SoonerCare Comprehensive Managed Care Program
Request for Public Feedback in Program Design

 

Planned Comprehensive Medicaid Managed Care Implementation

On June 18, 2020, Governor Kevin Stitt and Oklahoma Health Care Authority (OHCA) CEO Kevin Corbett announced that the state would seek proposals from qualified managed care organizations (MCOs) to improve health outcomes, increase access to care, and increase system accountability in the Medicaid program (SoonerCare). The Request for Proposals (RFP) is currently in development, with a planned release this fall and an anticipated implementation date of October 1, 2021. OHCA is establishing requirements and is seeking stakeholder input prior to finalizing the RFP. OHCA will accept responses from any interested party including individuals and program participants, providers, trade associations, companies and other organizations. Responses need not address every question. Responses should be submitted by 5:00pm Central Time on August 17, 2020. Responses should be submitted via email to Procurement@okhca.org and can be submitted as a letter attachment. Please reference 80720200002 in the subject line of your response. 

 

Comprehensive Managed Care for Oklahoma: A Key Tool for Program Improvement

Oklahoma is pursuing a comprehensive Medicaid managed care approach that will allow the state to achieve its payment and delivery system reform goals:

Heart with pulse Improve health outcomes for Oklahomans  
Gears Transform payment and delivery system reform statewide by moving toward value-based payment and away from payment based on volume 
Star Improve member satisfaction 
Money Contain costs through better coordinating services 
Bullseye Increase cost predictability to the state 


The following sections provide information on the planned managed care program and identifies areas where additional input is requested.

 

Managed Care Enrollees  Heart with pulseStarBullseye

Managed Care enrollment will provide SoonerCare members with better access to a system that is more coordinated and has greater cost predictability.

To improve health outcomes, children, low-income parents, pregnant women, and adults ages 19-64 (expansion population) will be required to enroll in MCOs, which will be responsible for their access to and quality of care.

  • Individuals enrolled in SoonerCare due to their status as “Aged, Blind, or Disabled” (ABD) will initially remain in fee-for-service
  • Senior citizens and people enrolled in both Medicare and Medicaid (“dual eligibles”) will initially remain in fee-for-service Medicaid
  • Individuals who transition to long term care in a nursing facility or ICF/IDD will be disenrolled from the MCO after 60 days in an institutional care setting
  • MCOs will serve members across the state

To ensure that each member has a health plan responsible for their care and health, the SoonerCare application will include a choice of plans. People who do not choose a plan will have one assigned. Members will have opportunities to switch plans.

Questions for Stakeholder Input: Enrollees
  • How and when should OHCA transition ABD and other initially excluded individuals to managed care?
  • Should the state require each MCO enroll all populations or should the state allow specialty plans such that an MCO could propose to serve only certain populations, such as children in foster care, American Indians/Alaska Natives, people with Serious Mental Illness, or other groups?
  • How can MCOs better engage individuals in their health care and healthy behaviors, such as seeing a doctor regularly, quitting smoking, and eating healthier?  

 

Benefits Provided through MCOs  Heart with pulseGears

Managed care enrollees will receive the same benefits and services they receive currently, plus some extra benefits. The MCOs will manage physical health, behavioral health, vision, and non-emergency medical transportation for their members. Members will not need a referral to receive pregnancy care, behavioral health, vision, family planning, emergency care and care from Indian Health Care Providers for AI/AN members. In addition, MCOs may offer “value added” benefits that are not available in traditional Medicaid, such as additional medical supplies and health and wellness incentives.

SoonerCare will continue to use an evidence-based approach to care, and medical necessity will continue to be used to guide the appropriateness of services. Delivered services will be consistent with accepted prevention, diagnostic and treatment practices.

AI/AN members in managed care will continue to have access to Indian Health Service (IHS) or Tribal health care providers of their choice.

To ensure appropriate and sufficient behavioral health care, each MCO must:

  • Allow reimbursement for co-location of physical health and behavioral health services 
  • Operate a behavioral health crisis line and coordinate with the statewide crisis line where applicable
  • Integrate behavior and physical health


To help members address the root causes of many health issues, MCOs will be required to engage in Social Determinants of Health strategies, including:

  • Screening enrollees for social needs
  • Providing enrollees with referrals to social services and tracking the outcomes of referrals
  • Partnering with community-based organizations or social service providers
  • Requiring employment of community health workers or other non-traditional health workers


Questions for Stakeholder Input: Benefits

  • What would make it easier for individuals to access health care? How could managed care plans help individuals resolve problems with accessing care?
  • What strategies would improve the integration of services (especially behavioral and physical health), including through provider communication, shared assessments and planning, and data sharing?
  • How could MCOs best facilitate referrals and track outcomes of referrals to social services such as housing assistance, food security, education and employment assistance? How could OHCA measure MCO performance on social risk factor mitigation strategies? 
  • How can MCOs improve access to evidence-based behavioral health care, such as Screening, Brief Intervention and Referral to Treatment (SBIRT), medication assisted treatment for opioid use disorder or, assertive community treatment?
  • What types of value-added services would be most impactful for members in terms of improving health outcomes, prevention and member satisfaction?
  • How can MCOs improve access to transportation for SoonerCare members? Should ride-sharing services like Uber and Lyft continue to be options for rides to medical appointments?
 
Quality and Accountability  Heart with pulseGearsStar

MCOs will be held accountable for providing members with quality care that improves their health. OHCA will collect MCO data and assess plan performance on process and outcome measures.

OHCA will require MCOs to support the agency’s quality goals and actively improve access, quality of care and health outcomes for SoonerCare members.

  • Areas for quality measurement include population health goals identified as state priorities: tobacco use, opioid-related overdose deaths, childhood obesity, behavioral health access, diabetes, cardiovascular disease, infant mortality and pregnancy outcomes
  • MCOs will reimburse providers using a methodology with a performance-based component that incentivizes outcomes for state-priority conditions
  • OHCA is investigating the use of incentive measures, quality pools and other programs; MCOs will participate in OHCA efforts to provide enrollees access to quality health care

Questions for Stakeholder Input: Quality and Accountability
  • What mechanisms should the state use to incentivize MCOs to improve member outcomes?
  • What are the most important indicators of MCO performance? Why? 
  • What measures of health outcomes should be tracked?

 

Care Management and Coordination  Heart with pulseGearsMoney

MCOs have experience managing members’ health, including for populations with complex or multiple needs. Medicaid MCOs work under federal utilization and care management requirements. OHCA is also developing state requirements and standards for MCOs regarding:

  • Prior authorization (PA): services subject to PA, timeliness standards for approval
  • Use of practice guidelines
  • Utilization management program standards

To support providers’ efforts to organize patient care and appropriately share information among providers engaged in a patient’s care, MCOs will be required to:

  • Conduct health screenings to identify ongoing need, current providers, and social determinants of health
  • Develop care plans for identified enrollees and establish care management and care coordination based on identified risk and particular health conditions 
  • Design health management programs with a holistic approach to member health
  • Conduct health education in priority areas and on emerging issues

In addition, MCOs will support Patient Centered Medical Homes under a re-design that utilizes a value-based strategy that includes integration of behavioral health and social determinants, enhanced care coordination payments and performance measurement. 


Questions for Stakeholder Input: Care Management and Coordination 
  • How can utilization management tools work best for members and providers? 
  • How should the state encourage or require consistency across MCOs in the utilization management process to reduce provider administrative burden?
  • What specific network development, care delivery and care coordination approaches should MCOs be required to employ to better meet enrollees’ behavioral health needs?
  • How can MCOs improve the management and coordination for members with chronic or complex health conditions? 
  • What should MCOs do to reduce barriers to care and improve coordination for populations such as children in foster care, AI/AN members, individuals with serious mental illness, justice-involved individuals, and others whose needs present unique considerations? 

 

Member Services  Heart with pulseStar

Medicaid MCOs must follow federal rules for providing responsive and meaningful member assistance, to include: 

  • Answer member questions timely via telephone or email and resolve grievances and appeals timely
  • Frequently update provider directories online to help members locate health care providers 
  • Provide member materials in the prevalent non-English languages and ensure written materials are easily understood by individuals of varying literacy levels

Questions for Stakeholder Input: Member Services
  • What metrics should be used to measure MCO performance with regards to member services? 
  • How can MCOs best serve individuals who primarily speak a non-English language? Individuals who may not understand health care terminology? 
  • How can MCOs use technology (such as web-based applications and mobile phones) to help members with their health care needs? 
  • How can MCOs best communicate with members who do not have a mobile phone, computer or reliable internet service? 
  • How can MCOs communicate with members and receive regular input and feedback on program improvements? 
  • What tools and resources would help members search for providers? What information should be provided?

 

Provider Payments and Services  GearsBullseyeMoney

Each MCO must meet OHCA and federal requirements, including negotiating provider rates that ensure member access to care.

  • As required by CMS, do not pay a provider for provider-preventable conditions
  • Continue to pay Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) using the current Prospective Payment System, until/unless an Alternative Payment Methodology is developed
  • Pay Indian Health Care Providers at the encounter rate whether or not they are in network
  • Non-network Indian Health Care Providers can refer an AI/AN patient to a network provider 
  • Require MCOs to credential health care providers timely while verifying their credentials and checking for a history of health care fraud
  • Maintain and/or expand telehealth availability

Questions for Stakeholder Input: Provider Payments and Services
  • What metrics should be used to measure MCO performance with regards to provider services? 
  • Should OHCA require MCOs to maintain a minimum level of reimbursement? How should this be accomplished? How should the state sustain provider compensation?
  • What is appropriate for timely payment of claims?
  • What provider services functions or processes should be standardized across MCOs? How should this be accomplished? What are the barriers to standardizing the function and how should these be addressed?
  • How can MCOs best communicate to providers about updates and changes to plan policies?
  • How can MCOs help providers navigate plan administrative requirements for activities such as submitting claims or resolving billing issues? Beyond contracting and billing issues, what kinds of supports could MCO provider services staff offer to network providers? 
  • What can OHCA and MCOs do to prepare and help providers to successfully participate in shared accountability models that reward providers for quality and improved health outcomes? 
  • How can MCOs support primary care providers in caring for their patients? What infrastructure, programs, training or coaching would be useful?

 

Network Adequacy  Heart with pulseStar

Because access to providers is a cornerstone of appropriate and adequate care, MCOs must ensure members receive timely access to care, including:

  • Examples of industry standards include:
    • Primary care medical home appointments within 30 days from request for routine care, 72 hours for non-urgent sick care, 24 hours for urgent care
    • Specialist and behavioral health appointments within 60 days from request for routine care, 24 hours for urgent care
    • Require all Primary Care Providers have at least some same-day acute care appointments
    • Availability of services within time and distance proximity standards to most members’ residences, differentiated by provider type (ex. in-network specialists available within 60 miles or 60 minutes of most members’ residences)
     
  • Show the MCO has sufficient Indian Health Care Providers in its network to ensure timely access to services to these providers for AI/AN enrollees

Questions for Stakeholder Input: Network Adequacy
  • How should MCOs work with providers to ensure timely access to care standards are met? 
  • What are reasonable time and distance standards in Oklahoma by provider type? 
  • How should MCOs recruit more health care providers in Oklahoma to participate in Medicaid? 
  • How should MCOs support workforce development for different types of providers, including pediatric dentists, pediatric psychiatrists, primary care providers, and behavioral health providers?

 

Grievances and Appeals  Heart with pulseStar

To ensure accountability to the state and SoonerCare members, MCOs must meet OHCA and federal requirements for timely and meaningful grievances and appeals processes. Grievances and appeals can be filed by members or providers on their behalf.

  • MCOs will resolve appeals within 30 days for standard requests and within 72 hours for expedited requests
  • MCOs will resolve grievances in writing within 30 days

Questions for Stakeholder Input: Grievances and Appeals
  • How can MCOs and the state receive feedback and be accountable for addressing member concerns? Are there proactive approaches that should be explored? 
  • How can the state and MCOs use appeals data to improve utilization management and access?

 

Administrative Requirements  Heart with pulseStar

OHCA will hold MCOs to high standards for responsiveness and accountability by requiring Medicaid MCOs:

  • Gain accreditation by a federally-approved accreditation body (NCQA, URAC, AAAHC) 
  • Maintain an Oklahoma presence, including having plan operations in Oklahoma and an office located no more than 100 miles from OHCA, at which executive team and key staff work 
  • Participate in the state Health Information Exchange to allow the MCOs and providers to improve care by eliminating redundant tests and procedures, support care coordination and transitions, and facilitate the exchange of electronic health records and care plans

Questions for Stakeholder Input: Administrative Requirements

  • How can OHCA and MCOs streamline data sharing but still maintain appropriate patient privacy and security? What data should be shared between MCOs and providers to facilitate patient care? 
  • What are the barriers to data sharing and how can they be overcome, including for providers with limited resources and technology? 
  • How can MCOs help identify member and provider fraud? What methods of fraud prevention and detection should be deployed? 
  • Should the state require MCOs to offer health plans on the Oklahoma Health Insurance Marketplace?