Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Unlike a traditional fee-for-service system, in which a provider is paid directly by an insurer for every service delivered, under managed care, an insurance company, organization, or provider is responsible for providing a specified set of services for each insured member in return for a set monthly payment, known as the capitation rate.
A managed care organization is an entity that receives a capitated payment and coordinates a patient’s care through a defined network of physicians and hospitals. An HMO, or Health Maintenance Organization, is a variety of managed care organization that typically requires patients to seek care from doctors and other providers who work for or contract with the HMO. In exchange for being limited in their choice of providers, patients enrolled in an HMO typically have lower out-of-pocket costs than in a fee-for-service plan.
From 1995-2004, Oklahoma’s Medicaid agency, OHCA, ran two managed care program. A fully capitated managed care HMO program, known as SoonerCare Plus, operated in urban areas but was discontinued in 2004. The second program, SoonerCare Choice, operated in rural areas only from 1995-2004 and then statewide from 2004-2023. Under the SoonerCare Choice program, most children and working-age adults selected or were assigned to a Primary Care Provider/Care Manager (PCP/CM), who received a monthly capitated payment for coordinating the care of each of their patients.
After several failed attempts to relaunch a capitated managed care program under Governor Kevin Stitt, the Legislature in 2022 passed SB 1337 requiring the state to issue a request for proposal and to award at least three Medicaid managed care contracts to health plans or provider-led entities like accountable care organizations to take effect by October 2023. In addition, a separate statewide contract would be awarded to a health plan to provide comprehensive integrated health coverage to foster children, former foster children up to 25 years of age, juvenile justice-involved children, and children receiving adoption assistance. The RFP (Request for Proposals) for the new program, known as Sooner Select, was released in November 2022 and was expected to provide medical, behavioral, and pharmacy coverage to nearly one million eligible recipients. A month later, OHCA announced that the implementation date for Sooner Select had been deferred to April 2024.
In June, OHCA announced the results of the RFP process. The contracted entities selected to serve the medical plans are Aetna Better Health of Oklahoma, Humana Healthy Horizons of Oklahoma and Oklahoma Complete Health, which was also awarded the contract to serve the children’s specialty program. A lawsuit against OHCA was filed by a non-selected provider, United HealthCare, alleging violations of the Oklahoma Open Records Act.