Okla. Stat. tit. 56, § 56-4002.5

authority required.

A. A contracted entity shall be responsible for all

administrative functions for members enrolled in its plan including,

but not limited to, claims processing, authorization of health

services, care and case management, grievances and appeals, and

other necessary administrative services.

B. Prior to the execution of a contract between a contracted

entity and the Oklahoma Health Care Authority, the contracted entity

shall obtain the appropriate certificate of authority issued by the

Insurance Department.

1. A contracted entity shall obtain a certificate of authority

issued by the Insurance Department to operate as a health

maintenance organization when the contracted services to be

delivered include physical health services, behavioral health

services, and prescription drug services.

2. A contracted entity shall obtain a certificate of authority

issued by the Insurance Department to operate as an accident and

health insurer or as a prepaid dental plan organization when the

contracted services to be delivered include dental services.

C. 1. To ensure providers have a voice in the direction and

operation of the contracted entities selected by the Oklahoma Health

Care Authority under Section 4002.3b of this title, each contracted

entity shall have a shared governance structure that includes:

a. representatives of local Oklahoma provider

organizations who are Medicaid providers,

b. essential community providers, and

c. a representative from a teaching hospital owned,

jointly owned, or affiliated with and designated by

the University Hospitals Authority, University

Hospitals Trust, Oklahoma State University Medical

Authority, or Oklahoma State University Medical Trust.

2. No less than one-third (1/3) of the contracted entity's

local governing body shall be comprised of representatives of local

Oklahoma provider organizations.

3. No less than two members of the contracted entity's clinical

and quality committees shall be representatives of local Oklahoma

provider organizations, and the committees shall be chaired or co-

chaired by a representative of a local Oklahoma provider

organization.

D. A contracted entity shall promptly notify the Authority of

all material changes affecting the delivery of care or the

administration of its program.

E. A contracted entity shall have a medical loss ratio that

meets the standards provided by 42 C.F.R., Section 438.8.

F. A contracted entity shall provide patient data to a provider

upon request to the extent allowed under federal or state laws,

Oklahoma Statutes - Title 56. Poor Persons Page 308

rules or regulations including, but not limited to, the Health

Insurance Portability and Accountability Act of 1996.

G. A contracted entity or a subcontractor of a contracted

entity shall not enforce a policy or contract term with a provider

that requires the provider to contract for all products that are

currently offered or that may be offered in the future by the

contracted entity or subcontractor.

H. Nothing in this act or in a contract between the Authority

and a contracted entity shall prohibit the contracted entity from

contracting with a statewide or regional accountable care

organization.

I. Nothing in this act, in a contract between the Authority and

a contracted entity, or in a contract between a contracted entity

and a provider shall prohibit any provider from contracting with

more than one contracted entity.

J. A contracted entity shall not withhold, fail to offer, or

make impracticable a contract with a provider on the basis of

independent practice or lack of hospital system affiliation.

K. All contracted entities shall:

1. Use the same drug formulary, which shall be established by

the Authority; and

2. Ensure broad access to pharmacies including, but not limited

to, pharmacies contracted with covered entities under Section 340B

of the Public Health Service Act. Such access shall, at a minimum,
der on the basis of

independent practice or lack of hospital system affiliation.

K. All contracted entities shall:

1. Use the same drug formulary, which shall be established by

the Authority; and

2. Ensure broad access to pharmacies including, but not limited

to, pharmacies contracted with covered entities under Section 340B

of the Public Health Service Act. Such access shall, at a minimum,

meet the requirements of the Patient's Right to Pharmacy Choice Act,

Section 6958 et seq. of Title 36 of the Oklahoma Statutes.

L. Each contracted entity and each participating provider shall

submit data through the state-designated entity for health

information exchange to ensure effective systems and connectivity to

support clinical coordination of care, the exchange of information,

and the availability of data to the Authority to manage the state

Medicaid program.