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- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the fifth in a series produced by the Louisiana Department of Health (LDH)to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Medicaid Managed Care Programs (R.S. 40:1253.2): improved care coordination with patient-centered medical homes for Medicaid recipients; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. Beginning in February of 2012, the original Medicaid Managed Care Program included two models of coordinated care networks: full-risk managed care organizations (MCOs), known as prepaid plans and primary care case management (PCCM) known as shared savings plans. The state contracted with three prepaid and two shared savings plans, and individuals were given the option of choosing the plan that best met their needs. However, not all Medicaid services were available from health plans, and some health plan members continued to receive certain services under the fee-for-service program. In addition, many individuals covered by Medicaid were not eligible to enroll in and receive services from a health plan. The program has continued to evolve with each year of operation. LDH has progressively integrated services and populations into the Medicaid Managed Care Program. The following timeline includes major milestones in the growth of our managed care program: Pharmacy benefits were “carved-in” to the prepaid plan benefit package on November 1, 2012. Dental benefits have been provided to all Medicaid populations under a single Dental Benefits Program Manager (DBPM) since July 1, 2014. The delivery model was transitioned from three risk-bearing MCOs and two shared-savings PCCMs to five risk-bearing MCOs on February 1, 2015. Hospice benefits were added on February 1, 2015. EPSDT PCS benefits were added on February 1, 2015. Retroactive linkages to Healthy Louisiana were implemented on February 1, 2015. Specialized behavioral health benefits were added on December 1, 2015. The ability to “opt-out” of physical health services was eliminated as of December 1, 2015, for the following populations: children under age 19 with a disability or special healthcare need, children in foster care, and Native Americans/Alaskan Natives. The populations became mandatory participants in Healthy Louisiana. Prior to December 1, 2015, all specialized behavioral health services were provided through the managed care program as a carve out service under the Louisiana Behavioral Health Partnership operated by Magellan. To facilitate the integration of SBH services, members already enrolled in a health plan began to receive their specialized behavioral health services through their existing plan. For other individuals, eligible for specialized behavioral health services but not currently enrolled in managed care, a special open enrollment period was held in the fall of 2015 to give them an opportunity to choose their own plan for behavioral health service continuation. For ease of access and coordination, all non-emergency transportation services (NEMT) for this partial benefits group are also provided by their chosen health plan. The partial benefits group continues to receive all physical health and long-term care services through fee-for-service Medicaid. It is also worth noting that while there was much planning and outreach for Medicaid expansion during this reporting period, the effective eligibility date for the expansion population began on July 1, 2016, and are therefore not covered in this reporting period. Medicaid expansion will be addressed in the State Fiscal Year 2017 report. This report includes 26 measures as outlined in La. Revised Statute 40:1253.2. It covers program operations for July 2015 through June 2016 (State Fiscal Year 2016), except the following measures which are reported on a calendar year basis per the contract between the Department and the health plans: Section 7 – Medical Loss Ratio Section 8 – Health Outcomes Section 9 – Member and Provider Satisfaction Surveys Section 10 – Audited Financial Statements Section 25 – Medicaid Drug Rebates Information included in this report was collected from multiple sources. To the greatest extent possible, the data is extracted from state systems which routinely collect and maintain operational data on the Medicaid Managed Care Program. When unavailable from state sources, data were collected from the health plans, sourced from either routine reporting deliverables or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse) are maintained by the Medicaid program contracted fiscal intermediary, which in State Fiscal Year (SFY) 2016 was Molina Healthcare. Detailed recipient and provider information, as well as, claims payment data for this report were extracted from the MARS data warehouse. The state administrative system, called ISIS, maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to health plans. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with their annual external quality reviews. Additionally, plans are contractually required to obtain accreditation from the National Committee for Quality Assurance (NCQA) for their Medicaid health plan serving Louisiana members. NCQA accreditation involves a rigorous process involving comprehensive reviews of the plans’ policies, procedures and practices. For State Fiscal Year 2016, four of the health plans had obtained accreditation from NCQA. Aetna as a new plan was in the process of applying for accreditation. In addition to standing operational quality assurances and EQRO reviews, the data included in this report was independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the health plans or the Department used to generate data. For data originating from the MARS Data Warehouse or the MMIS, Myers and Stauffer generated its own data from encounters or data extracts for each health plan and compared its results to the results the Department produced. For data originating from the health plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10 percent variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix XII for the survey instrument.
Downloadable Assets:
2016 Managed Care Transparency Report Appendix I. Total Number of Health Care Providers (Section 4) Appendix II. Primary Care Service Providers (Section 5) Appendix IV. Member Satisfaction Surveys (Section 9) 1. Aetna Appendix IV. Member Satisfaction Surveys (Section 9) 2. Amerigroup Appendix IV. Member Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix IV. Member Satisfaction Surveys (Section 9) 5. UnitedHealthcare Appendix IV. Member Satisfaction Surveys (Section 9) 6. MCNA Appendix V. Provider Satisfaction Surveys (Section 9) 2. AmeriHealth Caritas Louisiana Appendix V. Provider Satisfaction Surveys (Section 9) 3. Louisiana Healthcare Connections Appendix V. Provider Satisfaction Surveys (Section 9) 4. UnitedHealthcare Appendix V. Provider Satisfaction Surveys (Section 9) 5. MCNA Appendix VI. Annual Audited Financial Statements (Section 10) 1. Aetna Appendix VI. Annual Audited Financial Statements (Section 10) 2. Amerigroup Appendix VI. Annual Audited Financial Statements (Section 10) 3. AmeriHealth Caritas Appendix VI. Annual Audited Financial Statements (Section 10) 4. Louisiana Healthcare Connections Appendix VI. Annual Audited Financial Statements (Section 10) 6. MCNA Appendix VII. Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix VIII. Total number of denied claims (Section 20) Appendix IX. Claims paid to out-of-network providers (Section 23) Appendix X. Pharmacy benefits by month (Section 24) Appendix XI. Dental Program (Section 26) Appendix XII. MSLC Survey -
Details:
- Medicaid
- Managed Care
Managed Care Rate Setting Executed Contract
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- Medicaid
Fee-for-Service Transportation Broker Executed Contract
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- Medicaid
- Managed Care
Original Period Certified: December 2015 Actual Period Covered: December 2015 NEMT Services The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
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- Medicaid
- Managed Care
Original Period Certified: December 2015 Actual Period Covered: December 2015 - Physical Health The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
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Details:
- Medicaid
- Managed Care
Original Period Certified: July 2015 – November 2015 Actual Period Covered: July 1, 2015 – November 30, 2015 The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
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- Medicaid
- Managed Care
Managed Care Enrollment Broker Executed Contract
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- Medicaid
- Managed Care
Original Period Certified: December 2015 - January 2016 Actual Period Covered: January 2016 - Specialized Behavioral Health The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
Downloadable Assets:
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Details:
- Medicaid
- Managed Care
Original Period Certified: December 2015 - January 2016 Actual Period Covered: January 2016 Physical Health The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
Downloadable Assets:
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Details:
- Medicaid
- Managed Care
Original Period Certified: July 2016 - January 2017 Actual Period Covered: July 1, 2016 - January 31, 2017 Non-Expansion The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
Downloadable Assets:
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Details:
- Medicaid
- Managed Care
Original Period Certified: February 2016 - January 2017 Actual Period Covered: February 1, 2016 - June 30, 2016 The Louisiana Department of Health (LDH) has contracted with Milliman, Inc. to develop actuarially sound capitation rate ranges for the Healthy Louisiana program (formerly Bayou Health). Rate certification letters certify universal rates for a given time period, e.g., a state fiscal year. Rates shown in these letters are not the rates actually paid to participating Managed Care Organizations (MCO), as the actual rates paid to each MCO are risk-adjusted. That is, the rates paid to each MCO are the universal rates in the rate letter as adjusted for the expected costs of that MCO’s enrolled members, based on the members’ health conditions and health status. Original rate letters are often replaced with revised rate letters for the same time period. Revisions are necessary whenever there are programmatic changes (e.g., changes in services or populations covered) that impact rates effective within the original rate letter time period. Revisions may cover the entire period or only part of the period (going forward from the effective date of a program change prior to the end the period). Sometimes a rate letter is supplemented with an issue-specific companion certification. For example, the Affordable Care Act (ACA) Primary Care Physician (PCP) enhanced payment, which was an add-on to PMPMs paid in 2013 and 2014 as required by Section 1202 of the Affordable Care Act, had its own certification letter. Keywords: Managed Care 2.0, Capitation Rate
Downloadable Assets:
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Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 1.0 Amerigroup Healthy Blue Community Health Solutions LaCare AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan This report is the third in a series produced by the Louisiana Department of Health to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Medicaid managed care programs: improved care coordination with patient-centered medical homes for Medicaid recipients; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. The first and second reports included 23 measures as outlined in Act 212 of the 2013 Regular Legislative Session. The first report, submitted to the Legislature on January 2, 2014, covered July 2012 through June 2013 (State Fiscal Year 2013). The second report, submitted to the Legislature on December 31, 2014, covered January 2013 through December 2013 (Calendar Year 2013). The Department shifted the reporting periods, from State Fiscal Year (SFY) in the first report to Calendar Year (CY) in the second report, duplicating six months of the first report (January 2013 through June 2013). The shift in reporting periods provided for complete claims data given Act 212’s requirement of annual transparency report submission by January 1 and Medicaid’s timely filing policy which allows providers 365 days from the date of service to file a claim for payment. Act 158 of the 2015 Regular Legislative Session modified reporting requirements for the transparency report, adding three new measures and clarifying the reporting period. This third report includes 26 measures, and it covers July 2013 through June 2014 (State Fiscal Year 2014), duplicating six months of the second report (July through December 2013). All measures are reported on a fiscal year basis, except the following measures which are reported on a calendar year basis per the contract between the Department and the health plans: Section 7 – Medical Loss Ratio Section 8 – Health Outcomes Section 9 – Member and Provider Satisfaction Surveys Section 10 – Audited Financial Statements Section 25 – Medicaid Drug Rebates Act 158 provides sufficient time for complete claims reporting for a state fiscal year by shifting the due date for report submission from January 1 to June 30. This report covers the original contracting period for the Medicaid managed care program (beginning February 1, 2012) which includes physical and basic behavioral health services provided by both fullrisk managed care organizations, called prepaid health plans and referred to in this document as managed care organizations (MCOs), and plans serving as primary care case management (PCCM) entities, referred to as shared savings health plans. Information included in this report was collected from multiple sources. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse) are maintained by the Medicaid program’s contracted fiscal intermediary, which in State Fiscal Year 2014 was Molina Healthcare. The MMIS contains detailed recipient and provider information and the MARS Data Warehouse contains claims payment information. The state administrative system, called ISIS, is maintained by the Office of Technology Services within the Division of Administration and contains information on payments to health plans. The provider registry is maintained by Molina and contains information submitted by the health plans or their contracted providers. The provider registry is updated weekly with new information overwritten onto older information, which limits the utility of the data to point-in-time information. To the greatest extent possible, the data originate from state systems rather than the health plans. Where unavailable from state sources, data were collected from the health plans, sourced from either routine reporting deliverables or ad hoc reports requested specifically for this purpose. Data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the health plans or the Department used to generate data. For data originating from the MARS Data Warehouse or the MMIS, Myers and Stauffer generated its own data for each health plan and compared its results to the results the Department produced. For data originating from the health plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10 percent variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix 14.IX for the survey instrument. To ensure maximum reliability, subject matter experts within the Department and Myers and Stauffer also reviewed the data. In some cases, the health plans also reviewed data pulled on their plans by the Department for reasonability. In addition, health plans’ internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with annual external quality reviews. An additional validation was performed by either the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) as part of the contractually required health plan accreditation process. Plans are contractually required to obtain accreditation from either NCQA or URAC for their Bayou Health plan serving Louisiana members. All Bayou Health plans have obtained accreditation from these national accrediting bodies, which are rigorous processes involving comprehensive reviews of the plans’ policies, procedures and practices.
Downloadable Assets:
2014 Managed Care Transparency Report Appendix 14.I: Total Number of Health Care Providers (Section 4) Appendix 14.II: Primary Care Service Providers (Section 5) Appendix 14.III: Contracted Providers with Closed Panels (Section 6) Appendix 14.IV: Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix 14.V: Total number of denied claims (Section 20) Appendix 14.VI: Total number of clean claims (Section 21) Appendix 14.VII: Claims paid to out-of-network providers (Section 23) Appendix 14.VIII: Pharmacy benefits by month (Section 24) Appendix 14.IX: MSLC Survey