Archived Proposed Policy Changes


Sign up for OHCA Web Alerts


Sign up for Web Alerts to receive an e-mail when a new rule is proposed.

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  

  • Proposed Policy  
  • State Plan Amendments
  • SoonerCare Choice Waivers
  • Home and Community-Based Service Waivers
  • Provider Letters
  •  


    Proposed Policy


    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# 17-02 — 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 

    Theproposed 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# 17-04B — 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# 17-05A — 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# 17-05B — 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# 17-06 — 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# 17-07 — 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



    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# 17-13 — 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# 17-14 — 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# 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 # 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 # 17-13 — 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 # 17-16 — 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

     
     

     

    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 



    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 andInsure 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

    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 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.

 

 

 


 

 

 

  

 

    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.