Archived Proposed Policy Changes


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The Oklahoma Health Care Authority (OHCA) seeks advice and consultation from medical professionals, professional and tribal organizations, and the general public in developing new or amended policies and rules. The proposed policy page is designed to give all constituents an opportunity to review and make comments regarding upcoming rule changes.

All comments regarding proposed administrative rules will be considered during the rulemaking process and become a part of the official work folder. All rule changes are subject to the Oklahoma Administrative Procedures Act

For Quick Reference Search; please click the applicable archive Proposed Policy Changes  

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    Proposed Policy


    APA WF# 19-01 — Retroactive Eligibility

    The proposed revisions to policy provide for a retroactive period of eligibility, in accordance with 42 C.F.R. § 435.915.

    Please view the circulation document here: APA WF# 19-01, and submit feedback via the comment box below.

    Circulation Date: 07/02/2019

    Comment Due Date: 07/31/2019

    Medical Advisory Committee: 07/18/2019

    Board Meeting: 08/21/2019

     


     

     

     APA WF# 19-02 — Certified Community Behavioral Health Clinics (CCBHC) Project

    The proposed revisions will incorporate new rules to sustain the CCBHC project beyond its demonstration period in Oklahoma. The proposed revisions will outline CCBHC member eligibility, provider participation requirements, and program scope.

    Please view the circulation document here: APA WF# 19-02, and submit feedback via the comment box below.

    Circulation Date: 05/03/2019

    Comment Due Date: 05/17/2019

    Medical Advisory Committee: 05/16/2019

    Board Meeting: 05/21/2019


    APA WF# 19-03 — Applied Behavior Analysis (ABA) Services

    The proposed revisions will add new language establishing coverage and reimbursement for ABA services as an Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The proposed language will define scope of service, provider criteria and credentialing requirements, medical necessity, intervention criteria, and extension requests for continued services. Other revisions will update outdated policy language.

    Please view the circulation document here: APA WF# 19-03, and submit feedback via the comment box below.

    Circulation Date: 05/03/2019

    Comment Due Date: 05/17/2019

    Medical Advisory Committee: 05/16/2019

    Board Meeting: 05/21/2019
     
    Please view all comments received here: APA WF# 19-03 Comment Document.

     


     

    APA WF# 19-06 — Diabetes Self-Management Training (DSMT) Services

    The proposed rule changes will establish diabetes self-management training (DSMT) as a new benefit in the SoonerCare program. DSMT is an educational disease management benefit designed to teach members how to successfully manage and control his/her diabetes.

    Please view the circulation document here: APA WF# 19-06, and submit feedback via the comment box below.

    Circulation Date: 09/04/2019

    Comment Due Date: 10/04/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 10/16/2019


     

    APA WF# 19-05 — Therapeutic Foster Care Revisions

    The proposed revisions will align therapeutic foster care policy with current practice. Revisions will add new language establishing a more intensive treatment program for children in DHS and OJA custody known as Intensive Treatment Family Care (ITFC). The proposed revisions will define ITFC, member criteria for the provision of ITFC services, provider participation and credentialing requirements, and program coverage and limitations. Lastly, the proposed revisions will establish reimbursement methodology and applicable rates for ITFC services.  

    Please view the circulation document here: APA WF# 19-05, and submit feedback via the comment box below.

    Circulation Date: 07/11/2019

    Comment Due Date: 08/03/2019

    Medical Advisory Committee: 07/18/2019

    Board Meeting: 08/21/2019

     

    APA WF# 19-08 — Telehealth Services

    The proposed revisions bring OHCA policy into compliance with recently enacted Senate Bill 575, which becomes effective on July 1, 2019.  The rules also establish and/or clarify requirements for the provision of telehealth services, including those services provided in a school setting.

    Please view the circulation document here: APA WF# 19-08, and submit feedback via the comment box below.

    Circulation Date: 06/24/2019

    Comment Due Date: 07/27/2019

    Medical Advisory Committee: 07/18/2019

    Board Meeting: 08/21/2019


    APA WF# 19-08 — Telehealth Services Revisions

    The proposed revisions bring OAC 317:30-3-27 into compliance with recently enacted Senate Bill 575, which becomes effective on October 1, 2019.  The rules also establish and/or clarify requirements for the provision of telehealth services, including those services provided in a school setting.

    Please view the circulation document here: APA WF# 19-08, and submit feedback via the comment box below.

    Circulation Date: 08/05/2019

    Comment Due Date: 09/04/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 09/18/2019

     
     
     

    APA WF# 19-10 — American Indian/Alaska Native Cost Sharing Exemption

    The proposed revisions make Oklahoma's administrative code language consistent with Oklahoma's State Plan language.

    Please view the circulation document here: APA WF# 19-10, and submit feedback via the comment box below.

    Circulation Date: 06/24/2019

    Comment Due Date: 07/23/2019

    Medical Advisory Committee: 07/18/2019

    Board Meeting: 08/21/2019

     


     

    APA WF# 19-11 — Board Organization and Policy Revisions

    The proposed revisions will comply with Senate Bill 456, which was signed into law on March 13, 2019, and directed the reorganization of the OHCA Board. The seven-member Board was replaced with a nine-member Board. Further revisions will establish that the chair and vice-chair elections are held at the last regular meeting before January 1st of each year. Other revisions are needed to correct outdated language.

    Please view the circulation document here: APA WF# 19-11, and submit feedback via the comment box below.

    Circulation Date: 07/03/2019

     Comment Due Date: 08/01/2019

     Medical Advisory Committee: 07/18/2019

     Board Meeting: 08/21/2019


    APA WF# 19-12 — High Risk Obstetrical Services (HROB) Revisions

    The proposed revisions will add "family practice physician - obstetrics" (FP/OB) as a new provider type under the enhanced services for medically high risk pregnancies policy. This policy change will address and improve access to care for obstetrical related services in rural Oklahoma areas. Further revisions will update policy to reflect current business practices.

    Please view the circulation document here: APA WF# 19-12, and submit feedback via the comment box below.

    Circulation Date: 07/17/2019

    Comment Due Date: 08/16/2019

    Medical Advisory Committee: 07/18/2019

    Board Meeting: 08/21/2019

     

    APA WF# 19-13A — Long-Term Care Facilities

    The proposed revisions will bring the Oklahoma Health Care Authority (OHCA) into compliance with Senate Bill 280.

    Please view the circulation document here: APA WF# 19-13A, and submit feedback via the comment box below.

    Circulation Date: 08/29/2019

    Comment Due Date: 09/17/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 09/18/2019

      

    APA WF# 19-13B — Long-Term Care Facilities

    The proposed revisions will bring the Oklahoma Health Care Authority (OHCA) into compliance with Senate Bill 280.

    Please view the circulation document here: APA WF# 19-13B, and submit feedback via the comment box below.

    Circulation Date: 08/29/2019

    Comment Due Date: 09/17/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 09/18/2019

     


     

     

     

    APA WF# 19-13A — Long-Term Care Facilities

    This policy change had been previously posted for comments. It has since been updated.  

    The proposed revisions will bring the Oklahoma Health Care Authority (OHCA) into compliance with Senate Bill 280.

    Please view the circulation document here: APA WF# 19-13A, and submit feedback via the comment box below.

    Circulation Date: 09/05/2019

    Comment Due Date: 09/17/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 09/18/2019



     

     

    APA WF# 19-13B — Long-Term Care Facilities

    This policy change had been previously posted for comments. It has since been updated.  

    The proposed revisions will bring the Oklahoma Health Care Authority (OHCA) into compliance with Senate Bill 280.

    Please view the circulation document here: APA WF# 19-13B, and submit feedback via the comment box below.

    Circulation Date: 09/05/2019

    Comment Due Date: 09/17/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 09/18/2019

      Please view all comments received here: APA WF# 19-13B Comment Spreadsheet.
     

     


     

     APA WF# 19-16 — Behavioral Health Targeted Case Management (TCM) Updates

    The proposed rule change, requested by the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), increases the TCM monthly limits that are reimbursable by SoonerCare.

    Please view the circulation document here: APA WF# 19-16, and submit feedback via the comment box below.

    Circulation Date: 09/04/2019

    Comment Due Date: 09/16/2019

    Medical Advisory Committee: 09/05/2019

    Board Meeting: 09/18/2019

     

    APA WF# 18-02 — Work and Community Engagement Requirements as a Condition of SoonerCare Eligibility for Adults

    The proposed policy will establish work and community engagement requirements as a condition of SoonerCare eligibility for adults who do not meet certain exemptions.

    Please view the circulation document here: APA WF# 18-02, and submit feedback via the comment box below.

    Circulation Date: 07/03/2018

    Comment Due Date: 09/03/2018

    Medical Advisory Committee Meeting: 07/19/2018

    Board Meeting: TBD

     


    APA WF# 18-01 — Laboratory Services Policy Update

     

    The proposed revisions update laboratory services policy.

    Please view the circulation document here: APA WF# 18-01, and submit feedback via the comment box below.

    Circulation Date: 08/23/2018

    Comment Due Date: 09/24/2018

    Medical Advisory Committee Meeting: 09/20/2018

    Board Meeting: 10/11/2018

    Please view all comments received here: APA WF# 18-01 Comment Document.

    APA WF# 18-01 Laboratory Services Policy Update

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule

    The proposed revisions update laboratory services policy.

    Please view the circulation document here: APA WF# 18-01, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019


    The following emergency rule was pulled and will instead go through the 2018 permanent rulemaking session.
      
     
    APA WF# 18-05 — Exclusions of certain underpayments from resources

    The proposed revisions amend policy to be consistent with federal law which excludes the unspent portion of Social Security Retirement, Survivors, and Disability Insurance (RSDI) or Supplemental Security Income (SSI) retroactive payments when determining the resources of an Aged, Blind, and Disabled (ABD) individual.

    Please view the circulation document here: APA WF# 18-05, and submit feedback via the comment box below.

    Circulation Date: 10/22/2018

    Comment Due Date: 11/21/2018

    Medical Advisory Committee Meeting: 11/15/2018

    Board Meeting: 12/13/2018

     


     

     

     

    APA WF# 18-05 — Exclusions of Certain Underpayments from Resources

    The proposed revisions amend policy to be consistent with federal law which excludes the unspent portion of Social Security Retirement, Survivors, and Disability Insurance (RSDI) or Supplemental Security Income (SSI) retroactive payments when determining the resources of an Aged, Blind, and Disabled (ABD) individual.

    Please view the circulation document here: APA WF# 18-05, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019


     

     

     

    APA WF# 18-06 — Inpatient Psychiatric Services Revisions

    The proposed revisions will establish a prior authorization requirement for inpatient psychiatric services for adults. Revisions will also align the time requirement of the first individual treatment by the physician to the requirement of completion of the psychiatric evaluation. Other revisions will involve limited rewriting aimed at clarifying text.

     Please view the circulation document here: APA WF# 18-06, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019


     

     

     

    APA WF# 18-10 — Oklahoma Electronic Health Records (EHR) Incentive Program Policy Revisions

    The proposed revisions amend the Oklahoma EHR Incentive Program policy by changing policy regarding the required SoonerCare patient volume criteria and about documentation to support or correct the provider's EHR attestation.

    Please view the circulation document here: APA WF# 18-10, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019


    APA WF# 18-07A Preadmission Screening and Resident Review (PASRR) Revisions

    The proposed revisions will incorporate new language to clarify that the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be used for diagnostic purposes in Medicaid-certified nursing facility admissions. Revisions will also involve limited rewriting aimed at clarifying text, eliminating redundancies, and updating outdated terminology.

    Please view the circulation document here: APA WF# 18-07A, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

     

     

    APA WF# 18-07B Preadmission Screening and Resident Review (PASRR) revisions

    The proposed revisions will incorporate new language to clarify that the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be used for diagnostic purposes in Medicaid-certified nursing facility admissions. Revisions will also involve limited rewriting aimed at clarifying text, eliminating redundancies, and updating outdated terminology.

    Please view the circulation document here: APA WF# 18-07B, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-09 Suspended Claims Review and/or Prepayment Review

    The proposed revisions add new general provider policies to define various review mechanisms used by OHCA to help ensure that reimbursements are for medically necessary, correctly and/or appropriately billed medical supplies and services.

    Please view the circulation document here: APA WF# 18-09, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

     

    APA WF# 18-12 — Tax Equity and Fiscal Responsibility Act (TEFRA) Policy Revisions

    The proposed revisions will amend Tax Equity and Fiscal Responsibility Act (TEFRA) policy by removing references to the Oklahoma Department of Human Services and replacing them with the Oklahoma Health Care Authority.

    Please view the circulation document here: APA WF# 18-12, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019 

     

    APA WF# 18-13 Application Fees and Provider Screening

    The proposed revisions to the general provider policies are added to establish provider enrollment application fees and other provider screening and enrollment requirements mandated by federal regulation.

    Please view the circulation document here: APA WF# 18-13, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-14 Countable Income and Resources Policy Change

    The proposed revisions amend countable income and resources policy, specifically the policy on resource disregards.

    Please view the circulation document here: APA WF# 18-14, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-15A Change Timeframes for Appeals

    The proposed revisions change all of the appeals rules to extend the length of time that appeals can be submitted from twenty days to thirty days of the date of an adverse agency action.

    Please view the circulation document here: APA WF# 18-15A, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-15B Change Timeframes for Appeals

    The proposed revisions change all of the agency's appeals rules, to extend the length of time that appeals can be submitted from twenty days to thirty days of the date of an adverse agency action.

    Please view the circulation document here: APA WF# 18-15B, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-15C Change Timeframes for Appeals

    The proposed revisions change all of the agency's appeals rules, to extend the length of time that appeals can be submitted from twenty days to thirty days of the date of an adverse agency action.

    Please view the circulation document here: APA WF# 18-15C, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-16 Non-Emergency Transportation Parity Compliance

    The proposed revisions will amend policy to provide non-emergency transportation (NET) to pregnant women covered under the Title XXI State Plan.  The revisions are needed to comply with Parity federal regulations which instruct the State to provide equivalent services to all children covered under the Plan.

    Please view the circulation document here: APA WF# 18-16, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-17 Maternal Depression Screening Policy Revisions

    The proposed revisions will add coverage and reimbursement language for maternal depression screenings at Early and Periodic Screening Diagnostic and Treatment (EPSDT) at well-child visits. The policy will also reiterate how the Oklahoma Health Care Authority adopts and utilizes the American Academy of Pediatrics’ Bright Futures periodicity schedule including for the maternal depression screenings. Additionally, the proposed revisions will also update the child abuse section to provide a more thorough explanation of how to report child abuse including clarifying text, and updating outdated citations.

    Please view the circulation document here: APA WF# 18-17, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

      APA WF# 18-18 Mobile Dental Clinics 

    This rule was pulled from the 2018-2019 Permanent Rulemaking Session.

    The proposed revisions will add coverage and reimbursement for preventive dental services received through mobile dental clinics.  Additionally, revisions will delineate mobile dental clinic provider participation requirements pursuant to the Oklahoma State Dentistry Act, while also defining coverage and limitations for preventive dental services, billing requirements, basic consent form requirements, and follow-up care requirements.   

    Please view the circulation document here: APA WF# 18-18, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

     

     

     

    APA WF# 18-19 — Oklahoma Cares Breast and Cervical Cancer Treatment (BCC) Program Revisions

    The proposed revisions to the BCC policy add reference to the American Society for Colposcopy and Cervical Pathology Consensus and National Comprehensive Cancer Network, which provides guidelines for "in need of treatment" determinations. In addition, the term "OKDHS worker" will be replaced with the term "eligibility coordinator" to make policy current; including clean-up and removal of outdated language.

    Please view the circulation document here: APA WF# 18-19, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019

     
     

     

     

    APA WF# 18-20 — Programs of All-Inclusive Care for the Elderly (PACE) Revisions

    The proposed revisions to the PACE policy will update Uniform Comprehensive Assessment Tool requirements in order to reflect current business practices.

    Please view the circulation document here: APA WF# 18-20, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019

     

     

     

    APA WF# 18-21A — ADvantage Waiver Revisions

    The proposed revisions to the ADvantage Waiver will add new language to outline requirements for personal care services and consumer directed personal assistance services and supports (CD-PASS) for case management services. Revisions will also remove and update outdated policy in order to align with current business practices and ensure rules are in accordance with state laws and regulations.

     Please view the circulation document here: APA WF# 18-21A, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019
     

     

     


     

     

    APA WF# 18-21B — ADvantage Waiver Revisions

    The proposed revisions to the ADvantage Waiver will add new language to outline requirements for personal care services and consumer directed personal assistance services and supports (CD-PASS) for case management services. Revisions will also remove and update outdated policy in order to align with current business practices, and ensure rules are in accordance with state laws and regulations.

    Please view the circulation document here: APA WF# 18-21B, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019

    APA WF# 18-22A — Developmental Disabilities Division (DDS) Revisions

    The proposed revisions to the DDS policy amend the rules to implement changes recommended during the annual Oklahoma Department of Human Services (DHS) DDS rule review process. Revisions will also eliminate and update outdated policy in order to better align with current business practices.

    Please view the circulation document here: APA WF# 18-22A, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 02/14/2019

     


     

     

    APA WF# 18-22B — Developmental Disabilities Division (DDS) Revisions

    The proposed revisions to the DDS policy amend the rules to implement changes recommended during the annual Oklahoma Department of Human Services (DHS) DDS rule review process. Proposed revisions will reflect new service requirements for employment services through Home and Community-Based Services Waivers. Additional revisions will eliminate and update outdated policy in order to better align with current business practices.

    Please view the circulation document here: APA WF# 18-22B, and submit feedback via the comment box below.

    Circulation Date: 12/17/2018

    Comment Due Date: 01/16/2019

    Public Hearing: 01/16/2019

    Medical Advisory Committee: 01/17/2019

    Board Meeting: 12/14/2019

     

    APA WF# 18-23 Psychiatric Services in Nursing Facilities Revisions

    The proposed revisions will clarify provider types and reimbursement of psychiatric services as part of a direct physician service visit in a nursing facility. Revisions will also involve limited rewriting aimed at clarifying text, eliminating redundancies, and updating outdated terminology.

    Please view the circulation document here: APA WF# 18-23, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-24 Out-of-State Services

    The proposed revisions and additions will define and clarify coverage and reimbursement for services rendered by providers that are physically located outside of Oklahoma.  Additionally, revisions will delineate out-of-state services, provider participation requirements, prior authorizations, and medical records requirements.  Lastly, revisions will outline reimbursement criteria for out-of-state providers who do not accept the payment rate established through the State Plan.

    Please view the circulation document here: APA WF# 18-24, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-25 General Policy Language Cleanup

    The proposed policy revisions amend language to remove obsolete references and correct formatting errors for clarity and consistency.

    Please view the circulation document here: APA WF# 18-25, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-26 Residential Behavioral Management Services (RBMS) Group Homes Revisions

    The proposed revisions will streamline group home coverage and reimbursement policy language, and develop consistency with current practice. Revisions will involve limited rewriting aimed at updating outdated terminology.

    Please view the circulation document here: APA WF# 18-26, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-27 Updates to Medicare Crossover Policy

    The proposed revisions will streamline crossover payments for dual eligible individuals.

    Please view the circulation document here: APA WF# 18-27, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-28 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services in Inpatient Psychiatric Settings

    The proposed revisions will assure that members under twenty-one (21) years of age, residing in qualified inpatient psychiatric settings, have access to a full range of medically necessary EPSDT services. Revisions will also clarify that EPSDT services are accessible, regardless of whether such services are listed on the individual plan of care (IPC).

    Please view the circulation document here: APA WF# 18-28, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

    APA WF# 18-30 Federally Qualified Health Centers (FQHC) Encounter Limitations

    The proposed revisions will amend the FQHC policy to reinstate administrative rules to allow and better define multiple encounters at FQHCs. Additional revisions will also define and establish guidelines for multiple encounters.

    Please view the circulation document here: APA WF# 18-30, and submit feedback via the comment box below.

    Circulation Date: 01/16/2019

    Comment Due Date: 02/15/2019

    Public Hearing: 02/20/2019

    Medical Advisory Committee: 03/14/2019

    Board Meeting: 03/21/2019

     

     


     

    This policy change was previously posted for comments 11/08/2018 through 12/10/2018. The policy has since been updated. 

    APA WF# 18-08 (19-04) — Eligibility Termination as Indicated by Returned Mail (This APA WF# has been reassigned to APA WF# 19-04).

    The proposed revisions expedite compliance with the Act to Restore Hope, Opportunity and Prosperity to Everyone (HOPE Act), by allowing a member's eligibility to be terminated if mail is returned to the agency with address unknown.

    Please view the circulation document here: APA WF# 18-08 (19-04), and submit feedback via the comment box below.

    Circulation Date: 11/08/2018

    Comment Due Date: 12/27/2018

    Medical Advisory Committee Meeting: 01/17/2019

    Board Meeting: 02/14/2019

    Please view all comments received here: APA WF# 18-08 (19-04) Comment Document.


     

    The following emergency rule was pulled and will instead go through the 2018 permanent rulemaking session.

    APA WF# 18-09 — Suspended claims review and/or prepayment review

    The proposed revisions add new general provider policies to define various review mechanisms used by OHCA to help ensure that reimbursements are for medically necessary, correctly and/or appropriately billed medical supplies and services.

    Please view the circulation document here: APA WF# 18-09, and submit feedback via the comment box below.

    Circulation Date: 11/08/2018

    Comment Due Date: 12/10/2018

    Medical Advisory Committee Meeting: 01/17/2019

    Board Meeting: 02/14/2019



     

    APA WF# 17-01 — Policy Revision to Comply with Fairness in Medicaid Supplemental Needs Trusts Act

    The proposed revisions are necessary to comply with federal regulation.

    Please view the circulation document here: APA WF# 17-01, and submit feedback via the comment box below.

    Circulation Date: 03/07/2017

    Comment Due Date: 04/06/2017

    Medical Advisory Committee Meeting: 05/18/2017

    Board Meeting: 06/29/2017

     


     

     

    APA WF# 17-01 — Fairness in Medicaid Supplemental Needs Trusts Act

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    The proposed revisions are necessary to comply with federal regulation.

    Please view the circulation document here: APA WF# 17-01, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Board Meeting: 02/08/2018



    APA WF# 17-02 — Self-Employment Language in Insure Oklahoma Individual Plan Policy

    The proposed revisions strengthen program integrity in the Insure Oklahoma Individual Plan for self-employed individuals.

    Please view the circulation document here: APA WF# 17-02, and submit feedback via the comment box below.

    Circulation Date: 03/07/2017

    Comment Due Date: 04/06/2017

    Medical Advisory Committee Meeting: 05/18/2017

    Board Meeting: 09/27/2017

     



    APA WF# 17-03 — Indian Health Services, Tribal Program and Urban Indian Clinics (I/T/U) Four Walls 

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule. 

    The proposed I/T/U revisions are to align policy with federal regulations and allow I/T/Us to be reimbursed at the OMB rate for services provided outside of the four walls of their facilities.

    Please view the circulation document here: APA WF# 17-03, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Board Meeting: 02/08/2018


    APA WF# 17-03 — Indian Health Services, Tribal Program and Urban Indian Clinics (I/T/U) Four Walls  

    The proposed I/T/U revisions are to align policy with federal regulations and allow I/T/Us to be reimbursed at the OMB rate for services provided outside of the four walls of their facilities.

    Please view the circulation document here: APA WF# 17-03, and submit feedback via the comment box below.

    Circulation Date: 08/14/2017

    Comment Due Date: 09/13/2017

    Medical Advisory Committee Meeting: 09/21/2017

    Board Meeting: 11/09/2017

    APA WF# 17-04A — MFP PRTF Wraparound Services Demonstration

    Living Choice Rules are revised to add an additional population to be served in the Money Follows the Person demonstration. Living Choice is developing its implementation plan to transition eligible individuals from a Psychiatric Residential Treatment Facility back into the community.

    Please view the circulation document here: APA WF# 17-04A, and submit feedback via the comment box below.

    Circulation Date: 04/17/2017

    Comment Due Date: 05/17/2017

    Medical Advisory Committee Meeting: 05/18/2017

    Board Meeting: 06/29/2017

     


    APA WF# 17-04A — Money Follows the Person Demonstration for Psychiatric Residential Treatment Facility Wraparound Services  

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule. 

    Living Choice Rules are revised to add an additional population to be served in the Money Follows the Person demonstration. Living Choice is developing its implementation plan to transition eligible individuals from a Psychiatric Residential Treatment Facility back into the community.

     Please view the circulation document here: APA WF# 17-04A, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Board Meeting: 02/08/2018

     

     


    APA WF# 17-04B — MFP PRTF Wraparound Services Demonstration

    Living Choice rules are amended to replace the term Intermediate Care Facility for Mentally Retarded ICF/MR with Intermediate Care Facility for Individuals with Intellectual Disabilities ICF/IID. Oklahoma's MFP Demonstration for Psychiatric Residential Treatment Facility (PRTF) is added to transition youth, ages 16 through 18, who have been in an inpatient PRTF for 90 or more days during an episode of care.

    Please view the circulation document here: APA WF# 17-04B, and submit feedback via the comment box below.

    Circulation Date: 04/17/2017

    Comment Due Date: 05/17/2017

    Medical Advisory Committee Meeting: 05/18/2017

    Board Meeting: 06/29/2017

     


    APA WF# 17-04B — Money Follows the Person Demonstration for Psychiatric Residential Treatment Facility Wraparound Services  

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    Living Choice rules are amended to replace the term Intermediate Care Facility for Mentally Retarded (ICF/MR) with Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). Oklahoma's MFP Demonstration for Psychiatric Residential Treatment Facility (PRTF) is added to transition youth, ages 16 through 18, who have been in an inpatient PRTF for 90 or more days during an episode of care.

    Please view the circulation document here: APA WF# 17-04B, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Board Meeting: 02/08/2018


     

    APA WF# 17-05A — Medical Identification Card Policy Revisions

    The proposed medical identification card revisions revoke the section that refers to member medical identification cards.

    Please view the circulation document here: APA WF# 17-05A, and submit feedback via the comment box below.

    Circulation Date: 06/15/2017

    Comment Due Date: 07/19/2017

    Medical Advisory Committee Meeting: 07/20/2017

    Board Meeting: 08/24/2017

     

     


     

     

    APA WF# 17-05A — Medical Identification Card Policy Revisions 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed medical identification card revisions revoke the section that refers to member medical identification cards and amends up a sentence pertaining to SoonerCare insurance verification.

    Please view the circulation document here: APA WF# 17-05A, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


    APA WF# 17-05B — Medical Identification Card Policy Revisions

    The proposed medical identification card revisions remove references that refer to the issuing of or mailing of member medical identification cards.

    Please view the circulation document here: APA WF# 17-05B, and submit feedback via the comment box below.

    Circulation Date: 06/15/2017

    Comment Due Date: 07/19/2017

    Medical Advisory Committee Meeting: 07/20/2017

    Board Meeting: 08/24/2017

     

     


     

     

    APA WF# 17-05B — Medical Identification Card Policy Revisions 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed medical identification card revisions remove references that refer to the issuing of or mailing of member medical identification cards.

    Please view the circulation document here: APA WF# 17-05B, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     

     


    APA WF# 17-06 — Pharmacy Revisions

    The proposed pharmacy revisions will reduce brand name prescriptions from two (2) to one (1) per month per eligible non-institutionalized and non-wavier adult member. Revisions also remove coverage of optional non-prescription drugs for adults. (Insulin, nicotine replacement products for smoking cessation, and family planning products are not optional).

    Please view the circulation document here: APA WF# 17-06, and submit feedback via the comment box below.

    Circulation Date: 06/15/2017

    Comment Due Date: 07/14/2017

    Medical Advisory Committee Meeting: 07/20/2017

    Board Meeting: 08/10/2017

     

     


     

     

    APA WF# 17-06 — Pharmacy Revisions 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed pharmacy revisions will amend coverage and prior authorization of non-prescription drugs and compounded prescriptions, discontinue coverage of over the counter antihistamines for adults, and exempt naloxone for use in opioid overdose from the prescription limit. The proposed changes will also clarify claim submission and reversals when not picked up by the member within 15 days of the date of service, and update pharmacy policy to align with current practice.

    Please view the circulation document here: APA WF# 17-06, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     

     

     


      APA WF# 17-07 — School-Based Services Policy Revisions

    The proposed revisions remove unintended barriers for medical services rendered in the school setting pursuant to an Individual Education Plan.

    Please view the circulation document here: APA WF# 17-07, and submit feedback via the comment box below.

    Circulation Date: 08/14/2017

    Comment Due Date: 09/13/2017

    Medical Advisory Committee Meeting: 09/21/2017

    Board Meeting: 09/27/2017
     

    APA WF# 17-07 — School-Based Services Policy Revisions

    The proposed revisions remove unintended barriers for medical services rendered in the school setting pursuant to an Individual Education Plan.

    Please view the circulation document here: APA WF# 17-07, and submit feedback via the comment box below.

    Circulation Date: 08/14/2017

    Comment Due Date: 09/21/2017

     


     

     

     

     APA WF# 17-07 — School-Based Services Policy Revisions 

    The proposed revisions remove unintended barriers for medical services rendered in the school setting pursuant to an Individual Education Plan.

    Please view the circulation document here: APA WF# 17-07, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     



    Please note that this rule is initiated by the Oklahoma Department of Mental Health and Substance Abuse Services.

    APA WF# 17-09 — Behavioral Health Case Management Limits

    The Oklahoma Department of Mental Health and Substance Abuse Services is proposing revisions to Behavioral Health Targeted Case Management (TCM) reduce the yearly limit on the amount of TCM from 25 units per member per month to 16 units per member per year. A process for authorizing up to 25 units per member per month will be used for individuals who meet established medical necessity criteria demonstrating the need for additional units.

    Please view the circulation document here: APA WF# 17-09, and submit feedback via the comment box below.

    Circulation Date: 06/26/2017

    Comment Due Date: 07/28/2017

    Medical Advisory Committee Meeting: 07/20/2017

    Board Meeting: 08/24/2017

     


     

     

     

    APA WF# 17-09 — Behavioral Health (BH) Assessment and Targeted Case Management Updates 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed policy revisions will reduce the yearly limit on the amount of basic case management/resource coordination to 16 units per member per year. Policy revisions will clarify that intensive case management is only available to adults with Serious Mental Illness (SMI) in Programs of Assertive Community Treatment (PACT) and children with Serious Emotional Disturbance (SED) in a System of Care Network. Revisions will also clarify instances in which case management is not billable. Additionally, revisions will change requirements for BH assessments by allowing for diagnostic impressions on the assessment, while still requiring a diagnosis on the service plan. Other revisions will allow for one member signature page for both the assessment and treatment plan as well as allow a temporary change of service provider to be documented in a progress note for the service provided.

    Please view the circulation document here: APA WF# 17-09, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     

     

     


     

     

    APA WF# 17-10A — Expedited Appeals 

    The proposed revisions to the appeals policy are necessary to comply with federal regulation requiring expedited appeals as well as to remove language referring to nursing home wage enhancement due to changes in state statute.

    Please view the circulation document here: 17-10A Circulation Document, and submit feedback via the comment box below.

    Circulation Date: 09/26/2017

    Comment Due Date: 10/26/2017

    Medical Advisory Committee Meeting: 11/16/2017          

    Board Meeting: 12/14/2017


     

     

    APA WF# 17-10A — Expedited Appeals 

    The proposed revisions to the appeals policy are necessary to comply with federal regulation requiring expedited appeals.

    Please view the circulation document here: APA WF# 17-10A, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018


     

     

     

    APA WF# 17-10B — Move Notification Sections to Correct Area of Policy

    The proposed revisions to the notification sections of policy move sections to a more appropriate area of policy.

    Please view the circulation document here: 17-10B Circulation Document, and submit feedback via the comment box below. 

    Circulation Date: 09/26/2017

    Comment Due Date: 10/26/2017

    Medical Advisory Committee Meeting: 11/16/2017          

    Board Meeting: 12/14/2017
     

     


     

     

    APA WF# 17-10B — Notification Policy Revisions 

     The proposed revisions to notification policy move sections to the correct area of policy because they are applicable to all SoonerCare programs.

    Please view the circulation document here: APA WF# 17-10B, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Board Meeting: 03/22/2018

     
     

     APA WF# 17-12 — Wage Enhancement Policy Revisions

    The proposed revisions remove wage enhancement language and requirements for specified employees in nursing facilities (NF) serving adults and intermediate care facilities for individual with intellectual disabilities (ICFs/IIDs). The revisions are necessary to comply with changes in Oklahoma state statute which repeal Title 63 section 5022 and 5022.1. The change in state statue became effective July 1, 2017. The federal minimum wage and the change in rate setting methodology increased the wages for employees of NFs serving and ICFs/IIDs, resulting in the policy being obsolete.

    Please view the circulation document here: 17-12 Circulation Document, and submit feedback via the comment box below.

    Circulation Date: 10/3/2017

    Comment Due Date: 11/2/2017

    Medical Advisory Committee Meeting: 11/16/2017          

    Board Meeting: 12/14/2017  

     

     


     

     

    APA WF# 17-12 — Wage Enhancement Policy Revisions 

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule. 

    The proposed revisions revoke policythat refers to wage enhancement.

    Please view the circulation document here: APA WF# 17-12, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Board Meeting: 03/22/2018

     

     


    APA WF# 17-13 — Signature Requirements Revisions  

    The proposed electronic records/electronic signatures and signature requirements policy revisions reverse the three (3) day signature language back to the policy that was in place from 2011 to September 1, 2017. The proposed revisions clarify that the authentication of medical records is expected on the day the record is completed. The revisions also clarify that the signature of the rendering provider and date entry is expected within three (3) business days from the day the record is completed if the record is being transcribed.

    Please view the circulation document here:  APA WF# 17-13, and submit feedback via the comment box below.

    Circulation Date: 08/30/2017

    Comment Due Date: 09/21/2017

    Medical Advisory Committee Meeting: 09/21/2017

    Board Meeting: 09/27/2017


    APA WF# 17-13 — Signature Requirements Revisions 

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule. 

    The proposed electronic records/electronic signatures and signature requirements policy revisions reverse the three (3) day signature language back to the policy that was in place from 2011 to September 1, 2017. The proposed revisions clarify that the authentication of medical records is expected on the day the record is completed. The revisions also clarify that the signature of the rendering provider and date entry is expected within three (3) business days from the day the record is completed if the record is being transcribed.

    Please view the circulation document here: APA WF# 17-13, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Board Meeting: 02/08/2018



    APA WF# 17-14 — Adult Dental Emergency Extractions

    The proposed revision clarifies dental coverage for adults by amending the rule that limits dental services for adults to “emergency” extractions.

    Please view the circulation document here: APA 17-14 — Dental Emergency Extractions, and submit feedback via the comment box below.

    Circulation Date: 09/06/2017

    Comment Due Date: 09/21/2017

    Medical Advisory Committee Meeting: 09/21/2017

    Board Meeting: 09/27/2017

     


     

     

    APA WF# 17-14 — Adult Dental Emergency Extractions 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed revision clarifies dental coverage for adults by amending the rule that limits dental services for adults to “emergency” extractions.

    Please view the circulation document here: APA WF# 17-14, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     

     

     


    APA WF 17-15Student Earned Income Exclusion for Aged, Blind and Disabled (ABD) Applicants 

     

    The proposed ABD eligibility policy revisions remove specific amounts of a student's earned income that can be excluded because SSA revises the amounts on an annual basis. The revised policy refers to Oklahoma Department of Human Services (OKDHS) Appendix C-1. 

    Please view the circulation document here: APA WF# 17-15, and submit feedback via the comment box below.

    Circulation Date: 12/18/2017

    Comment Due Date: 01/17/2018

    Medical Advisory Committee Date: 01/18/2018

    Board Meeting: 02/08/2018


     

     

    APA WF# 17-15 — Student Earned Income Exclusion for Aged, Blind and Disabled (ABD) Applicants Revisions 

    The proposed ABD eligibility policy revisions remove specific amounts of a student's earned income that can be excluded because SSA revises the amounts on an annual basis.  The revised policy refers to Oklahoma Department of Human Services (OKDHS) Appendix C-1.

    Please view the circulation document here: APA WF# 17-15, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-16 — Accreditation Commission for Health Care (ACHC) accreditation option for Outpatient Behavioral Health Agencies 

    The proposed behavioral health revisions add the Accreditation Commission for Health Care (ACHC) as an additional accreditation option for outpatient behavioral health agencies. Revisions will also update policy terminology in order to align with current practice.

    Please view the circulation document here: APA WF# 17-16, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

     APA WF# 17-17 — Indian Health Services, Tribal Program and Urban Indian Clinics (I/T/U) Current Procedural Terminology (CPT) Language Removal 

    The proposed I/T/U policy is amended to remove the restriction to billing with a CPT procedure code for outpatient behavioral health encounters.

    Please view the circulation document here: APA WF# 17-17, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018

     
    APA WF# 17-18 — Therapeutic Leave Days Revisions 

    The proposed revisions eliminate therapeutic leave days for long-term care facilities, with the exception of Intermediate Care Facilities serving Individuals with Intellectual Disabilities, in an effort to meet the balanced budget requirements. Without the recommended revisions, the OHCA is at risk of exhausting its State appropriated dollars required to maintain the SoonerCare program.

    Please view the circulation document here: 17-18 Circulation Document, and submit feedback via the comment box below.

    Circulation Date: 10/17/2017

    Comment Due Date: 11/16/2017

    Medical Advisory Committee Meeting: 11/16/2017          

    Board Meeting: 12/14/2017

    APA WF 17-19 — Inpatient Behavioral Health Revisions

    The proposed inpatient behavioral health revisions will align policy with federal standards of restraint and seclusion for members under the age of 21. Rules will also be revised to update definitions. 

    Please view the circulation document here: APA WF# 17-19, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Medical Advisory Committee Date: 01/18/2018

    Board Meeting: 02/08/2018

     


    APA WF# 17-19 — Inpatient Behavioral Health Revisions  

     

     Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed inpatient behavioral health revisions will be amended to align policy with federal standards of restraint and seclusion for members under the age of 21. Rules will also revise certification of need for care, plan of care, and utilization review plan requirements. Other revisions will include minor updates of policy terminology.

    Please view the circulation document here: APA WF# 17-19, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     

     


    APA WF# 17-20 — Grandfathered CHIP children  

     

    The proposed revisions amend Qualifying Categorical Relationship policy by removing an eligibility group that no longer exists.

    Please view the circulation document here: APA WF# 17-20, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018

     


     

     

    APA WF# 17-21 — Income Rounding for Non-disabled Adults and Children Eligibility 

    The proposed revisions amend rules to mirror current online eligibility system computations to income by rounding cents down at each step in the computations. Additionally, revisions also amend pre-MAGI and post-MAGI policy by removing pre-MAGI policy.

    Please view the circulation document here: APA WF# 17-21, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-22A — Prior Authorization Policy Revisions 

    The proposed revisions amend prior authorization policy.

    Please view the circulation document here: APA WF# 17-22A, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-22B — Prior Authorization Policy Revisions 

    The proposed revisions amend prior authorization policy.

    Please view the circulation document here: APA WF# 17-22B, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018 

    APA WF# 17-23 — Breast and Cervical Cancer (BCC) Benefit Update

    The proposed Breast and Cervical Cancer (BCC) Benefit policy is amended to comply with federal regulation, which addresses optional eligibility for individuals needing treatment for breast and cervical cancer. In order to align revisions with federal regulation requirements, the references to "women" will be replaced with the terms that are inclusive of both males and females for eligibility purposes.

    Please view the circulation document here: APA WF# 17-23, and submit feedback via the comment box below.

    Circulation Date: 11/20/2017

    Comment Due Date: 12/19/2017

    Medical Advisory Committee Meeting: 01/18/2018

    Board Meeting: 02/08/2018

     


    APA WF# 17-23 — Breast and Cervical Cancer (BCC) Benefit Update  

    The proposed Breast and Cervical Cancer (BCC) Benefit policy is amended to comply with federal regulation, which addresses optional eligibility for individuals needing treatment for breast and cervical cancer. In order to align revisions with federal regulation requirements the references to "women" will be replaced with the terms that are inclusive of both males and females for eligibility purposes.

    Please view the circulation document here: APA WF# 17-23, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018

     


     

     

    APA WF# 17-24A ADvantage Waiver Revisions 

    The proposed revisions to the ADvantage Waiver include cleanup to remove and update outdated policy in order to align with current business practices.

    Please view the circulation document here: APA WF# 17-24A, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018


     

     

    APA WF# 17-24B — ADvantage Waiver Revisions 

    The proposed revisions to the ADvantage Waiver include clean-up to remove and update outdated policy in order to align with current business practices. In addition, proposed revisions add new language regarding the Ethics of Care Committee for the ADvantage and State Plan Personal Care program which outlines rules and processes. Proposed revisions clarify rules are in accordance with state laws and regulations.

    Please view the circulation document here: APA WF# 17-24B, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018

     


    APA WF# 17-25A — Developmental Disabilities Division Revisions  

     

    The proposed revisions to the Developmental Disabilities Services policy amend the rules to implement changes recommended during the annual Oklahoma Department of Human Services (DHS) Developmental Disabilities Services (DDS) rule review process.

    Please view the circulation document here: APA WF# 17-25A, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018

     


     

     

    APA WF# 17-25B — Developmental Disabilities Division Revisions 

    The proposed revisions to the Developmental Disabilities Services policy amend the rules to implement changes recommended during the annual Oklahoma Department of Human Services (DHS) Developmental Disabilities Services (DDS) rule review process.

    Please view the circulation document here: APA WF# 17-25B, and submit feedback via the comment box below.

    Circulation Date: 12/15/2017

    Comment Due Date: 01/16/2018

    Public Hearing: 01/16/2018

    Medical Advisory Committee: 01/18/2018

    Board Meeting: 02/08/2018

     


     

     

    APA WF# 17-26 — Insure Oklahoma Policy Revisions 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed revisions to the Insure Oklahoma policy is amended to strengthen program integrity in the Insure Oklahoma Individual Plan for self-employed individuals. In addition, proposed revisions will include minor language clean-up and removal of outdated language in order to reflect current business practices.

    Please view the circulation document here: APA WF# 17-26, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-27 — Medically Fragile Waiver Revisions 

    The proposed policy revisions to the Medically Fragile Waiver is being requested to provide clean-up to the (Overview, Services and Annual Re-evaluation) sections of existing policy for general clarification and alignment with current waiver operation and language included in the approved waiver; including updating of some acronyms used in existing policy.

    Please view the circulation document here: APA WF# 17-27, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-28 — Federally Qualified Health Center Services (FQHC) Alternative Payment Methodology (APM) 

    The proposed policy revisions will introduce a new optional payment methodology for Federally Qualified Health Centers (FQHCs).

    Please view the circulation document here: APA WF# 17-28, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Board Meeting: 03/22/2018 
    APA WF# 17-28 — Federally Qualified Health Center Services (FQHC) Alternative Payment Methodology (APM)    

     The proposed policy revisions will introduce a new optional payment methodology for Federally Qualified Health Centers (FQHCs).

     Please view the circulation document here: APA WF# 17-28, and submit feedback via the comment box below.

     Circulation Date: 12/12/2017

     Comment Due Date: 01/11/2018

     Medical Advisory Committee Meeting: 01/18/2018

     Board Meeting: 02/08/2018

     


     

     

     

    APA WF# 17-30 — Focus on Excellence (FOE) Policy Revisions  

    The proposed revisions add new language that define and describe the eligibility criteria for the FOE program in policy.

    Please view the circulation document here: APA WF# 17-30, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-32 — Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Periodicity Schedule Policy Revisions

    The proposed revisions will update the EPSDT Periodicity Schedule recommended for physicians and other practitioners who provide screening services to children.

    Please view the circulation document here: APA WF# 17-32, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Medical Advisory Committee Meeting: 03/15/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-33A — Nursing Facility Supplemental Payment Program Revisions

    The proposed revisions update guidelines for the nursing facility supplemental payment program.

    Please view the circulation document here: APA WF# 17-33A, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Board Meeting: 03/22/2018

     


     

     

    APA WF# 17-33B — Nursing Facility Supplemental Payment Program Revisions

    The proposed revisions update guidelines for the nursing facility supplemental payment program.

    Please view the circulation document here: APA WF# 17-33B, and submit feedback via the comment box below.

    Circulation Date: 01/17/2018

    Comment Due Date: 02/16/2018

    Public Hearing: 02/20/2018

    Board Meeting: 03/22/2018

     


    APA WF 17-33A — Nursing Facility Supplemental Payment Program 

    The proposed revisions update guidelines for the nursing facility supplemental payment program.

    Please view the circulation document here: APA WF# 17-33A, and submit feedback via the comment box below.

    Circulation Date: 01/10/2018

    Comment Due Date: 01/25/2018

    Medical Advisory Committee Date: 01/18/2018

    Board Meeting: 02/08/2018

     


    APA WF 17-33B — Nursing Facility Supplemental Payment Program 

    The proposed revisions update guidelines for the nursing facility supplemental payment program.

    Please view the circulation document here:  APA WF# 17-33B, and submit feedback via the comment box below.

    Circulation Date: 01/03/2018

    Comment Due Date: 01/25/2018

    Medical Advisory Committee Date: 01/18/2018

    Board Meeting: 02/08/2018


    APA WF# 16-01 — Reimbursement for Licensed Behavioral Health Professionals in Independent Practice

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) is proposing revisions to SoonerCare rules regarding coverage and reimbursement for services provided by Licensed Behavioral Health Professionals in independent practice. The proposed revisions revoke all coverage and reimbursement guidelines for this specific provider type, as ODMHSAS is requesting that independently contracted providers in private practice no longer be reimbursed for SoonerCare services. LBHP services will remain available to all SoonerCare members through SoonerCare contracted outpatient behavioral health agencies.  Changes are necessary to reduce the Agency's spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

    Please view the circulation document here: APA WF# 16-01, and submit feedback via the comment box below.

    Circulation Date: 01/08/2016

    Comment Due Date: 03/31/2016

    Medical Advisory Committee (MAC): 01/21/2016


    APA WF# 16-02 — Modify Reimbursement Structure for Eyeglasses

    Proposed policy changes will modify the reimbursement structure for eyeglasses.

    Please view the circulation document here: APA WF# 16-02, and submit feedback via the comment box below.

    Circulation Date: 06/17/2016

    Comment Due Date: 07/20/2016

    Medical Advisory Committee (MAC): 07/21/2016

    Board Meeting: 08/11/2016


    APA WF# 16-02 Policy Revision to Modify Reimbursement Structure for Eyeglasses

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    Proposed policy changes will modify the reimbursement structure for eyeglasses.

    Please view the circulation document here: APA WF# 16-02, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Board Meeting: 02/09/2017


    APA WF# 16-03Cost Sharing

    The proposed policy revisions include language cleanup to Chapter 30 to mirror Federal regulations enacted in 2013. Per Federal regulation the aggregate limit on premiums and cost sharing incurred by all members in the Medicaid household will not exceed 5 percent of the family's income applied on a monthly basis; the policy is revised to reflect this requirement.

    Please view the circulation document here: APA WF# 16-03, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-04 — Agency Therapy Limits 

    Proposed outpatient behavioral health agency policy changes will set daily and weekly limits for the amount of individual, group and family psychotherapy that are reimbursable by SoonerCare. The daily limits of individual, group and family therapies will be reduced to 4 units, 6 units and 4 units respectively. Additionally, weekly limits will be imposed that limit the total amount of group therapy in a week to 3 hours and Individual and Family therapy will cumulatively be limited to 2 hours per week.

    Please view the circulation document here: APA WF# 16-04, and submit feedback via the comment box below.

    Circulation Date: 03/28/2016

    Comment Due Date: 04/24/2016

    Medical Advisory Committee (MAC): 04/25/2016 

    Board Meeting: 04/28/2016


    APA WF# 16-04Agency Therapy Limits

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    Proposed outpatient behavioral health agency policy changes will set daily and weekly limits for the amount of individual, group and family psychotherapy that are reimbursable by SoonerCare. The daily limits of individual, group and family therapies will be reduced to 4 units, 6 units and 4 units respectively. In addition, weekly limits will be imposed that limit the total amount of group therapy in a week to 3 hours and Individual and Family therapy will cumulatively be limited to 2 hours per week. Additionally, revisions include adding language that excludes therapy limitations to outpatient behavioral health services provided in a therapeutic foster care setting.

    Please view the circulation document here: APA WF# 16-04, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Board Meeting: 02/09/2017


     

    APA WF# 16-05 — Independent LBHP Therapy Limits

    Proposed policy revisions for Licensed Behavioral Health Professionals who choose to practice on their own are revised in order to reduce the monthly limits of psychotherapy reimbursable by SoonerCare. The current limit of 8 units/sessions per month will be reduced to 4 units/sessions per month.

    Please view the circulation document here: APA WF# 16-05, and submit feedback via the comment box below.

    Circulation Date: 03/28/2016

    Comment Due Date: 04/24/2016

    Medical Advisory Committee (MAC): 04/25/2016

    Board Meeting: 04/28/2016


    APA WF# 16-05Independent LBHP Therapy Limits

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    Proposed policy revisions for Licensed Behavioral Health Professionals who choose to practice on their own are revised in order to reduce the monthly limits of psychotherapy reimbursable by SoonerCare. The current limit of 8 units/sessions per month will be reduced to 4 units/sessions per month.

    Please view the circulation document here: APA WF# 16-05, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Board Meeting: 02/09/2017


    APA WF# 16-06 — Treatment Plan Update Limits

    Proposed outpatient behavioral health agency policy changes will reduce the number of SoonerCare compensable service plan updates to one every six months. Outpatient behavioral health agencies will now be reimbursed for one initial comprehensive treatment plan and one update thereto bi-annually.

    Please view the circulation document here: APA WF# 16-06, and submit feedback via the comment box below.

    Circulation Date: 03/28/2016

    Comment Due Date: 04/24/2016

    Medical Advisory Committee (MAC): 04/25/2016

    Board Meeting: 04/28/2016


    APA WF# 16-07 — ADvantage Waiver

    The proposed policy revisions are to remove coverages for Speech and Language services from the Advantage Waiver, due to lack of utilization.

    Please view the circulation document here: APA WF# 16-07, and submit feedback via the comment box below.

    Circulation Date: 04/18/2016

    Comment Due Date: 05/17/2016

    Medical Advisory Committee (MAC): 05/19/2016

    Board Meeting: 08/10/2016


    APA WF# 16-08 — Fitness Plan for Certain Providers and Owners Identified through Credentialing

    The proposed revisions are added to establish credentialing procedures for newly enrolling providers, re-enrolling providers and owners of businesses who are identified either on a state or federal sanction database or through a fingerprint based criminal background check.

    Please view the circulation document here: APA WF# 16-08, and submit feedback via the comment box below.

    Circulation Date: 08/15/2016

    Comment Due Date: 09/15/2016

    Medical Advisory Committee (MAC): 09/15/2016

    Board Meeting: 10/13/2016


    APA WF# 16-08 — Screening Procedures and Fitness Plan for Certain Providers and Owners Designated High Risk  

    This policy change was previously posted for comments 8/15/2016 through 9/13/2016. The policy has since been updated.

    The proposed revisions are added to establish credentialing procedures for newly enrolling providers, re-enrolling providers and owners of businesses who are identified either on a state or federal sanction database or through a fingerprint based criminal background check.

    Please view the circulation document here: APA WF# 16-08, and submit feedback via the comment box below.

    Circulation Date: 09/13/2016

    Comment Due Date: 10/12/2016

    Medical Advisory Committee (MAC): 09/15/2016

    Board Meeting: 10/13/2016


    APA WF# 16-09 — Treatment Plan Update Limits

    Outpatient behavioral health agency rules are amended in order to reduce the number of SoonerCare compensable service plan updates to two in one year. Outpatient behavioral health agencies will now be reimbursed for one initial comprehensive treatment plan and one update thereto bi-annually. These changes were previously made in emergency rules approved by the OHCA Board on April 28, 2016 in rules identified by APA WF#16-06. Rules are now being brought forward for consideration as an emergency rule since the same section of Policy was amended during permanent rulemaking during the 2016 legislative session and will supersede the emergency rules subsequently approved on April 28. These emergency revisions are necessary to reduce the Oklahoma Department of Mental Health Substance Abuse Services' operations budget for the remainder of SFY 2016 in order to meet the balanced budget requirements as mandated by State law. Without the recommended revisions, the Department is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Behavioral Health Program.

    Please view the circulation document here: APA WF# 16-09, and submit feedback via the comment box below.

    Circulation Date: 07/22/2016

    Comment Due Date: 08/11/2016

    Board Meeting: 08/11/2016


    APA WF# 16-11School Based Language Cleanup Only

    Proposed School Based Services policy is revised to correct the number of units authorized for personal care services. Additionally, proposed changes will align timely filing requirements for school based targeted case management services with current agency requirements.

    Please view the circulation document here: APA WF# 16-11, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-12 Medical Residents' Licensure Requirements and Language Cleanup

    Proposed General Coverage policy adds contracting requirements for medical residents and adds language mirroring requirements set by regulatory state medical boards. Additional revisions remove language that pertains to non-licensed physicians in a training program and clarifies language exempting SoonerCare Choice members from office visits limits.

    Please view the circulation document here: APA WF# 16-12, and submit feedback via the comment box below.

    Circulation Date: 08/15/2016

    Comment Due Date: 09/15/2016

    Medical Advisory Committee (MAC): 09/15/2016

    Board Meeting: 10/13/2016


    APA WF# 16-12 Medical Residents' Licensure Requirements, Obstetrical Reimbursement, Molecular Pathology Changes and Language Cleanup 

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    Proposed General Coverage policy is revised to clarify licensing provisions and contracting requirements for medical residents, and clarify direct physician care visit limits. In addition, revisions clarify medical necessity criteria for molecular pathology services and the appropriate provider types that are allowed to order testing. Lastly, revisions reinstate the use of the global CPT codes for obstetrical reimbursement.

    Please view the circulation document here: APA WF# 16-12, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Board Meeting: 02/09/2017


    APA WF# 16-13 — Pharmacy Reimbursement

    Proposed policy amends the reimbursement structure for Indian Health Services, Tribal Programs, and Urban Indian Clinics (I/T/U) and non-I/T/U pharmacy providers. Changes will allow I/T/U pharmacies to be reimbursed at the federal Office of Management and Budget (OMB) encounter rate. In addition, non-I/T/U pharmacies will follow the Actual Acquisition Cost (AAC) pricing methodology. Rules are also revised to add a professional dispensing fee. Further, policy is revised to remove the limitations for smoking cessation benefits.

    Please view the circulation document here: APA WF# 16-13, and submit feedback via the comment box below.

    Circulation Date: 10/17/2016

    Comment Due Date: 11/16/2016

    Medical Advisory Committee (MAC): 11/17/2016

    Board Meeting: 12/08/2016


    APA WF# 16-13 — Pharmacy Reimbursement

    This policy change was previously posted for comments 10/17/2016 through 11/10/2016. The policy has since been updated.

    The proposed policy amends the reimbursement structure for Indian Health Services, Tribal Programs, and Urban Indian Clinics (I/T/U) and non-I/T/U pharmacy providers. Revisions modify the current pharmacy pricing methodology and will allow I/T/U pharmacies to be reimbursed at the federal Office of Management and Budget (OMB) encounter rate. Rules are also revised to modify the current structure for the dispensing fee. Further, policy is revised to remove the limitations for smoking cessation benefits, and to update references to outdated policy. 

    Please view the circulation document here: APA WF# 16-13, and submit feedback via the comment box below.

    Circulation Date: 11/10/2016

    Comment Due Date: 12/07/2016

    Medical Advisory Committee (MAC): 11/17/2016

    Board Meeting: 12/08/2016


    APA WF# 16-13Pharmacy Reimbursement

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    The proposed policy amends the reimbursement structure for Indian Health Services, Tribal Programs, and Urban Indian Clinics (I/T/U) and non-I/T/U pharmacy providers. Revisions modify the current pharmacy pricing methodology and will allow I/T/U pharmacies to be reimbursed at the federal Office of Management and Budget (OMB) encounter rate. Rules are also revised to modify the current structure for the dispensing fee. Further, policy is revised to remove the limitations for smoking cessation benefits, and to update references to outdated policy.

    Please view the circulation document here: APA WF# 16-13, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Board Meeting: 03/23/2017


       

    APA WF# 16-14Inpatient Behavioral Health Policy Revisions

    The proposed inpatient behavioral health policy amends existing language to reflect the total number of core active treatment hours for individuals in a Community Based Transitional setting. Revisions also add active treatment requirements for process group therapy. In addition, policy is amended to add 24 hour nursing/medical supervision criteria for continued stay in an acute level of care. Rules are also revised to allow more time between treatment plan reviews for residential levels of care. Further, rules are added to clarify that payment for Health Home transitioning services provided under arrangement with an inpatient provider will be directly reimbursed to the Health home outside of the inpatient facility's per diem or DRG rate.

    Please view the circulation document here: APA WF# 16-14, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-15 — Obstetrical Reimbursement

    The proposed Obstetrical policy revisions will reinstate the use of the global care CPT codes for obstetrical reimbursement.

    Please view the circulation document here: APA WF# 16-15, and submit feedback via the comment box below.

    Circulation Date: 09/02/2016

    Comment Due Date: 10/10/2016

    Medical Advisory Committee (MAC): 09/15/2016

    Board Meeting: 10/13/2016


    APA WF# 16-15A Obstetrical Reimbursement, Prior Authorization Changes for High Risk Obstetrical Services, and Language Cleanup

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed Obstetrical policy revisions reinstate the use of the global care CPT codes for obstetrical reimbursement, adds the term certified to the title nurse midwives, and updates documentation requirements for obtaining high risk obstetrical services.  Additional proposed revisions are general cleanup of terms.

    Please view the circulation document here: APA WF# 16-15A, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Board Meeting: 02/09/2017


    APA WF# 16-15BObstetrical Reimbursement

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    The proposed Obstetrical policy revisions will reinstate the use of the global care CPT codes for obstetrical reimbursement.

    Please view the circulation document here: APA WF# 16-15B, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Board Meeting: 02/09/2017


    APA WF# 16-16A — Nursing Facility Supplemental Payment Program

    The proposed revisions add guidelines for the nursing facility supplemental payment program.

    Please review and submit feedback, via the comment box below, for the proposed rule changes, APA WF#16-16A and the proposed State Plan Amendment (SPA) pages, OK SPA 16-22 Nursing Facility Supplemental Payment Program.

    Circulation Date: 11/08/2016

    Comment Due Date: 12/07/2016

    Medical Advisory Committee (MAC): 11/17/2016

    Board Meeting: 12/08/2016


    APA WF# 16-16ANursing Facility Supplemental Payment Program

    This rule has previously been approved by the OHCA Board of Directors and the Governor, as an Emergency Rule.

    The proposed revisions add guidelines for the nursing facility supplemental payment program.  

    Please view the circulation document here: APA WF# 16-16A , and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Board Meeting: 03/23/2017


    APA WF# 16-16BNursing Facility Supplemental Payment Program  

    Please note, revisions of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed revisions add guidelines for the nursing facility supplemental payment program.

    Please view the circulation document here: APA WF# 16-16B, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-16B — Nursing Facility Supplemental Payment Program

    The proposed revisions add guidelines for the nursing facility supplemental payment program.

    Please review and submit feedback, via the comment box below, for the proposed rule changes, APA WF# 16-16B and the proposed State Plan Amendment (SPA) pages, OK SPA 16-22 Nursing Facility Supplemental Payment Program.

    Circulation Date: 11/08/2016

    Comment Due Date: 12/07/2016

    Medical Advisory Committee (MAC): 11/17/2016

    Board Meeting: 12/08/2016


    APA WF# 16-18 — Telemedicine Consent

    The proposed telemedicine revisions remove language regarding written informed consent for telemedicine to align with changes in The Oklahoma Telemedicine Act.

    Please view the circulation document here: APA WF# 16-18, and submit feedback via the comment box below.

    Circulation Date: 11/02/2016

    Comment Due Date: 12/01/2016

    Medical Advisory Committee (MAC): 11/17/2016

    Board Meeting: 12/08/2016


    APA WF# 16-18Telemedicine Revisions

    Please note, revisions of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed telemedicine revisions replace telemedicine with telehealth, define telehealth, remove language requiring informed consent, and update text to mirror current practice.

    Please view the circulation document here: APA WF# 16-18, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-19Policy Revision to Allow Additional TEFRA Developmental Evaluation Options

    The proposed Tax Equity and Fiscal Responsibility Act (TEFRA) revisions allow providers other than those providers in the SoonerStart Early Intervention Program to evaluate applicants under the age of three for the measurement of developmental milestones in order to determine institutional level of care for TEFRA children.

    Please view the circulation document here: APA WF# 16-19, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-21SPARC Membership Increase and Allowance for Alternate

    The proposed revisions to the State Plan Amendment Rate Committee (SPARC) policy increase SPARC membership and allows for appointed alternates.

    Please view the circulation document here: APA WF# 16-21, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-22Purchasing Language Cleanup

    The proposed Purchasing revisions amend outdated language that references the Oklahoma Department of Central Services as it was consolidated under the Office of Management and Enterprise Services in 2011.

    Please view the circulation document here: APA WF# 16-22, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-23I/T/U and FQHC Cleanup

    Proposed Indian Health Services, Tribal Program and Urban Indian Clinics (I/T/U) and Federally Qualified Health Centers (FQHC) policy is amended to remove the minimum 45-50 minute time requirement for outpatient behavioral health encounters. Rules are also revised to include parameters to assure quality of care and appropriate billing for pharmacy outpatient encounters. Further, revisions add requirements for I/T/U providers who render home health services. Revisions also include updates to policy references.

    Please view the circulation document here: APA WF# 16-23, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-24ADevelopmental Disabilities Services Revisions

    The proposed revisions to the Developmental Disabilities Services policy implement changes recommended during the annual Oklahoma Department of Human Services (DHS) Developmental Disabilities Services (DDS) rule review process. Proposed revisions include cleanup to mirror current business practices.

    Please view the circulation document here: APA WF# 16-24A, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-24BDevelopmental Disabilities Services Revisions

    The proposed revisions to the Developmental Disabilities Services policy amend the rules to implement changes recommended during the annual Oklahoma Department of Human Services (DHS) Developmental Disabilities Services (DDS) rule review process. Proposed revisions include clean-up to mirror current business practices.

    Please view the circulation document here: APA WF# 16-24B, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-25AADvantage Waiver Revisions

    The proposed revisions update rules for the Advantage program and related services. The revisions add language to comply with Federal regulations specific to home and community based settings. Rules also clarify compensable services and contract requirements. In addition, rules outline audit procedures for specific providers.

    Please view the circulation document here: APA WF# 16-25A, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-25BADvantage Waiver Revisions 

    The proposed revisions update rules for the ADvantage program and related services. The revisions add language to comply with Federal regulations specific to home and community based settings. Rules also clarify compensable services and contract requirements. In addition, rules outline audit procedures for specific providers.

    Please view the circulation document here: APA WF# 16-25B, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-26Molecular Pathology Changes

    Proposed Laboratory Services policy clarifies reimbursement requirements for molecular pathology tests that examine multiple genes in a single test panel.

    Please view the circulation document here: APA WF# 16-26, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-27 Home Health Face to Face Requirement

    Proposed Home Health revisions add language that directs Home Health providers to conduct and document a face-to-face encounter in accordance with federal regulation.  

    Please view the circulation document here: APA WF# 16-27, and submit feedback via the comment box below.

    Circulation Date: 12/16/2016

    Comment Due Date: 01/15/2017

    Public Hearing: 01/17/2017

    Medical Advisory Committee: 01/19/2017

    Board Meeting: 02/09/2017


    APA WF# 16-28APolicy Revisions to Contracting Rules

    The proposed provider contracting revisions revoke administrative sanction rules as the language is obsolete and does not accord with current agency practices. Proposed revisions also revoke other agency rules which have been substantively revised to clarify what the agency may consider when deciding whether to terminate a contract with a particular enrolled provider. Also, proposed revisions add a new rule which explains what factors OHCA may take into consideration when deciding whether to approve an application for a new or renewing provider enrollment contract. In addition, proposed revisions add a new rule which modifies and replaces the Emergency Rule which will expire on September 14, 2017.  The new rule fulfills a Federal requirement for all state Medicaid agencies to institute fingerprint-based criminal background checks for certain "high categorical risk" providers who want to contract with the state. Proposed revisions also add a new rule which streamlines, clarifies and provides examples of the kinds of conduct that may serve as a basis for a for-cause termination of a provider contract.

    Please view the circulation document here: APA WF# 16-28A, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-28BPolicy Revisions to Appeals Rules

    Please note, sections of this rule were previously approved, as an Emergency Rule, by the OHCA Board of Directors and the Governor. Additional revisions have not yet been approved.

    The proposed revisions remove reference to OAC 317:30-3-19 as this section is being revoked. In addition, language is revised to outline grievance procedures and processes for the Nursing Facility Supplemental Payment Program.

    Please view the circulation document here: APA WF# 16-28B, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-29General Policy Language Cleanup

    The proposed policy revisions update references to the physical address of the Oklahoma Health Care Authority, amend language to remove references to outdated terms and correct formatting errors for clarity and consistency.

    Please view the circulation document here: APA WF# 16-29, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-30Insure Oklahoma Policy Changes and Cleanup

    The proposed policy revisions include minor language cleanup to reflect current business practices. In addition, proposed revisions add new language regarding college student enrollment and eligibility requirements for the Insure Oklahoma IP members.

    Please view the circulation document here: APA WF# 16-30, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-31ALong Term Care Policy Revisions

    The proposed Long Term Care policy revisions update rules to align with current business practices and state and federal regulation requirement. In addition, revisions remove references to outdated terminology.

    Please view the circulation document here: APA WF# 16-31A, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-31BLong Term Care Policy Revisions

    The Proposed Long Term Care policy revisions update rules to remove references to outdated terminology and other general cleanup of terms as appropriate.

    Please view the circulation document here: APA WF# 16-31B, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-32Provider Contracting Updates and Language Cleanup

    The proposed revisions amend rules to mirror contracting requirements for various provider types. In addition, revisions update hospital abuse reporting policy.

    Please view the circulation document here: APA WF# 16-32, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-33Therapeutic Foster Care Policy Revisions

    The proposed Therapeutic Foster Care revisions remove specific time requirements and add frequency limitations to behavioral health assessment services. Additional revisions clarify oversight requirements for licensure candidates who provide biopsychosocial assessments. Rules are also revised to clarify specific clinical documentation requirements for changes to the service plan prior to the scheduled three month review or update. Revisions also update numerical references and add taglines to align with current Administrative Procedures Act (APA) guidelines.

    Please view the circulation document here: APA WF# 16-33, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-34Diagnostic Cast and Oral/Facial Images

    The proposed Dental policy is revised to allow dental providers to submit oral or facial images as evidence of medical necessity for certain services. In addition, revisions add the term certified to nurse midwife to align with terminology utilized by the Oklahoma Nursing Board.

    Please view the circulation document here: APA WF# 16-34, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-35Outpatient Behavioral Health Policy Revisions

    The proposed policy revisions remove outdated references to Axis diagnosis and add new language to align with changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM). Additional revisions clarify clinical outpatient behavioral health agency provider documentation requirements for changes to the service plan prior to the scheduled six month review/update. Rules are also revised to clarify that behavioral health case management is not reimbursable for members who are enrolled in a Health Home. Additionally, rules are revised to clarify that, unless otherwise specified in rule, reimbursement is not allowed for outpatient behavioral health services provided to members who are considered to be in "inpatient status". Further, rules are amended to reduce the number of SoonerCare compensable service plan updates to two in one year. As a result, outpatient behavioral health agencies will receive reimbursement for one initial comprehensive treatment plan and one update thereto bi-annually.

    Please view the circulation document here: APA WF# 16-35, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017


    APA WF# 16-36Program Integrity Audits and Records' Signatures

    The proposed Program Integrity Audits revisions clarify the OHCA audit process. The proposed electronic records and signatures revisions set a consistent timeframe for medical records to be authenticated. Revisions also include other minor cleanup to improve consistency.

    Please view the circulation document here: APA WF# 16-36, and submit feedback via the comment box below.

    Circulation Date: 01/18/2017

    Comment Due Date: 02/17/2017

    Public Hearing: 02/21/2017

    Medical Advisory Committee Meeting: 03/09/2017

    Board Meeting: 03/23/2017



    Please view the 2015 Rule Changes here: 2015 Rule Changes  
     

     

    Please view the 2014 Rule Changes here: 2014 Rule Changes


     

    Please view the 2013 Rule Changes here: 2013 Rule Changes


     
     

     Please view the 2012 Rule Changes here: 2012 Rule Changes


     

     Please view the 2011 Rule Changes here: 2011 Rule Changes


     

     Please view the 2010 Rule Changes here: 2010 Rule Changes


     

     

     State Plan Amendments (SPA)  


    OK SPA 20-0003 Diabetes Self-Management Training (DSMT)

    The proposed State Plan Amendment (SPA) will add new language establishing coverage and reimbursement for DSMT, an educational disease management benefit designed to teach individuals how to better manage and control their diabetes. The proposed revisions will define member eligibility for DSMT services, provider participation requirements, and program coverage and limitations. Lastly, the proposed amendment establishes the reimbursement methodology and applicable rates for DSMT services.

    Please view the draft SPA pages here: OK SPA 20-0003, and submit feedback via the comment box below.

    Effective Date: 01/01/2020

    Tribal Consultation Dates: 01/08/2019; 09/03/2019

    Circulation Date: 09/10/2019 – 10/10/2019

    Please view all comments received here: OK SPA 20-0003 Comment Spreadsheet.


     

     

     OK SPA 19-0001 EPSDT Services for Children in Inpatient Psychiatric Settings

    Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services for Children in Inpatient Psychiatric Settings — The proposed State Plan amendment (SPA) will implement language to comply with federal regulations and reflect that children under twenty-one (21) years of age, who are residing in an inpatient psychiatric facility must be provided all medically necessary services, regardless of whether such services are noted in the plan of care.

    Please view the draft SPA pages here: OK SPA 19-0001, and submit feedback via the comment box below.

    Effective Date: 01/01/2019

    Tribal Consultation Date: 01/08/2019

    60-day Expedited Tribal Consultation Date: 01/08/2019 – 03/09/2019

    Circulation Date: 01/18/2019 – 02/17/2019



     
     

     

     OK SPA 19-02 Deductible and Coinsurance for Medicare Claims

    Oklahoma’s (OK) state plan amendment (SPA) 19-02, deductible and coinsurance for Medicare claims, proposes to update the reimbursement and percentage amount for the deductible and coinsurance on crossover claims to reflect current practice.

    Please view the draft SPA pages here: OK SPA 19-02, and submit feedback via the comment box below.  

    Effective Date: 1/1/2019

    Circulation Date: 12/27/2018

    Tribal Consultation Date: 11/6/2018

    60-day Tribal Consultation Period: 11/5/2019 – 01/05/2019

     


     

    OK SPA 19-0003 — Provider Directory for Members

    The proposed State Plan amendment establishes the development and use of a member-friendly provider directory.  The directory will be available to members as well as providers and will include, but is not limited to, the following search options:  provider’s name or NPI, provider type/specialty, PCP providers, behavioral health/substance abuse providers, providers by program (SoonerCare/Insure Oklahoma), zip code, physician gender, language of provider, and whether the physician or provider is accepting new patients.  The directory will be updated every seven (7) days to ensure accurate, up-to-date information is provided, and will be accessible through mobile devices, tablets, etc.  This change is pursuant to the 21st Century Cures Act (Cures Act).

    Please view the draft SPA pages here: OK SPA 19-0003, and submit feedback via the comment box below.

    Effective Date:  09/01/2019

    Tribal Consultation Date:  01/08/2019

    60-Day Tribal Consultation:  01/08/2019 – 03/09/2019   

    Circulation Date:  04/03/2019 – 05/04/2019

     


     

    OK SPA 19-05 Limitation of Outpatient Laboratory, X-Ray, and Select Machine Testing Services for Adults

    The proposed revisions will establish a benefit limitation of for outpatient laboratory, x-ray, and select machine testing services provided to adults on a fee-for-service basis. Revisions will include a $500 cap on services per member per year; however, certain diagnoses will be exempt from this restriction [in addition to some high cost diagnostic testing (i.e., MRI, MRA, etc.)]. Further exclusions will include services provided to individuals under twenty-one (21) as well as services received through federally qualified health centers (FQHCs) and Indian Health Service, tribal government(s), or urban Indian health program (ITU) facilities. A process for authorizing additional claims will be used for individuals who meet medical necessity criteria demonstrating the need for additional services. Changes are needed to limit inappropriate billing of wellness panels and other preventive tests in accordance with section 1902 of The Social Security Act.

    Please view the draft SPA pages here: OK SPA 19-05, and submit feedback via the comment box below.

    Effective Date: 04/01/2020

    Tribal Consultation Date: 01/08/2019

    60-day Tribal Consultation Date: 01/08/2019 – 03/09/2019

    Circulation Date: 01/08/2019 – 03/10/2019

     


     

    OK SPA 19-0006 — Residential Behavior Management Services (RBMS)

    The Oklahoma Department of Human Services (DHS) and Oklahoma Office of Juvenile Affairs (OJA) propose revisions to coverage and reimbursement policy for Residential Behavior Management Services (RBMS) in group home settings. The proposed revisions will outline and clarify provider participation requirements, RBMS treatment components, establish new levels of care, and remove references to services provided in wilderness camps and Diagnostic and Evaluation (D&E) centers. Additional revisions will incorporate recent federal mandates, as applicable, related to licensure, accreditation, and nurse staffing requirements. Additionally, DHS and OJA propose replacing the existing payment structure for RBMS providers, established in March of 1998, by incorporating staffing, facility, and operational costs into a per diem/per recipient rate based on an established level of care. 

    Please view the draft SPA pages here: OK SPA 19-0006, and submit feedback via the comment box below. 

    Effective Date:  09/01/2019

    Tribal Consultation Date:  01/08/2019

    60-Day Tribal Consultation:  01/08/2019 – 03/09/2019   

    Circulation Date:  03/19/2019 – 04/18/2019

     


     

    OK SPA 19-0007 Applied Behavioral Analysis (ABA) Services

    The proposed Title XIX state plan amendment (SPA) establishes coverage and reimbursement for ABA services as an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program benefit. The proposed language will define provider participation and credentialing requirements, medical necessity criteria, coverage and service limitation guidelines, and reimbursement methodology.

    Please view the draft SPA pages here: OK SPA 19-0007, and submit feedback via the comment box below.

    Effective Date: 07/01/2019

    Tribal Consultation Date: 01/08/2019 & 05/07/2019

    60-day Tribal Consultation Date: 01/08/2019 – 03/09/2019

    Circulation Date: 06/07/2019 – 06/22/2019

    Please view all comments received here: OK SPA 19-0007 Comment Spreadsheet.


      

     

     OK SPA #19-08 Supplemental Hospital Offset Payment Program Cost-to-Charge Ratio Calculation Update for Critical Access Hospitals

    OHCA recommends a change to the way cost is calculated for Critical Access Hospital (CAH) inpatient Supplemental Hospital Offset Payment Program (SHOPP) payments. Historically, an inpatient specific cost-to-charge ratio has not been used for calculating inpatient SHOPP payments. In lieu of the inpatient specific cost-to-charge ratio, OHCA utilized the generic hospital cost-to-charge ratio which is applied to DRG outlier payments. This current method is a blended (inpatient/outpatient) CCR that is an average of cost reports available from the most recent three-year period. OHCA currently uses an outpatient specific cost-to-charge ratio in calculations for SHOPP CAH payments. CMS has approved OHCA to implement the proposed CCR methodology for UPL demonstration purposes, but to implement the change for SHOPP CAH payments would require a State Plan amendment. This is proposed as a more appropriate method to calculate a hospitals inpatient cost-to-charge ratio and more accurately reimburse CAHs for inpatient services under SHOPP.

    Please view the draft SPA pages here: OK SPA 19-08, and submit feedback via the comment box below.

    Tribal Consultation: 11/06/2018

    Circulation Date: 11/08/2018

    Comment Due Date:  12/08/2018

    Requested Effective Date: 01/01/2019

     


     

    OK SPA 19-09 Out-of-State Services

    Oklahoma’s (OK) state plan amendment (SPA) 19-09, out-of-state services, proposes to define and clarify coverage and reimbursement for services rendered by providers that are physically located outside of Oklahoma.  Additionally, revisions will delineate out-of-state services, provider participation requirements, prior authorizations, and medical records requirements.  Lastly, revisions will outline reimbursement criteria for out-of-state providers who do not accept the payment rate established through the Oklahoma State Plan.

    Please view the draft SPA pages here: OK SPA 19-09, and submit feedback via the comment box below.

    Effective Date: 09/01/2019

    Circulation Date: 01/16/2019

    Tribal Consultation Date: 01/08/2019

    60-day Tribal Consultation Period: 01/08/2019 – 03/09/2019

     


     

    OK SPA 19-0010 CCBH Services

    Certified Community Behavioral Health (CCBH) Services — The Department of Mental Health and Substance Abuse Services (ODMHSAS) will seek approval of a State Plan Amendment (SPA) to sustain CCBHs beyond their grant demonstration period in Oklahoma. Currently, there are three (3) CCBHs providing services to SoonerCare members. The services provided include nine (9) types of behavioral health treatment services, with an emphasis on the provision of 24-hour crisis care, utilization of evidence based practices, care coordination, and integration with physical health. The proposed SPA and new rules will outline CCBH member eligibility, provider participation requirements, program scope, and reimbursement methodology.

    Please view the draft SPA pages here: OK SPA 19-0010, and submit feedback via the comment box below.

    Effective Date: 04/01/2019

    Tribal Consultation Date: 01/08/2019

    14-day Expedited Tribal Consultation Date: 01/08/2019 – 1/22/2019

    Circulation Date: 01/14/2019 – 01/29/2019

     


     

    OK SPA 19-0011 Retroactive Eligibility

    The proposed Title XIX state plan amendment (SPA) enables the State to grant retroactive eligibility to pregnant women and children under 19. Eligibility for Medicaid shall be effective no later than the third month before the date of application if the following conditions are met: (1) if the individual received covered Medicaid services at any time during the above period; and (2) if the individual would have been eligible for Medicaid at the time they received the services if they had applied or someone had applied for them. Previously, the Center for Medicaid and Medicare Services (CMS) had allowed Oklahoma to waive the requirement of retroactive eligibility for pregnant women and children under 19; however, in the latest approval of Oklahoma’s 1115(a) waiver, CMS removed this exception.

    Please view the draft SPA pages here: OK SPA 19-0011, and submit feedback via the comment box below.

    Effective Date: 04/01/2020

    Tribal Consultation Date: 01/08/2019

    60-day Tribal Consultation Date: 01/08/2019 – 03/09/2019

    Circulation Date: 06/19/2019 – 07/31/2019

     


     

    OK SPA 19-0013 Reimbursement Methodology for Partial Hospitalization Program (PHP) Services

    This SPA has been updated to reflect a change in the reimbursement rate, as well as, a new effective date of 04/01/2019.

    The proposed State Plan Amendment (SPA) allows the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) to request a change to the current reimbursement for PHP from a one hour unit of service to a single daily payment for all services provided in a day.  This methodology is in line with the Healthcare Common Procedure Coding System (HCPCS) guidelines for the PHP Code, H0035, and will reduce the likelihood of a payment error finding. 

    Please view the draft SPA pages here: OK SPA 19-0013, and submit feedback via the comment box below.

    Effective Date: 04/01/2019

    Tribal Consultation Date: 11/06/2018

    60-day Tribal Consultation:  11/06/2018 – 01/05/2019

    Circulation Date: 01/28/2019 – 02/27/2019

     


     

    OK SPA 19-0014 Increased Enhanced Payments for State University Affiliated Physicians

    The proposed revisions will increase the enhanced payments made for services provided by physicians who are employed by or contracted with state universities. The current payments rates are set at 140 percent of the Medicare allowable and will be increased to 175 percent. The increase is based on the maximum percentage allowed by the Medicare Equivalent of the Average Commercial Rate calculation. The additional state share will be provided by the University of Oklahoma and Oklahoma State University.

    Please view the draft SPA pages here: OK SPA 19-0014, and submit feedback via the comment box below.

    Effective Date: 07/01/2019

    Tribal Consultation Date: 03/05/2019

    60-day Tribal Consultation Date: 03/05/2019 – 05/04/2019

    Circulation Date: 04/10/2019 – 05/10/2019

     


     

    OK SPA 19-0016 Federally Qualified Health Centers (FQHC) Limitation

    The proposed State Plan amendment (SPA) will allow for adult members to receive multiple encounters at an FQHC within a 24-hour period.

    Please view the draft SPA pages here: OK SPA 19-0016, and submit feedback via the comment box below.

    Effective Date: 09/01/2019

    Tribal Consultation Date: 01/08/2019

    60-day Tribal Consultation Date: 01/08/2019 – 03/09/2019

    Circulation Date: 04/10/2019 – 05/10/2019

     


     

     

    OK SPA 19-0016 Federally Qualified Health Centers (FQHC) & Rural Health Clinics (RHC) Limitation

    The proposed State Plan amendment (SPA) will reflect current rules and business practice of reimbursing for four (4) visits per adult member per month within FQHCs and RHCs. Further revisions will allow for adult members to receive more than one (1) medically necessary encounter at an FQHC within a 24-hour period when the appropriate modifier is applied.

    Please view the draft SPA pages here: OK SPA 19-0016, and submit feedback via the comment box below.

    Effective Date: 09/01/2019

    Tribal Consultation Date: 09/03/2019

    14-day Expedited Tribal Consultation Date: 09/03/2019 – 09/17/2019

    Circulation Date: 09/10/2019 – 09/25/2019

     


     

     

     

    OK SPA 19-0015 Administration Organization Update

    An amendment to Oklahoma's State Plan is needed to update the organizational structure and functions within the Agency. The State Plan amendment is necessary to reflect current practice.

    Please view the draft SPA pages here: OK SPA 19-0015, and submit feedback via the comment box below.  

    Effective Date: 01/01/2019  

    Circulation Date: 03/05/2019 

    Tribal Consultation Date: 01/08/2019 

    60-day Tribal Consultation Period: 01/08/2019 – 03/09/2019  


     

    OK SPA 19-0018 Qualified Behavioral Health Aide I & Qualified Behavioral Health Aide II Provider Qualifications and Rates

    The Oklahoma Department of Human Services (DHS) seeks to increase the established rate for the Qualified Behavioral Health Aide (QBHA) / Treatment Parent Specialist (TPS) who provides services to children in Therapeutic Foster Care (TFC).  Additionally, the Oklahoma DHS seeks to establish a rate for the QBHA II/TPS who provides services to children in Intensive Treatment Family Care (ITFC).  The QBHA/TPS serves as an integral member of the TFC/ITFC team who provides high levels of care for the child, participates in the development and implementation of interventions, transports the child to therapy, documents interventions, and helps the child practice learned skills.  The proposed rate will be higher for the QBHA II/TPS providing services to children in ITFC, as children served in ITFC often present with more complex behavioral health needs that require more frequent intervention by the QBHA II/TPS.  Further, the State is proposing to increase the rate for QBHA I/TPS in an effort to increase access to services for eligible children, as medically necessary.

    Please view the draft SPA pages here: OK SPA 19-0018, and submit feedback via the comment box below.

    Effective Date:  09/01/2019 or upon CMS and Governor’s approval. 

    Tribal Consultation Date:  06/18/2019

    60-Day Tribal Consultation:  06/18/2019 – 08/17/2019   

    Circulation Date:  07/12/2019 – 08/11/2019

     
    OK SPA 19-0019 Outpatient Services Frontispiece    

    The proposed revisions clarify in the State Plan that an update to the Agency’s fee schedule for outpatient services occurs when the Medicare rates are updated pursuant to the specified reimbursement methodology in the Plan.  

    Please view the draft SPA pages here: OK SPA 19-0019, and submit feedback via the comment box below. 

    Circulation Date: 03/05/2019 

    Effective Date: 01/01/2019  

    Tribal Consultation Date: 03/05/2019  

    14-day Expedited Tribal Consultation Period: 03/05/2019 – 03/19/2019

     


     

     

    OK SPA 19-0020 Inpatient Psychiatric Services (Under 21) Payment to State-owned PRTFs

    The proposed Title XIX State Plan revision will allow for a cost-based reimbursement to state-owned psychiatric residential treatment facilities (PRTFs) rendering inpatient psychiatric services to individuals under the age of twenty-one (21). This amendment is necessary to align the State Plan with current practice.

    Please view the draft SPA pages here: OK SPA 19-0020, and submit feedback via the comment box below.

    Effective Date: 09/01/2019

    Tribal Consultation Date: 01/08/2019

    60-day Tribal Consultation Date: 05/07/2019 – 07/06/2019

    Circulation Date: 06/20/2019 – 07/20/2019

     

     


     

     

    OK SPA 19-0023 Rural Health Clinics Reimbursement Methodologies

    The proposed SPA and policy changes will revise the payment methodology for Rural Health Clinics (RHCs) to increase access to care in rural areas. Additionally, a minor change was made to the proposed SPA language on 05/23/2019 to reflect the accurate frequency of rate notifications to hospital-based RHCs from CMS.

    Please view the draft SPA pages here: OK SPA 19-0023, and submit feedback via the comment box below.

    Effective Date: 07/01/2019

    Tribal Consultation Date: 05/07/2019

    60-day Tribal Consultation Date: 05/07/2019– 07/06/2019

    Circulation Date: 05/07/2019 – 06/06/2019

    Please view all comments received here: OK SPA 19-0023 Comment Spreadsheet.


     

     

    OK SPA 19-0025 Nursing Facility Annual Rate Rebasing

    The proposed SPA will increase the Quality of Care (QOC) Fee for Regular Nursing Facilities and Nursing Facilities serving patients with Acquired Immune Deficiency Syndrome (AIDS) per 56 O.S. § 2011, Section 2002.  The change will match federal funds with QOC funds collected from providers to issue rate increases to these facilities.

    Please view the draft SPA pages here: OK SPA 19-0025, and submit feedback via the comment box below.

    Effective Date: 07/01/2019

    Tribal Consultation Date: 06/18/2019

    60-day Tribal Consultation Date: 06/18/2019– 08/17/2019

    Circulation Date: 06/20/2019 – 07/22/2019

     


     

    OK SPA 19-0026 — Telehealth Services 

    The proposed Title XIX State Plan amendment (SPA) will revise language regarding parental consent and primary care provider notification for telehealth services provided in school settings.  Additional changes include revisions regarding confidentiality of protected health information and adding language that defines telehealth program coverage and limitations.  The SPA is needed revisions are needed to comply with Senate Bill 575 (SB 575) which amended Oklahoma Statutes (O.S.) 25, Sections 2004 and 2005.

    Please view the draft SPA pages here: OK SPA 19-0026, and submit feedback via the comment box below.

    Effective Date:  07/01/2019

    Tribal Consultation Date:  06/18/2019

    60-Day Tribal Consultation:  06/18/2019 – 08/17/2019   

    Circulation Date:  06/21/2019 – 07/21/2019

    OK SPA 19-0028 Inpatient Psychiatric Add-on Payment

    The proposed revisions will create a general specialty add-on payment for children with specialized treatment needs who are being served in psychiatric hospitals, hospitals with a psychiatric wing, and psychiatric residential treatment facilities (PRTFs). Revisions will help offset the increased cost of serving children with specialized treatment needs. 

    Please view the draft SPA pages here: OK SPA 19-0028, and submit feedback via the comment box below.

    Effective Date: 09/01/2019

    Tribal Consultation Date: 07/02/2019

    60-day Tribal Consultation Date: 07/02/2019 – 08/31/2019

    Circulation Date: 07/16/2019 – 08/15/2019

     


     

     

    OK SPA 19-0031-A Personal Needs Allowance Increase and OK SPA 19-0031-B Rate Increase for Regular Nursing Facilities and Nursing Facilities Serving Patients with AIDS and Focus on Excellence Program Updates

    This SPA has been updated to reflect a change in the language. This SPA will be posted for an additional 15 day comment period.

    The OHCA is proposing revisions to bring the agency into compliance with Oklahoma Senate Bill 1044 and Senate Bill 280. These revisions will increase the personal needs allowance for residents of nursing homes as well as increase rates and recalculate the Quality of Care fee for regular nursing facilities and nursing facilities serving residents with Acquired Immune Deficiency Syndrome (AIDS). Further revisions will establish new quality measures and criteria as well as recalculate the incentive reimbursement rate plan for nursing facilities participating in the Focus on Excellence (FOE) program. Revisions to the state’s FOE incentive program include the potential for participating nursing facilities to earn up to $5.00 per Medicaid patient day if the four metrics outlined in the state plan are met or exceeded. The FOE program update also includes a provision that redistributes funds remaining from payments not earned to those who achieve the metrics.

    Please view the draft SPA pages here: OK SPA 19-0031-A and OK SPA 19-0031-B, and submit feedback via the comment box below.

    Effective Date: 10/01/2019

    Tribal Consultation Date: 07/02/2019

    60-day Tribal Consultation Date: 07/02/2019 – 08/31/2019

    Circulation Date: 08/02/2019 – 09/01/2019; 09/05/2019 – 09/20/2019 

    Please note, this SPA has been updated on the following dates:

    • August 2, 2019;
    • August 6, 2019;
    • August 9, 2019 (split into two separate SPAs 19-0031A and 19-0031B); and
    • September 5, 2019 
      Please view all comments received here: OK SPA 19-0031A&B Comment Spreadsheet.

     

     

     

    OK SPA 19-0034 Outpatient Services Rate Increase

    In keeping with Sections 1 and 2 of SB 1044, 57th Leg., 1st Sess. (Okla. 2019), revisions are needed to increase the current reimbursement rates for all outpatient SoonerCare-contracted provider types by five percent (5%), with the following exemptions: services financed through appropriations to other state agencies; Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); non-emergency transportation capitated payments; services provided to Insure Oklahoma (IO) members; payments for drug ingredients/physician supplied drugs; Indian Health Services/Tribal/Urban Clinics (I/T/Us); Federally Qualified Health Centers (FQHCs); and Rural Health Centers (RHCs). All rate increases must comply with state and federal law as well as state cost reimbursement methodologies.

    Please view the draft SPA pages here: OK SPA 19-0034, and submit feedback via the comment box below.

    Effective Date: 10/01/2019

    Tribal Consultation Date: 07/02/2019

    60-day Tribal Consultation Date: 07/02/2019 – 08/31/2019

    Circulation Date: 08/02/2019 – 09/01/2019


     

     

     

    OK SPA 19-0035 Inpatient Services Rate Increase

    In keeping with Sections 1 and 2 of SB 1044, 57th Leg., 1st Sess. (Okla. 2019), revisions are needed to increase the current reimbursement rates for all inpatient SoonerCare-contracted provider types by five percent (5%), with the following exemptions: services financed through appropriations to other state agencies; Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); non-emergency transportation capitated payments; services provided to Insure Oklahoma (IO) members; payments for drug ingredients/physician supplied drugs; Indian Health Services/Tribal/Urban Clinics (I/T/Us); Federally Qualified Health Centers (FQHCs); and Rural Health Centers (RHCs). All rate increases must comply with state and federal law as well as state cost reimbursement methodologies.

    Please view the draft SPA pages here: OK SPA 19-0035, and submit feedback via the comment box below.

    Effective Date: 10/01/2019

    Tribal Consultation Date: 07/02/2019

    60-day Tribal Consultation Date: 07/02/2019 – 08/31/2019

    Circulation Date: 08/02/2019 – 09/01/2019


     

     

     

    OK SPA 19-0036 State Plan Personal Care Services Rate Increase

    In keeping with the First Regular Session of the Fifty Seventh Oklahoma Legislature, the proposed Title XIX state plan amendment (SPA) is needed to increase the current reimbursement for State Plan personal care direct care services by four percent (4%).

    Please view the draft SPA pages here: OK SPA 19-0036, and submit feedback via the comment box below.

    Effective Date: 10/01/2019

    Tribal Consultation Date: 06/18/2019

    60-day Tribal Consultation Date: 06/18/2019 – 08/17/2019

    Circulation Date: 08/02/2019 – 09/01/2019


    OK SPA 19-0037 Pharmacy Dispensing Fee Rate Increase   

    In keeping with Sections 1 and 2 of SB 1044, 57th Leg., 1st Sess. (Okla. 2019), revisions are needed to increase the current reimbursement rate for the professional dispensing fee of SoonerCare-contracted pharmacies. The state plan amendment (SPA) proposes to update the reimbursement rate for the professional dispensing fee by five percent (5%). All rate increases must comply with state and federal law as well as state cost reimbursement methodologies. 

    Please view the draft SPA pages here: OK SPA 19-0037, and submit feedback via the comment box below. 

    Effective Date: 10/01/2019                                               

    Tribal Consultation Date: 07/02/2019

    60-day Tribal Consultation Date: 07/02/2019 – 08/31/2019

    Circulation Date: 08/02/2019 – 09/01/2019

    Please view all comments received here: OK SPA 19-0037 Comment Spreadsheet.

     


     

     

    OK SPA 19-0038 Behavioral Health Targeted Case Management (TCM)

    The proposed State Plan Amendment (SPA) will remove language limiting the amount of TCM that is reimbursable by SoonerCare. The TCM limit per member month will increase from 16 units per member per year to 12 units per member per month.

    Please view the draft SPA pages here: OK SPA 19-0038, and submit feedback via the comment box below.

    Effective Date: 7/01/2019

    Tribal Consultation Date: 09/03/2019

    14-day Expedited Tribal Consultation Date: 09/03/2019 – 09/17/2019

    Circulation Date: 09/10/2019 – 09/25/2019


    OK SPA 20-0001 — Provider Directory for Members

    The proposed State Plan amendment establishes the development and use of a member-friendly provider directory.  The directory will be available to members as well as providers and will include, but is not limited to, the following search options:  provider’s name or NPI, provider type/specialty, PCP providers, behavioral health/substance abuse providers, providers by program (SoonerCare/Insure Oklahoma), zip code, physician gender, language of provider, and whether the physician or provider is accepting new patients.  The directory will be updated every seven (7) days to ensure accurate, up-to-date information is provided, and will be accessible through mobile devices, tablets, etc.  This change is pursuant to the 21st Century Cures Act (Cures Act).

    Please view the draft SPA pages here: OK SPA 20-0001, and submit feedback via the comment box below.

    Effective Date:  01/01/2020

    Tribal Consultation Date:  01/08/2019

    60-Day Tribal Consultation:  01/08/2019 – 03/09/2019   

    Circulation Date:  08/20/2019 – 09/19/2019

     
     
     OK SPA 18-01 Breast and Cervical Cancer Benefit Update 

     

    Oklahoma’s (OK) state plan amendment (SPA) 18-01, Breast and Cervical Cancer (BCC) benefit update, proposes to amend the Title XIX state plan in order to comply with federal regulation which addresses optional eligibility for individuals needing treatment for breast and cervical cancer. In order to align policy with federal regulation requirements the term "women" will be replaced with the term "individuals".

    Please view the draft OK SPA 18-01 here: OK SPA 18-01 BCC Benefit Update Redlined SPA, and submit feedback via the comment box below.

    Effective Date: 2/1/2018 

    Circulation Date: 1/3/2018

    Tribal Consultation Date: 9/5/2017 

    60-day Tribal Consultation Period: 9/5/2017 – 11/4/2017

     


     

     

     

    OK SPA 18-02 Inpatient Psychiatric Services for Individuals under Age 21

    Oklahoma’s (OK) state plan amendment (SPA) 18-02, inpatient psychiatric services for individuals under age 21, will align settings and reimbursement methodology for inpatient psychiatric services for individuals under age 21 with federal regulation and guidance. The proposed SPA will revise and expand the identification of settings where inpatient psychiatric services for individuals under age 21 are provided and delineate requirements for reimbursement within each setting. Additionally, the SPA will update the list of accrediting bodies for psychiatric facilities to meet federal regulations. Other revisions include page format and grammatical changes.

    Please view the draft OK SPA 18-02 here: OK SPA 18-02 Inpatient Psych Services for Individuals under Age 21, and submit feedback via the comment box below. 

    Tribal Consultation: 11/07/2017

    60-day Tribal Consultation Period: 10/24/17 - 12/23/17

    Circulation Date: 1/30/2018

    Comment Due Date: 03/01/2018 

    Requested Effective Date: 01/01/2018

    This SPA was previously posted for a 30-day comment period from 01/12/2018 through 02/11/2018 and was re-posted for an additional 30-day comment period due to a subsequent change in the language which further clarifies that the IEP includes all relevant supporting documentation.

    OK SPA 18-03 School-based Health Services — The proposed school-based health services (SBS) revisions clarifies the definition of school-based services. Language is added to outline notification requirements for schools regarding parental/legal guardian consent. Other revisions will remove specific references that are no longer applicable. Changes are needed to align with current practice and federal regulation.  

    Please view the draft SPA pages here: OK SPA 18-03, and submit feedback via the comment box below. 

    Tribal Consultation: 11/07/2017 & 01/02/2018 

    Comment Due Date: 03/17/2018   

    Requested Effective Date: 01/01/2018

     

     

     


     

     

    OK SPA 18-06 EPSDT Periodicity Schedule Update  

    The proposed revisions will update the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Periodicity Schedule recommended for physicians and other practitioners who provide screening services to children. The proposed periodicity schedule will reflect recommendations by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD).

    Please view the draft SPA pages here: OK SPA 18-06, and submit feedback via the comment box below.

    Tribal Consultation: 01/02/2018

    Comment Due Date:  02/16/2018 

    Requested Effective Date: 09/01/2018

     


     

     

     

    OK SPA 18-07 Accreditation Commission for Health Care (ACHC) Accreditation Option for Outpatient Behavioral Health Organizations

    The proposed behavioral health revisions will add the ACHC as an additional accreditation option for outpatient behavioral health organizations.

    Please view the draft SPA pages here: OK SPA 18-07, and submit feedback via the comment box below.  

    Tribal Consultation: 11/07/2017

    Comment Due Date:  02/16/2018 

    Requested Effective Date: 09/01/2018

     


     

     

    OK SPA 18-08 Value-based Contract for Pharmaceuticals

    Oklahoma’s (OK) state plan amendment (SPA) 18-08, Value-based Contract for Pharmaceuticals, will incorporate value-based purchasing contract language to policy. Value-based purchasing contracts provide an opportunity to increase supplemental drug rebates, help clarify the complicated drug purchasing landscape for the SoonerCare program, and help improve patient access to evidence-based therapies while helping the program predict and manage prescription drug costs.

    Please view the draft OK SPA 18-08 here: OK SPA 18-08 Value-based Contract for Pharmaceuticals, and submit feedback via the comment box below.  

    Tribal Consultation: 01/02/2018

    60-day Tribal Consultation Period: 12/17/18 - 2/16/18

    Circulation Date: 1/30/2018  

    Comment Due Date: 03/01/2018 

    Requested Effective Date: 01/01/2018

     


     

     

    18-09 Outpatient Hospital Dental and ENT Rates —The proposed revisions will provide a new methodology for increasing the reimbursement rate for dental services in an outpatient hospital. The new method uses the cost of dental services and the cost of services in the Ambulatory Patient Classification group 5164 to calculate the rate for all outpatient hospitals.

    Please view the draft SPA pages here: OK SPA 18-09; submit feedback via the comment box below.

    As part of the federal requirements for documentation of access to care and service payment rates found at 42 CFR 447.203, the State must submit an access to care analysis for any service within a state plan amendment that proposes to reduce or restructure provider payment rates.

    Please view the draft Access to Care Analysis pages here for OK SPA 18-09; submit feedback via the comment box below.

    Tribal Consultation: 11/07/17

    Comment Due Date:   03/30/2018

     


     

    Recovery Audit Contractor (RAC) Exception – The proposed revision seeks an exemption from the recovery audit contract (RAC) requirement.  Federal RAC programs execute audits for the purpose of identifying under/overpayments of Medicaid claims under the state plan. The state has developed an internal audit process, which performs the tasks of a RAC program.  Therefore, the Agency is seeking an exemption to the RAC requirement, as it is duplicative of the auditing activities that the State already performs. 

    Please view the draft SPA pages here: OK SPA 18-11, and submit feedback via the comment box below.

    Tribal Consultation: 03/06/18

    Comment Due Date:  05/20/18

    Requested Effective Date: 04/01/18

     


     

     

    OK SPA # 18-23 Provider Rate Reduction Exemption for Indian Health Services, Tribal Program and Urban Indian Clinic (I/T/U) Services Provided Outside of the Office of Management and Budget (OMB) Rate

    Oklahoma's (OK) state plan amendment (SPA) 18-23 will allow the Oklahoma Health Care Authority (OHCA) to exempt I/T/U services provided outside of the Office of Management and Budget (OMB) rate and reimbursed at 100 percent Federal Medical Assistance Percentage (FMAP) from proposed provider rate reductions.

    Please view the draft SPA pages here: OK SPA 18-23, and submit feedback via the comment box below.

    Tribal Consultation: 11/07/2017

    60-day Tribal Consultation Period: 11/07/2017-01/06/2018

    Circulation Date: 08/23/2018

    Comment Due Date:  09/22/2018

    Requested Effective Date: 10/01/2018

    Please view all comments received here: OK SPA 18-23 Comment Document.


     


    OK SPA 18-24 Parity Compliance  

    A proposed Title XXI State Plan Amendment (SPA) will add language to comply with the Mental Health Parity and Additional Act and CHIP final rule at 42 CFR 457.496.  The OHCA is requesting deemed compliance with Parity through EPSDT.

    Please view the draft SPA pages here:  OK SPA 18-24 Parity Compliance, and submit feedback via the comment box below.

     Tribal Consultation: 05/16/2018

     Comment Due Date:  06/29/2018

     Requested Effective Date: 10/02/2017

     


     

     

    OK SPA # 18-17 Nursing Facility Rate Changes

    For the rate period beginning July 1, 2018, the Quality of Care fee will be recalculated for regular nursing facilities, nursing facilities serving residents with Acquired Immune Deficiency Syndrome, regular (greater than 16 beds) intermediate care facilities for individuals with intellectual disabilities (ICF/IID), and acute (16 beds or less) ICF/IID.  A proposed amendment to the state plan will propose a new rate for regular nursing facilities and nursing facilities serving residents with Acquired Immune Deficiency Syndrome based on the recalculation of the Quality of Care fee.

    Please view the draft SPA pages here: OK SPA 18-17, and submit feedback via the comment box below.

    Tribal Consultation: 05/16/2018

    Comment Due Date:  06/29/2018

    Requested Effective Date: 07/01/2018

     


     

    OK SPA 18-18 Acute Level 1 Psychiatric Hospitals Rate Increase

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) is proposing to increase the reimbursement rate by 3% for SoonerCare services provided by Acute Level 1 Inpatient Psychiatric Hospitals beginning July 1, 2018, subject to CMS approval.

    Please view the draft SPA pages here:  OK SPA 18-18 Acute Level 1 Psych Hospitals Rate Increase, and submit feedback via the comment box below.

    Tribal Consultation: 05/16/2018

    Comment Due Date:  07/15/2018

    Requested Effective Date: 07/01/2018  

     

     


     

     

    OK SPA 18-19 Licensure Candidates Rate Increase 

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) is proposing to increase the reimbursement rate by 3% for SoonerCare services provided by  Licensure Candidates beginning July 1, 2018, subject to CMS approval.

    Please view the draft SPA pages here:  OK SPA 18-19 Licensure Candidates Rate Increase, and submit feedback via the comment box below.

    Tribal Consultation: 05/16/2018

    Comment Due Date:  07/15/2018

    Requested Effective Date: 07/01/2018

     


     

     

    OK SPA 18-20 Level 1 LBHPs (Psychologists) Rate Increase

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) is proposing to increase the reimbursement rate by 3% for SoonerCare services provided by Level 1 LBHPs (psychologists) in independent practice beginning July 1, 2018, subject to CMS approval.

    Please view the draft SPA pages here:  OK SPA 18-20 Level 1 LBHPs (Psychologists) Rate Increase, and submit feedback via the comment box below.

    Tribal Consultation: 05/18/2018

    Comment Due Date:  07/15/2018

    Requested Effective Date: 07/01/2018



       

     

    OK SPA 18-21 Vaccine Rate Methodology  

    A proposed State Plan Amendment (SPA) will add language to establish that the rate methodology used for vaccines is the equivalent to Medicare Part B, ASP + 6%. When ASP is not available, an equivalent price is calculated using Wholesale Acquisition Cost (WAC). If no Medicare, ASP, or WAC pricing is available, then the price will be calculated based on invoice cost.

    Please view the draft SPA pages here:  OK SPA 18-21 Vaccine Rate Methodology, and submit feedback via the comment box below.

    Tribal Consultation: 05/16/2018

    Comment Due Date:  06/29/2018

    Requested Effective Date: 07/01/2018

     



     

    OK SPA 18-22 Nursing Home Supplemental Payment Program  

    This SPA was previously posted with an effective date of 04/01/2018; the new effective date is 05/01/2018. 

    The proposed revisions will add a nursing home supplemental payment program for nursing facilities and will change the methodology for computing the Upper Payment Limit.  

    Please view the draft OK SPA 18-22 here: OK SPA 18-22 NF Supplemental Payment SPA, and submit feedback via the comment box below.  

    Tribal Consultation: 11/07/2017

    60-day Tribal Consultation Period: 11/07/2017 - 01/06/2018

    Circulation Date: 04/09/2018 

    Comment Due Date: 04/20/2018 

    Requested Effective Date: 05/01/2018


     


    OK SPA # 18-25 — Pharmacy State Plan Revision

    The proposed pharmacy revisions will remove language regarding cosmetic or hair growth medications and sexual or erectile dysfunction medications from the State Plan.  Currently, the State Plan has language noting that the aforementioned medications are not a covered benefit; however, the language is being removed all together to comply with federal guidance.

    Please view the draft SPA pages here: OK SPA 18-25, and submit feedback via the comment box below.

    Tribal Consultation: 01/02/2018

    Comment Due Date:   02/09/2018

    Requested Effective Date: 01/01/2018

    OK SPA 18-26 Outpatient Services Rate Increase Update

    Revisions are needed to increase the current reimbursement rates for all SoonerCare-contracted provider types by three percent (3%) with the following exemptions: services financed through appropriations to other state agencies, Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS), non-emergency transportation capitated payments, services provided to Insure Oklahoma (IO) members, payments for drug ingredients/physicians supplied drugs, Indian Health Services/Tribal/Urban Clinics (I/T/U), Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs). The is SPA proposed to update the fee-for-service (FFS) fee schedule rates to include a three percent (3%) increase to reimbursement for outpatient services including but not limited to the following services/providers: vaccine administration, outpatient hospital, clinical laboratory, physician, physician assistants, home health, freestanding ambulatory surgery center (ASC), dental, renal dialysis facilities, anesthesiologists, hospice, ambulance transportation providers, and eyeglasses. All rate increases must comply with state and federal law as well as state cost reimbursement methodologies.

    Please view the draft SPA pages here: OK SPA 18-26, and submit feedback via the comment box below.

    Tribal Consultation: 09/04/2018

    14-day Expedited Tribal Consultation Period: 09/04/2018-09/18/2018

    Comment Due Date:  09/12/2018

    Requested Effective Date: 10/01/2018


    OK SPA 18-27 Inpatient Services Rate Increase 

    Revisions are needed to increase the current reimbursement rates for all SoonerCare-contracted provider types by three percent (3%) with the following exemptions: services financed through appropriations to other state agencies, Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS), non-emergency transportation capitated payments, services provided to Insure Oklahoma (IO) members, payments for drug ingredients/physicians supplied drugs, Indian Health Services/Tribal/Urban Clinics (I/T/U), Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs). The state plan amendment (SPA) proposes to update the reimbursement rates for inpatient hospital services to include a three percent (3%) increase. All rate increases must comply with state and federal law as well as state cost reimbursement methodologies. 

    Please view the draft SPA pages here: OK SPA 18-27, and submit feedback via the comment box below.

    Tribal Consultation: 09/04/2018

    14-day Expedited Tribal Consultation Period: 09/04/2018-09/18/2018

    Comment Due Date:  09/12/2018

    Requested Effective Date: 10/01/2018  

    OK SPA 18-28 Long-term Care Facilities Rate Increase

    Revisions are needed to increase the current reimbursement rates for SoonerCare-contracted long-term care facilities by four percent (4%). The four percent (4%) increase for long-term facilities is calculated only on the portion of the rate funded by state appropriations, resulting in an increase on the total rate of 3.2 percent (3.2%) for regular nursing facilities and 3.5 percent (3.5%) for regular and acute Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs). All rate increases must comply with state and federal law as well as state cost reimbursement methodologies.  

    Please view the draft SPA pages here: OK SPA 18-28, and submit feedback via the comment box below.

    Tribal Consultation: 09/04/2018

    14-day Expedited Tribal Consultation Period: 09/04/2018-09/18/2018

    Comment Due Date:  09/12/2018

    Requested Effective Date: 10/01/2018


    OK SPA 18-29 Outpatient BH Rehab and Clinic

    Pursuant to Oklahoma HB3707, the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) is proposing a three percent (3%) rate increase for licensed behavioral health professionals and licensure candidates for psychotherapy services provided in outpatient behavioral health clinics.

    Please view the draft SPA pages here:  OK SPA 18-29 Outpatient BH Rehab and Clinic, and submit feedback via the comment box below.

    Tribal Consultation:  05/16/2018

    Comment Due Date:  09/27/2018

    Requested Effective Date:  07/01/2018

    Please view all comments received here: OK SPA 18-29 Comment Document.   

    OK SPA 18-30 Pharmacy Dispensing Fee Rate Increase

    Revisions are needed to increase the current reimbursement rate for the professional dispensing fee of SoonerCare-contracted pharmacies. The state plan amendment (SPA) proposes to update the reimbursement rate for the professional dispensing fee by three percent (3%). All rate increases must comply with state and federal law as well as state cost reimbursement methodologies.

    Please view the draft SPA pages here: OK SPA 18-30, and submit feedback via the comment box below.

    Tribal Consultation: 09/04/2018

    14-day Expedited Tribal Consultation Period: 09/04/2018-09/18/2018

    Comment Due Date:  09/12/2018

    Requested Effective Date: 10/01/2018

     



     

    OK SPA # 18-39 Supplemental Reimbursement for Ground Ambulance Transportation Providers

    Oklahoma's (OK) state plan amendment (SPA) 18-39 proposes to implement a supplemental reimbursement program for SoonerCare contracted ground ambulance transportation providers, in addition to their current rate of payment, effective October 1, 2018.  Additional federal dollars will be leveraged through Certified Public Expenditure (CPE) to reduce the gap between Medicaid payments and the actual cost of providing ground ambulance transportation services.  The state plan amendment defines the scope, payment methodology, cost reporting requirements, and payment frequency for supplemental payments.

    Please view the draft SPA pages here: OK SPA 18-39, and submit feedback via the comment box below.

    Tribal Consultation: 07/11/2018

    60-day Tribal Consultation Period: 7/11/2018 – 9/9/2018

    Circulation Date: 09/28/2018

    Comment Due Date:  10/28/2018

    Requested Effective Date: 10/01/2018Please view all comments received here: OK SPA # 18-39 Comment Document.

     



    OK TXXI SPA 18-0001 Health Service Initiatives - Sickle Cell Disease Care Kits, Safe Sleep, and Long-Acting Reversible Contraceptive Devices

    Health service initiatives (HSIs) protect public health and/or the health of individuals, improves or promotes a state’s capacity to deliver public health services, strengthen the human and material resources necessary to accomplish public health goals to improve children’s health, and targets low-income children under 19. Due to an increase in the Children's Health Insurance Program (CHIP) Federal Medical Assistance Percentages (FMAP) for FY19 to fund HSIs, the Oklahoma Health Care Authority (OHCA) is amending the Title XXI State Plan to propose three new initiatives including: Sickle Cell Disease (SCD) Care Kits; Safe Sleep, and Long-Acting Revisable Contraceptive (LARC) Devices. 

    As partnership with the Supporters of Families with Sickle Cell Disease, Inc., the proposed SCD Care Kits HSI will create and distribute care kits to mothers of diagnosed children, ages newborn to 5 years old. A second care kit will be provided to children, ages 6 to 18 years old, and their parents(s)/caregiver(s) who are currently living with the disease and associated diagnosis. The state match will be provided by the OHCA.

    As an existing partnership between the Oklahoma State Health Department and various birthing hospitals, the proposed Safe Sleep HSI will provide safe sleeps cribs and infant safe sleep education to parents of newborns. In an effort to reduce the number of infant deaths related to Sudden Infant Death Syndrome (SIDS) and Sudden Unexpected Infant Death (SUID), this HSI seeks to increase access to the use of infant safe sleep environments and improvements in safe sleep practices. The state match will be provided by the Oklahoma State Health Department.

    The proposed LARC Devices HSI will seek to purchase long-acting reversible contraceptive devices for the Oklahoma State Health Department. It will serve to supply various Health Department locations across the state with these contraceptive devices in an effort to increase access to the devices and accomplish public health goals to improve children's health. The state match will be provided by the Oklahoma State Health Department.

    Please view the draft OK TXXI SPA 18-0001 here: OK TXXI SPA 18-0001 HSIs (SCD Care Kits, Safe Sleep, LARC) Redlined SPA, and submit feedback via the comment box below. 

    HSI Request #6 (SCD Care Kits) Tribal Consultation Date: 07/11/17

    HSI Request #7 (Safe Sleep) Tribal Consultation Date: 03/07/17 

    HSI Request #8 (LARC Devices) Tribal Consultation Date: 07/11/17 

    Circulation Date: 04/13/18  

    Comment Due Date: 04/20/18  

    Requested Effective Date: 10/01/18

    OK SPA # 18-0013 Revise and Update CHIP Goals and Objectives  – The proposed changes will revise and update the current Title XXI State Plan’s Strategic Objectives and Performance Goals.  These changes are being proposed because current measures and goals are obsolete, and it will allow the OHCA to effectively report on the Children’s Health Insurance Program (CHIP) through the CHIP annual report.  The revisions will update Section 9, of the Title XXI state plan, and establish new targets for performance to ensure the agency is in compliance with applicable federal regulations.

    The Title XXI state plan will also be revised to update language to reflect current practices regarding  tribal consultation and public notice processes, renumber sections, remove obsolete processes, and correct grammatical errors in order to comport with the new Title XXI state plan template format.

    Please view the draft SPA pages here: OK SPA 18-0013, and submit feedback via the comment box below.

    Tribal Consultation: 05/16/18

    Comment Due Date:   08/29/18

    Requested Effective Date: 09/01/2018  


    OK TXXI SPA 18-0016 Health Service Initiative - Reach Out and Read

    Health service initiatives (HSIs) protect public health and/or the health of individuals, improves or promotes a state’s capacity to deliver public health services, strengthen the human and material resources necessary to accomplish public health goals to improve children’s health, and targets low-income children under 19. Due to an increase in the Children's Health Insurance Program (CHIP) Federal Medical Assistance Percentages (FMAP) for FFY19 to fund HSIs, the Oklahoma Health Care Authority (OHCA) is amending the Title XXI State Plan to propose a new HSI. 

    In partnership with the University of Oklahoma, the Reach Out and Read HSI will provide training to pediatric and primary care providers in order to integrate the evidence-based ROR model into their practice. Providers will be trained to incorporate the use of an age appropriate, culturally sensitive, new book to be given to the child during the exam and used by the provider as a tool for assessment and anticipatory guidance. The book will be used to survey the child’s gross and fine motor skills, cognitive and speech milestones, and to observe parent/child interactions. The provider models reading the book aloud to the child, helps the parent understand the importance of language and development skills, and gives a prescription for reading aloud. Providers will also be provided with standardized developmental screening tools, i.e., Ages& Stages Questionnaires, and trained on their use. The state match will be provided by the University of Oklahoma.

    Please view the draft OK TXXI SPA 18-0016 here: OK TXXI SPA 18-0016 ROR SPA Redlined, and submit feedback via the comment box below. 

    HSI Request #9 (Reach Out and Read) Tribal Consultation Date: 09/05/17 

    Circulation Date: 07/02/18  

    Comment Due Date: 08/01/18

    Requested Effective Date: 11/01/18

      

     


     

     

     OK SPA # 17-05 — Tribal, IHS, and Urban Indian Health Program Facilities Designated as FQHCs 

    Tribal, IHS, and Urban Indian Health Program Facilities Designated as FQHCs — The proposed revisions allow I/T/Us who choose to contract and are designated as Federally Qualified Health Centers to be reimbursed at the Federal Office of Management and Budget (OMB) rate for services provided outside of the four walls of their facilities. These revisions are necessary in order to come into compliance with federal regulations. 

    Please view the draft SPA pages here: OK SPA 17-05, and submit feedback via the comment box below.

    Tribal Consultation: 03/07/2017

    Comment Due Date:    12/20/2017

    Requested Effective Date: 01/01/2018

     


     

     

     OK SPA # 17-06 — Hospice Care Concurrent Treatment for Children  

    A proposed state plan amendment (SPA) will align Medicaid hospice services with current program operations and federal regulations. The proposed SPA will allow children to receive hospice services without forgoing other medical/curative services which children are entitled to under Medicaid. Additional revisions to the hospice state plan pages are made to make the benefit more descriptive.

    Please view the draft state plan amendment (SPA) pages here: Hospice Care Concurrent Treatment for Children, and submit feedback via the comment box below.

      Requested Effective Date: 07/01/2017

      Tribal Consultation Date: 05/23/2017

     Comment Due Date:  06/22/2017
     

    OK SPA # 17-07 — Long acting reversible contraceptives (LARC) Devices  

    This proposed state plan amendment (SPA) will revise coverage language to increase access and utilization of LARC devices. The proposed SPA will expand access to these devices by    removing unnecessary restrictions.  Changes within the proposed SPA will support appropriate birth spacing, which can reduce infant and maternal mortality.

     Please view the draft SPA pages here: OK SPA # 17-07 — Long acting reversible contraceptives (LARC) Devices, and submit feedback via the comment box below.

     Requested Effective Date: 07/01/2017 

     Tribal Consultation Date: 05/23/2017

     Comment Due Date:   06/23/2017
     

    OK SPA # 17-08 — Long-Term Care Facilities Rebasing Rates

    A proposed state plan amendment (SPA) will revise the Quality of Care fee for regular nursing facilities, nursing facilities serving residents with Acquired Immune Deficiency Syndrome (AIDS), regular (greater than 16 beds) intermediate care facilities for individuals with intellectual disabilities (ICF/IID), and acute (16 beds or less) intermediate care facilities for individuals with intellectual disabilities (ICF/IID).

    Please view the draft SPA pages here: OK SPA 17-08, and submit feedback via the comment box below.

    Tribal Consultation: 05/23/17

    Comment Due Date:  07/22/2017

    Requested Effective Date: 07/01/2017



     

    OK SPA # 17-09 — Pharmacy Brand Name Reduction and Elimination of Over-The-Counter for Adults

    The proposed state plan amendment (SPA) will reduce brand name prescriptions from two (2) to one (1) per month per eligible non-institutionalized and non-wavier adult member. Revisions also remove coverage of optional non-prescription drugs for adults. (Insulin, nicotine replacement products for smoking cessation, and family planning products are not optional.)

    Please view the draft SPA pages here: OK SPA 17-09, and submit feedback via the comment box below.

    Tribal Consultation: 05/23/2017

    Comment Due Date: 08/16/2017

    Requested Effective Date: 10/01/2017

    OK SPA # 17-12 — Outpatient Hospital Dental and ENT Rates

    The proposed revisions will provide a new methodology for increasing the reimbursement rate for dental services in an outpatient hospital. The new method uses the cost of dental services and the cost of services in the Ambulatory Patient Classification group 5164 to calculate the rate for all outpatient hospitals.  

    Please view the draft SPA pages here: OK SPA 17-12, and submit feedback via the comment box below.

    Tribal Consultation: 11/07/17                                                                                 

    Comment Due Date:   01/05/2018

    Requested Effective Date: 01/01/2018


    OK SPA # 17-13 — Behavioral Health Targeted Case Management Units Limitation

    A state plan amendment (SPA) is proposed in order to coincide with the Oklahoma Department of Mental Health and substance Abuse Services’ (ODMHSAS) proposed rule changes within APA WF # 17-09, Behavioral Health Case Management Limit, that were posted to OHCA’s public website for a 30-day comment period of June 26, 2017- July 28, 2017. The SPA limits the number of Behavioral Health Targeted Case Management (TCM) units to 16 units per member per year. A process for authorizing up to 25 units per member per month will be used for individuals who meet established medical necessity criteria demonstrating the need for additional units.

    Please view the draft SPA pages here: OK SPA 17-13 BH TCM Units Limitation, and submit feedback via the comment box below.

    Requested Effective Date: 09/01/2017

    Tribal Consultation Date: 07/11/2017

    Comment Due Date:  09/21/2017

     


     

     

    OK SPA # 17-15 — Federally Qualified Health Center Services (FQHC) Alternative Payment Methodology (APM)  

    The proposed revisions will introduce a new optional payment methodology for Federally Qualified Health Centers (FQHCs). FQHCs are currently reimbursed through a Prospective Payment System (PPS) methodology; the proposed revision will add the Alternative Payment Methodology (APM) as an optional reimbursement method for FQHCs.

    Please view the draft SPA pages here: OK SPA 17-15, and submit feedback via the comment box below. 

     Tribal Consultation: 11/07/17

    Comment Due Date:  01/03/2018  

    Requested Effective Date: 04/01/2018  


    OK SPA # 17-16 — Private Duty Nursing (PDN)  

    PDN Rate Increase - OHCA proposes to increase the rate paid for private duty nursing (PDN) from $6.30 per 15 minute unit ($25.20/hour) to $7.55 per 15 minute unit ($30.20/hour).  The adjustment attempts to better align the rates with the current economic situation experienced by this industry in Oklahoma as well as recruit and retain nurses in the field. The proposed rate increase will necessitate a state plan amendment.

    Please view the draft SPA pages here: OK SPA 17-16, and submit feedback via the comment box below.

    Tribal Consultation: 09/05/17

    Comment Due Date:   10/08/2017

    Requested Effective Date: 10/01/2017

     

    OK SPA # 17-17 — Nursing Facilities' Wage Enhancement Payments Redaction

    A proposed state plan amendment (SPA) removes wage enhancement language and requirements for specified employees in nursing facilities (NF) serving adults and intermediate care facilities for individual with intellectual disabilities (ICFs/IIDs). The revisions are necessary to comply with changes in Oklahoma state statute, which became effective July 1, 2017. The federal minimum wage and the change in rate setting methodology increased the wages for employees of NFs serving adults and ICFs/IIDs, resulting in the policy being obsolete.

    Please view the draft state plan amendment (SPA) pages here: OK 17-17 NFs' Wage Enhancement Payments Redaction Draft SPA, and submit feedback via the comment box below.

    Requested Effective Date: 01/01/2018

    Tribal Consultation Date: 09/05/0217

    Comment Due Date: 11/01/2017
     
     

     

     

    Genetic Counseling — The proposed amendment to the State Plan will allow members to access genetic counseling after genetic testing has found that a member displays clinical features of a suspected genetic condition, is at direct risk of inheriting the genetic condition in question, or has been diagnosed with a condition where identification of specific genetic changes will impact treatment or management. Currently, the State Plan limits this service to women with a high-risk pregnancy.   

     Please view the draft state plan amendment (SPA) here: Genetic Counseling SPA Draft, and submit feedback via the comment box below.

     Effective Date: 04/01/2017 

     Tribal Consultation Date: 03/07/2017 

     Circulation Date: 03/07/2017 

     60-day Tribal Consultation Period: 03/07/2017 - 05/06/2017


     

    Pharmacy State Plan Amendment – The proposed amendment to the State Plan will revise language to reflect OHCA’s participation in the Sovereign States Drug Consortium for supplemental rebate negotiation. The amendment will also update the pharmacy coverage to specify that investigational drugs are not covered; even if they have been FDA approved but are part of a post marketing study or trial.  Changes to reflect new federal regulations and the Affordable Care Act (ACA) guidelines regarding covered outpatient drugs and reimbursement were previously submitted to CMS for these pages.  

    Please view the draft state plan amendment (SPA) here: Pharmacy SPA Draft, and submit feedback via the comment box below.

    Effective Date: 01/01/2017

    Tribal Consultation Date: 03/07/2017

    Circulation Date: 03/07/2017

    14-day Expedited Tribal Consultation Peroid: 03/07/2017 - 03/20/2017 


            

     

    Title XXI Health Service Initiative (HSI) - Due to an increase in the CHIP FMAP for FY16 and FY17 to fund health service initiatives, the OHCA is exploring two projects including one targeting blood lead screening test awareness and utilization and one that would provide safe sleeps cribs to hospitals to distribute to families in need as part of an existing partnership between the State Health Department and various birthing hospitals. State match will be provided by either partner agencies or by the Oklahoma Health Care Authority.  HSIs protect public health and/or the health of individuals, improves or promotes a state’s capacity to deliver public health services, strengthen the human and material resources necessary to accomplish public health goals to improve children’s health, and targets low-income children under 19.

    Please view the draft state plan amendment (SPA) here: HSI SPA Draft, and submit feedback via the comment box below.

    Effective Date: 07/01/2017 

    Tribal Consultation Date: 03/07/2017 

    Circulation Date: 03/07/2017 

    Comment Due Date: 03/20/2017


     

     Access Monitoring Review Plan 

     

    OHCA is proposing the final draft of the Access Monitoring Review Plan for comment from interested parties. Comments will be considered until September 9, 2016.


    Rate Reduction for Licensed Behavioral Health Professionals in Independent Practice

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for Licensed Behavioral Health Professionals in Independent Practice. A methodology change is requested to establish Independent Practice LBHP reimbursement rates for Common Procedure Terminology (CPT) codes which equate to 70% of the rates paid to LBHPs in an outpatient behavioral health clinic setting. Changes are necessary to reduce the Agency's spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

    Please view the full rate reduction proposal here: Licensed Behavioral Health Professionals in Independent Practice. Please submit all comments by close of business, April 25, 2016 via the comment box below. Thank you for your participation in the process.

    The following meetings are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    April 25th, 2016 at 10:00a.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    April 28th, 2016 at 1:00p.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Rate Reduction for Residential Psychiatric Services 

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for Private, in-state Psychiatric Residential Treatment Facilities (PRTF), Private Psychiatric Hospitals (Institutions for Mental Disease) and General Hospitals with Psychiatric Units. A prospective per diem payment is made based on facility peer group for a comprehensive package of services and room and board; the proposed rates are 15% less than the current rates in effect. Changes are necessary to reduce the Agency's spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

    Please view the full rate reduction proposal here: Residential Psychiatric Services. Please submit all comments by close of business, April 25, 2016 via the comment box below. Thank you for your participation in the process.

    The following meetings are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    April 25th, 2016 at 10:00a.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    April 28th, 2016 at 1:00p.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Rate Reduction for Behavioral Health Licensure Candidates 

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for Behavioral Health Licensure Candidates. The reimbursement rates for services provided by Licensure Candidates in outpatient behavioral health clinics will be reduced by 10%. This reduction will create new payment rates for outpatient behavioral health agencies which in the aggregate equal 67.4% of the 2007 Medicare Physician Fee Schedule. Changes are necessary to reduce the Agency's spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

    Please view the full rate reduction proposal here: Behavioral Health Licensure Candidates. Please submit all comments by close of business, April 25, 2016, via the comment box below. Thank you for your participation in the process.

    The following meetings are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    April 25th, 2016 at 10:00a.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    April 28th, 2016 at 1:00p.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Rate Reduction for Psychologists in Independent Practice  

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for Psychologists in Independent Practice. The new rates will be 87.07% of the CY2013 Medicare Physician Fee Schedule. Changes are necessary to reduce the Agency's spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

    Please view the full rate reduction proposal here: Psychologists in Independent Practice. Please submit all comments by close of business, April 25, 2016 via the comment box below. Thank you for your participation in the process.

    The following meetings are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    April 25th, 2016 at 10:00a.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    April 28th, 2016 at 1:00p.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Rate Reduction for Freestanding Psychiatric Hospitals 

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for freestanding psychiatric hospitals. Rates for freestanding psychiatric hospitals in effect as of 4-30-2016 will be decreased by 3 percent. Changes are necessary to reduce the Agency's spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

    Additionally, the State provides clarification that the inpatient hospital provider rate cut of 7.75 percent promulgated in 2014 with an effective of July 1, 2014, was applicable to inpatient DRG and freestanding rehabilitation hospitals only; the 2014 inpatient hospital provider rate cut of 7.75 percent did not affect freestanding psychiatric hospitals.

    Please view the full rate reduction proposal here: Freestanding Psychiatric Hospitals. Please submit all comments by close of business, April 25, 2016 via the comment box below. Thank you for your participation in the process.

    The following meetings are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    April 25th, 2016 at 10:00a.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    April 28th, 2016 at 1:00p.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


     

    Access to Care Analysis RE: OK SPA 16-19 Freestanding Psychiatric Hospitals Rate Reduction

    As part of the documentation of access to care and service payment rates federal requirements found at 42 CFR 447.203, the State must conduct an access to care analysis for any service within a state plan amendment that proposes to reduce or restructure provider payment rates in circumstances when the changes could result in diminished access.

    OK SPA 16-19, Freestanding Psychiatric Hospitals Rate Reduction, was submitted June 22, 2016, with an effective date of May 1, 2016, and approved on February 10, 2017. This is the first annual update to the access to care analysis for the reduced payment rate within OK SPA 16-19.  

    Please view the draft access to care analysis here: OK SPA 16-19 Freestanding Psych Hospitals Rate Reduction 2017 Annual Access to Care Analysis, and submit feedback via the comment box below.

    Circulation Date: 08/03/2017

    Comment Due Date: 09/02/2017 

    Access to Care Analysis RE: OK SPA 16-20 Independent Practice LBHP & Psychologist Rate Reduction

    As part of the documentation of access to care and service payment rates federal requirements found at 42 CFR 447.203, the State must conduct an access to care analysis for any service within a state plan amendment that proposes to reduce or restructure provider payment rates in circumstances when the changes could result in diminished access.

    OK SPA 16-20, Freestanding Psychiatric Hospitals Rate Reduction, was submitted June 24, 2016, with an effective date of May 1, 2016, and approved on April 5, 2017. This is the first annual update to the access to care analysis for the reduced payment rate within OK SPA 16-20.  

    Please view the draft access to care analysis here: OK SPA 16-20 Independent Practice LBHP & Psychologist Rate Reduction 2017 Access to Care Analysis, and submit feedback via the comment box below.

    Circulation Date: 08/03/2017

    Comment Due Date: 09/02/2017

    Access to Care Analysis RE: OK SPA 16-21 Psychiatric Residential Treatment Facilities (PRTF) Rate Reduction

    As part of the documentation of access to care and service payment rates federal requirements found at 42 CFR 447.203, the State must conduct an access to care analysis for any service within a state plan amendment that proposes to reduce or restructure provider payment rates in circumstances when the changes could result in diminished access.

    OK SPA 16-21, Freestanding Psychiatric Hospitals Rate Reduction, was submitted June 24, 2016, with an effective date of May 1, 2016, and approved on February 14, 2017. This is the first annual update to the access to care analysis for the reduced payment rate within OK SPA 16-21.  

    Please view the draft access to care analysis here: OK SPA 16-21 PRTF Rate Reduction 2017 Annual Access to Care Analysis, and submit feedback via the comment box below.

    Circulation Date: 08/03/2017

    Comment Due Date: 09/02/2017  

     


     

     

    Access to Care Analysis RE: OK SPA 16-26 Licensure Candidate Rate Reduction

    As part of the documentation of access to care and service payment rates federal requirements found at 42 CFR 447.203, the State must conduct an access to care analysis for any service within a state plan amendment that proposes to reduce or restructure provider payment rates in circumstances when the changes could result in diminished access.

    OK SPA 16-26, Licensure Candidate Rate Reduction, was submitted June 24, 2016, with an effective date of May 1, 2016, and approved on February 13, 2017. This is the first annual update to the access to care analysis for the reduced payment rates within OK SPA 16-26.  

    Please view the draft access to care analysis here: OK SPA 16-26 Licensure Candidate Rate Reduction 2017 Annual Access to Care Analysis, and submit feedback via the comment box below.

    Circulation Date: 08/03/2017

    Comment Due Date: 09/02/2017

     

     


       

     

    Proposed amendment to the State Plan, reduction of payments for coinsurance and deductibles on all crossover claims 

    Due to further anticipated decreases in state appropriated funding, OHCA will propose a State Plan Amendment (SPA) to reduce payments for coinsurance and deductibles on all Medicare crossover claims. The proposed methodology is to consider the Medicare paid amount payment in full for all crossover claims, excluding ITU provided services and physician supplied drugs. Total payments from all sources will not be less than the Medicaid established rate of payment per claim. No payment will be made when the sum of payments from all other sources is greater than the Medicaid rate. The new payment methodology for crossover claims will take effect for services rendered on or after June 1, 2016.

    Please submit all comments by close of business May 1, 2016, via the comment box below. Thank you for your participation in the process.

    The following meetings about the proposed changes are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    May 10, 2016 at 10 a.m. 
    Charles Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    May 12, 2016 at 1 p.m.
    Charles Ed McFall Boardroom
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Rate Revision for Behavioral Health Assessments performed in Outpatient Behavioral Health Agencies 

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for Behavioral Health Assessments provided by outpatient behavioral health agencies. The current rates are based on a percentage of the 2007 Medicare Physician Fee Schedule and vary based on the length of the assessment. The proposed methodology would create a single reimbursement rate per assessment session regardless of time spent and would equate to 80% of the CY2016 MPFS for CPT code 90791 for fully licensed behavioral health professionals and 70% of the CY2016 MPFS for CPT code 90791 for licensure candidates.

    Please submit all comments by close of business, August 5, 2016, via the comment box below. Thank you for your participation in the process. 


    Nursing Facility Rate Changes 

    For the rate period beginning July 1, 2016, a proposed amendment to the Title XIX State Plan will amend the reimbursement rates as follows for long-term care facilities: 

    • Regular Nursing Facilities. A revision will be made, establishing the pool amount for other and direct care components of the rate at $158,741,836. This will make the base rate $107.57 per patient day. 
    • Nursing Facilities serving residents with Acquired Immune Deficiency Syndrome (AIDS). A revision will be made to set the base rate at $199.19 per patient day. 
    • Regular (greater than 16 beds) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). A revision will be made to set the base rate at $122.32 per patient day. 
    • Acute (16 beds or less) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). A revision will be made to set the base rate at $156.51 per patient day. 

    Please submit all comments by close of business, August 5, 2016, via the comment box below. Thank you for your participation in the process.  


    Change in Upper Payment Limit (UPL) Methodology & Supplemental Payments

    The Oklahoma Health Care Authority proposes to change the Upper Payment Limit methodology and establish a Supplemental Payment for nursing facilities.

    Please submit all comments by close of business, August 10, 2016, via the comment box below. Thank you for your participation in the process.


    Access Monitoring Review Plan 

    CMS recently issued a final rule directing State Medicaid programs to analyze and monitor access to care for Medicaid fee-for-service programs. Through an access monitoring review plan, the State will demonstrate access to care by measuring the following: enrollee needs; the availability of care and providers; utilization of services; characteristics of the enrolled members, and estimated levels of provider payment from other payers. The plan must be created in consultation with the Medical Advisory Committee and be published and made available to the public for a period of no less than 30 days prior to being submitted to CMS. The State will submit the initial access monitoring review plan to CMS on July 1, 2016; the State will have to provide CMS a renewed plan noting any access issues and how the State resolved the issues every 5 years. Further, the state must conduct and submit an access monitoring review plan when promulgating a State Plan Amendment that affects payment methodology and/or rates.

    Please view the plan document here: Access Monitoring Review Plan, and submit feedback via the comment box below by close of business May 19, 2016. Thank you for your participation in the process.

    Medical Advisory Committee (MAC) Meeting:
    May 19, 2016 at 1:00p.m.
    Ed McFall Boardroom
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Diagnosis-Related Group (DRG) Transfer Outlier Payments Method Change  

    The OHCA will change transfer methodology policy to reflect current practice as follows:

    Transfers pay the lesser of transfer fee or Diagnosis-Related Group (DRG). In the case of a transfer, the Transfer Allowable Fee for the Transferring Facility shall be calculated as follows:  Transfer Allowable Fee = (MS-DRG Allowable Fee/Mean Length of Stay) X (Length of Stay + 1 day). The total Transfer Allowable Fee paid to the transferring facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. Outlier payments will be paid to the transferring hospital, if applicable. Payment to the receiving facility, if it is also the discharging facility, will be at the DRG allowable plus outlier if applicable. No budget impact will result from this change in methodology as the action simply aligns the policy with the current practice.

    Please view the full transfer methodology policy change here: DRG Transfer Outlier Payments. Please submit all comments by close of business, May 28, 2016 via the comment box below. Thank you for your participation in the process.

    SPARC: 03/22/16

    BOARD: 03/24/16  


    Title XXI Health Service Initiative (HSI) - MAGI 

    Due to an increase in the CHIP FMAP for FY16 and FY17 to fund health service initiatives, the OHCA is exploring a project designed to offer direct MAGI methodology instruction for agency enrollment partners. State match will be provided by a partner agency. HSIs protect public health and/or the health of individuals, improves or promotes a state’s capacity to deliver public health services, strengthen the human and material resources necessary to accomplish public health goals to improve children’s health, and targets low-income children under 19.

    Please submit all comments by close of business, February 20, 2016 via the comment box below. Thank you for your participation in the process.


     

    Title XXI Health Service Initiative (HSI) 

    Due to an increase in the CHIP FMAP for FY16 and FY17 to fund health service initiatives, the OHCA is exploring various projects including two projects targeting long acting reversible contraceptives (LARC); a foster child behavior health coordination and passport upgrade project; a naloxone rescue kits project; an outpatient donor breast milk project; and an academic detailing program targeting attention deficit hyperactivity disorder (ADHD) medications and atypical antipsychotic medications. State match will be provided by partner agencies and/or organizations. HSIs protect public health and/or the health of individuals, improve or promote a state’s capacity to deliver public health services, strengthen the human and material resources necessary to accomplish public health goals to improve children’s health, and target low-income children under 19.

    Please submit all comments by close of business, February 3, 2016 via the comment box below. Thank you for your participation in the process. 


    Supplemental Hospital Offset Payment Program (SHOPP)

    The Supplemental Hospital Offset Payment Program (SHOPP)  was created and implemented in 2011 for the purpose of assuring access to quality care for Oklahoma Medicaid members. The program is designed to assess Oklahoma hospitals, unless exempt, a supplemental hospital offset payment program fee. Hospitals that are owned or operated by a federally recognized Indian Tribe or the Indian Health Service are among the exempt providers. 

    The OHCA is seeking to amend a State Plan page regarding SHOPP in order to address Centers for Medicare & Medicaid Services (CMS) concerns related to cost-to-charge ratio (CCR) and trending. CMS changed cost report formats in 2011 which changes the lines, specified in the State Plan, used to calculate the inpatient CCR.  Also, CMS advises that we mention trending of costs in the State Plan. 

    Circulated Date: 09/25/2015   

    OHCA Comment Due Date: 10/07/2015 

    Proposed Submittal Date: 10/12/2015 


    RFI Care Coordination Model

    Pursuant to House Bill 1566 passed by the Oklahoma Legislature in 2015, it is the intent of the Oklahoma Health Care Authority (OHCA) to issue a Request for Proposal (RFP) for care coordination model(s) for the Aged, Blind and Disabled (ABD) populations. To comply with the direction of the bill, the OHCA is soliciting information and input from a wide variety of stakeholders including but not limited to SoonerCare members, advocates, providers, health care systems, and the general public through a Request for Information (RFI) process, for the development and requirements of the RFP.  Please submit all comments by the close of business July 24, 2015. Thank you for your participation in the process.    

    Circulated Date:  06/24/2015     

    OHCA Comment Due Date: 07/24/2015


    Hospitals Deemed Disproportionate Share

    Due to reductions in Agency budgets for SFY 2016, ODMHSAS is seeking to amend a State Plan page related to the deemed disproportionate share payment for hospitals to have the denominator include days attributable to Medicaid patients between 21 and 65 years of age in an Institution for Mental Diseases (IMD). The change is necessary in order to increase revenues to Griffin Memorial Hospital to balance ODMHSAS' state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated. 

    Circulated Date: 07/17/2015 

    OHCA Comment Due Date: 09/16/2015 

    Proposed Submittal Date: 09/30/2015  


    Developmental Disabilities Services Providers

    Reimbursement for services will be changed to the following rates:  Homemaker (State Fund)/Homemaker Respite, $3.20; Habilitation Training Specialist (State Fund), $3.78; Self-Directed Habilitation Training Specialist, $3.78; Intensive Personal Supports (State Fund), $3.78; Daily Living Supports (Therapeutic Leave), $143.97. Also, Group Home Respite Six Bed, $67.79; Seven Bed, $57.90; Eight Bed, $50.66; Nine Bed, $ 46.32; 10 Bed, $42.70; 11 Bed, $40.05; and 12-Bed, $37.63. Also, Group Home Community Living/Respite Six Bed, $125.45; Seven Bed, $121.35; Eight Bed, $111.46; Nine Bed, $103.74; 10 Bed, $97.46; 11 Bed, $92.16; 12 Bed, $87.09; Group Home Alternative – Four Bed, $272.85; Agency Companion-Close (Therapeutic Leave)/Respite, $90.23; Agency Companion-Enhanced (Therapeutic Leave)/Respite, $117.49; Agency Companion-Pervasive (Therapeutic Leave)/Respite, $1128.34; and Agency Companion-Intermittent (Therapeutic Leave)/Respite, $62.97. Additionally, Center Based Prevocational Services (State Fund), $4.67; Community Based Prevocational Services (State Fund), $9.34; Pre-vocational HTS-SUPP Supports (State Fund), $11.77; Enhanced Community Based Prevocational (State Fund), $12.47; Community Based Individual Services (State Fund) $15.13; Job Stabilization/Extended Services, $1.29; Job Coaching Service, $3.12; Enhanced Job Coaching Service, $3.63; Job Coaching Individual Services (State Fund), $4.15; Employment Specialist, $5.66; Transportation – Mileage Indirect, $.47; and Transportation-Adapted-Non-emergency Van, $1.21.   

    Circulated Date: 07/15/2015 

    OHCA Comment Due Date: 08/11/2015


    DRG Hospital Readmissions

    The OHCA proposes to reduce payment for hospital readmissions occurring within 30 days since the last hospital discharge date. OHCA will set the target to 102% for CY 2015, decreasing 1% per year until the target is 100%.  A target of 102% means we would allow a hospital to have 102% of the potentially-preventable admissions that we would expect based on statewide data before we assess a penalty.

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    DRG Hospital Outlier Payment

    The OHCA proposes to reduce DRG outlier payments by increasing DRG threshold to $50,000. Currently the DRG threshold is $27,000.  

    State Plan Amendment & Rate Change  

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    DRG Hospital Lesser of Transfer Fee or DRG

    The OHCA proposes to pay lesser of transfer fee or DRG. Payment to the receiving Facility, if it is also the final discharging Facility, will be at the DRG allowable. Currently, both are paid at the DRG allowable. No outlier payments will be allowed for transfers.

    State Plan Amendment & Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    Physician Services in Facility Setting

    The OHCA proposes to pay like Medicare for physician services performed in a facility setting.

    State Plan Amendment & Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    Mid-level Practitioner Reimbursement

    The OHCA proposes to reduce payments to mid-level practitioners to 85% of the appropriate OHCA physician fee schedule.

    State Plan Amendment & Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    Mid-level Practitioner Reimbursement

    The OHCA proposes to reduce payments to mid-level practitioners to 85% of the appropriate OHCA physician fee schedule.

    State Plan Amendment & Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    Nursing Facility Crossovers

    The OHCA proposes to reduce payments for coinsurance and deductibles from 100% to 75%.

    State Plan Amendment & Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    Durable Medical Equipment

    The OHCA proposes to reimburse for stationary oxygen using the Medicare competitive bid rate. In addition, the agency proposes to eliminate coverage for sterile water and gloves.

    State Plan Amendment & Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015


    Polycarbonate Lenses

    The OHCA proposes to reduce payments for polycarbonate lenses to $10 per lens.

    Rate Change

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

    Medical Advisory Committee (MAC): 05/21/2015

    State Plan Amendment Rate Committee (SPARC) Meeting: 06/18/2015    

    Board: 06/25/2015 


    Mental Health Substance Use Screening

    Rules were revised during 2015 permanent rulemaking to add coverage of Mental Health/Substance Use Disorder (MH/SUD) screens provided in outpatient behavioral health agencies. ODMHSAS proposes to reimburse for screens provided by qualified providers using approved evidence based tools at a rate of $25.32 per event. 

    Circulated Date: 07/15/2015 

    OHCA Comment Due Date: 08/11/2015 


    Independent Practitioners Rate Equalization

    The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) proposes to revise the payment methodology for independent Licensed Behavioral Health Practitioners (LBHPs) in order to equalize payment for their services with the payments made for services provided by the same level of provider in an outpatient behavioral health agency setting. This change is being proposed due to the agency budget shortfall of SFY2016. This change does not affect the methodology for Physicians, Psychiatrists or Psychologists.   

    Circulated Date: 07/15/2015 

    OHCA Comment Due Date: 08/11/2015 


    Severe Combined Immunodeficiency Disorder (SCID) Newborn Screen

    The Oklahoma State Department of Health (OSDH) has recently (February 2015) added a new test to the existing state-mandated panel for newborn screening (NBS). This test, which screens for Severe Combined Immunodeficiency Disorder (SCID), was approved as part of the national Recommended Uniform Screening Panel (RUSP) for newborn testing, which includes 31 core disorders and 26 secondary disorders, in May 2010. The OSDH NBS Program has systematically adopted all testing reflected in the nationally-recognized RUSP. SCID includes more than 10 genetic disorders characterized by profound defects in both cellular immunity and specific antibody production, and is estimated to occur in about 1/33,000 births. Early identification of the asymptomatic SCID infant during the first few weeks of life is essential for successful treatment, which generally involves allogeneic hematopoietic stem cell transplantation. SCID infants who are treated early have almost 10-fold lower total clinical care costs compared with those treated later.  If undiagnosed, SCID infants usually die from severe infections with the first year of life. Unfortunately, while SCID is potentially treatable, it is infrequently recognized prior to the onset of devastating infec­tions.   

    This test will also detect clinically important, non-SCID T-cell-related lymphocyte deficiencies in newborns, which can also be associated with serious morbidities in early childhood. Currently more than half of the babies born in the US are screened for SCID. SCID testing in newborns involves real-time PCR – a technology that is currently not part of other NBS testing – to amplify T-cell receptor excision circles (TRECs). The OSDH Public Health Laboratory (PHL) secured funding from the CDC in 2013 to develop the capacity to offer SCID screening of newborns in Oklahoma; these funds were used to purchase equipment, reagents and consumables for test validation and to hire testing personnel. Following comprehensive test validation, the OSDH PHL implemented routine, population-based SCID screening of newborns in February 2015. The CDC funds were not intended, and are insufficient, to sustain any long term testing; therefore, OSDH is requesting a charge of $6 to be added to the current fee in order to offset the added costs incurred in performing SCID screening. These costs included those associated with laboratory analysis of dried blood spot specimens and follow-up triage of presumptive cases by Screening and Special Services.  

    Circulated Date: 07/15/2015 

    OHCA Comment Due Date: 08/11/2015


    Exome Sequence Analysis

    The Oklahoma Health Care Authority (OHCA) recommends adding a rate for a new code (81415) for exome sequence analysis.     

    Circulated Date: 07/15/2015 

    OHCA Comment Due Date: 08/11/2015 


    Addition of Health Home services - Adults

    The Oklahoma State Plan will be amended to include the addition of Health Home services as authorized in federal law. Two new service delivery models will be created as a result of the State Plan Amendment. One health home will provide an integrated system of services to assist children with serious emotional disturbance. The adult health home will serve qualifying individuals with serious mental illness. Health home providers will coordinate all primary, acute and behavioral health and long-term care services and supports to treat the whole person. 

     Circulated Date: 07/10/2014 

     OHCA Comment Due Date: 08/09/2014 

     Proposed Submittal Date: 10/01/2014 


    Addition of Health Home services - Children

    The Oklahoma State Plan will be amended to include the addition of Health Home services as authorized in federal law. Two new service delivery models will be created as a result of the State Plan Amendment. One health home will provide an integrated system of services to assist children with serious emotional disturbance. The adult health home will serve qualifying individuals with serious mental illness. Health home providers will coordinate all primary, acute and behavioral health and long-term care services and supports to treat the whole person. 

     Circulated Date: 07/10/2014 

     OHCA Comment Due Date: 08/09/2014 

     Proposed Submittal Date: 10/01/2014 


    PACE SPA Draft

    State Plan Amendment to allow for additional Program for All-Inclusive Care for the Elderly (PACE) providers to contract with OHCA.   

    PACE SPA Enclosure 7 Page 6  

    Circulated Date: 04/17/2014 

    OHCA Comment Due Date: 05/19/2014 

    Proposed Submittal Date: 07/01/2014


    SPA 01-13

    State Plan Change for Reimbursement of certain Outpatient Drugs 

    Circulated Date: 03/22/2013 

    OHCA Comment Due Date: 04/04/2013 


     

     
     

    SoonerCare and 1115 Demonstration Waiver Amendments 


    Health Access Networks (HAN) 1115(a) Demonstration Waiver Amendment, Effective: October 1, 2019

    With this amendment request, the OHCA seeks approval of the following modifications to the 1115(a) demonstration for the current extension period that will be in effect through December 31, 2023:

    Effective October 1, 2019, the waiver Special Terms and Conditions (STCs) will be updated for the Health Access Networks (HANs), contingent upon CMS approval. HANs are non-profit administrative entities that work with providers to coordinate and improve the quality of care for SoonerCare members.

    The OHCA proposes to remove three paragraphs that are either duplicative or no longer applicable to HAN duties from STC 40. The paragraphs identified for removal are in relation to 1) ensuring access to all levels of care, 2) submitting a development plan, and 3) offering core components of electronic medical records, improved access to specialty care, telemedicine, and expanded quality improvement strategies.

    OHCA proposes to continue the currently approved monitoring and evaluation components identified in the STCs. The hypotheses and measures provided in the current evaluation design remain applicable with the following corrections to STC 84, Evaluation of the HANs.

    One correction will be to remove the word “pilot” from the reference to the program in the first paragraph. In addition, the subsequent paragraphs will be revised to reflect the evaluation design that the state has submitted to Centers for Medicare and Medicaid Services (CMS) including the following:

    a. Impact on costs: The implementation and expansion of the HANs will reduce costs associated with the provision of health care services to SoonerCare beneficiaries served by the HANs;

    b. Impact on access to care: The implementation and expansion of the HANs will improve access to and the availability of health care services to SoonerCare beneficiaries served by the HANs;

    c. Impact on quality and coordination: The implementation and expansion of the HANs will improve the quality and coordination of health care services to SoonerCare beneficiaries served by the HANs, with specific focus on the populations at greatest risk, including those with multiple chronic illnesses; and

    d. Impact on the patient-centered medical home (PCMH) program: The implementation and expansion of the HANs will enhance the State’s PCMH program through an evaluation of primary care physician (PCP) profiles that incorporates a review of utilization, disease guideline compliance, and cost.

    Amending the language will not have any effect on budget neutrality for the 1115(a) demonstration waiver.

    The proposed amendment was presented at the OHCA Medical Advisory Committee meeting and The Children’s Health Group (TCHG) meeting at the dates listed below:  

    OHCA Medical Advisory Committee Meeting
    March 14, 2019
    1:00 p.m.
    Oklahoma Health Care Authority
    Ed McFall Boardroom
    4345 N. Lincoln Boulevard
    Oklahoma City, Oklahoma 73105

    The Children’s Health Group Quarterly Meeting
    April 9, 2019
    5:00 p.m.
    OU Health Sciences Center Campus
    Provost’s Conference Room
    #233 Bird Library
    1105 N. Stonewall Ave.
    Oklahoma City, Oklahoma 73117

    The OHCA welcomes comments from the public regarding the amendment to the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver program. Please view the waiver amendment in its entirety here: Health Access Network Waiver Amendment. The public notice for the waiver amendment can be viewed on the Agency’s Policy Change and Native American Consultation webpages. The amendment will be available for a 30-day public comment period from March 11, 2019 through April 10, 2019. 

    Comments may also be made at https://www.medicaid.gov after the amendment has been submitted to CMS on or after April 11, 2019.

    Please view additional documents here: 

     1.      SoonerCare Choice Budget Neutrality  

     2.      CMS Standard Funding Questions 

     3.      1115(a) Waiver Projects Currently Undergoing Application and Amendment

     


     

     

     1115(a) Demonstration Health Management Program Waiver Amendment  

    Pursuant to 42 CFR § 431.408 and 42 CFR § 447.205, the Oklahoma Health Care Authority (OHCA) is providing public notice of a proposed amendment to the 1115(a) demonstration waiver. The proposed waiver amendment was presented at the September 4, 2018 and January 8, 2019 Tribal Consultations and two public meetings (refer to meeting information below). Additionally, the amendment was posted for a 30-day public review period from October 1, 2018, through October 30, 2018; however, the supplemental documentation for submission to Centers for Medicare and Medicaid Services (CMS) has since updated and the Agency is seeking an additional 30-day public review period.  

    The OHCA currently has an approved 1115(a) waiver for the 2018-2023 demonstration extension period. Effective July 1, 2019 and contingent upon CMS approval, the OHCA seeks approval of the following modifications to the demonstration for the current 2018-2023 extension period:  

    The waiver amendment requests a revision to the waiver special terms and conditions to reflect a more current description of the Health Management Program (HMP). The HMP was developed in response to a state mandate found at Oklahoma Statute §56-1011.6., and seeks to improve the quality of care and reduce cost of care for SoonerCare members with chronic conditions.   

    The “Health Management Program Defined” section will provide for more data analytic options than the current reference to HMP predictive modeling software. These are data sources that include but are not limited to claims, Health Information Exchange Information, provider referral, and other sources.   

    In addition, the HMP “Services” section is revised to focus more broadly on interventions used in HMP, removing limitations that refer to settings, and to allow for new approaches in practice facilitation to address emerging health trends.   

    The OHCA also proposes to add a sentence to the description regarding the length of time a member may be served in HMP, as follows: Maximum benefit is determined individually for each member served, and considers diagnoses, goals, and progress achieved.   

    The revised approach to the “Services” section will ask CMS to list HMP interventions along with brief descriptions and note that interventions include but are not limited to: health coaching, practice facilitation, health navigation, performance improvement projects, and assistance with transitions of care.   

    It is the intention of the OHCA to include the funding for HMP in its State Fiscal Year 2020 budget request. An HMP vendor is selected through a professional services contract procurement process that is open to the public and is implemented in accordance with state and federal purchasing requirements. The current budget request is not to exceed $15 million total dollars with an estimated state share of $5,220,000 for State Fiscal Year 2020.   

    The proposed amendment was presented at the OHCA Medical Advisory Committee and the Oklahoma Child Health Group at the dates listed below:   

    OHCA Medical Advisory Committee
    September 20, 2018
    1:00 p.m.
    Ed McFall Boardroom
    Oklahoma Health Care Authority
    4345 N. Lincoln Boulevard
    Oklahoma City, Oklahoma   

    Oklahoma Child Health Group
    October 9, 2018
    5:00 p.m.
    Oklahoma State Department of Health
    1000 NE 10th Street
    Oklahoma City, Oklahoma   

    The OHCA welcomes comments from the public regarding the amendment to the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver program. Please view the waiver amendment in its entirety here: Health Management Program Waiver Amendment. The amendment to the waiver will be posted online at www.okhca.org from January 23, 2019 through February 22, 2019.  

    Comments and questions may be submitted online through the Policy Change Blog or the Native American Consultation Page and by contacting the OHCA Federal Authorities Unit by telephone at 405-522-7270 or by written comment at 4345 N. Lincoln Blvd., Oklahoma City, OK 73105.   

    Comments may also be made at https://www.medicaid.gov after the amendment has been submitted to CMS on or after February 23, 2019. 

    Please view additional documents here: 

    1.  SoonerCare Choice Budget Neutrality  
    2.  CMS Standard Funding Questions
    3.  1115(a) Waiver Projects Currently Undergoing Application and Amendment

     


     

     

     1115(a) Demonstration Health Management Program Waiver Amendment

    Pursuant to 42 CFR § 431.408 and 42 CFR § 447.205, the Oklahoma Health Care Authority (OHCA) is providing public notice of its plan to submit an amendment to the 1115(a) demonstration waiver. The OHCA currently has an approved 1115(a) waiver for the 2018-2023 demonstration period.

    With this amendment request, the OHCA seeks approval of the following modifications to the demonstration for the 2018-2023 extension period:

    Effective July 1, 2019, the waiver special terms and conditions will be updated for the Health Management Program (HMP), contingent upon CMS approval. The HMP was developed in response to a state mandate found at Oklahoma Statute §56-1011.6., and seeks to improve the quality of care and reduce cost of care for SoonerCare members with chronic conditions.

    The “Health Management Program Defined” section will provide for more options for data analytics than the current reference to HMP predictive modeling software. These are data sources that include but are not limited to claims, Health Information Exchange Information, provider referral and other sources.

    In addition, the HMP “Services” section will be revised to focus more broadly on interventions used in HMP and remove limitations that refer to settings, and to allow for new approaches in practice facilitation to address emerging health trends.

    The OHCA also proposes to add a sentence to the description regarding the length of time a member may be served in HMP, as follows: Maximum benefit is determined individually for each member served, and considers diagnoses, goals and progress achieved.

    The revised approach to the “Services” section will ask CMS to list HMP interventions along with brief descriptions and note that interventions include but are not limited to health coaching, practice facilitation, health navigation, performance improvement projects and assistance with transitions of care.

    It is the intention of the OHCA to include the funding for HMP in its State Fiscal Year 2020 budget request. An HMP vendor is selected through a professional services contract procurement process that is open to the public and is implemented in accordance with state and federal purchasing requirements. The current budget request is not to exceed $15 million total dollars with an estimated state share of $5,220,000 for State Fiscal Year 2020.

    The proposed amendment will be presented at the next scheduled Medical Advisory Committee and the Oklahoma Child Health Group pursuant to the below:

    Medical Advisory Committee
    September 20, 2018
    1:00 p.m.
    Ed McFall Boardroom
    Oklahoma Health Care Authority
    4345 N. Lincoln Boulevard
    Oklahoma City, Oklahoma

    Oklahoma Child Health Group
    October 9, 2018
    5:00 p.m.
    Oklahoma State Department of Health
    1000 NE 10th Street
    Oklahoma City, Oklahoma

    The OHCA welcomes comments from the public regarding the amendment to the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver program. Please view the waiver amendment in its entirety here: Health Management Program Waiver Amendment Request Draft. The amendment to the waiver will be posted online at www.okhca.org from October 1, 2018, through October 30, 2018.

    Comments and questions may be submitted online through the Policy Change Blog or the Native American Consultation Page and by contacting the OHCA Federal & State Reporting Division by telephone at 405-522-7914 or by written comment at 4345 N. Lincoln Blvd., Oklahoma City, OK 73105.

    Comments may also be made at https://www.medicaid.gov after the amendment has been submitted to CMS on or after January 7, 2019.

    Please view additional documents here:

    1.  SoonerCare Choice Budget Neutrality
    2.  1115(a) Waiver Project Currently Undergoing Application and Amendment
    3.  CMS Standard Funding Questions
     

     

     1115(a) Demonstration Waiver Community Engagement Amendment

    Pursuant to 42 CFR § 431.408, the Oklahoma Health Care Authority (OHCA) is providing public notice of its plan to submit an amendment to the existing approved 2018 Section 1115(a) extension waiver for the SoonerCare Choice and Insure Oklahoma programs.

    The proposed amendment will implement community engagement requirements as a condition of SoonerCare eligibility for certain adults not otherwise exempted.

    It is the intent of the Oklahoma Health Care Authority to submit the amendment no later than October 1, 2018 with an effective date of February 1, 2019.  The initial budget impact for system modifications is estimated at $700,000 total dollars with $70,000 of the total being state share.  However, additional dollars are anticipated for the administration of the program but an exact amount is unknown at this time.

    The OHCA expects to conduct several public meetings around the state during the months of July-September.  As of this date, the agency has scheduled the below required public meetings. Information on additional meetings will be provided on the agency’s public website as future dates and times are determined.

     
    July 11, 2018 at 11:00 a.m.
     

    Tribal Consultation

    Ed McFall Boardroom

    Oklahoma Health Care Authority

    4345 N. Lincoln Blvd, Oklahoma City, Oklahoma


       

    July 19, 2018 at 1:00 p.m. 

    Medical Advisory Committee

    Ed McFall Boardroom

    Oklahoma Health Care Authority

    4345 N. Lincoln Blvd, Oklahoma City, Oklahoma

     

    August 10, 2018 at 11:30 a.m.

    OU Sooner Health Access Network

    OU - Tulsa Schusterman Center - Learning Center

    4502 E. 41st Street, Tulsa, Oklahoma     

     

    August 16, 2018 at 3:00 p.m.

    Comanche County Health Department

    1010 SW Sheridan Road, Lawton, Oklahoma

     

    August 17, 2018 at 3:00 p.m.

    Norman Regional - Porter Campus

    Education Center, Rooms ABC

    901 N. Porter Avenue, Norman, Oklahoma


    August 20, 2018 at 1:30 p.m.

    Pawnee City Hall

    510 Illinois Street, Pawnee, Oklahoma

     

    August 21, 2018 at 1:30 p.m.

    Variety Care - Lafayette Clinic

    500 SW 44th Street, Oklahoma City, Oklahoma


    August 23, 2018 at 3:00 p.m.

    Northwestern Oklahoma State University

    Room 131

    2929 East Randolph Avenue, Enid, Oklahoma


    August 24, 2018 at 10:00 a.m.

    Eastern Oklahoma State College - McAlester Campus

    1802 College Avenue, McAlester, Oklahoma


    August 24, 2018 at 2:00 p.m.

    Kiamichi Technology Center - Poteau Campus

    1509 South McKenna Street, Poteau, Oklahoma     

     

    August 27, 2018 at 3:00 p.m.

    James O. Goodwin Health Center

    5051 South 129th East Avenue, Tulsa, Oklahoma


    September 20, 2018 at 1:00 p.m.

    Medical Advisory Committee

    Charles Ed McFall Boardroom

    Oklahoma Health Care Authority

    4345 N. Lincoln Blvd, Oklahoma City, Oklahoma                 

     
    The OHCA welcomes comments from the public regarding the amendment to the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver program. Please view the waiver amendment in its entirety here: Community Engagement Waiver Amendment Request Draft. Comments and questions may be submitted below, via email at OHCAcommunityengagement@okhca.org, or with the OHCA Federal & State Reporting Unit by telephone at 405-522-7914. Comments may be submitted from July 3, 2018 through September 30, 2018.

     Please view additional documents here:

    1. SoonerCare Choice Budget Neutrality
    2. 1115(a) Waiver Projects Currently Undergoing Application and Amendment
    3. CMS Standard Funding Questions 
    4.   Continuous Comment Document 

     


     

     

     1115(a) Demonstration Waiver Supplemental Payment Amendment

    Pursuant to 42 CFR § 431.408, the Oklahoma Health Care Authority (OHCA) is providing public notice of its plan to submit an amendment to the existing approved 2018 Section 1115(a) extension waiver for the SoonerCare Choice and Insure Oklahoma programs.

    The proposed amendment would add supplemental payments to qualified entities for residency training and loan repayment programs in recognition of the higher cost associated with service delivery and physician recruitment and training to maintain sufficient access to quality preventive, primary and specialty healthcare for SoonerCare members.

    It is the intent of the Oklahoma Health Care Authority to submit the amendment no later than January 19, 2018 with an effective date on or after March 1, 2018.  The total estimated annual budget impact is one hundred and five million dollars ($105,000,000) of which the estimated state share is forty-three million, five hundred one thousand, five hundred dollars ($43,501,500) which is funded by participating entities.

    A public meeting will be held at the following location:

    January 18, 2018 at 1:00 p.m.
    Medical Advisory Committee             
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK.  

    Additionally, a special tribal consultation was held January 12, 2018 at 3:00 p.m. at the above location.

    Please view the waiver amendment in its entirety here: 1115 Supplemental Payment Amendment

    The OHCA welcomes comments from the public regarding the amendment to the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver program. The application waiver will be posted online at the OHCA Public Webpage from January 15, 2018 through January 19, 2018. 

    Comments and questions may be submitted online at the Policy Change Blog and the Native American Consultation Page or by contacting Bill Garrison, OHCA Federal & State Reporting Coordinator by telephone at 405-522-7914.

    Please view additional documents here:

    1.  Budget Neutrality for 1115 Waiver Amendment
    2.  Budget Neutrality for 1115 Waiver Amendment Worksheet
    3. Waiver Projects Currently Undergoing Application or Amendment

    Waiver Projects Currently Undergoing Application, Renewal, or Amendment 

    Purpose of this Webpage 

    In accordance with federal and state law, the Oklahoma Health Care Authority as a single state Medicaid agency, must notify the public of its intent to submit to the Centers for Medicare and Medicaid Services (CMS) any new 1115 demonstration waiver project or extension renewal or amendment to any previously approved demonstration waiver project and must make available at least a 30-day public comment period at minimum 30 days prior to submitting to CMS the new 1115 demonstration waiver project or extension renewal or amendment.

    Public notices, including the description of the new 1115 Demonstration Waiver project or, extension renewal or amendment to an existing demonstration waiver project to be submitted to CMS, will be posted here along with links to the full public notice and the application/extension/amendment document to be submitted to CMS.

    The full public notices will include:

    • the address, telephone number and internet address where copies of the new demonstration waiver project or extension or amendment document is available for public review and comment; 
    • the postal address where written comments can be sent;  
    • the minimum 30-day time period in which comments will be accepted;  
    • the locations, dates and times of at least two public hearings convened by the State to seek input, (At least one of the two required public hearings will use telephonic and/or web conference capabilities to ensure statewide accessibility to the public hearing.);
    • and a link to the CMS website to access comments received by CMS during their 30-day public comment period after the application/extension/amendment has been submitted to CMS.

    Comments may be provided during scheduled public hearings or in writing during the public comment period. To submit comments, write to

    Oklahoma Health Care Authority
    Federal and State Policy Division
    4345 N. Lincoln Blvd,
    Oklahoma City, OK 73105 

    Locations, dates and times for public hearings will be published on the upcoming public hearings page of this website.

    If you need this material in an alternative format, such as large print, please contact the Communications Division at 405-522-7300.

    SoonerCare Choice and Insure Oklahoma 1115 Demonstration Waiver Public Notice and Amended Application

    Added 08/31/17
    View or print the extension renewal request application to be submitted to CMS for SoonerCare Choice and Insure Oklahoma 1115 Demonstration Waiver 

    Public Notice 

    Added 08/31/17
     View or print public comments regarding SoonerCare Choice and Insure Oklahoma 1115 Demonstration Waiver extension renewal request application  

    Added 08/31/17
    View or print the SoonerCare Choice and Insure Oklahoma 1115 Demonstration Waiver and Post Award Forum Public Hearing Presentation

    Added 08/31/17
    View or print the public notice regarding the extension renewal request for the SoonerCare Choice and Insure Oklahoma 1115 Demonstration Waiver  

    The Oklahoma Health Care Authority (OHCA) as the single state Medicaid agency is providing public notice of its intent to submit to the Centers of Medicare and Medicaid Services (CMS) a written request to amend the SoonerCare Choice and Insure Oklahoma 1115 Demonstration waiver and to hold public hearings to receive comments on the extension renewal request to the Demonstration.

    The State will request an amendment to the SoonerCare Choice and Insure Oklahoma 1115 Demonstration waiver to remove the pilot status of the Health Access Networks (HAN) to allow the possibility of statewideness. Statewideness in accordance with Section 1902(a)(1) will also be removed from the waiver list.  

    The State does not request any additional waivers to implement the changes to the Demonstration:

    The State will seek to eliminate the following waiver and expenditure authorities related to its Health Access Network statewideness:  

    •  Statewideness/Uniformity Section
       
      § 1902(a)(1)
       To enable the state to provide Health Access Networks (HANs) only in certain geographical areas of the State.

    In addition, the second, of two public meetings described below, will also serve as the 2017 Post Award Forum to allow any discussion or feedback regarding the waiver. 

    Waiver List

    • § 1902(a)(23)(A)
      To enable the state to restrict beneficiaries’ freedom of choice of care management providers, and to use selective contracting that limits freedom of choice of certain provider groups to the extent that the selective contracting is consistent with beneficiary access to quality services. No waiver of freedom of choice is authorized for family planning providers.
    • § 1902(a)(34)
      To enable the state to waive retroactive eligibility for demonstration participants, with the exception of Tax Equity and Fiscal Responsibility Act (TEFRA) and Aged, Blind, and Disabled populations.

    Expenditure Authorities

    • Demonstration Population 5. Expenditures for health benefits coverage for individuals who are “Non-Disabled Low Income Workers” age 19–64 years who work for a qualifying employer and have no more than 200 percent of the federal poverty level (FPL), and their spouses.  
    • Demonstration Population 6. Expenditures for health benefits coverage for individuals who are “Working Disabled Adults” 19-64 years of age who work for a qualifying employer and have income up to 200 percent of the FPL.
    • Demonstration Population 8. Expenditures for health benefits coverage for no more than 3,000 individuals at any one time who are full-time college students age 19 through age 22 and have income not to exceed 200 percent of the FPL, who have no creditable health insurance coverage, and work for a qualifying employer.
    • Demonstration population 10. Expenditures for health benefits coverage for foster parents who work for an eligible employer and their spouses with household incomes no greater than 200 percent of the FPL.
    • Demonstration Population 11. Expenditures for health benefits coverage for individuals who are employees and spouses of not-for-profit businesses with 500 or fewer employees, work for a qualifying employer, and with household incomes no greater than 200 percent of the FPL.
    • Demonstration Population 12. Expenditures for health benefits coverage for individuals who are “Non-Disabled Low Income Workers” age 19–64 years whose employer elects not to participate in the Premium Assistance Employer Coverage Plan, who are self-employed, or unemployed, and have income up to 100 percent of the FPL, and their spouses.
    • Demonstration Population 13. Expenditures for health benefits coverage for individuals who are “Working Disabled Adults” 19-64 years of age whose employer elects not to participate in the Premium Assistance Employer Coverage Plan, as well as those who are self-employed, or unemployed (and seeking work) and who have income up to 100 percent of the FPL.
    • Demonstration Population 14. Expenditures for health benefits coverage for no more than 3,000 individuals at any one time who are full-time college students age 19 through age 22 and have income not to exceed 100 percent of the FPL, who have no creditable health insurance coverage, and do not have access to the Premium Assistance Employer Coverage Plan.
    • Demonstration Population 15. Expenditures for health benefits coverage for individuals who are working foster parents, whose employer elects not to participate in Premium Assistance Employer Coverage Plan and their spouses with household incomes no greater than 100 percent of the FPL.
    • Demonstration Population 16. Expenditures for health benefits coverage for individuals who are employees and spouses of not-for-profit businesses with 500 or fewer employees with household incomes no greater than 100 percent of the FPL, and do not have access to the Premium Assistance Employer Coverage Plan.
    • Health Access Networks Expenditures. Expenditures for Per Member Per Month payments made to the Health Access Networks for case management activities.
    • Premium Assistance Beneficiary Reimbursement. Expenditures for reimbursement of costs incurred by individuals enrolled in the Premium Assistance Employer Coverage Plan and in the Premium Assistance Individual Plan that are in excess of five percent of annual gross family income.
    • Health Management Program. Expenditures for otherwise non-covered costs to provide health coaches and practice facilitation services through the Health Management Program.
    • Work Force Development Supplemental Payments to State Teaching Universities.Expenditures for reimbursement to state teaching universities to grow and improve the healthcare workforce in Oklahoma. 

    The State continues to evaluate whether it will request other waivers or expenditure authorities.

    The extension renewal to the Demonstration will further the objectives of Title XIX by providing a medical home and premium assistance insurance across the continuum of coverage. The removal of the pilot status of the Health Access Networks, this will allow for statewideness of the program.

    This extension renewal will be statewide and will operate from calendar years 2019 through 2021. The State anticipates that this extension renewal will affect most of the approximately 545,858 SoonerCare Choice individuals covered under the Demonstration as of June 2017.

    The Demonstration extension renewal, including the proposed amendment, will test hypotheses related to access to care, quality of care management, integration of Indian Health Services, and access to affordable health insurance. The State expects that, over the life of the Demonstration, covering SoonerCare Choice enrollees will be comparable to what the costs would have been for covering the same group of Oklahomans using traditional Medicaid. The State does not anticipate that the extension renewal to the Demonstration will affect its current waiver trend rate or per capita cost estimates, which can be found in the Demonstration Populations table below.

    The information in the table below is provided by The Pacific Health Policy Group (PHPG) which has been retained by the OHCA as an independent contractor. The information is pulled from the Budget Neutrality exhibits which incorporate full-year enrollment and expenditure data through calendar year 2016 (demonstration year 21). Expenditures reflect C-Report amounts.

    Projections for the remainder of the current extension period are based on Medicaid Eligibility Group (MEG) specific assumptions, as described in detail throughout the chapter.  Updates to worksheets previously submitted are described in text boxes included at the top of each worksheet (where applicable).  Traditional MEG projections for 2018 incorporate the CMS-mandated rebasing methodology, with 1) the budget neutrality PMPM set equal to the 2016 actual PMPM, trended to 2018 and 2) savings limited to a five-year look back period. Annual aggregate savings/ (deficit) projections for 2019 – 2021 are capped at 25 percent of actual prior to being added to cumulative savings/ (deficit) projections.

     Demonstration Populations

     Trend

    DY 23 (2018) projection PMPM

    DY 24 (2019) projection PMPM

    DY 25 (2020) projection PMPM

    DY 26 (2021) projection PMPM

    TANF-Urban

     4.40%

     $256.79

     $268.56

     $280.43

     $292.82

    TANF-Rural

     4.40%

     $226.92

     $238.32

     $248.75

     $259.64

    ABD-Urban

     4.20%

     $1,121.61

     $1,170.14

     $1219.23

     $1270.38

    ABD-Rural

     4.20%

     $1,091.15

     $1,138.39

     $1,186.15

     $1,235.91

    Non-Disabled Working Adults (Employer Plan)

     4.40%

     $326.90

     $341.28

     $356.29

     $371.97

    Disabled Working Adults (Employer Plan)1

     4.20%

     $0

     $0

     $0

     $0

    TEFRA Children

     4.20%

     $777.48

     $810.14

     $844.16

     $879.62

    CHIP Medicaid Expansion Children2  


     

     $0

     $0

     $0

     $0

    Full-Time College Students (Employer Plan)

     4.40%

     $261.27

     $272.76

     $284.77

     $297.30

    Foster Parents (Employer Plan)3 

     

     $0

     $0

     $0

     $0

    Not-for-Profit Employees (Employer Plan)3

     

     $0

     $0

     $0

     $0

    Non-Disabled Working Adults (Individual Plan)

     

     $592.84

     $618.93

     $646.16

     $674.59

    Disabled Working Adults (Individual Plan)

     

     $4,737.34

     $4,936.31

     $5,143.63

     $5,359.66

    Full-Time College Students (Individual Plan)

     

     $197.21

     $205.88

     $214.94

     $224.40

    Foster Parents (Individual Plan)3

     

    $0

    $0

    $0

    $0

    Not-for-Profit Employees (Individual Plan)3

     

    $0

    $0

    $0

    $0

    • Demonstration Year (DY) 
    • Per Member Per Month (PMPM)

    1All WDA enrollment has occurred within the IP component of the program.  

    2One additional population, CHIP Medicaid Expansion, is reported separately in the Budget Neutrality per PHPG. 

    3The OHCA is not projecting any enrollment for this MEG during the renewal period.

    View or print the extension renewal request application to be submitted to CMS for SoonerCare Choice and Insure Oklahoma 1115 Demonstration Waiver

    The Demonstration application may also be viewed from 8 AM – 4:00 PM Monday through Friday at:

    Oklahoma Health Care Authority
    Federal and State Policy Division
    4345 N. Lincoln Blvd,
    Oklahoma City, OK 73105
    Contact: Sherris Harris-Ososanya 

    Public comments may be submitted until midnight on Friday, September 22, 2017. Comments may be submitted by agency blog to comments box or by regular mail to

    Oklahoma Health Care Authority
    Federal and State Policy Division
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105   

     View comments that others have submitted.

    Comments may also be viewed at the OHCA Public Webpage.

    The State held two public hearings during the public comment period.

    SoonerCare Choice and Insure Oklahoma Waiver Extension Renewal Public Hearing
    July 11, 2017 at 5:00p.m. 
    The Child Health Workgroup, 
    OU Robert Bird Library
    First Floor Conference Room
    Oklahoma City, OK 73104. 

    Videoconferencing will be available for this meeting:  

    •  OU College of Medicine, Tulsa;
    •  Northwestern Oklahoma State University, Enid;
    •  Eastern Oklahoma State University, Wilburton and
    •  Stillwater Medical Center

    SoonerCare Choice and Insure Oklahoma Waiver Extension Renewal Public Hearing
    September 21, 2017 at 1:00p.m. 
    Medical Advisory Committee Meeting
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK.

    Videoconferencing will be available for this meeting.

    Please submit comments via the comment box below.

     

     


     

     

     2018 SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver Extension Request

    Pursuant to  42 CFR § 431.408, the Oklahoma Health Care Authority (OHCA) is providing  public notice of its plan to submit an extension application for the SoonerCare Choice and Insure Oklahoma 1115(a) waiver to the Centers for Medicare and Medicaid Services (CMS) for the period January 1 2018, to December 31, 2018.  

    The waiver allows the state to offer managed care in a Primary Care Case Management (PCCM) model in which the OHCA contracts directly with providers throughout the state to provide SoonerCare Choice members a Patient-Centered Medical Home (PCMH) and also to operate the Insure Oklahoma program. The demonstration provides additional services such as the Health Management Program, Health Access Networks and Workforce Development for Teaching Universities. The extension application requires approval from our federal partners, CMS, to continue services provided under the waiver. 

    The State will apply no later than August 1, 2017 to extend the demonstration with one amendment to existing language.  The amendment will provide payment methodology and metrics for supplemental payments to the state of Oklahoma teaching Universities.

    Supplemental Payment Methodology

    The OHCA proposes to make supplemental payments to state teaching universities to grow and improve the healthcare workforce in the state of Oklahoma.  State universities can receive payments for programs that reach defined metrics such as primary care residents in training, percentage of graduating class entering primary care, retention rate for medical students within 5 years after completion of residency/fellowship training and percentage of nurses completing clinical rotation training in Medicaid contracted hospitals.  This list of  public meetings will be held at the following locations:

    May 18, 2016 at 1:00p.m. 
    Medical Advisory Committee Meeting
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK.
    Videoconferencing is also available for this meeting. 

    May 24, 2016 at 3:00p.m.
    Child Health Workgroup
    Cleveland County Health Department
    50 12th Ave N.E. Norman, Oklahoma City, OK. 

    Please view the full 2018 SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver Extension Request here: SoonerCare/Insure Oklahoma 1115 Waiver Extension.    

    The OHCA welcomes comments from the public regarding the extension SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver programs. The application will be posted from May 18, 2017 through June 30, 2017.

    Comments can be submitted via the comment box below or by contacting Sherris Harris-Ososanya, OHCA Federal & State Reporting Coordinator, by telephone at 405-522-7507.

    Please view the additional attachments for the 2018 SoonerCare Choice and Insure Oklahoma 1115 (a) Demonstration Waiver Extension Request below:

    1. SoonerCare Budget Neutrality SCBN 2016-2018 Extension UPDATED May 2017 
    2. SoonerCare Budget Neutrality SCBN 2016-2018 Extension UPDATED May 2017 
    3. SoonerCare Evaluation Design 2015-2016 
    4. 2016 Child (CHIP) Medicaid Executive Summary - Oklahoma Health Care Authority 
    5. 2016 Adult Medicaid Executive Summary - Oklahoma Health Care Authority 
    6. SoonerCare HMP SFY2015 Evaluation Jul16 
    7. 1115 Demonstration Waiver Banner 
    8. OU SoonerHAN Annual Report FY2016 
    9. OU SoonerHAN Annual Report CY 2016 Jul-Dec 2016 
    10. PHCC Annual Report FY16
    11. PHCC Annual Report AR 16 Jul-Dec 
    12. OSU HAN Annual Report Fiscal Year 2016 
    13. OSU HAN Annual Report July 2015-December 2016 
    14. Oklahoma 1115 Budget Neutrality Model Worksheet, December 2016 
    15. The Children's Health Group Quarterly Meeting April 2017 
    16. SoonerCare Choice Insure Oklahoma Post Award Forum PowerPoint April 2017 
    17. Post Award Forum Newspaper Publication Notice April 2017 
    18. Accessibility Report 
    19. Child Health Workgroup 
    20. Newspaper Publication Notice May 2017

    2017-2018 SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver Update 

    The Oklahoma Health Care Authority Reporting unit is seeking comments from the public regarding the current SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver on an update to the demonstration for an extension through 2017-2018. 

    Please view the full original SoonerCare Renewal application here: SoonerCare Renewal Application. Please submit all comments by close of business, June 3, 2016, via the comment box below. The OHCA will respond in writing to any feedback received during the comment period. Thank you for your participation in the process. 

    Also, an overview of the feedback received will be discussed in the public meetings mentioned below. Input from meeting participants will also be summarized and submitted to the Centers for Medicare and Medicaid Services.

    April 19, 2016 5:00p.m.
    OPQIC Oklahoma Perinatal Quality Improvement Collaborative Meeting, 
    Stephenson Cancer Center
    Fifth Floor Conference Room
    Oklahoma City, OK 73104. 

     Videoconferencing is also available for this meeting:  

    •  OU College of Medicine, Tulsa;  
    •  Northwestern Oklahoma State University, Enid;  
    •  Eastern Oklahoma State University, Wilburton and  
    •  Stillwater Medical Center.  

    May 19, 2016 at 1:00p.m. 
    Medical Advisory Committee Meeting
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK. 

     


     

     

2017-2018 SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver Update  

The Oklahoma Health Care Authority Waiver Development and Reporting unit is seeking comments from the public regarding the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver update to the extension of the Demonstration, 2017-2018. The application requests approval of the waiver in its present form, with the addition of language to specify Medical Residents must be licensed in the State in which they practice.  

Please view the full 2017-2018 SoonerCare Renewal Application here: SoonerCare Renewal Application. Please note, that to view the document attachments please select the paperclip in the renewal document.

The comment period is open from August 26, 2016 until September 26, 2016. Please submit all comments by close of business, September 26, 2016, via the comment box below. The OHCA will respond in writing to any feedback received during the comment period.

The public meetings have been conducted for this waver at the locations mentioned below. Input from meeting participants was summarized and included in proposed extension submission to the Centers for Medicare and Medicaid Services.

1.            April 19, 2016 5:00p.m.OPQIC Oklahoma Perinatal Quality Improvement Collaborative Meeting

2.            May 19, 2016 at 1:00p.m. Medical Advisory Committee Meeting

    1115 Waiver Demonstration Feedback

    The Oklahoma Health Care Authority Waiver Development and Reporting unit is seeking comments from the public regarding the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver Application for Extension of the Demonstration, 2016-2018. The comment period is open from now until Dec. 5, 2014. OHCA will respond in writing to any feedback received during the comment period.

    Also, an overview of the feedback will be discussed in the public meetings mentioned below as received. Input from meeting participants will also be summarized and included in the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver Application for Extension of the Demonstration, 2016-2018 to the Centers for Medicare and Medicaid Services.

    Click here to offer feedback.

    Click here to view the application for extension of SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver.

    The public will have the opportunity to provide meaningful comment on the SoonerCare demonstration waiver September 9 through December 5, 2014.

    1. September 16 at 5:30 p.m.
        OHIP Children's Health Workgroup Meeting
        OU Health Sciences Center Campus,
        OU College of Medicine
        Provost Conference Room (Room 223)
        Bird Library
        Oklahoma City, OK

        Video conferencing is also available for this meeting:
        -OU College of Medicine, Tulsa;
        -Northwestern Oklahoma State University, Enid; and
        -Eastern Oklahoma State University, Wilburton.


    2. November 20 at 1 p.m. 
        Medical Advisory Committee Meeting
        Charles Ed McFall Boardroom
        Oklahoma Health Care Authority
        4345 N Lincoln Blvd.
        Oklahoma City, OK


     

    SC Waiver 12-01

    Modification to the Health Management Program within SoonerCare Choice 

    Circulated Date: 09/05/2012 

    OHCA Comment Due Date: 10/15/2012  


    Amendment Request

    1115(a) SoonerCare Research and Demonstration Waiver   

    05/06/2014 Tribal Agenda

    Circulated Date: 04/25/2014 

    OHCA Comment Due Date: 05/25/2014  

    Proposed Submittal Date: 05/09/2014 


    Insure Oklahoma Sponsor's Choice Option

    The 1115 demonstration waiver and corresponding agency rules will be amended to reflect a third Insure Oklahoma option. The Insure Oklahoma Choice program will establish coverage for sponsoring organizations, eligible populations including dependent spouses and children, qualifying benefit plans, cost sharing and expenditure authorities. The evaluation design will be modified to incorporate the Insure Oklahoma Choice program as well.

    Circulation Date: 06/12/2015 

    OHCA Comment Due Date: 07/17/2015

    Proposed Submittal Date: 07/31/2015


     
     
     

     Home and Community-Based Services (HBCS) Waivers’ Amendments 


     

    In-Home Supports Waiver for Adults Amendment

    The Oklahoma Department of Human Services is seeking to amend the In-Home Supports Waiver for Adults (IHSW-A). The IHSW-A serves individuals with Intellectual Disabilities age 18 and over. The Oklahoma Legislature mandated a four percent rate increase on fixed and uniform provider rates.  As a result, an update of the estimated cost of the waiver for years 3-5 has been made as well as an increase in the individual member cost limit.  Currently, the cost limit amount is $22,235.00 per member, per plan of care year.  This amount will be increased to $23,131.00.  Other updates include further explanation related to the exclusion of room and board cost, clarification of provider rate methodology, the addition of Electronic Visit Verification procedure, clarification related to member safeguard procedure, removal of the contracted agency staff oversight requirement from individual Homemaker providers (they are supervised by DDS Foster Care Specialists), billing system vendor change from HP Enterprises to DXC Technology, vocational services definition and limits update and confirmation that Oklahoma’s Statewide Transition Plan was granted final approval.

    The waiver amendment is available for review here. The amendment will be effective upon approval by the Centers for Medicare and Medicaid Services (CMS) or October 1, 2019, whichever is earliest. Please submit all comments by close of business, August 1, 2019. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     

    In-Home Supports Waiver for Children Amendment

    The Oklahoma Department of Human Services is seeking to amend the In-Home Supports Waiver for Children (IHSW-C). The IHSW-C serves individuals with Intellectual Disabilities age 3 through 17. The Oklahoma Legislature mandated a four percent rate increase on fixed and uniform provider rates.  As a result, an update of the estimated cost of the waiver for years 3-5 has been made as well as an increase in the individual member cost limit.  Currently, the cost limit amount is $14,825.00 per member, per plan of care year.  This amount will be increased to $15,426.00.  Other amendments include, an update of cost neutrality information, clarification of provider rate methodology, the addition of Electronic Visit Verification procedure, clarification related to member safeguard procedure, billing system vendor change from HP Enterprises to DXC Technology, vocational services definition and limits update and confirmation that Oklahoma’s Statewide Transition Plan was granted final approval.

    The waiver amendment is available for review here. The amendment will be effective upon approval by the Centers for Medicare and Medicaid Services (CMS) or October 1, 2019, whichever is earliest. Please submit all comments by close of business, August 1, 2019. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     


     

     

    Community Waiver Amendment

    The Oklahoma Department of Human Services is seeking to amend the Community Waiver.  The Community Waiver serves individuals with Intellectual Disabilities beginning at age three. The Oklahoma Legislature mandated a four percent rate increase on fixed and uniform provider rates.  As a result, an update of the estimated cost of the waiver for years 4-5 has been made as well as an update of the number of unduplicated participants served through the waiver for year 5.  Other amendments include, an update of cost neutrality information, clarification of provider rate methodology, clarification related to a waiver member’s medication management, critical incidents and safeguard procedure, the addition of Electronic Visit Verification procedure language, billing system vendor change from HP Enterprises to DXC Technology, vocational services definition and limits update, confirmation that Oklahoma’s Statewide Transition Plan was granted final approval, level of care evaluation approval procedure change, Specialized Medical Supplies and Assistive Technology service definition and provider qualifications update, language clean-up to ensure reference to “mental retardation” has been changed to “intellectual disabilities”, removal of the contracted agency staff oversight requirement from individual Homemaker providers (they are supervised by DDS Foster Care Specialists), confirmation that Extended Duty Nursing may be provided in a facility, Daily Living Supports and Intensive Personal Supports services may now be provided by a relative/legal guardian, Agency Companion provider qualification update and a change in the sampling approach described in the Quality Improvement Strategy for the Health and Welfare section of the waiver. 

    The waiver amendment is available for review here. The amendment will be effective upon approval by the Centers for Medicare and Medicaid Services (CMS) or October 1, 2019, whichever is earliest. Please submit all comments by close of business, August 1, 2019. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.


     

    Homeward Bound Waiver Amendment

    The Oklahoma Department of Human Services is seeking to amend the Homeward Bound Waiver.  The Homeward Bound Waiver serves individuals with Intellectual Disabilities who have been certified by the United States District Court for the Northern District of Oklahoma as a member of the Plaintiff Class in Homeward Bound et al., Case No. 85-C-437-e.  The Oklahoma Legislature mandated a four percent rate increase on fixed and uniform provider rates.  As a result, an update of the estimated cost of the waiver for years 4-5 has been made.  Other amendments include, an update of cost neutrality information, clarification of provider rate methodology, clarification related to a waiver member’s medication management, critical incidents and safeguard procedure, the addition of Electronic Visit Verification procedure language, billing system vendor change from HP Enterprises to DXC Technology, vocational services definition and limits update, confirmation that Oklahoma’s Statewide Transition Plan was granted final approval, level of care evaluation approval procedure change, Specialized Medical Supplies and Assistive Technology service definition and provider qualifications update, language clean-up to ensure reference to “mental retardation” has been changed to “intellectual disabilities”, removal of the contracted agency staff oversight requirement from individual Homemaker providers (they are supervised by DDS Foster Care Specialists), confirmation that Extended Duty Nursing may be provided in a facility, Daily Living Supports and Intensive Personal Supports services may now be provided by a relative/legal guardian and a change in Agency Companion provider qualifications.  

    The waiver amendment is available for review here. The amendment will be effective upon approval by the Centers for Medicare and Medicaid Services (CMS) or October 1, 2019, whichever is earliest. Please submit all comments by close of business, August 1, 2019. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     


     

     

    Medically Fragile Waiver Amendment

    Per CFR 441.304, a waiver amendment is required for substantive changes that include an increase in slot participation for unduplicated members, the Oklahoma Health Care Authority Medically Fragile Waiver is increasing slot participation in the waiver.  During Fiscal Year 19, the Medically Fragile waiver met the awarded number of slots.  Awarded slots cannot not be exceeded, therefore an amendment must be submitted.   

    The requested effective date of the slot increase will be July 1, 2019 upon Centers for Medicare and Medicaid Services (CMS) approval. Per the HCBS Technical Guide, “A retroactive effective date can be permitted for the purpose of increasing the unduplicated number of participants”. 

    The Medically Fragile Waiver serves adults 19 years of age and older who have been diagnosed with a medically fragile condition who require a Hospital/Skilled Nursing Facility level of care and whose needs could not otherwise be met through another Oklahoma Waiver.  All Medically Fragile Waiver members receive services in a home and community setting.

    The waiver amendment is available for review here.  Please submit all comments by close of business, August 2, 2019. Comments can be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: QA & Community Living Services: 1915(c) Waivers.

    To request a free hard copy of a waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105.   Attention: QA & Community Living Services: 1915(c) Waivers.

     

    Medically Fragile Waiver Amendment Rate Increase

    Pursuant to 42 C.F.R. § 441.301, the Oklahoma Health Care Authority (OHCA) is required to give public notice and receive public input on any significant proposed changes to the 1915(c) Home and Community-Based Services (HCBS) waivers.

    Revisions are needed to increase the current reimbursement rates for all SoonerCare-contracted provider types by five percent (5%), with the following exemptions: services financed through appropriations to other state agencies; Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); non-emergency transportation capitated payments; services provided to Insure Oklahoma (IO) members; payments for drug ingredients/physician supplied drugs; Indian Health Services/Tribal/Urban Clinics (I/T/Us); Federally Qualified Health Centers (FQHCs); and Rural Health Centers (RHCs).  The agency’s proposed revisions are in keeping with Sections 1 and 2 of the SB 1044, 57th Leg., 1st Sess. (Okla. 2019), except that reimbursement rates for PACE providers (Program for the All-inclusive Care for the Elderly) will also be increased by five percent (5%).  All rate increases must comply with state and federal law as well as state cost reimbursement methodologies. 

    The effective date of the 5% rate increase will be upon notification from the Centers for Medicare and Medicaid Services (CMS) or on 10/01/2019, whichever is first.

    The Medically Fragile Waiver serves adults 19 years of age and older who have been diagnosed with a medically fragile condition who require a Hospital/Skilled Nursing Facility level of care and whose needs could not otherwise be met through another Oklahoma Waiver.   All Medically Fragile Waiver members receive services in a home and community setting.

    The waiver amendment is available for review here.  Please submit all comments by close of business, August 3, 2019. Comments can be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105.

    Attention: QA& Community Living Services: 1915(c) Waivers.

    To request a free hard copy of a waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105.

    Attention: QA & Community Living Services: 1915(c) Waivers.

     


    ADvantage Waiver Amendment

    The Oklahoma Department of Human Services is seeking to amend the ADvantage Waiver.  ADvantage provides services and supports to assist older adults and adults with physical disabilities to live independently in their homes and communities. The Oklahoma Legislature has mandated a four percent rate increase on fixed and uniform provider rates.  As a result, an update of the estimated cost of the waiver for years 4-5 has been made.

    The waiver amendment is available for review here. The amendment will be effective upon approval by the Centers for Medicare and Medicaid Services (CMS) or October 1, 2019, whichever is earliest. Please submit all comments by close of business, August 3, 2019. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.


      Medically Fragile Waiver Amendment 

    Revisions are needed to increase the current reimbursement rates for the Medically Fragile Waiver services by three percent (3%) with the following exemptions: services financed through appropriations to other state agencies, Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS), non-emergency transportation capitated payments, services provided to Insure Oklahoma (IO) members, payments for drug ingredients/physicians supplied drugs, Indian Health Services/Tribal/Urban Clinics (I/T/U), Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs). All rate increases must comply with state and federal law as well as state cost reimbursement methodologies.

    The waiver amendment is available for review using the following link here. Please submit all comments by close of business, October 14, 2018.


     
     

     

     

    ADvantage Waiver Amendment

    Pursuant to House Bill 3708, the Oklahoma Department of Human Services is increasing certain provider rates for the ADvantage program.  These include a 7% rate increase for ADvantage direct care, case management and State Plan personal care effective upon CMS approval or October 1, 2018, whichever is earlier. The ADvantage waiver serves older adults and persons with disabilities who reside in a community setting.

    The waiver amendment is available for review here. Please submit all comments by close of business, June 29, 2018. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers

     


     

     

    In Home Supports Waiver for Adults Amendment

    The Oklahoma Department of Human Services is seeking an amendment to the In-Home Supports Waiver for Adults (IHSW-A). The IHSW-A serves individuals with intellectual disabilities age 18 and over. The specific changes being proposed include; an updated estimate of cost for waiver years 2-5, an updated number of unduplicated participants served through the waiver for years 2-5 as well as, an increase in the individual cost limit.  Currently, the cost limit is $20,761.00 per member, per plan of care year.  The cost limit being proposed will increase the amount to $22,235.00. The changes are effective upon CMS approval or October 1, 2018, whichever is earlier.

    The waiver amendment is available for review using the following link here. Please submit all comments by close of business, June 29, 2018. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     


     

     

     

    In-Home Supports Waiver for Children Amendment

    The Oklahoma Department of Human Services is seeking an amendment to the In-Home Supports Waiver for Children (IHSW-C). The IHSW-C serves individuals with intellectual disabilities ages 3 through 17. The specific changes being proposed include an updated estimate cost for waiver years 2-5, an updated number of unduplicated participants served through the waiver for years 2-5 as well as, an increase in the individual cost limit.  Currently, the cost limit is $13,844.00 per member, per plan of care year.  The cost limit being proposed will increase the amount to $14,825.00. The changes are effective upon CMS approval or October 1, 2018, whichever is earlier.

    The waiver amendment is available for review here. Please submit all comments by close of business, June 29, 2018. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     

     


     

     

     

    Community Waiver Amendment

    The Oklahoma Department of Human Services is seeking to amend the Community Waiver.  The Community Waiver serves individuals with Intellectual Disabilities beginning at age three. The specific changes include an update of the estimated cost of the waiver for years 3-5 as well as an update of the number of unduplicated participants served through the waiver for years 3-5.  The proposed changes are effective upon CMS approval or October 1, 2018, whichever is earlier.

    The waiver amendment is available for review here. Please submit all comments by close of business, June 29, 2018. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers

     


     

     

     

     

    Homeward Bound Waiver Amendment

    The Oklahoma Department of Human Services is seeking to amend the Homeward Bound Waiver.  The Homeward Bound Waiver serves individuals with Intellectual Disabilities who have been certified by the United States District Court for the Northern District of Oklahoma as a member of the Plaintiff Class in Homeward Bound et al., Case No. 85-C-437-e. The specific changes include an update of the estimated cost of the waiver for years 3-5 as well as an update of the number of unduplicated participants served through the waiver for years 3-5.  The proposed changes are effective upon CMS approval or October 1, 2018, whichever is earlier.

    The waiver amendment is available for review here. Please submit all comments by close of business, June 29, 2018. Comments may be submitted in writing to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  

    To request a free hard copy of the waiver, please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers

     

     


     

     

    Medically Fragile Waiver Renewal 

    The Oklahoma Health Care Authority is seeking a 5 year renewal of the Medically Fragile Waiver. The Medically Fragile program is a home and community-based alternative to placement in a hospital and/or skilled nursing unit of a nursing facility. The Medically Fragile waiver serves individuals 19 years of age and older who have a life-threatening condition, require frequent specialized treatment and have a dependency on medical technology. Specific changes to the renewal include, but are not limited to, (1) Modifying performance measures to adhere to CMS guidance from HCB setting regulations, (2) Adding language and performance measures to comply with Electronic Visit Verification regulations, (3) Adding language limiting conflict of interest for service plan development and monitoring with service delivery, and (4) Other changes include general clarification, alignment with state statute and cleanup.

    Please view the renewal application here: Medically Fragile Waiver Renewal. Please submit all comments by close of business, March 25, 2018, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, OK 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of waivers please call 1-888-287-2433 or send your request to the Oklahoma Health Care Authority, 4345 N Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

       

     

     
     
     
     ADvantage Waiver 

    The Department of Human Services lost $69 million in state funding for the State Fiscal Year 2018 as a result of the Oklahoma Supreme Court ruling the cigarette fee unconstitutional. In October, DHS was required to submit a revised budget to the Oklahoma Office of Management and Enterprise Services (OMES) to fulfill Oklahoma’s constitutional requirements for a balanced budget. The revised budget resulted in additional reductions to DHS services. The ADvantage waiver serves the frail and elderly adults with physical disabilities age 21 and over who do not have intellectual disabilities or cognitive impairment. DHS is terminating the ADvantage Waiver effective December 1, 2017.

    Please view the waiver amendment here: ADvantage Waiver. Please submit all comments by close of business, November 30, 2017, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of the waiver amendment please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention Health Policy 1915© Waivers.

     


     

     

     

    In-Home Supports Waiver for Adults

    In October, the Oklahoma Department of Human Services (DHS) was required to submit a revised budget to the Oklahoma Office of Management and Enterprise Services (OMES) to fulfill Oklahoma’s constitutional requirement to maintain a balanced budget for State Fiscal Year 2018 following the loss of $69 million from their operating budget. This is the amount of appropriations DHS would have received from the cigarette fee that was ruled unconstitutional by the Oklahoma Supreme Court. When the cigarette fee was struck down, additional reductions became necessary. As a result, DHS is terminating the In-Home Supports Waiver for Adults (IHSW-A) effective December 1, 2017. The IHSW-A serves individuals with intellectual disabilities age 18 and over. Upon termination of the waiver, current service recipient’s names will be added to the statewide waiver request list for Developmental Disability Service (DDS) waiver services with his or her original application date.

    Please view the waiver amendment here: In-Home Supports Waiver for Adults. Please submit all comments by close of business, November 30, 2017, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of the waiver amendment please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention Health Policy 1915© Waivers.


     
     

     

     In-Home Supports Waiver for Adults Amendment

    The Oklahoma Department of Human Services is seeking waiver amendment approval for the In-Home Supports Waiver for Adults (IHSW-A) to meet the balanced budget requirements as mandated by state law. The IHSW-A serves individuals with Intellectual Disabilities ages 18 and over. Due to Oklahoma’s budget crisis, costs saving actions are necessary. In an effort to minimize that impact on members served, and in lieu of an elimination of service, the individual cost limit for adults has been reduced.

    Please view the renewal application here: In-Home Supports Waiver for Adults. Please submit all comments by close of business, August 14, 2017, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915© Waivers.

    To request a hard copy of the waivers please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention Health Policy 1915© Waivers.


    In-Home Supports Waiver for Children Amendment

    The Oklahoma Department of Human Services is seeking waiver amendment approval for the In-Home Supports Waiver for Children (IHSW-C) to meet the budget requirements as mandated by State law. The IHSW-C serves individuals with Intellectual Disabilities ages 3 to 17. Due to Oklahoma’s budget crisis, costs saving actions are necessary. In an effort to minimize that impact on members served, and in lieu of an elimination of service, the individual cost limit for children has been reduced.

    Please view the renewal application here: In-Home Supports Waiver for Children. Please submit all comments by close of business, August 14, 2017, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of the waivers please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention Health Policy 1915(c) Waivers.
     

      

    In-Home Supports for Adults Waiver Renewal Application  

    The Oklahoma Department of Human Services is seeking a 5 year renewal of the In-Home Supports for Adults (IHSW-A) waiver. The IHSW-A serves individuals with Intellectual Disabilities age 18 and over. Specific changes include, but are not limited to, (1) Updating the rate determination methods section with details related to the fixed rate method associated with Prevocational and Supported Employment services; (2) Updating the Family Counseling service provider section; (3) Updating the Person Centered Planning and Service Delivery section; (4) Updating language regarding critical incidents and reporting, dental service providers, seclusion and restraints and supported employment services definition and limits; (5) Updating Specialized Medical Supplies and Assistive Technology language to remove waiver coverage of incontinence supplies as these supplies are now covered by SoonerCare; (6) Updated unduplicated number of participants and reserved capacity number; and (7) Deleted Physician Services from Appendices C and J. Other changes include general clarification and cleanup. 
      
    Please view the renewal application here: In-Home Supports for Adults Waiver Renewal Application. Please submit all comments by close of business, February 3, 2017, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.
     
    To request a hard copy of the waivers please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.  
     

     

    In-Home Supports for Adults Waiver Renewal Application – Extended Comment Period

    The Oklahoma Department of Human Services is seeking a 5 year renewal of the In-Home Supports for Adults (IHSW-A) waiver. The IHSW-A serves individuals with Intellectual Disabilities age 18 and over. Specific changes include, but are not limited to, (1) Updating the rate determination methods section with details related to the fixed rate method associated with Prevocational and Supported Employment services; (2) Updating the Family Counseling service provider section; (3) Updating the Person Centered Planning and Service Delivery section; (4) Updating language regarding critical incidents and reporting, dental service providers, seclusion and restraints and supported employment services definition and limits; (5) Updating Specialized Medical Supplies and Assistive Technology language to remove waiver coverage of incontinence supplies as these supplies are now covered by SoonerCare; (6) Updated unduplicated number of participants and reserved capacity number; and (7) Deleted Physician Services from Appendices C and J. Other changes include general clarification and cleanup.

    Please view the renewal application here: In-Home Supports for Adults Waiver Renewal Application. Please submit all comments by close of business, April 14, 2017, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of the waivers please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     

    In-Home Supports for Children Waiver Renewal Application

    The Oklahoma Department of Human Services is seeking a 5 year renewal of the In-Home Supports for Children (IHSW-C) waiver. The Oklahoma Department of Human Services is seeking a 5 year renewal of the In-Home Supports for Children (IHSW-C) waiver. The IHSW-C serves individuals with Intellectual Disabilities age 3 to 17. Specific changes include, but are not limited to, (1) Updating Person Centered Planning and Service Delivery section; (2) Unduplicated number of participants and reserved capacity numbers; (3) Updating cost data/estimates updated throughout Appendix J; (4) Updating Specialized Medical Supplies and Assistive Technology language to remove waiver coverage of incontinence supplies as these supplies are now covered by SoonerCare; and (5) Added Prevocational and Supported Employment services for members age 16 and above. Other changes include general clarification and cleanup.

    Please view the renewal application here: In-Home Supports for Children Waiver Renewal Application. Please submit all comments by close of business, February 3, 2017, via the comment box below.  Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of the waivers please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     


     

     

    In-Home Supports for Children Waiver Renewal Application – Extended Comment Period

    The Oklahoma Department of Human Services is seeking a 5 year renewal of the In-Home Supports for Children (IHSW-C) waiver. The Oklahoma Department of Human Services is seeking a 5 year renewal of the In-Home Supports for Children (IHSW-C) waiver. The IHSW-C serves individuals with Intellectual Disabilities age 3 to 17. Specific changes include, but are not limited to, (1) Updating Person Centered Planning and Service Delivery section; (2) Unduplicated number of participants and reserved capacity numbers; (3) Updating cost data/estimates updated throughout Appendix J; (4) Updating Specialized Medical Supplies and Assistive Technology language to remove waiver coverage of incontinence supplies as these supplies are now covered by SoonerCare; and (5) Added Prevocational and Supported Employment services for members age 16 and above. Other changes include general clarification and cleanup.

    Please view the renewal application here: In-Home Supports for Children Waiver Renewal Application. Please submit all comments by close of business, April 14, 2017, via the comment box below.  Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

    To request a hard copy of the waivers please call 1-888-287-2443 or send your request to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.

     

     


     

    Medically Fragile Waiver Amendment  

    The Medically Fragile waiver is amended to propose a reinstatement of the three percent provider rate reduction that was implemented April 1, 2016. The Oklahoma Health Care Authority is proposing to reinstate the above reduced rates to select programs and provider types that the agency has identified serve our most vulnerable populations and provide access to critical programs. Additionally, clean-up changes have been made to align the waiver with policy. The proposed effective date of the changes is December 1, 2016. 

    Please view the waiver amendment here: Medically Fragile Waiver Amendment. Please submit all comments by close of business, August 29, 2016, via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers. A non-electronic version of this amendment can be requested by writing to the address above or calling 1-888-287-2443.

 


    Community Waiver Renewal Application 

    The Oklahoma Department of Health and Human Services is seeking a 5 year renewal of the DDS Community waiver. The Community waiver serves individuals who are 3 years of age and older with a diagnosis of intellectual disability and certain persons with related conditions determined to meet the ICF/IID level of care.

    Please view the renewal application here: Community Waiver Renewal Application. Please submit all comments by close of business, March 31, 2016, via the comment box below.  


    Homeward Bound Waiver Renewal Application  

    The Oklahoma Department of Health and Human Services is seeking a 5 year renewal of the Homeward Bound waiver. The Homeward Bound waiver serves individuals who are 18 years of age and older with a diagnosis of intellectual disability and certain persons with related conditions determined to meet the ICF/IID level of care. Persons in the Homeward Bound waiver are also certified as a member of the plaintiff class in the Homeward Bound vs. the Hissom Memorial Center lawsuit.

    Please view the renewal application here: Homeward Bound Waiver Renewal Application. Please submit all comments by close of business, March 31, 2016, via the comment box below.


     

    ADvantage Waiver Renewal Application  

    The Oklahoma Department of Human Services is seeking a 5 year renewal of the ADvantage waiver.  The ADvantage waiver serves the frail elderly and adults with physical disabilities age 21 and over who do not have intellectual disabilities or cognitive impairment. Specific changes include, but are not limited to, (1) Removal of Speech and Language services-this service has not been utilized therefore, they are asking the services be removed; (2) Removal of waiver to limit CD PASS-this service has not been provided statewide in the past and required a “waiver of statewideness” however, they have expanded CD PASS statewide and ask that the restriction be removed; (3) Other changes include general clarification and clean-up.

    Please view the renewal application here: ADvantage Waiver Renewal Application. Please submit all comments by close of business, March 31, 2016, via the comment box below. 


    1915(c) HCBS Waiver Amendment 

    The 1915(c) HCBS Waiver is amended to implement proposed rate cuts due to current and forecasted state budget concerns.

    Circulation Date: 12/01/2015 

    OHCA Comment Due Date: 12/30/2015

    Proposed Submittal Date: 01/01/2016


    Statewide Transition Plan : Statewide Transition Plan outlines the process that OHCA will utilize to ensure compliance with all of the Home and Community-Based Services requirements.      

    Circulated Date: 12/16/2015  

    OHCA Comment Due Date: 01/16/2016 


    Oklahoma Transition Plan for Home and Community-Based Services (HCBS) Setting  

    The purpose of this Transition Plan is to ensure the individuals receiving Home and Community-Based Services (HCBS) are integrated in and have access to supports in the community, including opportunities to seek employment, work in competitive integrated settings, engage in community life, and control personal resources.  The State has prepared a revised transition plan in order to comply with federal regulations for community-based settings. Overall, the Transition Plan provides assurance that the individuals receiving HCBS have the same degree of access as individuals not receiving Medicaid HCBS. This updated Transition Plan outlines the proposed process that Oklahoma will be utilizing to ensure implementation of the new HCBS requirements.

    The Proposed Transition Plans will be posted on the OHCA website on December 16, 2015. The comment period will be open for no less than 30 days. 

    Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers.


     

    Amended Statewide Transition Plan   

    Pursuant to 42 C.F.R. § 441.301, the Oklahoma Health Care Authority (OHCA) is required to give public notice and receive public input on any significant proposed changes to the 1915(c) Home and Community-Based Services (HCBS) waivers. 

    In effort to comply with the requirements of 42 C.F.R. § 441.301 the Oklahoma Health Care Authority will host a public meeting at 9:00 a.m. on December 7, 2015, at OHCA in the OHCA board room. The OHCA office is located at 4345 N. Lincoln Blvd, Oklahoma City, Oklahoma 73105. 


    ADvantage and State Plan Personal Care Providers

    Reimbursement for services will be changed to the following rates:  CD-PASS Personal Service Assistant, $3.20; Advanced Personal Service Assistant, $3.84; and Optional Expense, $.97; Case Management-Standard, $13.75; Case Management Very Rural, $19.69; Transitional Case Management – Very Rural, $19.69; Transitional Case Management – Standard, $13.75. Also, Personal Care, $3.78; Advanced Supportive Restorative, $4.07; In-home Respite, $3.78; Extended Respite per day, $160.07; Assisted Living – Standard, $44.01; Assisted Living – Intermediate, $59.40; and Assisted Living – High, $83.09. 

    Circulated Date: 07/15/2015 

    OHCA Comment Due Date: 08/11/2015


    Community Waiver Amendment

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    Homeward Bound Waiver Amendment

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    In-Home Supports for Adults Waiver Amendment 

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    In-Home Supports for Children Waiver Amendment

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    Medically Fragile Waiver Amendment

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    My Life; My Choice Waiver Amendment

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    Sooner Seniors Waiver Amendments 

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    Sooner Seniors Waiver Amendments 

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    ADvantage Waiver Amendment

    Circulation Date: 07/03/2014  

    OHCA Comment Due Date: 08/03/2014


    Community Waiver Amendment

    Circulation Date: 02/07/2014  

    OHCA Comment Due Date: 03/06/2014


    Homeward Bound Waiver Amendment

    Circulation Date: 02/07/2014  

    OHCA Comment Due Date: 03/06/2014


    In-Home Supports for Adults Waiver Amendment

    Circulation Date: 02/07/2014  

    OHCA Comment Due Date: 03/06/2014


    In-Home Supports for Children Waiver Amendment

    Circulation Date: 02/07/2014  

    OHCA Comment Due Date: 03/06/2014


    Medically Fragile Waiver Amendment

    Circulation Date: 02/05/2014  

    OHCA Comment Due Date: 03/05/2014


     

    My Life; My Choice Renewal

    Circulation Date: 07/08/2013 

    OHCA Comment Due Date: 08/08/2013


     

    My Life; My Choice Waiver Amendment

    Circulation Date: 06/18/2013 

    OHCA Comment Due Date: 06/28/2013


     

    In-Home Support Waiver for Adults Renewal

    Circulation Date: 02/17/2012 

    OHCA Comment Due Date: 03/19/2012


    In-HomeSupport Waiver for Children Renewal

    Circulation Date: 02/17/2012 

    OHCA Comment Due Date: 03/19/2012


     

     


    Across-the-Board Rate Reductions


     

    Proposed Amendments to the State Plan, 1115 SoonerCare Choice demonstration waiver, Medically Fragile 1915(c) waiver, Living Choice Demonstration and Program of All-Inclusive Care for the Elderly (PACE) Capitation contract rates

    In recognition of worsening state budget conditions in late 2015, OHCA proposed a three percent provider rate reduction to be effective January 1, 2016. The OHCA hosted two public forums on this decision, which was set to impact inpatient freestanding rehabilitation hospitals and hospitals utilizing DRG payment methodologies, outpatient hospital providers, clinical laboratories, physician & physician assistants, home health providers, freestanding ambulatory surgery centers/clinics, dentists, emergency transportation, DMEPOS, renal dialysis facilities, anesthesiologists, certified registered nurse anesthetists & anesthesiologist assistants, vaccine administration, and hospice providers. Public Notice was also published in five state newspapers prior to the hearings and implementation of the rate change, in accordance with federal regulations. A State Plan Amendment Rate Committee hearing which afforded public comment was hosted December 9, 2015, and the OHCA Board voted to approve the new rates as recommended by the State Plan Amendment Rate Committee.  The OHCA then implemented the January 1, 2016, rate reduction in the amount of 3.00 percent to providers reimbursed on the Medicaid physician fee schedule and other payment methodologies.  This prior rate change encompassed inpatient freestanding rehabilitation hospitals and hospitals utilizing DRG payment methodologies, outpatient hospital providers, clinical laboratories, physician & physician assistants, home health providers, freestanding ambulatory surgery centers/clinics, dentists, emergency transportation, DMEPOS, renal dialysis facilities, anesthesiologists, certified registered nurse anesthetists & anesthesiologist assistants, eye glasses, vaccine administration, and hospice providers. The budget reductions at that time did not include federally qualified health centers (FQHCs), rural health centers (RHCs), complex rehabilitation technology provider services, non-emergency transportation, payments for drug ingredients/physician supplied drugs, child abuse exams Insure Oklahoma, health access networks, or services that are reimbursed with all federal dollars.  OHCA did not take action to reduce services for which other state agencies are appropriated the state dollars to operate specific SoonerCare programs.

    Due to further anticipated decreases in state appropriated funding, OHCA will implement an across-the-board provider rate reduction of up to and including 25.00 percent effective for services on or after June 1, 2016. The across-the-board provider rate reductions will impact inpatient freestanding rehabilitation hospitals and hospitals utilizing DRG payment methodologies, outpatient hospital providers, clinical laboratories, physician & physician assistants, home health providers, freestanding ambulatory surgery centers/clinics, dentists, emergency transportation, DMEPOS, renal dialysis facilities, anesthesiologists, certified registered nurse anesthetists & anesthesiologist assistants, eye glasses, vaccine administration, nursing facilities, ICFs/IID, and hospice providers. SoonerCare Choice care coordination, and SoonerExcell incentive payments, along with Program of All-Inclusive Care for the Elderly (PACE) capitation rates, the Medically Fragile waiver, and the Living Choice demonstration will also be impacted by the up to and including 25.00 percent across-the-board provider rate reduction.

    The budget reductions will not include federally qualified health centers (FQHCs), rural health centers (RHCs), complex rehabilitation technology provider services, non-emergency transportation, payments for drug ingredients/physician supplied drugs, child abuse exams, Insure Oklahoma, health access networks, or services that are reimbursed with all federal dollars.  OHCA is not taking action to reduce services for which other state agencies are appropriated the state dollars to operate specific SoonerCare programs. 

    Please submit all comments by close of business May 1, 2016, via the comment box below. Thank you for your participation in the process.

    The following meetings about the proposed changes are open to the public:

    State Plan Amendment Rate Committee (SPARC) Meeting
    May 10, 2016 at 10:00a.m. 
    Ed McFall Boardroom 
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105

    Board Meeting
    May 12, 2016 at 1:00p.m.
    Ed McFall Boardroom
    Oklahoma Health Care Authority 
    4345 N. Lincoln Blvd, Oklahoma City, OK 73105


    Proposed Amendments to the State Plan, Medically Fragile Waiver, Living Choice Demonstration, and Program of All-Inclusive Care for the Elderly (PACE) Capitation Contract Rates 

    On January 1, 2016, the Oklahoma Health Care Authority (OHCA) implemented a three percent across-the-board provider rate reduction which affected SoonerCare Choice care coordination and provider incentive payments, Program of All-Inclusive Care for the Elderly (PACE) capitation rates, the Medically Fragile waiver and the Living Choice demonstration. The January 1, 2016 budget cuts excluded services financed through appropriations to other state agencies, complex rehabilitation technology provider services, long term care facilities, child abuse exams, non-emergency transportation, Insure Oklahoma, payments for drug ingredients/ physician supplied drugs, services paid for by other state agencies, excluding school based services and services provided to Native Americans through Indian Health Services Indian/Tribal/Urban Clinics.  The January 1, 2016 provider rate reductions were implemented to accommodate a State revenue failure which caused a decrease in appropriated funding and to submit a balanced budget.

    The OHCA proposes a reinstatement of the three percent provider rate reduction that was implemented on January 1, 2016 for the following services and/or programs: emergency transportation, Private Duty Nursing (PDN), the Medically Fragile waiver, the Living Choice demonstration, and Program of all-Inclusive Care for the Elderly (PACE).  OHCA is proposing to reinstate the above reduced rates to select programs and provider types that the agency has identified serve our most vulnerable populations and provide access to critical programs.  While the agency is unable to reinstate all programs and provider types at this time, adequate and sufficient provider rates continues to be a priority of our agency. 

    Please submit all comments by close of business, August 5, 2016, via the comment box below. Thank you for your participation in the process.


     

    Proposed Amendments to the State Plan, 1115 SoonerCare Choice demonstration waiver, Medically Fragile 1915(c) waiver, Living Choice demonstration and Program of All-Inclusive Care for the Elderly (PACE) Capitation Contract Rates —  

    In order to minimize the impact of current and forecasted state budget concerns, OHCA will implement administrative and three percent provider rate cuts.  These include across the board reductions to provider reimbursement; SoonerCare Choice care coordination and provider incentive payments; Program of All-Inclusive Care for the Elderly (PACE) capitation rates, the Medically Fragile waiver and the Living Choice demonstration. The budget cuts will not include federally qualified health centers (FQHCs); rural health centers (RHCs), complex rehabilitation technology provider services, Insure Oklahoma, health access networks or services that are reimbursed with all federal dollars. Some SoonerCare services are funded by other state agencies. OHCA is not taking action to reduce services for which other state agencies are appropriated the state dollars to operate specified SoonerCare programs. Budget reduction changes will take effect January 1, 2016, or later.

    Please visit the agenda here: SPARC 12-09-2015 Agenda.

    Circulated Date: 12/01/2015  

    OHCA Comment Due Date: 12/31/2015  

    Board Meeting Date: 12/10/2015

     


                                                                                        2017 Provider Letters

     

 

Provider Letter OHCA 2017-01 Perinatal Dental Coverage for Insure Oklahoma  

Effective February 1, 2017, the Insure Oklahoma Individual Plan will terminate coverage of perinatal dental care for pregnant women. The SoonerCare program eliminated coverage of perinatal dental care for pregnant women on July 16, 2014, due to budget reduction actions.

To mirror the SoonerCare program, Insure Oklahoma policy regarding perinatal dental coverage for pregnant women will be modified to remove the obsolete reference and discontinued service.

Please view the Provider Letter in its entirety here: Provider Letter 2017-01.

Submit all comments by close of business, February 6, 2017, via the comment box below.

 

 

Provider Letter OHCA 2017-03 Emergency Ground Ambulance Coverage for Insure Oklahoma 

Emergency ground ambulance coverage for Insure Oklahoma Individual Plan members has been added effective September 1, 2016.

Due to the retroactive effective date, claims for these services may have been denied if they were submitted between September 1, 2016 and February 2, 2017. Please submit any previously denied or unfiled claims for reimbursement as soon as possible to ensure that timely filing requirements are met. 

Please view the Provider Letter in its entirety here: Provider Letter 2017-03.

Submit all comments by close of business, March 9th, 2017, via the comment box below.

 


 

 

Provider Letter OHCA 2017-04 Prior Authorization of Medications Used to Treat Skin Cancer

Effective April 10, 2017, the Oklahoma Health Care Authority (OHCA) will require a prior authorization (PA) for the following medications: Odomzo® (Sonidegib), Erivedge® (Vismodegib), Keytruda® (Pembrolizumab), Opdivo® (Nivolumab), Yervoy® (Ipilimumab), Tafinlar® (Dabrafenib), Zelboraf® (Vemurafenib), Cotellic® (Cobimetinib), Mekinist® (Trametinib), Imlygic® (Talimogene Laherparepvec).

If a SoonerCare member is currently on therapy with one of these medications, the medication will be “grandfathered.” Based on past claims, PA will be automatic for drugs obtained through the pharmacy claim system.

Please view the Provider Letter in its entirety here: Provider Letter 2017-04.

Submit all comments by close of business, April 10, 2017, via the comment box below.

 



 

Provider Letter OHCA 2017-07 Prior Authorization Required Process Change – Effective July 1, 2017

Effective July 1, 2017, the Oklahoma Health Care Authority (OHCA) will transition to a fully electronic prior authorization (PA) submission process. (This change was referenced previously in Provider Letter OHCA 2016-29.) PA requests must be initiated online through the SoonerCare Provider Portal using the “Medical” radio button. This new process includes the upload of clinical documentation.

PA status notifications will continue to be available through the SoonerCare Provider Portal. The PA notification process for members will also remain the same. 

Please note that these changes do not affect dental, pharmacy or behavioral health PAs.

OHCA will cover these PA changes during our 2017 Spring SoonerCare Provider Training, which begins April 13. To register for a location near you, please visit Provider Training.

Please view the Provider Letter in its entirety here: Provider Letter 2017-07.

Submit all comments by close of business, May 8, 2017, via the comment box below.


     

 

Provider Letter OHCA 2017-09 Important Changes to the Referral Process – Effective September 1, 2017

Beginning September 1, 2017, electronic referrals through the SoonerCare Provider Portal will no longer be available for medical home SoonerCare Choice providers.  This change will give providers flexibility to adopt a referral process that works better for their individual practices.

Claims submitted on or after September 1, 2017 will no longer require an electronic referral and providers may begin using alternative referral methods. As an option, an updated paper referral form (SC-10) will be made available.

Please remember this change only affects SoonerCare Choice PCPs who need to refer members for specialty care. This new referral process is not related to Prior Authorization (PA). PA requests originate from the member's treating physician.

Please view the Provider Letter in its entirety here: Provider Letter 2017-09.

Submit all comments by close of business, June 19, 2017, via the comment box below.

 

Provider Letter OHCA 2017-10 Prior Authorization of CPT 95951 and Medical Review required for CPT 95957 – Effective June 15, 2017  

Effective June 15, 2017, the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) of American Medical Association (AMA) Current Procedural Terminology (CPT) code 95951, “monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation, each 24 hours”. This requires identifying appropriate billing modifiers if applicable.

In addition, effective June 15, 2017, the OHCA will require medical record documentation to be attached to any claim for AMA CPT code 95957, “digital analysis of electroencephalogram (EEG)”. These claims will require medical review prior to reimbursement to determine medical necessity.

Please view the Provider Letter in its entirety here: Provider Letter 2017-10.

Submit all comments by close of business, June 19, 2017, via the comment box below.

 


 

 

Provider Letter OHCA 2017-12 Prior Authorization of Electroencephalographic (EEG) Monitoring CPT codes 95950, 95953, and 95956 – Effective August 1, 2017

Effective August 1, 2017, the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) of American Medical Association Current Procedural Terminology (CPT) codes 95950,95953, and 95956.

Due to the complexity of these special EEG tests, the OHCA expects the interpretation of these CPT codes to be performed by a neurologist or a pediatric neurologist. 

Please view the Provider Letter in its entirety here: Provider Letter 2017-12.

Submit all comments by close of business, August 21, 2017, via the comment box below.

 


 

 

 

Provider Letter OHCA 2017-23 Changes to the Mailing of Member Identification Cards – Effective November 1, 2017 

Effective November 1, 2017, the Oklahoma Health Care Authority (OHCA) will no longer be mailing plastic member ID cards. This is part of our continuing efforts to be fiscally responsible and reduce paper usage.

As an added convenience, providers now have the option to print ID cards from the SoonerCare Provider Portal. To print a member ID card from the Portal, simply select the Eligibility Tab; check the member’s eligibility and then select “Display Member ID Card.”  If the member does not currently have eligibility, the button will not be displayed.

Please view the Provider Letter in its entirety here: Provider Letter 2017-23.

Submit all comments by close of business, October 9, 2017, via the comment box below. 

 

 


 

 

Provider Letter OHCA 2017-24 Prior Authorization for Molecular Pathology CPT Codes

Effective September 1, 2017, the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) for the following molecular pathology Current Procedural Terminology (CPT) codes: 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81479, and 81599.

Please remember that when testing for more than one gene in a single test, the OHCA considers it appropriate to bill the single code reflective of the test being performed. Billing multiple codes when multiple genes are examined as part of a single test is not appropriate and will not be approved.

The OHCA requires the submission of all of the following documents for prior authorization review:

  • HCA-13A Prior Authorization Form Cover Sheet
  • HCA-12A Prior Authorization Form
  • Objective clinical records supporting the medical necessity of the request

Please view the Provider Letter in its entirety here: Provider Letter 2017-24.

Submit all comments by close of business, August 31, 2017, via the comment box below.

 


 Provider Letter OHCA 2017-28 Prior Authorization of Medications Used to Treat Lung Cancer 

 

Effective October 1, 2017, the Oklahoma Health Care Authority (OHCA) will require a prior authorization (PA) for the following medications: Xalkori® (Crizotinib), Zykadia® (Ceritinib), Alecensa® (Alectinib), Alunbrig™ (Brigatinib), Tarceva® (Erlotinib), Gilotrif® (Afatinib), Tagrisso™ (Osimertinib), Cyramza® (Ramucirumab), and Tecentriq® (Atezolizumab).

If a SoonerCare member is currently on therapy with one of these medications, the medication will be “grandfathered”. If the drug is obtained through the pharmacy claim system, it will be automatically prior authorized based on past claims.

Please view the Provider Letter in its entirety here: Provider Letter 2017-28.

Submit all comments by close of business, October 2, 2017, via the comment box below.

 


Provider Letter OHCA 2017-29 Pharmacy Revisions for Optional Non-Prescription Products and Compounded Prescriptions

Beginning October 1, 2017 or upon the Governor’s approval, whichever is later, two changes affecting pharmacies will occur. 

First, coverage of optional non-prescription products for adults will be limited to insulin, smoking cessation products, and family planning products. Non-prescription products such as antihistamines and lice treatments will continue to be available for children.

Second, there will be a change to the policy for compounded prescriptions. For adults, all compound claims costing $75 or more will require prior authorization based upon medical necessity.

Please view the Provider Letter in its entirety here: Provider Letter 2017-29.

Submit all comments by close of business, October 2, 2017, via the comment box below.

 


 

 

Provider Letter OHCA 2017-30 Prior Authorization for Cystic Fibrosis Current Procedural Terminology (CPT) Code – Effective October 1, 2017

Effective October 1, 2017, the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) for the following CPT code:

  •   81220 – CFTR (Cystic Fibrosis Transmembrane Conductance Regulator) (e.g., cystic fibrosis) gene analysis; common variants

The OHCA will not be approving requests for 81220 for cystic fibrosis screening in the general population. However, this code may be considered medically necessary as a diagnostic test following abnormal newborn screening or in children with clinical features suggestive of cystic fibrosis.

Please view the Provider Letter in its entirety here: Provider Letter 2017-30.

Submit all comments by close of business, October 16, 2017, via the comment box below. Thank you for your participation in this process.

 

 


 

 

Provider Letter OHCA 2017-31 Non-Billable Speech Therapy Services – Effective October 15, 2017

The Oklahoma Health Care Authority (OHCA) routinely reviews the American Medical Association Current Procedural Terminology (CPT) codes for utilization, medical necessity and standards of care. The Centers for Medicare and Medicaid Services (CMS) has determined the codes listed below are bundled into other provided services and are not separately billable. As a result, in accordance with this CMS directive, any prior authorization request for CPT 92605 or CPT 92618 will be denied.

Please view the Provider Letter in its entirety here: Provider Letter 2017-31.

Submit all comments by close of business, November 6, 2017, via the comment box below.

 


 

 

 

Provider Letter OHCA 2017-32 Ventricular Assist Device Implantation – Effective December 1, 2017

The Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) for all codes associated with Ventricular Assist Device (VAD) insertion.  Removal of the device will not require PA. PA guidelines for VADs are located on the Medical Authorization Unit (MAU) page of the OHCA website available at www.okhca.org. Please note: Retro PAs will be allowed 30 days from the date of service.

Please view the Provider Letter in its entirety here: Provider Letter 2017-32.

Submit all comments by close of business, November 20, 2017, via the comment box below.

 


 

 

Provider Letter OHCA 2017-33 OHCA Program Updates – Effective October 6, 2017 and November 1, 2017 

 

The Oklahoma Health Care Authority (OHCA) promulgated emergency rules that were approved by the OHCA Board on September 27, 2017. These rules include the three-day signature requirements and the adult dental emergency extractions. Both rules received gubernatorial approval on October 6, 2017. The three-day signature requirements rule change has an effective date of October 6, 2017. The adult dental emergency extractions has an effective date of November 1, 2017.

Please view the Provider Letter in its entirety here: Provider Letter 2017-33.

Submit all comments by close of business, December 6, 2017, via the comment box below.

 


Provider Letter OHCA 2017-34 Prior Authorization for Vimizim® (Elosulfase Alfa) and Fabrazyme® (Agalsidase Beta) – Effective December 15, 2017 

 

 

Effective December 15, 2017, the Oklahoma Health Care Authority (OHCA) will require a prior authorization (PA) for the coverage of Vimizim® (Elosulfase Alfa) and Fabrazyme® (Agalsidase Beta). The approval criteria can be found in the "Metabolic Disorders section" on the Prior Authorization page of OHCA website.

Please view the Provider Letter in its entirety here: Provider Letter 2017-34.

Submit all comments by close of business, December 6, 2017, via the comment box below.

 


 

 

Provider Letter OHCA 2017-35 InterQual® Prior Authorization Implementation, Knee & Hip Arthroplasty

The Oklahoma Health Care Authority (OHCA) is implementing InterQual® guidelines in our prior authorization (PA) request process. InterQual® evidence-based questions and answers will be embedded into the SoonerCare Provider Portal PA function. Over time, the OHCA anticipates the InterQual® implementation will help to automate the PA processing further, thereby shortening the average review time.

The OHCA will complete implementation in phases. Total knee and hip arthroplasty surgeries, American Medical Association Current Procedural Terminology codes 27447, 27130, and 27132, will be the first codes routed to InterQual®. All SoonerCare providers who request these codes will be part of this initial implementation phase.

Please view the Provider Letter in its entirety here: Provider Letter 2017-35.

Submit all comments by close of business, December 18, 2017, via the comment box below.

 


 

 

Provider Letter OHCA 2018-01 Prior Authorization of Medications Used to Treat Acute Lymphoblastic Leukemia and Chronic Myeloid Leukemia

Effective February 15, 2018, the Oklahoma Health Care Authority (OHCA) will require a prior authorization (PA) for the following medications: Blincyto® (Blinatumomab), Besponsa® (Inotuzumab Ozogamicin), Bosulif® (Bosutinib), Gleevec® (Imatinib), Iclusig® (Ponatinib), Synribo® (Omacetaxine), Sprycel® (Dasatinib), and Tasigna® (Nilotinib).

If a SoonerCare member is currently on therapy with one of these medications, the medication will be “grandfathered”. If the drug is obtained through the pharmacy claim system, it will be automatically prior authorized based on past claims.

Please view the Provider Letter in its entirety here: Provider Letter 2018-01.

Submit all comments by close of business, February 12, 2018, via the comment box below.

 


 

 

Provider Letter OHCA 2018-02 Billing Professional Fees

The OHCA expects all professional services provided by physicians and non-physician providers to be billed with the appropriate Common Procedural Terminology (CPT) and/or Healthcare Common Procedure Coding System (HCPCS) code on a Centers for Medicare & Medicaid Services (CMS) 1500 form.

Effective immediately, please ensure any professional services rendered are billed using the appropriate CMS-1500 form. Any claims submitted for professional services on an outpatient Uniform Billing – 04 claim form will be subject to recoupment.

Please view the Provider Letter in its entirety here: Provider Letter 2018-02.

Submit all comments by close of business, March 29, 2018, via the comment box below.

 


Provider Letter OHCA 2018-04 Prior Authorization for Microarray Current Procedural Terminology (CPT) Codes – Effective May 1, 2018

Effective May 1, 2018 the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) for the following molecular pathology Current Procedural Terminology (CPT) codes:

  • 81228 – Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis)
  • 81229 - Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities

Please view the Provider Letter in its entirety here: Provider Letter 2018-04.

Submit all comments by close of business, April 23, 2018, via the comment box below. Thank you for your participation in this process.

 


 

 

Provider Letter OHCA 2018-05 Provider Enrollment/Renewal Application Fees

Effective January 1, 2018, institutional providers will be responsible for application fees at the time of new and revalidation (renewal) enrollments.

Below is a link to the Federal Register requiring these fees:

https://www.federalregister.gov/documents/2017/12/04/2017-25972/medicare-medicaid-and-childrens-health-insurance-programs-provider-enrollment-application-fee-amount

Please view the Provider Letter in its entirety here: Provider Letter 2018-05.

Submit all comments by close of business, Monday, May 7, 2018, via the comment box below. Thank you for your participation in this process.

 


 

Provider Letter OHCA 2018-06 Increase in Dental Procedure Code – Effective January 1, 2018

Effective January 1, 2018, the Oklahoma Health Care Authority (OHCA) increased the reimbursement rate for Dental Procedure Code (CDT) D9999 from $274.95 to $914.71 for procedures performed in an outpatient hospital setting. This change will help to increase access to outpatient facilities by our contracted dental providers, thereby increasing availability of services to our members.

Please view the Provider Letter in its entirety here: Provider Letter 2018-06.

Submit all comments by close of business, May 23, 2018, via the comment box below. Thank you for your participation in this process.

 

 


 

Provider Letter OHCA 2018-07 Decrease Rate for APC Group 5164 – Effective January 1, 2018

Effective January 1, 2018, the Oklahoma Health Care Authority (OHCA) changed the reimbursement rate for the procedures in APC Group 5164 from $1,197.60 to $914.71. This change will help to address a large disparity found in reimbursement between codes that involve similar levels of service.

Please view the Provider Letter in its entirety here: Provider Letter 2018-07.

Submit all comments by close of business, May 23, 2018, via the comment box below. Thank you for your participation in this process.

 

 


 

Provider Letter OHCA 2018-08 Prenatal Vitamins

The Oklahoma Health Care Authority is engaged in an effort to improve the quality of prenatal care for our members.

The goal is to improve the utilization of prenatal vitamins in pregnant members receiving SoonerCare services.  Maternal nutrition, including adequate vitamin and mineral intake before and during pregnancy, can improve the chances of having a healthy pregnancy. Additionally, it can reduce the baby’s risk of developing health issues later in life, including diabetes, obesity, and heart disease. Prenatal vitamins also can assist mothers-to-be in meeting the required daily nutrient intake for a healthy pregnancy.

Please view the Provider Letter in its entirety here: Provider Letter 2018-08.

Submit all comments by close of business, Thursday, May 24, 2018, via the comment box below. Thank you for your participation in this process.

 

 


 

 

Provider Letter OHCA 2018-09 Prior Authorization for Otiprio® - Effective June 11, 2018

Effective June 11, 2018, the Oklahoma Health Care Authority will require a prior authorization (PA) for the coverage of Otiprio® (ciprofloxacin otic suspension, 6 mg).

To request a prior authorization for Otipiro® use form PHARM-18, which is located on the forms page of the SoonerCare website at www.okhca.org/forms.

Please view the Provider Letter in its entirety here: Provider Letter 2018-09.

Submit all comments by close of business, June 7, 2018, via the comment box below.

 


Provider Letter OHCA 2018-10 Prior Authorization of Medications Used to Treat Chronic Lymphocytic Leukemia – Effective July 12, 2018

 

Effective July 12, 2018, the Oklahoma Health Care Authority (OHCA) will require a prior authorization (PA) for the following medications:  Arzerra ® (Ofatumumab), Gazyva (Obinutuzumab), Imbruvica (Ibrutinib), Venclexta™ (Venetoclax), and Zydelig® (Idelalisib).

If a SoonerCare member is currently on therapy with one of these medications, the medication will be “grandfathered.” A “grandfathered” drug that is obtained through the pharmacy claim system will automatically be prior-authorized based on past claims.

Please view the Provider in its entirety here: Provider Letter 2018-10.

Submit all comments by close of business, July 6, 2018, via the comment box below.

 


Provider Letter OHCA 2018-12 Prior Authorization for Gene Expression Profiling CPT Code – Effective August 1, 2018

 

Effective August 1, 2018 the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) for the following Current Procedural Terminology (CPT) code:

  • 81519 – Oncology (breast), mRNA gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score

Please view the Provider Letter in its entirety here: Provider Letter 2018-12.

Submit all comments by close of business, July 26, 2018, via the comment box below. Thank you for your participation in this process.

 


 

Provider Letter OHCA 2018-13 Indian Health Service, Tribal and Urban Indian Clinics (I/T/U) Revenue Codes

The Oklahoma Health Care Authority (OHCA) has made one change to an existing revenue code (513) and added one revenue code (528), as these are required for billing the encounter rate by an I/T/U.

Please view the Provider Letter in its entirety here: Provider Letter 2018-13.

Submit all comments by close of business, August 23, 2018, via the comment box below. Thank you for your participation in this process.

 


Provider Letter OHCA 2018-23 Removal of Prior Authorization of Orbactiv®

Effective 9/1/2018, Orbactiv® (oritavancin) for injection will no longer require prior authorization.  

Claims for Orbactiv® will process without a prior authorization if 1,200mg (three 400mg vials) is not exceeded in a 30-day period. 

Please view the Provider Letter in its entirety here: Provider Letter 2018-23.

Submit all comments by close of business, October 1, 2018, via the comment box below. Thank you for your participation in this process.

 


 

Provider Letter OHCA 2018-24 Acute Inpatient Psychiatric Services Prior Authorization Requirements for Adults

Beginning September 17, 2018 the Oklahoma Health Care Authority will require prior authorization (PA) for adult acute inpatient psychiatric admissions. This procedure change will ensure compliance with utilization control policy for acute inpatient psychiatric services.

A PA will be required for admission to inpatient mental health and medical detoxification treatment services in a psychiatric or medical bed.  PAs will not be necessary for acute extensions or for any member whose primary insurance is Medicare.

Upon discharge, facilities are required to fax both the discharge date using the Discharge Notification Form and the member’s aftercare summary, which will allow the PA to be updated for claims processing.

Please view the Provider Letter in its entirety here: Provider Letter 2018-24.

Submit all comments by close of business, Friday, October 12, 2018, via the comment box below. Thank you for your participation in this process.

 


 

Provider Letter OHCA 2018-25 Billing professional fees for adults age 21-64 being served in a psychiatric hospital setting

It has come to the attention of the Oklahoma Health Care Authority (OHCA) that some providers are billing professional services for adults between the ages of 21-64 who are being served in a psychiatric hospital setting. 

Per Oklahoma Administrative Code 317:30-5-95.1, coverage for adults aged 21 to 64 is limited to services in a psychiatric unit of a general hospital (see OAC 317:30-5-95). Should a psychiatric hospital choose to admit a member in this age range, OHCA may not be billed by the psychiatric hospital, physician and/or clinic for any room and board charges or professional services associated with the inpatient stay.

Please view the provider letter in entirety here: Provider Letter 2018-25.

Submit all comments by close of business, November 5, 2018, via the comment box below. Thank you for your participation in this process.

 


Provider Letter OHCA 2019-01 Laboratory and Diagnostic Testing

 

The Oklahoma Health Care Authority (OHCA) has found that some providers are ordering and performing laboratory tests without a medical indication.

All providers should review their internal processes and procedures and ensure they are ordering and/or performing laboratory and other diagnostic testing that are medically indicated and appropriate pursuant to Oklahoma Administrative Code (OAC) 317:30-3-1(d).

Please view the Provider Letter in its entirety here: Provider Letter 2019-01.

Submit all comments by close of business, Monday, February 24, 2019, via the comment box below.

 


 

Provider Letter OHCA 2019-06 Change in Billing for Supprelin LA

Effective July 1, 2019, the Oklahoma Health Care Authority (OHCA) will change the way Supprelin® LA for central precocious puberty is billed

Supprelin® LA is only available through the medical benefit. The current billing code used is J9226. This code may change in the future based on guidance from the Centers for Medicare and Medicaid Services (CMS). It is the provider’s responsibility to assure codes used for billing are up to date and accurate.

Supprelin LA continues to require a prior authorization (PA). The specific PA requirements for Supprelin® LA are below and can be located on the OHCA website at www.okhca.org/pa in the “Diabetes/Endocrine” therapeutic category. Use the PA form PHARM-18, which can be found on the OHCA website at www.okhca.org/rxforms.

Please view the Provider Letter in its entirety here: Provider Letter 2019-06.

Submit all comments by close of business, Friday, June 28, 2019, via the comment box below.

 


 

 

Provider Letter OHCA 2019-07 Provider Contract Backdating – Effective August 1, 2019  

Effective August 1, 2019, the Oklahoma Health Care Authority (OHCA) will no longer backdate provider contracts prior to the date that the provider was screened.

Pursuant to federal law, the OHCA must require all participating providers to be screened in accordance with the requirements of Subpart E of Part 455 of Title 42 of the Code of Federal Regulations, titled “Provider Screening and Enrollment.” See also Oklahoma Administrative Code § 317:30-3-19.4.

Please view the Provider Letter in its entirety here: Provider Letter 2019-07.

Submit all comments by close of business, Thursday, August 15, 2019, via the comment box below.

 


 

Provider Letter 2019-08 Prior Authorization Changes for Medication Assisted Treatment – Effective July 31, 2019  

The Oklahoma Health Care Authority (OHCA), in an effort to combat the prescription drug abuse epidemic in Oklahoma, is improving access for SoonerCare members to medication assisted treatment (MAT). The OHCA is currently working to change prior authorization (PA) requirements for MAT. Effective July 31st, 2019, the OHCA will no longer require a PA on select products.

Please view the Provider Letter in its entirety here: Provider Letter 2019-08.

Submit all comments by close of business, Friday, August 23, 2019, via the comment box below.

 


 

Provider Letter OHCA 2019-16 Clarification of Laboratory Services Policy Changes

Recently, the Oklahoma Health Care Authority (OHCA) promulgated rules that updated Oklahoma Administrative Code (OAC) 317:30-5-20 Laboratory Services. The OHCA would like to clarify appropriate screening services and how such sources should meet medical criteria that is outlined in OAC 317:30-3-1(f).  

Please view the Provider Letter in its entirety here: Provider Letter 2019-16.

Submit all comments by close of business, Thursday, September 12, 2019, via the comment box below.

 


 

 

OHCA Provider Letter 2019-17 No Prior Authorization (PA) Requirement for Psychiatric or Medical Detoxification Services Received in a Non-Psychiatric Unit of a Hospital for Adults

The Oklahoma Health Care Authority (OHCA) reminds all SoonerCare providers that the PA requirement for adult acute inpatient psychiatric admissions (effective September 17, 2018) ONLY applies when psychiatric or medical detoxification services are provided in a psychiatric unit of a general hospital. However, there is no PA requirement for psychiatric or medical detoxification services provided to adults in a non-psychiatric unit setting of a general hospital. For example, if a member who was admitted to the ICU or other hospital medical bed after an attempted suicide by alcohol overdose, has withdrawal symptoms complications, receives medical care and a psychiatric consult, and does not transfer to a psychiatric unit, a PA request is NOT required.

Please view the Provider Letter in its entirety here: Provider Letter 2019-17.

Submit all comments by close of business, Wednesday, October 9, 2019, via the comment box below.

 


 

OHCA Provider Letter 2019-19 New Out-of-State Services Rules and Supportive Processes

The Oklahoma Health Care Authority (OHCA) recently added new policies and procedures for out-of-state services. Oklahoma Administrative Code (OAC) 317:30-3-89 through 317:30-3-92 defines out-of-state services, reimbursement for these services, and payment for lodging and meals.

A comprehensive process was undertaken in formulating these policies, including: extensive research of federal and state laws, other states' Medicaid policies, and coverage by private insurance carriers; detailed review of OHCA's historical and current policies and practices regarding out-of-state care; and robust engagement with Oklahoma providers, including those affiliated with Oklahoma's three medical schools, in order to assess and strengthen OHCA's network of in-state, specialized care.

Please view the Provider Letter in its entirety here: Provider Letter 2019-19.

Submit all comments by close of business, Thursday, October 10, 2019, via the comment box below.

 

 


2019 Access Monitoring Review Plan (AMRP)
 

Federal regulation at 42 CFR 447.203, documentation of access to care and services payments, directs State Medicaid programs to analyze and monitor access to care for Medicaid fee-for-service programs through the Access Monitoring Review Plan (AMRP). Through the AMRP, the State demonstrates access to care by measuring the following: enrollee needs; the availability of care and providers; utilization of services; characteristics of the enrolled members; and estimated levels of provider payment from other payers. The AMRP must be taken through consultation with the State's Medical Advisory Committee (MAC) and be published and made available to the public for a period of no less than 30 days prior to being submitted to the Centers for Medicare & Medicaid Services (CMS). The State submitted the initial access monitoring review plan on September 28, 2016 and must submit a revised plan every three years. The AMRP will note any access issues identified during the prior three years and if any issues were identified, the plan will include a corrective action plan. Further, the AMRP includes the State’s access to care analyses conducted for State Plan amendments that reduced and/or restructured payment rates that could diminish access to care which were promulgated and approved within the previous three years. 

Please view the draft SPA pages here:  2019 Access Monitoring Review Plan, and submit feedback via the comment box below. 

 

MAC Date:  09/05/2019   

Circulation Date:  08/27/2019 – 09/26/2019

Submittal to CMS Date:  09/30/2019


 

     Disclaimer: Oklahoma Health Care Authority (OHCA) policy comment section will be reviewed and considered under the current policy rule change. Personal information should not be shared/or submitted in the comment section. This comment section is reserved for proposed policy rule changes.