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Regular Session, 2012
SENATE BILL NO. 629
BY SENATOR JOHNS
MEDICAID. Provides for certain "transparency" reporting to the legislature by the
Department of Health and Hospitals concerning the Louisiana Medicaid Bayou Health
program and the Louisiana Behavioral Health Partnership and Coordinated System of Care
programs. (8/1/12)
AN ACT1
To enact Part LXXII of Chapter 5 of Title 40 of the Louisiana Revised Statutes of 1950, to2
be comprised of R.S. 40:1300.351 through 1300.353, relative to Medicaid; to require3
the Department of Health and Hospitals to submit an annual report to the legislature4
on the Louisiana Medicaid Bayou Health and Louisiana Behavioral Health5
Partnership and Coordinated System of Care programs; to provide for the6
information to be included in the report; and to provide for related matters.7
Be it enacted by the Legislature of Louisiana:8
Section 1. Part LXXII of Chapter 5 of Title 40 of the Louisiana Revised Statutes of9
1950, comprised of R.S. 40:1300.351 through 1300.353, is hereby enacted to read as10
follows:11
PART LXXII. MEDICAID TRANSPARENCY12
§1300.351. Legislative intent13
A. It is in the best interest of the citizens of the state that the Legislature14
of Louisiana ensure that the Louisiana Medicaid program is operated in the15
most efficient and sustainable method possible. With the transition of over two-16
thirds of the Medicaid eligible population from a fee-for-service based program17 SB NO. 629
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to a managed care organization based program, it is imperative that there is1
adequate reporting from the Department of Health and Hospitals in order to2
ensure the following outcomes are being achieved:3
(1) Improved care coordination with patient-centered medical homes for4
Medicaid recipients.5
(2) Improved health outcomes and quality of care as measured by metric,6
such as the Healthcare Effectiveness Data and Information Set (HEDIS).7
(3) Increased emphasis on disease prevention and the early diagnosis and8
management of chronic conditions.9
(4) Improved access to Medicaid services.10
(5) Improved accountability with a decrease in fraud, abuse, and11
wasteful spending.12
(6) A more financially sustainable Medicaid program.13
B. It is in the best interest of the citizens of the state that the Legislature14
of Louisiana ensures that the Louisiana Medicaid program as it relates to the15
severely mentally ill recipients is operated in the most efficient and sustainable16
method possible. The transition of the services of the office of behavioral health17
within the Department of Health and Hospitals to a managed care system in18
which a single statewide management organization operates as a single point of19
entry to behavioral health services requires adequate reporting from the20
Department of Health and Hospitals in order to ensure the following outcomes21
are being achieved:22
(1) Implementation of a Coordinated System of Care for youth and their23
families or caregivers that utilizes a family and youth driven practice model,24
provision of wraparound facilitation by child and family teams, family and25
youth supports, and overall management of these services by the statewide26
management organization.27
(2) Improved access, quality, and efficiency of behavioral health services28
for children not eligible for the Coordinated System of Care and for adults with29 SB NO. 629
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severe mental illness and addictive disorders, through management of these1
services by the statewide management organization.2
(3) Smooth and efficient transition of behavioral health service delivery3
and operations from a regional based approach coordinated through the office4
of behavioral health within the Department of Health and Hospitals to the use5
of human service districts or local government entities.6
(4) Seamless coordination of behavioral health services with the7
comprehensive healthcare system without losing attention to the special skills8
of the behavioral health professionals.9
(5) Advancement of a resiliency, recovery, and consumer-focused system10
of person-centered care.11
(6) Implementation of best practices and evidence-based practices that12
are effective and efficient and are supported by the data collected from13
measuring outcomes, quality, and accountability.14
(7) The efficient and effective use of state general funds in order to15
maximize federal funding of behavioral services provided by the Medicaid16
program.17
§1300.352. Bayou Health; reporting18
Beginning January 1, 2013, and annually thereafter, the Department of19
Health and Hospitals shall submit an annual report concerning the Louisiana20
Medicaid Bayou Health program to the Senate and House committees on health21
and welfare which shall include but not be limited to the following information:22
(1) The name and geographic service area of each coordinated care23
network which has contracted with the Department of Health and Hospitals.24
(2) The total number of healthcare providers in each coordinated care25
network broken down by provider type and specialty and by each geographic26
service area. The initial report shall also include the total number of providers27
enrolled in the fee-for-service Medicaid program broken down by provider type28
and specialty for each geographic service area for the period, either calendar29 SB NO. 629
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or state fiscal year, prior to the date of services initially being provided under1
Bayou Health.2
(3) The total and monthly average of the number of members enrolled3
in each network broken down by eligibility group.4
(4) The percentage of primary care practices that provide verified5
continuous phone access with the ability to speak with a primary care provider6
clinician within thirty minutes of member contact for each coordinated care7
network.8
(5) The percentage of regular and expedited service authorization9
requests processed within the time frames specified by the contract for each10
coordinated care network. The initial report shall also include comparable11
metrics or regular and expedited service authorizations and time frames when12
processed by the Medicaid fiscal intermediary for the period, either calendar13
or state fiscal year, prior to the date of services initially being provided under14
Bayou Health.15
(6) The percentage of clean claims paid for each provider type within16
thirty calendar days and the average number of days to pay all claims for each17
coordinated care network. The initial report shall also include the percentage18
of clean claims paid within thirty days by the Medicaid fiscal intermediary19
broken down by provider type for the period, either calendar or state fiscal20
year, prior to the date of services initially being provided under Bayou Health.21
(7) The number of claims denied or reduced by each coordinated care22
network for each of the following reasons:23
(a) Lack of documentation to support medical necessity.24
(b) Prior authorization was not on file.25
(c) Member has other insurance that must be billed first.26
(d) Claim was submitted after the filing deadline.27
(e) Service was not covered by the coordinated care network.28
(f) Due to process, procedure, notification, referrals, or any other29 SB NO. 629
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required administrative function of a coordinated care network.1
(g) The initial report shall also include the number of claims denied or2
reduced for each of the reasons set forth in this Paragraph by the Medicaid3
fiscal intermediary for the period, either calendar or state fiscal year, prior to4
the date of services initially being provided under Bayou Health.5
(8) The number and dollar value of all claims paid to non-network6
providers by claim type categorized by emergency services and non-emergency7
services for each coordinated care network by geographic service area.8
(9) The number of members who chose the coordinated care network9
and the number of members who were auto-enrolled into each coordinated care10
network, broken down by coordinated care network.11
(10) The amount of the total payments and average per member per12
month payment paid to each coordinated care network.13
(11) The Medical Loss Ratio of each coordinated care network and the14
amount of any refund to the state for failure to maintain the required Medical15
Loss Ratio.16
(12) A comparison of health outcomes, which includes but is not limited17
to the following outcomes among each coordinated care network:18
(a) Adult asthma admission rate.19
(b) Congestive heart failure admission rate.20
(c) Uncontrolled diabetes admission rate.21
(d) Adult access to preventative/ambulatory health services.22
(e) Breast cancer screening rate.23
(f) Well child visits.24
(g) Childhood immunization rates.25
(h) The initial report shall also include a comparison of health outcomes26
for each of the aforementioned metrics in this Paragraph for the Medicaid27
fee-for-service program for the period, either calendar or state fiscal year, prior28
to the date of services initially being provided under Bayou Health.29 SB NO. 629
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(13) A copy of the member and provider satisfaction survey report for1
each coordinated care network.2
(14) A copy of the annual audited financial statements for each3
coordinated care network.4
(15) The total amount of savings to the state for each shared savings5
coordinated care network.6
(16) A brief factual narrative of any sanctions levied by the Department7
of Health and Hospitals against a coordinated care network.8
(17) The number of members, broken down by each coordinated care9
network, who file a grievance or appeal and the number of members who10
accessed the state fair hearing process and the total number and percentage of11
grievances or appeals which reversed or otherwise resolved in favor of the12
member.13
(18) The number of members who receive unduplicated Medicaid14
services from each coordinated care network broken down by provider type,15
specialty, and place of service.16
(19) The number of members who received unduplicated outpatient17
emergency services broken down by coordinated care network and aggregated18
by the following hospital classifications:19
(a) State.20
(b) Non-state non-rural.21
(c) Rural.22
(d) Private.23
(20) The number of total inpatient Medicaid days broken down by24
coordinated care network and aggregated by the following hospital25
classifications:26
(a) State.27
(b) Public non-state non-rural.28
(c) Rural.29 SB NO. 629
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(d) Private.1
(21) The number of claims for emergency services, broken out by2
coordinated care network, whether the claim was paid or denied and by3
provider type. The initial report shall also include comparable metrics for4
claims for emergency services which were processed by the Medicaid fiscal5
intermediary for the period, either calendar or state fiscal year, prior to the6
date of services initially being provided under Bayou Health.7
(22) Any other metric or measure which the Department of Health and8
Hospitals deems appropriate for inclusion in the report.9
§1300.353. Louisiana Behavioral Health Partnership; reporting10
Beginning January 1, 2013, and annually thereafter, the Department of11
Health and Hospitals shall submit an annual report for the Coordinated System12
of Care and an annual report for the Louisiana Behavioral Health Partnership13
to the Senate and House committees on health and welfare which shall include14
but not be limited to the following information:15
(1) The name and geographic service area of each human service district16
or local government entity through which behavioral health services are being17
provided.18
(2) The total number of healthcare providers in each human service19
district or local government entity, if applicable or by parish, broken down by20
provider type, applicable credentialing status, and specialty.21
(3) The total number of Medicaid and non-Medicaid members enrolled22
in each human service district or local government entity, if applicable, or by23
parish.24
(4) The total and monthly average number of adult Medicaid enrollees25
receiving services in each human service district or local government entity, if26
applicable, or by parish.27
(5) The total and monthly average number of adult non-Medicaid28
patients receiving services in each human service district or local government29 SB NO. 629
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entity, if applicable, or by parish.1
(6) The total and monthly average number of children receiving services2
through the Coordinated System of Care by human service region or local3
government entity, if applicable, or by parish.4
(7) The total and monthly average number of children not enrolled in the5
Coordinated System of Care receiving services as Medicaid enrollees in each6
human service district or local government entity, if applicable, or by parish.7
(8) The total and monthly average number of children not enrolled in the8
Coordinated System of Care receiving services as non-Medicaid enrollees in9
each human service district or local government entity, if applicable, or by10
parish.11
(9) The percentage of calls received by the statewide management12
organization that were referred for services in each human service district or13
local government entity, if applicable, or by parish.14
(10) The average length of time for a member to receive confirmation15
and referral for services, using the initial call to the statewide management16
organization as the start date.17
(11) The percentage of all referrals that were considered immediate,18
urgent and routine needs in each human service district or local government19
entity, if applicable, or by parish.20
(12) The percentage of clean claims paid for each provider type within21
thirty calendar days and average number of days to pay all claims for each22
human service district or local government entity.23
(13) The total number of claims denied or reduced for each of the24
following reasons:25
(a) Lack of documentation.26
(b) Lack of prior authorization.27
(c) Service was not covered. 28
(14) The percentage of members who provide consent for release of29 SB NO. 629
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information to coordinate care with the member's primary care physician and1
other healthcare providers.2
(15) The number of outpatient members who received services in3
hospital-based emergency rooms due to a behavioral health diagnosis.4
(16) A copy of the statewide management organization's report to the5
Department of Health and Hospital on quality management which shall6
include:7
(a) The number of qualified quality management personnel employed by8
the statewide management organization to review performance standards,9
measure treatment outcomes and assure timely access to care.10
(b) The mechanism utilized by the statewide management organization11
for generating input and participation of members, families/caretakers, and12
other stakeholders in the monitoring of service quality and determining13
strategies to improve outcomes.14
(c) Documented demonstration of meeting all the federal requirements15
for 42 CFR 438.240 and with the utilization management required by the16
Medicaid program as described in 42 CFR 456.17
(d) Documentation that the statewide management organization has18
implemented and maintained a formal outcomes assessment process that is19
standardized, relatable and valid in accordance with industry standards.20
(17) Any other metric or measure which the Department of Health and21
Hospitals deems appropriate for inclusion in the report.22 SB NO. 629
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The original instrument was prepared by Christopher D. Adams. The
following digest, which does not constitute a part of the legislative
instrument, was prepared by Michelle Broussard-Johnson.
DIGEST
Johns (SB 629)
Proposed law requires that beginning January 1, 2013, and annually thereafter, the
Department of Health and Hospitals shall submit an annual report concerning the Louisiana
Medicaid Bayou Health program and the Louisiana Behavioral Health Partnership and
Coordinated System of Care programs to the Senate and House committees on health and
welfare which shall include certain information as provided for in proposed law.
Effective August 1, 2012.
(Adds R.S. 40:1300.351-1300.353)
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Health and Welfare to
the original bill
1. Sets forth the information and data required in the annual report from the
Louisiana Behavioral Health Partnership and Coordinated System of Care
programs.
2. Provides all the data and information for the initial required report include
data and information for the calendar years 2009, 2010, and 2011.
Senate Floor Amendments to engrossed bill
1. Changes "human resource district" to "human service district".
2. Removes initial report requirement for calendar years 2009, 2010, and 2011.