HLS 13RS-974 ORIGINAL
Page 1 of 13
Regular Session, 2013
HOUSE CONCURRENT RESOLUTI ON NO. 75
BY REPRESENTATIVE BARROW
HEALTH/DHH: Requires transparency in Medicaid managed care programs operated by
DHH
A CONCURRENT RESOLUTI ON1
To authorize and direct the Department of Health and Hospitals to ensure transparency in2
its Medicaid managed care programs through annual reports to the legislature on the3
coordinated care network initiative known as "Bayou Health", the Louisiana4
Behavioral Health Partnership, and the Coordinated System of Care.5
WHEREAS, it is in the best interest of all citizens of this state that the Louisiana6
Medicaid program is operated in the most efficient and sustainable manner possible; and7
WHEREAS, with the transition of over two-thirds of Louisiana's Medicaid enrollees8
since 2011 from a state-operated fee-for-service program to a program known as "Bayou9
Health" which relies on managed care coordinated by private insurance companies, it is10
imperative that the Department of Health and Hospitals, hereafter referred to as11
"department", report adequate information to the Legislature of Louisiana on financing and12
outcomes of such coordinated care; and13
WHEREAS, as a policymaking body, the legislature requires reporting of this type14
in order to ensure that the department is achieving the following priority outcomes:15
(1) Improved care coordination with patient-centered medical homes for Medicaid16
recipients.17
(2) Improved health outcomes and quality of care as measured by a valid metric,18
such as the Healthcare Effectiveness Data and Information Set (HEDIS).19
(3) Increased emphasis on disease prevention and early diagnosis and management20
of chronic conditions.21 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(4) Improved access to Medicaid services.1
(5) Improved accountability with a decrease in fraud, abuse, and wasteful spending.2
(6) A more financially sustainable Medicaid program; and3
WHEREAS, it is in the best interest of all citizens of this state that services of the4
Louisiana Medicaid program for enrollees with mental health and behavioral health needs5
are delivered in the most efficient and sustainable manner possible; and6
WHEREAS, with the transition of services of the department's office of behavioral7
health to a system in which a private contractor operates as a statewide management8
organization providing a single point-of-entry for behavioral health services, it is imperative9
that the department report adequate information to the Legislature of Louisiana on financing10
and outcomes of this managed care system; and11
WHEREAS, as a policymaking body, the legislature requires reporting of this type12
in order to ensure that the department is achieving the following priority outcomes:13
(1) Implementation of a Coordinated System of Care for youth and their families or14
caregivers that utilizes a family-and youth-driven practice model, provision of wraparound15
facilitation by child and family teams, family and youth supports, and overall management16
of these services by the statewide management organization.17
(2) Improved access, quality, and efficiency of behavioral health services for18
children not eligible for the Coordinated System of Care, and for adults with severe mental19
illness and addictive disorders, through management of these services by the statewide20
management organization.21
(3) Smooth and efficient transition of behavioral health service delivery and22
operations from a regional based approach coordinated through the office of behavioral23
health within the Department of Health and Hospitals to the use of human service districts24
or local government entities.25
(4) Seamless coordination of behavioral health services with the comprehensive26
health care system without losing attention to the special skills of the behavioral health27
professionals.28
(5) Advancement of a resiliency-, recovery-, and consumer-focused system of29
person-centered care.30 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(6) Implementation of evidence-based best practices that are effective, efficient, and1
supported by data collected from measuring outcomes, quality, and accountability.2
(7) The efficient and effective use of state general funds in order to maximize federal3
funding of behavioral services provided by the Medicaid program.4
THEREFORE, BE IT RESOLVED that the Legislature of Louisiana does hereby5
authorize and direct the department, beginning January 1, 2014, and annually thereafter, to6
submit a report concerning the Medicaid coordinated care network initiative known as7
"Bayou Health" to the House and Senate committees on health and welfare which includes8
but is not limited to the following information:9
(1) The name and geographic service area of each coordinated care network which10
has contracted with the department.11
(2) The total number of health care providers in each coordinated care network12
broken down by provider type and specialty and by each geographic service area. The initial13
report shall also include the total number of providers enrolled in the fee-for-service14
Medicaid program broken down by provider type and specialty for each geographic service15
area for the period, either calendar or state fiscal year, prior to the date of services initially16
being provided under Bayou Health.17
(3) The total and monthly average of the number of members enrolled in each18
network broken down by eligibility group.19
(4) The percentage of primary care practices that provide verified continuous phone20
access with the ability to speak with a primary care provider clinician within thirty minutes21
of member contact for each coordinated care network.22
(5) The percentage of regular and expedited service authorization requests processed23
within the time frames specified by the contract for each coordinated care network. The24
initial report shall also include comparable metrics or regular and expedited service25
authorizations and time frames when processed by the Medicaid fiscal intermediary for the26
period, either calendar or state fiscal year, prior to the date of services initially being27
provided under Bayou Health.28
(6) The percentage of clean claims paid for each provider type within thirty calendar29
days and the average number of days to pay all claims for each coordinated care network.30 HLS 13RS-974 ORIGINAL
HCR NO. 75
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The initial report shall also include the percentage of clean claims paid within thirty days by1
the Medicaid fiscal intermediary broken down by provider type for the period, either2
calendar or state fiscal year, prior to the date of services initially being provided under3
Bayou Health.4
(7)(a) The number of claims denied or reduced by each coordinated care network5
for each of the following reasons:6
(i) Lack of documentation to support medical necessity.7
(ii) Prior authorization was not on file.8
(iii) Member has other insurance that must be billed first.9
(iv) Claim was submitted after the filing deadline.10
(v) Service was not covered by the coordinated care network.11
(vi) Due to process, procedure, notification, referrals, or any other required12
administrative function of a coordinated care network.13
(b) The initial report shall also include the number of claims denied or reduced for14
each of the reasons set forth in this Paragraph by the Medicaid fiscal intermediary for the15
period, either calendar or state fiscal year, prior to the date of services initially being16
provided under Bayou Health.17
(8) The number and dollar value of all claims paid to non-network providers by18
claim type categorized by emergency services and nonemergency services for each19
coordinated care network by geographic service area.20
(9) The number of members who chose the coordinated care network and the21
number of members who were autoenrolled into each coordinated care network, broken22
down by coordinated care network.23
(10) The amount of the total payments and average per member per month payment24
paid to each coordinated care network.25
(11) The medical loss ratio of each coordinated care network and the amount of any26
refund to the state for failure to maintain the required medical loss ratio.27
(12) A comparison of health outcomes among each coordinated care network which28
shall include but shall not be limited to the following:29
(a) Adult asthma hospital admission rate.30 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(b) Congestive heart failure hospital admission rate.1
(c) Uncontrolled diabetes hospital admission rate.2
(d) Adult access to preventative or ambulatory health services.3
(e) Breast cancer screening rate.4
(f) Well child visits.5
(g) Childhood immunization rates.6
(13) A comparison of health outcomes for each of the aforementioned metrics for7
the Medicaid fee-for-service program for the period, either calendar or state fiscal year, prior8
to the date of services initially being provided under Bayou Health.9
(14) A copy of the member and provider satisfaction survey report for each10
coordinated care network.11
(15) A copy of the annual audited financial statements for each coordinated care12
network.13
(16) The total amount of savings to the state for each shared savings coordinated14
care network.15
(17) A brief factual narrative describing any sanctions levied by the department16
against a coordinated care network.17
(18) The number of members, broken down by each coordinated care network, who18
file a grievance or appeal and the number of members who accessed the state fair hearing19
process and the total number and percentage of grievances or appeals which reversed or20
otherwise resolved a decision in favor of the member.21
(19) The number of members who received unduplicated Medicaid services from22
each coordinated care network, broken down by provider type, specialty, and place of23
service.24
(20) The number of members who received unduplicated outpatient emergency25
services, broken down by coordinated care network and aggregated by the following hospital26
classifications:27
(a) State.28
(b) Nonstate nonrural.29
(c) Rural.30 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(d) Private.1
(21) The number of total inpatient Medicaid days broken down by coordinated care2
network and aggregated by the following hospital classifications:3
(a) State.4
(b) Public nonstate nonrural.5
(c) Rural.6
(d) Private.7
(22) The number of claims for emergency services, broken out by coordinated care8
network, whether the claim was paid or denied and by provider type. The initial report shall9
also include comparable metrics for claims for emergency services that were processed by10
the Medicaid fiscal intermediary for the period, either calendar or state fiscal year, prior to11
the date of services initially being provided under Bayou Health.12
(23) The following information concerning pharmacy benefits broken down by each13
coordinated care network and by month:14
(a) Total number of prescription claims.15
(b) Total number of prescription claims subject to prior authorization.16
(c) Total number of prescription claims denied.17
(d) Total number of prescription claims subject to step therapy or fail first protocols.18
(24) Any other metric or measure which the department deems appropriate for19
inclusion in the report.20
BE IT FURTHER RESOLVED that the Legislature of Louisiana does hereby21
authorize and direct the department, beginning January 1, 2014, and annually thereafter, to22
submit reports concerning the Coordinated System of Care and the Louisiana Behavioral23
Health Partnership to the House and Senate committees on health and welfare that shall24
include but not be limited to the following information:25
(1) The name and geographic service area of each human services district or local26
government entity through which behavioral health services are being provided.27
(2) The total number of health care providers in each human services district or local28
government entity, if applicable or by parish, broken down by provider type, applicable29
credentialing status, and specialty.30 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(3) The total number of Medicaid and non-Medicaid members enrolled in each1
human services district or local government entity, if applicable, or by parish.2
(4) The total and monthly average number of adult Medicaid enrollees receiving3
services in each human services district or local government entity, if applicable, or by4
parish.5
(5) The total and monthly average number of adult non-Medicaid patients receiving6
services in each human services district or local government entity, if applicable, or by7
parish.8
(6) The total and monthly average number of children receiving services through the9
Coordinated System of Care by human services region or local government entity, if10
applicable, or by parish.11
(7) The total and monthly average number of children not enrolled in the12
Coordinated System of Care receiving services as Medicaid enrollees in each human services13
district or local government entity, if applicable, or by parish.14
(8) The total and monthly average number of children not enrolled in the15
Coordinated System of Care receiving services as non-Medicaid enrollees in each human16
services district or local government entity, if applicable, or by parish.17
(9) The percentage of calls received by the statewide management organization that18
were referred for services in each human services district or local government entity, if19
applicable, or by parish.20
(10) The average length of time for a member to receive confirmation and referral21
for services, using the initial call to the statewide management organization as the start date.22
(11) The percentage of all referrals that were considered immediate, urgent, and23
routine in each human services district or local government entity, if applicable, or by parish.24
(12) The percentage of clean claims paid for each provider type within thirty25
calendar days and average number of days to pay all claims for each human services district26
or local government entity.27
(13) The total number of claims denied or reduced for each of the following reasons:28
(a) Lack of documentation.29
(b) Lack of prior authorization.30 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(c) Service was not covered.1
(14) The percentage of members who provide consent for release of information to2
coordinate care with the member's primary care physician and other health care providers.3
(15) The number of outpatient members who received services in hospital-based4
emergency rooms due to a behavioral health diagnosis.5
(16) A copy of the statewide management organization's report to the department6
on quality management, which shall include all of the following information:7
(a) The number of qualified quality management personnel employed by the8
statewide management organization to review performance standards, measure treatment9
outcomes, and assure timely access to care.10
(b) The mechanism utilized by the statewide management organization for11
generating input and participation of members, families, caretakers, and other stakeholders12
in the monitoring of service quality and determining strategies to improve outcomes.13
(c) Documentation verifying that all the federal requirements set forth in 42 CFR14
438.240 have been met within the utilization management standards required by the15
Medicaid program as described in 42 CFR 456.16
(d) Documentation verifying that the statewide management organization has17
implemented and maintained a formal outcomes assessment process that is standardized,18
relatable, and valid in accordance with industry standards.19
(17) Any other metric or measure that the department deems appropriate for20
inclusion in the report.21
BE IT FURTHER RESOLVED that the Legislature of Louisiana does hereby22
authorize and direct the department to make publicly available on its Internet website all of23
the following items:24
(1) All informational bulletins, health plan advisories, and published guidance25
concerning the Bayou Health coordinated care network program.26
(2) All Medicaid state plan amendments and any correspondence related thereto,27
which shall be made publicly available within twenty-four hours of submission to the28
Centers for Medicare and Medicaid Services.29 HLS 13RS-974 ORIGINAL
HCR NO. 75
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(3) All formal responses to the department by the Centers for Medicare and1
Medicaid Services regarding any Medicaid state plan amendment, which shall be made2
publicly available within twenty-four hours of receipt by the department.3
BE IT FURTHER RESOLVED that a suitable copy of this Resolution be transmitted4
to the secretary of the Department of Health and Hospitals.5
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Barrow HCR No. 75
Directs DHH, beginning Jan. 1, 2014, and annually thereafter, to submit a report concerning
the Medicaid coordinated care network initiative known as "Bayou Health" to the legislative
committees on health and welfare which includes but is not limited to the following
information:
(1)The name and geographic service area of each coordinated care network which has
contracted with the department.
(2)The total number of health care providers in each coordinated care network broken
down by provider type and specialty and by each geographic service area. The initial
report shall also include the total number of providers enrolled in the fee-for-service
Medicaid program broken down by provider type and specialty for each geographic
service area for the period, either calendar or state fiscal year, prior to the date of
services initially being provided under Bayou Health.
(3)The total and monthly average of the number of members enrolled in each network
broken down by eligibility group.
(4)The percentage of primary care practices that provide verified continuous phone
access with the ability to speak with a primary care provider clinician within 30
minutes of member contact for each coordinated care network.
(5)The percentage of regular and expedited service authorization requests processed
within the time frames specified by the contract for each coordinated care network.
The initial report shall also include comparable metrics or regular and expedited
service authorizations and time frames when processed by the Medicaid fiscal
intermediary for the period, either calendar or state fiscal year, prior to the date of
services initially being provided under Bayou Health.
(6)The percentage of clean claims paid for each provider type within thirty calendar
days and the average number of days to pay all claims for each coordinated care
network. The initial report shall also include the percentage of clean claims paid
within 30 days by the Medicaid fiscal intermediary broken down by provider type
for the period, either calendar or state fiscal year, prior to the date of services initially
being provided under Bayou Health.
(7)(a)The number of claims denied or reduced by each coordinated care network for each
of the following reasons:
(i)Lack of documentation to support medical necessity. HLS 13RS-974 ORIGINAL
HCR NO. 75
Page 10 of 13
(ii)Prior authorization was not on file.
(iii)Member has other insurance that must be billed first.
(iv)Claim was submitted after the filing deadline.
(v)Service was not covered by the coordinated care network.
(vi)Due to process, procedure, notification, referrals, or any other required
administrative function of a coordinated care network.
(b)The initial report shall also include the number of claims denied or reduced
for each of the reasons set forth by the Medicaid fiscal intermediary for the
period, either calendar or state fiscal year, prior to the date of services
initially being provided under Bayou Health.
(8)The number and dollar value of all claims paid to nonnetwork providers by claim
type categorized by emergency services and nonemergency services for each
coordinated care network by geographic service area.
(9)The number of members who chose the coordinated care network and the number
of members who were autoenrolled into each coordinated care network, broken down
by coordinated care network.
(10)The amount of the total payments and average per member per month payment paid
to each coordinated care network.
(11)The medical loss ratio of each coordinated care network and the amount of any
refund to the state for failure to maintain the required medical loss ratio.
(12)A comparison of health outcomes, which includes but is not limited to the following
outcomes among each coordinated care network:
(a)Adult asthma hospital admission rate.
(b)Congestive heart failure hospital admission rate.
(c)Uncontrolled diabetes hospital admission rate.
(d)Adult access to preventative or ambulatory health services.
(e)Breast cancer screening rate.
(f)Well child visits.
(g)Childhood immunization rates.
(13)The initial report shall also include a comparison of health outcomes for each of the
aforementioned metrics for the Medicaid fee-for-service program for the period,
either calendar or state fiscal year, prior to the date of services initially being
provided under Bayou Health.
(14)A copy of the member and provider satisfaction survey report for each coordinated
care network.
(15)A copy of the annual audited financial statements for each coordinated care network.
(16)The total amount of savings to the state for each shared savings coordinated care
network.
(17)A brief factual narrative describing any sanctions levied by the department against
a coordinated care network.
(18)The number of members, broken down by each coordinated care network, who file
a grievance or appeal and the number of members who accessed the state fair hearing
process and the total number and percentage of grievances or appeals which reversed
or otherwise resolved a decision in favor of the member. HLS 13RS-974 ORIGINAL
HCR NO. 75
Page 11 of 13
(19)The number of members who received unduplicated Medicaid services from each
coordinated care network, broken down by provider type, specialty, and place of
service.
(20)The number of members who received unduplicated outpatient emergency services,
broken down by coordinated care network and aggregated by the following hospital
classifications:
(a)State.
(b)Nonstate nonrural.
(c)Rural.
(d)Private.
(21)The number of total inpatient Medicaid days broken down by coordinated care
network and aggregated by the following hospital classifications:
(a)State.
(b)Public nonstate nonrural.
(c)Rural.
(d)Private.
(22)The number of claims for emergency services, broken out by coordinated care
network, whether the claim was paid or denied and by provider type. The initial
report shall also include comparable metrics for claims for emergency services that
were processed by the Medicaid fiscal intermediary for the period, either calendar
or state fiscal year, prior to the date of services initially being provided under Bayou
Health.
(23)The following information concerning pharmacy benefits broken down by each
coordinated care network and by month:
(a)Total number of prescription claims.
(b)Total number of prescription claims subject to prior authorization.
(c)Total number of prescription claims denied.
(d)Total number of prescription claims subject to step therapy or fail first
protocols.
(24)Any other metric or measure which the department deems appropriate for inclusion
in the report.
Further, directs DHH, beginning Jan. 1, 2014, and annually thereafter, to submit reports
concerning the Coordinated System of Care and the La. Behavioral Health Partnership to the
legislative committees on health and welfare that include but are not limited to the following
information:
(1)The name and geographic service area of each human services district or local
government entity through which behavioral health services are being provided.
(2)The total number of health care providers in each human services district or local
government entity, if applicable or by parish, broken down by provider type,
applicable credentialing status, and specialty.
(3)The total number of Medicaid and non-Medicaid members enrolled in each human
services district or local government entity, if applicable, or by parish.
(4)The total and monthly average number of adult Medicaid enrollees receiving services
in each human services district or local government entity, if applicable, or by parish. HLS 13RS-974 ORIGINAL
HCR NO. 75
Page 12 of 13
(5)The total and monthly average number of adult non-Medicaid patients receiving
services in each human services district or local government entity, if applicable, or
by parish.
(6)The total and monthly average number of children receiving services through the
Coordinated System of Care by human services region or local government entity,
if applicable, or by parish.
(7)The total and monthly average number of children not enrolled in the Coordinated
System of Care receiving services as Medicaid enrollees in each human services
district or local government entity, if applicable, or by parish.
(8)The total and monthly average number of children not enrolled in the Coordinated
System of Care receiving services as non-Medicaid enrollees in each human services
district or local government entity, if applicable, or by parish.
(9)The percentage of calls received by the statewide management organization that
were referred for services in each human services district or local government entity,
if applicable, or by parish.
(10)The average length of time for a member to receive confirmation and referral for
services, using the initial call to the statewide management organization as the start
date.
(11)The percentage of all referrals that were considered immediate, urgent, and routine
in each human services district or local government entity, if applicable, or by parish.
(12)The percentage of clean claims paid for each provider type within 30 calendar days
and average number of days to pay all claims for each human services district or
local government entity.
(13)The total number of claims denied or reduced for each of the following reasons:
(a)Lack of documentation.
(b)Lack of prior authorization.
(c)Service was not covered.
(14)The percentage of members who provide consent for release of information to
coordinate care with the member's primary care physician and other health care
providers.
(15)The number of outpatient members who received services in hospital-based
emergency rooms due to a behavioral health diagnosis.
(16)A copy of the statewide management organization's report to the department on
quality management, which shall include all of the following information:
(a)The number of qualified quality management personnel employed by the
statewide management organization to review performance standards,
measure treatment outcomes, and assure timely access to care.
(b)The mechanism utilized by the statewide management organization for
generating input and participation of members, families, caretakers, and other
stakeholders in the monitoring of service quality and determining strategies
to improve outcomes.
(c)Documentation verifying that all the federal requirements set forth in 42 CFR
438.240 have been met within the utilization management standards required
by the Medicaid program as described in 42 CFR 456. HLS 13RS-974 ORIGINAL
HCR NO. 75
Page 13 of 13
(d)Documentation verifying that the statewide management organization has
implemented and maintained a formal outcomes assessment process that is
standardized, relatable, and valid in accordance with industry standards.
(17)Any other metric or measure that the department deems appropriate for inclusion in
the report.
Further, directs DHH to make publicly available on its website all of the following items:
(1)All informational bulletins, health plan advisories, and published guidance
concerning the Bayou Health coordinated care network program.
(2)All Medicaid state plan amendments and any correspondence related thereto, which
shall be made publicly available within 24 hours of submission to the Centers for
Medicare and Medicaid Services.
(3)All formal responses to the department by the Centers for Medicare and Medicaid
Services regarding any Medicaid state plan amendment, which shall be made
publicly available within 24 hours of receipt by the department.