1. 10/23/20151 Presented 2008 A Medical Home for Every SoonerCare Choice Member

2. 10/23/20152 Objectives Part I – ProgramPart I – Program SoonerCare Choice TodaySoonerCare Choice Today Medical Advisory Task Force (MAT)Medical Advisory Task Force (MAT) Enhancing the SoonerCare Choice Medical HomeEnhancing the SoonerCare Choice Medical Home Transition TimelineTransition Timeline Part II – Financing the PCMHPart II – Financing the PCMH Questions and CommentsQuestions and Comments

3. 10/23/20153 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”.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.PCPs manage the basic health care needs, including after hours care and specialty referral of the members on their panel.

4. 10/23/20154 PCP Network SoonerCare Choice has over 400,000 members enrolled statewideSoonerCare Choice has over 400,000 members enrolled statewide Over 1,000 PCPs (up from 800+ in 2003)Over 1,000 PCPs (up from 800+ in 2003) Each PCP has a max panel of 2,500Each PCP has a max panel of 2,500 PA or APN PCPs have a max panel of 1,250PA or APN PCPs have a max panel of 1,250 Average panel size of 300 members per PCPAverage panel size of 300 members per PCP

5. 10/23/20155 Who Can be a PCP Today? Physicians General Practitioners Family Practice Internal Medicine OB/GYNsPediatricians Physician Assistants (PA) Advanced Practice Nurses (APN) FQHCsRHCs IHS Facilities

6. 10/23/20156 Medical Advisory Task Force Created At the request of providers the MAT was created February 2007At the request of providers the MAT was created February 2007 Representatives delegated by provider associationsRepresentatives delegated by provider associations –OOA –OSMA –OAFP –AAP, Oklahoma

7. 10/23/20157 Medical Advisory Taskforce Four Top Priorities Change in current payment structureChange in current payment structure Medical homeMedical home AutoassignmentAutoassignment CredentialingCredentialing

8. 10/23/20158 Joint Principles of the Patient- Centered Medical Home In March 2007 the AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians, developed the following joint principles to describe the characteristics of the PC-MH. Personal Physician Personal Physician Physician Directed Practice Physician Directed Practice Whole Person Orientation Whole Person Orientation Adequate Payment Adequate Payment Quality and Safety Quality and Safety Enhanced Access Enhanced Access Care is coordinated and / or integrated Care is coordinated and / or integrated

9. 10/23/20159 Patient-Centered Medical Home Builds on successes already achieved in SoonerCare Choice  Medicare  Private Payers  Large, Self Insured Employers  State Government  Patient-Centered Primary Care Collaborative Adopted by other payers:

10. Current SoonerCare Choice Reimbursement Monthly Capitated “Bundled” payment Case Management / Care Coordination FeeCase Management / Care Coordination Fee Primary care office visitsPrimary care office visits Limited lab servicesLimited lab services Other codes paid on FFS basis Incentive Payments EPSDT / 4 th DTaP bonusEPSDT / 4 th DTaP bonus (lump sum payments) 10/23/201510

11. 10/23/201511 Recommended PCMH Reimbursement A monthly care coordination paymentA monthly care coordination payment A visit-based fee-for-service componentA visit-based fee-for-service component A performance-based componentA performance-based component Source: The Patient Centered Primary Care Collaborative http://www.patientcenteredprimarycare.org/ The most effective way to re-align payment incentives to support the PCMH would be to combine traditional fee- for-service for office visits with a three part model that includes:

12. 10/23/201512 SoonerCare Choice Comparison Prepayment for case management only Referrals only needed for specialty care Group contracts must designate a medical director Elimination of default autoassignment Online provider enrollment Current funding remains the same Provider determines medical necessity Federal restriction (e.g. EMTALA, co-pays) What Stays the Same? What Changes?

13. 10/23/201513 Proposed Additional SoonerCare Choice Changes Coverage of new codes (e.g. after hours)Coverage of new codes (e.g. after hours) OB/GYN specialists that do not provide primary care may no longer be PCPsOB/GYN specialists that do not provide primary care may no longer be PCPs Members may change PCPs within the monthMembers may change PCPs within the month Case Mgmt payment will be based on date processedCase Mgmt payment will be based on date processed

14. 10/23/201514 Other Initiatives Foster Care Pilot ProjectFoster Care Pilot Project Outreach to households with newbornsOutreach to households with newborns Electronic NB-1Electronic NB-1 Transformation GrantTransformation Grant –“No Wrong Door” eligibility enrollment enhancement. Target date October 2009 Health Access Networks PilotHealth Access Networks Pilot

15. 10/23/201515 Proposed Timeline Target date January 2009Target date January 2009 All eligible members rolled over with current PCPAll eligible members rolled over with current PCP Seamless for members, PCPsSeamless for members, PCPs Contract updates needed by November 1, 2008Contract updates needed by November 1, 2008

16. Medical Home Part II Financing the New Model 10/23/201516

17. 10/23/201517 Eligibility CategoryAdultsChildrenTotal % Adults% Children TANF 34,392 318,801 353,193 0.10 0.90 ABD/SSI 26,759 11,974 38,733 0.69 0.31 Children in Custody - - - - - Adults, Duals and HCBW - - - - - Total 61,151 330,775 391,926 0.16 0.84 Source: OHCA Annual Report, SFY07 Average Monthly Enrollment: 84% are children

18. Age GroupTANFABD/SSITotal%TANF % ABD/SSI Adults 34,392 26,759 61,151 0.56 0.44 Children 318,801 11,974 330,775 0.96 0.04 Total 353,193 38,733 391,926 0.90 0.10 Approximately 44% of adults may require ongoing care coordination; 4% of children 10/23/201518

19. Definition of Capitation: A fixed payment for treating a fixed number of individuals whether they are ill or well…..A fixed payment for treating a fixed number of individuals whether they are ill or well….. Rate paid on entire panel whether member is seen or notRate paid on entire panel whether member is seen or not 10/23/201519

20. Current Primary Care Payment Structure Capitated Bundled Rates include payment for: Monthly case management based on age/sex cells – Weighted average = $2.23 pmpmMonthly 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)E&M Visits based on 100% of Medicare fee schedule and actuarial based utilization assumptions (somewhat higher than actual encounter data received) 10/23/201520 Average total payment for physicians = $24 pmpm

21. 10/23/201521 Proposed New SoonerCare Choice Reimbursement Monthly Case Mgmt / Care Coordination Fee –Peer grouped by type of panel and capabilities of practice Visit based component –Fee for service Expanded Performance Component (SoonerExcell) Transitional Payments in Year 1 “Unbundled” to incorporate PCMH principles

22. Peer Grouped based on type of practice –Children only; –Adults and Children; –Adults Only –FQHCs/RHCs And Level of Medical Home –Tier 1 = Entry Level Medical Home; –Tier 2 = Advanced Level Medical Home; –Tier 3 = Optimal Level Medical Home 10/23/201522 Case Management/ Care Coordination Fee

23. Type of PracticeTier 1Tier 2Tier 3 Children Only$3.06$ 5.08$6.02 Children & Adults$3.53$ 7.57$8.92 Adults Only$5.92$10.74$12.60 FQHCs/RHCs$0.00 Case Management/Care Coordination Fee Summary Draft – July 21, 2008 Rates based on a blend of the recommended rates for the Medicare medical home demonstration and the current SoonerCare rate for case management 10/23/201523

24. 10/23/201524 Incentive Component (SoonerExcell) Child Health Exams (EPSDT) and DTaP (1.5 m) Generic Drug Prescribing (.5 m) Cervical cancer screenings (.3 m) Breast cancer screenings (.05 m) Physician inpatient admitting and visits (.85 m) ER utilization (.5 m) Payments made quarterly. First payment made in April 09 based on claim dates of service Oct – Dec and adjudicated through March 2009.

25. 10/23/201525 Transitional Payments Year 1 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 $3 million set aside

26. Transitional Payments, (cont’d) Distribution 10/23/201526 Total pool divided by total eligible member monthsTotal pool divided by total eligible member months Per Member amount is multiplied by actual MM in quarterPer Member amount is multiplied by actual MM in quarter This amount is multiplied by a factor determined by a provider’s financial response to the medical home modelThis amount is multiplied by a factor determined by a provider’s financial response to the medical home model There are two categories of factors determined by the provider’s rural/urban classificationThere are two categories of factors determined by the provider’s rural/urban classification Providers with above average utilization will receive an additional payment equal to 50% of the initial paymentProviders with above average utilization will receive an additional payment equal to 50% of the initial payment No provider will be made more than 90% whole with transitional paymentsNo provider will be made more than 90% whole with transitional payments

27. Increased Encounter data for: Increased Utilization (20%) Improved coding New Codes Underreporting 10/23/201527 Budget Assumptions Conversion from Capitation to FFS

28. 10/23/201528 Questions Comments Request your input: MedHomeComments@okhca.orgRequest your input: MedHomeComments@okhca.org MedHomeComments@okhca.org Updates in global and banner messages, provider letters, OHCA public website at www.okhca.org/medical-homeUpdates in global and banner messages, provider letters, OHCA public website at www.okhca.org/medical-home www.okhca.org/medical-home Contact OHCAContact OHCA Melody Anthony Provider Services Director 405.522.7360 / Melody.Anthony@okhca.org Melody.Anthony@okhca.org Provider Services 877-823-4529, option 2

29. 10/23/201529 Additional Resources Patient-centered primary care collaborative http://www.pcpcc.net/Patient-centered primary care collaborative http://www.pcpcc.net/ http://www.pcpcc.net/ AAFP patient-centered medical home http://www.aafp.org/online/en/home/membership/initiat ives/pcmh.htmlAAFP patient-centered medical home http://www.aafp.org/online/en/home/membership/initiat ives/pcmh.html http://www.aafp.org/online/en/home/membership/initiat ives/pcmh.html http://www.aafp.org/online/en/home/membership/initiat ives/pcmh.html AAP medical home news http://www.aap.org/AAP medical home news http://www.aap.org/http://www.aap.org/ Medicare medical home pilotMedicare medical home pilot