A. High-Level Description of the Recommended Patient-Centered Service Delivery Model

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1 A. Recommended Patient-Centered Service Delivery Model A. High-Level Description of the Recommended Patient-Centered Service Delivery Model 1. Name and describe Respondents chosen model including reason for selecting the model Amerigroup recommends the Fully Capitated, Comprehensive Managed Care Organization model to meet the needs of eligible ABD SoonerCare participants. This model includes personcentered, integrated coordination and delivery of physical health, behavioral health, and Long- Term Services and Supports (LTSS). Specialized populations often have more complex health care needs, and we understand the integrated physical and behavioral health interventions critical to meeting each participant s unique needs and preferences. We strongly believe that participants are best served and outcomes improved when care coordination is available to assist them in accessing the full range of program services and supports needed to address their needs and preferences. This coordination model includes a person-centered process that begins with discovery, assessment, and planning; proceeds to meeting participants medical and non-medical needs; and ultimately provides them access to the quality of life and level of independence they desire. In all cases, a key component is the active participation by the participant or his/her caregiver in the service planning and delivery process. Our recommendation is based on our robust experience developing and managing integrated solutions with state agency partners. For 24 years, Amerigroup and our affiliate health plans have been strong proponents of a fully integrated model of care that emphasizes person-centered care coordination and service delivery. Collectively, we manage the delivery of integrated physical and behavioral health services for more than 882,000 SSI/ABD participants across 15 states. In eight of these states, we manage the full spectrum of physical health, behavioral health, and LTSS for more than 270,000 participants.1 Our participants in these programs include individuals served through a variety of Home- and Community-Based Services (HCBS) waivers, including adults of all ages, children with disabilities, and individuals with intellectual and developmental disabilities. Based on this experience, we believe fully integrating care coordination and service delivery will help achieve Oklahoma s overarching health care goals of improving outcomes, access to care, and sustainability while containing costs. Specifically, benefits of the proposed model include: Improved quality of care and health outcomes, particularly related to the delivery of preventive care services such as screenings and immunizations Comprehensive continuum of services and supports across urban, rural, and frontier geographies so that members have appropriate, timely, and convenient access to care Person-centered, culturally competent care coordination that supports the participant s physical, behavioral, functional, and social strengths and needs 1 This number is inclusive of enrollees in our Medicare-Medicaid Dual Demonstration Plans. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 1

2 A. Recommended Patient-Centered Service Delivery Model Budget predictability, fiscal accountability, and aligned incentives across programs Quality management systems to reduce preventable, unnecessary, inappropriate and/or duplicative services and to reduce preventable hospital readmissions and emergency room utilization Integrated data that facilitates monitoring of quality metrics and use of comprehensive and holistic predictive modeling to identify priority needs and connect the participant to the appropriate level of care coordination Improved service delivery oversight from beginning to end and across all areas (care coordination, provider relations, quality improvement, and program integrity) The model also supports risk-based arrangements with providers to drive improvements in quality metrics. A comprehensive managed care model offers additional opportunities to evaluate new payment approaches (such as episode-based models, incentives, and payment tiers) and to integrate a variety of delivery models (such as health homes). A fully capitated, comprehensive managed care model will help OHCA achieve its goals of improved quality outcomes and reduced spending trends through collaborative partnerships with qualified MCOs accountable for administering and coordinating all services and for providing the individualized supports needed for participants to thrive in the community of their choice. 2. Describe how the model addresses the needs of the ABD patient population To best serve ABD SoonerCare participants, Amerigroup recommends a comprehensive and fully integrated managed care model that provides a single point of accountability for coordination of services across the care continuum to reduce fragmentation and duplication while improving access. The fully integrated managed care model emphasizes the whole person. To accomplish this, MCO service coordinators are responsible for making sure individuals and their families needs are met, regardless of their level of need. For those with the greatest or most complex needs, MCOs may deploy a multidisciplinary team led by a team member with skills and expertise matched to the individual and his or her family (or designated representatives). Within this model, critical service coordination activities include: Matching members with a community-based service coordinator according to the level of support needed Providing service coordinators who are familiar with and responsible for managing services across multiple programs Implementing person-centered planning using a multidisciplinary team Establishing a single point of access to a network of providers and integrated benefits Coordinating and collaborating across each participant s system of care Continuously assessing the effectiveness of interventions and participants health and supportive services OK RFI Care Coordination for the Aged, Blind, and Disabled Page 2

3 A. Recommended Patient-Centered Service Delivery Model Guiding participants and their families in comprehensive transition planning to assure continuity in health and social services and supports Using technology to support efficient care coordination Conducting ongoing outreach to engage all stakeholders Using a multidisciplinary approach, comprehensive service and care coordination provides the necessary flexibility to help participants access the right mix of services and supports to meet their unique needs. For instance, individuals with Down syndrome often experience cardiac and gastrointestinal challenges for which coordination between medical and long-term care services can successfully prevent or minimize acute hospitalizations, limit life disruptions, and lead to a better quality of life. We believe this model is well-suited to address many of the challenges faced by individuals in the ABD category of eligibility in Oklahoma. The model benefits participants and the State by: Improving utilization of screenings and prevention services while decreasing unnecessary emergency room visits and hospital readmissions Eliminating silos across programs by managing all services so that care is fully coordinated and seamless for the participant Supporting participants during transitions between levels of care, service delivery systems, and provider changes and supporting children and families during key life transitions from post-secondary and pediatric systems to adult health care systems, vocational and employment programs to retirement Connecting participants, their families, and caregivers to HCBS and social supports to assist them in achieving their quality of life goals Promoting ongoing development of a provider network with experience serving individuals with complex needs Supporting development of additional capacity and resources for HCBS including development of innovative delivery and support models designed to serve urban, rural, and frontier areas of Oklahoma Based on our experience and the results we ve seen in other states, we believe this model will help improve Oklahoma s indicators around quality of care and health outcomes as well as the State s focus on behavioral health as a key investment area, given the high rates of readmission for behavioral health conditions. A fully integrated and comprehensive model will enable MCOs to better address participants medical, behavioral, and LTSS needs through early screenings, comprehensive assessments, and integrated care plans based on the participant s level of need, goals, and preferences. Results from across the country strongly support the efficiency and effectiveness of a comprehensive and integrated care model. As an example, the 2013 State of Kansas Medicaid OK RFI Care Coordination for the Aged, Blind, and Disabled Page 3

4 A. Recommended Patient-Centered Service Delivery Model redesign (KanCare) uses MCOs to coordinate the full range of populations and services on a capitated basis. To date, the program has increased access to primary care providers by 23 percent, increased access to home- and community-based services by 22 percent, and reduced inpatient hospitalization by 19 percent. In addition, KanCare has saved the state more than $1 billion since its inception.2 The Health and Human Services Commission in Texas reports that its Medicaid enrollees covered through the STAR+PLUS Program and receiving care coordination in an integrated environment have lower rates of inpatient stays and emergency room visits when compared to rates for SSI beneficiaries in non-integrated environments without care coordination. The Texas Conservative Coalition Research Institute underscored the benefits of a fully capitated MCO model noting that it provides the best quality of care to Texans at the lowest cost to the state.3 In New Mexico, the CoLTS program has reintegrated 207 participants from nursing facilities into the community and has kept 2,345 health dual eligible participants out of nursing facility placement, according to the New Mexico Human Services Department.4 In a fully integrated model, MCOs provide members with consistency and continuity of care as they transition across programs, levels of care, and service settings. MCOs can more easily follow participants through the care continuum, making sure they are connected to and understand the full range of services and supports available to them. For example, in our Kansas affiliate s fully integrated model, our care coordinators assist children with autism as they age out of and into programs, such as services available through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, the autism waiver, and individuals with intellectual disabilities waivers. In the absence of a managed care approach, several different case managers would have been separately involved with the participant and family, contributing to duplicated or fragmented care. Singular care coordination offered through fully integrated care streamlines transitions, assuring continuity of care and enhancing participant satisfaction. 2 Colyer, J. (2015, June). KanCare: Improving Health Outcomes with Coordinated Care. Presented at the 22 nd Annual Midwestern Regional Conference, Overland Park, KS. 3 Texas Conservative Coalition Research. Star Plus Medicaid Managed Care: The Best Option for Texas. March Retrieved from 4 New Mexico Human Services Department, Medical Assistance Division. Coordination of Long-Term Services Program (CoLTS) Fact Sheet (2011). Retrieved from OK RFI Care Coordination for the Aged, Blind, and Disabled Page 4

5 A. Recommended Patient-Centered Service Delivery Model 3. Explain Respondents approach for implementation of the model Amerigroup recommends that OHCA engage MCO partners with extensive experience in planning, implementing, and evaluating capitated and comprehensive managed care programs for populations with complex needs. This includes experience in smoothly transitioning participants and providers from a Fee-For-Service (FFS) model to a managed care environment with minimal disruption. Our experience validates that one of the most important elements in successful implementation of a new program is establishing a deliberate planning process, which involves key stakeholders in open and frequent dialogue about the program design and policy decisions at early stages of the process. With this planning process as a foundation, multiple complementary strategies involving the State, the MCO, and stakeholders can occur in a timely fashion, such as: Identifying and engaging key stakeholders to provide valuable insight into the needs of Medicaid beneficiaries in urban, rural, and frontier areas as well as the local health care and services landscape Establishing an extensive provider network and community resource network that supports existing provider-participant relationships, social supports, and continuity of care to minimize disruption Assisting and supporting providers in the transition to a managed care program Identifying and reaching out to participants who have acute or chronic health care needs (including children and adults with specialized health care needs and participants who require in-home supports) Identifying critical activities and timelines to support successful implementation such as transferring up-to-date participant locating information so that MCO partners can actively engage participants and coordinating level of care and annual reassessments as earlier as possible in the implementation and transition processto avoid gaps in eligibility or disruption of services From the program s outset, a strong partnership between the State, participating MCOs, and stakeholders fosters collaboration and problem-solving to meet mutual goals. Such an approach also promotes transparency in program policy development and a mutual understanding of program and contractual details, such as processes, terms, logistics, and communication channels, and the costs and resources necessary for the program s long-term viability. Additional information regarding our proposed approach for implementation is included in Section H., Anticipated Overarching Timelines. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 5

6 B. Populations Served B. Populations Served 1. Identify proposed eligible populations (All members or target specific populations based on geographic areas, aid category, specific health conditions, etc.) Amerigroup recommends establishing a statewide capitated and comprehensive managed care model that includes all individuals who meet the ABD program eligibility criteria regardless of age, disability, dual eligibility, setting, or jurisdictional status (including tribal reservations). In our experience, a capitated and comprehensive managed care model is best suited to provide a continuum of services and supports to individuals with a range of needs from basic to complex. The broad inclusion of ABD participants across aid categories and health conditions (as well as all covered services) enables the MCO to provide each participant with the covered services he or she needs at the right intensity and in the most appropriate, least restrictive setting. This approach removes eligibility and funding silos that may have developed over time and that have inadvertently created barriers to a participant s access to certain services. Inclusion of all eligible populations will require MCOs to have a multidisciplinary care management system that addresses their unique needs across a continuum of programs, services, and settings. For this reason, Amerigroup recommends that OHCA deem experience in delivering integrated services and supports across all program areas and populations as a key criterion for MCO selection. 2. For each of the populations selected, state whether services would be provided statewide, within certain county(s), or will Respondent employ regionalization i. Define which county(s) in which the model would operate ii. Define which county(s) included in each region Amerigroup recommends that selected SoonerCare MCOs provide services for ABD participants statewide. Amerigroup affiliates operate statewide comprehensive and integrated programs for ABD members in states such as Kansas and Tennessee. In these states, which include urban, rural, frontier, and tribal areas, our experience has taught us that statewide coverage has substantial benefits for states, members, and providers, including the following: Enhanced continuity of care. A statewide provider network prevents fragmentation and decreases the number of transition points in the system. This is critical to maintain continuity and maximize positive health outcomes, especially for mobile individuals and families, such as tribal members moving to and from a reservation. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 6

7 B. Populations Served Increased access to specialty care. Through a statewide MCO, subspecialists, tertiary centers, and inpatient facilities are available to all participants without limitation or restriction. This is particularly valuable to rural, frontier, and tribal populations because it facilitates in-network access to care anywhere in the state and is coordinated by the same case manager. Given the concentration of specialists, tertiary care, and ancillary supports in the Oklahoma City Tulsa corridor, access to this care for outlying communities is essential. Consistency of quality and access standards. Statewide contracting supports the consistent statewide application of standards for reporting, care quality, and access to care. Replication of innovations and best practices. Statewide contracts also offer an opportunity for MCOs to share and collaborate on initiatives and best practices that benefit participants across Oklahoma. For example, MCOs can use technology-driven strategies in remote communities (such as providing rural participants with remote access to specialty services through telemedicine) and diffuse this type of community-level innovation to similar communities across the state. Administrative simplification and efficiencies. Compared to other coverage geographies (county or regions), statewide coverage is more efficient and less administratively burdensome for the State. In addition, statewide coverage decreases administrative burden for providers, such as having to contract with multiple MCOs across multiple regions, and minimizes confusion for participants who might otherwise be required to seek services across regional boundaries or transition to new MCOs based on changes in residence. Economies of scale. Statewide coverage can offer MCOs sufficient enrollment levels to create significant cost efficiencies in areas such as staffing, network development, contracting, purchasing, and technology. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 7

8 C. Covered Services and Benefits C. Covered Services and Benefits 1. Describe proposed covered services and benefits for each population Amerigroup recommends a comprehensive services and benefits package for all ABD participants, regardless of age, disability, dual eligibility, institutional setting, or jurisdictional status (including tribal reservations). This package includes all current State plan services and benefits relating to physical health, behavioral health (including residential substance abuse and psychiatric treatment), dental care, pharmacy, and LTSS (including HCBS waivers, personal care, nursing facilities, and Intermediate Care Facilities for Individuals with Development Disabilities (ICF/IDD)) as well as the State s Money Follows the Person (MFP) Program. We also recommend including the Program for All-Inclusive Care for the Elderly (PACE). However, if the State decides not to include this program, then we suggest strong collaboration with the MCO to assure coordination as participants transition in and out of the program. We recognize that Legislature requires phase-in of institutionalized participants two years after the managed care program is implemented; thus, we suggest MCOs and the State work closely during the initial implementation to lay the foundation for successfully including these participants. We recommend inclusion of all current HCBS waiver programs including: ADvantage Waiver Community Waiver Medically Fragile Waiver Homeward Bound Waiver Sooner Seniors Waiver 1 In-Home Supports for Adults Waiver My Life My Choice Waiver In-Home Supports for Children Waive To achieve efficacy and cost effectiveness, we also recommend the State consider including an in lieu of benefit that allows the MCO to substitute a non-covered service for a covered service on an individual basis, if it is in the best interest of the participant. By including this broad array of services in the benefit package, the State can hold contracted MCOs more accountable for making sure each participant receives the services and supports needed at the right intensity and in the least restrictive setting. Further, we recommend the State consider MCOs with demonstrated understanding of the population and services the program will need as well as an MCO s ability to offer value-added services that address current gaps in services and that incentivize participants to access preventive care and adhere to treatment recommendations. 1 Amerigroup is aware that the State is seeking CMS approval to terminate the Sooner Seniors and My Life My Choice waivers, effective December 1, Should CMS approve the transition, our recommendation remains the same, as we understand that members would transition and be served through the ADvantage Waiver. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 8

9 C. Covered Services and Benefits 2. Describe the clinical effectiveness and evidence-base supporting the proposed covered services and benefits Many individuals who are aging or who have disabilities need help navigating the health care system and linking to social supports. Access to the full array of services through a single managed care program will improve the participant s ability to access services and supports. This is particularly important to assure smooth transitions across levels of care, geography, and settings and/or providers. For example, in a fully integrated program, a care coordinator can work with an individual waiting for a waiver slot to identify services and close care gaps through the benefits available under the State plan and that may be available from other sources of coverage, including through MCO value-added benefits and social supports. The care coordinator can prepare and educate the individual and family regarding covered HCBS waiver services and revise the participant s service plan to reflect the individual s preferences upon enrollment into the waiver. The same level of service for those transitioning among other programs or categories of eligibility is invaluable to assuring the well-being of participants and achieving long-term cost savings for the State. The clinical effectiveness and evidence supporting a fully integrated, comprehensive approach is demonstrated across multiple states that have adopted this model. Across each state, this approach facilitated outcome improvements that met or exceeded Oklahoma s established quality targets. Examples are provided below. Kansas has seen significant cost savings within its implementation of KanCare. This program includes the full range of populations and services, including institutional and all waiver-related services, MFP, and a consumer-directed program providing supports for those with disabilities in the workforce. Our Kansas affiliate is one of three MCOs participating in the KanCare program and has been instrumental in driving a successful program. According to the Kansas Governor s Office, KanCare has saved the state over $1 billion since implementation in The program has increased access to primary care providers by 23 percent, increased access to HCBS by 22 percent; and reduced inpatient hospitalization by 19 percent. 2 Tennessee s Medicaid program (TennCare) is a fully integrated managed care program covering physical health, behavioral health, and LTSS for 1.3 million members. As one of four participating MCOs in the state, our affiliate health plan in Tennessee has implemented programs that have helped achieve a 68 percent decrease in emergency room visits per 1,000 members and reduced inpatient episodes, with the average length of an inpatient stay decreased by 23 percent (across program participants). In addition, sub-acute days per 10,000 members decreased by 70 2 Colyer, J. (2015, June). KanCare: Improving Health Outcomes with Coordinated Care. Presented at the 22nd Annual Midwestern Regional Conference, Overland Park, KS. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 9

10 C. Covered Services and Benefits percent with the full integration of behavioral health services for individuals with serious and persistent mental illness (SPMI) into the TennCare program. Additionally, ABD members accessed their primary care providers and preventive care at an increased rate. For example, our affiliate plan developed a program to improve screening rates for members with cardiovascular disease who receive LTSS. In its first year, the program boosted low-density lipoprotein screening rates by 120 percent in the target population. In Texas, the STAR+PLUS Medicaid Program serves individuals who are elderly or who have a disability. Our Texas affiliate implemented programs for this population that resulted in a 38 percent increase in access to community-based adult day services, a 32 percent increase in access to personal assistance and improved outcomes, including a 38 percent reduction in inpatient stays for targeted ABD members. 3. Explain reason for any proposed non-covered services and benefits Amerigroup recommends a model that includes broad covered services and benefits. Therefore, we do not propose any non-covered services or benefits. Given the nature of the program s service delivery model, inclusion of PACE will require development of an effective coordination and reimbursement model for these participants. If the State determines PACE will not be included in the comprehensive program, effective coordination between MCOs and PACE providers will be essential to assure smooth transitions into and out of the PACE program as participants exercise their right to choose services and settings. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 10

11 D. Provider Network D. Provider Network 1. Describe provider network recruitment and retention, including types of providers (for example primary care, specialty care, dental, HCBS, case/care management, LTC, other, etc.) Amerigroup and our affiliate health plans manage the delivery of integrated physical and behavioral health services for more than 882,000 SSI/ABD participants across 15 states. In eight of these states, we manage provider networks that support the full spectrum of physical health, behavioral health, and LTSS for more than 270,000 participants 1. Our experience shows us that effective network development and maintenance requires ongoing MCO collaboration with the provider community to develop person-centered, integrated, and culturally competent programs that address the wide range of complex physical and behavioral health care, social support, and possible long-term service and support needs of ABD beneficiaries. Successful MCOs must be able to demonstrate a solid provider engagement strategy and experience developing fully accessible networks that reflect the needs and preferences of participants. We recommend that OHCA assess MCOs experience working with participants, families and caregivers, providers, community-based organizations, and advocates to identify and support a comprehensive provider network. Individuals with disabilities and chronic health care needs often spend years finding the right providers to meet their needs, and it is critical to their ongoing well-being that those relationships are considered during network development and maintained in the emerging program. MCOs should have demonstrated organizational experience building integrated provider networks with adequate capacity, breadth, and scope to coordinate services across of the full spectrum of physical health, behavioral health, LTSS, and institutional providers necessary to both meet OHCA s requirements and the needs of ABD SoonerCare participants. OHCA should require that MCOs have experience recruiting and managing a comprehensive network that reflects the cultural preferences and diversity of program participants, inclusive of all provider types such as: 1 Inclusive of enrollees in Amerigroup Medicare-Medicaid Dual Demonstration Plans. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 11

12 D. Provider Network Primary care Specialty care Behavioral health Substance use disorders Hospitals Nursing facilities and ICFs/IDD HCBS including State plan personal care and HCBS waivers Indian Health Services (IHS)/Tribal 638 Pharmacy Case/care management Home health Federally qualified health centers Rural health clinics Dental Vision Transportation Additional ancillary services providers A comprehensive and accessible network will be essential to meeting the unique needs of the ABD SoonerCare participants and supporting implementation of a comprehensive managed care model. We recommend that OHCA require respondents to demonstrate an understanding of the network development needs for State health plan services, such as professional specialists, that differ from the traditional Sooner Care program. Qualified respondents should be able to clearly articulate the differences in primary care, specialists, and ancillary composition of the network necessary to serve ABD participants as compared to the composition of the network required to serve a traditional TANF and CHIP membership. Additionally, MCOs should demonstrate a strong understanding of the cultural and geographical considerations unique to the Oklahoma health care delivery system. MCOs must demonstrate a solid provider engagement strategy backed by a successful history of recruitment, education, retention, and compliance with state standards across all provider types. MCOs should also have experience successfully working with and supporting a wide range of provider types including smaller, traditional HCBS providers and IHS/Tribal 638 providers critical to serving Oklahoma s ABD participants. In addition to MCO network development activities, it is important that OHCA take an early and active role in the provider communication strategy for program implementation. OHCA should educate and encourage all qualified providers to participate in the MCOs networks prior to contract award. Frequent and open communication with the provider community regarding critical timelines and milestones related to program implementation will facilitate provider engagement as early as possible. When establishing the planned implementation timeline and milestones for the program, we suggest that OHCA allow an appropriate time period for MCOs to efficiently and effectively recruit providers during both the pre- and post-award periods. Adequate time to complete provider credentialing should also be considered. Such considerations will allow MCOs time for network development activities and to demonstrate meaningful progress throughout the transition and readiness review stages of implementation. Effective network development for comprehensive managed care programs requires early and frequent outreach to all providers, and in particular, traditional LTSS providers, many who may need hands-on assistance making the transition from FFS Medicaid. To assess MCOs OK RFI Care Coordination for the Aged, Blind, and Disabled Page 12

13 D. Provider Network experience and capabilities related to provider support for the program, we suggest OHCA request and evaluate MCOs ability to demonstrate their experience with initial and ongoing provider engagement, retention, education, and communication strategies. MCOs should be able to address the unique business needs of small and mid-size providers for eligibility verification; authorization access; billing and claims payment; and provider service, training, and comprehensive technical assistance, as well as provider accessibility, service levels to participants, and other provider performance metrics. Provider Retention We recommend OHCA select MCOs who understand that many LTSS providers are small businesses. MCOs should be experienced in providing individual administrative support, processing provider payments frequently to support cash flow, offering electronic claims submission and funds transfer, and responding timely to requests for authorization or assistance. Often, issues related to claims payment are a barrier to provider retention and, to that end we suggest that OHCA require that all eligible providers have a National Provider Identifier to support accuracy of payments and provider directory information. OHCA should also consider establishing the definition of a clean claim for the SoonerCare ABD program, set payment floors for certain LTSS services, and establish reduced rates for providers who decline to participate in the program after good faith contracting efforts (for example, a non-participating provider fee schedule). These requirements will help assure providers and MCOs that payment rates will not be a barrier to success of the program. To support provider retention and satisfaction, MCOs should be experienced in developing creative methods for streamlining the administrative processes that support the provision of care and services. Experience shows us that providers will value timely and accurate payment, resources for provider questions and assistance, and having a designated staff member as a primary point of contact to resolve issues. Innovative payment structures have proven effective in increasing provider satisfaction. OHCA should collaborate with MCOs to develop incentive programs and performance metrics that take into account the unique provider types and needs of the covered ABD population and that support the overarching goals of the program. For example, a measure might emphasize access to the types of providers available to deliver HCBS services instead of a more typical time or distance related access measure. OHCA should allow for the development and analysis of adequate baseline data prior to the implementation of any incentives. Initial and ongoing provider training and education are critical to maintaining a network that is able to meet the unique needs of ABD individuals. MCOs should have experience designing and providing proactive provider education that addresses program- and provider-specific needs and requirements as well as helping providers transition from FFS Medicaid to a managed care environment all of which are essential to a successful implementation of the new model. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 13

14 E. Provider Payment Structure E. Provider Payment Structure 1. Explain provider payment methodology, assumptions, and constraints a. Specific to covered benefits and services (As listed in Section 3.3,Item C) b. Specific to other benefits and services c. Show estimated amounts of provider payments for evidence-based performance outcomes (for example amounts of withholds, performance payments based on quality metrics, etc.) Covered Benefits and Services We recommend that OHCA consider engaging MCOs with demonstrated experience developing and administering flexible payment strategies designed to meet the unique needs of the State. Given the importance that behavioral health, substance use disorder, HCBS waiver, nursing facility, and ICF/IDD providers represent in terms of access to coordinated services, OHCA should require MCOs to demonstrate expertise in successfully helping providers shift from FFS to a comprehensive managed care program. MCOs should provide a well-articulated quality incentive payment structure and a provider education, remediation, and servicing strategy focused on the specific provider types serving the ABD population and for whom a managed care model will be a new undertaking. A qualified MCO will be able to describe its approach for the unique provider types included in the SoonerCare ABD managed care program. OHCA should consider asking MCOs to articulate a payment strategy that helps smoothly transition providers new to managed care by using the FFS rates for at least the initial 12 months of the program. Considerations in this regard include: Establishing a floor at 100 percent of Medicaid FFS rates for HCBS waiver, nursing facility, and ICF/IDD providers (when phased in) to proactively address concerns related to reduced rates or cash flow and to encourage contracting and collaboration Establishing a rate structure that pays percent of the Medicaid FFS rate for providers who refuse to contract with an MCO following three documented good faith contracting attempts (We believe this will encourage providers, especially those new to managed care, to engage early with the selected MCOs and become educated about the business processes so that cash flow and access to services are not interrupted.) Collaborating with MCOs to establish guidelines around single case agreements and other similar means for MCOs and providers to support continuity of care for participants whose care might be compromised by a shift to an in-network provider Implementing the ABD care coordination model with a payment structure that closely mimics FFS Medicaid, then developing new methodologies reflective of the local provider community once the program has matured OK RFI Care Coordination for the Aged, Blind, and Disabled Page 14

15 E. Provider Payment Structure OHCA should contract with MCOs experienced with traditional reimbursement methodologies for Medicaid providers such as FFS, per diems, Diagnosis-Related Groups (DRGs), case rates, capitation, and prospective payment systems. MCOs should also have solid experience with reimbursement strategies for the full range of provider types such as HCBS waiver, nursing facility, and IHS/Tribal 638 providers. Potential compensation methodologies that OHCA might consider are highlighted in Table E-1. Table E-1. Potential Compensation Methodologies Provider Type Primary Care Specialists Behavioral Health Substance Use Disorders Federally Qualified Health Centers and Rural Health Clinics Hospitals, Tertiary Facilities Mental Health/Substance Abuse Facilities Ancillary Nursing Facilities HCBS Waiver, State Plan Personal Care Health Homes IHS/Tribal 638 Potential Compensation Methodology Per Service or Capitation Per Service Per Service Per Service PPS Inpatient: DRGs and Per Diem Outpatient: Fixed Rate Per Line Item Inpatient: DRGs and Per Diem Outpatient: Fixed Rate Per Line Item Per Service or Case Rate Per Diem Per Service consistent with current state unit methodology Per Service or Capitation OMB Rate OHCA should also seek MCOs that bring experience developing and implementing provider models that facilitate care coordination and improved care access on a systems level such as Patient-Centered Medical Homes and Health Homes. These models have the potential to show measured improvements in the quality of health care delivery. Our experience shows us that improved facilitation of care coordination and improved access can result in a reduction of unnecessary inpatient admissions and emergency room visits. Other Benefits and Services Amerigroup recommends a model that proposes broad covered services and benefits and therefore does not necessitate a provider payment methodology for any non-covered services or benefits. MCOs should be given the flexibility to determine which services or goods may be offered as value-added benefits as well as their corresponding reimbursement methodologies. Estimated Amounts of Provider Payments for Evidence-based Performance Outcomes Incentive programs should compensate providers for providing high-quality, integrated services that align with OHCA s clinical quality, performance, and outcome goals and allow for straightforward administration by MCOs. We recommend that the State remain open to ongoing dialogue around the development of unique incentives targeted to the provider types that will deliver services to the SoonerCare ABD population consistent with preferred outcomes. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 15

16 E. Provider Payment Structure Selected MCOs should have demonstrated experience driving improved health outcomes and quality of life for ABD participants, while appropriately managing costs through evidence-based performance outcomes that fully integrate physical health, behavioral health, and social services and supports across the spectrum of providers. Based on our experience with similar programs in other states, we anticipate that 10 percent of an MCO s total assigned participants could be receiving primary care services from a provider participating in an evidence-based performance outcomes contract within the first year of program operation. We would expect this percentage to increase over time as the program matures based on total participants assigned to the MCO. OHCA should consider establishing a baseline for MCO evidence-based performance outcome measures during the first year of program operation and then establish year-over-year improvement goals. This will establish a reliable baseline from which to determine the validity and appropriate structure for a quality incentive program. Selected MCOs should have solid experience collaborating with stakeholders, providers, participants, advocacy organizations, and others in the design of incentive programs. They should demonstrate experience meeting requirements for traditional outcomes measures as well as newer methods such as applicable National Outcomes Measures and National Core Indicators. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 16

17 F. Provider Payment Structure F. State Payment Structure 1. Explain how payments are made by the state to the party(s) responsible for the objectives of the recommended model (As listed in Section 3.1, Items-K) a. Methodology b. Assumptions c. Constraints Rates for MCOs should be actuarially sound and account for differences in clinical acuity, care/residential setting, types of service utilization (physical health, behavioral health, and LTSS), and dual eligible status. MCOs should be incentivized to support participants individual goals for independence by avoiding unnecessary nursing facility admissions and lengthy stays. LTSS risk adjustment models should be adjusted based on the outcomes of participants periodic LTSS assessments as opposed to traditional risk adjustment models that rely on medical and behavioral health diagnoses. Risk adjustment systems based only on clinical status and utilization are not appropriate for programs that include LTSS such as HCBS. Payments would be made to MCOs based on a Per Member Per Month (PMPM) capitation amount that reflects the expected medical expense for participants and includes a reasonable allowance for MCOs administrative costs, cost-of-capital, and risk margin. Since the capitation rates need to reflect the expected costs of participants, states typically establish groupings on eligible participants with similar expected expense into rate cells. Such grouping typically reflects the eligibility category through which a participant became eligible for Medicaid, whether the participant is eligible for Medicare, his or her age and gender, and any waiver programs for which the individual is eligible. Appropriate integration of HCBS into LTSS programs is essential. Several states are experimenting with payment models and other approaches that reward appropriate use of HCBS. Many states have adopted a blended rate approach in setting LTSS premium. Under a blended rate approach, the state s actuaries first determine the actuarial sound rate for individuals living in the community and receiving HCBS, as well as the actuarially sound rates for individuals living in a nursing facility. The state s actuary then projects a reasonable estimate of the mix of individuals who will be living in the community versus living in a nursing facility during the rating period, typically factoring in a slight increase in the percentage of individuals living in the community. The MCO then receives this blended rate for each LTSS participant. This approach assures that the MCOs are properly incented to help individuals continue to reside safely in their homes in accordance with the individual s goals, since the MCO does not receive additional revenues for those who need to reside in a nursing facility. Finally, we recommend that OHCA incentivize MCOs with quality bonuses for achieving designated performance metrics, such as rates of diversions from nursing home and ICF/IDD to HCBS; appropriate use of skilled nursing facility days; an individual s participation in his or her service planning; reductions in nursing facility, emergency room, and hospital OK RFI Care Coordination for the Aged, Blind, and Disabled Page 17

18 F. Provider Payment Structure admission/readmission rates; and overall improvement or maintenance of high participant satisfaction. 2. Explain how proposed payments comply with existing and proposed Federal and State requirements The proposed payment methodology outlined above relies on an actuarially sound PMPM capitation rate. The payments rates are established by the state s actuary prior to the beginning of the contract period and are certified by this actuary as actuarially sound in accordance with existing Federal and State requirements. Additionally, CMS has established significant guidance to states in determining whether the proposed capitation rates meet Federal regulations. CMS is currently seeking comments on their Medicaid Managed Care Modernization Proposed Rule. This proposed rule updates and replaces part of the Code of Federal Regulations in the following sections: 42 CFR Parts 431, 433, 438, 440, 457, and 495. It provides additional guidance regarding the rate setting process and clarifies the standards for determining actuarial soundness. The proposed payment methodology outlined above would be evaluated for actuarial soundness using any new or revised Federal and State requirements established prior to program implementation. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 18

19 G. Impact of Model G. Impact of Model 1. Explain estimated implementation costs and anticipated savings, for years 1through 5. a. Methodology b. Assumptions c. Constraints Implementation Costs Methodology One of our organization s core competencies is successfully implementing new programs, including those reflecting a paradigm shift, in a manner that smoothly transitions participants, providers, and stakeholders and avoids disruption to care. During the last 24 years, Amerigroup s affiliate health plans have successfully planned and carried out over 100 publicly-funded program implementations including roll out of new managed care programs, service area expansions, population expansions, and program enhancements. While the exact implementation costs for the proposed model cannot be determined until the specific requirements of the program and MCO contract are defined, we would anticipate implementation costs in the range of $2,500,000 to $4,000,000 based on our experience with similar programs. Assumptions Our estimate of implementation costs above assumes that OHCA develops and implements a managed care program substantially consistent with our recommended model. Constraints As noted above, a precise estimate cannot be developed until the specific requirements of the program and MCO contract are defined. Anticipated Savings Years One to Five Methodology Amerigroup and our affiliate health plans generate savings for our state customers by providing high-quality care in the most appropriate setting and at the right time. We monitor metrics, such as emergency room utilization, hospital readmissions, and nursing facility utilization, to evaluate savings and outcomes. We deliver savings and high-quality care through a variety of approaches such as comprehensive care management and coordination that includes health education, disease management, and complex case management. For example, we develop programs and use advanced technologies to reduce readmissions and preventable emergency room use, support successful transitions across settings or levels of care, and strengthen in-home and communitybased living. We offer pay-for-performance incentives to providers and facilities for the delivery of efficient, evidence-based, and high-quality care. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 19

20 G. Impact of Model We estimate the anticipated savings for years one to five of the program to be in excess of $180 million dollars. Table G-1 summarizes our development of this estimate. Table G-1. Comprehensive Managed Care - Potential Savings Estimate Estimate of possible savings from comprehensive managed care for Oklahoma ABD population compared to FFS for 5 year period (in $1,000) (State and Federal Dollars) Current FFS Program for ABD Population Year 1 Year 2 Year 3 Year 4 Year 5 CY2016 CY2017 CY2018 CY2019 CY Year Total Savings Inpatient and Nursing Facility $1,006,561 $1,036,758 $1,067,861 $1,099,897 $1,132,894 $5,343,972 Physician, lab, X-ray, and other Acute $576,721 $594,023 $611,843 $630,199 $649,105 $3,061,891 Drugs $303,511 $312,616 $321,994 $331,654 $341,604 $1,611,379 Rehab, Therapy, HCBS and other services $523,104 $538,797 $554,961 $571,610 $588,758 $2,777,231 Administrative Costs $102,421 $105,493 $108,658 $111,918 $115,275 $543,765 Total Current Program Costs $2,512,318 $2,587,688 $2,665,318 $2,745,278 $2,827,636 $13,338,238 Total Integrated Program Savings Inpatient and Nursing Facility $980,794 $1,003,084 $1,032,657 $1,063,092 $1,094,417 $5,174,044 Physician, lab, X-ray, and other Acute $553,698 $564,381 $581,312 $598,752 $616,714 $2,914,858 Drugs $286,028 $290,108 $298,811 $307,775 $317,008 $1,499,730 Rehab, Therapy, HCBS and other services $513,479 $526,405 $542,197 $558,463 $575,217 $2,715,761 Administrative Costs $161,046 $164,494 $169,393 $174,438 $179,632 $849,003 Total Integrated Program Costs $2,495,045 $2,548,473 $2,624,371 $2,702,520 $2,782,988 $13,153,397 Total ABD Managed Care Savings $17,273 $39,215 $40,948 $42,758 $44,648 $184,841 Total ABD Savings Percent 0.7% 1.5% 1.5% 1.6% 1.6% 1.4% Assumptions We developed our estimate of current FFS spending from OHCA s Annual Report for State Fiscal Year (SFY) This report provided the total annual expenditures by type of service by aid category (Appendix B). We combined the statewide spending for the ABD aid categories to determine total spending for these populations and then trended them forward to project FFS spending in future calendar years. We assumed unit cost and utilization tends combined to be 2.0 percent and the population growth trend to be 1.0 percent per year. These trend assumptions are consistent with Oklahoma ABD trends from FY 2013 to FY 2014, and they are also similar to trends we have seen in other states. We incorporated administrative cost differences in the savings calculations. Services that are typically not provided in a FFS environment - such as care coordination, disease management, case management, fraud and abuse efforts, contracting, and network management - are added costs compared to the FFS environment, but create savings over time. For administrative costs, we assumed FFS as 4.25 percent of total medical expenses and managed care as 6.9 percent. This FFS assumption is based on information from the 2014 Annual Report showing total SoonerCare OK RFI Care Coordination for the Aged, Blind, and Disabled Page 20

21 G. Impact of Model administrative costs. We excluded costs associated with Electronic Health Records (EHR) from the total. We based the savings assumptions on actuarial estimates from other states with similar managed care programs and our current industry experience. These estimates are intended to be an illustration of savings opportunity only. Constraints As with any projection of health care expenditures, a number of factors can impact the estimates. Our estimates above assume that a fully integrated managed care program consistent with our recommended design is developed by the State, and that the current regulatory environment at both the State and Federal level is not significantly altered from today s environment (except for anticipated changes such as those in the Medicaid Managed Care Modernization Proposed Rule). 2. Describe the quality and anticipated effect of the model on population health outcomes as related to (materials provided in Respondent s Library): a. CMS recommended benchmarks b. State identified areas including preventive screenings, tobacco cessation, obesity, immunizations, diabetes, hypertension, prescription drug use, hospitalizations, readmissions, emergency room use c. Core measures identified within the Oklahoma Health Plan (OHIP) 2020 d. Respondent suggestions for other benchmarks e. Considerations for Value-Based performance designs, specifically those that support and align with objectives identified within the Oklahoma State Innovation Model design To help OHCA achieve its overall program goals, MCOs must have a history of implementing service delivery systems that improve outcomes at the individual, population, and system level for individuals who are ABD eligible. In selecting partners, OHCA should look for MCOs that demonstrate successful experience conducting routine analysis of data elements to identify opportunities for program performance improvement. MCO experience should include: Tracking and monitoring performance and quality at the aggregate and individual provider and participant levels Identifying opportunities for improvement Measuring the successful implementation of interventions Evaluating effectiveness in meeting program goals OHCA should continue to seek innovative approaches to quality and performance-based strategies for the proposed model. We recommend that OHCA measure program performance through industry standard measures (such as HEDIS, CAHPs, and provider satisfaction surveys) as well as develop outcomes measures that align with the core values of the new program. We OK RFI Care Coordination for the Aged, Blind, and Disabled Page 21

22 G. Impact of Model recommend performance outcomes related to ongoing monitoring of provider satisfaction, such as claims payment turnaround times, as quality indicators of sound business processes. Anticipated Effect on CMS Recommended Benchmarks, State Identified Areas, and Core Measures Identified Within the Oklahoma Health Plan (OHIP) 2020 While specific effects on identified measures will depend on final program design, subsequent to the implementation of an integrated, full risk managed care model for ABD SoonerCare participants, we typically expect the following types of outcomes: Increased access to preventive care services Increased number of participants that live and thrive in the community in tandem with decreased nursing facility utilization as a result of transitioning participants into more functional settings in the community and at home Reduced unnecessary and avoidable inpatient stays and emergency room utilization through improved care coordination and care management Increased access to home- and community-based services further facilitating community tenure for participants Improved quality of service and lowered costs through improved coordination between providers Reduced or prevented decline in function and the need for more intensive interventions through enhanced primary care to manage chronic conditions Increased participant involvement and self-directed care through person-centered planning, which helps participants live more independent and healthier lives These outcomes are supported by the experience of our affiliate health plans in other markets. To best meet the needs of participants, MCOs should have expertise in developing performance management programs focused on improving and enhancing quality of care and services. These programs must be continuous, objective, and systematic in measurement and analysis. Further, MCOs should demonstrate experience in facilitating improved outcomes through quality measurements that include CMS recommended benchmarks, state-identified quality metrics, and additional ones, such as Core Measurements identified in the OHIP 20/20 Report. It will be important for MCOs to also have experience with Triple Aim objectives improved care, better health for populations, and lower cost to assist OHCA in meeting the overarching goals of the program. Based on information from Leavitt Partners 1 and PHPG s SoonerCare Choice Program Independent Evaluation 2, we understand that the existing program has had mixed results on indicators of quality of care and health outcomes. For example, preventive screenings and health management measures are lower than the national average (including breast/cervical cancer 1 Leavitt Partners. Covering the Low-Income, Uninsured in Oklahoma: Recommendations for a Medicaid Demonstration Proposal (2013). 2 The Pacific Health Policy Group (PHPG). SoonerCare Choice Program Independent Evaluation (2014). OK RFI Care Coordination for the Aged, Blind, and Disabled Page 22

23 G. Impact of Model screening rates, cholesterol management rates, and performance on all adult comprehensive diabetes measures) and emergency room utilization rates are high, especially for those who have a disability. OHCA would benefit from contracting with MCOs that bring demonstrated experience improving these and similar outcome measures and can offer immediate assistance to OHCA on improving low performing indicators. Respondent Suggestions for other Benchmarks Based on our experience, we recommend OHCA continue to include a range of HEDIS measures for covered physical and behavioral health services and general measures of participant satisfaction. Additional measures should specifically evaluate LTSS performance, such as individual s participation in service planning, rates of participation in consumer direction, prevalence of falls, quality of life satisfaction, timeliness of services, the degree to which LTSS are meeting individuals needs, and successful nursing home transitions to the community. These measures should build upon OHCA s established HCBS waiver quality measures such as National Core Indicators, Oklahoma Advocates Involved in Monitoring (OK AIM) survey, other HCBS requirements, and corresponding monitoring activities. Process measures should be used only where the process demonstrably leads to improved (or maintained, as applicable) health outcomes and an improved quality of life. OHCA should select MCOs with experience implementing quality measures that build on existing widely accepted, evidence-based, and peer-reviewed measures of quality and that are specifically tailored to address the needs of ABD SoonerCare participants. Further, MCOs should demonstrate organizational capabilities for improving health outcomes and quality of life, delivering timely and effective care, and reporting a range of quality and performance measures. We recommend MCOs experienced with measures that reflect and address the user s home environment, the participation of caregivers, use of self-direction, social interactions, abilities and level of independence of the individual, and care setting. Experience should also include familiarity with quality of life measures, such as the National Core Indicators, designed to promote enhanced self-care, personal preferences, and independence through improved service coordination, community integration and involvement, expanded accessibility to assistive technology, and enhanced participation in the economic mainstream. Regardless of measures, measurement objectives, and methods of achievement used to reinforce quality or performance initiatives; it is most important that OHCA and MCOs collaborate on developing and using these metrics. Final technical specifications for the measures must be administrable and be clearly communicated to all relevant stakeholders. This will assure that all of the goals established by the State are met while also streamlining administration for OHCA, MCOs, and providers. Finally, measures of performance should align with value-based purchasing approaches and performance goals should also align with the overall goals of the program. Considerations for Value-Based Performance Designs We support a value-based delivery system aimed toward improving quality of care and outcomes while decreasing overall cost of care. The impact of any value-based performance designs should be measured in terms of access, outcomes, quality of care, and savings. Based on our experience, OK RFI Care Coordination for the Aged, Blind, and Disabled Page 23

24 G. Impact of Model we have outlined considerations for OHCA when implementing a value-based performance system that support and align with Oklahoma s State Innovation Model objectives of: Achieving consensus among stakeholders and aligning quality measures (Phase One) Transforming the healthcare delivery system (Phase Two) Enhancing data and value-based analytics (Phase Three) For Phase One of the SIM to achieve consensus among stakeholders and align clinical and population-based health measures - OHCA should focus on bringing together experts and stakeholders from across the state, including MCOs, to define system-wide performance measures. As part of Phase Two, it will be important for OHCA, MCOs, and providers to work collaboratively in developing a multi-payor, value-based purchasing model that fairly compensates providers, incentivizes healthy behaviors, and reinforces quality and evidencebased practices. Key to this model will be all stakeholders working together to develop and agree on a set of common quality measures and a consistent approach to measuring performance. This will assure stakeholders work toward the same goals and focus on the same measurements, while also allowing the delivery of consistent quality information to participants. To support Phase Three, OHCA should require MCOs to demonstrate their capacity for proactively using sophisticated data analytics to identify opportunities to enhance consumer outcomes and implement strategies that result in improved health and wellness. In order to shift to a model focused on wellness and prevention, MCOs should also have the capability for data sharing with other system partners to help facilitate a more holistic view of participants to coordinate their care. In addition, MCOs should demonstrate their commitment and ability to work with and encourage providers to adopt and meaningfully use EHR. Technology adoption and use can vary widely across providers; thus, MCOs must be able to deliver information in a way that providers can use while also promoting the benefits that health information technology can offer, including better care coordination, prevention, wellness, and improved quality. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 24

25 H. Anticipated Overarching Timelines H. Anticipated Overarching Timelines (including key activities and milestones) 1. Development 2. Transition/Readiness Activities 3. Implementation of member enrollment 4. Implementation of member service delivery We commend the State for its dedication to a thoughtful and carefully planned implementation process that allows sufficient time for planning, stakeholder engagement and education, and MCO transition and readiness activities, including provider network development, engagement, and education. Through our experience managing successful start-ups in other states, we have gained insight into what works and what doesn t. Using this knowledge, we developed a proposed implementation timeline depicted in Figure H-1 below, and provided additional information on each implementation stage in the sections that follow. Upon contract award, we recommend the selected MCOs collaborate with OHCA to finalize a transition and implementation schedule that allows adequate time to effectively launch all aspects of the program. Figure H-1 Proposed Implementation Timeline OK RFI Care Coordination for the Aged, Blind, and Disabled Page 25

26 H. Anticipated Overarching Timelines Development Activities We recommend OHCA adopt the following activities during the development phase: Engage and initiate stakeholder input, including through current RFI activities and related stakeholder meetings. These efforts would occur three to nine months prior to RFP release and continue throughout the implementation process. Finalize a program design based on stakeholder feedback and other requirements. These efforts would include consolidating stakeholder feedback, determining final program design, developing the RFP and associated draft MCO contracts, and drafting necessary State plan amendments, waiver applications or amendments. These efforts should be completed approximately months prior to the go-live date. Include additional opportunities for stakeholder input during the RFP administration process. Ideally, the State will incorporate a draft RFP and model contract review period into this process to allow for stakeholder input on these critical documents prior to the actual procurement period. This activity should allow for a two- to five-month response period (depending on the scope of the RFP) so prospective MCOs have adequate time to prepare a response. Include sufficient time for a thorough readiness review and transition process. The State should be prepared to complete the evaluation of all responses and make final RFP awards approximately nine months prior to the intended go-live date. This time period allows for sufficient time for the State and MCOs to collaborate on a comprehensive and effective readiness review and transition process. Pursue any necessary CMS program approval timely. The State should actively work with CMS throughout the design and development phase to finalize and obtain approval of any required state waiver applications or amendments. The content of these documents will dictate ultimate program design and subsequently impact the final MCO contract to be executed following RFP award announcements. Given the extensive resources and time necessary to develop a comprehensive and accessible provider network, prospective MCOs should initiate network development activities. These efforts will continue through the go-live date for the program. Transition/Readiness Activities The following section highlights a proposed set of key activities OHCA may want to include as part of the transition and readiness activities. Ongoing outreach and engagement: OHCA and selected MCOs should convene meetings to introduce the managed ABD program concepts, performance measures, participant engagement and protections, and to discuss issues and priorities. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 26

27 H. Anticipated Overarching Timelines OHCA and MCO implementation meetings: Following RFP awards, OHCA should establish regular and frequent meetings between OHCA staff and MCO implementation teams to provide an ongoing and open forum for strong collaboration between all parties. This also allows an opportunity for questions and issues regarding the implementation to be addressed quickly and effectively. Readiness Review Tool and Schedule Development: As soon as possible following RFP award announcements, OHCA should prepare and distribute a readiness review schedule and associated evaluation tool to be used in assessing MCO preparedness for program implementation. A comprehensive readiness review should include desk audit components as well as an on-site review and systems readiness review. MCO Network Development: MCOs should continue to recruit providers, perform related network development activities such as conducting provider training sessions, hiring and training staff, and developing participant and provider educational materials. MCO Readiness Reviews: OHCA or its designee should complete all readiness reviews approximately three months prior to go-live to verify that all MCOs have been approved for operations in advance of enrollment material mailings to participants. Participant Assessments: For participants requiring annual re-assessments and level of care determinations, OHCA should consider requiring current case managers to conduct all necessary assessments at least 60 days in advance of the go-live (ahead of required due dates, as applicable) so that adequate resources are in place to complete these critical tasks. Often, case management resources may transition to MCO staff positions, which provide significant opportunities for continuity of care for participants. However it may also present challenges to complete such assessments in the final weeks prior to go-live. Conducting such assessments early in the implementation process reduces the risks of gaps in care and eligibility. OK RFI Care Coordination for the Aged, Blind, and Disabled Page 27