© 2024 KGOU
Colorful collared lizard a.k.a mountain boomer basking on a sandstone boulder
News and Music for Oklahoma
Play Live Radio
Next Up:
0:00
0:00
0:00 0:00
Available On Air Stations

Oklahoma’s transition to managed Medicaid brings new benefits, challenges

Oklahoma providers hold a rally on April 26 at the Oklahoma State Capitol against the state’s transition to managed Medicaid, or SoonerSelect.
Jillian Taylor
/
StateImpact Oklahoma
Oklahoma providers hold a rally on April 26 at the Oklahoma State Capitol against the state’s transition to managed Medicaid, or SoonerSelect. 

More than 600,000 Oklahomans on Medicaid are now seeing their care coordinated by private insurance companies. Proponents say the rollout has been going well, but some providers and the people they serve are experiencing challenges.

Amanda Paul was inspired to become a speech-language pathologist because of her daughter, who experienced language and learning problems as a child. Now, Paul runs her own clinic in downtown Chickasha, where she serves mostly Medicaid families.

She uses shelves filled with toys to connect with kids with autism, Down syndrome and sensory issues, and she teaches them how to communicate. She does all of this while handling the day-to-day operations of her rural, independent practice.

“I do it all. I’m the secretary, the speech path, the janitor. It’s all me,” Paul said.

Paul said her job has become much harder in the past few months as the state transitions to managed Medicaid, or SoonerSelect. In a 10-month turnaround, the Oklahoma Health Care Authority (OHCA) went from paying providers to paying private companies to coordinate Medicaid care.

The state contracted with the medical plans Humana Healthy Horizons, Aetna Better Health and Oklahoma Complete Health, which also runs Oklahoma’s Children Specialty Program. They went live April 1.

A month into the new system, Paul said she only received about 5% of the claims she sent out. She’s had to cancel client visits and spend late nights figuring out why she wasn’t getting paid.

“My blood pressure is normally under control. Last week, it was 191 over 101 because of the stress,” Paul said.

Jillian Taylor
/
StateImpact Oklahoma
Amanda Paul and one of her clients, Ashlie Killman, at Paul’s practice in Chickasha

But she kept seeing patients. That was the case for multiple providers in mental health and occupational therapy, who told StateImpact they waited weeks to receive only small portions of their payments. They all continued seeing patients for free until they mostly resolved their issues with the plans. Paul said she’s still working on that. Even now, only one plan has given her some checks from May, while the other two have provided about half of them from April.

As of May 13, 616,224 Oklahomans on Medicaid are now seeing their medical care coordinated by private insurance companies instead of OHCA. Proponents say the change incentivizes preventative care and its rollout has been going well. But it has caused problems for some Oklahomans on Medicaid and the smaller providers, like Paul, who are serving them.

What is managed care and how did Oklahoma get it?

OHCA began its transition to SoonerSelect in 2022 after Gov. Kevin Stitt signed Senate Bill 1337 — authored by Sen. Greg McCortney (R-Ada) and Rep. Marcus McEntire (R-Duncan) — and Senate Bill 1396 — authored by McCortney and Rep. Kevin Wallace (R-Wellston).

SB 1337 required OHCA to enter capitated contracts with entities to deliver Medicaid services. It left out the state’s aged, blind and disabled populations, meaning they will still be served under the OHCA-led Medicaid program, SoonerCare.

SB 1396 added to an already existing Supplemental Hospital Offset Payment Program, which taxes hospitals and uses collected fees to attract more federal money. That total is redistributed to participating hospitals. The bill brought an opportunity to invest additional funding into hospitals, and they received an accelerated payment of $252.4 million in April.

Since those bills were signed, OHCA has been working to make providers and members aware of the transition through things like newsletters, social media posts, town halls and provider meetings.

SoonerSelect health plan enrollment began Feb. 1 and ended March 10, and if members didn’t actively choose a plan, OHCA enrolled them in one on their behalf. OHCA’s Public Information Officer Emily Long said at the end of open enrollment, about 20% of Oklahomans had actively chosen a plan.

Oklahoma’s Medicaid Director Traylor Rains said to help the agency maintain its oversight role, OHCA created a 20-person operation division that specifically focuses on SoonerSelect. They also brought on some consultants to help them meet the needs of managed care.

Long said the transition to SoonerSelect allows Oklahoma to achieve goals like improving health outcomes, customer satisfaction and investing in preventative primary care. Each of the plans offers a list of unique benefits, including monetary incentives for attending well-child and primary care visits, making care managers available to members and waiving copays for certain services.

The Oklahoma Health Care Authority manages Oklahoma's Medicaid program, known as SoonerCare.
The Frontier
The Oklahoma Health Care Authority manages Oklahoma's Medicaid program.

Problems for providers

Rains said the state’s contract requires the insurance companies to pay 90% of all clean claims in 14 calendar days.

“That claim coming into the managed care plan has to have the right provider information on it … and match all the editing criteria,” Rains said.

The operation team receives reports from companies that it will use to verify if plans meet that target. If they don’t, they could face monetary penalties.

The Oklahoma Health Care Authority found challenges early in the transition, including errors in processing claims and issues with direct deposits and call centers. They sought to address those through multi-week office hours with the plans and provider-specific town halls. Plans also offer advance or interim payments to providers experiencing cash flow issues.

StateImpact reached out to Oklahoma’s three medical-managed care plans about the transition. Humana Healthy Horizons interviewed with StateImpact. Aetna Better Health and Oklahoma Complete Health sent statements. Those are included at the end of the article.

Humana Healthy Horizons in Oklahoma CEO Joseph Fairbanks said 99.9% of the plan’s clean claims are being paid out in 14 days, and their average for claims processing is within six days of receipt.

Some of the issues Paul said she struggled with included getting her claims for one plan through the online provider portal, Availity. She also found out later that she had been billing incorrectly for another plan. Those issues took a lot of late nights to solve, and she said she’s still stressing week to week as she waits for more payments to come in. She’s had to consider closing down at points.

Fairbanks said although overall feedback has been positive from providers, certain ones, like Paul, are more likely to have issues.

“By their nature, because they're either individually run provider clinics or they have a smaller staff, they don't have as many resources as some of the larger providers did to prepare. So we have to help them substantially more than we do some of the larger providers,” Fairbanks said.

The Oklahoma State Medical Association President Dr. Edgar Boyd said it can be challenging for providers to have to choose between paying their bills and serving their patients. It’s a choice, he said, they don’t want to have to make as the transition continues.

“I don't want to see patients cut off from access to care, just because their provider can't afford to float the loan any longer,” Boyd said.

Problems for patients

Boyd, a practicing otolaryngologist in Muskogee, said despite communications from OHCA, he worried his Medicaid patients weren’t prepared.

“I would see patients in my office in early March and ask them if they had selected their new insurance company for their child,” Boyd said. “‘Oh no, we have SoonerCare Medicaid.’ I go ‘Well it’s changing come April 1st.’ ‘Oh, we didn't know anything about that.’”

Stillwater resident Donna Waldrop said she tried to prepare as much as she could before the transition. Waldrop receives Medicaid as a live-in caregiver for her best friend, and she chose Humana Healthy Horizons because most of her doctors were taking it. But she said she had to change some of her specialists because they didn’t take Humana.

Specialists like her rheumatologist. She said they canceled her appointment the day before in May despite a 90-day continuity of care period required by the Oklahoma Health Care Authority. This means that Oklahomans should be able to see their regular providers through June even if they’re contracted with a different insurance than what they chose.

That meant she had to push back getting surgery for a torn ligament in her hip because she needed the specialist’s approval.

“I am just beside myself because I had all these things planned out, specialists I was supposed to go see in May to try to get my hip done by the summer. Because I am a caregiver. I have to plan this out very carefully. … I probably will have to live with this for at least another year,” Waldrop said.

Waldrop said she will also lose her psychiatrist because the company they work under will no longer take Medicaid after the continuity of care period. A company spokesperson from Lifestance, an online behavioral health company, told StateImpact why in an email:

“We work hard with each insurer to ensure sustainable levels of investment in mental health care. Unfortunately, the significant regulatory burden associated with accepting SoonerCare, combined with reimbursement levels that do not cover the cost of care, made it impossible for us to continue to contract with SoonerCare at the moment. We remain committed to continuing to engage with the state to identify a sustainable path forward for mental health care.”

Waldrop said as of late May, she changed her plan to Oklahoma Complete Health, allowing her to get a delayed appointment in July with her rheumatologist. She said she’s worried about further delaying surgery for both herself and her friend.

“It is eventually going to cause me to not be able to work if it gets worse. … This is the kind of injury that needs surgery to fix. If not, you live with it, and you become more disabled. If this is not fixed, I will need a hip replacement. I’m 45,” Waldrop said.

Positive potential

Although some providers and people say this transition has been difficult, others disagree. Stigler Health and Wellness Center CEO Teresa Huggins said they felt prepared for the transition and supported by the plans.

She looks forward to seeing the impacts this model could have on preventative care through some of its added benefits. Her goal is to use this transition to strengthen the center’s care model.

“We hope that those outcomes will be better quality indicators, better health outcomes for them, and then that would result obviously in less cost to the state,” Huggins said.

Oklahoma’s Medicaid Director Traylor Rains said overall, the Health Care Authority feels this transition has gone as well as the agency could have expected on a short turnaround. Long said Oklahoma has improved from where it was at the beginning of April when the rollout of SoonerSelect launched.

“We are continuing to work with our partners at the plans and providers to resolve any other issues that come up because it's very important for us for our providers to feel that they are supported and that we can help them in any way that we can,” Long said.

But as the transition continues, providers like Amanda Paul and patients like Donna Waldrop are dealing with the growing pains.

Statements from contracted entities

Aetna Better Health:
Aetna Better Health of Oklahoma is deeply committed to improving health outcomes for SoonerSelect members. We recognize that the state’s transition to managed care is significant and are working closely with our members and the state to ensure coverage is continued and enhanced for all SoonerSelect members both in the short and long term.

-Aetna Executive Director of Communications Alex Kepnes

Oklahoma Complete Health:

Oklahoma Complete Health is excited about the opportunity to deliver innovative solutions to address the drivers of health, remove barriers to care and deliver better health outcomes for Oklahomans.

We believe primary care is the foundation of comprehensive health care. It is imperative that we educate our members about the importance of choosing and working closely with their primary care providers.

To assure continuity of care for members, Oklahoma Complete Health is honoring all OHCA prior authorizations.

If a provider holds a current authorization issued by OHCA, no further prior authorizations requests need to be submitted unless notified by Oklahoma Complete Health.

-Oklahoma Complete Health Chief Medical Officer Dr. Lynn Mitchell

Additional Resources:

  • Oklahomans have until the end of June to change their plans. They can call 800-987-7767, option 5 to talk with choice counselors. 
  • OHCA SoonerSelect Contact: SoonerSelect@okhca.org
  • Provider resources are available on OHCA’s website 
  • Member resources are available on OHCA’s website

StateImpact Oklahoma is a partnership of Oklahoma’s public radio stations which relies on contributions from readers and listeners to fulfill its mission of public service to Oklahoma and beyond. Donate online.

Jillian Taylor reports on health and related topics for StateImpact Oklahoma.
StateImpact Oklahoma reports on education, health, environment, and the intersection of government and everyday Oklahomans. It's a reporting project and collaboration of KGOU, KOSU, KWGS and KCCU, with broadcasts heard on NPR Member stations.
More News
Support nonprofit, public service journalism you trust. Give now.