Archived Proposed Policy Changes


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

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

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

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     Proposed Policy


     

    APA WF# 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: 06/29/2017

     


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# 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 Clean Up  

    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# 16-12Medical 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# 16-13Pharmacy 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# 16-13 - 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# 16-14Inpatient 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# 16-15AObstetrical 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

    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  

    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

    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

    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# 16-27Home 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 clean-up 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

     
     

     


     

    APA WF# 15-01 — Dental Coverage for Organ Transplant Clearance and Coverage for Emergency Oral Examinations 

    The proposed Dental policy revisions add coverage for medically necessary dental services for adult SoonerCare members needing dental clearance for organ transplant approval. The aforementioned changes were approved during promulgation of the emergency rule. The following are proposed changes not previously reviewed: The proposed Dental policy is revised to mirror new terminology from the Code on Dental Procedures and Nomenclature (CDT), to clean up outdated language, and allow dentist to perform emergency evaluations as medically necessary. Proposed revisions also clarify the separate note requirement must address the 5A's and that the signature is one office note signature provided at the end of the visit.

    Please view the circulation document here: APA WF# 15-01, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


     

    APA WF# 15-02 — Language Clean-Up Due to OHCA Determining Eligibility Instead of DHS and Update Transitional Medical Assistance (TMA) Policy to Match Federal Regulations  

    OHCA proposes rules to clean up language by referencing an OHCA income chart for determining eligibility instead of a DHS chart because OHCA now determines eligibility eligibility groups. OHCA also proposes rules to update policy regarding Transitional Medical Assistance (TMA) benefits due to MAGI rules for income eligibility. OHCA also proposes rule revisions to update policy regarding Family Planning Program because TPL information is stored on OHCA systems.

    Please view the circulation document here: APA WF# 15-02, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-03DRG Outlier Payments for Transferring Hospitals 

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

    The proposed policy revisions clarify reimbursement methodology for DRG hospitals.  DRG outlier payments to transferring hospitals, previously removed in emergency rules, is restored.

    Please view the circulation document here: APA WF# 15-03, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


     

    APA WF# 15-04 — Eliminate Adult Asleep Studies and Remove Coverage for Removal of Benign Skin Lesions for Adults 

    The proposed policy revisions remove coverage for removal of benign skin lesions for adults and eliminate adult sleep studies. 

    Please view the circulation document here: APA WF# 15-04, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


     

    APA WF# 15-06Coverage for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) 

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

    The proposed policy revisions regarding coverage for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) restrict coverage for continuous positive airway pressure devices (CPAP) to children only. These proposed revisions were promulgated during the Emergency rule session.

    Please view the circulation document here: APA WF# 15-06, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

     Board Meeting: 02/11/2016  


    APA WF# 15-07A — General Coverage by Category and Obstetrical Reimbursement 

    The proposed Obstetrical policy revisions decrease the number of ultrasounds and biophysical profiles/non-stress test for high risk pregnancy members.  The proposed revisions also amend rules to allow for a general OB to request the high risk obstetrical (HROB) services/package for pregnant women to ensure pregnant women with high risk conditions receive HROB services. The proposed General Coverage policy revisions revoke payment for removal of benign skin lesions for adults and eliminate coverage for adult sleep studies. The aforementioned changes were approved during promulgation of the emergency rule. The following are proposed changes not previously reviewed: Further proposed revisions to Obstetrical policy modify the billing and payment methodology for obstetrical care. Additional changes amend the General Coverage policy to clarify the separate note and signature requirement for providers performing tobacco use cessation counseling.  The revisions clarify that the separate note requirement must address the 5A's and the signature is one office note signature provided at the end of the visit. An additional change includes general clean-up of terms.

    Please view the circulation document here: APA WF# 15-07A, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-07B — Obstetrical Reimbursement 

    Proposed Obstetrical policy amends the reimbursement structure for OB services.

    Please view the circulation document here: APA WF# 15-07B, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-08 — Urine Drug Screening and Testing  

    The proposed Urine Drug Screening policy establishes rules for the appropriate administration of urine drug screening and testing. Current policy does not specify controls on this service other than general medical necessity. Additionally,   revisions are proposed to clean-up reimbursement language found in general laboratory services policy. The aforementioned changes were approved during promulgation of the emergency rule. The following are proposed changes not previously reviewed: The proposed Urine Drug Screening policy is also revised to add clarification to distinguish types of urine drug tests, and general clean-up for the administration of urine drug screenings. Lastly, proposed revisions include additional changes to reimbursement language for general laboratory services.

    Please view the circulation document here: APA WF# 15-08, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-09Timely Filing 

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

    The proposed rules are revised to decrease the time for submitting and resubmitting claims for payment. These proposed revisions were promulgated during the emergency rule making session.

    Please view the circulation document here: APA WF# 15-09, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-10Long-term Care Eligibility Rules are Revised to be Consistent with Federal Regulation 

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

    Proposed policy changes for long-term care eligibility are to be consistent with federal regulations in regards to home equity, home exemption criteria and the counting of annuities.

    Please view the circulation document here: APA WF# 15-10, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-13Joint Injections  

    Proposed physician policy changes will allow payment for a joint injection and office visit if the claim is billed appropriately and medical documentation supports separate payments.  

    Please view the circulation document here: APA WF# 15-13, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-14AConflict Free Case Management 

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

    Proposed policy at OAC 317:35-17-5 is revised to comply with 42 CFR 441.301 regarding conflict of interest provisions for case management services. These policy revisions are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan. The State is currently out of compliance. Without the recommended changes, the State may be in risk of losing federal funding.  

    Please view the circulation document here: APA WF# 15-14A, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-14BConflict Free Case Management 

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

    ADvantage Policy is revised to comply with 42 CFR 441.301 regarding conflict of interest provisions for case management services. These policy revisions are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan. The State is currently out of compliance. Without the recommended changes, the State may be in risk of losing federal funding.  

    Please view the circulation document here: APA WF# 15-14B, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-15Drug Benefit  

    Proposed pharmacy policy changes will reflect guidance in federal law regarding included and excluded prescription drug coverage and to update the list of covered over-the-counter drugs.

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

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-17 — Modify Reimbursement Structure for Eyeglasses 

    Proposed policy changes will modify the reimbursement structure for eyeglasses and clarify other requirements and provisions for SoonerCare coverage of eyeglasses frames and lenses.

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

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-18 — Complex Rehabilitation Technology  

    Proposed DME policy is amended to comply with Senate Bill 494.  The revisions establish focused regulations and policies for Complex Rehabilitation Technology products and services for people with complex physical disabilities.

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

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

     Medical Advisory Committee (MAC): 03/10/2016

     Board Meeting: 03/24/2016


    APA WF# 15-21 — Diagnostic Testing Facilities 

    The proposed Diagnostic Testing Facility policy is amended to define services that fall within the scope of authority for independent diagnostic testing facilities (IDTF). The proposed changes clarify reimbursement for rendered services and physician oversight.

    Please view the circulation document here: APA WF# 15-21, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-22Health Record Signature Requirements  

    The proposed rules are revised clarify when a medical record must be authenticated. Current rules only address signature requirements for edits of a medical record.

    Please view the circulation document here: APA WF# 15-22, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


     

    APA WF# 15-24 — Dental Oversight Requirements for Supervision of Anesthetists and General Clean-up of Terms 

    The proposed Dental policy is amended to mirror new terminology from the Code on Dental Procedures and Nomenclature (CDT), to clean up outdated language, and to add oversight requirements for the supervision of certified registered nurse anesthetists.

    Please view the circulation document here: APA WF# 15-24, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-27ASoonerCare Primary Care Providers  

    OHCA proposes policy changes that would clarify inconsistent and conflicting language authorizing medical residents as Primary Care Physicians (PCP) under SoonerCare. Language cleanup will reflect current OHCA practices.

    Please view the circulation document here: APA WF# 15-27A, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-27BSoonerCare Primary Care Providers  

    OHCA proposes policy changes that would clarify inconsistent and conflicting references to language authorizing medical residents as Primary Care Physicians (PCP) under SoonerCare. Cleanup of language would accurately reflect OHCA practices and requirements for payment under SoonerCare.

    Please view the circulation document here: APA WF# 15-27B, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-28 — I/T/U Language Update  

    Proposed Indian Health Services, Tribal Programs and Urban Indian Clinics (I/T/U) policy is revised for clarity and consistency with other sections of Chapter 30.

    Please view the circulation document here: APA WF# 15-28, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-29 Behavioral Health Case Management  

    Proposed Behavioral Health Case Management policy changes will transfer coverage guidelines and provider requirements for case management services to another Part of rules addressing guidelines for services provided by Outpatient Behavioral Health Agencies.

    Please view the circulation document here: APA WF# 15-29, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-30Biopsychosocial Requirements  

    Proposed outpatient Behavioral Health Agency policy changes will allow providers more flexibility in conducting biopsychosocial assessments by removing specific required elements. Further, the agency is also proposing rule revision to remove specific minimum time requirements for behavioral health assessment services. By removing the time requirements from rules, there will be more flexibility in allowing providers to bill in alternative ways that may be different based upon the type of assessment conducted.

    Please view the circulation document here: APA WF# 15-30, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


     APA WF# 15-32 Health Home   

    Department of Mental Health & Substance Abuse Services proposes language clean up to clarify inconsistencies between OHCA rules and Health Home Certification.

    Please view the circulation document here: APA WF# 15-32, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-36 — Diabetic Testing Supplies 

    Proposed supplies rules are revised to remove specific limits on the quantity of diabetic testing supplies.

    Please view the circulation document here: APA WF# 15-36, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-38 — Quality of Care Fund Reports 

    Proposed Quality of Care (QOC) policy revisions clean up existing language to reflect the modernization of OHCA business practices.

    Please view the circulation document here: APA WF# 15-38, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-40Hospital Leave Payments  

    Proposed policy change would clean up existing language to reflect the elimination of hospital leave payments implemented in 2014. Hospital leave payments are no longer made to long term care facilities. Payments will continue for therapeutic leave.

    Please view the circulation document here: APA WF# 15-40, and submit feedback via the comment box below.

    Circulation Date: 12/16/2015

    Comment Due Date: 01/15/2016

    Public Hearing: 01/19/2016

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

    Board Meeting: 02/11/2016


    APA WF# 15-41 — Third Party Liability 

    Proposed revisions to policy clarify the payer of last resort provisions when third party liability claims are involved.

    Please view the circulation document here: APA WF# 15-41, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-42 — Audit Procedures  

    Proposed program integrity audit and review policy is revised to clarify OHCA audit procedures and address issues such as extrapolation, reconsideration and audits.

    Please view the circulation document here: APA WF# 15-42, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-43 — Appeal Procedures  

    Proposed policy revisions clarify and make corrections to instructions for the submission of claim inquiries by providers, and language cleanup.

    Please view the circulation document here: APA WF# 15-43, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-48 — Service Quality Review/ TPS Employment Relationship with TFC  

    Proposed policy replace Inspection of Care language with the more appropriate Service Quality Review language to mirror practice and other policy changes. In addition, minor cleanup changes were made and the term outpatient was removed where referenced regarding behavioral health services to minimize confusion for Therapeutic Foster Care providers. In addition, rules are also revised to broaden the definition of employment to align with Therapeutic Foster Care (TFC) agencies' employment practices with Treatment Parent Specialist (TPS).

    Please view the circulation document here: APA WF# 15-48, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-50 — Home-Real Property in a Revocable Trust 

    Proposed policy revisions clarify home property revocable trust exemptions.

    Please view the circulation document here: APA WF# 15-50, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-52 — Amend Appeal Process to Clarify and Limit the Scope of the ALJ's Jurisdiction 

    Proposed policy revisions correct citations and references to state statutes, clarify the Administrative Law Judge's jurisdiction and clean up language for clarity and accuracy.

    Please view the circulation document here: APA WF# 15-52, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-53 — Audit Appeals Process 

    Proposed policy is revised to clarify the purpose of the Program Integrity audit appeal hearings, clarify which issues are appealable and streamline the process of audit appeal hearings. In addition, OHCA proposed revisions revoke the rules in nursing home provider contract appeals policy.   

    Please view the circulation document here: APA WF# 15-53, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-54 — Insure Oklahoma Clean Up  

    Proposed Insure Oklahoma policy revisions will clarify inconsistent and conflicting language. Language cleanup will reflect current OHCA practices. In addition, emergency transportation will be added to the Insure Oklahoma Individual Plan.

    Please view the circulation document here: APA WF# 15-54, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-55 — Programs of the All-Inclusive Care for the Elderly (PACE) Transfer Guidelines  

    Policy is being revised to provide clarification on enrollment standards for members who voluntarily dis-enroll and wish to transfer from one PACE site to another PACE site to align with current business practices.

    Please view the circulation document here: APA WF# 15-55, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-56 — Pharmacy Lock-in  

    OHCA proposes revisions to the policy that would strengthen the consequences of not adhering to the lock-in restrictions by sanctioning members who have been locked in with a single prescriber and pharmacy.

    Please view the circulation document here: APA WF# 15-56, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-57 — Long Term Care (LTC) Clean Up 

    The purpose is to clean the different sections of the waiver to assure that the waiver and policy language are the same and to detail operation and procedural changes that have occurred since receiving the five year renewal.

    Please view the circulation document here: APA WF# 15-57, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-58 — DSM Reference Cleanup and Ad Hoc Reviews  

    Proposed policy revisions remove outdated references to Axis I and II diagnosis language. Additional revisions clarify assessment and evaluation criterion and include cleanup to outdated language. Rules are also revised to remove outdated references to provider manual to reflect current medical necessity manual. In addition policy is revised to include Service Quality Review requirements for Ad Hoc reviews.

    Please view the circulation document here: APA WF# 15-58, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-61 — Appeal Process for Contract Terminations 

    Proposed Grievance Procedures and Process policy is amended to add language about the panel composition and to better clarify the appeal process.

    Please view the circulation document here: APA WF# 15-61, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-62 — Staffing Ratio  

    Proposed policy revisions clarify nurse staffing ratio, 24 hour nursing care requirements and outline supervisions requirements for psychiatric facilities. In addition, revisions clarify that any unit that does not allow clear line of site due to presence of walls or doors is a separate unit. Additionally, revisions include adding a requirement that admission assessments for inpatient psychiatric care both acute and residential levels must be completed by a Licensed Behavioral Health Professionals (LBHP) or candidate for licensure.

    Please view the circulation document here: APA WF# 15-62, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-65 — Behavioral Health Admission Assessment and Evaluations 

    Proposed policy revisions clarify that candidates for licensure can perform assessments and psychosocial evaluations when appropriate and medically necessary. In addition revisions clarify evaluation and re-evaluation criteria.

    Please view the circulation document here: APA WF# 15-65, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF# 15-66 — Application Process for Military Personnel 

    The proposed rule revisions will allow active military personnel who applied for Home and Community-Based Services (HCBS) in another state to have the application date honored in the state of Oklahoma.

    Please view the circulation document here: APA WF# 15-66, and submit feedback via the comment box below.

    Circulation Date: 01/15/2016

    Comment Due Date: 02/16/2016

    Public Hearing: 02/18/2016

    Medical Advisory Committee (MAC): 03/10/2016

    Board Meeting: 03/24/2016


    APA WF # 15-14A — Conflict Free Case Management

    Proposed policy at OAC 317:35-17-5 is revised to comply with 42 CFR 441.301 regarding conflict of interest provisions for case management services.  These policy revisions are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan.  The State is currently out of compliance.  Without the recommended changes, the State may be in risk of losing federal funding.  

    Circulation Date: 10/16/2015

    Comment Due Date: 11/15/2015

    Medical Advisory Committee (MAC): 09/19/2015

    Board Meeting: 12/10/2015


    APA WF # 15-14BConflict Free Case Management

    ADvantage Policy is revised to comply with 42 CFR 441.301 regarding conflict of interest provisions for case management services.  These policy revisions are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan.  The State is currently out of compliance. Without the recommended changes, the State may be in risk of losing federal funding. 

    Circulation Date: 10/16/2015

    Comment Due Date: 11/15/2015

    Medical Advisory Committee (MAC): 09/19/2015

    Board Meeting: 12/10/2015


    APA WF# 15-10 — Long-Term Care Rule Changes

    Long-term care eligibility rules are clarified to be consistent with 42 U.S. Code § 1396p. Changes include increasing home equity maximum amount to $500,000 plus the increase by the annual percentage increase in the urban component of the consumer price index, and allowing the individual to decrease this equity interest through the use of a reverse mortgage or home equity loan. The term "relative" is removed from the home exemption rules for members who fail to return back home from a long-term care institution. The term "assets" is changed to also include annuities purchased by, or on behalf of, an annuitant seeking long-term care services. 

    Circulation Date: 06/16/2015 

    Comment Due Date: 07/16/2015

    Medical Advisory Committee (MAC): 07/16/2015

    Board Meeting: 08/12/2015


    APA WF# 15-01 — Adult Dental Coverage for Organ Transplant Clearance

     

    The proposed policy revisions add coverage for medically necessary dental services for adult SoonerCare members needing dental clearance for organ transplant approval.

    Circulation Date: 06/16/2015 

    Comment Due Date: 07/16/2015

    Medical Advisory Committee (MAC): 07/16/2015

    Board Meeting: 08/12/2015


    APA WF 15-03 — DRG Hospital

    The proposed policy revisions clarify reimbursement methodology for DRG hospitals. Rules state that covered inpatient services provided to eligible members admitted to acute care and critical access hospitals will be reimbursed the lesser of the billed charges or the DRG amount.

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

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

    Board Meeting: 06/25/2015


    APA WF 15-04 — Revoke payment for removal of benign skin lesions and eliminate coverage for adult sleep studies 

    The proposed policy revisions revoke payment for removal of benign skin lesions for adults. In addition, the proposed policy revisions eliminate coverage for adult sleep studies. 

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

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

    Board Meeting: 06/25/2015


    APA WF 15-05 High Risk Obstetrical Services

    The proposed policy revisions to the High risk Obstetrical   program include: allowing the provider to be  Board Eligible or Board Certified, decreasing the number of units allowed for ultrasounds from six to three; decreasing the number of units for a singleton fetus for biophysical profiles/non-stress tests or any combination thereof to a total of 5, with one test per week beginning at 34 weeks gestation and continuing to 38 weeks; and, decreasing the number of ultrasounds currently granted to the Maternal Fetal Medicine (MFM) doctors to assist in the diagnosis of a high risk condition from six to one. These changes align with the current standards of care and reflect the current number of ultrasounds and biophysical profiles currently being utilized. 

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

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

    Board Meeting: 06/25/2015


    APA WF 15-06 — Coverage for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

    The proposed policy revisions regarding coverage for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) restrict coverage for continuous positive airway pressure devices (CPAP) to children only.

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

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

    Board Meeting: 06/25/2015


    APA WF 15-08 — Urine drug screening and testing

    The proposed policy revisions establish policy for the appropriate administration of urine drug screening and testing to align with recommended allowances based on clinical evidence and standards of care. Criteria include: purpose for urine testing, coverage requirements, non-covered testing, provider qualifications, and medical record documentation requirements necessary to support medical necessity. Additionally, revisions include clean-up to reimbursement language from general laboratory services policy.

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

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

    Board Meeting: 06/25/2015


    APA WF 15-09 — Timely Filing

    The proposed policy revisions are to restrict the timely filing of claims for reimbursement from 12 months to six months. In addition, policy regarding resubmission is revised to update the deadline from 24 months to 12 months. Changes to the timely filing restrictions are in accordance with federal authority. Remove changes to timely filing for Medicare crossover claims in the proposed rule at 317:30-5-44. Timely filing for crossover claims will remain one year. In addition, language corrections are included.

    Circulation Date: 05/06/2015

    Comment Due Date: 06/07/2015

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

    Board Meeting: 06/25/2015


    APA WF # 14-02 FQHC & RHC Encounter Limitation

    Rules are revised to limit encounters within Federally Qualified Health Centers (FQHC) and Rural Health Clinic Services (RHC) to one encounter per member per day as well as limit encounters to a total of four visits per member per month for adults. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-04 — Hospital Readmission

    Rules are amended to reduce/deny payment for preventable readmissions that occur within 30 days from discharge. The current policy reviews readmissions occurring within 15 days of prior acute care admissions or a related condition to determine medical necessity and appropriateness of care. If it is determined either or both admissions may be inappropriate, payment for either or both admissions may be denied.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-05 — Policy Change for Member Copayments

    Agency cost-sharing rules are revised to permit an increase of copays to the federal maximum. Additionally, policy is amended to add diabetic supplies and smoking cessation counseling and products to the service copayment exemption list in order to ensure member have access to necessary services that improve member health outcomes.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-07 — Policy Change for Oxygen and Oxygen Equipment

    Oxygen and oxygen equipment rules are revised to require a prior authorization after the initial three months. In addition, rules are revised to clarify arterial blood gas analysis (ABG) and pulse oximetry testing and Certificate of Medical Necessity requirements. Rules for rental oxygen are amended to clarify that reimbursement for rented oxygen concentrators includes both stationary and portable oxygen systems.   

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-12 — Elimination of Hospital Leave

    Rules are revoked to eliminate payment for hospital leave to nursing facilities and ICF/IIDs to reserve beds for members who are absent from the facility. Hospital leave is planned or unplanned leave when the patient is admitted to a licensed hospital.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF 14-13 — Psychosocial Rehabilitation (PSR) Service Eligibility Criteria & PSR Day Program Progress Note Clarification

    Rules are amended to add eligibility criteria required in order to receive psychosocial rehabilitation (PSR) services. Adult PSR services will be limited to members with a history of psychiatric hospitalization or admissions to crisis centers; have been determined disabled by the Social Security Administration for mental health reasons; or who are residing in residential care facilities. Children's PSR services will be limited to members with a history of psychiatric hospitalization or admissions to crisis centers; have been determined disabled by the Social Security Administration for mental health reasons; or have a current Individual Education Plan (IEP) for emotional disturbance. Revisions to outpatient behavioral health rules are also made to clarify that daily or weekly summary notes and related requirements are for rehab day programs only and that all other rehab should follow general progress note requirements, to create a distinction in terminology between Licensed Behavioral Health Professionals (LBHPs) who are fully licensed by their respective licensing board and those individuals who are under supervision for licensure from an approved licensing board (Licensure Candidates). Additionally, rules are amended to clarify that group psychotherapy is not reimbursable for children younger than 3. The aforementioned clarification was an oversight in last year’s rule promulgation cycle. Other grammatical changes are included.  

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-14A Conflict of Interest Policy

    Policy is revised to ensure all 1915(c) waiver programs comply with federal regulation regarding conflict of interest provisions for case management services.  The regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the person centered service plan.is revised to include all 1915(c) waiver programs to comply with 42 CFR 441.301 regarding conflict of interest provisions for case management services.  These emergency changes are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan.  Without the recommended changes, the State is out of compliance with CMS and may be in risk of losing federal funding. Additionally, rules are modified to provide clarification within the institutional transition case management service definition. Without the recommended changes, the policy will remain inconsistent with references to institutional transition as transitional case management services.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-14B — Conflict of Interest Policy

    Policy is revised to ensure all 1915(c) waiver programs comply with federal regulation regarding conflict of interest provisions for case management services.  These emergency changes are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan.  Without the recommended changes, the State is out of compliance with CMS and may be in risk of losing federal funding. Additionally, rules are modified to provide clarification within the institutional transition case management service definition. Without the recommended changes, the policy will remain inconsistent with references to institutional transition as transitional case management services. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-15 — Behavioral Health Outpatient Billable Hours

    Rules are revised to limit the number of hours that outpatient behavioral health rendering providers can be reimbursed to 35 hours per week. Additionally, rules are revised to correct scrivener’s errors made during the 2014 permanent rulemaking session. The 2014 permanent rules clarified that individual and group psychotherapy services as well as testing cannot be provided to children ages 0-3.Rules are revised to limit the number of hours that outpatient behavioral health rendering providers can be reimbursed to 35 hours per week. Additionally, rules are revised to correct scrivener’s errors made during the 2014 permanent rulemaking session.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-16 — Health Homes

    Rules are added to create coverage guidelines for Health Homes. Health Homes are created to promote enhanced integration and coordination of primary, acute, behavioral health, and long-term services and supports for persons across the lifespan with chronic illness. The purpose of the Health Home is to improve the health status of SoonerCare members with Serious Mental Illness or Serious Emotional Disturbance by promoting wellness and prevention and to improve access and continuity in healthcare for these members by supporting coordination and integration of primary care services in specialty behavioral healthcare settings. Additionally, rules are added to create a distinction between LBHPs and Licensure Candidates.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-17 — Moving to an SSI Criteria State for Determining Medicaid Eligibility for Aged, Blind, and Disabled Individuals

    In order to come into compliance with federal regulations, rules regarding eligibility determinations for Aged, Blind, and Disabled (ABD) individuals applying for Medicaid services are amended. Policy changes include adding new language regarding the Asset Verification System to check the income or resources of ABD applicants held at financial institutions, updating how resources are counted towards the maximum resource limit, exempting the value of one automobile regardless of its value from the maximum resource limit, expanding the income disregards list, and disregarding $20 of unearned income. Rules regarding income received from capital resources and rental property are amended to deduct the severance tax from the gross income for ABD applicants. Rules regarding infrequent or irregular income are amended to better match the Social Security Administration rules for determining Supplemental Security Income.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-19A — Transition of 1915(c) Waivers

    The OHCA is exploring options to transition the operational functions of its internal 1915c Waiver services and responsibilities.  The two (2) internal waivers include: (a) My Life My Choice and (b) Sooner Seniors.  Factors under consideration and exploration to transition the operational waiver responsibilities include, but are not limited to, contracting with an external entity to perform all operational services or transitioning some or all members into other existing waivers as applicable.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-19B — Transition of 1915(c) Waivers

    The OHCA is exploring options to transition the operational functions of its internal 1915c Waiver services and responsibilities.  The two (2) internal waivers include: (a) My Life My Choice and (b) Sooner Seniors.  Factors under consideration and exploration to transition the operational waiver responsibilities include, but are not limited to, contracting with an external entity to perform all operational services or transitioning some or all members into other existing waivers as applicable. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-20 — Hospital Presumptive Eligibility

    In compliance with federal regulations, OHCA is implementing Hospital Presumptive Eligibility (HPE). HPE allows participating hospitals to make presumptive eligibility (PE) determinations, on behalf of the agency, for applicants who are deemed eligible for Medicaid services based on preliminary information provided by the applicant. Hospitals may then provide services under HPE and bill OHCA. Hospitals are guaranteed payment for HPE services, regardless of whether or not the applicant is later found eligible for SoonerCare. The rules will delineate the parameters of the HPE program, eligibility guidelines, and hospital participation rules.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-22 — Update to DME Policy

    Policy is revised to update Part 17 (Medical Suppliers) in Chapter 30 to clarify rules for durable medical equipment (DME) services. Changes include updating billing and PA requirements for DME items, updating the list of DME items that require a certificate of medical necessity, clarifying that repairs for rental DME items are not covered, and revising the definition of invoice. Additionally, language is added to clarify that only one wheelchair is covered and deemed medically necessary; back-up wheelchairs are not covered items.  

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015 


    APA WF # 14-23 — DDS Third-party Employers

    The proposed amendments revise rules to implement policy changes recommended during the annual Developmental Disabilities Services (DDS) policy review process.  The policy changes recommended will assist DDS in becoming compliant with the new regulations of the Fair Labor Standards Act (FLSA) for "domestic service" employees, who provide "companionship services" to members.  The Department of Labor has issued a new final ruling that precludes third party employers from claiming the companion exemption.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-25 — Dental

    The proposed dental policy is revised to align practice with the Code on Dental Procedures and Nomenclature (CDT) and to ensure the delivery of dental services meets the standard of care. Proposed revisions include the elimination of the perinatal dental program, guidelines for x-rays, comprehensive and periodic oral evaluations, and dental sealants. Rules are revised to add coverage for the replacement of sealants; current policy restricts coverage for replacement sealants when medically necessary. Revisions also include clean-up to remove language regarding composite and amalgam restorations as it is referenced in a different section. Proposed revisions outline guidelines for stainless steel crowns to clarify that placement is allowed once for a minimum period of 24 months as well as other clean-up for clarity.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015

    APA WF # 14-28 — Allergy Testing Rules

    The Agency's rules are revised to establish policy for the appropriate administration of allergy testing and immunotherapy services. Criteria include: definition of allergy testing and immunotherapy, coverage requirements, non-covered services, reimbursement conditions, appropriate delivery sites, provider qualifications, and documentation requirements for home administration of immunotherapy. Additionally, revisions include clean-up to remove allergy reimbursement language from injection policy as it is referenced in the new section. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-33 — Policy Change for the Tax Equity Fiscal Responsibility Act (TEFRA) Program

    Policy is amended to change the TEFRA program eligibility rules to match federal guidelines for level of care (LOC). Changes include replacing all TEFRA language regarding mental retardation or ICF/MR to individuals with intellectual disabilities or ICF/IID. Rules regarding ICF/IID LOC eligibility will change to match current DSM-5 and SSA guidelines regarding intellectual disabilities. Specific LOC criteria for determining both hospital and nursing facility will be added to coincide with the ICF/IID criteria. TEFRA rules will also allow one additional psychological evaluation after the age of six, as medically needed. Finally, the Definitions section is updated to include the term "Ineligible Spouse". 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-34 — Waiver Services List 

    The revisions amend rules to implement policy changes recommended during the Oklahoma Department of Human Services (DHS) Developmental Disabilities Services (DDS) annual policy review process.  The recommended policy revisions will position DDS to utilize best practice in the administration of the statewide Request for Waiver Services list.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-36 — Long-Term Care Rule Changes

    Long-term care eligibility rules are clarified to be more consistent with 42 U.S. Code § 1396p. Changes include increasing the home equity maximum amount to $500,000 plus the increase by the annual percentage increase in the urban component of the consumer price index, and allowing the individual to decrease this equity interest through the use of a reverse mortgage or home equity loan. The term "relative" is removed from the home exemption rules for members who fail to return back home from a long-term care institution. The term "assets" is changed to also include annuities purchased by, or on behalf of, an annuitant seeking long-term care services.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-38 Individual Plan of Care

    Inpatient psychiatric hospital policy is revised to clarify that the member's signature on the Individual Plan of Care is required at the time of completion. However, if the member was too physically ill or their acuity level precluded them from signing the plan of care and/or the plan of care review at the time of completion, the member must sign the plan when their condition improves but before discharge. Rules are also revised to indicate that the individual plan of care must adhere to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-39 — Therapeutic Foster Care

    Agency policy is revised to indicate a 1.5 hours daily limit on services billed by the Treatment Parent Specialist (TPS) within the Therapeutic Foster Care (TFC) setting. This change in policy aligns with limitations delineated within the State Plan for this particular provider and setting. Additionally, rules are revised to make a distinction between LBHPs and Licensure Candidates.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-42 — History and Physical Evaluation

    Policy is revised to reflect that the History and Physical (H&P) should be completed within 24 hours after admission into an inpatient psychiatric hospital. Current agency rules reflect a timeframe of 48 hours to complete the H&P after admission into an inpatient psychiatric hospital. This change in policy is to comply with federal regulation. Rules are also amended to clarify that a psychiatric evaluation is performed by an allopathic or osteopathic physician with a current license and a board certification/eligible in psychiatry. Further, rules are amended to clarify that the psychiatric evaluation is completed within 60 hours of admission to an inpatient psychiatric facility to align with federal regulations. Revisions to the rules will also require that providers be responsible for any federal overpayment identified by CMS, even if the amount exceeds the liability described in the SQR audit findings. Additionally, rules are amended to reflect a distinction between LBHPs and Licensure Candidates.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-44 — Electronic Notices

    OHCA allows electronic notices to be sent to SoonerCare members' designated email addresses. Members may actively select that they wish to receive electronic communications from the agency through the SoonerCare application. The agency will confirm that the member is informed of their right to change this election at any time, ensure that members receive mailed notice of this election, and that all notices are posted on the SoonerCare application for member viewing within one business day. In instances of failed electronic communications, the agency will notify the member, through the mail, of this failed correspondence and that action is necessary. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-45 — Psychiatric Residential Treatment Programs Staffing Ratios

    Agency policy is revised to indicate that non-specialty Psychiatric Residential Treatment Facilities (PRTF) should have a staff to member ratio of 1:6 during routine awake hours and 1:8 during sleeping hours. Additionally, changes are made to clarify that staffing ratios should always be present for each individual unit not by facility or program.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-46A — DDS

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

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-46B — DDS

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

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-47 — Combined Psychiatric Evaluation & History and Physical Evaluation

    Policy is revised to indicate that when the H&P or a combined H&P and psychiatric evaluation are completed by an allopathic or osteopathic physician with a current license and a board certification/eligible in psychiatry, the assessment(s) may count as the first visit by the physician in active treatment. Current language may create confusion as to whether these assessments count toward the first visit by the physician under active treatment; inclusion of this language provides clarity. Additionally, rules are revised to include a distinction between LBHPs and Licensure Candidates.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-48 — Targeted Case Management

    The Agency is proposing rule revisions to its behavioral health case management policy in order to clarify existing service limits within administrative code. Changes are also made in order to create distinction between fully licensed "Licensed Behavioral Health Professionals" and "Licensure Candidates" who are actively and regularly pursuing board approved supervision. Revisions are also proposed in order to correct scrivener’s errors made during the 2014 permanent rulemaking session.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-49A — Insure Oklahoma Eligibility

    The methodology for determining Insure Oklahoma (IO) eligibility, for both IP and ESI, is changing to the Modified Adjusted Gross Income (MAGI) methodology. The MAGI methodology will supersede previous IO eligibility criteria. The new rules will reference the MAGI methodology rules already established at OAC 317:35-6-39 through 317:35-6-54. Additional changes include amending the requirement that members notify the agency of changes in household circumstances from within 30 calendar days to 10 days. Rules will be added to indicate changes in the member's household circumstances may require an eligibility redetermination for IO. References to IO's various FPLs will be removed; IO's income standards will now be published online using standard IO Income forms. Additionally, the reasonable opportunity for SoonerCare members to obtain citizenship or alienage documentation is changed from 60 days to 90 days.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-49B Insure Oklahoma Eligibility

    The methodology for determining Insure Oklahoma (IO) eligibility, for both IP and ESI, is changing to the Modified Gross Adjustment Income (MAGI) methodology. The MAGI methodology will supersede previous IO eligibility criteria. The new rules will reference the MAGI methodology rules already established at OAC 317:35-6-39 through 317:35-6-54. Additional changes include amending the requirement that members notify the agency of changes in household circumstances from within 30 calendar days to 10 days. Rules will be added to indicate changes in the member's household circumstances may require an eligibility redetermination for IO. References to IO's various FPLs will be removed; IO's income standards will now be published online using standard IO Income forms. Additionally, the reasonable opportunity for SoonerCare members to obtain citizenship or alienage documentation is changed from 60 days to 90 days. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-50 Telemedicine — The OHCA rule for Telemedicine is being revised to clarify the definition for telemedicine, and to remove the definitions sections for consistency. Proposed changes also remove coverage guidelines to expand the scope of the telemedicine delivery method. Revisions remove requirements for a presenter at the originating site to align with the Oklahoma Medical Licensure rules, and to remove guidelines regarding the required use of OHCA-approved telemedicine networks. Proposed revisions also eliminate the originating site fee payment. Additional clean-up ensures no restrictions on services rendered using the telemedicine delivery model. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-52A SoonerRide

    Rules remove mention to inpatient under the exclusion group as this is not considered an eligibility standard. Rules also remove coverage for non-emergency transport to VA facilities as these facilities are not contracted with the Oklahoma Health Care Authority. Rules also clarify coverage guidelines for escorts and remove mention of the My Life, My Choice group as the waiver is set to expire.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-52B — SoonerRide

    Rules remove mention to inpatient under the exclusion group as this is not considered an eligibility standard. Rules also remove coverage for non-emergency transport to VA facilities as these facilities are not contracted with the Oklahoma Health Care Authority. Rules also clarify coverage guidelines for escorts, and rules remove mention of the My Life, My Choice group as the waiver is set to expire.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-53 — Mental Health Substance Use Screenings

    The Agency is proposing rule revisions to its outpatient behavioral health policy in order to add service coverage for mental health/substance use disorder screening for SoonerCare adult and child members within an outpatient behavioral health agency setting. Changes are also made in order to create distinction between fully licensed "Licensed Behavioral Health Professionals" and "Licensure Candidates" who are actively and regularly pursuing board approved supervision.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-55 — Distinction Between LBHP & Licensure Candidate

    The Agency is proposing rule revisions to its behavioral health policy in order to create a distinction in terminology between Licensed Behavioral Health Professionals (LBHPs) who are fully licensed by their respective licensing board and those individuals who are under supervision for licensure from an approved licensing board (Licensure Candidates). Revisions are also proposed in order to correct scrivener’s errors made during the 2014 permanent rulemaking session.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-58 High Risk Obstetrical Services 

    OHCA rules for high risk obstetrical (HROB) services are revised to increase access in rural areas. Currently high risk obstetrical services are allowed only after an evaluation with Maternal Fetal Medicine doctor and the member is deemed high risk; enhanced services are allowed, only after a prior authorization request and treatment plan are initiated and submitted by the MFM. The initial intent of the HROB program was to promote the establishment of a relationship between the MFM's in urban areas with mothers located in rural communities. However, it appears that pregnant women in rural communities rarely travel to the urban areas to receive services. Allowing the general OB to request the HROB services/package for pregnant women will allow ensure pregnant women with high risk conditions receive HROB services. 

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-60 Federally Qualified Health Centers (FQHC)

    Rules are revised to allow FQHC's to be reimbursed at the PPS rate immediately upon receiving their Health Resources and Services Administration (HRSA) grant award letter. Currently, OHCA requires the facility to submit the award letter and their Medicare certification number before they can contract as an FQHC. In the interim, facilities contracted as a clinic and were paid the fee for service (FFS) rate.Rules are revised to remove the requirement for FQHC's to submit the Medicare Certification number in conjunction with the Health Resources and Services Administration (HRSA) grant award letter.

    Circulation Date: 01/16/2015 

    Comment Due Date: 02/16/2015

    Public Hearing: 02/18/2015    

    Medical Advisory Committee (MAC): 03/12/2015  

    Board: 03/26/2015


    APA WF # 14-02

    Rule text will be circulated for public comment 01/16/2015. A public hearing will be held 02/18/2015.  

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-04 

    Rule text will be circulated for public comment 01/16/2015. A public hearing will be held 02/18/2015. 

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-08 — Provider Policy for Payment of Glasses

    This emergency rule was approved 07/01/14 and is now being promulgated through the permanent rule process.  

    Rules are amended to limit the number of payment for glasses to two per year. Any additional glasses beyond this limit must be prior authorized and determined to be medically necessary.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-09 — SoonerCare Choice Enrollment Ineligibility

    This emergency rule was approved 07/01/14 and is now being promulgated through the permanent rule process.   

    SoonerCare Choice enrollment ineligibility rules are amended to include making individuals with other forms of creditable health insurance coverage ineligible for SoonerCare Choice; individuals in the former foster care eligibility group are also ineligible for SoonerCare Choice. Additionally, members who are currently enrolled in SoonerCare Choice who have or gain other forms of creditable insurance will be disenrolled from the program. Children who are known to be in OKDHS custody are now eligible to participate in SoonerCare Choice. 

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-11 

    Rule text will be circulated for public comment 1/16/2015 in APA WF # 14-25. A public hearing will be held 02/18/2015.

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-12 — Elimination of Hospital Leave

    This emergency rule was approved 07/01/14 and is now being promulgated through the permanent rule process.

    Rules are revoked to eliminate payment for hospital leave to nursing facilities and ICF/IIDs. Hospital leave is planned or unplanned leave when the patient is admitted to a licensed hospital.  

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-13 

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015.

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-14

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015.  

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-15 

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015.  

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-16

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015. 

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-17

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015. 

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-18 — State Plan Personal Care Services

    Rules for the State Plan Personal Care services are amended to match current processes and procedures that are currently in place at OKDHS. Changes include policy clean up to remove unnecessary or redundant language regarding service settings and the criteria for persons eligible to serve as Personal Care Assistants.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-24 — 340B Drug Discount Program

    Policy is added to outline special provisions and contracting requirements for providers participating in the 340B Drug Discount Program per federal regulation.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-26 — Nurse Aide Training

    The Agency's nurse aide training program rules are revised to specify that payment for training will be directly reimbursed to qualified nurse aides on a quarterly basis for every quarter the individual is employed in a nursing facility. Rules are also revised to establish a maximum rate for reimbursement for nurse aides who have paid for training and competency examination fees.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-27 — Private Duty Nursing services

    Private Duty Nursing (PDN) rules are revised to reflect an OHCA physician will be responsible for utilizing the acuity grid to help make a determination for medical necessity. The Care Management nurses' responsibility will be to gather, summarize, and present the individual cases to the physician.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-29A — Lock-in policy clean up

    Policy is revised to clean up language regarding the pharmacy lock-in program. Current policy locks members in to one primary physician and/or on pharmacy. Policy is revised to allow members to be locked in to an approved prescriber rather than primary care physician and pharmacy.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-29B — Lock-in policy clean up

    Policy is revised to clean up language regarding the pharmacy lock-in program. Current policy locks members in to one primary physician and/or on pharmacy. Policy is revised to allow members to be locked in to an approved prescriber rather than primary care physician and pharmacy.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-35 — DMEPOS Free Choice

    Rules regarding SoonerCare member's freedom of choice to select their provider of durable medical equipment, prostethics, orthotics, and supplies (DMEPOS) are amended to state that providers must inform members of this right when filling or ordering DMEPOS.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-38

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015.  

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-41 — Referrals for Specialty Services

    Policy is revised to convey that electronic referrals will eliminate the need of paper referral documentation within members' medical records.

    Circulation Date: 12/16/2014

    Comment Due Date: 01/15/2015

    Public Hearing: 01/15/2015    

    Medical Advisory Committee (MAC): 01/15/2015 

    Board: 02/12/2015


    APA WF # 14-42 

    Rule text will be circulated for public comment 1/16/2015. A public hearing will be held 02/18/2015.

    Public Hearing: 02/18/2015  

    MAC: 03/12/2015 

    Board: 03/26/2015


    APA WF # 14-34Developmental Disabilities Services

    Developmental Disabilities Services (DDS) policy is revised to comply with state and federal regulations regarding Home and Community-Based Services (HCBS) Waivers for persons with intellectual disabilities or certain persons with related conditions: (1) include timeframes for how long psychological evaluations are considered valid to determine eligibility for DDS HCBS Waiver services; (2) include timeframes for reporting any address changes or other contact information to DHS; and (3) provide timeframes when an individual is removed from the Request for Waiver Services List when the individual fails to respond or does not provide DHS requested information.  Without the recommended changes, the State is out of compliance with CMS and may be in risk of losing federal funding.

    Circulation Date: 10/22/2014 

    Comment Due Date: 11/20/2014   

    Medical Advisory Committee (MAC): 11/20/2014 

    Board: 12/11/2014


    APA WF # 14-23 — Developmental Disabilities Services

    Developmental Disabilities Services (DDS) policy is revised to comply with 29 CFR 552.109 regarding domestic service employees employed by third-party employers, or employers other than the individual receiving services, or his or her family, or household.  The regulation precludes third party employers from claiming the companion exemption.   

    Circulation Date: 10/22/2014 

    Comment Due Date: 11/20/2014   

    Medical Advisory Committee (MAC): 11/20/2014 

    Board: 12/11/2014


    APA WF # 14-15 — Behavioral Health Billable Hours 

    Rules are revised to limit the number of hours that outpatient behavioral health rendering providers can be reimbursed to 35 hours per week. Without the recommended revisions, ODMHSAS is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Behavioral Health Program. 

    Circulation Date: 07/30/2014 

    Comment Due Date: 09/03/2014   

    Medical Advisory Committee (MAC): 09/03/2014 

    Board: 09/11/2014


    APA WF # 14-16  Health Homes

    Rules are added to create coverage guidelines for Health Homes. Health Homes are created to promote enhanced integration and coordination of primary, acute, behavioral health, and long-term services and supports for persons across the lifespan with chronic illness. 

    Circulation Date: 08/05/2014 

    Comment Due Date: 09/03/2014   

    Medical Advisory Committee (MAC): 09/03/2014 

    Board: 09/11/2014


    APA WF # 14-17 — Moving to an SSI Criteria State for Determining Medicaid Eligibility for Aged, Blind, and Disabled Individuals

    Rules are amended to come into compliance with federal regulations regarding eligibility determinations for Aged, Blind, and Disabled (ABD) individuals applying for Medicaid services. OHCA is transitioning from a 209(b) State to the Supplemental Security Income (SSI) Criteria administrative option. This change includes amending current policy, the State Plan, and 1915(c) Home and Community Based Services Waivers pertaining to financial criteria for determining countable income and resources for ABD populations and matching that to current Social Security Administration regulations for persons receiving SSI. 

    Circulation Date: 08/06/2014

    Comment Due Date: 09/03/2014   

    Medical Advisory Committee (MAC): 09/03/2014 

    Board: 09/11/2014


    APA WF # 14-14 — HCBS Final Rule

    Policy is revised to include all 1915(c) waiver programs to comply with 42 CFR 441.301 regarding conflict of interest provisions for case management services.  These emergency changes are necessary as the regulation states providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management services or develop the person centered service plan.  Without the recommended changes, the State is out of compliance with CMS and may be in risk of losing federal funding.

    Circulation Date: 08/14/2014

    Comment Due Date: 09/03/2014   

    Medical Advisory Committee (MAC): 09/03/2014 

    Board: 09/11/2014   


    APA WF # 14-10  Psychosocial rehabilitation (PSR) Service Eligibility Criteria

    Rules are amended to add eligibility criteria required in order to receive psychosocial rehabilitation (PSR) services. Adult PSR services will be limited to members with a history of psychiatric hospitalization or admissions to crisis centers; have been determined disabled by the Social Security Administration for mental health reasons; or who are residing in residential care facilities. Children's PSR services will be limited to members with a history of psychiatric hospitalization or admissions to crisis centers; have been determined disabled by the Social Security Administration for mental health reasons; or have a current Individual Education Plan (IEP) for emotional disturbance. These emergency revisions are necessary to reduce the Oklahoma Department of Mental Health Substance Abuse Services' operations budget 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.

    Circulation Date: 06/03/2014

    Comment Due Date: 06/25/2014   

    Medical Advisory Committee (MAC): 06/11/2014 

    Board: 06/26/2014   


    APA WF # 14-02 — FQHC & RHC Encounter Limitation

    Rules are revised to limit encounters within Federal Qualified Health Centers (FQHC) and Rural Health Clinic Services (RHC) to one encounter per member per day as well as limit encounters to a total of four visits per member per month for adults. These emergency revisions are necessary to reduce the Agency's operations budget in order to meet the balanced budget requirements as mandated by State law. Without the recommended revisions, the Agency is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Program. 

     **These rules have been revised since the previous posting, which ended May 31.  This revision to this rule clarifies that a prior authorization is required for reimbursement for visits exceeding the limit for children. 

    Circulation Date: 06/05/2014

    Comment Due Date: 06/25/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014  


    APA WF # 14-04 — Hospital Readmissions

    Rules are amended to reduce/deny payment for preventable readmissions that occur within 30 days from discharge. The current policy reviews readmissions occurring within 15 days of prior acute care admissions or a related condition to determine medical necessity and appropriateness of care. If it is determined either or both admissions may be inappropriate, payment for either or both admissions may be denied. These emergency revisions are necessary to reduce the Agency's operations budget in order to meet the balanced budget requirements as mandated by State law. Without the recommended revisions, the Agency is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Program. 

     **These rules have been revised since the previous posting, which ended May 31.  This revision to this rule clarifies that OHCA will review readmissions that are potentially preventable.

    Circulation Date: 06/05/2014

    Comment Due Date: 06/25/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014  


    APA WF # 14-06  Dental

    Rules are revised to eliminate the perinatal dental benefit.  

    **These rules have been revised since the previous posting, which ended May 31.  The revisions to this rule remove language that eliminated coverage of pulpotomies and indirect caps.  Under the revised rule, those services will remain compensable.  The revised rule maintains the proposed elimination of perinatal dental benefits for adults. 

    Circulation Date: 06/05/2014

    Comment Due Date: 06/25/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014  


    APA WF # 14-03 — Elimination of Hospital Leave

    Rules are revoked to eliminate payment for hospital leave to nursing facilities and ICF/IIDs. Hospital leave is planned or unplanned leave when the patient is admitted to a licensed hospital.  

    **These rules have been revised since the previous posting, which ended May 31.  The revision to this rule reinstates therapeutic leave days, while still eliminating hospital leave days for nursing facilities and ICF/IIDs.  

    Circulation Date: 06/10/2014

    Comment Due Date: 06/25/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014 


    APA WF # 14-02 — FQHC & RHC Encounter Limitation

    Rules are revised to limit encounters within Federal Qualified Health Centers (FQHC) and Rural Health Clinic Services (RHC) to one encounter per member per day as well as limit encounters to a total of four visits per member per month for adults. These emergency revisions are necessary to reduce the Agency's operations budget in order to meet the balanced budget requirements as mandated by State law. Without the recommended revisions, the Agency is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Program.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014 


    APA WF # 14-03 — Elimination of Hospital & Therapeutic Leave  

    Rules are revoked to eliminate payment to nursing facilities to reserve beds for members who are absent from the facility. Therapeutic leave is any planned leave other than hospitalization that is for the benefit of the patient. Hospital leave is planned or unplanned leave when the patient is admitted to a licensed hospital. These emergency revisions are necessary to reduce the Agency's operations budget in order to meet the balanced budget requirements as mandated by State law. Without the recommended revisions, the Agency is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Program.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014 


    APA WF # 14-04 — Hospital Readmissions

    Rules are amended to reduce/deny payment for preventable readmissions that occur within 30 days from discharge. The current policy reviews readmissions occurring within 15 days of prior acute care admissions or a related condition to determine medical necessity and appropriateness of care. If it is determined either or both admissions may be inappropriate, payment for either or both admissions may be denied. These emergency revisions are necessary to reduce the Agency's operations budget in order to meet the balanced budget requirements as mandated by State law. Without the recommended revisions, the Agency is at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Program.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014 


    APA WF # 14-05 Cost Sharing

    Agency's cost-sharing rules are revised to permit an increase of copays to the federal maximum.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014


    APA WF # 14-06  Dental

    Dental rules are revised to eliminate the perinatal dental benefit . Further, coverage is eliminated for pulp cap indirect and therapeutic pulpotomies.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014


    APA WF # 14-07  Oxygen

    Oxygen and oxygen equipment rules are revised to require a prior authorization after the initial three months. In addition, rules are revised to clarify arterial blood gas analysis (ABG) and pulse oximetry testing and Certificate of Medical Necessity requirements.  

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014


    APA WF # 14-08 — Limiting Reimbursement for Eyeglasses

    Rules are amended to limit the number of payments for glasses to two per year. Any additional glasses beyond this limit must be prior authorized and determined to be medically necessary. These changes are needed in order to reduce the overall costs of the Medicaid program.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014


    APA WF # 14-09 — SoonerCare Choice Enrollment Ineligibility

    SoonerCare Choice rules regarding enrollment ineligibility are amended to include making individuals with other forms of creditable health insurance coverage ineligible for SoonerCare Choice. Additionally, members who are currently enrolled in SoonerCare Choice who have or gain other forms of creditable insurance will be disenrolled from SoonerCare Choice. These changes are needed in order to reduce the overall costs of the Medicaid Program.

    Circulation Date: 05/01/2014

    Comment Due Date: 05/31/2014   

    Medical Advisory Committee (MAC): 05/15/2014 

    Board: 06/26/2014


    APA WF # 13-08 Systems Simplification Implementation

    The proposed policy was an Emergency Rule and is now proposed as a Permanent Rule. 

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-13 Long Acting Reversible Contraceptive Devices

     

    Policy is amended to allow reimbursement for Long Acting Reversible Contraceptive (LARC) devices to hospitals outside of the Diagnosis Related Group (DRG) methodology.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-16 — Insure Oklahoma

     

    Insure Oklahoma (IO) rules are revised to align with the Special Terms and Conditions of the Section 1115 Demonstration Waiver. In accordance with waiver special terms and conditions, the federal government has approved a one year (calendar) extension of the IO program.   Rules are revised to remove Individual Plan children (while retaining Employer Sponsored Insurance (ESI) children) and limit adult Individual Plan enrollment to persons with household income at or below 100 percent of FPL. Revisions also include changes to the Individual Plan copayment structure; copayments cannot exceed current federal maximums with the exception of emergency room (ER) visits, in which case the existing copay for ER visits will remain at $30.00. Additionally, rules are revised to remove the references to eligibility income determinations.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-24 ADvantage Address Confidentiality Program

     

    Policy is added to include information on the Address Confidentiality Program (ACP). The ACP provides victims of domestic violence, sexual assault, or stalking with a substitute address and mail forwarding service that can be utilized when victims interact with state and local agencies.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-25 ADvantage Billing Procedures

     

    Policy is amended to include information on rounding of billable time as per the Interactive Voice Response Authentication (IVRA) system. This change in policy will enforce compliance, clarify information for providers, and reflect practices already taking place. Additionally, minor policy revisions are made to the policy.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-26 — Genetic Testing

    Policy is revised to add language that sets boundaries as to what is deemed approved genetic testing methods. Problems have recently arisen which call for more stringent policy, particularly issues regarding lab billing for expensive methods that lack sufficient evidence for their use.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-27 Infectious Disease Billing    

    Policy is added to include language that explicitly addresses proper billing in regard to nucleic acid testing of single/multiple infectious organisms in a specimen.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-30 Audit Appeals     

    Policy is amended to more accurately reflect each party's responsibilities in an audit and clarify other audit procedures in order to streamline the process. The proposed changes define responsibilities of providers, who can represent a provider in her/his absence, and the duties of the docket clerk and the Administrative Law Judge during an audit. Further, the rule clarifies timeframes for document submission and prehearings.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-33 1915(c) Waiver Change for PERS service for Medically Fragile, Sooner Seniors, and My Life, My Choice    

    Policy is amended to change the service criteria for Personal Emergency Response System (PERS) to also include that OHCA's Care Management Team can authorize PERS service when the member's service plan indicates the member is at high risk for falls and the service will help prevent premature or unnecessary institutionalization.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-34 — Tax Equity Fiscal Responsibility Act (TEFRA) Program   

    Policy is amended to change TEFRA program rules to better match current business practices and federal regulations. Changes include changing all TEFRA language regarding mental retardation or ICF/MR to individuals with intellectual disabilities or IID to match Public Law 111-256. As well, rules regarding cost effectiveness analyses being posted on MEDATS will be changed to require that the cost effectiveness analyses are reported annually with no specification as to where that report will reside. Rules regarding TEFRA eligibility for applicants aged three years and older for the ICF/IID level of care change the IQ requirements from 75 or less to 70 or less to match current DSM-5 and SSA guidelines regarding intellectual disabilities. Additionally, changes also include amending the current criteria to state that applicants can either have an IQ of 70 or less, or have a full-scale adaptive functional assessment indicating a functional age that does not exceed 50% of child's age to match current DSM-5 and SSA guidelines regarding intellectual disabilities. It also removes the rule that requires the assessment be either Battelle or Vineland since SSA does not specify which test is to be used. Finally, another amendment requires that one additional psychological evaluation be administered for all approved TEFRA children once they reach the age of sixteen.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-35 Electronic Fund Transfer Enrollment    

    Policy is amended to specify that providers enroll in Electronic Fund Transfers for Medicaid reimbursement via the electronic enrollment process.  Language referencing the Provider Relations unit will be removed as this unit no longer exists.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-43  Therapy Provider Qualifications       

    OHCA rules for therapy services are revised to add “services may be provided under the direction of a qualified provider.”

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-45 — Inpatient Psychiatric Rules        

    The Agency's inpatient psychiatric hospital rules are being revised to establish medical necessity criteria specific for admission and continued stays in community based transitional (CBT) programs as these facilities are a lower level of care than psychiatric residential treatment facilities (PRTF) and acute residential treatment facilities. Changes are also being proposed to the rules regarding "active treatment" requirements for children under the age of 18. The change will allow providers flexibility to better tailor treatment to the individual needs of the child. Additional proposed changes include:  revisions to Inspection of Care (IOC) rules, clarifying which types of facilities will be still receive on-site inspections, allowing psychosocial evaluations or admission assessments to substituted for the first therapy session, and allowing the use of mechanical restraints for children 18-20 since they are treated on the adult care unit. Other revisions are also made to make minor "cleanup" changes to terminology, which include changes mandated by the Diagnostic and Statistical Manual (DSM) V. 

    **This circulation document has been updated to change (317:30-5-95.42) from a full recoupment to a partial recoupment.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-46 — Outpatient Behavioral Health Services          

    The Agency's outpatient behavioral health (OBH) rules are revised to remove the behavioral health rehabilitation specialist (BHRS) designation from policy since, effective July 1, 2014, these services will only be reimbursed if provided by an LBHP, CADC or Case Manager II (CM II). Changes are also made to the rules to clarify that OBH services cannot be separately billable to individuals residing in nursing facilities. Reimbursements for these services are included within the nursing facility rate, as required by federal regulation. Additionally, clarification is made that individual and group psychotherapy services cannot be provided to children ages 0-3 unless medical necessity criteria is met, and partial hospitalization (PHP) and day treatment language is amended to clarify psychosocial rehabilitation is not allowed for children ages 0-3 and prior authorization is required for children ages 4-6. Additional changes include: additional supervision requirements for paraprofessionals by licensed, master level staff that render services to members outside of an agency setting, revising peer recovery support specialist services to include youth ages 16-18 that are transitioning into adulthood, revise behavioral health rehabilitation service documentation requirements, and clarifying when services may be rendered without a treatment plan. Other revisions are also made to make minor "cleanup" changes to terminology, which include changes mandated by the Diagnostic and Statistical Manual (DSM) V. 

    **Policy 317:30-5-241.1 and 317:30-5-241.3 have been updated.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-47 Bio-Psychosocial Evaluations and Assessments          

    The Agency's psychologists and licensed behavioral health provider rules are revised to add coverage for bio-psychosocial assessments for adults when required by OHCA as part of a preoperative prior authorization protocol for organ transplant or bariatric surgical procedures. Revisions are also made to clarify that payment for behavioral health services are not separately reimbursable for members residing in a nursing facility.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-48 Providers under supervision for licensure     

    The Agency's licensed behavioral health provider rules are revised to eliminate reimbursement for services provided by behavioral health professionals under supervision for licensure if they work under the direction of an individually contracted LBHP, outside of an agency setting. The additional oversight requirements imposed upon agencies provide a better training ground for individuals under supervision and afford OHCA and the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) better opportunity to ensure the quality of services being provided to SoonerCare members.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-49 — Transitional Case Management        

    The Agency's behavioral health case management rules are revised to ensure consistency with changes in case manager provider requirements made in Title 450 of the Oklahoma Administrative Code, by the certifying agency, the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS). Provider qualifications are being revised in order to reflect the legislature's intent, as expressed during the 2013 legislative session. Case management reimbursement rules are also being revised in order to allow reimbursement for transitional case management provided during the last 30 days of an inpatient stay. This change will ensure successful integration back into the community upon discharge from the inpatient facility. 

    **Policy 317:30-5-595 (2), provider qualifications, has been updated

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-50 Therapeutic Foster Care

    The Agency's therapeutic foster care (TFC) rules are revised to allow for the completion of assessments and treatment plans from 14 days to 30 days. This change aligns with current practice that mandates when provisional diagnosis documentation must be submitted. All documentation will now be due to the OHCA within 30 days of admission to a TFC facility. The Agency is also proposing rule revisions to disallow coverage of Psychosocial Rehabilitation (PSR) services for children below age 6 unless services are medically necessary and required pursuant to Federal Early and Periodic Screening Diagnostic and Treatment (EPSDT) laws. Additionally, the agency is proposing to add detail language requirements for developing and rendering assessments, service plans, and PSR services. Other revisions are also made to make minor "cleanup" changes to terminology, which include changes mandated by the Diagnostic and Statistical Manual (DSM) V.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-51 Fluoride varnish        

    Policy is revised to expand the age for which application of fluoride varnish during course of a well child screening is covered, from ages 12 months to 42 months to ages 6 months to 60 months.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-52 School Based Services        

    OHCA rules related to IDEA and School Based services are revised for clarity and consistency. Revisions include removing references to outdated terms and/or policy, and adding guidelines for school-based services and evaluations as it relates to the Individual Education Plan/ Individual Family Service Plan (IEP/IFSP) for clarity and consistency.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-53 Laboratory Payment Rates

    Policy is revised to clarify clinical laboratory services will be reimbursed in accordance with methodology approved under the State Plan.

    Circulation Date: 01/15/2014

    Comment Due Date: 02/14/2014   

    Public Hearing: 02/24/2014 

    Medical Advisory Committee (MAC): 03/26/2014

    Board: 03/27/2014


    APA WF # 13-04  HANs Care Management Services

    Policy is revised to give providers greater flexibility in the populations with complex health care needs that can receive care management services through HANs. Policy is also amended to remove the HMP care management component as a responsibility of the HAN and to allow HMP to provide health coaching services to “high risk” or “at risk” members that are in the HAN but not receiving care management services through the HAN. These changes streamline policy in the waiver, contract, and OHCA rules.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-07  Diabetic Supplies

    Rules are revised to clarify diabetic supplies (e.g., test strips and lancets) are covered items when medically necessary and prescribed by a physician, physician assistant, or an advanced practice nurse using the appropriate diagnostic certification. In addition, the amended proposed rule change will allow OHCA flexibility to manage the dispensed quality and refill limit of glucose testing supplies related to gestational diabetes.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-10  Remove OKDHS from Adm 41

    Policy is being revised to remove reference to OKDHS from Adm 41, a form used to claim therapeutic and hospital leave. The form has not been utilized in over 7 years and the agency now tracks leave through its claims system; therefore, the process to claim leave in the rules is obsolete and must be amended to reflect current practice.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-11 340B Drug Discount Program

    The proposed 340B Drug Discount program rules are implemented to comply with Federal Mandate. The 340B mandate requires states to include their 340B Drug Discount program rules in their State plan and Medicaid policy.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-12 DME

    Policy is revised to clarify the use of options for manually pricing durable medical equipment items. Policy will be modified to reflect that OHCA will calculate and compare prices based on different methodologies, then use the lesser of the two for reimbursement. One method will use manufacturer Suggested Retail Price (MSRP) minus 20%. The other option for manually-priced DME items will be invoice cost plus 20%.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-17 Tobacco Cessation

    Tobacco cessation counseling policy is revised to include Maternal/Child Health Licensed Clinical Social Workers (LCSWs) with certification as a tobacco treatment specialist as a qualified provider for cessation counseling services.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-18  Tuberculosis

    Rules are revised to update references to other areas of policy within the text. The policy that is referenced in the tuberculosis rules is outdated and it has been revoked. Additionally, correct policy references are inserted to replace the revoked policy.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-19A  ADvantage

    Policy will be revised to provide clarification that ADvantage program residential units are deemed to be rental units and that members in the program are to be provided with a lockable compartment within each member’s rental unit for valuables. Additionally, minor grammatical changes will be made through the policy.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-19B  ADvantage

    Policy will be revised to provide clarification regarding interdisciplinary team (IDT) meetings for case management services in the ADvantage Assisted Living waiver as well as other minor changes. Policy changes specify that IDT meetings, except for extraordinary circumstances, are to be held in the member’s home.

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-20 PACE

    PACE rules are revised to replace ADvantage policy reference with a more precise ADvantage policy that defines the PACE eligibility criteria and the PACE eligibility determination for the PACE program. The proposed rule change to the PACE program will align rules to reflect the PACE model and PACE CFR Part 460. 

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-21 Pharmacy

    Pharmacy rules are revised to update and make general clean up changes and to comply with Federal Law on claims for covered over-the counter (OTC) products, which must be prescribed by a health care professional with prescriptive authority. Additional revisions include removing hard coded dates that no longer apply, removing the “Upper limit” reference from brand necessary certification product policy, and clarifying the product-based prior authorization for tier one and tier two products. 

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-29  Ventilator-dependent Individuals

    Ventilator-dependent and tracheostomy care rules are implemented to comply with Federal Law, 42 CFR 440.185 regulations for ventilator-dependent individuals and clarify coverage for Nursing Home admission for ventilator-dependent and tracheostomy care services for resident in a nursing home facility.  

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-32  Sooner Seniors and My Life, My Choice Waiver Services

    Policy will be amended to remove language regarding the Level of Care Evaluation Unit (LOCEU) and to state that only categorical relationship to age is necessary per SSA guidelines for Sooner Senior Waiver Services only. In addition, policy will be amended to change the scope of waiver services regarding Pharmacological Evaluations for Sooner Seniors and My Life, My Choice Waivers. This service will be redefined as Pharmacological Therapy Management, and its scope of work will be changed to include a case management approach to reviewing medication profiles of qualified members who meet medication utilization criterion or if they are referred for this service by a care manager.  

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-39  Dental

    Dental policy rules are revised to clarify documentation requirements.  Furthermore, rules are revised to align ambulatory surgery center (ASC) policy with Title 63 Oklahoma Statue §2567 to recognized dental ambulatory surgical center (DASC) as an established ambulatory surgical center. 

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 13-40 Hospitals

    OHCA rules for hospitals are revised to clarify the definition of inpatient and outpatient status. Current policy is silent to the appropriate claim filing guidelines for members who are admitted as inpatient, but leave or are discharged before the midnight census. The proposed revisions would clarify that hospitals may submit an outpatient claim for the ancillary services provided to the member while they were on inpatient status. Most hospitals already re-bill the denied inpatient claims; a policy change would provide written clarification for hospitals they are not violating OHCA policy. 

    Circulation Date: 12/16/2013

    Comment Due Date: 01/15/2014

    Public Hearing: 01/27/2014

    Medical Advisory Committee (MAC): 01/30/2014

    Board: 02/13/2014


    APA WF # 12-43  Nursing Facilities

    Nursing Facility rules are revised to add language clarifying that all program requirement set out in State Statute and OHCA policy regarding wage enhancements for certain nursing facility employees have been met. In addition , rules are revised to clarify the Quality of care fee assessed by OHCA is authorized through the State plan, and CMS, and the removal of language incorrectly stating that the rates for public ICF's/MR are set through a public rate setting process rather than the current practice of reimbursement based on cost report. 

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-42  LTC Sub-Acute Hospital Reimbursement

    LTC Sub-Acute Hospital Reimbursement Methodology rules are revised to amend LTC policy to update reimbursement language from a prospective per diem methodology to a cost based methodology. 

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-41 A and B Eligibility

    Eligibility Rules: (1) Rules are amended to comply with mandatory provisions of the ACA, such as determination of eligibility using Modified Adjusted Gross Income (MAGI); (2) rules are amended to add the mandatory eligibility group of children receiving Kinship Guardianship Assistance; and (3) rules are amended to eliminate presumptive eligibility for pregnant women. 

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-40 Inpatient Behavioral Health

    Inpatient Behavioral Health rules are being revised to clarify: (1)the medical necessity criteria required for admission and continued stay in PRTF and acute levels of care (2)individual Plans of care to ensure early parent/guardian involvement in the treatment of children under  the age 18 (3) “active treatment" requirement for individuals 18-21 years of age (4) "active treatment" requirement for children under 18 are further revised to provide more clarity in area that have been identified as causing provider confusion (5) Inspection of Care (IOC) rules to provide the pro-rating timeline used when reviewing clinical documentation for compliance with active treatment requirement as well as to clarify that certain "critical documentation" cannot be substituted with other evaluation/assessments.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-39 Genetic Testing

    Rules are amended to define the circumstances under which  genetic testing will be covered by OHCA.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-38 Electronic Health Records Updates

    Policy on the Oklahoma Health Records Incentive Program will be updated to account for changes in federal rules on the program:(1) Changes  include adding additional options for patient volume calculation (2)expanding the definition of a Children's hospital(3)adding exception to the Hospital-based eligible professional criteria(4) and allowing CMS to take over administrative appeals for cases in which they are the auditor on meaningful use provisions.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-37 Genetic Counseling

    Rules are amended to expand genetic counseling services to all members that are eligible for medically necessary genetic testing.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    The following APA WF 12-36 has been pulled for research and further studying of PDN services.

    APA WF # 12-36 Private Duty Nursing

    Policy will be amended to define eligible private duty nursing providers and require physicians to submit orders in addition to the treatment plan to verify medical need of treatments. OHCA will require a non-custodial caregiver to be the paid employee taking care of the child.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-35 Vaccine Administration

    Agency policy is amended with respect to vaccine administration as follows: (1) Adults. The change will allow for reimbursement of a separately payable administration fee for vaccines given to adults (2) Children. Separately, the policy clarifies Vaccines for Children Program administration fee per fee rules to state VFC providers may not charge multiple administration fees per shot.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-34 State Plan Personal Care

    Rules are revised to clarify compliance with Long Term Care Security Act regarding background checks for providers of direct access for long term care services.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-33 Supplemental Hospital Offset Payment Program (SHOPP)

    Rules are revised to clarify overpayment and recoupment procedures, if it is determined due to appeal, penalty or other reason that additional allocation /recoupment is necessary.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-32 SoonerCare Senior Waiver Services -

    Rules are revised to add Institutional Transition Services, Assisted Living Services and Self-Directed Goods and Services to the Sooner Senior Waiver Program. Additional revisions include removing language that does not align with program practices, for consistency and clarity purposes.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-31 My life,My Choice Waiver Services

    Rules are revised to add Institutional Transition Services, Assisted Living Services and Self-Directed Goods and Services to the My life,My Choice Waiver Program. Additional revisions include removing language that does not align with program practices, for consistency and clarity purposes.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-30 Medically Fragile Waiver Services

    Rules are revised to add Institutional Transition Services and Self-Directed Goods and Services to the Medically Fragile Waiver Program. Additional revisions include removing language that does not align with program practices, for consistency and clarity purposes.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-29 Community Spouse Allowance

    Rules are amended to clarify that a member receiving HCBS is considered a community spouse for the purpose of calculating  the community spouse allowance when his/her spouse is in a nursing facility. This change will bring the rules into compliance with Federal law and regulation and State plan. 

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-27 SoonerCare Home and Community Based Waiver Services (HCBS) Programs for Persons with Intellectual Disabilities

    Rules for are amended to clarify responsibilities for Agency Companion providers and Specialized Foster Care providers regarding reporting requirements when there are allegations of member maltreatment.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-25 SoonerCare Dental

    Rules are revised to update pulp cap language to align with current practice and language contained in 317:30-5-699. In addition, Orthodontic rules are revised to align verification of continuing education hours with the Oklahoma Board of  Dentistry prerequisite licensing requirements.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-24 Insure Oklahoma

    Rules are revised to align policy with state and federal requirements. Additionally, rules are revised to align adult outpatient behavioral health services with children outpatient behavioral services in the individual Plan.   

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-23 A and B SoonerRide

    Rules are revised to move meal and lodging related services to general provider policies as these services are not considered SoonerRide services. Additional revisions include clean-up to outdated Code of Federal Regulation references, and clarification concerning approved escort.    

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-22 Transportation

    Rules are revised to define emergency and urgent as it relates to Ambulance transports; rules are revised to clarify that out of state transports require a prior authorization. Additional revision include clean-up to remove obsolete language to align with current practices  

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-20 Telemedicine

    Rules are revised to include specific provider responsibilities to assure compliance with HIPAA guidelines.  

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-19 Behavioral Health  

    Amend Behavioral Health rules:(1) by clarifying Outpatient Rehabilitative Services; (2) Limit Psychosocial Rehabilitation Services (PSR) to age appropriate children; (3) Impose limits on PSR services based on the individual's level of needs as determined by standardized assessment tools recognized by ODMHSAS and OHCA.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-14 Obstetric

    Rules are revised to align policy with current obstetric policy and to clarify the type of Midwife covered as coverage is restricted to licensed certified nurse midwives. Additional revisions include format changes for consistency and clarity purposes.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-13 ICD-9 Coding

    Agency policy is revised to remove references to the ICD-9 International Classification of Diseases diagnosis coding, which is being replaced by a new system.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    The following APA WF 12-12 has been pulled from permanent rule process effective 2-20-2013. 

    APA WF # 12-12 ADvantage Assisted Living Waiver

    Rules are promulgated to create a new waiver for individuals currently receiving Assisted Living Services in the ADvantage Waiver. Members currently in the ADvantage Waiver and residing in an ADvantage certified assisted living center will transition into the ADvantage Assisted Living Waiver with no disruption in services.The same services currently available to members receiving Assisted Living Services in the ADvantage Waiver will be available to members in the new waiver. The new waiver is created in order to better control growth and utilization of services.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-09 Medicare Crossover Deductibles and Coinsurance

    Amend policy to allow 100% payment of Medicare Crossover deductibles and coinsurance for Skilled Nursing Facilities.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-08 Parental or Legal Guardian Consent

    Amend policy to match state law and current agency operational requirement for parental or legal guardian consent for rendered service to a minor child.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-07 Medicaid Income Pension Trust

    Amend policy to comply with federal law, which requires a prescription or referral from a physician or other practitioner of the healing arts before PT/OT/ST therapy services are rendered.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-06 Medicaid Income Pension Trust

    SoonerCare financial eligibility rules for Long-term Care services are amended to increase the income cap for the Medicaid Income Pension Trust (or Miller Trust) to the average monthly cost of nursing home care. 

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-05  Living Choice Demonstration Program

    Rules are revised to include clarification for billing of Institutional Case Management Transition services and the inclusion of additional services for persons with physical disabilities and long-term illnesses.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-04 A and B Advantage Waiver -

    Rules are revised to:(1) establish a maximum annual reimbursement cap for hospice services for members who exceed the waiver cost limit (2) disallow an active Power of attorney from being a paid caregiver for members self-directing their services (3) increase the maximum hours of Adult Day Health services to six hours (4) Advantage Waiver members receiving Assisted Living Services will be transitioned to a new waiver for Assisted Living before removal of Advantage Assisted Living services benefits (5) clarify the member/ provider dispute resolution process.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-03 Rural Health Clinics (RHCs)

    Rules are revised to allow RHCs to bill lab services separately, as they can under Medicare. In addition, RHC policy is also updated to eliminate language that is inapplicable to OHCA's policy.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-01 A and B Homeward Bound Waiver

    Rule revisions are proposed to provide exceptions for members of the Homeward Bound Waiver receiving Habilitation Training Specialist (HTS) services exceeding 40 hours per week, when the HTS resides in the same home as the member. The rule revisions are promulgated as a result of a lawsuit filed on behalf of class members of the Homeward Bound waiver.

    Circulation Date: 02/01/2013

    Comment Due Date: 03/03/2013

    Public Hearing: 03/04/2013

    Medical Advisory Committee (MAC): 03/13/2013

    Board: 03/14/2013


    APA WF # 12-09 - Medicare Crossover deductibles and Coinsurance

    Amend policy to allow 100% payment of Medicare Crossover deductibles and coinsurance for Skilled Nursing Facilities

    Circulation Date: 10/29/2012

    Comment Due Date: 11/29/2012

    Medical Advisory Committee (MAC): 11/14/2012

    Board: 12/13/2012


    APA WF # 12-08 - Parental or Legal Guardian Consent

    Amend Policy to match state law and current agency operational requirement for parental or legal guardian consent for rendered service to a minor child.

    Circulation Date: 10/29/2012

    Comment Due Date: 11/14/2012

    Medical Advisory Committee (MAC): 11/14/2012

    Board: 12/13/2012


    APA WF # 12-07 - Prescription or Referral

    Amend policy to comply with federal law, which requires a prescription or referral from a physician or other practitioner of the healing arts before PT/OT/ST therapy services are rendered.

    Circulation Date: 10/29/2012

    Comment Due Date: 11/14/2012

    Medical Advisory Committee (MAC): 11/14/2012

    Board: 12/13/2012


    APA WF # 12-06 - Medicaid Income Pension Trust

    SoonerCare financial eligibility rules for Long-term Care services are amended to increase the income cap for the Medicaid Income Pension Trust (or Miller Trust) to the average monthly cost of nursing home care. 

    Circulation Date: 09/19/2012

    Comment Due Date: 10/19/2012

    Medical Advisory Committee (MAC): 09/20/2012

    Board: 11/08/2012


    APA WF # 11-43 — Physician Services

    Circulation Date: 12/28/2011

    Comment Due Date: 01/18/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 12-01 — HCBS Waiver

    Circulation Date: 04/02/2012

    Comment Due Date: 06/02/2012

    Medical Advisory Committee (MAC): 05/17/2012 

    Board:06/14/2012


    APA WF # 11-42 Eligibility

    Circulation Date: 12/22/2012

    Comment Due Date: 01/18/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-41Behavioral Health

    Circulation Date: 12/30/2011

    Comment Due Date: 01/18/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-40 — Eligibility

    Circulation Date: 12/16/2011

    Comment Due Date: 01/18/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-39HCBS Waivers

    Circulation Date: 02/06/2012

    Comment Due Date: 02/26/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-38Durable Medical Equipment

    Circulation Date: 12/24/2011

    Comment Due Date: 01/12/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-36Dental

    Circulation Date: 12/28/2012

    Comment Due Date: 01/18/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-35PACE

    Circulation Date: 12/16/2011

    Comment Due Date: 01/05/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-34 Durable Medical Equipment

    Circulation Date: 12/14/2011

    Comment Due Date: 01/12/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-33 Insure Oklahoma

    Circulation Date: 12/16/2011

    Comment Due Date: 01/16/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-32  DDSD Waivers

    Circulation Date: 12/01/2011

    Comment Due Date: 01/02/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-31  Purchasing

    Circulation Date: 12/01/2011

    Comment Due Date: 01/01/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-30 School Base Billing

    Circulation Date: 12/07/2011

    Comment Due Date: 01/07/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-29 HCBS Waivers

    Circulation Date: 12/14/2011

    Comment Due Date: 01/09/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-27 Behavioral Health

    Circulation Date: 12/29/2011

    Comment Due Date: 01/18/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-26 Provider Contracts

    Circulation Date: 12/07/2011

    Comment Due Date: 12/28/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-25A SoonerRide

    Circulation Date: 12/14/2011

    Comment Due Date: 01/14/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-25B SoonerRide

    Circulation Date: 12/07/2011

    Comment Due Date: 01/14/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-24 Behavioral Health

    Circulation Date: 10/19/2011

    Comment Due Date: 11/07/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-21 HCBS Waivers

    Circulation Date: 02/03/2012

    Comment Due Date: 02/26/2012

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-20 General Provider Policies

    Circulation Date: 08/31/2011

    Comment Due Date: 09/19/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-19Individual Providers and Specialties (ESRD)

    Circulation Date: 12/02/2011

    Comment Due Date: 12/28/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-18 — SHOPP

    Circulation Date: 08/26/2011

    Comment Due Date: 09/14/2011

    Medical Advisory Committee (MAC): 09/15/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-17 — DME

    Circulation Date: 08/03/2011

    Comment Due Date: 08/23/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-16 — Cost Sharing

    Circulation Date: 08/04/2011

    Comment Due Date: 08/24/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-15 — LTC Eligibility

    Circulation Date: 09/30/2011

    Comment Due Date: 10/19/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-14 HCBS Waivers

    Circulation Date: 12/14/2011

    Comment Due Date: 01/09/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-13 — HCBS Waivers

    Circulation Date: 12/14/2011

    Comment Due Date: 01/09/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-11 Advantage Waiver

    Circulation Date: 08/05/2011

    Comment Due Date: 08/25/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-08 — Eligibility

    Circulation Date: 11/30/2011

    Comment Due Date: 12/19/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-07 — Coverage

    Circulation Date: 05/04/2011

    Comment Due Date: 05/18/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-05 — Coverage

    Circulation Date: 04/29/2011

    Comment Due Date: 05/18/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-04 — General

    Circulation Date: 10/18/2011

    Comment Due Date: 11/06/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-03 — SoonerPlan

    Circulation Date: 09/30/2011

    Comment Due Date: 10/19/2011

    Medical Advisory Committee (MAC): 01/19/2011

    Public Hearing: 02/22/2012

    Board:03/08/2012


    APA WF # 11-02 — Eligibility

    Circulation Date: 04/13/2011 

    Comment Due Date: 05/02/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-69 — Advantage Waiver

    Circulation Date: 02/09/2011 

    Comment Due Date: 03/02/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-74 — Children's Health

    Circulation Date: 02/03/2011 

    Comment Due Date: 02/24/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-04 — Behavioral Health FQHC

    Circulation Date: 01/31/2011

    Comment Due Date: 02/19/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-37 — Oklahoma Cares "BCC" Program

    Circulation Date: 01/27/2011

    Comment Due Date: 02/14/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-59 — DDSD Waiver

    Circulation Date: 01/27/2011

    Comment Due Date: 02/14/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-70 — Medically Fragile Waiver

    Circulation Date: 01/27/2011

    Comment Due Date: 02/14/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-71 — HCBS Assessment

    Circulation Date: 01/27/2011

    Comment Due Date: 02/14/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-53 — Behavioral Health

    Circulation Date: 01/27/2011

    Comment Due Date: 02/15/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-68 — Telemedicine

    Circulation Date: 01/19/2011

    Comment Due Date: 02/09/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-67  — Medical Operations

    Circulation Date: 01/19/2011

    Comment Due Date: 02/09/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-58  — Dental

    Circulation Date: 01/12/2011

    Comment Due Date: 02/01/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-77 — Eligibility

    Circulation Date: 01/04/2011

    Comment Due Date: 01/24/2011

    Medical Advisory Committee (MAC): 03/09/2011

    Board:03/10/2011


    APA WF # 10-66  — Child Health

    Circulation Date: 12/17/2010

    Comment Due Date: 01/07/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-61 — Durable Medical Equipment (DME)

    Circulation Date: 12/16/2010

    Comment Due Date: 01/05/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-63  — Eligibility

    Circulation Date: 12/13/2010

    Comment Due Date: 01/01/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-65 — Indian Health and Eligibility

     

    Circulation Date: 12/10/2010

    Comment Due Date: 12/30/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-60 — Electronic Signature & Records

    Circulation Date: 12/09/2010

    Comment Due Date: 12/29/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-56 — Indian Services

    Circulation Date: 12/08/2010

    Comment Due Date: 12/28/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-62 — Pharmacy

    Circulation Date: 12/02/2010

    Comment Due Date: 12/22/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


    APA WF # 10-52 — Air/Ambulance Transportation

    Circulation Date: 12/02/2010

    Comment Due Date: 12/22/2011

    Medical Advisory Committee (MAC): 01/20/2011

    Board:02/10/2011


     

      


     

     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 # 17-09 — 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

     

     


     

     

    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


     

    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 


    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 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.

  

 

    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.