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• 2021 Managed Care Transparency Report

  Details:

  August 31, 2022

  • 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