Provider FAQ: Recipient Outreach

What happens when a patient comes into our office and we find he is not linked to our Health Plan?

Unless it is an emergency, the patient should be referred to the PCP the Health Plan has assigned him/her, if the patient knows who the PCP is. If not, the patient can be referred to the Health Plan’s Member Services toll-free number. The name of the patient's Health Plan can be determined by the eligibility verification system, which will be maintained for providers by Gainwell Technologies.

How difficult is it to link a patient not in our Health Plan to our Health Plan?

Providers do not directly link patients to a Health Plan. Medicaid and LaCHIP enrollees select their Health Plans and indicate their preferred provider or, if no choice is made, they are assigned to a Plan. During the first 90 days of enrollment, enrollees can change Plans for any reason. After the initial 90 days, the patients are locked into that Health Plan until the next open enrollment, unless they have good cause to change Plans. Patients wishing to change Health Plans should be referred to the Enrollment Center’s toll-free number, 1-855-229-6848. Patients wishing to change doctors should be referred to their Health Plan’s Member Services toll free number.

How does LDH assign Medicaid patients to the Health Plans?

Medicaid enrollees who do not actively select a Health Plan will be auto assigned based on an algorithm defined in the enrollment broker contract.

How does LDH handle those patients that have Medicaid as a secondary insurance?

Medicare Dual eligibles are excluded from Health Plan enrollment. For members with commercial insurance as the primary payer, Medicaid via the Health Plan will be the payer of last resort.

Will the patient be allowed to move from one Health Plan to another?

Medicaid enrollees are allowed to change Health Plans during annual open enrollment, in the first 90 days of enrollment, or at any time for cause.

Do the patient's ID cards look different for each Health Plan?

Yes. Each patient has both a Medicaid card to obtain carved out services and a second member ID card issued by the Health Plan. The contract requires that the Health Plan issued ID card include the name of the PCP, the PCP’s address and phone number, and numbers for the Plans Member services.

What programs are available?

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.

How will Health Plans ensure that their patients use their regular doctor's office when patients may have easy and unregulated access to urgent care clinics?

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).

Can a recipient choose a specialist as their PCP?

It depends on the Health Plan's policy. Check with your Health Plan first.

Which Medicaid recipients are excluded from participation in the Managed Care Plans?

The populations that are excluded from participation in the Managed Care Plans and who will receive all their services in the regular Medicaid program are

  • Recipients over age 21 who are residents of an intermediate care facility for the developmentally disabled (ICFDD).
  • Recipients with limited eligibility periods of 3 months or less (Spend-down Medically Needy)
  • Recipients receiving a limited benefit package (for example the Medicare Savings Plan)


Are there any limits for providers on marketing with a Health Plan?

Providers are allowed to tell their patients which Health Plans they have enrolled with, so their patients can choose a Health Plan with that provider in it, if they wish. But, providers must disclose all Health Plans of which they are a member, and providers cannot steer patients toward any particular Health Plan. Also, any signage or other forms of marketing in a provider’s office must be equal. If a provider has a large sign for one Health Plan, he or she must have signs of the same size for the other plans in which he or she participates.

Why can't expectant mothers choose a pediatrician prior to the baby's birth?

A Medicaid number cannot be assigned to a baby until after birth. The baby will be automatically assigned to the mother's health plan. The mother will have an opportunity to change the baby's plan, if she wishes.