SoonerCare 2.0

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Oklahoma’s Medicaid program, SoonerCare, currently covers only children, pregnant women, elderly adults, and disabled adults. The state continues to explore ways to offer affordable access to quality care for more Oklahomans.

The state is seeking approval from the Centers for Medicare & Medicaid Services for a Healthy Adult Opportunity demonstration waiver. The application lists a proposed July 1, 2021 effective date. This would apply only to the expansion population — Oklahoma adults ages 19-64 with income less than 133% federal poverty level ($16,970 annual income for an individual; $34,846 for a family of four), who do not otherwise qualify for Medicaid.

Key Points for HAO

  • The Healthy Adult Opportunity waiver allows the state more flexibility in how it administers the plan for the expansion population of healthy adults — such as incentive programs for healthy behaviors, added benefits such as  mental health offerings, the ability to address social health determinants, and more. The state is also using this time of innovation in its health care system to move from a traditional fee-for-service model toward outcome and value-based care.
  • To enhance alignment between Medicaid policies and the commercial health insurance market, individuals in SoonerCare 2.0 will be asked to invest in their health via monthly premiums. The premium amount will be based on household income and the number of people in the household participating in the demonstration ($0-$10 for individuals, $0-$15 for families).
  • The traditional SoonerCare population — low-income parents, children, pregnant women, elderly adults and people eligible on the basis of disability — will not be directly affected by changes related to SoonerCare 2.0, although they may see benefits as the state reinvests its shared savings from the changes back into the program. 

On the Calendar:

In accordance with state and federal guidance on social distancing and CMS authorization during the COVID-19 pandemic, OHCA is conducting its public meetings and hearings virtually.

CMS has posted the state’s Healthy Adult Opportunity waiver application for public comment. It is available here. The federal public comment period will be open May 28-June 27, 2020. 

SoonerCare 2.0 Goals & Priorities

Reform Goals:

  1. Reduce the uninsured through a responsible SoonerCare expansion.
    SoonerCare 2.0 will create access to coverage for thousands of low-income adults with a household income up to 133% of the federal poverty level ($16,970 for an individual and $34,846 for a family of four in 2020).
  1. Improve health outcomes for Oklahomans.
    The Healthy Adult Opportunity waiver – which applies only to the expansion population – provides the state flexibilities in how it administers the plan, such as incentives for healthy behaviors, the ability to address social health determinants and encourage overall engagement in personal health care outcomes.

  2. Achieve delivery system reform focused on improving health outcomes while maintaining fiscal responsibility for Oklahoma taxpayers.
    The Healthy Adult Opportunity waiver for the expansion population will be synced with health care delivery reform in. To increase the effectiveness of SoonerCare and achieve better outcomes, the state is exploring alternative delivery systems, moving away from a fee-for-service model and placing a strong emphasis on quality of service and health outcomes, while maintaining fiscal responsibility for Oklahoma taxpayers.

  3. Improve access to care in rural Oklahoma.
    OHCA will work with health care providers, communities and payers to take advantage of new federal opportunities to redesign and administer health care services in rural Oklahoma. This includes an expansion of telehealth services and the use of community health workers as extenders.

  4. Incentivize members to access services when and where appropriate, and introduce private insurance concepts like premiums to prepare members to move off SoonerCare and into private coverage.

    Because SoonerCare 2.0 reform applies only to the expansion population of healthy adults, members will be incentivized through community engagement requirements and financial participation through low premiums and co-pays. This will allow for added benefits in the future such as dental or mental health offerings.

    Population health priorities to be improved by SoonerCare 2.0:

  1. Reduce the number of opioid-related overdose deaths.
  2. Decrease the incidence of childhood obesity.
  3. Improve access to community behavioral health care services.
  4. Encourage tobacco cessation and reduce tobacco-related illness.
  5. Increase prevention of cardiovascular disease.

SoonerCare 2.0 Funding

Ninety percent of costs for expansion enrollees will be paid by the federal government. No new state taxpayer dollars will be used to fund expansion. Provisions will be established to allow the state to end expansion if the federal government changes its financial commitment.
Maximizing federal funding allows the state the ability to:
  • Promote integrated care and improve health outcomes, explore reinstating an adult dental benefit in SoonerCare, with a focus on preventive dental services.
  • Pursue substance use disorder and serious mental illness waivers to expand access to prevention and treatment services.
  • Coordinate with jails and prisons to help former inmates apply for SoonerCare coverage upon release, helping them get access to important behavioral health services immediately, thus reducing the risk of recidivism.
  • Help jails and prisons capture SoonerCare funding for hospitalizations and surgeries as allowed under federal Medicaid law.
  • Ensure providers understand SoonerCare program rules and consequences for billing fraudulently.
  • Deter SoonerCare eligibility fraud by creating a new policy to recover benefit costs when coverage is gained fraudulently.

Frequently Asked Questions

What is SoonerCare 2.0?

SoonerCare 2.0 is Oklahoma’s name for the state’s implementation of the CMS Healthy Adult Opportunity demonstration waiver.

Besides the expanded population, how is SoonerCare 2.0 different?

While the state’s spending on the expanded population will be matched at a 90% rate by the federal government, there is a per person expenditure cap. The Healthy Adult Opportunity is widely being described as a block grant, but the proposed model is not a traditional block grant and incorporates financial components already available through 1115 waiver authority.

After two years of data, CMS will evaluate and determine whether the State has met certain health outcome goals. If so, the state can switch to an aggregate cap at that time, which will be calculated on the previous two years of data. This will open the door to the shared savings portion of the Healthy Adult Opportunity demonstration. If the state is able to keep expenses below that aggregate cap, while also meeting certain levels of minimum coverage and key performance metrics, the state and federal government will split that savings up to 50-50. Since the funding is 90% federal, 10% state, the shared savings will be a net gain for the state and those funds will be reinvested into SoonerCare, potentially into new or enhanced programs for the traditional SoonerCare population. This could be used to target trouble areas that will have a broader impact on members’ health and the state’s health outcomes.

Under both cap models, the state will also have flexibility to implement administrative changes without advanced approval, giving Oklahoma flexibility to adjust policies as needed. The plan also offers flexibility regarding prescription drug coverage while outlining certain minimums.

The Healthy Adult Opportunity demonstration waiver allows the state to implement limited cost-sharing models for the expansion population. The state may require members of the expansion population be employed, enrolled in a continuing education or technical training program, or to participate in certain community engagement activities.

How will the state achieve the savings while maintaining adequate coverage?

Our current effort is focused on improving health outcomes. Past attempts at service delivery reform have been budget-driven and focused primarily on achieving specific cost savings targets at the expense of quality. We will follow the best practices already established in other states, where cost savings reliably flow from better care coordination and the elimination of inappropriate or unnecessary care. The highest priority is always to improve patient outcomes.

How would this differ from the full Medicaid expansion? What does full expansion look like in terms of the details you discussed for HAO?

HAO is full Medicaid expansion in the fact that all adults are eligible for SoonerCare if they make at or below 133% of the federal poverty level. HAO differs from state plan Medicaid expansion in that there are additional requirements tied to maintaining eligibility such as community engagement requirements and nominal premiums.

Why is expansion only available for individuals with income up to 133% FPL?

This is the income limit allowed for the adult expansion population in the Affordable Care Act.

What is the purpose of work requirements as part of the HAO expansion population?

A large body of research has shown that employed individuals are healthier than those who are not employed. Enhancing employment opportunities for working-age people can improve health status and decrease the overall cost of providing health care. Employment can improve health by increasing social capital, enhancing psychological well-being, providing income and reducing the negative health impacts of economic hardship. Incentivizing employment, pursuit of educational and/or vocational activities and volunteerism promotes all of these objectives.

How much will the expansion population pay in monthly premiums and co-pays? Why?

Premiums are tiered based on the family's income with the understanding that those with lower incomes should have lower premiums. Depending on income, premiums will be $0, $5 or $10 monthly for an individual or $0, $7.50 or $15 for families.
Premium payments are critical to member engagement, as studies have shown that making regular monthly premiums may lead to better health outcomes for members. For example, in Indiana, where Medicaid eligible adults are required to pay monthly premiums, members making contributions had higher satisfaction rates, higher primary and preventative care utilization, higher prescribed drug adherence, and lower emergency room use than those who did not. (The Lewin Group, Indiana Healthy Indiana Plan 2.0 Interim Evaluation Report (2016))
Individuals will be charged copayments in addition to their premium obligation, up to the 5% out-of-pocket cost sharing limit.


Related Links

OHCA Policy Blog

Press Releases

Medicaid Expansion

HAO Demonstration Waiver