An Improved Medical Home for Every SoonerCare Choice Member 4/11/2019 An Improved Medical Home for Every SoonerCare Choice Member Presented to Medical Advisory Taskforce November 20, 2008 4/11/2019 4/11/2019 1

Objectives SoonerCare Choice Today SoonerCare Choice Moving Forward Questions and Comments 4/11/2019 4/11/2019 2

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. 4/11/2019 4/11/2019 3

PCP Network SoonerCare Choice has over 400,000 members enrolled statewide Over 1,200 PCPs Average panel size of 333 members per PCP 4/11/2019 4/11/2019 4

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 4/11/2019 4/11/2019 5

New SoonerCare Choice Reimbursement 4/11/2019 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 4/11/2019 4/11/2019 6 6

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 4/11/2019 4/11/2019 7

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 4/11/2019 4/11/2019 8

What Stays the Same The name “SoonerCare Choice” 4/11/2019 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) 4/11/2019 4/11/2019 9 9

What Changes Monthly payment 4/11/2019 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 4/11/2019

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 4/11/2019

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 4/11/2019

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 4/11/2019

Incentive Component (SoonerExcel) 4/11/2019 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. 4/11/2019 4/11/2019 14 14

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 4/11/2019 4/11/2019 15

Implementation Timeline 4/11/2019 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 4/11/2019 4/11/2019 16 16

Questions Comments 877-823-4529, option 2 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 4/11/2019 4/11/2019 17