Managed Care and the Disabled Population

Mike Fogarty, CEO, Oklahoma Health Care Authority

April 17, 2002

SoonerCare ABD Population (D-link)

Transition of Persons with Disabilities into Managed Care

• Mandatory Enrollment
• Plus (July - October 1999)
  • Lifted Service Limits for Adults
• Choice (January - April 2000)

Challenges to Transition

• Lack of Infrastructure in Fee-for-Service Program to Serve this Population
• Limited Experience/Knowledge
  • Utilization Patterns
  • Health Care Needs of Population
• Pent-up Demand for Services
• Stress on Provider Networks/PCPs
• Coordination of Care
• Access to Specialty Care
• Adequate Financing/Rate Setting

Financing/Rate Setting

Original Implementation Features

• Plans not required to purchase re-insurance
• Two-tiered Stop Loss for plans
• ABD Bridge Payment in PCCM Program

Post Implementation Adjustments

• Adjustment of Plan ABD Capitation Rates for Pharmacy retroactive to July 1999 (Feb 2000)
• Quarterly Supplemental Payment for Enhanced Case Management (July 2000)
• Plan ABD Risk Allocation Monthly Payment from special appropriations retroactive to July 2000 (Oct 2000)
• Increased ABD Capitation Rates by 4.17% retroactive to July 2000 (April 2001)
• Risk Adjustment for ABD Population based on Kronick’s CDPS model (Jan 2003)

Coordination of Care Exceptional Needs Coordinators

• Minimum five years’ experience working with individuals with disabilities
• RN or social work background
• Point Person/Advocate
• Medical and Social Needs
• Coordinate care for members with medically diverse needs

Go to: Final Summary | Disability Conference | Provider Reimbursement | HRSA | HHS