Emergency Rule Ensures Enrollee Choice, Prohibits Provider Steering

The Louisiana Department of Health and Hospitals (DHH) adopted an emergency rule, effective Dec. 1, to comply with federal regulations, and protect Medicaid enrollees' right to choose how they receive their healthcare.

Through the Bayou Health program, enrollees can now choose to receive their healthcare through one of the five managed care health plans or, when eligible, through the Medicaid fee-for-service program. The Emergency Rule supplements the existing Coordinated Care Network Rule.

The Emergency Rule defines provider steering as any conduct intended to recommend whether or not to enroll in a managed care health plan or Medicaid fee-for-service (legacy Medicaid), or to enroll in a specific managed care health plan over another health plan. This conduct is prohibited by any health care provider enrolled with Medicaid or a managed care health plan, or any Medicaid contracted managed care entity or health plan, including shared savings plans and capitated plans.

Examples of provider steering include, but are not limited to, offering enrollees incentives for selecting one managed care health plan over another plan, and allowing an enrollee to use a provider's fax, office telephone, or computer to enroll into a specific managed care health plan.

Providers may inform enrollees of the health plans they accept and the benefits, services and specialty care services offered through those health plans. However, they must disclose information on all the health plans they accept. If DHH determines a provider has steered a Medicaid enrollee to enroll with a particular managed care health plan or to participate in legacy Medicaid, DHH may impose any of the following sanctions:

• disenrollment from the Medicaid Program;
• recoupment of payments for services rendered to steered Medicaid enrollee;
• fined up to $5,000 for each steered enrollee; or
• require the provider to inform the steered Medicaid enrollee of sanctions imposed against the provider and invite the enrollee to choose a different health plan.

In addition to these sanctions, any managed care health plan may immediately terminate its provider services agreement with the provider.

For additional guidance on what is permissable conduct, providers can reference Informational Bulletin 12-31.

The Emergency Rule can be found online at www.MakingMedicaidBetter.com. Inquiries about this Emergency Rule can be submitted by mail to J. Ruth Kennedy, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030.