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1 STATE OF OKLAHOMA
2 2nd Session of the 60th Legislature (2026)
3 HOUSE BILL 3626 By: Lawson
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6 AS INTRODUCED
7 An Act relating to Medicaid; amending 56 O.S. 2021,
Section 4002.8, as last amended by Section 3, Chapter
8 372, O.S.L. 2025 (56 O.S. Supp. 2025, Section
4002.8), which relates to adverse determinations and
9 procedures; adding to who can review the appeal;
stating the requirements for a psychologist; amending
10 56 O.S. 2021, Section 4002.12, as last amended by
Section 7, Chapter 448, O.S.L. 2024 (56 O.S. Supp.
11 2025, Section 4002.12), which relates to minimum
rates of reimbursement, value-based payment
12 arrangements, and payment methodologies; directing
the Oklahoma Health Care Authority to establish a
13 reimbursement rate for psychologists upon appeal; and
providing an effective date.
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17 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
18 SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.8, as
19 last amended by Section 3, Chapter 372, O.S.L. 2025 (56 O.S. Supp.
20 2025, Section 4002.8), is amended to read as follows:
21 Section 4002.8. A. A contracted entity shall utilize uniform
22 procedures established by the Authority under subsection B of this
23 section for the review and appeal of any adverse determination by
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1 the contracted entity sought by any member or provider adversely
2 affected by such determination.
3 B. The Authority shall develop procedures for members or
4 providers to seek review by the contracted entity of any adverse
5 determination made by the contracted entity.
6 C. A provider shall have six (6) months from the receipt of a
7 claim denial to file an appeal.
8 D. A contracted entity shall ensure that all appeals of adverse
9 determinations made by the contracted entity are reviewed by a
10 licensed physician or, if appropriate for the requested service, a
11 licensed mental health professional. The contracted entity shall
12 not use any automated claim review software or other automated
13 functionality for such appeals.
14 E. The physician or mental health professional who reviews the
15 appeal shall:
16 1. Possess a current and valid unrestricted license in any
17 United States jurisdiction;
18 2. Be of the same or similar specialty as a physician,
19 psychologist, or mental health professional who typically manages
20 the medical condition or disease. This requirement shall be
21 considered met:
22 a. for a physician, if:
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1 (1) the physician maintains board certification for
2 the same or similar specialty as the medical
3 condition in question, or
4 (2) the physician's training and experience:
5 (a) includes treatment of the condition,
6 (b) includes treatment of complications that may
7 result from the service or procedure, and
8 (c) is sufficient for the physician to determine
9 if the service or procedure is medically
10 necessary or clinically appropriate, or
11 b. for a psychologist, if:
12 (1) the psychologist is currently licensed in
13 accordance with the Psychologists Licensing Act
14 in Title 59 of the Oklahoma Statutes,
15 (2) the psychologist has training and experience in
16 the testing for and treatment of the condition,
17 or
18 (3) the psychologist's training and experience is
19 sufficient to determine if the service is
20 medically necessary or clinically appropriate, or
21 c. for a other mental health professional professionals,
22 if the mental health professional's training and
23 experience:
24 (1) includes treatment of the condition, and
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1 (2) is sufficient for the mental health professional
2 to determine if the service is medically
3 necessary or clinically appropriate;
4 3. Not have been directly involved in making the adverse
5 determination;
6 4. Not have any financial interest in the outcome of the
7 appeal; and
8 5. Consider all known clinical aspects of the health care
9 service under review including, but not limited to, a review of any
10 medical records pertinent to the active condition that are provided
11 to the contracted entity by the member's provider, or a health care
12 facility, and any pertinent medical literature provided to the
13 contracted entity by the provider.
14 F. Upon receipt of notice from the contracted entity that the
15 adverse determination has been upheld on appeal, the member or
16 provider may request a fair hearing from the Authority. The
17 Authority shall develop procedures for fair hearings in accordance
18 with 42 C.F.R., Part 431.
19 SECTION 2. AMENDATORY 56 O.S. 2021, Section 4002.12, as
20 last amended by Section 7, Chapter 448, O.S.L. 2024 (56 O.S. Supp.
21 2025, Section 4002.12), is amended to read as follows:
22 Section 4002.12. A. Until July 1, 2027, the Oklahoma Health
23 Care Authority shall establish minimum rates of reimbursement from
24 contracted entities to providers who elect not to enter into value-
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1 based payment arrangements under subsection B of this section or
2 other alternative payment agreements for health care items and
3 services furnished by such providers to enrollees of the state
4 Medicaid program. Except as provided by subsection I of this
5 section, until July 1, 2027, such reimbursement rates shall be equal
6 to or greater than:
7 1. For an item or service provided by a participating provider
8 who is in the network of the contracted entity, one hundred percent
9 (100%) of the reimbursement rate for the applicable service in the
10 applicable fee schedule of the Authority; or
11 2. For an item or service provided by a non-participating
12 provider or a provider who is not in the network of the contracted
13 entity, ninety percent (90%) of the reimbursement rate for the
14 applicable service in the applicable fee schedule of the Authority
15 as of January 1, 2021.
16 B. A contracted entity shall offer value-based payment
17 arrangements to all providers in its network capable of entering
18 into value-based payment arrangements. Such arrangements shall be
19 optional for the provider but shall be tied to reimbursement
20 incentives when quality metrics are met. The quality measures used
21 by a contracted entity to determine reimbursement amounts to
22 providers in value-based payment arrangements shall align with the
23 quality measures of the Authority for contracted entities.
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1 C. Notwithstanding any other provision of this section, the
2 Authority shall comply with payment methodologies required by
3 federal law or regulation for specific types of providers,
4 including, but not limited to, Federally Qualified Health Centers,
5 rural health clinics, pharmacies, Indian Health Care Providers, and
6 emergency services.
7 D. A contracted entity shall offer all rural health clinics
8 (RHCs) contracts that reimburse RHCs using the methodology in place
9 for each specific RHC prior to January 1, 2023, including any and
10 all annual rate updates. The contracted entity shall comply with
11 all federal program rules and requirements, and the transformed
12 Medicaid delivery system shall not interfere with the program as
13 designed.
14 E. The Oklahoma Health Care Authority shall establish minimum
15 rates of reimbursement from contracted entities to Certified
16 Community Behavioral Health Clinic (CCBHC) providers who elect
17 alternative payment arrangements equal to the prospective payment
18 system rate under the Medicaid State Plan.
19 F. The Authority shall establish an incentive payment under the
20 Supplemental Hospital Offset Payment Program that is determined by
21 value-based outcomes for providers other than hospitals.
22 G. 1. Psychologist reimbursement shall reflect outcomes.
23 Reimbursement shall not be limited to therapy and shall include, but
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1 not be limited to, patient intake administration, testing, and
2 assessment.
3 2. The Authority shall establish a reimbursement rate for
4 psychologists who are successful upon appeal pursuant to section
5 4002.8 of this title that compensates them for the hours spent by
6 the psychologist on the appeal. Such reimbursement shall take into
7 account the hours spent on the administration of the appeal that
8 would have otherwise been spent on providing services to patients.
9 H. Coverage for Medicaid ground transportation services by
10 licensed Oklahoma emergency medical services shall be reimbursed at
11 no less than the published Medicaid rates as set by the Authority.
12 All currently published Medicaid Healthcare Common Procedure Coding
13 System (HCPCS) codes paid by the Authority shall continue to be paid
14 by the contracted entity. The contracted entity shall comply with
15 all reimbursement policies established by the Authority for the
16 ambulance providers. Contracted entities shall accept the modifiers
17 established by the Centers for Medicare and Medicaid Services
18 currently in use by Medicare at the time of the transport of a
19 member that who is dually eligible for Medicare and Medicaid.
20 I. 1. The rate paid to participating pharmacy providers is
21 independent of subsection A of this section and shall be the same as
22 the fee-for-service rate employed by the Authority for the Medicaid
23 program as stated in the payment methodology in OAC 317:30-5-78,
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1 unless the participating pharmacy provider elects to enter into
2 other alternative payment agreements.
3 2. A pharmacy or pharmacist shall receive direct payment or
4 reimbursement from the Authority or contracted entity when providing
5 a health care service to the Medicaid member at a rate no less than
6 that of other health care providers for providing the same service.
7 J. Notwithstanding any other provision of this section,
8 anesthesia shall continue to be reimbursed equal to or greater than
9 the anesthesia fee schedule established by the Authority as of
10 January 1, 2021. Anesthesia providers may also enter into value-
11 based payment arrangements under this section or alternative payment
12 arrangements for services furnished to Medicaid members.
13 K. The Authority shall specify in the requests for proposals a
14 reasonable time frame in which a contracted entity shall have
15 entered into a certain percentage, as determined by the Authority,
16 of value-based contracts with providers.
17 L. Capitation rates established by the Oklahoma Health Care
18 Authority and paid to contracted entities under capitated contracts
19 shall be updated annually and in accordance with 42 C.F.R., Section
20 438.3. Capitation rates shall be approved as actuarially sound as
21 determined by the Centers for Medicare and Medicaid Services in
22 accordance with 42 C.F.R., Section 438.4 and the following:
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1 1. Actuarial calculations must include utilization and
2 expenditure assumptions consistent with industry and local
3 standards; and
4 2. Capitation rates shall be risk-adjusted and shall include a
5 portion that is at risk for achievement of quality and outcomes
6 measures.
7 M. The Authority may establish a symmetric risk corridor for
8 contracted entities.
9 N. The Authority shall establish a process for annual recovery
10 of funds from, or assessment of penalties on, contracted entities
11 that do not meet the medical loss ratio standards stipulated in
12 Section 4002.5 of this title.
13 O. 1. The Authority shall, through the financial reporting
14 required under subsection G of Section 4002.12b of this title,
15 determine the percentage of health care expenses by each contracted
16 entity on primary care services.
17 2. Not later than the end of the fourth year of the initial
18 contracting period, each contracted entity shall be currently
19 spending not less than eleven percent (11%) of its total health care
20 expenses on primary care services.
21 3. The Authority shall monitor the primary care spending of
22 each contracted entity and require each contracted entity to
23 maintain the level of spending on primary care services stipulated
24 in paragraph 2 of this subsection.
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1 SECTION 3. This act shall become effective November 1, 2026.
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3 60-2-15156 TJ 12/18/25
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Req. No. 15156 Page 10Every fact on this page links to its source, starting with the official bill record.