An Improved Medical Home for Every SoonerCare Choice Member

1. Presented OHCA Fall Training October 9, 2008 An Improved Medical Home forEvery SoonerCare Choice Member 6/5/2014 1

2. Objectives • SoonerCare Choice Today • Medical Advisory Task Force (MAT) • SoonerCare Choice Moving Forward • Questions and Comments 6/5/2014 2

3. 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. 6/5/2014 3

4. PCP Network • SoonerCare Choice has over 400,000 members enrolled statewide • Over 1,200 PCPs • Average panel size of 333 members per PCP 6/5/2014 4

5. Current Primary Care Payment Structure Average total payment for physicians = $24 pmpm Capitated Bundled Rates include payment for: • Monthly case management based on age/sex cells – Weighted average = $2.23 pmpm • E&M Visits based on 100% of Medicare fee schedule and actuarial based utilization assumptions (somewhat higher than actual encounter data received) 6/5/2014 5

6. 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 6/5/2014 6

7. Medical Advisory Taskforce Four Top Priorities • Change in current payment structure • Medical home • Autoassignment • Credentialing 6/5/2014 7

8. 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 6/5/2014 8

9. New SoonerCare Choice Reimbursement 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 “Unbundled” to incorporate PCMH principles 6/5/2014 9

10. 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 6/5/2014 10

11. 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 6/5/2014 11

12. 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) 6/5/2014 12

13. 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 provider’s ability to request panel hold • system stops enrollment at 95% capacity

14. 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) • PCP’s can collect the member co-pay

15. 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.

16. 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

17. 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. 6/5/2014 17

18. 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 Transitional Payments; Qualifications 6/5/2014 18

19. 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 6/5/2014 19

20. Questions Comments • Questions: MedHomeComments@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@okhca.org Provider Services 877-823-4529, option 2 6/5/2014 20