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