Library: Policy

317:55-5-22. Payment to providers

Revised 7-1-23

(a) Provider payment.

(1) The CE and DBM shall establish rates for participating providers are reasonable to cover access to services.

(2) The CE and DBM shall abide by state and federal requirements related to payment of specific provider types as described in the Contract.

(3) Pursuant to 56 O.S. § 4002.12, the OHCA shall establish minimum rates of reimbursement from CEs to providers who elect not to enter into a value-based payment arrangement or other alternative payment arrangements for health care services rendered to Enrollees.

(4) Applicable exceptions to OAC 317:55-5-22(3) can be found at 56 O.S. § 4002.12(I).

(b) Non-participating provider payment. If the CE or DBM is unable to provide covered services to an Enrollee within its network of participating providers, the CE or DBM must adequately and timely arrange for the provision and payment of these services by non-participating providers. Except as otherwise provided by law and/or specified for IHCPs, FQHCs, RHCs, and CCBHs, the CE or DBM will reimburse non-participating providers for covered services provided to Enrollees at a minimum of ninety percent (90%) of the current Medicaid fee schedule, unless the CE or DBM and the non-participating provider has agreed to a different reimbursement amount.

(c) Value-based payments. The CE and DBM shall implement value-based payment strategies and quality improvement initiatives to promote better care, better health outcomes, and lower spending for publicly funded health care services. OHCA will follow the withhold payment schedule and perform annual assessments to ensure CEs and DBMs are adhering to the VBP target requirements in accordance with the Contract. Pursuant to 42 C.F.R. § 438.10(f)(3), if the CE uses physician financial incentive plans, the Contractor must make available information about the incentive program. The CE shall also provide information about any physician incentive plans to OHCA prior to its initial use and prior to any subsequent revisions, and report information to OHCA as specified in the reporting manual. Any such incentive plans must comply with all applicable laws, including, without limitation 42 U.S.C. § 1395mm(i)(8) and 42 C.F.R § 417.479.