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 - Intermediate sanctions

Current through Vol. 41, No. 20, July 1, 2024
(a)
Intermediate sanctions obligation.
OHCA will establish
				  intermediate sanctions that it may impose on an MCO if OHCA makes any of the
				  determinations specified in
				  42 C.F.R. §
											438.700(b)-(d).
(b)
Adoption of intermediate
				  sanctions.
OHCA adopts the intermediate sanctions as provided at
				  42 C.F.R. §
											438.702.
(c)
Imposition of sanctions.
If
				  OHCA makes a determination per
				  42 C.F.R. §§
											438.700 or
				  438.706
				  and thereby imposes intermediate sanctions as listed at
				  42 C.F.R. §§
											438.702 or
				  438.706,
				  OHCA will consider the totality of and follow all relevant regulations at 42
				  C.F.R. Part 438 , Subpart I.
(d)
Required imposition of temporary management.
In accordance with
				  42 C.F.R. §
											438.706(b), OHCA will impose
				  the intermediate sanction of temporary management, regardless of any other
				  sanction that may be imposed, if OHCA finds that an MCO has repeatedly failed
				  to meet substantive requirements in sections 1903(m) or 1932 of the Act or 42
				  C.F.R. Part 438 . In this situation, OHCA will also grant enrollees the right
				  to terminate enrollment without cause, as described in
				  42 C.F.R. §
											438.702(a)(3), and must
				  notify the affected enrollees of their right to terminate enrollment.
				  Notwithstanding any other Section of these rules, OHCA will not delay
				  imposition of temporary management to provide a hearing before imposing this
				  sanction. OHCA will continue this sanction until the MCO can ensure that the
				  sanctioned behavior will not recur.
(e)
Retained authority.
OHCA
				  retains authority to impose additional sanctions under State statutes or State
				  regulations that address areas of noncompliance specified in
				  42 C.F.R. §
											438.700, as well as additional areas of
				  noncompliance. Nothing in 42 C.F.R. Part 438 , Subpart I, prevents OHCA from
				  exercising that authority.
(f)
Notice.
Before imposing an intermediate sanction, OHCA will give
				  the affected MCO timely written notice that explains the basis and nature of
				  the sanction and any other appeal rights that OHCA elects to provide.
(g)
Right to request fair
				  hearing.
Though not required under federal regulation, OHCA provides
				  each MCO the right, upon notice of a sanction other than optional or required
				  temporary management, to request a fair hearing before an administrative law
				  judge (ALJ) retained by OHCA. The cost of actions necessary to process an MCO's
				  request will be paid by OHCA.
(1) An MCO must
				  file any request for fair hearing within thirty (30) days after receiving the
				  notice.
(2) The ALJ has
				  jurisdiction to hear any request under this section. The ALJ will review the
				  appeal for legal authority and jurisdiction. If legal authority and
				  jurisdictional requirements are met, the ALJ will conduct an administrative
				  hearing according to the hearing practices of OAC
				  317:2-1-5,
				  provide proposed findings of fact and conclusions of law to the parties, and
				  send written notice to the parties of the final order sustaining or denying
				  imposition of the sanction.
(3) At
				  the ALJ's discretion, the ALJ will:
(A)
				  Establish a scheduling order;
(B)
				  Establish reasonable procedures such as authorizing pleadings to be filed by
				  facsimile or electronic mail;
(C)
				  Rule on all interlocutory motions;
(D) Require briefing of any or all
				  issues;
(E) Conduct hearings in a
				  forum and manner as determined by the ALJ;
(F) Rule on the admissibility of all
				  evidence;
(G) Question
				  witnesses;
(H) Impose appropriate
				  sanctions against any person failing to obey an order of the ALJ or authorized
				  under the rules in this section which will include:
(i) Refusing to allow the person to assert or
				  oppose designated claims or defenses, or prohibiting that person from
				  introducing designated matters in evidence;
(ii) Excluding all testimony of an
				  unresponsive or evasive witness; or
(iii) Expelling the person from further
				  participation in the hearing;
(I) Take official notice of any material fact
				  not appearing as evidence in the record, if the fact is among traditional
				  matters of judicial notice;
(J)
				  Administer oaths or affirmations;
(K) Determine the location of the hearing and
				  manner in which it will be conducted;
(L) Allow either party to request that the
				  hearing be recorded by a court reporter with costs to be borne by the
				  requesting party. The original of such transcription, if ordered, will be given
				  to the ALJ with a copy to be given to the requesting party;
(M) Recess and reconvene the
				  hearing;
(N) Set and/or limit the
				  time frame of the hearing;
(O) Make
				  proposed findings of facts and conclusions of law; and
(P) Sustain or deny OHCA's imposition of the
				  sanction(s).