1. An Improved Medical Home for Every SoonerCare Choice Member
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An Improved Medical Home for Every SoonerCare Choice Member
Presented to Medical Advisory Taskforce
November 20, 2008
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2. Objectives SoonerCare Choice Today SoonerCare Choice Moving Forward
Questions and Comments
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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.
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4. 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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5. Current Primary Care Payment Structure
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)
Average total payment for physicians =
$24 pmpm
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6. New SoonerCare Choice Reimbursement
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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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7. Care Coordination Fee Peer Grouped based on type of practice And
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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8. Care Coordination Fee Type of Practice Tier 1 Tier 2 Tier 3
Children Only
$3.58
$ 4.65
$6.19
Children & Adults
$4.33
$ 5.64
$7.50
Adults Only
$5.02
$6.53
$8.69
IHS
$3.00
FQHCs/RHCs
$0.00
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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9. What Stays the Same The name “SoonerCare Choice”
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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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10. What Changes Monthly payment
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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 provider’s ability to request panel hold
system stops enrollment at 95% capacity
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11. What Changes Members may change PCPs within the month
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
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12. Provider Education
Presented SoonerCare Choice education classes over 58 times beginning in March 2008
Over 1,200 provider staff educated.
Called every providers office to educate and answer questions
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13. Contract Renewal Mailed all providers contract information in October
Called to remind providers of renewal process when educating them on the new SoonerCare model
Send written reminder for renewal
Currently 15% of contracts in house
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14. Incentive Component (SoonerExcel)
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Incentive Component (SoonerExcel)
Child Health Exams (EPSDT) and DTaP
Cervical cancer screenings
Breast cancer screenings
Physician inpatient admitting and visits
ER utilization
Generic Drug Prescribing
$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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15. 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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16. Implementation Timeline
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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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17. Questions Comments 877-823-4529, option 2
Questions:
Updates in global and banner messages, provider letters, OHCA public website at
Contact OHCA
Melody Anthony
Provider Services Director /
Provider Services
, option 2
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