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Regular Session, 2012 ENROLLED
SENATE BILL NO. 629
BY SENATOR JOHNS
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
to a managed care organization based program, it is imperative that there is18
adequate reporting from the Department of Health and Hospitals in order to19
ensure the following outcomes are being achieved:20
(1) Improved care coordination with patient-centered medical homes for21
Medicaid recipients.22
(2) Improved health outcomes and quality of care as measured by metric,23
such as the Healthcare Effectiveness Data and Information Set (HEDIS).24
(3) Increased emphasis on disease prevention and the early diagnosis and25
management of chronic conditions.26
(4) Improved access to Medicaid services.27 SB NO. 629 ENROLLED
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(5) Improved accountability with a decrease in fraud, abuse, and1
wasteful spending.2
(6) A more financially sustainable Medicaid program.3
B. It is in the best interest of the citizens of the state that the Legislature4
of Louisiana ensures that the Louisiana Medicaid program as it relates to the5
severely mentally ill recipients is operated in the most efficient and sustainable6
method possible. The transition of the services of the office of behavioral health7
within the Department of Health and Hospitals to a managed care system in8
which a single statewide management organization operates as a single point of9
entry to behavioral health services requires adequate reporting from the10
Department of Health and Hospitals in order to ensure the following outcomes11
are being achieved:12
(1) Implementation of a Coordinated System of Care for youth and their13
families or caregivers that utilizes a family and youth driven practice model,14
provision of wraparound facilitation by child and family teams, family and15
youth supports, and overall management of these services by the statewide16
management organization.17
(2) Improved access, quality, and efficiency of behavioral health services18
for children not eligible for the Coordinated System of Care and for adults with19
severe mental illness and addictive disorders, through management of these20
services by the statewide management organization.21
(3) Smooth and efficient transition of behavioral health service delivery22
and operations from a regional based approach coordinated through the office23
of behavioral health within the Department of Health and Hospitals to the use24
of human service districts or local government entities.25
(4) Seamless coordination of behavioral health services with the26
comprehensive healthcare system without losing attention to the special skills27
of the behavioral health professionals.28
(5) Advancement of a resiliency, recovery, and consumer-focused system29
of person-centered care.30 SB NO. 629 ENROLLED
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(6) Implementation of best practices and evidence-based practices that1
are effective and efficient and are supported by the data collected from2
measuring outcomes, quality, and accountability.3
(7) The efficient and effective use of state general funds in order to4
maximize federal funding of behavioral services provided by the Medicaid5
program.6
§1300.352. Bayou Health; reporting7
Beginning January 1, 2013, and annually thereafter, the Department of8
Health and Hospitals shall submit an annual report concerning the Louisiana9
Medicaid Bayou Health program to the Senate and House committees on health10
and welfare that shall include but not be limited to the following information:11
(1) The name and geographic service area of each coordinated care12
network which has contracted with the Department of Health and Hospitals.13
(2) The total number of healthcare providers in each coordinated care14
network broken down by provider type and specialty and by each geographic15
service area. The initial report shall also include the total number of providers16
enrolled in the fee-for-service Medicaid program broken down by provider type17
and specialty for each geographic service area for the period, either calendar18
or state fiscal year, prior to the date of services initially being provided under19
Bayou Health.20
(3) The total and monthly average of the number of members enrolled21
in each network broken down by eligibility group.22
(4) The percentage of primary care practices that provide verified23
continuous phone access with the ability to speak with a primary care provider24
clinician within thirty minutes of member contact for each coordinated care25
network.26
(5) The percentage of regular and expedited service authorization27
requests processed within the time frames specified by the contract for each28
coordinated care network. The initial report shall also include comparable29
metrics or regular and expedited service authorizations and time frames when30 SB NO. 629 ENROLLED
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processed by the Medicaid fiscal intermediary for the period, either calendar1
or state fiscal year, prior to the date of services initially being provided under2
Bayou Health.3
(6) The percentage of clean claims paid for each provider type within4
thirty calendar days and the average number of days to pay all claims for each5
coordinated care network. The initial report shall also include the percentage6
of clean claims paid within thirty days by the Medicaid fiscal intermediary7
broken down by provider type for the period, either calendar or state fiscal8
year, prior to the date of services initially being provided under Bayou Health.9
(7) The number of claims denied or reduced by each coordinated care10
network for each of the following reasons:11
(a) Lack of documentation to support medical necessity.12
(b) Prior authorization was not on file.13
(c) Member has other insurance that must be billed first.14
(d) Claim was submitted after the filing deadline.15
(e) Service was not covered by the coordinated care network.16
(f) Due to process, procedure, notification, referrals, or any other17
required administrative function of a coordinated care network.18
(g) The initial report shall also include the number of claims denied or19
reduced for each of the reasons set forth in this Paragraph by the Medicaid20
fiscal intermediary for the period, either calendar or state fiscal year, prior to21
the date of services initially being provided under Bayou Health.22
(8) The number and dollar value of all claims paid to non-network23
providers by claim type categorized by emergency services and non-emergency24
services for each coordinated care network by geographic service area.25
(9) The number of members who chose the coordinated care network26
and the number of members who were auto-enrolled into each coordinated care27
network, broken down by coordinated care network.28
(10) The amount of the total payments and average per member per29
month payment paid to each coordinated care network.30 SB NO. 629 ENROLLED
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(11) The Medical Loss Ratio of each coordinated care network and the1
amount of any refund to the state for failure to maintain the required Medical2
Loss Ratio.3
(12) A comparison of health outcomes, which includes but is not limited4
to the following outcomes among each coordinated care network:5
(a) Adult asthma admission rate.6
(b) Congestive heart failure admission rate.7
(c) Uncontrolled diabetes admission rate.8
(d) Adult access to preventative/ambulatory health services.9
(e) Breast cancer screening rate.10
(f) Well child visits.11
(g) Childhood immunization rates.12
(h) The initial report shall also include a comparison of health outcomes13
for each of the aforementioned metrics in this Paragraph for the Medicaid14
fee-for-service program for the period, either calendar or state fiscal year, prior15
to the date of services initially being provided under Bayou Health.16
(13) A copy of the member and provider satisfaction survey report for17
each coordinated care network.18
(14) A copy of the annual audited financial statements for each19
coordinated care network.20
(15) The total amount of savings to the state for each shared savings21
coordinated care network.22
(16) A brief factual narrative of any sanctions levied by the Department23
of Health and Hospitals against a coordinated care network.24
(17) The number of members, broken down by each coordinated care25
network, who file a grievance or appeal and the number of members who26
accessed the state fair hearing process and the total number and percentage of27
grievances or appeals which reversed or otherwise resolved a decision in favor28
of the member.29
(18) The number of members who receive unduplicated Medicaid30 SB NO. 629 ENROLLED
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services from each coordinated care network, broken down by provider type,1
specialty, and place of service.2
(19) The number of members who received unduplicated outpatient3
emergency services, broken down by coordinated care network and aggregated4
by the following hospital classifications:5
(a) State.6
(b) Non-state non-rural.7
(c) Rural.8
(d) Private.9
(20) The number of total inpatient Medicaid days broken down by10
coordinated care network and aggregated by the following hospital11
classifications:12
(a) State.13
(b) Public non-state non-rural.14
(c) Rural.15
(d) Private.16
(21) The number of claims for emergency services, broken out by17
coordinated care network, whether the claim was paid or denied and by18
provider type. The initial report shall also include comparable metrics for19
claims for emergency services that were processed by the Medicaid fiscal20
intermediary for the period, either calendar or state fiscal year, prior to the21
date of services initially being provided under Bayou Health.22
(22) Any other metric or measure which the Department of Health and23
Hospitals deems appropriate for inclusion in the report.24
§1300.353. Louisiana Behavioral Health Partnership; reporting25
Beginning January 1, 2013, and annually thereafter, the Department of26
Health and Hospitals shall submit an annual report for the Coordinated System27
of Care and an annual report for the Louisiana Behavioral Health Partnership28
to the Senate and House committees on health and welfare that shall include but29
not be limited to the following information:30 SB NO. 629 ENROLLED
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(1) The name and geographic service area of each human service district1
or local government entity through which behavioral health services are being2
provided.3
(2) The total number of healthcare providers in each human service4
district or local government entity, if applicable or by parish, broken down by5
provider type, applicable credentialing status, and specialty.6
(3) The total number of Medicaid and non-Medicaid members enrolled7
in each human service district or local government entity, if applicable, or by8
parish.9
(4) The total and monthly average number of adult Medicaid enrollees10
receiving services in each human service district or local government entity, if11
applicable, or by parish.12
(5) The total and monthly average number of adult non-Medicaid13
patients receiving services in each human service district or local government14
entity, if applicable, or by parish.15
(6) The total and monthly average number of children receiving services16
through the Coordinated System of Care by human service region or local17
government entity, if applicable, or by parish.18
(7) The total and monthly average number of children not enrolled in the19
Coordinated System of Care receiving services as Medicaid enrollees in each20
human service district or local government entity, if applicable, or by parish.21
(8) The total and monthly average number of children not enrolled in the22
Coordinated System of Care receiving services as non-Medicaid enrollees in23
each human service district or local government entity, if applicable, or by24
parish.25
(9) The percentage of calls received by the statewide management26
organization that were referred for services in each human service district or27
local government entity, if applicable, or by parish.28
(10) The average length of time for a member to receive confirmation29
and referral for services, using the initial call to the statewide management30 SB NO. 629 ENROLLED
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organization as the start date.1
(11) The percentage of all referrals that were considered immediate,2
urgent and routine needs in each human service district or local government3
entity, if applicable, or by parish.4
(12) The percentage of clean claims paid for each provider type within5
thirty calendar days and average number of days to pay all claims for each6
human service district or local government entity.7
(13) The total number of claims denied or reduced for each of the8
following reasons:9
(a) Lack of documentation.10
(b) Lack of prior authorization.11
(c) Service was not covered. 12
(14) The percentage of members who provide consent for release of13
information to coordinate care with the member's primary care physician and14
other healthcare providers.15
(15) The number of outpatient members who received services in16
hospital-based emergency rooms due to a behavioral health diagnosis.17
(16) A copy of the statewide management organization's report to the18
Department of Health and Hospital on quality management, which shall19
include:20
(a) The number of qualified quality management personnel employed by21
the statewide management organization to review performance standards,22
measure treatment outcomes and assure timely access to care.23
(b) The mechanism utilized by the statewide management organization24
for generating input and participation of members, families/caretakers, and25
other stakeholders in the monitoring of service quality and determining26
strategies to improve outcomes.27
(c) Documented demonstration of meeting all the federal requirements28
for 42 CFR 438.240 and with the utilization management required by the29
Medicaid program as described in 42 CFR 456.30 SB NO. 629 ENROLLED
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(d) Documentation that the statewide management organization has1
implemented and maintained a formal outcomes assessment process that is2
standardized, relatable and valid in accordance with industry standards.3
(17) Any other metric or measure that the Department of Health and4
Hospitals deems appropriate for inclusion in the report.5
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: