Steven:

The change to multiple CE/MCOs should be done in a way that does not disrupt continuity of care for SoonerCare members.

If a member does not make an active choice of MCO, the state assigns them to one, likely round-robin style. Instead, the state should assign people who do not make their own choice only to an MCO which includes their current PCP, specialists, hospital.  This is practical, since the state agency has all that info already from both the patient claims records and MCO network lists. This is especially critical for the start of the MCO plan in April 2024 when 500,000+ members will move to commercial MCOs.

Any need for members to change providers because of state auto-assignment of a MCO/CE will inhibit and delay access to care.  While the SPA does allow members to change their MCO/CE within 90 days after assignment, but why not try to “get it right” at the start by assigning to an MCO/CE which already includes the member’s current providers?

Reference: SPA 23-0007 Public Notice. See “Enrollment” section, pages 3-4 in: https://oklahoma.gov/content/dam/ok/en/okhca/docs/policy/public-notices/2023/5.12.23%20Public%20Notice.pdf

Steven Goldman, PhD

Oklahoma City

[These views are written as an individual, not connected to any organization or employment]

OHCA Response: 

If a member does not select a new MCE/DBP by end of the grace period, they are auto-assigned to an MCE or PAHP (dental benefit provider (DBP)). The Agency will attempt to assign members to providers that they have previously had a relationship with, when there is a record of such a previous relationship.   

Steven:

Oklahoma Medicaid plans to move members from the state-run managed care system to private, commercial managed care companies (called “contracted entities” or CEs). The target date is April, 2024 for this “SoonerSelect” program.

Why an antiquated “15th of the month” rule for upcoming transitions to managed care in Oklahoma Medicaid? The state plan amendment to allow private, commercial managed care organizations for medical and dental has the old “15th of the month” rule for newly enrolled Medicaid members.

Please see the Public Notice “Enrollment” section at bottom of page 3 in:

https://oklahoma.gov/content/dam/ok/en/okhca/docs/policy/public-notices/2023/5.12.23%20Public%20Notice.pdf

For current Medicaid/SoonerCare members, there will be a 60-day sign-up period prior to the first start of private CEs. If a member does not actively choose a CE in that 60 days, then they will be assigned to a CE.  It is hoped that the state agency will assign members to a CE which includes their current providers, since the state agency has this information.

For newly enrolled members, the “15th of the month rule” will be used. While Medicaid coverage will start immediately upon successful application, the CE plan will be delayed 2-6 weeks. If new application is done by the 15th of a month, then CE coverage starts the first of the next month, while new applications after the 15th of a month means a delay in CE coverage to the start of the second month.

This seems unnecessarily complex, especially for a high-need Medicaid population with low literacy about health business systems..  New Medicaid members will have to adapt to two medical systems as they begin coverage—start in the wide-network state system, then adapt to a likely narrower MCO/CE.  Member uncertainty likely leads to their delayed actions to get services.  One person enrolling on the 14th has just 2 weeks to pick their MCO/CE while their friend enrolling on the 16th has 6 weeks. Rather than an enforced 2-to-6 week delay with the 15th of the month rule, why not allow new members to choose and join their MCO/CE immediately, if that’s what they want to do? For extended choice time, would a rule of 60-days plus until the end of that month be reasonable?

For the MCO/CEs there are clear advantages to the 15th of the month rule. The delay in responsibility means that the acute medical needs that lead to Medicaid enrollment get paid by the state-run system ---such as an ER admission for surgery. The MCO/CE just picks up the cost of after-care and Rx refills. In this computerized age, a partial-month PMPM payment should not be a problem if a member joins an MCO mid-month. Plus, given the high cost often of initial visits (lab tests, scans, etc), it may be cost-effective for the state to make a full-month PMPM payment to the MCO/CE, rather than the state paying out for that first visit.

The communication challenge is immense for the Medicaid population about making choices and transitions (as seen in Unwinding)---how to make rules simpler and more easily understandable?  There needs to be a design to the system that encourages members to access services, but also allows choice. This SPA notes that members have 90 days after an initial CE/MCO choice to make a change, so allowing an initial choice at time of a new application may be reasonable. The goal is for members to not be forced through multiple confusing transitions which inhibit care.

Steven Goldman, PhD

Oklahoma City

[These views are written as an individual, not connected to any organization or employment]

OHCA Response:

Managed care plans require time to set up a member and do the necessary intake/assessments. The 15th of the month logic is used to allocate plan membership and properly reimburse the capitation payments to the managed care plans. 

When a member applies and is found eligible for SoonerCare, the member will be immediately able to use the fee-for-service program or SoonerCare Choice. If the member enrolls before the 15th of the month, SoonerCare Choice providers will get the case management fee for that month for the member, otherwise they will not receive the case management fee until the following month. Of note, the PCP has to see the member before they will receive a case management fee.

For example: A potential member applies on June 28th; they are eligible to receive services under a manage care plan, and they choose their managed care plan. Since we the plans already received their CAP for the month of July, this member will be on the daily roster with an effective managed care enrollment date of August 1st. The member will be enrolled in a FFS program from June 28th to July 31st. This process is typical of Medicaid managed care programs.