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• 2016 Managed Care Transparency Report

  Details:

  June 30, 2017

  • 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