Louisiana

In Louisiana:
 
  • Medicaid services are delivered primarily through a primary care case management (PCCM) program called Bayou Health, which enrolls beneficiaries into one of five managed care Health Plans. Each of the five Health Plans that have contracts with Bayou Health to provide Medicaid services are accountable to the Louisiana Department of Health and Hospitals (DHH) and the state of Louisiana. Bayou Health was rolled out statewide in June 2012, and DHH anticipates that all Bayou Health participants will have access to a medical home, called Care Coordination Networks (CCNs), as the program continues to grow. There were a total of 1,208,859 beneficiaries enrolled in Louisiana’s Medicaid program as of July 2011. Of these, 789,871 were enrolled in managed care.*
  • Louisiana operates Bayou Health under a 1932(a) State Plan Amendment.
  • Bayou Health replaced KIDMED, Louisiana’s former EPSDT program, and now coordinates EPSDT services for members. Louisiana also offers two Medicaid Waiver Programs to children with developmental disabilities: Children’s Choice and New Opportunities. Services offered by these waiver programs include: case management, personal care respite support, environmental modifications and equipment. 
As of 2013, 822,015 individuals were eligible for EPSDT Louisiana Medicaid. According to CMS data from 2013, Louisiana achieved an EPSDT screening ratio of 94% and a participation ratio of 67%. 386,065 children received dental services of any kind, with 364,090 receiving preventive dental services.
 
*Note that all Louisiana enrollment data was collected prior to the complete rollout of Bayou Health.
 
Last updated May 2014
 
Medical Necessity
Louisiana’s definition of medical necessity, as defined in Title 50, Public Health Medical Assistance, Part I, Subpart 1, Chapter 11, §1101 is as follows:
  • Medically necessary services are defined as those health care services that are in accordance with generally accepted evidence-based medical standards or that are considered by most physicians (or other independent licensed practitioners) within the community of their respective professional organizations to be the standard of care.
 
  • In order to be considered medically necessary, services must be:
    • Deemed reasonably necessary to diagnose, correct, cure, alleviate or prevent the worsening of a condition or conditions that endanger life, cause suffering or pain or have resulted or will result in a handicap, physical deformity or malfunction.
    • Those for which no equally effective, more conservative and less costly course of treatment is available or suitable for the recipient.
 
  • Any such services must be individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment and neither more nor less than what the recipient requires at that specific point in time.
 
  • Although a service may be deemed medically necessary, it doesn’t mean the service will be covered under the Medicaid program. Services that are experimental, non-FDA approved, investigational or cosmetic are specifically excluded from Medicaid coverage and will be deemed "not medically necessary".
The Medicaid director, in consultation with the Medicaid medical director, may consider authorizing services at his discretion on a case-by-case basis.
 
Additionally, each of the five managed care plans that contract with Bayou Health have their own policies for referrals and prior authorization for services.
Initiatives to Improve Access

Reporting & Data Collection Louisiana contracts with IPRO to serve as an External Quality Review Organization (EQRO) to monitor the different managed care plans. The results form IPRO’s analysis are available on the Louisiana Department of Health and Hospitals Bayou Health page. IPRO tracked plan compliance with contract requirements including those related to care coordination, screening and referral services for EPSDT beneficiaries, and the integration of behavioral health and referral services as defined by the EPSDT benefit. Additionally, each CCN operating under the managed care plans are required to report on different performance measure sets including AHRQ and CHIPRA measures.
Behavioral Health
Behavioral health services are integrated into the services provided by the managed care plans. Louisiana also has two waiver programs that they use to provide services to individuals with developmental disabilities within a home or community-based setting.
 
The New Opportunities Waiver (NOW) provides: individualized and family support services, center-based respite, community integration and development, supported living, skilled nursing services, and others. To qualify for NOW the child must meet financial criteria and be three years and older and have a developmental disability that manifested prior to age 22.
 
The Children’s Choice Waiver (CC) offers support to children with developmental disabilities who currently live at home with their families, or who will leave an institution to return home. Services provided under this waiver include: all medically necessary Medicaid services, case management, family support, center-based respite, and family training. To qualify for CC the child must meet financial criteria, be age birth through 18 years, meet certain medical and/or psychological criteria, and meet the federal definition for developmental disability.
Support to Providers and Families  
Care Coordination
Under Bayou Health, the Louisiana Department of Health and Hospitals is simultaneously implementing two separate payment models designed to encourage care coordination.
 
The first is a prepaid model; in which three managed care plans (Amerigroup Louisiana, Amerihealth Mercy of Louisiana, Inc. and Louisiana Health Care Connections, Inc.) receive monthly risk-adjusted capitated payments. The plans also receive lump sump payments for obstetrical delivery to cover the cost of prenatal and post-partum costs. Networks are liable for 100% of any costs above the capitation rate.
 
The second is the shared savings model; in which two managed care plans (Community Health Solutions, Inc. and United Healthcare of Louisiana) receive per-member per-month (PMPM) enhanced primary care case management fees and, if earned, lump sum shared savings payments. The CCNs are required to pay a portion of these fees to primary care providers as a PMPM care coordination payment. The network’s fee is also subject to certain performance and savings benchmarks being met.  
Oral Health
The Louisiana Department of Health and Hospitals recently completed a competitive procurement process to select Managed Care of North America Dental (MCNA) to provide dental services to Medicaid and Louisiana Children’s Health Insurance Program (LaCHIP) enrollees. The anticipated start date for this program is July 1, 2014.