Oklahoma Health Care Authority outlines April 1 launch, provider protections and payment rules for Sooner Select

Ellen Bittner, chief executive officer of the Oklahoma Health Care Authority, opened a provider briefing on the agency's transition to Sooner Select, the state's new managed-care delivery model, and introduced the plans selected to serve SoonerCare members.

The agency said three medical plans'Aetna Better Health, Humana Healthy Horizons and Oklahoma Complete Health'and two dental plans'DentiQuest and Liberty Dental'will participate. Oklahoma Complete Health will operate a single statewide children's specialty plan for children in the custody of child welfare and juvenile-justice services; those children will be automatically enrolled, officials said.

Traylor, an Oklahoma Health Care Authority presenter, said the transition aims to shift payment toward value-based models, improve member satisfaction and contain costs through care coordination. "We always pay on time," Traylor said, noting contracts include a maximum turnaround of 14 days from claim submission and that many plans expect to pay in seven days or less.

To drive outcomes, the authority said contracts contain specific quality metrics, time frames and both incentives and penalties over a five-year period. Contract language requires contracted entities to spend 11% of medical spend on primary care; the authority noted current primary-care spending in its fee-for-service system is roughly 4% of total health care costs.

The agency also said it will require a single provider portal for eligibility, billing and prior-authorizations and a centralized credentialing process to limit duplicate administrative work. Traylor said plans may accept deeming for providers already credentialed in networks, and delegated credentialing will be allowed for large physician groups and hospital systems that use that model commercially.

On provider rates, Traylor announced that contractual rate floors for all providers will remain in effect until July 1, 2026, to give plans time to adopt value-based payment models without abrupt rate reductions.

Officials addressed coverage scope and exclusions: most SoonerCare populations will transition into the contracts, but members who are aged, blind or disabled and served by home- and community-based waivers will continue under current OHCA administration; American Indian and Alaska Native members may opt in voluntarily; dual Medicare-Medicaid beneficiaries will remain excluded and continue to be administered and monitored by the Health Care Authority.

Traylor described additional operational elements: the pharmacy preferred drug list will remain managed by the Health Care Authority and drug rebates will continue to accrue to the authority; non-emergency transportation must meet contract timeliness standards; and plans may offer value-added services'such as social-determinants supports'that could influence members' plan choice.

The agency highlighted a provider incentive pool tied to outcomes. Traylor said state legislation directed about $100,000,000 from the supplemental hospital offset payment (SHOP) pool to community providers, and that moving to managed care could increase SHOP-related dollars by about $600,000,000 annually by adjusting the upper payment limit used for supplemental payments.

On timeline and enrollment mechanics, the authority said dental plans will go live in February and medical plans on April 1, 2024, subject to federal approval. Notices to members will begin in November; based on other states'experience, officials expect fewer than 25% of members will actively choose a plan. If members do not choose, the agency will auto-assign plans with a round-robin algorithm designed to keep families together and align members with their most recent primary care provider. Members will have about a 90-day period to change plans before coverage becomes fixed for the plan year.

Officials said prior-authorization medical-necessity criteria used by plans cannot be more restrictive than current Health Care Authority standards without OHCA and physician approval. Work groups are still deciding which national tools (for example, InterQual or Milliman) to use for inpatient psychiatry levels-of-care guidance.

Providers raised questions during the session. A member identifying herself as president of the Oklahoma Osteopathic Association said her group "was not consulted at all" about advisory committee nominations; Traylor responded that OHCA used a public nomination portal, solicited recommendations from associations when they existed and vetted nominees for conflicts of interest, and encouraged ongoing input and representation.

Traylor said the authority will publish committee memberships and meeting minutes, create member- and provider-facing materials (a website, pamphlets and toolkits), and urged providers to give feedback if they observe contract noncompliance.

Next steps: OHCA said it will announce quality advisory committee members and meeting details in the coming weeks, begin member notices in November, launch dental plans in February and start medical plan enrollment April 1, 2024, contingent on CMS approval.