There are prompt payment requirements as part of the subcontract requirements that all Health Plans must include in their contracts with network providers. These include the provision that the Health Plan shall pay ninety percent (90%) of all clean claims of each provider type, within fifteen (15) business days of the date receipt. The Health Plan shall pay ninety-nine (99%) of all clean claims of each provider type, within thirty (30) calendar days of the date of receipt. The date of receipt is the date the prepaid Health Plan receives the claim, as indicated by its date stamp on the claim. The date of payment is the date of the check or Electronic Fund Transfer (EFT). The Health Plan and its subcontractors may, by mutual agreement, establish an alternative payment schedule. Any alternative schedule must be stipulated in the
All five (5) Health Plans are contracting with providers statewide now. To ensure inclusion in a Health Plan's initial printing of their Provider Directory for that GSA, providers need to have executed a contract with that Health Plan
by October 31, 2011, for GSA A;
by December 30, 2011, for GSA B; and
by February 27, 2012, for GSA C.
All deadlines and a complete listing of the timelines for statewide implementation can be found on the Making Medicaid Better Web site, under "Helpful Information".
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.
The department will ensure both the shared and pre-paid plans are available in each of the three Geographical Service Areas being used to phase in BAYOU HEALTH for Medicaid recipients (see map). The department anticipates two to three of each type of Health Plan will operate in each region.
Health Plans can ensure better coordination of member services, and will ease the burden on providers by assuming responsibility for referrals, care management services and disease management services. Health Plans have more flexibility than the current Medicaid program to restructure resources. The Plans will be better able than the current Medicaid program to support providers by assisting with issues such as transportation, referrals and patient compliance that can be problematic in the current program. The networks will better support providers in dealing with problematic patients so doctors do not have to expend the time and resources to do so.
As part of the contract, the Health Plans will be mandated to have strong, clearly outlined grievances-and-appeals processes. DHH will remain the final determiner of medical necessity, and any systemic denial of medically necessary services through a Health Plan would be treated as fraud.
One of the benefits we anticipate from BAYOU HEALTH implementation is that Health Plans will provide greater coordination of care and more intensive case management for complex patients than in our current Medicaid model. Note that members can see providers who practice in GSAs other than the GSA in which the member resides. The prepaid Plans (Amerigroup, LaCare, Louisiana Healthcare Connections) are required to provide their members will all necessary specialty care. The shared savings Plans (Community Health Solutions, UnitedHealth care Communty Plan) will coordinate specialty care through physicians in the Louisiana Medicaid provider network. The Health Plans should be able to provide additional specifics of care coordination and case management for their members.
School Based Health Clinics (SBHCs) can contract with the Prepaid Health Plans to provide services according to the terms of their contract. However, only those SBHCs that are open 12 months a year can serve as a PCP (and thus contract with a Shared Savings Plan). If the SBHC does not have a contract with a Health Plan or arrangements are not made by the Health Plan to pay the SBHC out of network, SBHCs will not receive reimbursement from Medicaid or the BAYOU HEALTH Plan in which the child is enrolled. DHH's contracts with the Health Plans do not include the current CommunityCARE policies relative to referrals needed by SBHCs for under age 12 and not needed for age 12 and over. Coordination of the child's care, however, is a contract requirement.
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.
Yes. All Medicaid ID numbers associated with your practice, including those for individual providers, for all sites and those associated specifically with CommunityCARE should all be given to each Health Plan you are contracting with to ensure appropriate linkages are made to Medicaid enrollees.
If these Health Plans have this allowance, apparently they have made a business decision-based on their considerable Medicaid managed care experience in other states to allow open access to specialists and not require prior authorization.
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.
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.
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 )