Presented

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An Improved Medical Home forEvery SoonerCare
Choice Member

• Presented
• OHCA Fall Training
• October 9, 2008

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Objectives

• SoonerCare Choice Today
• Medical Advisory Task Force (MAT)
• SoonerCare Choice Moving Forward
• Questions and Comments

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What is SoonerCare Choice Today?

• SoonerCare Choice is a managed care model in
  which each member is linked to a primary care
  provider who serves as their medical home.

PCPs manage the basic health care needs,
including after hours care and specialty referral
of the members on their panel.
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PCP Network

• SoonerCare Choice has over 400,000 members
  enrolled statewide
• Over 1,200 PCPs
• Average panel size of 333 members per PCP

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Current Primary Care Payment Structure

• Capitated Bundled Rates include payment for
• Monthly case management based on age/sex cells
  Weighted average 2.23 pmpm
• EM Visits based on 100 of Medicare fee schedule
  and actuarial based utilization assumptions
  (somewhat higher than actual encounter data
  received)

Average total payment for physicians 24 pmpm
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Medical Advisory Task Force Created

• At the request of providers the MAT was created
  February 2007
• Representatives delegated by provider
  associations
• OOA
• OSMA
• OAFP
• AAP, Oklahoma

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Medical Advisory Taskforce Four Top Priorities

• Change in current payment structure
• Medical home
• Autoassignment
• Credentialing

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Patient Centered Medical Home
Builds on successes already achieved in
SoonerCare Choice patterned after North Carolina
and Alabama medical home models
Adopted by other payers

• Medicare

• Private Payers

• Large, Self Insured Employers

• Patient-Centered Primary Care Collaborative

• State Government

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New SoonerCare Choice Reimbursement
Unbundled to incorporate PCMH principles

• Monthly Care Coordination Fee
• Peer grouped by type of panel and capabilities of
  practice
• Visit based component
• Fee for service
• Expanded Performance Component (SoonerExcel)
• Transitional Payments in Year 1

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Care Coordination Fee

• Peer Grouped based on type of practice
• Children only
• Adults and Children
• Adults Only
• And
• Level of Medical Home
• Tier 1 Entry Level Medical Home
• Tier 2 Advanced Level Medical Home
• Tier 3 Optimal Level Medical Home

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Care Coordination Fee
Rates based on a blend of the recommended rates
for the Medicare medical home demonstration and
the current SoonerCare rate for case
management Tier 1 includes additional add on
payments for 24/7 voice to voice and electronic
communication from OHCA
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What Stays the Same

• The name SoonerCare Choice
• Access to care requirements
• Current funding
• Provider determines medical necessity
• Visit limits
• Unlimited for children
• Unlimited for adults at their medical home
• 4 visit limit for adults outside their medical
  home - includes specialty care
• Federal restriction (e.g. EMTALA, co-pays)

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What Changes

• Monthly payment
• Paid monthly for care coordination only
• Care Coordination payment will be based on date
  processed
• Group contracts must designate a medical director
• OB/GYN providers can not be PCP
• Elimination of default autoassignment
• Elimination of providers ability to request
  panel hold
• system stops enrollment at 95 capacity

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What Changes

• Members may change PCPs within the month
• Referrals for specialty care only
• Provider who sees children MUST participate in
  VFC and MUST report in OSIIS
• Coverage of new codes (99050, 99051)
• PCPs can collect the member co-pay

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Copayments

• Children 0 20 will have no copayment
• Adults age 21 and over will have their current
  copayments
• PCPs can not refuse to see adult patients who do
  not have their copayment.
• PCPs may not dismiss patient for failure to pay
  copayments while assigned to the PCP.
• PCPs may bill the member or pursue collections
  for unpaid copayments.

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Billing Changes

• RHC will use the UB-04 claim for Choice members
  beginning Jan. 1, 2008.
• RHCs should use appropriate CPT codes in addition
  to the revenue code billed.
• IHS and FQHC billing procedures remain the same

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Incentive Component(SoonerExcel)

• Child Health Exams (EPSDT) and DTaP (1.5 m)
• Cervical cancer screenings (.3 m)
• Breast cancer screenings (.05 m)
• Physician inpatient admitting and visits (.85 m)
• ER utilization (.5 m)
• Generic Drug Prescribing (1 m)
• 4.25 million set aside

Payments made quarterly. First payment made in
April 09 based on claim dates of service Oct
Dec and adjudicated through March 2009.
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Transitional Payments Qualifications

• At least 250 SoonerCare members on their panel
  (200 for mid-levels)
• Not on the QA/QI noncompliance list for medical
  reasons
• Average office visit per member must be within
  one office visit per year of the average
  utilization for their panel type
• Payments monthly for first year
• 3.75 million set aside

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Implementation Timeline

• Target date January 2009
• All eligible members rolled over with current PCP
• Seamless for members, PCPs
• Choice renewals currently in process return ASAP

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Questions Comments

• Questions MedHomeComments_at_okhca.org
• Updates in global and banner messages, provider
  letters, OHCA public website at
  www.okhca.org/medical-home
• Contact OHCA
• Melody Anthony
• Provider Services Director
• 405.522.7360 / Melody.Anthony_at_okhca.org
• Provider Services
• 877-823-4529, option 2

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