About SoonerCare 2.0

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 19-65 who are not otherwise eligible for Medicaid.

The traditional Medicaid 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 Medicaid 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 Medicaid 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 Medicaid expansion

Based on our analysis, expanding Medicaid to low-income adults with household income up to 138% of the federal poverty level ($17,608 for an individual and $36,156 for a family of four in 2020) will have the following impacts:

Medicaid expansion by the numbers 
Estimated newly eligible adults 220,000
Estimated new 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 Medicaid to low-income adults up to 138% of the federal poverty limit, 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 Medicaid expansion for Oklahoma.

 

Expansion program funding

Ninety percent of costs for expansion enrollees will be paid by the federal government. The 10% state share will be paid for by a combination of savings offsets elsewhere in the state’s budget and through provider assessments. 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 Oklahoma’s Medicaid program 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. Health plans will be incentivized and held accountable for improving the health of members and will pay providers through incentives toward outcomes.

 
 

Improve access to care: Rural health stabilization

The state government 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 could include 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 Medicaid coverage upon release, helping them get access to important behavioral health services immediately, thus reducing the risk of recidivism.
  • Help jails and prisons capture Medicaid funding for hospitalizations and surgeries as allowed under federal Medicaid law.
    Protect against fraud
  • Ensure providers understand Medicaid program rules and consequences for billing fraudulently.
  • Deter Medicaid 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, reinstate an adult dental benefit in Medicaid, 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 90-10 rate, there is a per person expenditure cap. The Health 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 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 the state’s Medicaid program, potentially into new or enhanced programs for the traditional Medicaid 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.

 

 

Timeline