SoonerHealth+ managed care RFP released

Posted on: 12/7/16

The state of Oklahoma released the “SoonerHealth+” request for proposals (RFP) on Nov. 30.  SoonerHealth+ is designed as a managed care program for Oklahoma Medicaid’s aged, blind and disabled (ABD) population. The Oklahoma Health Care Authority (OHCA) was directed by the Legislature last year to issue an RFP for care coordination models for the ABD populations.  Other SoonerCare members will remain in the fee-for-service Medicaid program.

Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care plans that accept a set per member per month (capitation) payment for these services. Many of the terms of the state’s managed care arrangement are required by federal rules for Medicaid managed care, which were significantly strengthened earlier this year.

OHCA has divided the state into an East Region and a West Region, and plans may propose to serve the SoonerHealth+ population in either or both regions. OHCA intends to award three contracts in each region, but at its discretion may award as few as two or as many as four contracts.

OHCA and their actuarial consultant are still developing the rates per member per month to be paid to the managed care plans, and will publish these rates in mid-January. Plans’ proposals are due to OHCA by Feb. 28, 2017. OHCA will award contracts to plans by the end of June 2017, and the contractors will begin delivering service to SoonerHealth+ members April 1, 2018.  

Members will be asked to select one of the managed care plans initially, and will be auto-assigned to one of the plans if no selection is made. Members will be able to switch between managed care plans once in their first 90 days of enrollment without showing cause. After that, members are “locked in” to the plan until an annual open enrollment period, during which they may switch plans. In renewal periods, members will also have the right to switch plans during the first 90 days, whether they made an open enrollment change or not.

The initial contracts with managed care plans will terminate on June 30, 2019, with options to renew at OHCA’s discretion for four additional one-year terms, and an additional six-month (July-December) term at the end of the contract.

Plans are not asked to submit provider network listings as part of their proposal. Evaluation of plans’ provider networks will be one part of a readiness review process to be completed late in 2017, prior to the start of enrollment.  

Contractors will be required to have a sufficient provider network to ensure access and appointment wait times established by OHCA. The networks are to include “a sufficient number and type of hospitals and essential community providers to ensure that members may access a range of covered physical and mental health services in the setting most appropriate for a member’s treatment needs.” Network hospitals should be available “within 30 miles of a member’s residence, except in rural areas where access time may be greater. If greater, the standard needs to be the community standard for accessing care and exceptions must be justified and documented to the OHCA on the basis of community standards.”

The RFP requires contractors to set payment rates for providers that are “reasonable to ensure member access to services.” This may be the SoonerCare fee schedule, or a separate rate and/or methodology negotiated with a provider. Generally, contractors are required to pay out-of-network providers at the current Medicaid fee schedule rate in the absence of a negotiated rate.

The contractors are required to pay 90 percent of “clean” provider claims within 30 days, and 99 percent within 90 days. Shorter timelines apply to nursing facility and Home & Community-Based Services claims. The RFP sets out requirements for provider manuals, websites, call centers, and training, as well as a provider complaint system and complaint reporting to OHCA.

The full 365-page SoonerHealth+ RFP is available on the OHCA website(Rick Snyder)

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