SoonerCare 2.0

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The Centers for Medicare & Medicaid Services’ new Healthy Adult Opportunity program emphasizes value-based care and gives states unique flexibility to create programs within a defined budget. The focus is limited to adults ages 19-64 who are not otherwise eligible for SoonerCare.

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. However, this population may see some benefit as the state reinvests its shared savings back into SoonerCare. The Healthy Adult Opportunity program provides a framework for the Oklahoma Medicaid reform plan, known as SoonerCare 2.0.

    Reform Goals of SoonerCare 2.0:

  1. Reduce the uninsured through a responsible SoonerCare expansion.
  2. Improve health outcomes for Oklahomans.
  3. Achieve delivery system reform focused on improving health outcomes while maintaining fiscal responsibility for Oklahoma taxpayers.
  4. Improve access to care in rural Oklahoma.
  5. 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.

    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.

Reducing the uninsured: Responsible SoonerCare expansion

 

Based on our analysis, expanding SoonerCare to low-income adults with 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) will have the following impacts:

SoonerCare expansion by the numbers 
Estimated newly eligible adults 220,000
Estimated newly eligible adults who will enroll 180,000
Total cost of coverage expansion $1.24 billion annually
     State share $150 million
     Federal share $1.1 billion

Action Steps: Submit state plan amendment and 1115 waiver request

Oklahoma will submit a state plan amendment to expand SoonerCare to low-income adults up to 133% of the federal poverty level, effective July 1, 2020. Oklahoma will simultaneously pursue CMS approval for an 1115 waiver to establish new flexibilities through a per person expenditure cap, charge premiums for the expansion population and waive retroactive coverage requirements, as well as pursue community engagement requirements. 1115 waiver implementation will be synced with health care delivery system reform in 2021. Together these reforms will provide incentives for members to participate financially, be more engaged in their own health care outcomes and contain costs through a responsible SoonerCare expansion for Oklahoma.


Expansion program 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.      

Delivery system reform

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.

Improve access to care: Rural health stabilization

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.

Other Reforms 

    Maximize federal funding
  • 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.
    Protect against fraud
  • 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.
    Benefits changes
  • 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.
                          

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, the state can switch to an aggregate cap, 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 90-10, 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 demonstration opportunity allows the state to implement limited cost-sharing models for the Healthy Adult Opportunity population. The state may require members of the expansion population be employed, enrolled in a continuing education or technical training program, or participating 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.

  

SC 2 Timeline

                          


Information on public hearings is below:
 

VIRTUAL MEETING
April 7, 2020 at 2:00 p.m. Central Time
Register for Zoom Meeting: https://okhca.zoom.us/webinar/register/WN_eVbm3RGkSpePlAk4oK0BpA
Meeting Agenda


Comments on any item that is currently open for public comment can be submitted to federal.authorities@okhca.org. They may also be submitted via the OHCA Policy Blog.



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