APA WF 23-06A Transition to SoonerSelect
The proposed rule additions/revisions will outline and address state-sanctions and complementary non-compliance remedies required of the medical contracted entities (CEs) and dental benefit managers (DBMs) and will define terms, processes, and regulations that were outlined in the Oklahoma Senate Bill 1337 (SB1337) and the published RFP/Model Contract. Other rule additions will include, but are not limited to, managed care mandatory and voluntary populations (American Indian/Alaskan Native (AI/AN) members), processes for network adequacy, provider requirements, termination of contracts, transition of care policies, medical necessity, required notices and grievances and appeals. These changes comply with SB1337 and Oklahoma Senate Bill 1396 (SB 1396), which directs the Oklahoma Health Care Authority to transition to a new health care program, called SoonerSelect.
Please view the circulation document here: APA WF # 23-06A and submit feedback via the comment box below.
Circulation Date: 01/27/2023
Comment Due Date: 02/27/2023
Medical Advisory Committee (MAC) Meeting: 03/02/2023
Board Meeting: 03/22/2023
Comments
Dianna Berry:
Thank you for the opportunity to provide comment.
The proposed policy includes existing language regarding the initiation of an appeal. Specifically, the language in OAC 317:2-1-2(b) Member process review reads,
"(1) The appeals process allows a member to appeal a decision relating to program benefits. Examples are decisions involving medical services, prior authorizations for medical services, or discrimination complaints.
(2) In order to initiate an appeal, the member must file a LD-1 (Member Complaint/Grievance Form) within thirty (30) calendar days of the date the OHCA sends written notice of its action, in accordance with Oklahoma Administrative Code (OAC) 317:2-1-2(a), above, or, in matters in which a formal notice is not sent by the agency, within thirty (30) days of the date on which the member knew or should have known the facts or circumstances serving as the basis for appeal.
(3) If the LD-1 form is not received timely, the OHCA administrative law judge (ALJ) will cause to be issued a letter stating the appeal will not be heard. In the case of tax warrant intercept appeals, if the LD-1 form is not received by OHCA within the timeframe pursuant to 68 O.S. § 205.2, OHCA similarly will cause to be issued a letter stating the appeal will not be heard because it is untimely."
The language in the latter part of (2) above (in "matters" (emphasis added) in which a formal notice is not sent by the agency, within thirty (30) days of the date on which the member knew or should have known the facts or circumstances serving as the basis for the appeal) appears to violate the provisions of 42 CFR 435.917(a) Notice of eligibility determinations, which requires the agency to "provide all applicants and beneficiaries with timely and adequate written notice of "any" decision affecting their eligibility, including an approval, denial, termination or suspension of eligibility, or a denial or change in benefits and services..."
Additionally, pursuant to 42 CFR 345.917(b) Content of notice, the notice must be consistent with Section 431.210 and clearly state the action the agency intends to take, specific reasons supporting the intended action, and specific regulations that support, or federal law that requires the action.
Pursuant to 42 CFR 431.211, the notice must be "sent" (emphasis added) at least 10 days before the date of action, unless the reason for the action qualifies under one of the exceptions (death of beneficiary, signed statement from the beneficiary that he no longer wants services, fraud, etc.), in which a shorter written notice period is allowed
Failing to provide the required and specific written notice denies an applicant and beneficiary his/her due process rights and places the applicant/beneficiary at significant risk of losing benefits for which he/she may be entitled.
OHCA Response:
Thank you for your comment. Please note, the OHCA sends out all notices required by the federal regulations.
