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Regular Session, 2013
SENATE BILL NO. 55
BY SENATOR JOHNS
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
HEALTH/HOSPITALS DEPT. Provides for Medicaid transparency. (8/1/13)
AN ACT1
To enact Part LXXIII of Chapter 5 of Title 40 of the Louisiana Revised Statutes of 1950, to2
be comprised of R.S. 40:1300.361 through 1300.365, 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; to provide for department information; to7
provide for Medicaid state plan amendments; and to provide for related matters.8
Be it enacted by the Legislature of Louisiana:9
Section 1. Part LXXIII of Chapter 5 of Title 40 of the Louisiana Revised Statutes10
of 1950, comprised of R.S. 40:1300.361 through 1300.365, is hereby enacted to read as11
follows:12
PART LXXIII. MEDICAID TRANSPARENCY13
§1300.361. Legislative intent14
A. It is in the best interest of the citizens of the state that the Legislature15
of Louisiana ensure that the Louisiana Medicaid program is operated in the16
most efficient and sustainable method possible. With the transition of over two-17 SB NO. 55
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thirds of the Medicaid eligible population from a fee-for-service based program1
to a managed care organization based program, it is imperative that there is2
adequate reporting from the Department of Health and Hospitals in order to3
ensure the following outcomes are being achieved:4
(1) Improved care coordination with patient-centered medical homes for5
Medicaid recipients.6
(2) Improved health outcomes and quality of care as measured by metric,7
such as the Healthcare Effectiveness Data and Information Set (HEDIS).8
(3) Increased emphasis on disease prevention and the early diagnosis and9
management of chronic conditions.10
(4) Improved access to Medicaid services.11
(5) Improved accountability with a decrease in fraud, abuse, and12
wasteful spending.13
(6) A more financially sustainable Medicaid program.14
B. It is in the best interest of the citizens of the state that the Legislature15
of Louisiana ensures that the Louisiana Medicaid program as it relates to the16
severely mentally ill recipients is operated in the most efficient and sustainable17
method possible. The transition of the services of the office of behavioral health18
within the Department of Health and Hospitals to a managed care system in19
which a single statewide management organization operates as a single point of20
entry to behavioral health services requires adequate reporting from the21
Department of Health and Hospitals in order to ensure the following outcomes22
are being achieved:23
(1) Implementation of a Coordinated System of Care for youth and their24
families or caregivers that utilizes a family and youth driven practice model,25
provision of wraparound facilitation by child and family teams, family and26
youth supports, and overall management of these services by the statewide27
management organization.28
(2) Improved access, quality, and efficiency of behavioral health services29 SB NO. 55
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for children not eligible for the Coordinated System of Care and for adults with1
severe mental illness and addictive disorders, through management of these2
services by the statewide management organization.3
(3) Smooth and efficient transition of behavioral health service delivery4
and operations from a regional based approach coordinated through the office5
of behavioral health within the Department of Health and Hospitals to the use6
of human service districts or local government entities.7
(4) Seamless coordination of behavioral health services with the8
comprehensive healthcare system without losing attention to the special skills9
of the behavioral health professionals.10
(5) Advancement of a resiliency, recovery, and consumer-focused system11
of person-centered care.12
(6) Implementation of best practices and evidence-based practices that13
are effective and efficient and are supported by the data collected from14
measuring outcomes, quality, and accountability.15
(7) The efficient and effective use of state general funds in order to16
maximize federal funding of behavioral services provided by the Medicaid17
program.18
§1300.362. Bayou Health; reporting19
Beginning January 1, 2014, and annually thereafter, the Department of20
Health and Hospitals shall submit an annual report concerning the Louisiana21
Medicaid Bayou Health program to the Senate and House committees on health22
and welfare that shall include but not be limited to the following information:23
(1) The name and geographic service area of each coordinated care24
network which has contracted with the Department of Health and Hospitals.25
(2) The total number of healthcare providers in each coordinated care26
network broken down by provider type and specialty and by each geographic27
service area. The initial report shall also include the total number of providers28
enrolled in the fee-for-service Medicaid program broken down by provider type29 SB NO. 55
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and specialty for each geographic service area for the period, either calendar1
or state fiscal year, prior to the date of services initially being provided under2
Bayou Health.3
(3) The total and monthly average of the number of members enrolled4
in each network broken down by eligibility group.5
(4) The percentage of primary care practices that provide verified6
continuous phone access with the ability to speak with a primary care provider7
clinician within thirty minutes of member contact for each coordinated care8
network.9
(5) The percentage of regular and expedited service authorization10
requests processed within the time frames specified by the contract for each11
coordinated care network. The initial report shall also include comparable12
metrics or regular and expedited service authorizations and time frames when13
processed by the Medicaid fiscal intermediary for the period, either calendar14
or state fiscal year, prior to the date of services initially being provided under15
Bayou Health.16
(6) The percentage of clean claims paid for each provider type within17
thirty calendar days and the average number of days to pay all claims for each18
coordinated care network. The initial report shall also include the percentage19
of clean claims paid within thirty days by the Medicaid fiscal intermediary20
broken down by provider type for the period, either calendar or state fiscal21
year, prior to the date of services initially being provided under Bayou Health.22
(7) The number of claims denied or reduced by each coordinated care23
network for each of the following reasons:24
(a) Lack of documentation to support medical necessity.25
(b) Prior authorization was not on file.26
(c) Member has other insurance that must be billed first.27
(d) Claim was submitted after the filing deadline.28
(e) Service was not covered by the coordinated care network.29 SB NO. 55
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(f) Due to process, procedure, notification, referrals, or any other1
required administrative function of a coordinated care network.2
(g) The initial report shall also include the number of claims denied or3
reduced for each of the reasons set forth in this Paragraph by the Medicaid4
fiscal intermediary for the period, either calendar or state fiscal year, prior to5
the date of services initially being provided under Bayou Health.6
(8) The number and dollar value of all claims paid to nonnetwork7
providers by claim type categorized by emergency services and nonemergency8
services for each coordinated care network by geographic service area.9
(9) The number of members who chose the coordinated care network10
and the number of members who were auto-enrolled into each coordinated care11
network, broken down by coordinated care network.12
(10) The amount of the total payments and average per member per13
month payment paid to each coordinated care network.14
(11) The Medical Loss Ratio of each coordinated care network and the15
amount of any refund to the state for failure to maintain the required Medical16
Loss Ratio.17
(12) A comparison of health outcomes, which includes but is not limited18
to the following outcomes among each coordinated care network:19
(a) Adult asthma admission rate.20
(b) Congestive heart failure admission rate.21
(c) Uncontrolled diabetes admission rate.22
(d) Adult access to preventative/ambulatory health services.23
(e) Breast cancer screening rate.24
(f) Well child visits.25
(g) Childhood immunization rates.26
(13) The initial report shall also include a comparison of health outcomes27
for each of the aforementioned metrics in this Paragraph for the Medicaid28
fee-for-service program for the period, either calendar or state fiscal year, prior29 SB NO. 55
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to the date of services initially being provided under Bayou Health.1
(14) A copy of the member and provider satisfaction survey report for2
each coordinated care network.3
(15) A copy of the annual audited financial statements for each4
coordinated care network.5
(16) The total amount of savings to the state for each shared savings6
coordinated care network.7
(17) A brief factual narrative of any sanctions levied by the Department8
of Health and Hospitals against a coordinated care network.9
(18) The number of members, broken down by each coordinated care10
network, who file a grievance or appeal and the number of members who11
accessed the state fair hearing process and the total number and percentage of12
grievances or appeals which reversed or otherwise resolved a decision in favor13
of the member.14
(19) The number of members who receive unduplicated Medicaid15
services from each coordinated care network, broken down by provider type,16
specialty, and place of service.17
(20) The number of members who received unduplicated outpatient18
emergency services, broken down by coordinated care network and aggregated19
by the following hospital classifications:20
(a) State.21
(b) Nonstate nonrural.22
(c) Rural.23
(d) Private.24
(21) The number of total inpatient Medicaid days broken down by25
coordinated care network and aggregated by the following hospital26
classifications:27
(a) State.28
(b) Public nonstate nonrural.29 SB NO. 55
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(c) Rural.1
(d) Private.2
(22) The number of claims for emergency services, broken out by3
coordinated care network, whether the claim was paid or denied and by4
provider type. The initial report shall also include comparable metrics for5
claims for emergency services that were processed by the Medicaid fiscal6
intermediary for the period, either calendar or state fiscal year, prior to the7
date of services initially being provided under Bayou Health.8
(23) The following information concerning pharmacy benefits broken9
down by each coordinated care network and by month:10
(a) Total number of prescription claims.11
(b) Total number of prescription claims subject to prior authorization.12
(c) Total number of prescription claims denied.13
(d) Total number of prescription claims subject to step-therapy or fail14
first protocols.15
(24) Any other metric or measure which the Department of Health and16
Hospitals deems appropriate for inclusion in the report.17
§1300.363. Louisiana Behavioral Health Partnership; reporting18
Beginning January 1, 2014, and annually thereafter, the Department of19
Health and Hospitals shall submit an annual report for the Coordinated System20
of Care and an annual report for the Louisiana Behavioral Health Partnership21
to the Senate and House committees on health and welfare that shall include but22
not be limited to the following information:23
(1) The name and geographic service area of each human service district24
or local government entity through which behavioral health services are being25
provided.26
(2) The total number of healthcare providers in each human service27
district or local government entity, if applicable or by parish, broken down by28
provider type, applicable credentialing status, and specialty.29 SB NO. 55
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(3) The total number of Medicaid and non-Medicaid members enrolled1
in each human service district or local government entity, if applicable, or by2
parish.3
(4) The total and monthly average number of adult Medicaid enrollees4
receiving services in each human service district or local government entity, if5
applicable, or by parish.6
(5) The total and monthly average number of adult non-Medicaid7
patients receiving services in each human service district or local government8
entity, if applicable, or by parish.9
(6) The total and monthly average number of children receiving services10
through the Coordinated System of Care by human service region or local11
government entity, if applicable, or by parish.12
(7) The total and monthly average number of children not enrolled in the13
Coordinated System of Care receiving services as Medicaid enrollees in each14
human service district or local government entity, if applicable, or by parish.15
(8) The total and monthly average number of children not enrolled in the16
Coordinated System of Care receiving services as non-Medicaid enrollees in17
each human service district or local government entity, if applicable, or by18
parish.19
(9) The percentage of calls received by the statewide management20
organization that were referred for services in each human service district or21
local government entity, if applicable, or by parish.22
(10) The average length of time for a member to receive confirmation23
and referral for services, using the initial call to the statewide management24
organization as the start date.25
(11) The percentage of all referrals that were considered immediate,26
urgent and routine needs in each human service district or local government27
entity, if applicable, or by parish.28
(12) The percentage of clean claims paid for each provider type within29 SB NO. 55
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thirty calendar days and average number of days to pay all claims for each1
human service district or local government entity.2
(13) The total number of claims denied or reduced for each of the3
following reasons:4
(a) Lack of documentation.5
(b) Lack of prior authorization.6
(c) Service was not covered.7
(14) The percentage of members who provide consent for release of8
information to coordinate care with the member's primary care physician and9
other healthcare providers.10
(15) The number of outpatient members who received services in11
hospital-based emergency rooms due to a behavioral health diagnosis.12
(16) A copy of the statewide management organization's report to the13
Department of Health and Hospitals on quality management, which shall14
include:15
(a) The number of qualified quality management personnel employed by16
the statewide management organization to review performance standards,17
measure treatment outcomes and assure timely access to care.18
(b) The mechanism utilized by the statewide management organization19
for generating input and participation of members, families/caretakers, and20
other stakeholders in the monitoring of service quality and determining21
strategies to improve outcomes.22
(c) Documented demonstration of meeting all the federal requirements23
for 42 CFR 438.240 and with the utilization management required by the24
Medicaid program as described in 42 CFR 456.25
(d) Documentation that the statewide management organization has26
implemented and maintained a formal outcomes assessment process that is27
standardized, relatable and valid in accordance with industry standards.28
(17) Any other metric or measure that the Department of Health and29 SB NO. 55
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Hospitals deems appropriate for inclusion in the report.1
§1300.364. Department of Health and Hospitals information2
The Department of Health and Hospitals shall make publicly available3
all informational bulletins, health plan advisories, and guidance published by4
the department concerning the Louisiana Bayou Health Medicaid program.5
Such information shall be published and available to the public on the6
department's website.7
§1300.365. Medicaid state plan amendments8
The Department of Health and Hospitals shall make available to the9
public on the department's website all Medicaid state plan amendments and any10
related correspondence within twenty-four hours of submission to the Centers11
for Medicare and Medicaid Services. All formal responses by the Centers for12
Medicare and Medicaid Services regarding any state plan amendment shall be13
made available to the public on the department's website within twenty-four14
hours of receipt of the correspondence by the department.15
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Christopher D. Adams.
DIGEST
Proposed law requires that beginning January 1, 2014, 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.
Proposed law requires the report to include but not be limited to the following items
concerning the Louisiana Medicaid Bayou Health program:
(1)The name and geographic service area of each network.
(2)The total number of healthcare providers in each network broken down by provider
type and specialty and by each geographic service area.
(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.
(5)The percentage of regular and expedited service authorization requests processed
within the time frames specified by the contract for network. SB NO. 55
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(6)The percentage of clean claims paid for each provider type within 30 calendar days
and the average number of days to pay all claims for each network.
(7)The number of claims denied or reduced by each network for reasons enumerated in
proposed law.
(8)The number and dollar value of all claims paid nonnetwork providers by claim type
categorized by emergency services and nonemergency services.
(9)The number of members who chose the network and the number of members who
were auto-enrolled into each network.
(10)The amount of the total payments and average per member per month payment paid.
(11)The Medical Loss Ratio of each network and the amount of any refund to the state
for failure to maintain required ratios.
(12)A comparison of health outcomes, which includes but is not limited to the following
outcomes enumerated in proposed law.
(13)A copy of the member and provider satisfaction survey report for each network.
(14)A copy of the annual audited financial statements for each coordinated care network.
(15)The total amount of savings to the state for each shared savings coordinated care
network.
(16)A brief factual narrative of any sanctions levied by DHH against a network.
(17)The number of members, broken down by 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 in favor of the member.
(18)The number of members who receive unduplicated Medicaid services from each
network broken down by provider type, specialty, and place of service.
(19)The number of members who received unduplicated outpatient emergency services
broken down by network and aggregated by certain enumerated hospital
classifications.
(20)The number of total inpatient Medicaid days broken down by network and
aggregated by certain enumerated hospital classifications.
(21)The number of claims for emergency services, broken out by network, whether the
claim was paid or denied and by provider type.
(22)The number of claims for pharmacy benefits, broken out by network and by the
month.
(23)Any other metric or measure which DHH deems appropriate for inclusion in the
report.
Proposed law requires the report to include but not be limited to the following items
concerning the Louisiana Behavioral Health Partnership and Coordinated System of Care
programs:
(1)The name and geographic service area of each human service district or local SB NO. 55
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government entity through which behavioral health services are being provided.
(2)The total number of healthcare providers in each human service 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
service 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 service district or local government entity, if applicable, or by parish.
(5)The total and monthly average number of adult non-Medicaid patients receiving
services in each human service 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 service 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 service
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 service
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 service 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
needs in each human service 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 service district or local
government entity.
(13)The total number of claims denied or reduced broken down by specified reasons.
(14)The percentage of members who provide consent for release of information to
coordinate care with the member's primary care physician and other healthcare
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 of
Health and Hospital on quality management, which shall include specified data.
(17)Any other metric or measure that the Department of Health and Hospitals deems
appropriate for inclusion in the report. SB NO. 55
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Proposed law provides the Department of Health and Hospitals shall make publicly available
all informational bulletins, health plan advisories, and guidance published by the department
concerning the Louisiana Bayou Health Medicaid program. Proposed law further provides
such information shall be published and available to the public on the department's website.
Proposed law provides the Department of Health and Hospitals shall make available to the
public on the department's website all Medicaid state plan amendments and any related
correspondence within 24 hours of submission to the Centers for Medicare and Medicaid
Services. Proposed law further provides all formal responses by the Centers for Medicare
and Medicaid Services regarding any state plan amendment shall be made available to the
public on the department's website within 24 hours of receipt of the correspondence by the
department.
Effective August 1, 2013.
(Adds R.S. 40:1300.361-1300.365)