SOONERHEALTH STAKEHOLDER MEETING THE PACIFIC HEALTH POLICY GROUP

SOONERHEALTH+ STAKEHOLDER MEETING THE PACIFIC HEALTH POLICY GROUP JULY 26, 2016

HB 1566 “The Oklahoma Health Care Authority shall initiate requests for proposals for care coordination models for aged, blind and disabled persons. Care coordination models for members receiving institutional care shall be phased in two (2) years after the initial enrollment period of a care coordination program. ” Sooner. Health+ - Jul 2016 Stakeholder Meeting 2

WHO ARE OUR ABD MEMBERS*? Medicare/Medicaid Dual Eligibles not receiving long term care Frail elders/persons with physical disabilities receiving Long Term Services and Supports (LTSS) or residing in a nursing facility (NF) Sooner. Care Choice (SCC) “Medicaid-only” ABD members Persons with intellectual/ developmental disabilities receiving waiver services or residing in an ICF-I/D (or on waiting list) *Persons with serious mental illness can be found in all categories Sooner. Health+ – Jul 2016 Stakeholder Meeting 3

TODAY’S MEETING Recap of stakeholder process Update on Request for Proposals Developing draft RFP and model contract Incorporating federal requirements from final CMS rule Incorporating stakeholder recommendations Next steps Sooner. Health+ - Jul 2016 Stakeholder Meeting 4

STAKEHOLDER MEETINGS - OKC DATE (2015) LOCATION ATTENDEES July 21 OKC (and remote) Mix of attendees (members/families, advocates, providers, case managers, other) September 8 OKC (and remote) Mix of attendees (members/families, advocates, providers, case managers, other) October 13 OKC (and remote) Mix of attendees (members/families, advocates, providers, case managers, other) November 10 OKC (and remote) Mix of attendees (members/families, advocates, providers, case managers, other) OKC (and August (multiple remote) dates) Sooner. Health+ - Jul 2016 Stakeholder Meeting Presentations from potential contractors, with stakeholders in attendance 5

STAKEHOLDER MEETINGS - REGIONAL DATE (2015) LOCATION ATTENDEES September 21 Mc. Alester Regional stakeholder – mix of attendees September 22 Lawton Regional stakeholder – mix of attendees September 23 Enid Regional stakeholder – mix of attendees September 29 Muskogee Regional stakeholder – mix of attendees September 30 Tulsa Regional stakeholder – mix of attendees October 7 Woodward Regional stakeholder – mix of attendees October 5 Tahlequah Elder care members and caregivers October 6 Ardmore Parents/support team of medically fragile child October 7 Oklahoma City Member/parents of children/adults with I/DD Sooner. Health+ - Jul 2016 Stakeholder Meeting 6

STAKEHOLDER MEETING ATTENDEES Providers Members and Families • Physicians • ADvantage waiver and PACE • Hospitals • I/DD waiver and waiting list • Federally Qualified Health Centers (primary care, dental, behavioral health) • Medically fragile • IHS providers • Non-emergency transportation providers • ADvantage waiver case managers and in-home service providers • PACE provider • I/DD waiver service providers • Nutrition/home delivered meal providers Sooner. Health+ - Jul 2016 Stakeholder Meeting Other • Elected officials • State agency representatives (observers) • Health plans (observers) 7

STAKEHOLDER MEETING TOPICS What is care coordination? How does the care coordination cycle function today, by ABD group? What are the key principles of effective care coordination? How well are these met today? How could they be strengthened? Sooner. Health+ - Jul 2016 Stakeholder Meeting 8

STAKEHOLDER MEETINGS - OUTCOME Meetings were driven by experience and concerns of participants; no two meetings were identical Regions were not identical in their outlook, although broad areas of commonality existed PHPG looked for themes across meetings to inform identification of principles of effective, member/family centered care coordination Written stakeholder submissions also were accepted and carefully reviewed as part of the process Note: Process relied on stakeholders who participated; not all stakeholders in the state took part Sooner. Health+ - Jul 2016 Stakeholder Meeting 9

STAKEHOLDERS - CARE COORDINATION CYCLE Determine/ recertify eligibility Monitor outcomes Care Member & Family Assess needs Team Coordinate services Sooner. Health+ - Jul 2016 Stakeholder Meeting Develop care plan 10

RFP PROCESS – UPDATE The Sooner. Health+ draft RFP, including “model contract” standards, is nearing completion The draft will be submitted to CMS for review and approval Proposal submission requirements and evaluation criteria will be finalized while CMS performs its review of the model contract Work on capitation payment rates also is underway Sooner. Health+ - Jul 2016 Stakeholder Meeting 11

RFP PROCESS – MODEL CONTRACT The model contract portion of the RFP contains MCO operational standards Model contract operational standards have been informed by: Best practices in other states with existing managed care programs CMS managed care “final rule” requirements Oklahoma stakeholder recommendations Sooner. Health+ - Jul 2016 Stakeholder Meeting 12

RFP PROCESS – MODEL CONTRACT Stakeholders provided recommendations on principles of effective care coordination through meetings and in written submissions Both sources were used in development of contract standards Many recommendations mirrored the CMS final rule Others were based on a desire to maintain what works well in Oklahoma today while closing identified gaps in the current system The model contract is 300+ pages and addresses over 20 operational areas Sooner. Health+ - Jul 2016 Stakeholder Meeting 13

RFP PROCSS – MODEL CONTRACT Member Related Provider Related • Enrollment and Disenrollment • Provider Network & Service Accessibility • Member Services • Provider Contracting & Services • Transition of Care • Indian Health Care Providers • Medical Management • Claims Processing • Care and Disease Management • Native American Population • Member Complaints and Appeals Quality Related • Licensure, Administration & Staffing • Quality Improvement • Contractor Performance Standards • Program Integrity/Compliance Note: Summary is informational only and does not include all model contract sections. CMS-approved contract will contain final sections Sooner. Health+ - Jul 2016 Stakeholder Meeting 14

RFP PROCESS – MODEL CONTRACT The next several slides provide examples of how stakeholder recommendations are addressed in the model contract The full list of recommendations (and contract requirements) is much more extensive The final model contract will be accompanied by a matrix that addresses written stakeholder recommendations in detail by documenting how each recommendation is addressed in the contract Sooner. Health+ - Jul 2016 Stakeholder Meeting 15

MODEL CONTRACT – ENROLLMENT RECOMMENDATION Use an independent third party to provide options counseling to all eligible members Members should have the option to continue enrollment in existing, successful programs, such as PACE, Behavioral Health Homes and Patient Centered Medical Homes CONTRACT • The OHCA will use an independent options counseling vendor • Members will be educated about the program and about which MCOs have providers a member uses in their networks • Members will have up to 90 days to choose a plan when the program begins; later enrollees will have 30 days • PACE will continue to be offered as an option to qualifying members, in lieu of MCO enrollment • Behavioral Health Homes will continue to serve qualifying members, in lieu of MCO enrollment • MCOs will be required to have Patient Centered Medical Homes for their Medicaid-only members Note: Summary of draft standards is informational only. CMS-approved contract will contain final standards Sooner. Health+ - Jul 2016 Stakeholder Meeting 16

MODEL CONTRACT – NEEDS ASSESSMENT RECOMMENDATION Require MCOs to provide person-centered assessments to all members Require MCOs to reassess members at least annually CONTRACT • MCOs will be required to perform an initial health risk screening on all members • MCOs must report their screening rates monthly to the OHCA • Based on the results of the screening, each member will be assigned to an appropriate care management risk level • Members, other than those in the lowest risk level, will then receive a comprehensive assessment of medical, functional, behavioral health and social service needs and preferences • MCOs will be required to reassess members at least annually and within 72 hours of a significant change Note: Summary of draft standards is informational only. CMS-approved contract will contain final standards Sooner. Health+ - Jul 2016 Stakeholder Meeting 17

MODEL CONTRACT – CARE PLANNING RECOMMENDATION CONTRACT Require MCOs to provide • MCOs will be required to develop person-centered care plans for all members planning for all members Allow the Member to participate in the development of the care • Interdisciplinary Team (IDT) must include the plan and require member or the member's legal guardian as a sign off of the care plan full participant upon the initial • Member or member’s legal guardian will sign development and upon the care plan prior to its implementation any subsequent change to the plan Note: Summary of draft standards is informational only. CMS-approved contract will contain final standards Sooner. Health+ - Jul 2016 Stakeholder Meeting 18

MODEL CONTRACT – CARE COORDINATION RECOMMENDATION CONTRACT Require MCOs to • For members who have existing care plans, continue existing care MCOs must accept the existing care plan for a plans during a time of period of 90 days or until a comprehensive transition until new assessment and new care plan have been providers are in place and completed and developed, whichever comes the new providers are meeting the requirements sooner of the care plan Require care plans that decrease or eliminate existing services for a member to undergo a secondary review prior to implementation • All care plans must be reviewed by a supervisory -level care manager at the MCO prior to implementation • Care plan updates for I/DD waiver members transitioning to MCOs will be subject to DHS DDS review Note: Summary of draft standards is informational only. CMS-approved contract will contain final standards Sooner. Health+ - Jul 2016 Stakeholder Meeting 19

MODEL CONTRACT – OUTCOMES MONITORING RECOMMENDATION CONTRACT The State must have in place a comprehensive quality management system that • measures the effectiveness of services in assisting individuals to achieve personal goals • Standard, national quality metrics must be incorporated, with outcomes reported no less than quarterly. • MCOs will be required to have a continuously updated Quality Improvement program that will be monitored by the OHCA The model contract includes a comprehensive schedule of physical health, behavioral health and HCBS clinical performance measures on which MCOs will be required to report. Reporting frequencies range from quarterly to annual, depending on the measure The model contract also includes a comprehensive schedule of non-clinical operational and financial reports to be used by the OHCA to monitor MCO performance Note: Summary of draft standards is informational only. CMS-approved contract will contain final standards Sooner. Health+ - Jul 2016 Stakeholder Meeting 20

MODEL CONTRACT – MEMBER RIGHTS RECOMMENDATION CONTRACT • MCOs must have Member Advocates/Ombudsmen with a direct reporting relationship to executive management and with responsibility for assisting members by: o Advocating on behalf of a member and his or her preferences with respect to receiving member- and familycentered care; o Assisting the member to access community-based resources to address non-medical needs and to support the member’s care plan objectives and independence; o Obtaining information about available services in and outside of the health plan; and o Filing complaints and appeals • MCOs must establish a standing Advisory Board that includes members, member representatives, advocates and providers. The advisory board will be member-majority and will be viewed as a quality goal by the OHCA and the board will be expected to help develop a comprehensive quality monitoring process The OHCA must require a newly funded ABD Coordinated Care Program State Ombudsman Program to be included in the ABD Coordinated Care Program model The OHCA should appoint at least three family advisors to a quality of care review committee and these appointees should represent an educated and diverse cadre of Medicaid-recipient families Note: Summary of draft standards is informational only. CMS-approved contract will contain final standards Sooner. Health+ - Jul 2016 Stakeholder Meeting 21

RFP - PROPOSAL SUBMISSION The proposal submission portion of the Sooner. Health+ RFP will encompass both technical requirements and price Technical portion will address: Bidder’s proposed region(s) or statewide Licensure/financial Experience and past performance in Oklahoma (if applicable) and other states (if applicable) Approach to meeting model contract requirements (“How will you…”) Case studies (clinical, member experience and provider experience) Medicaid/Medicare integration Innovative and “value-added” proposals for serving Coordinated Care Program members and contracting with providers Price portion will address capitation rates MCOs and providers will not be required to execute contracts as part of MCO proposal submission Note: Summary of proposal submission requirements is informational only. Final RFP will contain full set of requirements Sooner. Health+ - Jul 2016 Stakeholder Meeting 22

NEXT STEPS STEP Finalization and submission of draft model contract to CMS review period Release of RFP Written proposals due to OHCA TENTATIVE DATES August 2016 August – October 2016 November 2016 January 2017 (end of month) Contract awards May 2017 Readiness period June – December 2017 Start of member plan selection Start of Services Sooner. Health+ - Jul 2016 Stakeholder Meeting January 2018 April 2018 23

ACRONYM GUIDE Acronym Meaning ABD Aged, Blind or Disabled ASO Administrative Service Organization (see also MFFS) CCU OHCA Chronic Care Unit CMS Centers for Medicare and Medicaid Services EQRO External Quality Review Organization EVV Electronic Visit Verification ICF-I/D Intermediate Care Facility for Persons with Intellectual/Developmental Disabilities HAN Sooner. Care Health Access Network HCBS Home and Community-Based Services (see also LTSS) HEDIS® Healthcare Effectiveness Data and Information Set HMP Sooner. Care Health Management Program HRA Health Risk Assessment (also health risk screen) I/DD Intellectual/Developmental Disabilities IDT Interdisciplinary Team (also Interdisciplinary Care Team) Sooner. Health+ - Jul 2016 Stakeholder Meeting 24

ACRONYM GUIDE cont’d Acronym Meaning LTSS Long Term Services and Supports (see also HCBS) MFFS Managed Fee-for-Service (see also ASO) MLTSS Managed Long Term Services and Supports NF Nursing Facility P 4 P Pay-for-Performance PACE Program of All-Inclusive Care for the Elderly PCA Personal Care Assistant PCMH Patient-Centered Medical Home RFI Request for Information RFP Request for Proposals SCC Sooner. Care Choice TANF Temporary Assistance for Needy Families Sooner. Health+ - Jul 2016 Stakeholder Meeting 25