Transcript Every Child Deserves a Medical Home”

An Improved
Medical Home for
Every SoonerCare
Choice Member
Presented
OHCA Fall Training
October 9, 2008
7/18/2015
1
Objectives
•
•
•
•
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SoonerCare Choice Today
Medical Advisory Task Force (MAT)
SoonerCare Choice Moving Forward
Questions and Comments
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.
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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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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
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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
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–
–
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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
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
$3.00
$3.00
FQHCs/RHCs
$0.00
$0.00
$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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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 provider’s 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)
• PCP’s 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)
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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: [email protected]
• 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 / [email protected]
Provider Services
877-823-4529, option 2
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