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• 2015 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