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Regular Session, 2013 ENROLLED
SENATE BILL NO. 55
BY SENATORS JOHNS, ALARIO, ALLAIN, APPEL, BROOME, BROWN,
BUFFINGTON, CORTEZ, CROWE, DORSEY-COLOMB, ERDEY,
GUILLORY, HEITMEIER, KOSTELKA, LONG, MARTINY, MILLS,
MORRISH, MURRAY, NEVERS, PERRY, GARY SMI TH,
THOMPSON, WALSWORTH AND WARD AND
REPRESENTATIVES ADAMS, ARMES, BADON, BARROW,
BILLIOT, BROADWATER, BROSSETT, BURRELL, COX,
DANAHAY, DIXON, DOVE, GISCLAIR, GUINN, HARRISON,
HAVARD, HENSGENS, HOFFMANN, HONORE, HOWARD,
HUNTER, KATRINA JACKSON, JAMES, KLECKLEY, LEBAS,
LORUSSO, MONTOUCET, MORENO, JAY MORRIS, NORTON,
ORTEGO, POPE, PRICE, PYLANT, RICHARD, SMITH, THIBAUT
AND WILLMOTT
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
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
thirds of the Medicaid eligible population from a fee-for-service based program18
to a managed care organization based program, it is imperative that there is19
ACT No. 212 SB NO. 55 ENROLLED
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adequate reporting from the Department of Health and Hospitals in order to1
ensure the following outcomes are being achieved:2
(1) Improved care coordination with patient-centered medical homes for3
Medicaid recipients.4
(2) Improved health outcomes and quality of care as measured by metric,5
such as the Healthcare Effectiveness Data and Information Set (HEDIS).6
(3) Increased emphasis on disease prevention and the early diagnosis and7
management of chronic conditions.8
(4) Improved access to Medicaid services.9
(5) Improved accountability with a decrease in fraud, abuse, and10
wasteful spending.11
(6) A more financially sustainable Medicaid program.12
B. It is in the best interest of the citizens of the state that the Legislature13
of Louisiana ensures that the Louisiana Medicaid program as it relates to the14
severely mentally ill recipients is operated in the most efficient and sustainable15
method possible. The transition of the services of the office of behavioral health16
within the Department of Health and Hospitals to a managed care system in17
which a single statewide management organization operates as a single point of18
entry to behavioral health services requires adequate reporting from the19
Department of Health and Hospitals in order to ensure the following outcomes20
are being achieved:21
(1) Implementation of a Coordinated System of Care for youth and their22
families or caregivers that utilizes a family and youth driven practice model,23
provision of wraparound facilitation by child and family teams, family and24
youth supports, and overall management of these services by the statewide25
management organization.26
(2) Improved access, quality, and efficiency of behavioral health services27
for children not eligible for the Coordinated System of Care and for adults with28
severe mental illness and addictive disorders, through management of these29
services by the statewide management organization.30 SB NO. 55 ENROLLED
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(3) Smooth and efficient transition of behavioral health service delivery1
and operations from a regional based approach coordinated through the office2
of behavioral health within the Department of Health and Hospitals to the use3
of human service districts or local government entities.4
(4) Seamless coordination of behavioral health services with the5
comprehensive healthcare system without losing attention to the special skills6
of the behavioral health professionals.7
(5) Advancement of a resiliency, recovery, and consumer-focused system8
of person-centered care.9
(6) Implementation of best practices and evidence-based practices that10
are effective and efficient and are supported by the data collected from11
measuring outcomes, quality, and accountability.12
(7) The efficient and effective use of state general funds in order to13
maximize federal funding of behavioral services provided by the Medicaid14
program.15
§1300.362. Bayou Health; reporting16
Beginning January 1, 2014, and annually thereafter, the Department of17
Health and Hospitals shall submit an annual report concerning the Louisiana18
Medicaid Bayou Health program to the Senate and House committees on health19
and welfare that shall include but not be limited to the following information:20
(1) The name and geographic service area of each coordinated care21
network that has contracted with the Department of Health and Hospitals.22
(2) The total number of healthcare providers in each coordinated care23
network broken down by provider type and specialty and by each geographic24
service area. The initial report shall also include the total number of providers25
enrolled in the fee-for-service Medicaid program broken down by provider type26
and specialty for each geographic service area for the period, either calendar27
or state fiscal year, prior to the date of services initially being provided under28
Bayou Health.29
(3) The total and monthly average of the number of members enrolled30 SB NO. 55 ENROLLED
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in each network broken down by eligibility group.1
(4) The percentage of primary care practices that provide verified2
continuous phone access with the ability to speak with a primary care provider3
clinician within thirty minutes of member contact for each coordinated care4
network.5
(5) The percentage of regular and expedited service authorization6
requests processed within the time frames specified by the contract for each7
coordinated care network. The initial report shall also include comparable8
metrics or regular and expedited service authorizations and time frames when9
processed by the Medicaid fiscal intermediary for the period, either calendar10
or state fiscal year, prior to the date of services initially being provided under11
Bayou Health.12
(6) The percentage of clean claims paid for each provider type within13
thirty calendar days and the average number of days to pay all claims for each14
coordinated care network. The initial report shall also include the percentage15
of clean claims paid within thirty days by the Medicaid fiscal intermediary16
broken down by provider type for the period, either calendar or state fiscal17
year, prior to the date of services initially being provided under Bayou Health.18
(7) The number of claims denied or reduced by each coordinated care19
network for each of the following reasons:20
(a) Lack of documentation to support medical necessity.21
(b) Prior authorization was not on file.22
(c) Member has other insurance that must be billed first.23
(d) Claim was submitted after the filing deadline.24
(e) Service was not covered by the coordinated care network.25
(f) Due to process, procedure, notification, referrals, or any other26
required administrative function of a coordinated care network.27
(g) The initial report shall also include the number of claims denied or28
reduced for each of the reasons set forth in this Paragraph by the Medicaid29
fiscal intermediary for the period, either calendar or state fiscal year, prior to30 SB NO. 55 ENROLLED
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the date of services initially being provided under Bayou Health.1
(8) The number and dollar value of all claims paid to nonnetwork2
providers by claim type categorized by emergency services and nonemergency3
services for each coordinated care network by geographic service area.4
(9) The number of members who chose the coordinated care network5
and the number of members who were auto-enrolled into each coordinated care6
network, broken down by coordinated care network.7
(10) The amount of the total payments and average per member per8
month payment paid to each coordinated care network.9
(11) The Medical Loss Ratio of each coordinated care network and the10
amount of any refund to the state for failure to maintain the required Medical11
Loss Ratio.12
(12) A comparison of health outcomes, which includes but is not limited13
to the following outcomes among each coordinated care network:14
(a) Adult asthma admission rate.15
(b) Congestive heart failure admission rate.16
(c) Uncontrolled diabetes admission rate.17
(d) Adult access to preventative/ambulatory health services.18
(e) Breast cancer screening rate.19
(f) Well child visits.20
(g) Childhood immunization rates.21
(13) The initial report shall also include a comparison of health outcomes22
for each of the aforementioned outcomes in Paragraph (12) of this Subsection23
for the Medicaid fee-for-service program for the period, either calendar or state24
fiscal year, prior to the date of services initially being provided under Bayou25
Health.26
(14) A copy of the member and provider satisfaction survey report for27
each coordinated care network.28
(15) A copy of the annual audited financial statements for each29
coordinated care network.30 SB NO. 55 ENROLLED
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(16) The total amount of savings to the state for each shared savings1
coordinated care network.2
(17) A brief factual narrative of any sanctions levied by the Department3
of Health and Hospitals against a coordinated care network.4
(18) The number of members, broken down by each coordinated care5
network, who file a grievance or appeal and the number of members who6
accessed the state fair hearing process and the total number and percentage of7
grievances or appeals that reversed or otherwise resolved a decision in favor of8
the member.9
(19) The number of members who receive unduplicated Medicaid10
services from each coordinated care network, broken down by provider type,11
specialty, and place of service.12
(20) The number of members who received unduplicated outpatient13
emergency services, broken down by coordinated care network and aggregated14
by the following hospital classifications:15
(a) State.16
(b) Nonstate nonrural.17
(c) Rural.18
(d) Private.19
(21) The number of total inpatient Medicaid days broken down by20
coordinated care network and aggregated by the following hospital21
classifications:22
(a) State.23
(b) Public nonstate nonrural.24
(c) Rural.25
(d) Private.26
(22) The number of claims for emergency services, broken out by27
coordinated care network, whether the claim was paid or denied and by28
provider type. The initial report shall also include comparable metrics for29
claims for emergency services that were processed by the Medicaid fiscal30 SB NO. 55 ENROLLED
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intermediary for the period, either calendar or state fiscal year, prior to the1
date of services initially being provided under Bayou Health.2
(23) The following information concerning pharmacy benefits broken3
down by each coordinated care network and by month:4
(a) Total number of prescription claims.5
(b) Total number of prescription claims subject to prior authorization.6
(c) Total number of prescription claims denied.7
(d) Total number of prescription claims subject to step-therapy or fail8
first protocols.9
(24) Any other metric or measure which the Department of Health and10
Hospitals deems appropriate for inclusion in the report.11
§1300.363. Louisiana Behavioral Health Partnership; reporting12
Beginning January 1, 2014, and annually thereafter, the Department of13
Health and Hospitals shall submit an annual report for the Coordinated System14
of Care and an annual report for the Louisiana Behavioral Health Partnership15
to the Senate and House committees on health and welfare that shall include but16
not be limited to the following information:17
(1) The name and geographic service area of each human service district18
or local government entity through which behavioral health services are being19
provided.20
(2) The total number of healthcare providers in each human service21
district or local government entity, if applicable, or by parish, broken down by22
provider type, applicable credentialing status, and specialty.23
(3) The total number of Medicaid and non-Medicaid members enrolled24
in each human service district or local government entity, if applicable, or by25
parish.26
(4) The total and monthly average number of adult Medicaid enrollees27
receiving services in each human service district or local government entity, if28
applicable, or by parish.29
(5) The total and monthly average number of adult non-Medicaid30 SB NO. 55 ENROLLED
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patients receiving services in each human service district or local government1
entity, if applicable, or by parish.2
(6) The total and monthly average number of children receiving services3
through the Coordinated System of Care by human service district or local4
government entity, if applicable, or by parish.5
(7) The total and monthly average number of children not enrolled in the6
Coordinated System of Care receiving services as Medicaid enrollees in each7
human service district or local government entity, if applicable, or by parish.8
(8) The total and monthly average number of children not enrolled in the9
Coordinated System of Care receiving services as non-Medicaid enrollees in10
each human service district or local government entity, if applicable, or by11
parish.12
(9) The percentage of calls received by the statewide management13
organization that were referred for services in each human service district or14
local government entity, if applicable, or by parish.15
(10) The average length of time for a member to receive confirmation16
and referral for services, using the initial call to the statewide management17
organization as the start date.18
(11) The percentage of all referrals that were considered immediate,19
urgent and routine needs in each human service district or local government20
entity, if applicable, or by parish.21
(12) The percentage of clean claims paid for each provider type within22
thirty calendar days and the average number of days to pay all claims for each23
human service district or local government entity.24
(13) The total number of claims denied or reduced for each of the25
following reasons:26
(a) Lack of documentation.27
(b) Lack of prior authorization.28
(c) Service was not covered.29
(14) The percentage of members who provide consent for the release of30 SB NO. 55 ENROLLED
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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 Hospitals 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
of 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) The total amount of funding remitted by the state pursuant to its21
contract with the statewide management organization during the period22
addressed by the report, including an itemization of this amount which23
encompasses, at minimum, the total costs to the state associated with the24
following cost items:25
(a) Payment of claims to providers.26
(b) Administrative costs of the statewide management organization.27
(c) Profit for the statewide management organization.28
(18) An explanation of all changes during the period addressed by the29
report in any of the following program aspects:30 SB NO. 55 ENROLLED
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(a) Standards or processes for submission of claims by behavioral health1
service providers to the statewide management organization.2
(b) Types of behavioral health services covered through the statewide3
management organization.4
(c) Changes in reimbursement rates for covered services.5
(19) Any other metric or measure that the Department of Health and6
Hospitals deems appropriate for inclusion in the report.7
§1300.364. Department of Health and Hospitals information8
The Department of Health and Hospitals shall make available to the9
public all informational bulletins, health plan advisories, and guidance10
published by the department concerning the Louisiana Medicaid Bayou Health11
program. Such information shall be published and made available to the public12
on the department's website.13
§1300.365. Medicaid state plan amendments14
The Department of Health and Hospitals shall make available to the15
public on the department's website all Medicaid state plan amendments and any16
related correspondence within twenty-four hours of submission to the Centers17
for Medicare and Medicaid Services. All formal responses by the Centers for18
Medicare and Medicaid Services regarding any state plan amendment shall be19
made available to the public on the department's website within twenty-four20
hours of receipt of the correspondence by the department.21
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: