Provider FAQ: Health Plan Management
Each Health Plan is contractually required to provide members with health management for three specific chronic health conditions (diabetes, asthma and congestive heart failure) as well as care management for pregnant women to improve birth outcomes. In addition, some of the Plans are also offering programs for hypertension, COPD, sickle cell, or HIV. Prepaid Plans can offer Expanded Benefits, which are services beyond what is covered under the Louisiana Medicaid State Plan. Examples are hypoallergenic bedding for members with asthma, and vision screenings and dental cleanings for adults over the age of 21.
All five Plans can offer members incentives for healthy behaviors. Examples of actual programs are a $20 gift card for getting a health assessment within 90 days of enrollment, up to $65 in gift cards for keeping prenatal visits and post partum visits.
More information can be found on the Health Plan Comparison Chart, each Plan's brochure, and directly from the Plan.
Medicaid dental benefits statewide are managed by DentaQuest and MCNA Dental. Most but not all Medicaid and LaCHIP recipients will be enrolled in a Dental Plan. Recipients that are enrolled in a Dental Plan do not have the option to continue to receive dental services through legacy Medicaid, while some recipients are excluded from a Dental Plan. Providers must be credentialed with DentaQuest and/or MCNA to administer dental services to eligible Medicaid recipients.
Health Plans can ensure better coordination of member services, and will ease the burden on providers by assuming responsibility for referrals, care management services and disease management services. Health Plans have more flexibility to restructure resources. The Plans are better able to support providers by assisting with issues such as transportation, referrals and patient compliance that can be problematic in the current program. The networks better support providers in dealing with problematic patients so doctors do not have to expend the time and resources to do so.
As part of the contract, the Health Plans is mandated to have strong, clearly outlined grievances-and-appeals processes. LDH is the final determiner of medical necessity, and any systemic denial of medically necessary services through a Health Plan would be treated as fraud.
School Based Health Clinics (SBHCs) can contract with the Health Plans to provide services according to the terms of their contract. However, only those SBHCs that are open 12 months a year can serve as a PCP. If the SBHC does not have a contract with a Health Plan or arrangements are not made by the Health Plan to pay the SBHC out of network, SBHCs will not receive reimbursement from Medicaid or the Health Plan in which the child is enrolled. LDH's contracts with the Health Plans do not include policies relative to referrals needed by SBHCs for under age 12 and not needed for age 12 and over. Coordination of the child's care, however, is a contract requirement.
As improving quality is a key objective, LDH is requiring that Health Plans work with their network PCPs to attain formal recognition as a primary care medical home (PCMH), with the percentage increasing each year. The alternative to urgent care clinics in LDH's experience is often the hospital emergency room. To the extent that a Health Plan utilizes urgent care clinics, LDH's expectation would be that the care is coordinated with the PCP (e.g., payment to the urgent care facility contingent on their providing the clinical records of the visit to the PCP and or the Health Plan).
If these Health Plans have this allowance, apparently they have made a business decision-based on their considerable Medicaid managed care experience in other states to allow open access to specialists and not require prior authorization.