2015 Regular Session ENROLLED
SENATE BILL NO. 109
BY SENATOR JOHNS
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
1 AN ACT
2 To amend and reenact R.S. 40:1300.361(A)(2), 1300.362, 1300.363, and 1300.364, relative
3 to Medicaid reporting; to provide for reporting measures regarding the Medicaid
4 managed care program; to provide for reporting measures regarding the Louisiana
5 Behavioral Health Partnership program; to provide for an integration report of the
6 Louisiana Behavioral Health Partnership program; to provide for information to be
7 reported by the Department of Health and Hospitals; to provide for an effective date;
8 and to provide for related matters.
9 Be it enacted by the Legislature of Louisiana:
10 Section 1. R.S. 40:1300.361(A)(2), 1300.362, 1300.363, and 1300.364 are hereby
11 amended and reenacted to read as follows:
12 §1300.361. Legislative intent
13 A. It is in the best interest of the citizens of the state that the Legislature of
14 Louisiana ensure that the Louisiana Medicaid program is operated in the most
15 efficient and sustainable method possible. With the transition of over two-thirds of
16 the Medicaid eligible population from a fee-for-service based program to a managed
17 care organization based program, it is imperative that there is adequate reporting
18 from the Department of Health and Hospitals in order to ensure the following
19 outcomes are being achieved:
20 * * *
21 (2) Improved health outcomes and quality of care as measured by metric
22 metrics, such as the Healthcare Effectiveness Data and Information Set (HEDIS).
23 * * *
24 §1300.362. Bayou Health; reporting
ACT No. 158
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1 Beginning January 1, 2014, and annually thereafter, the A. The Department
2 of Health and Hospitals shall submit an annual report concerning the Louisiana
3 Medicaid Bayou Health program and, if not included within the Bayou Health
4 program, any managed care program providing dental benefits to Medicaid
5 enrollees to the Senate and House committees on health and welfare that shall
6 include but not be limited to the following information:. The report shall be
7 submitted by June thirtieth every year, and the applicable reporting period
8 shall be for the previous state fiscal year except for those measures that require
9 reporting of health outcomes which shall be reported for the calendar year
10 prior to the current state fiscal year. The report shall include:
11 (1) Except when inapplicable due to the types of healthcare benefits
12 administered by the particular managed care organization, the following
13 information related to the managed care organizations contracted with the state
14 to provide Medicaid-covered healthcare services to Medicaid enrollees:
15 (1)(a) The name and geographic service area of each coordinated care
16 network managed care organization that has contracted with the Department of
17 Health and Hospitals to provide healthcare services to Medicaid enrollees.
18 (b) The total number of employees employed by each managed care
19 organization which is based in Louisiana and the average salary paid to those
20 employees.
21 (c) The amount of the total payments and average per member per
22 month payment paid by the state to each managed care organization delineated
23 monthly.
24 (2)The total number of healthcare providers in each coordinated care network
25 broken down by provider type and specialty and by each geographic service area.
26 The initial report shall also include the total number of providers enrolled in the
27 fee-for-service Medicaid program broken down by provider type and specialty for
28 each geographic service area for the period, either calendar or state fiscal year, prior
29 to the date of services initially being provided under Bayou Health.
30 (d) The total number of healthcare providers contracted to provide
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1 healthcare services for each managed care organization delineated by provider
2 type, provider taxonomy code, and parish.
3 (e) The total number of providers contracted to provide healthcare
4 services for each managed care organization that provides primary care
5 services and submitted at least one claim for payment for services rendered to
6 an individual enrolled in the health plan delineated by provider type, provider
7 taxonomy code, and parish.
8 (f) The total number of providers contracted to provide healthcare
9 services for each managed care organization that has a closed panel for any
10 portion of the reporting period delineated by provider type, provider taxonomy
11 code, and parish.
12 (g) The medical loss ratio of each managed care organization and the
13 amount of any refund to the state for failure to maintain the required medical
14 loss ratio.
15 (h) A comparison of health outcomes, which includes but is not limited
16 to the following, among each managed care organization:
17 (i) Adult asthma admission rate.
18 (ii) Congestive heart failure admission rate.
19 (iii) Uncontrolled diabetes admission rate.
20 (iv) Adult access to preventative/ambulatory health services.
21 (v) Breast cancer screening rate.
22 (vi) Well child visits.
23 (vii) Childhood immunization rates.
24 (i) A copy of the member and provider satisfaction survey report for
25 each managed care organization.
26 (j) A copy of the annual audited financial statements for each managed
27 care organization. The financial statements shall be those of the managed care
28 organization operating in Louisiana and shall not be those financial statements
29 of any parent or umbrella organization.
30 (k) A brief factual narrative of any sanctions levied by the Department
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1 of Health and Hospitals against a managed care organization.
2 (l) For managed care organizations that administer dental benefits, a
3 comparison of oral health outcomes that includes but is not limited to the
4 percentage of eligible patients that saw a dentist in that fiscal year as well as the
5 following rates of procedures performed on those who saw a dentist:
6 (i) Adult oral prophylaxis.
7 (ii) Child oral prophylaxis.
8 (iii) Dental sealants.
9 (iv) Fluoride varnish.
10 (v) Amalgam fillings.
11 (vi) Composite fillings.
12 (vii) Stainless steel crowns.
13 (viii) Extractions of primary teeth.
14 (ix) Extractions of permanent teeth.
15 (x) Pulpotomies performed on primary teeth.
16 (xi) Root canals performed on permanent teeth.
17 (2) The following information regarding Medicaid enrollees receiving
18 healthcare services from a managed care organization:
19 (3)The total and monthly average of the number of members enrolled in each
20 network broken down by eligibility group.
21 (a) The total number of unduplicated enrollees enrolled during the
22 reporting period, and the monthly average of the number of members enrolled
23 in each managed care organization delineated by eligibility category of the
24 enrollees.
25 (4) The percentage of primary care practices that provide verified continuous
26 phone access with the ability to speak with a primary care provider clinician within
27 thirty minutes of member contact for each coordinated care network.
28 (5) The percentage of regular and expedited service authorization requests
29 processed within the time frames specified by the contract for each coordinated care
30 network. The initial report shall also include comparable metrics or regular and
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1 expedited service authorizations and time frames when processed by the Medicaid
2 fiscal intermediary for the period, either calendar or state fiscal year, prior to the date
3 of services initially being provided under Bayou Health.
4 (6) The percentage of clean claims paid for each provider type within thirty
5 calendar days and the average number of days to pay all claims for each coordinated
6 care network. The initial report shall also include the percentage of clean claims paid
7 within thirty days by the Medicaid fiscal intermediary broken down by provider type
8 for the period, either calendar or state fiscal year, prior to the date of services initially
9 being provided under Bayou Health.
10 (7) The number of claims denied or reduced by each coordinated care
11 network for each of the following reasons:
12 (a) Lack of documentation to support medical necessity.
13 (b) Prior authorization was not on file.
14 (c) Member has other insurance that must be billed first.
15 (d) Claim was submitted after the filing deadline.
16 (e) Service was not covered by the coordinated care network.
17 (f) Due to process, procedure, notification, referrals, or any other required
18 administrative function of a coordinated care network.
19 (g) The initial report shall also include the number of claims denied or
20 reduced for each of the reasons set forth in this Paragraph by the Medicaid fiscal
21 intermediary for the period, either calendar or state fiscal year, prior to the date of
22 services initially being provided under Bayou Health.
23 (8) The number and dollar value of all claims paid to nonnetwork providers
24 by claim type categorized by emergency services and nonemergency services for
25 each coordinated care network by geographic service area.
26 (9) The number of members who chose the coordinated care network and the
27 number of members who were auto-enrolled into each coordinated care network,
28 broken down by coordinated care network.
29 (10) The amount of the total payments and average per member per month
30 payment paid to each coordinated care network.
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1 (11) The Medical Loss Ratio of each coordinated care network and the
2 amount of any refund to the state for failure to maintain the required Medical Loss
3 Ratio.
4 (12) A comparison of health outcomes, which includes but is not limited to
5 the following outcomes among each coordinated care network:
6 (a) Adult asthma admission rate.
7 (b) Congestive heart failure admission rate.
8 (c) Uncontrolled diabetes admission rate.
9 (d) Adult access to preventative/ambulatory health services.
10 (e) Breast cancer screening rate.
11 (f) Well child visits.
12 (g) Childhood immunization rates.
13 (13) The initial report shall also include a comparison of health outcomes for
14 each of the aforementioned outcomes in Paragraph (12) of this Subsection for the
15 Medicaid fee-for-service program for the period, either calendar or state fiscal year,
16 prior to the date of services initially being provided under Bayou Health.
17 (14) A copy of the member and provider satisfaction survey report for each
18 coordinated care network.
19 (15) A copy of the annual audited financial statements for each coordinated
20 care network.
21 (16) The total amount of savings to the state for each shared savings
22 coordinated care network.
23 (17) A brief factual narrative of any sanctions levied by the Department of
24 Health and Hospitals against a coordinated care network.
25 (18) The number of members, broken down by each coordinated care
26 network, who file a grievance or appeal and the number of members who accessed
27 the state fair hearing process and the total number and percentage of grievances or
28 appeals that reversed or otherwise resolved a decision in favor of the member.
29 (19) The number of members who receive unduplicated Medicaid services
30 from each coordinated care network, broken down by provider type, specialty, and
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1 place of service.
2 (20) The number of members who received unduplicated outpatient
3 emergency services, broken down by coordinated care network and aggregated by
4 the following hospital classifications:
5 (a) State.
6 (b) Nonstate nonrural.
7 (c) Rural.
8 (d) Private.
9 (21) The number of total inpatient Medicaid days broken down by
10 coordinated care network and aggregated by the following hospital classifications:
11 (a) State.
12 (b) Public nonstate nonrural.
13 (c) Rural.
14 (d) Private.
15 (22) The number of claims for emergency services, broken out by
16 coordinated care network, whether the claim was paid or denied and by provider
17 type. The initial report shall also include comparable metrics for claims for
18 emergency services that were processed by the Medicaid fiscal intermediary for the
19 period, either calendar or state fiscal year, prior to the date of services initially being
20 provided under Bayou Health.
21 (23) The following information concerning pharmacy benefits broken down
22 by each coordinated care network and by month:
23 (a) Total number of prescription claims.
24 (b) Total number of prescription claims subject to prior authorization.
25 (c) Total number of prescription claims denied.
26 (d) Total number of prescription claims subject to step-therapy or fail first
27 protocols.
28 (24) Any other metric or measure which the Department of Health and
29 Hospitals deems appropriate for inclusion in the report.
30 (b) The number of members who proactively chose the managed care
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1 organization, and the number of members who were auto-enrolled into each
2 managed care organization, delineated by managed care organization.
3 (c) The total number of enrollees who received unduplicated Medicaid
4 services from each managed care network, broken down by provider type,
5 provider taxonomy code, and place of service.
6 (d) The total number and percentage of enrollees of each managed care
7 organization who had at least one visit with their primary care provider during
8 the reporting period.
9 (e) The following information concerning hospital services provided to
10 Medicaid enrollees:
11 (i) The number of members who received unduplicated outpatient
12 emergency services, delineated by managed care organization.
13 (ii) The number of total inpatient Medicaid days delineated by managed
14 care organization.
15 (iii) The total number of unduplicated members who received outpatient
16 emergency services and had at least one visit to a primary care provider within
17 the past year of receiving the outpatient emergency services.
18 (f) The number of members, delineated by each managed care
19 organization, who filed an appeal, the number of members who accessed the
20 state fair hearing process, and the total number and percentage of appeals that
21 reversed or otherwise resolved a decision in favor of the member. For purposes
22 of this Subparagraph, "appeal" means a request for review of an action.
23 (3) The following information related to healthcare services provided by
24 healthcare providers to Medicaid enrollees enrolled in each of the managed care
25 organizations:
26 (a) The total number of claims submitted by healthcare providers to each
27 managed care organization. The total number shall also be delineated by claims
28 for emergency services and claims for nonemergency services.
29 (b) The total number of claims submitted by healthcare providers to each
30 managed care organization which were adjudicated by the respective managed
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1 care organization and payment for services was denied. This item of the report
2 shall include a delineation between emergency and nonemergency claim denials.
3 Additionally, this item of the report shall include the number of denied claims
4 for each managed care organization delineated by the standard set of Claim
5 Adjustment Reason Codes published by the Washington Publishing Company.
6 (c) The total number of claims submitted by healthcare providers to each
7 managed care organization which meets the definition of a clean claim as it is
8 defined in the contract executed between the state and the managed care
9 organization, and the percentage of those clean claims that each of the managed
10 care plans has paid for each provider type within fifteen calendar days and
11 within thirty calendar days. In addition, the report shall include the average
12 number of days for each managed care organization to pay all claims of
13 healthcare providers delineated by provider type.
14 (d) The total number and percentage of regular and expedited service
15 authorization requests processed within the time frames specified by the
16 contract for each managed care organization. In addition, the report shall
17 contain the total number of regular and expedited service authorization
18 requests which resulted in a denial for services for each managed care
19 organization.
20 (e) The total number and dollar value of all claims paid to
21 out-of-network providers by claim type categorized by emergency services and
22 nonemergency services for each managed care organization by parish.
23 (f) The following information concerning pharmacy benefits delineated
24 by each managed care organization and by month:
25 (i) Total number of prescription claims.
26 (ii) Total number of prescription claims subject to prior authorization.
27 (iii) Total number of prescription claims denied.
28 (iv) Total number of prescription claims subject to step therapy or fail
29 first protocols.
30 (g) The report shall include the following information concerning
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1 Medicaid drug rebates and manufacturer discounts delineated by each managed
2 care organization and the prescription benefit manager contracted or owned by
3 the managed care organization and by month:
4 (i) Total dollar amount of the Medicaid drug rebates and manufacturer
5 discounts collected and used.
6 (ii) Total dollar amount of Medicaid drug rebates and manufacturer
7 discounts collected and remitted to the Department of Health and Hospitals.
8 (4) For managed care organizations that administer dental benefits, the
9 following information concerning prior authorization requests, delineated by
10 type of procedure:
11 (a) The number of prior authorization requests.
12 (b) The average and range of times for responding to prior
13 authorization requests.
14 (c) The number of prior authorization requests denied, delineated by the
15 reasons for denial.
16 (d) The number of claims denied after prior authorization was
17 approved, delineated by the reasons for denial.
18 (5) Any other metric or measure which the Department of Health and
19 Hospitals deems appropriate for inclusion in the report.
20 B. To the greatest extent possible, the Department of Health and
21 Hospitals shall include in the report at least three years of historical data for
22 each of the measures set forth in Subsection A of this Section.
23 §1300.363. Louisiana Behavioral Health Partnership; reporting
24 Beginning January 1, 2014, and annually thereafter, the A. The Department
25 of Health and Hospitals shall submit an annual report for the Coordinated System of
26 Care and an annual report for the Louisiana Behavioral Health Partnership to the
27 Senate and House committees on health and welfare that. The report shall be
28 submitted by June thirtieth of each year, and the applicable reporting period
29 shall be for the previous state fiscal year. The report shall include but not be
30 limited to the following information:
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1 (1) The name and geographic service area of each human service district or
2 local government entity through which behavioral health services are being provided.
3 (2) The total number of healthcare providers in each human service district
4 or local government entity, if applicable, or by parish, broken down by provider type,
5 applicable credentialing contracting status, and specialty.
6 (3)(2) The total number of Medicaid and non-Medicaid members enrolled in
7 each human service district or local government entity, if applicable, or by parish.
8 (4)(3) The total and monthly average number of adult Medicaid enrollees
9 receiving services in each human service district or local government entity, if
10 applicable, or by parish.
11 (5)(4) The total and monthly average number of adult non-Medicaid patients
12 adults not enrolled in the Medicaid program receiving services in each human
13 service district or local government entity, if applicable, or by parish.
14 (6)(5) The total and monthly average number of children receiving services
15 through the Coordinated System of Care by human service district or local
16 government entity, if applicable, or by parish.
17 (7)(6) The total and monthly average number of children not enrolled in
18 receiving Louisiana Behavioral Health Partnership services outside the
19 Coordinated System of Care receiving services as Medicaid enrollees in each human
20 service district or local government entity, if applicable, or by parish.
21 (8)(7) The total and monthly average number of children not enrolled in the
22 Medicaid program receiving Louisiana Behavioral Health Partnership services
23 outside the Coordinated System of Care receiving services as non-Medicaid
24 enrollees in each human service district or local government entity, if applicable, or
25 by parish.
26 (9) The percentage of calls received by the statewide management
27 organization that were referred for services in each human service district or local
28 government entity, if applicable, or by parish.
29 (10) The average length of time for a member to receive confirmation and
30 referral for services, using the initial call to the statewide management organization
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1 as the start date.
2 (11)(8) The percentage of all referrals that were considered immediate, urgent
3 and routine needs in each human service district or local government entity, if
4 applicable, or and the average length of time to authorize for services by parish.
5 (12)(9) The percentage of clean claims paid for each provider type within
6 thirty calendar days and the average number of days to pay all claims for each human
7 service district or local government entity.
8 (13)(10) The five most common reasons for denial of claims and the total
9 number of claims denied or reduced for each of the following reasons: according to
10 the cause presented.
11 (a) Lack of documentation.
12 (b) Lack of prior authorization.
13 (c) Service was not covered.
14 (14)(11) The percentage of members asked to and who provide consent for
15 the release of information to coordinate care with the member's primary care
16 physician and other healthcare providers.
17 (15)(12) The number of outpatient members who received services through
18 the Louisiana Behavioral Health Partnership in hospital-based emergency rooms
19 due to a behavioral health diagnosis.
20 (16)(13) A copy of the statewide management organization's report to the
21 Department of Health and Hospitals on quality management, which shall include:
22 (a) The number of qualified quality management personnel employed by the
23 statewide management organization to review performance standards, measure
24 treatment outcomes, and assure timely access to care.
25 (b) The mechanism utilized by the statewide management organization for
26 generating input and participation of members, families/caretakers, and other
27 stakeholders in the monitoring of service quality and determining strategies to
28 improve outcomes.
29 (c) Documented demonstration of meeting all the federal requirements of 42
30 CFR 438.240 and with the utilization management required by the Medicaid program
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1 as described in 42 CFR 456.
2 (d) Documentation that the statewide management organization has
3 implemented and maintained a formal outcomes assessment process that is
4 standardized, relatable, and valid in accordance with industry standards.
5 (17)(14) The total amount of funding remitted by the state pursuant to its
6 contract with the statewide management organization during the period addressed by
7 the report, including an itemization of this amount which encompasses, at minimum,
8 the total costs to the state associated with the following cost items:
9 (a) Payment of claims to providers.
10 (b) Administrative costs of the statewide management organization.
11 (c) Profit for the statewide management organization.
12 (18)(15) An explanation of all changes during the period addressed by the
13 report in any of the following program aspects:
14 (a) Standards or processes for submission of claims by behavioral health
15 service providers to the statewide management organization.
16 (b) Types of behavioral health services covered through the statewide
17 management organization.
18 (c) Changes in reimbursement rates for covered services.
19 (19)(16) Any other metric or measure that the Department of Health and
20 Hospitals deems appropriate for inclusion in the report.
21 B. Upon the integration of behavioral health into the Louisiana Medicaid
22 Bayou Health program, the final report produced pursuant to this Section for
23 the period starting July 1, 2015, shall be issued by June 30, 2016, or six months
24 following the integration date, whichever occurs later, and subsequent
25 behavioral health reporting shall be included in the report produced pursuant
26 to R.S. 40:1300.362.
27 §1300.364. Department of Health and Hospitals information
28 A. The Department of Health and Hospitals shall make available to the public
29 all informational bulletins, health plan advisories, and guidance published by the
30 department concerning the Louisiana Medicaid Bayou Health program. Such
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1 information shall be published and made available to the public on the department's
2 website.
3 B. Prior to August 1, 2015, every managed care organization contracted
4 with the state to provide Medicaid-covered healthcare services to Medicaid
5 enrollees shall report to the department the uniform resource locator of a
6 webpage which contains a publicly accessible copy of all practice guidelines
7 utilized by each managed care organization which are required to be made
8 available to healthcare providers pursuant to 42 CFR 438.236(c). The
9 department shall place and maintain publicly accessible web links to each of
10 these respective webpages upon its website.
11 Section 2. This Act shall become effective upon signature by the governor or, if not
12 signed by the governor, upon expiration of the time for bills to become law without signature
13 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
14 vetoed by the governor and subsequently approved by the legislature, this Act shall become
15 effective on the day following such approval.
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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