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This report is submitted in response to Act 482 of the 2018 Regular Legislative Session. The report contains requested data on the Medicaid expansion population and managed care organization (MCO) pharmacy benefit managers (PBM). As part of the Medicaid Managed Care Transparency Report, this report includes those expansion population counts and expenditures for individuals enrolled in an MCO for either full or partial benefits.
Downloadable Assets:
2025, Q1 Medicaid Managed Care Quarterly Transparency Report 2025, Q2 Medicaid Managed Care Quarterly Transparency Report 2025, Q3 Medicaid Managed Care Quarterly Transparency Report 2025, Q4 Medicaid Managed Care Quarterly Transparency Report 2026, Q1 Medicaid Managed Care Quarterly Transparency Report -
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
This report is the eleventh in a series of annual reports produced by the Louisiana Department of Health (LDH or “the Department”) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid managed care program (R.S. 40:1253.2). Aetna Better Health, Inc. (ABH); AmeriHealth Caritas Louisiana, Inc. (ACLA); Community Care Plan of Louisiana, Inc. (dba Healthy Blue) (HBL); Humana Health Benefit Plan of Louisiana, Inc. (dba Humana Healthy Horizons in Louisiana) (HHH); Louisiana Healthcare Connections, Inc. (LHCC); and UnitedHealthcare of Louisiana, Inc. (UHC).
Downloadable Assets:
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Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
This report is the tenth in a series of annual reports produced by the Louisiana Department of Health (LDH) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid managed care program (R.S. 40:1253.2). For the first six months of SFY 2023 (July – December 2022), five MCOs were contracted with LDH to manage physical and behavioral healthcare services. Effective January 1, 2023, the state began a new three-year contract for all continuing MCOs and added Humana as the sixth health plan. All data presented in this report for Humana is for the six months of operations, January 1 – June 30, 2023: Aetna Better Health, Inc. (ABH); AmeriHealth Caritas Louisiana, Inc. (ACLA); Community Care Plan of Louisiana, Inc. (dba Healthy Blue) (HBL); Humana Health Benefit Plan of Louisiana, Inc. (dba Humana Healthy Horizons in Louisiana) (HHH); Louisiana Healthcare Connections, Inc. (LHCC); and UnitedHealthcare of Louisiana, Inc. (UHC).
Downloadable Assets:
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Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the ninth in a series produced by the Louisiana Department of Health (LDH, or the Department) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid managed care program (R.S. 40:1253.2): • Improved care coordination with patient-centered medical homes for Medicaid enrollees; • Improved health outcomes and quality of care; • Increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; • Improved access to Medicaid services; • Improved accountability with a decrease in fraud, abuse, and wasteful spending; and • A more financially stable Medicaid program. Beginning in February 2012, the original Medicaid managed care program included two models of coordinated care networks: a full-risk, managed care organization (MCO) model delivered by prepaid health plans and a primary care case management (PCCM) model delivered by shared savings plans. The state contracted with three prepaid and two shared savings health plans, and individuals were given the option of choosing the plan that best met their needs. Not all Medicaid services are available from health plans, and some enrollees continue to receive certain services under the fee-for-service program. In addition, some populations covered by Medicaid were not eligible to enroll in and receive services from a health plan. LDH has progressively integrated services and populations into the Medicaid managed care program. The following timeline includes major milestones in the growth of the managed care program: • Pharmacy benefits were “carved-in” to the prepaid plan benefit package on November 1, 2012. • The provision of dental benefits to most Medicaid populations was contracted to a single prepaid ambulatory health plan referred to as a dental benefits program manager (DBPM) beginning July 1, 2014. • The delivery model transitioned from three full-risk MCOs and two shared-savings PCCM models to five full-risk MCOs on February 1, 2015. • Hospice benefits were added on February 1, 2015. • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) – Personal Care Services were added on February 1, 2015. • Retroactive linkages to a Medicaid managed care plan were implemented on February 1, 2015. • Specialized behavioral health benefits were added on December 1, 2015. • Non-emergency medical transportation and specialized behavioral health services were added on December 1, 2015, for enrollees not entitled to receive physical health services through an MCO. • Eligibility for Medicaid services expanded to include the new adult population on July 1, 2016. • Effective January 1, 2021, the DBPM program expanded to include a second contracted dental plan. • Effective January 1, 2021, covered dental services (EPSDT and Adult Denture) for individuals with intellectual disabilities (ICF/IID) moved from the fee-for-service (FFS) program to coverage through one of the two DBPMs. Transparency Report Measures and Data This report includes 31 areas of measurement outlined in La. Revised Statute 40:1253.2 and covers program operations for State Fiscal Year (SFY) 2022. All measures are reported for the SFY, July 1, 2021, through June 30, 2022, except for the following that are reported on a calendar year basis per the contract between the Department and the managed care entities: Section 7 – Medical Loss Ratio, Section 8 – Health Outcomes, Section 9 – Member and Provider Satisfaction Surveys, and Section 10 – Audited Financial Statements. The information included in this report was collected from multiple sources. To the greatest extent possible, the data were extracted from state systems that routinely collect and maintain operational data on the Medicaid managed care program. When unavailable from state sources, data were collected from the managed care entities or sourced from either routine reporting deliverables1 or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse, or MDW) are maintained by the Medicaid program’s contracted fiscal intermediary, Gainwell. Detailed enrollee and provider information, as well as claims payment data for this report, was extracted from the MARS Data Warehouse. The state administrative system, LaGOV Enterprise Resource Planning System – Finance Module (LaGOV) maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to the MCOs and DBPMs. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for the collection of data were validated by the Department’s contracted External Quality Review Organization (EQRO), Island Peer Review Organization (IPRO). In addition to standing operational quality assurances and EQRO reviews, the data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the managed care entities or the Department used to generate data. For data originating from the MARS Data Warehouse, Myers and Stauffer directly aggregated data from encounters or data extracts for each plan and compared its results to the results the Department produced. For data originating from the plans, Myers and Stauffer (MSLC) reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10% variance threshold established by the Department, it made recommendations to the Department or the health plan to improve the method used to collect data. See Appendix XIX and Appendix XX for the survey instruments.
Downloadable Assets:
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Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the eighth in a series produced by the Louisiana Department of Health (LDH or “the Department”) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid managed care program (R.S. 40:1253.2): • Improved care coordination with patient-centered medical homes for Medicaid enrollees; • Improved health outcomes and quality of care; • Increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; • Improved access to Medicaid services; • Improved accountability with a decrease in fraud, abuse and wasteful spending; and • A more financially stable Medicaid program. Beginning in February 2012, the original Medicaid managed care program included two models of coordinated care networks: a full-risk, managed care organization (MCO) model delivered by “prepaid health plans” and a primary care case management (PCCM) model delivered by “shared savings plans.” The state contracted with three prepaid and two shared savings health plans, and individuals were given the option of choosing the plan that best met their needs. Not all Medicaid services were available from health plans, and some enrollees continued to receive certain services under the fee-for-service program. In addition, some populations covered by Medicaid were not eligible to enroll in and receive services from a health plan. LDH has progressively integrated services and populations into the Medicaid managed care program. The following timeline includes major milestones in the growth of the managed care program: • Pharmacy benefits were “carved-in” to the prepaid plan benefit package on November 1, 2012. • The provision of dental benefits to all Medicaid populations was contracted to a single prepaid ambulatory health plan referred to as a “dental benefits program manager” (DBPM) beginning July 1, 2014. • The delivery model transitioned from three full-risk MCOs and two shared-savings PCCM models to five full-risk MCOs on February 1, 2015. • Hospice benefits were added on February 1, 2015. • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) – Personal Care Services were added on February 1, 2015. • Retroactive linkages to a Medicaid managed care plan were implemented on February 1, 2015. • Specialized behavioral health benefits were added on December 1, 2015. • Non-emergency medical transportation and specialized behavioral health services were added on December 1, 2015 for enrollees not entitled to receive physical health services through an MCO. • Eligibility for Medicaid services expanded to include the new adult population on July 1, 2016. • Effective January 1, 2021, the DBPM program expanded to include a second contracted dental plan. • Effective January 1, 2021, coverage of dental services for individuals with intellectual disabilities (ICF/IID) moved from the fee-for-service program to coverage through one of the two DBPMs. Transparency Report Measures and Data This report includes 31 areas of measurement outlined in La. Revised Statute 40:1253.2 and covers program operations for State Fiscal Year (SFY) 2021. All measures are reported for the SFY, July 1, 2020 through June 30, 2021, except for the following that are reported on a calendar year basis per the contract between the Department and the managed care entities: Section 7 – Medical Loss Ratio, Section 8 – Health Outcomes, Section 9 – Member and Provider Satisfaction Surveys, and Section 10 – Audited Financial Statements. Beginning with the SFY 2020 report the format was updated to consolidate all data elements regarding the Dental Benefits Program into Sections 30 – 41. Information included in this report was collected from multiple sources. To the greatest extent possible, the data were extracted from state systems that routinely collect and maintain operational data on the Medicaid managed care program. When unavailable from state sources, data were collected from the managed care entities or sourced from either routine reporting deliverables1 or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse or MDW) are maintained by the Medicaid program’s contracted fiscal intermediary, Gainwell. Detailed enrollee and provider information, as well as claims payment data for this report, was extracted from the MARS Data Warehouse. The state administrative system, called ISIS, maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to the MCOs and DBPMs. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for collection of data were validated by the Department’s contracted External Quality Review Organization (EQRO), Island Peer Review Organization (IPRO). In addition to standing operational quality assurances and EQRO reviews, the data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the managed care entities or the Department used to generate data. For data originating from the MARS Data Warehouse, Myers and Stauffer directly aggregated data from encounters or data extracts for each plan and compared its results to the results the Department produced. For data originating from the plans, Myers and Stauffer (MSLC) reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10% variance threshold established by the Department, it made recommendations to the Department or the health plan to improve the method used to collect data. See Appendices XVIII and XIX for the survey instruments.
Downloadable Assets:
2021 Managed Care Transparency Report Appendix I. Total Number of Health Care Providers (Section 4) Appendix II. Primary Care Service Providers (Section 5) Appendix III. Contracted Providers with Closed Panels (Section 6) Appendix IV. Satisfaction Surveys (Section 9) Member Surveys 1. Aetna Appendix IV. Satisfaction Surveys (Section 9) Member Surveys 2. AmeriHealth Caritas Louisiana Appendix IV. Satisfaction Surveys (Section 9) Member Surveys 3. Healthy Blue Appendix IV. Satisfaction Surveys (Section 9) Member Surveys 4. Louisiana Healthcare Connections Appendix IV. Satisfaction Surveys (Section 9) Member Surveys 5. UnitedHealthcare Appendix IV. Satisfaction Surveys (Section 9) Provider Surveys 1. Aetna Appendix IV. Satisfaction Surveys (Section 9) Provider Surveys 2. AmeriHealth Caritas Louisiana Appendix IV. Satisfaction Surveys (Section 9) Provider Surveys 3. Healthy Blue Appendix IV. Satisfaction Surveys (Section 9) Provider Surveys 4. Louisiana Healthcare Connections Appendix IV. Satisfaction Surveys (Section 9) Provider Surveys 5. UnitedHealthcare Appendix V. Annual Audited Financial Statements (Section 10) 1. Aetna Appendix V. Annual Audited Financial Statements (Section 10) 2. AmeriHealth Caritas Appendix V. Annual Audited Financial Statements (Section 10) 3. Healthy Blue Appendix V. Annual Audited Financial Statements (Section 10) 4. Louisiana Healthcare Connections Appendix V. Annual Audited Financial Statements (Section 10) 5. UnitedHealthcare Appendix VI. Number of enrollees who received services from each Managed Care Organization (Section 14) Appendix VII. Total number of denied claims (Section 19) Appendix VIII. Claims paid to out-of-network providers (Section 22) Appendix IX. Pharmacy benefits by month (Section 24) Appendix X. Pharmacy claims denied after authorization (Section 24) Appendix XI. PBM and drug rebate-monthly data (Section 25) Appendix XII. Adult Expansion Population (Section 26-29) Appendix XIII. Total Number of healthcare providers contracted - DBPM (Section 33) Appendix XIV. Member and Provider Satisfaction Surveys - DBPM (Section 34) Appendix XV. Annual audited financial statement - DBPM (Section 35) Appendix XVI. Total Number of Denied Claims - DBPM (Section 39) Appendix XVII. Prior Authorization Denials - DBPM (Section 41) Appendix XVIII. Myers and Stauffer MCO survey instrument Appendix XIX. Myers and Stauffer DBPM survey instrument -
Details:
- Medicaid
- Managed Care
Appendix XIV of Transparency Report
Downloadable Assets:
-
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the seventh in a series produced by the Louisiana Department of Health (LDH or “the Department”) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid Managed Care Program (R.S. 40:1253.2): improved care coordination with patient-centered medical homes for Medicaid enrollees; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. Beginning in February of 2012, the original Medicaid Managed Care Program included two models of coordinated care networks: full-risk managed care organizations (MCOs) known as “prepaid health plans,” and primary care case management (PCCM) known as “shared savings plans.” The state contracted with three prepaid and two shared savings plans, and individuals were given the option of choosing the plan that best meet their needs. Not all Medicaid services were available from health plans, and some enrollees continued to receive certain services under the fee-for-service program. In addition, many individuals covered by Medicaid were not eligible to enroll in and receive services from a health plan. LDH has progressively integrated services and populations into the Medicaid Managed Care Program. The following timeline includes major milestones in the growth of the managed care program: Pharmacy benefits were “carved-in” to the prepaid plan benefit package on November 1, 2012. Dental benefits have been provided to all Medicaid populations by a single prepaid ambulatory health plan referred to as a “dental benefits program manager” (DBPM) since July 1, 2014. The delivery model was transitioned from three full-risk MCOs and two shared-savings PCCMs to five full-risk MCOs on February 1, 2015. Hospice benefits were added on February 1, 2015. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) - Personal Care Services were added on February 1, 2015. Retroactive linkages to a Medicaid managed care plan were implemented on February 1, 2015. Specialized behavioral health benefits were added on December 1, 2015. Non-emergency medical transportation and specialized behavioral health services were added on December 1, 2015 for enrollees not entitled to receive physical health services through a MCO. Eligibility for Medicaid services was expanded to include the new adult population on July 1, 2016. Transparency Report Measures and Data This report includes 31 areas of measurement outlined in La. Revised Statute 40:1253.2. This report covers program operations for July 2019 through June 2020 (State Fiscal Year 2020), except for the following measures which are reported on a calendar year basis per the contract between the Department and the managed care entities: Section 7 – Medical Loss Ratio Section 8 – Health Outcomes Section 9 – Member and Provider Satisfaction Surveys Section 10 – Audited Financial Statements The State Fiscal Year 2020 presentation of this report has been updated to consolidate all data elements regarding the Dental Benefits Program into Sections 30 – 40. Information included in this report was collected from multiple sources. To the greatest extent possible, the data are extracted from state systems that routinely collect and maintain operational data on the Medicaid Managed Care Program. When unavailable from state sources, data were collected from the managed care entities or sourced from either routine reporting deliverables1 or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse or MDW) are maintained by the Medicaid program’s contracted fiscal intermediary, DXC Technologies (DXC), formerly Molina Healthcare. Detailed enrollee and provider information, as well as claims payment data for this report, were extracted from the MARS data warehouse. The state administrative system, called ISIS, maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to the MCOs and Dental Benefits Plan Manager. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for collection of data were validated by the Department’s contracted External Quality Review Organization (EQRO), Island Peer Review Organization (IPRO). In addition to standing operational quality assurances and EQRO reviews, the data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the managed care entities or the Department used to generate data. For data originating from the MARS Data Warehouse or MMIS, Myers and Stauffer generated its own data from encounters or data extracts for each plan and compared its results to the results the Department produced. For data originating from the plans, Myers and Stauffer (MSLC) reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10% variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendices XIX and XX for the survey instruments.
Downloadable Assets:
2020 Managed Care Transparency Report Appendix I. Total Number of Health Care Providers (Section 4) Appendix II. Primary Care Service Providers (Section 5) Appendix III. Contracted Providers with Closed Panels (Section 6) Appendix IV. Member Satisfaction Surveys (Section 9) 1. Aetna Appendix IV. Member Satisfaction Surveys (Section 9) 2. AmeriHealth Caritas Louisiana Appendix IV. Member Satisfaction Surveys (Section 9) 3. Healthy Blue Appendix IV. Member Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix IV. Member Satisfaction Surveys (Section 9) 5. UnitedHealthcare Appendix V. Provider Satisfaction Surveys (Section 9) Appendix VI. Annual Audited Financial Statements (Section 10) 1. Aetna Appendix VI. Annual Audited Financial Statements (Section 10) 2. AmeriHealth Caritas Louisiana Appendix VI. Annual Audited Financial Statements (Section 10) 3. Healthy Blue Appendix VI. Annual Audited Financial Statements (Section 10) 4. Louisiana Healthcare Connections Appendix VI. Annual Audited Financial Statements (Section 10) 5. UnitedHealthcare Appendix VII. Number of enrollees who received services from each Managed Care Organization (Section 14) Appendix VIII. Total number of denied claims (Section 19) Appendix IX. Claims paid to out-of-network providers (Section 22) Appendix X. Pharmacy benefits by month (Section 24) Appendix XI.Pharmacy claims denied after authorization (Section 24) Appendix XII. PBM and drug rebate-monthly data (Section 25) Appendix XIII. Adult Expansion Population (Section 26-29) Appendix XIV. Total Number of healthcare providers contracted - DBPM (Section 33) Appendix XV. Member and Provider Satisfaction Surveys - DBPM (Section 34) Appendix XVI. Annual audited financial statement - DBPM (Section 35) Appendix XVII. Total Number of Denied Claims - DBPM (Section 39) Appendix XVIII. Prior Authorization Denials - DBPM (Section 41) Appendix XIX. Myers and Stauffer MCO survey instrument Appendix XX. Myers and Stauffer MCNA survey instrument -
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the seventh in a series produced by the Louisiana Department of Health (LDH or “the Department”) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid Managed Care Program (R.S. 40:1253.2): • improved care coordination with patient-centered medical homes for Medicaid enrollees; • improved health outcomes and quality of care; • increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; • improved access to Medicaid services; • improved accountability with a decrease in fraud, abuse and wasteful spending; and • a more financially stable Medicaid program.
Downloadable Assets:
2019 Managed Care Transparency Report Appendix I. Total number of healthcare providers contracted (Section 4) Appendix II. Primary care service providers (Section 5) Appendix III. Contracted providers with closed panels (Section 6) Appendix IV. Member satisfaction surveys (Section 9) 1. Aetna Better Health Appendix IV. Member satisfaction surveys (Section 9) 2. AmeriHealth Caritas Louisiana Appendix IV. Member satisfaction surveys (Section 9) 3. Healthy Blue Appendix IV. Member satisfaction surveys (Section 9) 4. Louisiana Healthcare Connections Appendix IV. Member satisfaction surveys (Section 9) 5. UnitedHealthcare Appendix IV. Member satisfaction surveys (Section 9) 6. MCNA Appendix V. Medicaid managed care provider satisfaction survey 2018 (Section 9) Appendix VI. Annual audited financial statements (Section 10) 1. Aetna Better Health Appendix VI. Annual audited financial statements (Section 10) 2. AmeriHealth Caritas Louisiana Appendix VI. Annual audited financial statements (Section 10) 3. Healthy Blue Appendix VI. Annual audited financial statements (Section 10) 4. Louisiana Healthcare Connections Appendix VI. Annual audited financial statements (Section 10) 5. UnitedHealthcare Appendix VI. Annual audited financial statements (Section 10) 6. MCNA Appendix VII. Number of enrollees who received services (Section 15) Appendix VIII. Total number of denied claims (Section 20) Appendix IX. Claims paid to out-of-network providers (Section 23) Appendix X. Pharmacy benefits by month (Section 24) Appendix XI. Pharmacy claims denied after authorization (Section 24) Appendix XII. PBM and drug rebate – monthly data (Section 25) Appendix XIII. Dental program (Section 26) Appendix XIV. Adult expansion population (Sections 28-31) Appendix XV. Meyers and Stauffer MCO survey instrument Appendix XVI. Meyers and Stauffer MCNA survey instrument -
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the seventh in a series produced by the Louisiana Department of Health (LDH or “the Department”) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Louisiana’s Medicaid Managed Care Program (R.S. 40:1253.2): improved care coordination with patient‐centered medical homes for Medicaid enrollees; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. Beginning in February of 2012, the original Medicaid Managed Care Program included two models of coordinated care networks: full‐risk managed care organizations (MCOs) known as prepaid health plans, and primary care case management (PCCM) known as shared savings plans. The state contracted with three prepaid and two shared savings plans, and individuals were given the option of choosing the plan that best met their needs. However, not all Medicaid services were available from health plans, and some health plan members continued to receive certain services under the fee‐for‐service program. In addition, many individuals covered by Medicaid were not eligible to enroll in and receive services from a health plan. LDH has progressively integrated services and populations into the Medicaid Managed Care Program. The following timeline includes major milestones in the growth of the managed care program: Pharmacy benefits were “carved‐in” to the prepaid plan benefit package on November 1, 2012. Dental benefits have been provided to all Medicaid populations under a single Dental Benefits Program Manager (DBPM) since July 1, 2014. The delivery model was transitioned from three full‐risk MCOs and two shared‐savings PCCMs to five full‐risk MCOs on February 1, 2015. Hospice benefits were added on February 1, 2015. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) ‐ Personal Care Services were added on February 1, 2015. Retroactive linkages to a Medicaid managed care plan were implemented on February 1, 2015. Specialized behavioral health benefits were added on December 1, 2015. Eligibility for Medicaid services was expanded to include the new adult population on July 1, 2016. Medicaid Expansion On July 1, 2016, the state expanded eligibility for the Louisiana Medicaid program to include adults ages 19 to 64 years old with incomes at or below 138% of the federal poverty level. In State Fiscal Year 2018, 587,912 unduplicated members were enrolled in a managed care plan through the expansion. In this transparency report, the expansion population is included in the reporting for full‐benefit members. Additional information specific to the new adult expansion population can be found on the “LDH Medicaid Expansion Dashboard” at http://www.ldh.la.gov/HealthyLaDashboard/. Transparency Report Measures and Data This report includes 27 measures as outlined in La. Revised Statute 40:1253.2. It covers program operations for July 2017 through June 2018 (State Fiscal Year 2018), except for the following measures which are reported on a calendar year basis per the contract between the Department and the managed care entities: Section 7 – Medical Loss Ratio Section 8 – Health Outcomes Section 9 – Member and Provider Satisfaction Surveys Section 10 – Audited Financial Statements Section 25 – Medicaid Drug Rebates Information included in this report was collected from multiple sources. To the greatest extent possible, the data are extracted from state systems that routinely collect and maintain operational data on the Medicaid Managed Care Program. When unavailable from state sources, data were collected from the managed care entities or sourced from either routine reporting deliverables1 or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse or MDW) are maintained by the Medicaid program’s contracted fiscal intermediary, DXC Technologies (DXC), formerly Molina Healthcare. Detailed enrollee and provider information, as well as claims payment data for this report, were extracted from the MARS data warehouse. The state administrative system, called ISIS, maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to the MCOs and Dental Benefits Plan Manager. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO). In addition to standing operational quality assurances and EQRO reviews, the data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the managed care entities or the Department used to generate data. For data originating from the MARS Data Warehouse or MMIS, Myers and Stauffer generated its own data from encounters or data extracts for each plan and compared its results to the results the Department produced. For data originating from the plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10% variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix XII for the survey instrument.
Downloadable Assets:
2018 Managed Care Transparency Report Appendix I. Total Number of Health Care Providers (Section 4) Appendix II. Primary Care Service Providers (Section 5) Appendix III. Contracted Providers with Closed Panels (Section 6) Appendix IV. Member Satisfaction Surveys (Section 9) 1. Aetna Appendix IV. Member Satisfaction Surveys (Section 9) 2. AmeriHealth Caritas Louisiana Appendix IV. Member Satisfaction Surveys (Section 9) 3. Healthy Blue Appendix IV. Member Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix IV. Member Satisfaction Surveys (Section 9) 5. UnitedHealthcare Appendix IV. Member Satisfaction Surveys (Section 9) 6. MCNA Appendix V. Provider Satisfaction Surveys (Section 9) 1. Aetna Appendix V. Provider Satisfaction Surveys (Section 9) 2. AmeriHealth Caritas Louisiana Appendix V. Provider Satisfaction Surveys (Section 9) 3. Healthy Blue Appendix V. Provider Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix V. Provider Satisfaction Surveys (Section 9) 5. UnitedHealthcare Appendix V. Provider Satisfaction Surveys (Section 9) 6. MCNA Appendix VI. Annual Audited Financial Statements (Section 10) 1. Aetna Appendix VI. Annual Audited Financial Statements (Section 10) 2. AmeriHealth Caritas Louisiana Appendix VI. Annual Audited Financial Statements (Section 10) 3. Healthy Blue Appendix VI. Annual Audited Financial Statements (Section 10) 4. Louisiana Healthcare Connections Appendix VI. Annual Audited Financial Statements (Section 10) 5. UnitedHealthcare Appendix VI. Annual Audited Financial Statements (Section 10) 6. MCNA Appendix VII. Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix VIII. Total number of denied claims (Section 20) Appendix IX. Claims paid to out-of-network providers (Section 23) Appendix X. Pharmacy benefits by month (Section 24) Appendix XI. Dental Program (Section 26) Appendix XII. MSLC Survey -
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the sixth in a series produced by the Louisiana Department of Health (referenced as LDH or the Department) to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Medicaid Managed Care Programs (R.S. 40:1253.2): improved care coordination with patient‐centered medical homes for Medicaid recipients; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. Beginning in February of 2012, the original Medicaid Managed Care Program included two models of coordinated care networks: full‐risk managed care organizations (MCOs) known as prepaid health plans, and primary care case management (PCCM) known as shared savings plans. The state contracted with three prepaid and two shared savings plans, and individuals were given the option of choosing the plan that best met their needs. However, not all Medicaid services were available from health plans, and some health plan members continued to receive certain services under the fee‐for‐service program. In addition, many individuals covered by Medicaid were not eligible to enroll in and receive services from a health plan. The program has continued to evolve with each year of operation. LDH has progressively integrated services and populations into the Medicaid Managed Care Program. The following timeline includes major milestones in the growth of the managed care program: Pharmacy benefits were “carved‐in” to the prepaid plan benefit package on November 1, 2012. Dental benefits have been provided to all Medicaid populations under a single Dental Benefits Program Manager (DBPM) since July 1, 2014. The delivery model was transitioned from three full‐risk MCOs and two shared‐savings PCCMs to five full‐risk MCOs on February 1, 2015. Hospice benefits were added on February 1, 2015. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) ‐ Personal Care Services were added on February 1, 2015. Retroactive linkages to a Medicaid managed care plan were implemented on February 1, 2015. Specialized behavioral health benefits were added on December 1, 2015. Eligibility for Medicaid services was expanded to include the new adult population on July 1, 2016. Medicaid Expansion On July 1, 2016, the state expanded eligibility for the Louisiana Medicaid program to include adults, ages 19 to 64 years old, with incomes at or below 138 percent of the federal poverty level. All members of the new adult expansion population were enrolled through a special open enrollment period in one of the five health plans as a full‐benefit member. In addition, these members also received coverage for services under the adult denture program through the state’s DBPM. In State Fiscal Year 2017, 499,175 unduplicated members were enrolled through the expansion. In this transparency report, the expansion population is included in the reporting for full‐benefit members. Additional information specific to the new adult expansion population can be found on the “Healthy Louisiana” home page at www.healthy.la.gov. Transparency Report Measures and Data This report includes 26 measures as outlined in La. Revised Statute 40:1253.2. It covers program operations for July 2016 through June 2017 (State Fiscal Year 2017), except the following measures which are reported on a calendar year basis per the contract between the Department and the managed care entities: Section 7 – Medical Loss Ratio, Section 8 – Health Outcomes, Section 9 – Member and Provider Satisfaction Surveys, Section 10 – Audited Financial Statements, and Section 25 – Medicaid Drug Rebates. Information included in this report was collected from multiple sources. To the greatest extent possible, the data are extracted from state systems that routinely collect and maintain operational data on the Medicaid Managed Care Program. When unavailable from state sources, data were collected from the managed care entities or sourced from either routine reporting deliverables or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse) are maintained by the Medicaid program’s contracted fiscal intermediary, Molina Healthcare. Detailed recipient and provider information, as well as claims payment data for this report, were extracted from the MARS data warehouse. The state administrative system, called ISIS, maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to the MCOs and Dental Benefits Plan Manager. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with their annual external quality reviews. Additionally, plans are contractually required to obtain accreditation from the National Committee for Quality Assurance (NCQA) for their Medicaid health plan serving Louisiana members. NCQA accreditation involves a rigorous process involving comprehensive reviews of the plans’ policies, procedures and practices. All five MCOs have obtained accreditation from NCQA. In addition to standing operational quality assurances and EQRO reviews, the data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the managed care entities or the Department used to generate data. For data originating from the MARS Data Warehouse or MMIS, Myers and Stauffer generated its own data from encounters or data extracts for each plan and compared its results to the results the Department produced. For data originating from the plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10 percent variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix XII for the survey instrument.
Downloadable Assets:
2017 Managed Care Transparency Report Appendix I. Total Number of Health Care Providers (Section 4) Appendix II. Primary Care Service Providers (Section 5) Appendix III. Contracted Providers with Closed Panels (Section 6) Appendix IV. Member Satisfaction Surveys (Section 9) 1. Aetna Appendix IV. Member Satisfaction Surveys (Section 9) 2. Amerigroup Appendix IV. Member Satisfaction Surveys (Section 9) 3. AmeriHealth Caritas Louisiana Appendix IV. Member Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix IV. Member Satisfaction Surveys (Section 9) 5. UnitedHealthcare Appendix IV. Member Satisfaction Surveys (Section 9) 6. MCNA Appendix V. Provider Satisfaction Surveys (Section 9) 1. Aetna Appendix V. Provider Satisfaction Surveys (Section 9) 2. Amerigroup Appendix V. Provider Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix V. Provider Satisfaction Surveys (Section 9) 6. MCNA Appendix VI. Annual Audited Financial Statements (Section 10) 1. Aetna Appendix VI. Annual Audited Financial Statements (Section 10) 2. Amerigroup Appendix VI. Annual Audited Financial Statements (Section 10) 3. AmeriHealth Caritas Louisiana Appendix VI. Annual Audited Financial Statements (Section 10) 4. Louisiana Healthcare Connections Appendix VI. Annual Audited Financial Statements (Section 10) 5. UnitedHealthcare Appendix VI. Annual Audited Financial Statements (Section 10) 6. MCNA Appendix VII. Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix VIII. Total number of denied claims (Section 20) Appendix IX. Claims paid to out-of-network providers (Section 23) Appendix X. Pharmacy benefits by month (Section 24) Appendix XI. Dental Program (Section 26) Appendix XII. MSLC Survey -
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 2.0 Amerigroup Healthy Blue AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan Aetna Better Health This report is the fifth in a series produced by the Louisiana Department of Health (LDH)to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Medicaid Managed Care Programs (R.S. 40:1253.2): improved care coordination with patient-centered medical homes for Medicaid recipients; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. Beginning in February of 2012, the original Medicaid Managed Care Program included two models of coordinated care networks: full-risk managed care organizations (MCOs), known as prepaid plans and primary care case management (PCCM) known as shared savings plans. The state contracted with three prepaid and two shared savings plans, and individuals were given the option of choosing the plan that best met their needs. However, not all Medicaid services were available from health plans, and some health plan members continued to receive certain services under the fee-for-service program. In addition, many individuals covered by Medicaid were not eligible to enroll in and receive services from a health plan. The program has continued to evolve with each year of operation. LDH has progressively integrated services and populations into the Medicaid Managed Care Program. The following timeline includes major milestones in the growth of our managed care program: Pharmacy benefits were “carved-in” to the prepaid plan benefit package on November 1, 2012. Dental benefits have been provided to all Medicaid populations under a single Dental Benefits Program Manager (DBPM) since July 1, 2014. The delivery model was transitioned from three risk-bearing MCOs and two shared-savings PCCMs to five risk-bearing MCOs on February 1, 2015. Hospice benefits were added on February 1, 2015. EPSDT PCS benefits were added on February 1, 2015. Retroactive linkages to Healthy Louisiana were implemented on February 1, 2015. Specialized behavioral health benefits were added on December 1, 2015. The ability to “opt-out” of physical health services was eliminated as of December 1, 2015, for the following populations: children under age 19 with a disability or special healthcare need, children in foster care, and Native Americans/Alaskan Natives. The populations became mandatory participants in Healthy Louisiana. Prior to December 1, 2015, all specialized behavioral health services were provided through the managed care program as a carve out service under the Louisiana Behavioral Health Partnership operated by Magellan. To facilitate the integration of SBH services, members already enrolled in a health plan began to receive their specialized behavioral health services through their existing plan. For other individuals, eligible for specialized behavioral health services but not currently enrolled in managed care, a special open enrollment period was held in the fall of 2015 to give them an opportunity to choose their own plan for behavioral health service continuation. For ease of access and coordination, all non-emergency transportation services (NEMT) for this partial benefits group are also provided by their chosen health plan. The partial benefits group continues to receive all physical health and long-term care services through fee-for-service Medicaid. It is also worth noting that while there was much planning and outreach for Medicaid expansion during this reporting period, the effective eligibility date for the expansion population began on July 1, 2016, and are therefore not covered in this reporting period. Medicaid expansion will be addressed in the State Fiscal Year 2017 report. This report includes 26 measures as outlined in La. Revised Statute 40:1253.2. It covers program operations for July 2015 through June 2016 (State Fiscal Year 2016), except the following measures which are reported on a calendar year basis per the contract between the Department and the health plans: Section 7 – Medical Loss Ratio Section 8 – Health Outcomes Section 9 – Member and Provider Satisfaction Surveys Section 10 – Audited Financial Statements Section 25 – Medicaid Drug Rebates Information included in this report was collected from multiple sources. To the greatest extent possible, the data is extracted from state systems which routinely collect and maintain operational data on the Medicaid Managed Care Program. When unavailable from state sources, data were collected from the health plans, sourced from either routine reporting deliverables or ad hoc reports requested specifically for this purpose. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse) are maintained by the Medicaid program contracted fiscal intermediary, which in State Fiscal Year (SFY) 2016 was Molina Healthcare. Detailed recipient and provider information, as well as, claims payment data for this report were extracted from the MARS data warehouse. The state administrative system, called ISIS, maintained by the Office of Technology Services within the Division of Administration, was used to extract information on payments to health plans. As part of routine operations and as required by the Centers for Medicare and Medicaid Services (CMS), internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with their annual external quality reviews. Additionally, plans are contractually required to obtain accreditation from the National Committee for Quality Assurance (NCQA) for their Medicaid health plan serving Louisiana members. NCQA accreditation involves a rigorous process involving comprehensive reviews of the plans’ policies, procedures and practices. For State Fiscal Year 2016, four of the health plans had obtained accreditation from NCQA. Aetna as a new plan was in the process of applying for accreditation. In addition to standing operational quality assurances and EQRO reviews, the data included in this report was independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the health plans or the Department used to generate data. For data originating from the MARS Data Warehouse or the MMIS, Myers and Stauffer generated its own data from encounters or data extracts for each health plan and compared its results to the results the Department produced. For data originating from the health plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10 percent variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix XII for the survey instrument.
Downloadable Assets:
2016 Managed Care Transparency Report Appendix I. Total Number of Health Care Providers (Section 4) Appendix II. Primary Care Service Providers (Section 5) Appendix IV. Member Satisfaction Surveys (Section 9) 1. Aetna Appendix IV. Member Satisfaction Surveys (Section 9) 2. Amerigroup Appendix IV. Member Satisfaction Surveys (Section 9) 4. Louisiana Healthcare Connections Appendix IV. Member Satisfaction Surveys (Section 9) 5. UnitedHealthcare Appendix IV. Member Satisfaction Surveys (Section 9) 6. MCNA Appendix V. Provider Satisfaction Surveys (Section 9) 2. AmeriHealth Caritas Louisiana Appendix V. Provider Satisfaction Surveys (Section 9) 3. Louisiana Healthcare Connections Appendix V. Provider Satisfaction Surveys (Section 9) 4. UnitedHealthcare Appendix V. Provider Satisfaction Surveys (Section 9) 5. MCNA Appendix VI. Annual Audited Financial Statements (Section 10) 1. Aetna Appendix VI. Annual Audited Financial Statements (Section 10) 2. Amerigroup Appendix VI. Annual Audited Financial Statements (Section 10) 3. AmeriHealth Caritas Appendix VI. Annual Audited Financial Statements (Section 10) 4. Louisiana Healthcare Connections Appendix VI. Annual Audited Financial Statements (Section 10) 6. MCNA Appendix VII. Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix VIII. Total number of denied claims (Section 20) Appendix IX. Claims paid to out-of-network providers (Section 23) Appendix X. Pharmacy benefits by month (Section 24) Appendix XI. Dental Program (Section 26) Appendix XII. MSLC Survey -
Details:
- Legislative & Governmental Relations
- Medicaid
- Managed Care
Managed Care 1.0 Amerigroup Healthy Blue Community Health Solutions LaCare AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan This report is the third in a series produced by the Louisiana Department of Health to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Medicaid managed care programs: improved care coordination with patient-centered medical homes for Medicaid recipients; improved health outcomes and quality of care; increased emphasis on disease prevention and the early diagnosis and management of chronic conditions; improved access to Medicaid services; improved accountability with a decrease in fraud, abuse and wasteful spending; and a more financially stable Medicaid program. The first and second reports included 23 measures as outlined in Act 212 of the 2013 Regular Legislative Session. The first report, submitted to the Legislature on January 2, 2014, covered July 2012 through June 2013 (State Fiscal Year 2013). The second report, submitted to the Legislature on December 31, 2014, covered January 2013 through December 2013 (Calendar Year 2013). The Department shifted the reporting periods, from State Fiscal Year (SFY) in the first report to Calendar Year (CY) in the second report, duplicating six months of the first report (January 2013 through June 2013). The shift in reporting periods provided for complete claims data given Act 212’s requirement of annual transparency report submission by January 1 and Medicaid’s timely filing policy which allows providers 365 days from the date of service to file a claim for payment. Act 158 of the 2015 Regular Legislative Session modified reporting requirements for the transparency report, adding three new measures and clarifying the reporting period. This third report includes 26 measures, and it covers July 2013 through June 2014 (State Fiscal Year 2014), duplicating six months of the second report (July through December 2013). All measures are reported on a fiscal year basis, except the following measures which are reported on a calendar year basis per the contract between the Department and the health plans: Section 7 – Medical Loss Ratio Section 8 – Health Outcomes Section 9 – Member and Provider Satisfaction Surveys Section 10 – Audited Financial Statements Section 25 – Medicaid Drug Rebates Act 158 provides sufficient time for complete claims reporting for a state fiscal year by shifting the due date for report submission from January 1 to June 30. This report covers the original contracting period for the Medicaid managed care program (beginning February 1, 2012) which includes physical and basic behavioral health services provided by both fullrisk managed care organizations, called prepaid health plans and referred to in this document as managed care organizations (MCOs), and plans serving as primary care case management (PCCM) entities, referred to as shared savings health plans. Information included in this report was collected from multiple sources. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse) are maintained by the Medicaid program’s contracted fiscal intermediary, which in State Fiscal Year 2014 was Molina Healthcare. The MMIS contains detailed recipient and provider information and the MARS Data Warehouse contains claims payment information. The state administrative system, called ISIS, is maintained by the Office of Technology Services within the Division of Administration and contains information on payments to health plans. The provider registry is maintained by Molina and contains information submitted by the health plans or their contracted providers. The provider registry is updated weekly with new information overwritten onto older information, which limits the utility of the data to point-in-time information. To the greatest extent possible, the data originate from state systems rather than the health plans. Where unavailable from state sources, data were collected from the health plans, sourced from either routine reporting deliverables or ad hoc reports requested specifically for this purpose. Data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the health plans or the Department used to generate data. For data originating from the MARS Data Warehouse or the MMIS, Myers and Stauffer generated its own data for each health plan and compared its results to the results the Department produced. For data originating from the health plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10 percent variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix 14.IX for the survey instrument. To ensure maximum reliability, subject matter experts within the Department and Myers and Stauffer also reviewed the data. In some cases, the health plans also reviewed data pulled on their plans by the Department for reasonability. In addition, health plans’ internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with annual external quality reviews. An additional validation was performed by either the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) as part of the contractually required health plan accreditation process. Plans are contractually required to obtain accreditation from either NCQA or URAC for their Bayou Health plan serving Louisiana members. All Bayou Health plans have obtained accreditation from these national accrediting bodies, which are rigorous processes involving comprehensive reviews of the plans’ policies, procedures and practices.
Downloadable Assets:
2014 Managed Care Transparency Report Appendix 14.I: Total Number of Health Care Providers (Section 4) Appendix 14.II: Primary Care Service Providers (Section 5) Appendix 14.III: Contracted Providers with Closed Panels (Section 6) Appendix 14.IV: Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix 14.V: Total number of denied claims (Section 20) Appendix 14.VI: Total number of clean claims (Section 21) Appendix 14.VII: Claims paid to out-of-network providers (Section 23) Appendix 14.VIII: Pharmacy benefits by month (Section 24) Appendix 14.IX: MSLC Survey