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Louisiana Medicaid managed care contractors must meet the requirements of their contracts with LDH. If a contractor is non-compliant with contract requirements, LDH may apply administrative actions or assess monetary penalties and intermediate sanctions to obtain the level of performance required for successful operation of the managed care program. Keywords: MCO, health plan, noncompliance, administrative actions, non-compliance
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RFP #, DBPM 3.0 (1/1/2021 - present) DentaQuest (DQ) and Managed Care of North America (MCNA)
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Request for Proposals DQ Contract DQ Amd 1 DQ Amd 3 DQ Amd 4 DQ Amd 5 DQ Amd 6 DQ Amd 7 DQ Amd 8 DQ Amd 9 DQ Amd 10 DQ Amd 11 MCNA Contract MCNA Amd 1 MCNA Amd 2 MCNA Amd 3 MCNA Amd 4 MCNA Amd 5 MCNA Amd 6 MCNA Amd 7 MCNA Amd 8 MCNA Amd 9 MCNA Amd 10 MCNA Amd 11 DQ Amd 12 DQ Amd 13 DQ Amd 14 MCNA Amd 12 MCNA Amd 13 -
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- Medicaid
- Managed Care
Louisiana Medicaid managed care contractors must meet the requirements of their contracts with LDH. If a contractor is non-compliant with contract requirements, LDH may apply administrative actions or assess monetary penalties and intermediate sanctions to obtain the level of performance required for successful operation of the managed care program. Keywords: Managed Care 2.0, Aetna Better Health, AmeriHealth Caritas, Heathy Blue, Louisiana Healthcare Connections, UnitedHealthcare Community Plan, ABH, ACLA, HBL, LHCC, UHC, Non-Compliance, Admin Actions
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Keywords: RFP 3000017417, Managed Care 3.0, Aetna Better Health, ABH, Healthy Blue, HBL, AmeriHealth Caritas, ACLA, Louisiana Healthcare Connections, LHCC, UnitedHealthcare Community Plan, UHC, Humana Healthy Horizons, HHH
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ABH Original ABH Amd 1 ABH Amd 2 ABH Amd 3 ABH Amd 4 ABH Amd 5 ABH Amd 6 ABH Amd 7 ABH Amd 8 ACLA Original Contract ACLA Amd 1 ACLA Amd 2 ACLA Amd 3 ACLA Amd 4 ACLA Amd 5 ACLA Amd 6 ACLA Amd 7 ACLA Amd 8 HBL Original Contract HBL Amd 1 HBL Amd 2 HBL Amd 3 HBL Amd 4 HBL Amd 5 HBL Amd 6 HBL Amd 7 HBL Amd 8 HHH Original Contract HHHAmd 1 HHH Amd 2 HHH Amd 3 HHH Amd 4 HHH Amd 5 HHH Amd 6 HHH Amd 7 HHH Amd 8 LHCC Original Contract LHCC Amd 1 LHCC Amd 2 LHCC Amd 3 LHCC Amd 4 LHCC Amd 4 LHCC Amd 5 LHCC Amd 6 LHCC Amd 7 UHC Original Contract UHC Amd 1 UHC Amd 2 UHC Amd 3 UHC Amd 4 UHC Amd 5 UHC Amd 6 UHC Amd 7 UHC Amd 8 Att A: Model Contract -
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- Legislative & Governmental Relations
- Medicaid
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Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the ninth in a series produced by the Louisiana Department of Health (LDH, or the Department) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid managed care program (R.S. 40:1253.2): • Improved care coordination with patient-centered medical homes for Medicaid enrollees; • 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 2012, the original Medicaid managed care program included two models of coordinated care networks: a full-risk, managed care organization (MCO) model delivered by prepaid health plans and a primary care case management (PCCM) model delivered by shared savings plans. The state contracted with three prepaid and two shared savings health plans, and individuals were given the option of choosing the plan that best met their needs. Not all Medicaid services are available from health plans, and some enrollees continue to receive certain services under the fee-for-service program. In addition, some populations covered by Medicaid were not eligible to enroll in and receive services from a health plan. LDH has progressively integrated services and populations into the Medicaid managed care program. The following timeline includes major milestones in the growth of the managed care program: • Pharmacy benefits were “carved-in” to the prepaid plan benefit package on November 1, 2012. • The provision of dental benefits to most Medicaid populations was contracted to a single prepaid ambulatory health plan referred to as a dental benefits program manager (DBPM) beginning July 1, 2014. • The delivery model transitioned from three full-risk MCOs and two shared-savings PCCM models to five full-risk MCOs on February 1, 2015. • Hospice benefits were added on February 1, 2015. • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) – Personal Care Services were added on February 1, 2015. • Retroactive linkages to a Medicaid managed care plan were implemented on February 1, 2015. • Specialized behavioral health benefits were added on December 1, 2015. • Non-emergency medical transportation and specialized behavioral health services were added on December 1, 2015, for enrollees not entitled to receive physical health services through an MCO. • Eligibility for Medicaid services expanded to include the new adult population on July 1, 2016. • Effective January 1, 2021, the DBPM program expanded to include a second contracted dental plan. • Effective January 1, 2021, covered dental services (EPSDT and Adult Denture) for individuals with intellectual disabilities (ICF/IID) moved from the fee-for-service (FFS) program to coverage through one of the two DBPMs. Transparency Report Measures and Data This report includes 31 areas of measurement outlined in La. Revised Statute 40:1253.2 and covers program operations for State Fiscal Year (SFY) 2022. All measures are reported for the SFY, July 1, 2021, through June 30, 2022, except for the following that are reported on a calendar year basis per the contract between the Department and the managed care entities: Section 7 – Medical Loss Ratio, Section 8 – Health Outcomes, Section 9 – Member and Provider Satisfaction Surveys, and Section 10 – Audited Financial Statements. The information included in this report was collected from multiple sources. To the greatest extent possible, the data were extracted from state systems that routinely collect and maintain operational data on the Medicaid managed care program. When unavailable from state sources, data were collected from the managed care entities or sourced from either routine reporting deliverables1 or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse, or MDW) are maintained by the Medicaid program’s contracted fiscal intermediary, Gainwell. Detailed enrollee and provider information, as well as claims payment data for this report, was extracted from the MARS Data Warehouse. The state administrative system, LaGOV Enterprise Resource Planning System – Finance Module (LaGOV) maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to the MCOs and DBPMs. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for the collection of data were validated by the Department’s contracted External Quality Review Organization (EQRO), Island Peer Review Organization (IPRO). In addition to standing operational quality assurances and EQRO reviews, the 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 managed care entities or the Department used to generate data. For data originating from the MARS Data Warehouse, Myers and Stauffer directly aggregated data from encounters or data extracts for each plan and compared its results to the results the Department produced. For data originating from the plans, Myers and Stauffer (MSLC) 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% variance threshold established by the Department, it made recommendations to the Department or the health plan to improve the method used to collect data. See Appendix XIX and Appendix XX for the survey instruments.
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Original Period Certified: July 2024 - June 2025 Actual Period Covered: Present Period 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 3.0, Capitation Rate, Certification-6-21-24
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Fee-for-Service Transportation Broker Executed Contract
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Louisiana Medicaid managed care contractors must meet the requirements of their contracts with LDH. If a contractor is non-compliant with contract requirements, LDH may apply administrative actions or assess monetary penalties and intermediate sanctions to obtain the level of performance required for successful operation of the managed care program. Non-compliance reports for supporting managed care contractors who hold active contracts with LDH can be found here. Keywords: MCO, managed care, contractors, Gainwell, Health Management Systems, Maximus, Mercer, Southeastrans, vendor, non-compliance, noncompliance
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Original Period Certified: January - June 2024 Actual Period Covered: January - June 2024 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 3.0, Capitation Rate, Certification-2-14-2024
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This report is submitted under Act 210 of the 2013 Regular Legislative Session, which requires the Louisiana Department of Health (LDH) to submit an annual diabetes and obesity action plan to the Senate and House Committees on Health and Welfare after consulting with and receiving comments from the medical directors of each of its contracted Medicaid partners. Data presented on prevalence, utilization and costs of obesity and diabetes are based on 2022 paid healthcare claims submitted by each of the five Medicaid managed care organizations (MCOs) to Louisiana Medicaid and represent the Louisiana Medicaid managed care population only. Managed Care 3.0 Aetna, AmeriHealth Caritas, Healthy Blue, Humana, Louisiana Healthcare Connections, UnitedHealthcare Community Plan
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Louisiana Medicaid managed care contractors must meet the requirements of their contracts with LDH. If a contractor is non-compliant with contract requirements, LDH may apply administrative actions or assess monetary penalties and intermediate sanctions to obtain the level of performance required for successful operation of the managed care program. Non-compliance reports for dental benefit program managers who hold contracts with LDH are found here. Keywords: DBPM, MCO, noncompliance, administrative action, managed care, contract, non-compliance. Keywords: DPBM Non-Compliance Tracking Logs
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Original Period Certified: July 2023 - June 2024 Actual Period Covered: July 2023 - December 2023 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 3.0, Capitation Rate, Certification-12-6-2023
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