{"data":{"id":"us-ok/okla.-stat.-tit.-56-56-4002.12","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 56, § 56-4002.12","heading":"Minimum rates of reimbursement – Value-based payment","body":"arrangements.\n\nA. Until July 1, 2027, the Oklahoma Health Care Authority shall\n\nestablish minimum rates of reimbursement from contracted entities to\n\nproviders who elect not to enter into value-based payment\n\narrangements under subsection B of this section or other alternative\n\npayment agreements for health care items and services furnished by\n\nsuch providers to enrollees of the state Medicaid program. Except\n\nas provided by subsection I of this section, until July 1, 2027,\n\nsuch reimbursement rates shall be equal to or greater than:\n\n1. For an item or service provided by a participating provider\n\nwho is in the network of the contracted entity, one hundred percent\n\n(100%) of the reimbursement rate for the applicable service in the\n\napplicable fee schedule of the Authority; or\n\n2. For an item or service provided by a non-participating\n\nprovider or a provider who is not in the network of the contracted\n\nentity, ninety percent (90%) of the reimbursement rate for the\n\napplicable service in the applicable fee schedule of the Authority\n\nas of January 1, 2021.\n\nB. A contracted entity shall offer value-based payment\n\narrangements to all providers in its network capable of entering\n\ninto value-based payment arrangements. Such arrangements shall be\n\noptional for the provider but shall be tied to reimbursement\n\nincentives when quality metrics are met. The quality measures used\n\nby a contracted entity to determine reimbursement amounts to\n\nproviders in value-based payment arrangements shall align with the\n\nquality measures of the Authority for contracted entities.\n\nC. Notwithstanding any other provision of this section, the\n\nAuthority shall comply with payment methodologies required by\n\nfederal law or regulation for specific types of providers including,\n\nbut not limited to, Federally Qualified Health Centers, rural health\n\nclinics, pharmacies, Indian Health Care Providers and emergency\n\nservices.\n\nD. A contracted entity shall offer all rural health clinics\n\n(RHCs) contracts that reimburse RHCs using the methodology in place\n\nfor each specific RHC prior to January 1, 2023, including any and\n\nall annual rate updates. The contracted entity shall comply with\n\nall federal program rules and requirements, and the transformed\n\nMedicaid delivery system shall not interfere with the program as\n\ndesigned.\n\nE. The Oklahoma Health Care Authority shall establish minimum\n\nrates of reimbursement from contracted entities to Certified\n\nCommunity Behavioral Health Clinic (CCBHC) providers who elect\n\nalternative payment arrangements equal to the prospective payment\n\nsystem rate under the Medicaid State Plan.\n\nF. The Authority shall establish an incentive payment under the\n\nSupplemental Hospital Offset Payment Program that is determined by\n\nvalue-based outcomes for providers other than hospitals.\n\nG. Psychologist reimbursement shall reflect outcomes.\n\nReimbursement shall not be limited to therapy and shall include but\n\nnot be limited to testing and assessment.\n\nH. Coverage for Medicaid ground transportation services by\n\nlicensed Oklahoma emergency medical services shall be reimbursed at\n\nno less than the published Medicaid rates as set by the Authority.\n\nAll currently published Medicaid Healthcare Common Procedure Coding\n\nSystem (HCPCS) codes paid by the Authority shall continue to be paid\n\nby the contracted entity. The contracted entity shall comply with\n\nall reimbursement policies established by the Authority for the\n\nambulance providers. Contracted entities shall accept the modifiers\n\nestablished by the Centers for Medicare and Medicaid Services\n\ncurrently in use by Medicare at the time of the transport of a\n\nmember that is dually eligible for Medicare and Medicaid.\n\nI. 1. The rate paid to participating pharmacy providers is\n\nindependent of subsection A of this section and shall be the same as\n\nthe fee-for-service rate employed by the Authority for the Medicaid\nt the modifiers\n\nestablished by the Centers for Medicare and Medicaid Services\n\ncurrently in use by Medicare at the time of the transport of a\n\nmember that is dually eligible for Medicare and Medicaid.\n\nI. 1. The rate paid to participating pharmacy providers is\n\nindependent of subsection A of this section and shall be the same as\n\nthe fee-for-service rate employed by the Authority for the Medicaid\n\nprogram as stated in the payment methodology in OAC 317:30-5-78,\n\nunless the participating pharmacy provider elects to enter into\n\nother alternative payment agreements.\n\n2. A pharmacy or pharmacist shall receive direct payment or\n\nreimbursement from the Authority or contracted entity when providing\n\na health care service to the Medicaid member at a rate no less than\n\nthat of other health care providers for providing the same service.\n\nJ. Notwithstanding any other provision of this section,\n\nanesthesia shall continue to be reimbursed equal to or greater than\n\nthe anesthesia fee schedule established by the Authority as of\n\nJanuary 1, 2021. Anesthesia providers may also enter into value-\n\nbased payment arrangements under this section or alternative payment\n\narrangements for services furnished to Medicaid members.\n\nK. The Authority shall specify in the requests for proposals a\n\nreasonable time frame in which a contracted entity shall have\n\nentered into a certain percentage, as determined by the Authority,\n\nof value-based contracts with providers.\n\nL. Capitation rates established by the Oklahoma Health Care\n\nAuthority and paid to contracted entities under capitated contracts\n\nshall be updated annually and in accordance with 42 C.F.R., Section\n\n438.3. Capitation rates shall be approved as actuarially sound as\n\ndetermined by the Centers for Medicare and Medicaid Services in\n\naccordance with 42 C.F.R., Section 438.4 and the following:\n\n1. Actuarial calculations must include utilization and\n\nexpenditure assumptions consistent with industry and local\n\nstandards; and\n\n2. Capitation rates shall be risk-adjusted and shall include a\n\nportion that is at risk for achievement of quality and outcomes\n\nmeasures.\n\nM. The Authority may establish a symmetric risk corridor for\n\ncontracted entities.\n\nN. The Authority shall establish a process for annual recovery\n\nof funds from, or assessment of penalties on, contracted entities\n\nthat do not meet the medical loss ratio standards stipulated in\n\nSection 4002.5 of this title.\n\nO. 1. The Authority shall, through the financial reporting\n\nrequired under subsection G of Section 4002.12b of this title,\n\ndetermine the percentage of health care expenses by each contracted\n\nentity on primary care services.\n\n2. Not later than the end of the fourth year of the initial\n\ncontracting period, each contracted entity shall be currently\n\nspending not less than eleven percent (11%) of its total health care\n\nexpenses on primary care services.\n\n3. The Authority shall monitor the primary care spending of\n\neach contracted entity and require each contracted entity to\n\nmaintain the level of spending on primary care services stipulated\n\nin paragraph 2 of this subsection.","path":["OK Code","Title 56"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os56.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"b0dcb699d60afb1133d70bc37be3b600089beef6144bcc40282a993de57fffa3","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-56-56-4002.11","next":"us-ok/okla.-stat.-tit.-56-56-4002.12a"},"notice":"GroundRules: Original legal text. Not legal advice."}