Library: Policy

317:55-1-4. Eligible entities

Issued 7-1-23

        Eligible entities. The OHCA shall enter into a capitated contract for the delivery of statewide Medicaid services. Eligible entities include an accountable care organization, a provider-led entity, a commercial plan, or any other entity as determined by OHCA. The CE or DBM shall meet the following requirements:

(1) Licensure and certificate of authority.

(A) The CE must be licensed as a Health Maintenance Organization (HMO) pursuant to 36 O.S. § 6901 et seq.

(B) The CE must furnish OHCA with a certificate of authority, to operate as an HMO, prior to contract implementation.

(C) The DBM must be licensed and authorized, as prepaid dental health plan, and able to transact dental business in the State of Oklahoma in accordance with 36 O.S. § 6141 et seq.

(D) The DBM must furnish OHCA with a certificate of authority for accident and health insurance or pre-paid dental prior to contract implementation in accordance with 36 O.S. § 703.

(E) Any changes to the certificate of authority, for CE and DBM, must be reported immediately to the OHCA.

(2) Accreditation. The CE or DBM shall seek accreditation from a private independent accrediting entity, as well as, earn a National Committee for Quality Assurance (NCQA) Health Equity Accreditation in the State of Oklahoma, within eighteen (18) months of initial enrollment implementation. When undergoing accreditation, the CE or DBM shall submit reports documenting the status of the accreditation process as required in the Contract and reporting manual.

(A) Accreditation review. The CE or DBM shall authorize the accrediting entity to provide the OHCA a copy of the CE's or DBM's most recent accreditation review including:

(i) Accreditation status, survey type, and level (as applicable);

(ii) Accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and

(iii) Expiration date of the accreditation.

(B) Reaccreditation. The CE and DBM shall undergo reaccreditation in accordance with the timeframes required by the accrediting entity and federal regulations.

(C) Failure to achieve or maintain accreditation for a CE. Failure to achieve or maintain accreditation shall be considered a breach of the CE Contract and may result in intermediate sanctions/penalties or termination in accordance with OAC 317:55-5-10(e) (D) Failure to achieve or maintain accreditation for a DBM. Failure to achieve or maintain accreditation shall be considered a breach of the DBM Contract and may result in administrative remedies, including liquidated damages or termination, in accordance with OAC 317:50-5-11 and 317:55-5-12.