ENROLLED
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Regular Session, 2013
HOUSE CONCURRENT RESOLUTI ON NO. 75
BY REPRESENTATIVE BARROW
A CONCURRENT RESOLUTI ON
To authorize and direct the Department of Health and Hospitals to ensure transparency in
its Medicaid managed care programs through annual reports to the legislature on the
coordinated care network initiative known as "Bayou Health", the Louisiana
Behavioral Health Partnership, and the Coordinated System of Care.
WHEREAS, it is in the best interest of all citizens of this state that the Louisiana
Medicaid program is operated in the most efficient and sustainable manner possible; and
WHEREAS, with the transition of over two-thirds of Louisiana's Medicaid enrollees
since 2011 from a state-operated fee-for-service program to a program known as "Bayou
Health" which relies on managed care coordinated by private insurance companies, it is
imperative that the Department of Health and Hospitals, hereafter referred to as
"department", report adequate information to the Legislature of Louisiana on financing and
outcomes of such coordinated care; and
WHEREAS, as a policymaking body, the legislature requires reporting of this type
in order to ensure that the department is achieving the following priority outcomes:
(1) Improved care coordination with patient-centered medical homes for Medicaid
recipients.
(2) Improved health outcomes and quality of care as measured by a valid metric,
such as the Healthcare Effectiveness Data and Information Set (HEDIS).
(3) Increased emphasis on disease prevention and early diagnosis and management
of chronic conditions.
(4) Improved access to Medicaid services.
(5) Improved accountability with a decrease in fraud, abuse, and wasteful spending.
(6) A more financially sustainable Medicaid program; and ENROLLEDHCR NO. 75
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WHEREAS, it is in the best interest of all citizens of this state that services of the
Louisiana Medicaid program for enrollees with mental health and behavioral health needs
are delivered in the most efficient and sustainable manner possible; and
WHEREAS, with the transition of services of the department's office of behavioral
health to a system in which a private contractor operates as a statewide management
organization providing a single point-of-entry for behavioral health services, it is imperative
that the department report adequate information to the Legislature of Louisiana on financing
and outcomes of this managed care system; and
WHEREAS, as a policymaking body, the legislature requires reporting of this type
in order to ensure that the department is achieving the following priority outcomes:
(1) Implementation of a Coordinated System of Care for youth and their families or
caregivers that utilizes a family- and youth-driven practice model, provision of wraparound
facilitation by child and family teams, family and youth supports, and overall management
of these services by the statewide management organization.
(2) Improved access, quality, and efficiency of behavioral health services for
children not eligible for the Coordinated System of Care, and for adults with severe mental
illness and addictive disorders, through management of these services by the statewide
management organization.
(3) Smooth and efficient transition of behavioral health service delivery and
operations from a regional based approach coordinated through the office of behavioral
health within the Department of Health and Hospitals to the use of human service districts
or local government entities.
(4) Seamless coordination of behavioral health services with the comprehensive
health care system without losing attention to the special skills of the behavioral health
professionals.
(5) Advancement of a resiliency-, recovery-, and consumer-focused system of
person-centered care.
(6) Implementation of evidence-based best practices that are effective, efficient, and
supported by data collected from measuring outcomes, quality, and accountability.
(7) The efficient and effective use of state general funds in order to maximize federal
funding of behavioral services provided by the Medicaid program. ENROLLEDHCR NO. 75
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THEREFORE, BE IT RESOLVED that the Legislature of Louisiana does hereby
authorize and direct the department, beginning January 1, 2014, and annually thereafter, to
submit a report concerning the Medicaid coordinated care network initiative known as
"Bayou Health" to the House and Senate 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 thirty 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 thirty 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. ENROLLEDHCR NO. 75
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(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.
(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 in this Paragraph 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 non-network 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 among each coordinated care network which
shall include but shall not be limited to the following:
(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. ENROLLEDHCR NO. 75
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(g) Childhood immunization rates.
(13) 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.
(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. ENROLLEDHCR NO. 75
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(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.
BE IT FURTHER RESOLVED that the Legislature of Louisiana does hereby
authorize and direct the department, beginning January 1, 2014, and annually thereafter, to
submit reports concerning the Coordinated System of Care and the Louisiana Behavioral
Health Partnership to the House and Senate committees on health and welfare that shall
include but not be 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. ENROLLEDHCR NO. 75
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(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 thirty
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. ENROLLEDHCR NO. 75
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(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.
(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.
BE IT FURTHER RESOLVED that the Legislature of Louisiana does hereby
authorize and direct the department to make publicly available on its Internet 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 twenty-four 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 twenty-four hours of receipt by the department. ENROLLEDHCR NO. 75
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BE IT FURTHER RESOLVED that a suitable copy of this Resolution be transmitted
to the secretary of the Department of Health and Hospitals.
SPEAKER OF THE HOUSE OF REPRESENTATI VES
PRESIDENT OF THE SENATE