§56-4002.4. Network adequacy standards for contracted entities.
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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.
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 provider- owned 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.