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• 2014 Medicaid Managed Care Transparency Report

  Details:

  August 31, 2016

  • 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

• 2015 Medicaid Managed Care Transparency Report

  Details:

  August 31, 2016

  • Legislative & Governmental Relations
  • Medicaid
  • Managed Care

  Managed Care 1.0 Amerigroup Healthy Blue Community Health Solutions AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan This report is the fourth 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. This report includes 26 measures as outlined in Act 158 of the 2015 Regular Legislative Session. It covers July 2014 through June 2015 (State Fiscal Year 2015), 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 This report includes data for the Medicaid managed care program that has delivered physical and basic behavioral health services to Medicaid enrollees since February 1, 2012, as well the dental benefit plan that began delivering services on July 1, 2014. Data in the report includes two different contract periods for the managed care program that delivers physical and basic behavioral health services. The first contract period included two primary care case management entities, referred to as shared savings health plans, and three full-risk managed care organizations (MCOs), called prepaid health plans, and ended January 31, 2015. The second contract period includes five managed care organizations and began on February 1, 2015. Given material differences between the two contracts, data are presented separately for the July 1, 2014, through January 31, 2015, and February 1, 2015, through June 30, 2015, periods. 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 contracted fiscal intermediary, which in State Fiscal Year (SFY) 2015 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. 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. 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 15.XIV 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:

  2015 Managed Care Transparency Report Appendix 15.I: Total Number of Health Care Providers (Section 4) Appendix 15.II: Primary Care Service Providers (Section 5) Appendix 15.III: Contracted Providers with Closed Panels (Section 6) Appendix 15.IV: Medical Loss Ratio Reports (Section 9) - .1: Amerigroup Appendix 15.IV: Medical Loss Ratio Reports (Section 9) - .2: AmeriHealth Caritas Louisiana Appendix 15.IV: Medical Loss Ratio Reports (Section 9) - .3: Louisiana Healthcare Connections Appendix 15.V: Member Satisfaction Surveys (Section 9) - .1: Amerigroup Appendix 15.V: Member Satisfaction Surveys (Section 9) - .2: AmerHealth Caritas Louisiana Appendix 15.V: Member Satisfaction Surveys (Section 9) - .3: Louisiana Healthcare Connections Appendix 15.V: Member Satisfaction Surveys (Section 9) - .4: UnitedHealthcare - Shared Savings Appendix 15.VI: Provider Satisfaction Surveys (Section 9) - .1: Amerigroup Appendix 15.VI: Provider Satisfaction Surveys (Section 9) - .2: AmeriHealth Caritas Louisiana Appendix 15.VI: Provider Satisfaction Surveys (Section 9) - .3: Louisiana Healthcare Connections Appendix 15.VI: Provider Satisfaction Surveys (Section 9) - .4: UnitedHealthcare - Shared Savings Appendix 15.VII: Annual Audited Financial Statements (Section 10) - .1: Amerigroup Appendix 15.VII: Annual Audited Financial Statements (Section 10) - .2: AmeriHealth Caritas Louisiana Appendix 15.VII: Annual Audited Financial Statements (Section 10) - .3: Louisiana Healthcare Connections Appendix 15.VII: Annual Audited Financial Statements (Section 10) - .4: Community Health Solutions - Shared Savings Appendix 15.VII: Annual Audited Financial Statements (Section 10) - .5:UnitedHealthcare - Shared Savings Appendix 15.VIII: Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix 15.IX: Total number of denied claims (Section 20) Appendix 15.X: Total number of clean claims (Section 21) Appendix 15.XI: Claims paid to out-of-network providers (Section 23) Appendix 15.XII: Pharmacy benefits by month (Section 24) Appendix 15.XIII: Dental Program (Section 26) Appendix 15.XIV: MSLC Survey

• 2013 Medicaid Managed Care Transparency Report

  Details:

  January 31, 2015

  • 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 Act 212 of the 2013 Regular Session of the Louisiana Legislature requires the Louisiana Department of Health and Hospitals (DHH) to submit annual reports concerning the Bayou Health program to the Legislature’s Senate and House Committees on Health and Welfare. The following Bayou Health Transparency Report: Calendar Year (CY) 2013 is intended to provide all information outlined in Act 212 for the second annual report to the Legislature. This report presents information on the Bayou Health program during the 2013 calendar year. Information and data for inclusion in this report were collected and provided by the contracted Bayou Health plans. The health plans’ internal policies and procedures for collection of data were validated by DHH’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with 2013 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 those national accrediting bodies NCQA or URAC, which are rigorous processes involving comprehensive reviews of the plans’ policies, procedures and practices.

  Downloadable Assets:

  2013 Managed Care Transparency Report Appendix I: Number of Healthcare Providers by Provider Type, Plan, Service Area and Entity Type Appendix II: Number of Healthcare Providers by Provider Specialty, Plan, Service Area and Entity Type Appendix III: Number of Members Enrolled by Plan, Eligibility Group and Month Appendix IV: Total and Average per Member per Month Payment to Each Plan by Month Appendix V: Amerigroup Louisiana Medical Loss Ratio Report Appendix VI: AmeriHealth Caritas Louisiana Medical Loss Ratio Report Appendix VII: Louisiana Healthcare Connections Medical Loss Ratio Report Appendix VIII: Amerigroup Louisiana 2014 CAHPS Adult Medicaid Member Satisfaction Survey Appendix IX: Amerigroup Louisiana 2014 CAHPS Child Medicaid with CCC Member Satisfaction Survey Appendix X: AmeriHealth Caritas Louisiana 2014 CAHPS Adult Medicaid Member Satisfaction Survey Appendix XI: AmeriHealth Caritas Louisiana 2014 CAHPS Child Medicaid with CCC Member Satisfaction Survey Appendix XII: Louisiana Healthcare Connections 2014 Medicaid Adult CAHPS Appendix XIII: Louisiana Healthcare Connections 2014 Medicaid Child with CCC CAHPS Appendix XIV: Community Health Solutions of Louisiana 2014 CAHPS 5.0H Adult Medicaid Summary Report Appendix XV: Community Health Solutions of Louisiana 2014 CAHPS 5.0H Child Medicaid with Chronic Conditions Report Appendix XVI: UnitedHealthcare of Louisiana, Inc. 2014 HEDIS®/CAHPS Health Plan Survey Adult Medicaid Version Appendix XVII: UnitedHealthcare of Louisiana, Inc. 2014 HEDIS®/CAHPS Health Plan Survey Child Medicaid with CCC Measure Version Appendix XVIII: Amerigroup 2014 Provider Satisfaction Survey Report Appendix XIX: AmeriHealth Caritas Louisiana 2014 Provider Satisfaction Survey Report Appendix XX: Louisiana Healthcare Connections 2014 Provider Satisfaction Report Appendix XXI: Community Health Solutions of Louisiana 2014 Provider Satisfaction Survey Report Appendix XXII: UnitedHealthcare Community Plan 2014 Provider Satisfaction Survey Report Appendix XXIII: Amerigroup Louisiana, Inc. Audited Financial Statement Appendix XXIV: AmeriHealth Caritas Louisiana Audited Financial Statement Appendix XXV: Louisiana Healthcare Connections, Inc. Audited Financial Statement Appendix XXVI: Community Health Solutions of Louisiana Plan Audited Financial Statement Appendix XXVII: UnitedHealthcare of Louisiana, Inc. Audited Financial Statement Appendix XXVIII: Louisiana Shared Savings Program Interim Savings Determination for Program Year 1 Appendix XXIX: Number of Members Who Received Unduplicated Medicaid Services by Provider Specialty and Plan Appendix XXX: Amerigroup Louisiana, Inc. 2013 Pharmacy Report Appendix XXXI: AmeriHealth Caritas Louisiana 2013 Pharmacy Report Appendix XXXII: Louisiana Healthcare Connections 2013 Pharmacy Report

• 2012 Medicaid Managed Care Transparency Report

  Details:

  January 31, 2014

  • 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 On February 1, 2012, DHH launched the single-largest transformation of the delivery of health care services in Louisiana Medicaid history when it transitioned nearly 900,000 Medicaid and LaCHIP enrollees from the state’s 45-year old legacy, fee-for-service program to a managed health care delivery system for acute care services, known as Bayou Health. A core component of reorganizing Louisiana’s Medicaid acute care delivery system was an expansion and realignment of the state’s capacity to monitor health plan operations, system performance and member health outcomes. Through a variety of tools Bayou Health is tracking and assessing each Health Plan’s performance, as well as, the outcomes of Bayou Health as a whole. Act 212 of the 2013 Legislative Session reinforces this high level of transparency in reporting, ensuring Medicaid managed care operates in the most efficient and sustainable method possible. The Act calls for 24 separate reports on Health Plan performance, many compared to pre-Bayou Health Medicaid data. This report outlines responses to the request made by the legislature in Act 212 relative to Bayou Health management and performance.

  Downloadable Assets:

  2014 Managed Care Transparency Report Section 1 - CCN Name and Service Area Section 2 - Total Providers by Plan GSA and Specialty - Specialty - GSA A Section 2 - Total Providers by Plan GSA and Specialty - Specialty - GSA B Section 2 - Total Providers by Plan GSA and Specialty - Specialty - GSA C Section 2 - Total Providers by Plan GSA and Specialty - Provider Type - GSA A Section 2 - Total Providers by Plan GSA and Specialty - Provider Type - GSA B Section 2 - Total Providers by Plan GSA and Specialty - Provider Type - GSA C Section 3 - Total and Monthly Average Number of Members Enrolled in Each Network by Eligibility Group Section 4 - Continuous Phone Access Provided by PCPs Section 5 - Percentage of Regular and Expedited Service Authorization Requests Section 6 - Percentage of Clean Claims Paid for Providers and Average Number of Days to Pay Section 7 - Number of Claims Denied or Reduced by Each Coordinated Care Network by Reason Section 8 - Number and Dollar Value of Claims Paid to Non-Network Providers by Type Section 9 - Number of Members Who Chose Their Network Versus Auto-Enrolled Members Section 10 - Total Payments and Average Per Member Per Month for Each CCN Section 11 - Medical Loss Ratios for Coordinated Care Networks and Related Refunds - Amerigroup Louisiana Section 11 - Medical Loss Ratios for Coordinated Care Networks and Related Refunds - AmeriHealth Caritas Louisiana Section 11 - Medical Loss Ratios for Coordinated Care Networks and Related Refunds - Louisiana Healthcare Connections Section 12 - Comparison of Health Outcomes - Health Plan Rates Section 13 - Comparison of Health Outcomes - Pre Bayou Health Quality Measures Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Provider - Amerigroup Louisiana Part 1 Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Provider - Amerigroup Louisiana Part 2 Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Provider - Louisiana Healthcare Connections Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Provider - Community Health Solutions Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Provider - UnitedHealthcare Community Plan of Louisiana Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - Amerigroup Louisiana - Adult Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - Amerigroup Louisiana - Children Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - AmeriHealth Caritas Louisiana - Adult Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - AmeriHealth Caritas Louisiana - Children Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - Louisiana Healthcare Connections - Adult Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - Louisiana Healthcare Connections - Children Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - Community Health Solutions of Louisiana - Adult Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - Community Health Solutions of Louisiana - Children Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - UnitedHealthcare Community Plan of Louisiana - Adult Section 14 - Satisfaction Surveys for Each Bayou Health Plan - Member - UnitedHealthcare Community Plan of Louisiana - Children Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Amerigroup Louisiana Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Amerigroup Louisiana - Schedule Y - Parent Audit Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Amerigroup Louisiana - Schedule Z - Agreed Upon Procedures Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - AmeriHealth Caritas Louisiana Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - AmeriHealth Caritas Louisiana - Schedule Y - Parent Audit Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - AmeriHealth Caritas Louisiana - Schedule Z - Agreed Upon Procedures Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Louisiana Healthcare Connections Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Louisiana Healthcare Connections - Schedule Y - Parent Audit Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Louisiana Healthcare Connections - Schedule Z - Agreed Upon Procedures Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Community Health Solutions of Louisiana Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Community Health Solutions of Louisiana - Schedule W - Parent Audit Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - Community Health Solutions of Louisiana - Schedule X - Louisiana Audit Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - UnitedHealthcare Community Plan of Louisiana Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - UnitedHealthcare Community Plan of Louisiana - Schedule W - Parent Audit Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - UnitedHealthcare Community Plan of Louisiana - Schedule X - Louisiana Audit 1 Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - UnitedHealthcare Community Plan of Louisiana - Schedule X - Louisiana Audit 2 Section 15 - Annual Audited Financial Statements for Coordinated Care Networks - UnitedHealthcare Community Plan of Louisiana - Schedule AB - DOI Annual Filing Section 16 - Total Savings to the State for Each Shared-Savings Coordinated Care Network Section 17 - Narrative of Sanctions Levied by LDH against a Coordinated Care Network Section 18 - Grievances, Appeals, State Fair Hearings Section 19 - Recipients Receiving Services by Provider Type Section 19 - Recipients Receiving Services by Place of Service Section 20 - Number of Members Who Received Unduplicated Outpatient Emergency Service Section 21 - Total Inpatient Medicaid Days Section 22 - Emergency Services Claims by CCN Section 23 - Pharmacy Benefit Claims