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• 2017 Managed Care Transparency Report

  Details:

  June 30, 2018

  • 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