Provider FAQ: Health Plan Management

If I contract with a Health Plan and do not like the service, what is the procedure for dropping that Health Plan?

Each Health Plan subcontract with a provider must include a termination clause. Details on that termination clause are between the provider and the Health Plan.

What is the length of each provider's tenure with a Health Plan?

Provider contract terms should include the length of the contract. Details on that timeframe are between the provider and the Health Plan.

Are the transactions and payments between the Health Plan and the provider smooth and flawless?

There are prompt payment requirements as part of the subcontract requirements that all Health Plans must include in their contracts with network providers. These include the provision that the Health Plan shall pay ninety percent (90%) of all clean claims of each provider type, within fifteen (15) business days of the date receipt. The Health Plan shall pay ninety-nine (99%) of all clean claims of each provider type, within thirty (30) calendar days of the date of receipt. The date of receipt is the date the prepaid Health Plan receives the claim, as indicated by its date stamp on the claim. The date of payment is the date of the check or Electronic Fund Transfer (EFT). The Health Plan and its subcontractors may, by mutual agreement, establish an alternative payment schedule. Any alternative schedule must be stipulated in the subcontract.

Are Health Plans required to reimburse the current rates for provider based RHCs, or are they required to reimburse based on the cost + 10% formula for the duration of the contract?

Health Plans pay RHC claims based on the Medicaid PPS rate for that RHC in effect on the date of service. In addition, the existing cost settlement methodology has not changed.

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.

If I contract with a Health Plan, can I request exclusion from the plan's provider directory?

No. If a provider is in-network then the provider must be in the directory.

How does Healthy Louisiana affect dentists?

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.

What do the Health Plans do that Medicaid hasn’t done in the past?

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.

What is the mediation process between providers and the Health Plans?

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.

How do school-based health clinics function within the Health Plans?

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.

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).

Do I need to give the Health Plans I am contracting with all of my current Medicaid provider ID numbers?

Yes. All Medicaid ID numbers associated with your practice, including those for individual providers, for all sites should all be given to each Health Plan.

Why is there open access to in-network specialists in some of the Health Plans?

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.

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.

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.