Question A. RFI: Care Coordination for the Aged, Blind, and Disabled

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1 Question A High-Level description of the recommended Patient-Centered service delivery model 1. Name and describe Respondents chosen model including reason for selecting the model 2. Describe how the model addresses the needs of the ABD patient population 3. Explain Respondents approach for implementation of the model MCNA Insurance Company ( MCNA ) proposes a hybrid model for Oklahoma that combines the advantages of both the Fully Capitated Managed Care Organization (MCO) model and the Medicaid Fee for Service model. This hybrid model is a full risk, prepaid dental benefit program management (DBPM) model where the State places the dental benefit program manager at-risk for the provision of quality dental services and timely claims payment. DBPMs pay providers on a fee-for-service basis rather than capitation. The ideal DBPM model maintains the independence of the Medicaid dental program, maximizing budget transparency and the resources allocated to the dental program. Moreover, the State and its DBPM can focus on dental metrics and quality improvement goals based on best practices and evidence-based standards. These goals are developed by the state and monitored by dental professionals. Keeping dental separate from medical care is paramount in terms of program accountability. When dental is administered by health plans as a carved-in service, the ability of the dental community to influence clinical guidelines and policy development is severely compromised. Most medical plans subcontract with dental managed care plans to administer their dental benefits, resulting in duplicative administrative costs. Dollars appropriated for dental care risk being diverted into medical plan cost categories, such as hospital care and pharmacy services. Forcing dental providers to deal with the requirements of a large number of medical plans creates a significant administrative burden, increases their reluctance to participate in Medicaid, and stresses their already thin resources. Medical managed care plans have minimal experience in administering dental networks, managing the utilization of dental treatment services, or increasing quality of care measures such as the use of preventive services. Allowing medical plans to manage the dental benefits of Medicaid children under an integrated plan dilutes the State s efforts to increase the effectiveness of its financial commitment to dental services. Dental managed care is a proven solution for states seeking to improve oral health outcomes compared to Third Party Administration (TPA) or Carved-In models. The DBPM model can make a dramatic difference in the number of children receiving needed dental care. More than just an insurer of dental benefits, dental managed care is focused on getting children back on the road to good oral health by increasing the appropriate utilization of medically necessary covered services and decreasing fraud, waste, and abuse. MCNA has extensive experience serving aged, blind, and disabled members. In an effort to ensure access to care for vulnerable and special needs members, MCNA established a dedicated Case Management Unit. This unit is staffed by knowledgeable dental care professionals and nurses who lock MCNA Dental Page 4 of 19

2 arms with the caring community to identify resources and ensure our members receive the care they need. In Texas, for example, the proposed hybrid approach has yielded some of the highest dental HEDIS and utilization metrics for Medicaid and CHIP children s dental programs in the nation, while saving the state over half a billion dollars since implementation in A statewide competitive procurement to select a Dental Benefit Program Manager directly contracted by the state would permit the to implement a targeted and focused quality dental program for its Medicaid beneficiaries and dental providers. MCNA Dental Page 5 of 19

3 Question B Populations Served 1. Identify proposed eligible populations (All members or target specific populations based on geographic areas, aid category, specific health conditions, etc.) 2. For each of the populations selected, state whether services would be provided statewide, within certain county(s), or will Respondent employ regionalization i. Define which county(s) in which the model would operate ii. Define which county(s) included in each region The DBPM hybrid model will serve all Medicaid beneficiaries on a statewide basis. The program would encompass Medicaid covered dental services billed by dentists utilizing the ADA claim form and applicable covered Code on Dental Procedures and Nomenclature (CDT) codes. We would not distinguish between beneficiaries based on health conditions, aid category, or geographic areas. Ideally, a DBPM program would include all Medicaid eligible children and not be limited to children with ABD status. MCNA Dental Page 6 of 19

4 Question C Covered Services and Benefits 1. Describe proposed covered services and benefits for each population 2. Describe the clinical effectiveness and evidence-base supporting the proposed covered services and benefits 3. Explain reason for any proposed non-covered services and benefits MCNA would maintain the covered dental services currently offered by the State of Oklahoma. However, we recommend that the State consider additional adult benefits designed to reduce the need for costly emergency care. These benefits would include two exams, two cleanings, and one set of x- rays per year with a capped dollar amount for restorative care. This proposed covered service array focuses on preventive services for the maintenance of the individual s oral health. In 2014, MCNA became the first dental plan in the nation to receive Claims Processing Accreditation and Dental Plan Accreditation from URAC. This accreditation underscores our commitment to evidence based standards of care, continuous quality improvement, and industry best practices. MCNA ensures our dental services are accessible, appropriate, cost effective, and meet or exceed regulatory and contractual requirements, through the application of MCNA s Utilization Review Criteria and Guidelines by our Dental Directors and Clinical Reviewers. Additionally, our state-of-the-art management information system, DentalTrac, prevents inappropriate use of dental services through customized edits that are based on benefit plan design, service frequency limitations, and clinical guidelines. We strive to ensure members receive the right care, at the right time, in the right place. MCNA will ensure that services are not arbitrarily or inappropriately denied or reduced in amount, duration or scope as specified in the Oklahoma Medicaid State Plan. By tailoring our Utilization Management (UM) program to meet the needs of Oklahoma, MCNA ensures that the provision of dental care services are high quality, cost-effective and provided in the most appropriate setting consistent with the federal requirements of 42 CFR Chapter 456. Designed and guided by dentists, MCNA s UM program follows generally accepted dental standards of care and review criteria developed in conjunction with the guidelines of the American Academy of Pediatric Dentistry, the American Dental Association, the American Association of Oral and Maxillofacial Surgeons, the American Association of Endodontics, the American Academy of Periodontology, and the American College of Prosthodontists. The goal of the UM program is to monitor the appropriateness, quality and necessity of dental services provided to our members. The monitoring methodologies include prospective and retrospective review. The UM program facilitates the early detection of potential quality of care issues such as an inappropriate denial or reduction of dental benefits to which our members are entitled. All types of care are reviewed for dental necessity, appropriateness of services, level of care, location of care, and MCNA Dental Page 7 of 19

5 quality of care, as well as benefit and coverage determinations. Our UM program generates operational data and integrates captured information into the UM and Quality Improvement processes. Reports generated by our Quality Improvement Department are used to continuously monitor the efficacy of the UM program and the appropriateness of the dental care received by our members. MCNA Dental Page 8 of 19

6 Question D Provider Network 1. Describe provider network recruitment and retention, including types of providers (for example primary care, specialty care, dental, HCBS, case/care management, LTC, other, etc.) MCNA knows that the key to success in managing dental benefits for our members is our ability to maintain a robust provider network. MCNA s proven approach to recruitment ensures a strong provider base throughout our service areas. MCNA is aware that building and maintaining the network requires a consistent, concerted effort, and we will continue to recruit both general and specialty dentists throughout the term of our contract, if awarded. Our CEO, Dr. Jeffrey P. Feingold, understands the importance of maintaining strong relationships with the local dental community, and this is why he recruited Dr. Philip Hunke to serve as Market President of MCNA Insurance Company. Dr. Hunke is the former President of the American Academy of Pediatric Dentistry. He uses his professional relationships with dental associations across the nation to identify and recruit dental professionals in the states we serve. MCNA has streamlined clinical and administrative processes to reduce hurdles for providers and encourage participation in MCNA s network. Our success is evidenced by the fact that we have consistently exceeded our contractual requirements for network access in Texas, Louisiana, Florida, Kentucky, and Indiana. MCNA s credentialing and re-credentialing process is certified by NCQA. Our Credentialing Committee reviews every application received from providers seeking to participate in our network. The process ensures that MCNA enrolls qualified providers who meet NCQA credentialing standards and all requisite Oklahoma criteria. We understand that the Oklahoma provider community may have some apprehension about the transition from state-operated fee-for-service programs to dental managed care. Our past experience in successful transitions allows us to proactively address the concerns of our providers, specifically with respect to provider claims processing, reimbursements, and their options. MCNA believes the key to our previous successes can be attributed to the strong relationships we have built with our provider communities. Experience tells us the most effective way to build relationships is by establishing trust. MCNA establishes trust with our provider communities using the following five essential elements: MCNA Dental Page 9 of 19

7 Mutual Concern: MCNA demonstrates shared concern with our providers about the oral health of our members Keeping Commitments: MCNA exhibits integrity, ability and character in keeping commitments to our providers and members Open Communication: MCNA fosters an open communication environment with customers, employees, providers and members Active Collaboration: MCNA actively collaborates with community partners, providers and members to promote good oral health Long Term Perspective: MCNA invests in provider education and training to contribute to overall provider and member satisfaction Building trust with the Oklahoma provider community is a top network development priority. With this long-term perspective in mind, MCNA will conduct initial and ongoing provider orientations and webinars and provide a wealth of information through the Provider Portal and Provider Manual. MCNA s Provider Portal and Provider Manual educate providers on a wide spectrum of topics, and include our procedures for claims submissions, requirements for clean claims, payment and reimbursement options, submission of electronic and paper claims, and a complete user guide explaining the functionality of our Provider Portal. Providers can find informational and educational materials on our web-based Provider Portal. These materials include provider manuals, program descriptions, claim submission guidelines, video tutorials, ADA claim form completion instructions, and claim coding and processing guidelines. We make all efforts possible to maintain our provider network s awareness of changes in regulations, program administration, benefits, and other requirements that may impact their reimbursement or ability to treat our members. This investment and commitment to our provider partners has enabled us to retain dental providers in our network over time. MCNA Dental Page 10 of 19

8 Question E Provider Payment Structure 1. Explain provider payment methodology, assumptions, and constraints a. Specific to covered benefits and services (As listed in Section 3.3, Item C) b. Specific to other benefits and services c. Show estimated amounts of provider payments for evidence-based performance outcomes (for example amounts of withholds, performance payments based on quality metrics, etc.) Dental providers are paid on a fee-for-service basis using the State s Medicaid fee schedule. Usually a State will keep their current provider fee schedule in place as part of the new program to help with provider buy-in. Maintaining current reimbursement levels will also expedite the network development process. Providers will submit claims using the most current version of the ADA claim form. Claims can be submitted electronically using a clearinghouse or free of charge via the MCNA Provider Portal. MCNA can also accept paper claims, however, we strongly encourage electronic submission. The DBPM(s) will reimburse the providers within 30 calendar days, which is a shorter timeframe than the 45-day requirement of Oklahoma s Prompt-Pay law, 36 O.S Most payments are made via electronic funds transfer (EFT), but providers may also opt to receive paper checks. MCNA does not encourage the use of withholds for dental providers. This often has the unintended consequence of creating a barrier to care because the approach is viewed as punitive by the provider community and can impede participation. In terms of performance-based payments, MCNA would encourage the State to authorize the DBPM to implement a pay-for-quality program to incentivize increased utilization for key preventive dental measures. In Texas, MCNA s Stellar Treatment and Recognition Reward (STARR) program provides bonus payments to dentists based on their compliance with key dental care metrics such as timely access to care, routine and recall visits, sealant application, fluoride application, and early care intervention. We would welcome the opportunity to design a pay-for-quality program based on the goals of Oklahoma. MCNA Dental Page 11 of 19

9 Question F State Payment Structure 1. Explain how payments are made by the state to the party(s) responsible for the objectives of the recommended model (As listed in Section 3.1, Items A-K) a. Methodology b. Assumptions c. Constraints 2. Explain how proposed payments comply with existing and proposed Federal and State requirements In terms of a program transition from the current fee-for-service model to a fully capitated DBPM program administered by MCNA, the State would need to set an actuarially sound rate based on the benefit design and historic claims and cost data, including any proposed programmatic benefit limitations and/or cost sharing. Payments would be made on an agreed upon monthly schedule to the DBPM(s) on a per member per month (PMPM) basis for all members. Typically the PMPM rate also varies based on category of aid and benefit available. For example, in Louisiana the adult population has a much more limited benefit available and has a different, much lower rate than that of Medicaid or CHIP child members. Provider reimbursement rates are also factored into the PMPM rate buildup. This payment approach is consistent with CMS requirements and is already successfully in use in the neighboring states of Louisiana and Texas. The DBPM bears full risk under this approach. MCNA Dental Page 12 of 19

10 Question G Impact of Model 1. Explain estimated implementation costs and anticipated savings, for years 1 through 5. a. Methodology b. Assumptions c. Constraints 2. Describe the quality and anticipated effect of the model on population health outcomes as related to (materials provided in Respondent s Library): a. CMS recommended benchmarks b. State identified areas including preventive screenings, tobacco cessation, obesity, immunizations, diabetes, hypertension, prescription drug use, hospitalizations, readmissions, emergency room use c. Core measures identified within the Oklahoma Health Plan (OHIP) 2020 d. Respondent suggestions for other benchmarks e. Considerations for Value-Based performance designs, specifically those that support and align with objectives identified within the Oklahoma State Innovation Model design As noted in the response to item F, the cost to the State would be the payment of the actuarially sound PMPM rate for covered beneficiaries. Risk would be placed on the DBPM, thereby fixing the cost of the program and enabling Oklahoma to have budget predictability. MCNA believes that Oklahoma can achieve meaningful savings by implementing a DBPM model. Without full access to Oklahoma enrollment and eligibility data, it is difficult to quantify savings. However, we can offer feedback regarding the impact of MCNA managed care programs in Louisiana and Texas as a means for Oklahoma to evaluate the potential benefits of a DBPM model. Typically, a conservative estimate would be a savings of around 10% using a DBPM approach. These savings would begin in year one of the program because savings assumptions are built in to the initial PMPM rate. In Louisiana and Texas, managed care programs were introduced within the past three years, and studies have been conducted to assess the impact of these programs as compared with the prior fee-for-service systems. The table below shows the cost savings achieved by dental benefit program management activities in Louisiana and Texas. DBPM Savings vs. FFS Medicaid State Savings Achieved Louisiana 13.9% Texas 28.4% The sources of these statistics are as follows: Texas - Texas Medicaid Managed Care Cost Impact Study by Milliman dated February 11, In Texas, MCNA is one of two dental benefit program managers, and covers 45% of the overall managed population. Louisiana - Revised Louisiana Dental Benefit Program Capitation Rate Certification letter from Mercer Government Human Services Consulting dated April 16, In Louisiana, MCNA is the sole dental benefit program manager. MCNA Dental Page 13 of 19

11 MCNA has unparalleled skill and expertise in the administration of dental benefits for vulnerable populations. For over two decades, our founder Dr. Jeffrey P. Feingold has ensured that the pursuit of quality permeates throughout MCNA. Our years of experience working with state plan administrators, regulators, and dental providers shape our approach. The MCNA Quality Assessment and Performance Improvement program is a dynamic and forward-thinking road map designed to ensure that every operating unit of the company performs in concert with the singular goal of delivering access to high quality dental care to our members. The current CMA 2014 Clinical Quality Measures (CQMs) for adults and the OHIP 2020 Report do not contain any oral health measures for adults. In terms of children s services, the CMS CQM related to dental is the CMS75v1, Children Who Have Dental Decay or Cavities. This measure evaluates the percentage of children ages 0-20 that have had tooth decay or cavities during the measurement period. MCNA will ensure that this objective is met through our dedicated outreach efforts. We have a proven track record of ensuring the children we serve complete their annual dental visit. MCNA s HEDIS ADV rate for Texas exceeds the 95 th percentile and is one of the highest in the nation. Likewise in Florida MCNA has generated the highest HEDIS for the Florida Healthy Kids Corporation (CHIP program). The ability to engage members and providers is the cornerstone of our quality improvement strategy. Value based performance programs are one way that we drive appropriate utilization. The following is a detailed description of the pay-for-performance program MCNA implemented for the Texas Medicaid and CHIP programs. Texas Preventive Care Initiative Our Stellar Treatment and Recognition Reward (STARR) program identifies and rewards Texas network providers for excellence in the provision of quality preventive care services to our Medicaid and CHIP members in that state. The STARR Program is the first of its kind among the nation s managed dental care organizations. STARR was designed to recognize MCNA s network providers who render stellar preventive treatment to our members. It rewards Dental Home Providers (pediatric and general dentists) who perform a high volume of five core preventive care services at the highest levels of quality. The five preventive services selected for the program are listed below: Prophylaxis Treatments The professional removal of microbial plaque is necessary to the long-term inhibition of the development of tooth decay and gingival disease. Fluoride Application Fluoride applied to teeth fights dental decay by strengthening enamel, the outer hard covering of teeth. It is a safe and highly effective measure to reduce the risk of decay. Sealant Application Sealants are plastic coatings applied to molars, preventing bacteria from settling into the deep grooves on the teeth. They physically protect teeth from risk of decay. MCNA Dental Page 14 of 19

12 Recall Visits Regular professional dental care every six months for children through adolescence and beyond is necessary for the maintenance of good oral health. First Dental Home Visit Texas recognizes the establishment of the First Dental Home as the basis for the ongoing relationship between the dentist and patient. All qualifying network providers received an official STARR Program brochure along with a reward letter, which detailed the requirements for participation and a comprehensive overview of the program s reward structure. All qualifying providers are able to view their individual scorecard by accessing their account on MCNA s Provider Portal. Providers who qualified for a recognition reward shared in the allocated bonus pool for the program based on the number of members treated for each metric. MCNA Dental Page 15 of 19

13 Question H Anticipated Overarching Timelines (including key activities and milestones) 1. Development 2. Transition/Readiness Activities 3. Implementation of member enrollment 4. Implementation of member service delivery MCNA is familiar with the proposed timeline established by the regarding this procurement. We are comfortable with the ability to go-live within 30 days of contract award. MCNA knows a successful implementation of a DBPM model requires a flexible work plan, well-defined milestones and expectations, robust communication, ample financial and manpower resources, and a strong leadership team. We recognize that the transition phase will include all activities that must be completed successfully prior to our operational start date, including all Readiness Review activities that OHCA will conduct to determine whether we have implemented all systems and processes necessary to begin serving members. During the Contract Start-Up and Planning phase, MCNA will work with OHCA to define the project management and reporting standards to be followed. These standards will include the establishment of communication protocols for OHCA and MCNA staff, contacts with other OHCA contractors, schedules for key activities and milestones, a comprehensive plan for exchanging information, and the finalization of parameters for the contract deliverables. We believe setting sound goals is critical to the success of this project and use the SMART strategy to establish goals, measure progress, and ensure requirements and resources are in line with the RFP objectives. The SMART approach ensures the following are outlined in the project plan: Goals Scope Deliverables Resources Metrics (including timeliness) Staffing Communication protocols S M A R T SPECIFIC MEASURABLE ALIGNED RELEVANT TIME SPECIFIC Planned approach is clearly defined Project tracking and monitoring tools Project plan is aligned with RFP requirements Resource allocation and deployment Objectives are met timely for readiness review and operational start date MCNA Dental Page 16 of 19

14 Our transition planning process is comprehensive and involves the leadership of every major operational unit of MCNA. Weekly internal team meetings, documentation of requirements, continuous risk management, dedicated resources and support, and continuous communication with OHCA throughout the process, including post implementation, are the hallmarks of MCNA s turnkey approach to DBPM operations. All member and provider educational materials such as Member Handbooks, Provider Directories, and Provider Manuals will be submitted to OHCA for approval prior to distribution. Our provider orientation training sessions, seminars, and webinars will follow an OHCA approved schedule. Finally, we will work with OHCA, providers, and any other parties to identify and promptly resolve any problems arising after the operational start date, and will ensure ongoing communication with the provider community postimplementation. MCNA has two decades of experience serving Medicaid and CHIP members through a DBPM model. Our proprietary management information system is capable of receiving and processing enrollment data in the format and frequency specified by OHCA. Once the initial member enrollment data is received and loaded into our DentalTrac system, benefits can be administered immediately for those members. MCNA will be ready, willing, and able to serve members as soon as 30 days after contract execution, provided the enrollment data feed as well as historic claims data needed for benefit limitation management can be made available within that timeframe. MCNA Dental Page 17 of 19

15 Question I Market Feasibility Provide considerations, observations and potential opportunities and/or threats related to: 1. Environmental conditions 2. Conditions unique to the Oklahoma market 3. Conditions not unique to the Oklahoma market 4. Availability and range of community resources 5. Existing and Proposed Federal regulation(s) 6. Data Attainment, Cross-walking to Medicaid, and Use 7. Coordination of benefits and services between Medicare and Medicaid 8. Alignment of payment structures and goals MCNA has reviewed the Oklahoma market and our approach is consistent with existing and proposed Federal regulations. We exchange data with multiple states and managed care clients for the 3.2 million members we serve in Texas, Louisiana, Florida, Kentucky, and Indiana using HIPAA transaction code sets as well as proprietary formats required by certain state agencies. We do not anticipate any transition issues related to data exchange. Oklahoma is similar to Texas and Louisiana in that there are very rural areas where achieving adequate utilization can be a challenge. This geographical distribution is included in our network development strategy. Additionally, our proven approach to dental benefit plan management includes outreach efforts designed to target members who have not been to the dentist in accordance with the State s periodicity schedule. From partnering with community agencies and faith based organizations for health fairs, to using social media and text messaging to reach members lost to care, MCNA uses a variety of communication and outreach strategies to reach our members. We serve unique populations in other states such as Children of Migrant Farmworkers and members with special needs. MCNA will leverage this expertise to drive favorable care patterns for Oklahoma members. Although Medicare does not provide an adult dental benefit, MCNA has years of experience administering benefits for Medicare Advantage members. Should an opportunity for coordination arise, MCNA will coordinate benefits in accordance with State and Federal law. The proposed FFS provider payment structure aligns with program goals. We believe that the opportunity to implement a value based, pay-for-quality program in Oklahoma can further align providers with defined quality goals and would enhance oral health outcomes. MCNA Dental Page 18 of 19

16 Question J Approach to Integration with Medicare 1. Considerations, observations and potential opportunities and threats related to: a. Existing and Proposed Federal regulation(s) b. Data Attainment, Cross-walking to Medicaid, and Use c. Coordination of Benefits and Services between Medicare and Medicaid d. Alignment of Payment Structures and Goals Medicare does not currently provide a dental benefit. However, MCNA has experience administering dental benefits for Medicare Advantage plans. Should the State adopt an enhanced Medicaid dental benefit for adult members, MCNA would coordinate benefits and services as needed for any dualeligible members who have dental coverage through their Medicare Advantage plan. MCNA Dental Page 19 of 19