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Oklahoma—Summary of Healthcare Reform

 

Email Alert

by Cori H. Loomis*

December 4, 2008

Insure Oklahoma/O-EPIC Program: Overview and Impact

The Oklahoma Employer/Employee Partnership for Insurance Coverage (Insure Oklahoma/O-EPIC) program is designed and intended to assist in the purchase of health coverage. Oklahomans can participate in two ways:

  1. Employer Sponsored Insurance (ESI), which is designed to assist small business owners in providing their employees and their employees' families with health insurance, and

  2. Individual Plan (IP), which is designed to assist sole proprietors (self-employed), certain unemployed individuals, and working individuals who do not have access to small-group health coverage.

Insure Oklahoma/O-EPIC is covered under a Health Insurance Flexibility and Accountability (HIFA) waiver and is funded through Federal Medicaid funds, State matching funds generated from a tobacco sales tax, and individual and employer premiums.

The ESI Program utilizes the private employer-sponsored insurance market and provides subsidies to employers to pay for employee health insurance premiums. The ESI Program began operations in 2005 and provides premium subsidies to small employers (2-50) with low wage workers. Through the program, the employer pays only 25% of the premium of the low-wage worker, the employee pays up to 15% of the premium, and the state pays the remainder. Originally, low-income was defined as 185% of the federal poverty level (FPL), but in November 2007 the cap was increased to 200% FPL. 9,923 employees and dependents are now directly subsidized by the ESI Program. According to a recent survey, 56% of overall Insure Oklahoma enrollees were previously uninsured; 3,270 employers are now approved for the program.

The Individual Plan is a primary care case management program that is administered by the State Medicaid agency providing limited benefits and a $1 million maximum lifetime benefit. Primary Care Providers provide primary care services and refer enrollees for specialist services as medically necessary. The State Medicaid infrastructure provides administrative support and utilizes Medicaid providers to deliver care. Providers are paid Medicaid premiums and may charge additional co-pays. As of May 10, 2007, O-EPIC IP covered 238 people at an average monthly premium of $28.98 per person.

The program's passage was supported by insurers, small employers, hospitals, and doctors. It is funded by a tobacco tax and federal funds, based on a Medicaid HIFA waiver.

All Kids Act

In the 2007 legislative session, the Oklahoma legislature passed the "All Kids Act," which required the Oklahoma Health Care Authority (OHCA) to establish a program to provide medical coverage assistance to children 18 years of age and younger whose family income is between 185% and 300% of the federal poverty level. The measure requires OHCA to assist families in acquiring healthcare benefits for children in the program by offering subsidies toward the cost of privately sponsored health insurance, including employer-sponsored health insurance provided through the state's premium assistance program. If privately sponsored health insurance is not available, OHCA can allow applicants to purchase access to the state-administered healthcare benefit under the premium assistance program. OHCA is authorized to offer partial coverage to children who are enrolled in a high-deductible, private health insurance plan, or to offer a limited package of benefits to children in families who have private or employer-sponsored health insurance coverage that does not cover certain benefits, including dental or vision benefits.

The measure is intended to be a public-private partnership that allows individuals to purchase health insurance for their children using state and federal Medicaid funds, along with their own money. Under a portion of the plan, a family could expect to pay up to 26% of the premium and co-payment costs. Those unable to obtain private insurance are able to "buy into Medicaid," paying up to 51% of the premium and co-payment costs.

A sliding scale based on income is used to determine the families' out-of-pocket costs. Families with incomes up to 300% of the federal poverty level—$61,000 for a family of four—are eligible for the program.

RX for Oklahoma

On December 1, 2005, the OklahomaRx Discount Card was established by the state of Oklahoma to:

  • Combat skyrocketing drug prices with savings of 10% to 55%;
  • Provide significant discounts on prescription drugs for all Oklahoma residents;
  • Help families improve their health and well-being; and
  • Provide a low- or no-cost prescription discount card.

Under the program, discounts range from 10% to 55%, depending on the drugs and where they are purchased. More than 570 pharmacies in Oklahoma are participating in the program.

Focus on Excellence

Pursuant to the Oklahoma Medicaid Reform Act of 2006, the Oklahoma Health Care Authority (OHCA) was directed to implement a program called the "Focus on Excellence," which is intended to enable consumers to receive reliable information about every nursing home that contracts with SoonerCare or Medicaid, as well as other facilities that participate voluntarily. In all, about 85% of the state's nursing facilities are participating in this initiative to provide more information to Oklahomans.

Under the program, nursing facilities are given a simple star rating based on ten criteria, such as quality of life, employee, resident and family satisfaction, patient-to-nurse ratio, and compliance with state and federal requirements.

In addition to informing consumers, the program offers financial incentives to facilities to constantly strive for improvement. The Health Care Authority will award bonuses to nursing homes based on the ten rating factors.

*We would like to thank Cori H. Loomis, Esquire (Crowe & Dunlevy PC, Oklahoma City, OK) for providing this summary.

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