Unless it is an emergency, the patient should be referred to the PCP the Health Plan has assigned him/her, if the patient knows who the PCP is. If not, the patient can be referred to the Health Plan’s Member Services toll-free number. The name of the patient's Health Plan can be determined by the eligibility verification system, which will be maintained for providers by Molina.
During the first 30 days BAYOU HEALTH is implemented, the non-network provider can contact the recipient's Plan for authorization. The Plan will contact that PCP to offer a contract. If that PCP chooses not to contract with the Plan, the Plan will notify the recipient to determine if they wish to transfer to a new PCP. If so, the Plan will ask them to choose a new PCP. If they wish to stay with the previous PCP, the Plan will direct them to BAYOU HEALTH so they can choose a plan in which that PCP participates.
Providers do not directly link patients to a Health Plan. Medicaid and LaCHIP enrollees select their Health Plans and indicate their preferred provider or, if no choice is made, they are assigned to a Plan. Once enrollees choose a Plan or are automatically assigned, they have 90 days to change Plans for any reason. After 90 days, the patients are locked into that Health Plan until the next open enrollment, unless they have good cause to change Plans. Patients wishing to change Health Plans should be referred to the Enrollment Center’s toll-free number, 1-855-BAYOU-4U. Patients wishing to change doctors should be referred to their Health Plan’s Member Services toll free number.
Medicaid enrollees who do not actively select a Health Plan will be auto assigned based on an algorithm defined in the enrollment broker contract that is weighted toward a previous provider relationship.
1. If the potential member is transitioning from CommunityCARE, he/she will be assigned to a Plan with whom the last CommunityCARE doctor is a network provider.
2. If the member was not in CommunityCARE but was enrolled in Medicaid during the previous 12 months, paid claims data will be reviewed to determine the dominant PCP or if no PCP, the dominant specialist or if neither, then the dominant hospital.
3. If the member was not in Medicaid in the previous 12 months, we will look for existing or previous relationships of a household member, beginning with the youngest member.
4. If none of the above, the member will be enrolled to one of the five Health Plans on a “round robin” basis.
Medicare Dual eligibles are excluded from Health Plan enrollment. For members with commercial insurance as the primary payer, Medicaid via the BAYOU HEALTH Plan will be the payer of last resort. Those members enrolled in LaHIPP (DHH is paying the employee’s share of the premium for employer sponsored insurance) are excluded.
Yes. Each patient will have both a Medicaid card to obtain carved out services and a second member ID card issued by the Health Plan. The contract requires that the Health Plan issued ID card include the name of the PCP, the PCP’s address and phone number, and numbers for the Plans Member services.
No. All outreach and education of Medicaid and LaCHIP recipients will be coordinated by DHH and will directly target potential Health Plan members through a variety of media. DHH will be producing a brochure as well as a Health Plan Comparison Chart. Patients can also visit the enrollment site, www.bayouhealth.com.
Each Health Plan is contractually required to provide members with health management for three specific chronic health conditions (diabetes, asthma and congestive heart failure) as well as care management for pregnant women to improve birth outcomes. In addition, some of the Plans are also offering programs for hypertension, COPD, sickle cell, or HIV. Prepaid Plans can offer Expanded Benefits, which are services beyond what is covered under the Louisiana Medicaid State Plan. Examples are hypoallergenic bedding for members with asthma, and vision screenings and dental cleanings for adults over the age of 21.
All five Plans can offer members incentives for healthy behaviors. Examples of actual programs are a $20 gift card for getting a health assessment within 90 days of enrollment, up to $65 in gift cards for keeping prenatal visits and post partum visits.
More information can be found on the Health Plan Comparison Chart, each Plan's brochure, and directly from the Plan.
No – most, but not all, Medicaid recipients will enroll with BAYOU HEALTH.
The first recipients targeted for enrollment are Medicaid and LaCHIP recipients under age 19, their parents, pregnant women and enrollees who receive Medicaid because of age, disability or blindness.This group represents approximately two-thirds of all Medicaid enrollees, and includes all enrollees currently covered through CommunityCARE 2.0.
Native Americans and children under age 19 who receive SSI, are in foster care or are in juvenile justice custody will have the choice of voluntarily enrolling or remaining Medicaid fee-for-service recipients.
Recipients who are not part of the initial implementation are residents of a long-term care facility, Medicare dual eligibles, individuals enrolled in a Home and Community Based Waiver, recipients enrolled in Medicaid only for family planning services, Louisiana Health Insurance Premium Payment (LaHIPP) program recipients and children in the LaCHIP Affordable Plan.
As improving quality is a key objective, DHH is requiring that Health Plans work with their network PCPs to attain formal recognition as a primary care medical home (PCMH), with the percentage increasing each year. The alternative to urgent care clinics in DHH's experience is often the hospital emergency room. To the extent that a Health Plan utilizes urgent care clinics, DHH's expectation would be that the care is coordinated with the PCP (e.g., payment to the urgent care facility contingent on their providing the clinical records of the visit to the PCP and or the Health Plan).
Members contacting the Enrollment Center (or subsequently the Health Plan) to indicate preferred PCP are not restricted to only PCPs who practice in the GSA in which they reside. If their preferred PCP is in the Health Plan's Directory, they can request linkage to the PCP.
DHH's Contract with the Health Plans includes language that Health Plans can allow members to have a specialist as their PCP if the specialist is willing to perform the responsibilities of a PCP.
The member should contact member services for the Health Plan in which they are enrolled to request a specialist be assigned as their PCP, as this preference is not an option when enrolling through the Enrollment Center.
The populations that are excluded and will be in fee-for-service are
Medicare Dual Eligibles (people who have both Medicare and Medicaid)
Recipients who resident in a nursing facility, development center, or group home
Recipients enrolled in a Medicaid Home and Community Based Waiver (NOW, Children's Choice, Supports, Adult Day Health Care, Residential Options, Elderly & Disabled Adult (new name Community) or PACE
Recipients with limited eligibility periods of 3 months or less (Spend-down Medically Needy)
Recipients receiving a single service (family planning, for example)
New Medicaid and LaCHIP enrollees will be excluded for any retroactive period, the month they are added to the eligibility file, and up to two months following, until they are enrolled in a BAYOU HEALTH Plan (which will always be the first day of a month, except for newborns).
Providers are allowed to tell their patients which Health Plans they have enrolled with, so their patients can choose a Health Plan with that provider in it, if they wish. But, providers must disclose all Health Plans of which they are a member, and providers cannot steer patients toward any particular Health Plan. Also, any signage or other forms of marketing in a provider’s office must be equal. If a provider has a large sign for one Health Plan, he or she must have signs of the same size for the other plans in which he or she participates.
A Medicaid number cannot be assigned to a baby until after birth. The Baby will be automatically assigned to the mother's health plan. The mother will have an opportunity to change the baby's plan, if she wishes.
All members of a GSA where BAYOU HEALTH has been implemented should be linked (either by their own choice or auto assignment) to a health plan. If the aforementioned programs indicate that there is no linkage, the member would fall in one of the categories that is excluded from participation in BAYOU HEALTH, or is in the voluntary population.
Mailing Address: Department of Health & Hospitals | P. O. Box 629 | Baton Rouge, LA 70821-0629 Physical Address: 628 N. 4th Street | Baton Rouge, LA 70802 | PHONE: 225.342.9500 | FAX: 225.342.5568 | Disclaimer For Bayou Health1-855-BAYOU4U (1-855-229-6848 )