fair hearings, pursuant to OAC
				  317:2-3-12;
(6) Recordkeeping, pursuant to OAC
				  317:2-3-11; and
(7) Continuation of benefits, pursuant to OAC
				  317:2-1-2.6 and
				  317:2-3-5.1
.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 5 - GRIEVANCE, APPEAL AND PROVIDER COMPLAINT SYSTEM › Section 317:55-3-21 - Timing

Current through Vol. 41, No. 20, July 1, 2024
OHCA may only execute transition to a managed care delivery
					 system ninety (90) days after CMS has approved all contracts entered into
					 between OHCA and all MCOs or DBMs following OHCA's submission of readiness
					 review results to CMS, pursuant to
					 42 C.F.R. §
											438.66.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 5 - GRIEVANCE, APPEAL AND PROVIDER COMPLAINT SYSTEM › Section 317:55-3-21 - Provider complaint system

Current through Vol. 41, No. 20, July 1, 2024
The CE or DBM shall have written provider complaint
					 policies and procedures for an Enrollee, or an Enrollee's authorized
					 representative, to appeal a CE's or DBM's action and/or file a grievance. The
					 policies must address contractual requirements, including performance
					 standards, and federal funding requirements, including 42 C.F.R. Part 438
					 Subpart F and OAC
					 317:2-3-10.
(1) Timeframes, pursuant to OAC
				  317:2-3-2;
(2) Notices, pursuant to OAC
				  317:2-3-8; and
(3) Recordkeeping, pursuant to OAC
				  317:2-3-11.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 1 - MONITORING, PROGRAM INTEGRITY, DATA, AND REPORTING › Section 317:55-5-1 - MCO or DBM accreditation

Current through Vol. 41, No. 20, July 1, 2024
All MCOs and DBMs will be accredited in accordance with 45
					 C.F.R. § 165.275 by an accrediting entity recognized by the United States
					 Department of Health and Human Services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 1 - MONITORING, PROGRAM INTEGRITY, DATA, AND REPORTING › Section 317:55-5-1 - Monitoring system for all SoonerSelect programs

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				  with 42 C.F.R. §
											438.66, the OHCA will monitor each CE or DBM
				  to assess its ability and capacity to comply with program and Contract-specific
				  requirements and to assess its ability to perform satisfactorily in all major
				  operational areas.
(b) The CE or
				  DBM shall have a reporting monitoring process for ensuring compliance with all
				  Contract requirements, implementation deadlines for mandates and/or laws as
				  directed by CMS, CDC, or other federal or state government entity. The CE or
				  DBM shall report monthly on its compliance monitoring activities as required by
				  the reporting manual.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 1 - MONITORING, PROGRAM INTEGRITY, DATA, AND REPORTING › Section 317:55-5-2 - MCO or DBM readiness

Current through Vol. 41, No. 20, July 1, 2024
(a) According to
				  42 C.F.R. §
											438.66, during implementation and prior to
				  enrollment effective dates, the MCO or DBM will participate in a readiness
				  review process. To be deemed eligible to effect enrollments, the MCO or DBM
				  will complete all readiness review activities to the satisfaction of OHCA and
				  CMS. The readiness reviews will be conducted through one (1) or more desk
				  reviews and one or more on-site reviews. The MCO or DBM must satisfactorily
				  demonstrate readiness for MCP operations, including but not limited to focus
				  areas identified at
				  42 C.F.R. §
											438.66(b). At any stage(s)
				  of the readiness review process, OHCA may but is not required to provide an MCO
				  or DBM with notice(s) of deficiency and reasonable opportunity(ies) to cure the
				  deficiency. As between the parties to the managed care contract, OHCA has sole
				  authority to determine the readiness of any MCO or DBM.
(b) As a part of any readiness review, OHCA
				  will ensure the MCO or DBM meets the requirements at 56 O.S. §
				  4002.10.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 1 - MONITORING, PROGRAM INTEGRITY, DATA, AND REPORTING › Section 317:55-5-2 - Program integrity; data and reporting

Current through Vol. 41, No. 20, July 1, 2024
(a)
Program
				  integrity standards.
The CE and DBM shall comply with all state and
				  federal laws, regulations, and mandates including but not limited to
				  42 C.F.R. §
											438.608. The CE and DBM shall have and
				  implement written policies and procedures that are designed to detect and
				  prevent fraud, waste, and abuse pursuant to the Contract and federal
				  regulations. The CE and DBM shall:
(1)
				  Provide a monthly report (by close of the last calendar day of each month), of
				  all open Program Integrity related audits and investigations related to fraud,
				  waste, and abuse activities for identifying and collecting potential
				  overpayments, utilization review, and provider compliance.
(2) Refer credible allegations of fraud to
				  OHCA's Legal Division in writing within three (3) business days of
				  discovery.
(3) Suspend all payments
				  to the provider when a credible allegation of fraud exists.
(4) Participate in good faith at monthly
				  Program Integrity meetings held jointly with MFCU and OHCA.
(5) Participate in good faith at monthly
				  meetings with OHCA Program Integrity and Accountability Unit.
(6) Disclose any change in ownership and
				  control information to OHCA within thirty-five (35) calendar days.
(7) Submit to OHCA or HHS, within thirty-five
				  (35) days of request, full and complete information about:
(A) The ownership of any subcontractor with
				  whom the CE/DBM has had business transactions totaling more than twenty-five
				  thousand dollars ($25,000) during the twelve (12-month) period ending on the
				  date of the request; and
(B) Any
				  significant business transactions between the CE/DBM and any wholly owned
				  supplier, or between the provider and any subcontractor, during the five
				  (5-year) period ending on the date of request.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 1 - MONITORING, PROGRAM INTEGRITY, DATA, AND REPORTING › Section 317:55-5-3 - Critical incident reporting system

Current through Vol. 41, No. 20, July 1, 2024
(a) The CE shall
				  ensure that any serious incident that harms or potentially harms the Enrollee's
				  health, safety, or well-being, including incidents of seclusion and restraint,
				  are immediately identified, reported, reviewed, investigated, and corrected, in
				  compliance with state and federal law.
(b) When the Enrollee is in the care of a
				  behavioral health inpatient, PRTF, or crisis stabilization unit, critical
				  incidents shall include, but are not limited to the following:
(1) Suicide death;
(2) Non-suicide death;
(3) Death-cause unknown;
(4) Homicide;
(5) Homicide attempt with significant medical
				  intervention;
(6) Suicide attempt
				  with significant medical intervention;
(7) Allegation of physical, sexual, or verbal
				  abuse or neglect;
(8) Accidental
				  injury with significant medical intervention;
(9) Use of restraints/seclusion
				  (isolation);
(10) AWOL or absence
				  from a mental health facility without permission; or
(11) Treatment complications (medication
				  errors and adverse medication reaction) requiring significant medical
				  intervention.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-10 - Provider contracts and credentialing standards

Current through Vol. 41, No. 20, July 1, 2024
(a) All MCOs and
				  DBMs will formally credential and recredential network providers at a frequency
				  required by a single, consolidated provider enrollment and credentialing
				  process established by OHCA in accordance with
				  42 C.F.R. §
											438.214 and in coordination with MCOs and
				  DBMs.
(b) All MCOs and DBMs will
				  contract to the extent possible and practicable with all essential community
				  providers who receive directed payments in accordance with 42 C.F.R. Part 438
				  and any other providers as specified by OHCA through contract.
(c) Every MCO and DBM will contract with
				  every participating provider through a written provider agreement that:
(1) Identifies the contractual obligations
				  between the MCO or DBM and the participating provider; and
(2) Incorporates any provision required by
				  the contract between OHCA and the MCO or DBM for inclusion in the provider
				  agreement.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-10 - Non-compliance of contracted entities

Current through Vol. 41, No. 20, July 1, 2024
(a)
Failure
				  to comply.
If the CE fails to fulfill its duties and obligations or meet
				  performance standards under 42 C.F.R. Part 438, 42 U.S.C.
				  §
										1396b(m),
				  42 U.S.C. §
											1396u-2, Title 317 of the Oklahoma
				  Administrative Code, or the CE Contract, OHCA will notify the CE of unmet
				  performance expectations, violations or deficiencies, and may impose corrective
				  actions or any sanctions in addition to or instead of any actions or sanctions
				  specified in the Contract.
(b)
Non-material compliance deficiencies.
(1) If OHCA determines that unmet performance
				  expectations, violations, or deficiencies do not result in a material
				  deficiency or delay in the implementation or operation of services, the CE will
				  have five (5) business days (or the date specified by OHCA) of receipt of
				  notice to provide the OHCA with a written response that:
(A) Explains the reasons for the
				  deficiency;
(B) The CE's plan to
				  address or cure the deficiency; and
(C) The date and time by which the deficiency
				  will be cured.
(D) If the CE
				  disagrees with OHCA's findings, the CE shall provide its reasons for
				  disagreeing with OHCA's findings.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-11 - Network adequacy standards

Current through Vol. 41, No. 20, July 1, 2024
In accordance with
					 42
					 C.F.R. §
											438.604, the MCO or DBM will
					 submit documentation for which OHCA will base its certification to CMS that the
					 MCO or DBM has complied with requirements for availability and accessibility of
					 services, including health professional shortage areas and adequacy of the
					 MCO's or DBM's network, as set forth in
					 42 C.F.R. §§
											438.206,
					 438.14
					 and
					 438.68.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-11 - Non-compliance of dental benefit managers

Current through Vol. 41, No. 20, July 1, 2024
(a)
Failure
				  to comply.
If the DBM fails to fulfill its duties and obligations or
				  meet performance standards under
				  42 C.F.R. Part 438,
				  42 U.S.C. § 1396b(m),
				  42 U.S.C. §
											1396u-2, Title 317 of the Oklahoma
				  Administrative Code, or the DBM Contract, OHCA will notify the DBM of unmet
				  performance expectations, violations, or deficiencies, and may impose
				  corrective actions or any sanctions in addition to or instead of any actions or
				  sanctions specified in the Contract.
(b)
Non-material compliance
				  deficiencies.
(1) If OHCA determines
				  that unmet performance expectations, violations, or deficiencies do not result
				  in a material deficiency or delay in the implementation or operation of
				  services, the DBM will have five (5) business days (or the date specified by
				  OHCA) of receipt of notice to provide the OHCA with a written response that:
(A) Explains the reasons for the deficiency;
(B) The DBM's plan to address or
				  cure the deficiency; and
(C) The
				  date and time by which the deficiency will be cured; or
(D) If the DBM disagrees with OHCA's
				  findings, the DBM shall provide its reasons for disagreeing with OHCA's
				  findings.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-12 - Prior authorization requirements, generally

Current through Vol. 41, No. 20, July 1, 2024
The OHCA will establish prior authorization requirements
					 that are consistent with 56 O.S. §§ 4002-4004. MCOs and DBMs may
					 establish prior authorization of benefits to the extent these are consistent
					 with OHCA's policies and rules. The MCO or DBM may propose to impose additional
					 prior authorization requirements, subject to OHCA's review and approval, except
					 for those benefits identified in the Oklahoma Medicaid State Plan, rules, or
					 practices as exempt from prior authorization. The MCO or DBM may be less
					 restrictive on the requirements of a prior authorization than OHCA but may not
					 impose greater restrictions.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-12 - Termination of contract

Current through Vol. 41, No. 20, July 1, 2024
(a) The Contract
				  may be terminated prior to its scheduled expiration date only for the reasons
				  specified in this Section.
(1)
Termination for mutual consent.
OHCA and the CE or DBM may
				  terminate the contract by mutual written agreement.
(2)
Termination for convenience.
The OHCA may terminate the contract, in whole or in part, for convenience if it
				  is determined that termination is in the state's best interest.
(3)
Termination for default.
OHCA may, at its election, assign Enrollees to another DBM/CE or provide
				  benefits through other State Plan authority if the DBM/CE has breached this
				  contract and is unable or unwilling to cure such breach within the period of
				  time as specified in writing by OHCA.
(4)
Termination for unavailability of
				  funds.
If state, federal, or other funding is not sufficiently
				  appropriated, or is withdrawn, reduced, or limited in any way after the
				  effective date of the contract, OHCA may terminate this contract immediately,
				  effective on the close of business on the day specified. OHCA shall be the
				  final authority as to the availability of funds.
(5)
Termination for lack of
				  authority.
If any necessary federal or state approval or authority to
				  operate the SoonerSelect Medical or Dental program is not granted, or the
				  Oklahoma Legislature prohibits OHCA from contracting with a CE or DBM for the
				  provision of health care for Eligibles or Enrollees, OHCA may terminate this
				  contract immediately, effective on the close of business on the day specified.
(6)
Termination for
				  financial instability.
If the OHCA deems, in its sole discretion, that
				  the CE or DBM is financially unstable to the point of threatening the ability
				  of OHCA to obtain the services provided for under this contract, ceases to
				  conduct business in the normal course, makes a general assignment for the
				  benefit of creditors or suffers or permits the appointment of a receiver for
				  its business or its assets, then OHCA may, at its option, immediately terminate
				  this Contract effective on the close of business on the date specified.
(7)
Termination for
				  debarment.
The CE or DBM will not knowingly have a relationship with an
				  individual or affiliate, as defined in
				  42 C.F.R. §
												438.610.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-13 - Notification of material change

Current through Vol. 41, No. 20, July 1, 2024
An MCO or DBM will promptly, within one (1) business day,
					 notify OHCA of all changes materially affecting the delivery of care or the
					 administration of the MCP.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-13 - Notification of material change

Current through Vol. 41, No. 20, July 1, 2024
A CE or DBM will promptly, within one (1) business day,
					 notify OHCA of all changes materially affecting the delivery of care or the
					 administration of the plan.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-14 - Patient data

Current through Vol. 41, No. 20, July 1, 2024
An MCO or DBM will provide patient data to a provider upon
					 request to the extent allowed under federal or State laws, rules, or
					 regulations, including but not limited to the Health Insurance Portability and
					 Accountability Act of 1996.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 3 - NON-COMPLIANCE OF A CE AND/OR DBM AND NOTIFICATIONS › Section 317:55-5-14 - Patient data

Current through Vol. 41, No. 20, July 1, 2024
A CE or DBM will provide patient data to a provider upon
					 request to the extent allowed under federal or state laws, rules, or
					 regulations, including but not limited to the Health Insurance Portability and
					 Accountability Act of 1996.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 5 - FINANCE › Section 317:55-5-20 - Capitation rates

Current through Vol. 41, No. 20, July 1, 2024
OHCA will contract with an actuary, as defined at
					 42
					 C.F.R. §
											438.2, to establish actuarially
					 sound capitation rates, as described at
					 42 C.F.R. §§
											438.3(c),
					 438.4, and
					 438.5,
					 for OHCA to pay to MCOs and DBMs.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 5 - FINANCE › Section 317:55-5-20 - Financial standards and third-party liability

Current through Vol. 41, No. 20, July 1, 2024
(a)
Financial
				  standards.
The CE or DBM shall comply with Oklahoma Insurance Department
				  requirements for minimum net worth and risk- based capital in accordance with
				  applicable Oklahoma Statutes found in Title 36 Insurance.
(b)
Insolvency protection.
In
				  accordance with the requirements found at
				  42 C.F.R. §§
											438.106,
				  438.116,
				  36 O.S. § 6901, et seq., and
				  all contractual requirements, the CE and DBM will provide satisfactory
				  assurances to the OHCA to ensure that neither Enrollees nor the OHCA is held
				  liable or responsible for any of the following:
(1) Any debts obtained by the CE or
				  DBM;
(2) Covered services that are
				  provided to the Enrollee for which the OHCA does not pay the CE or DBM;
				  or
(3) Payment for covered services
				  that are in excess of the amount that the Enrollee would owe the CE or DBM if
				  those services were covered directly.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 5 - Requirements for Contracted Entities and Dental Benefits Managers › Part 5 - FINANCE › Section 317:55-5-21 - Medical loss ratio

Current through Vol. 41, No. 20, July 1, 2024
An MCO or DBM will have a medical loss ratio that, at
					 minimum, meets the standards provided by
					 42 C.F.R. §
											438.8.