Louisiana

Under Bayou Health, a Medicaid managed care program implemented in early 2012, Louisiana is implementing two new managed care models:
  1. A prepaid risk bearing managed care organizations model, and
  2. A coordinated care network with a shared savings model (CCN-S)

The coordinated care network with a shared savings model meets NASHPs set of three core characteristics and capabilities for inclusion under this map. The state defines coordinated care networks as organized health care delivery systems designed to improve access to care and the quality of services, as well as to promote healthier outcomes for Medicaid recipients through the establishment of a medical home system of care. Each CCN-S is required by state regulations to develop and maintain effective continuity of care activities, which ensure a continuum of care approach to providing health care services to members. The CCN-S can share in up to 60 percent of savings if the aggregate costs of authorized services are less than a risk-adjusted Per Capita Prepaid Benchmark (contingent upon meeting clinical quality performance measure benchmarks).

The state Department of Health and Hospitals put out Requests for Proposals for the CCN-S in April 2011. The Department announced in July 2011 that two entities, UnitedHealthcare of Louisiana, Inc. and Community Health Solutions of America, Inc., would be participating in the shared savings CCN model.

To learn more about Louisiana’s medical home initiatives, including the coordinated care networks, visit the Louisiana page of NASHP’s medical homes map.

Last updated November 2013.

 

Project Scope
Patient population: Participation in coordinated care networks in Louisiana is mandatory for categorically needy children up to 19 years of age and their parents; pregnant women; aged, blind, and disabled adults; uninsured women under the age of 65 who have been identified as being in need of treatment for breast and/or cervical cancer; uninsured women eligible through the Louisiana Children’s Health Insurance Program Prenatal Option; and medically needy individuals and families.
Participation is voluntary for Native Americans/Alaskan Natives and foster care children.
Covered services: A coordinated care network with a shared savings model (CCN-S) provides enhanced primary care case management in addition to contracting with primary care providers for primary care management. The CCN-S is also responsible for coordinating services outside of primary care including, but not limited to:
  • inpatient hospital services;
  • outpatient hospital services;
  • ancillary medical services;
  • organ transplant-related services;
  • EPSDT/Well Child visits;
  • emergency medical services;
  • communicable disease services;
  • emergency medical transportation;
  • home health services;
  • family planning services
  • basic behavioral health services;
  • school-based health clinic services;
  • physician services;
  • maternity services;
  • chiropractic services; and
  • rehabilitation therapy services (physical, occupational, and speech therapies).
Attribution: As part of the eligibility determination process, Medicaid and LaCHIP applicants shall receive information and assistance with making informed choices about the CCNs in their area of residence and the availability of choice counseling. These individuals will have the opportunity to talk with an enrollment broker who shall provide additional information to assist in choosing the appropriate CCN.
Each new recipient is given at least 30 calendar days from the postmark date of an enrollment form mailed by the enrollment broker to select a CCN and primary care provider (PCP). Recipients who fail to choose a CCN will be auto-assigned.

Authority
The Centers for Medicare & Medicaid Services approved a State Plan Amendment to implement Coordinated Care Networks as part of a new Medicaid managed care program, Bayou Health. The State Plan Amendment took effect on February 1, 2012.
Governance
Coordinated care networks contract with Louisiana’s Department of Health and Human Services.
Requirements for the makeup of the coordinated care network shared savings (CCN-S) entities are not specified, but the Request for Proposals released by the Louisiana Department of Health and Hospitals establishes that on-site readiness reviews of the CCN-S will focus on the performance of the governing body, among other areas.
Criteria for Participation
State regulations require that a Medicaid-participating entity operating under the coordinated care network shared savings (CCN-S) model be a successful bidder, awarded a contract, and pass a readiness review. A CCN-S must:
  • meet the definition of a primary care case manager in accordance with federal regulations;
  • be a legal entity domiciled in Louisiana and registered with the Louisiana Secretary of State’s Office to do business in the state;
  • have the capability to pre-process claims (with the exception of carved-out services) and transfer data to the department’s fiscal intermediary or have a contract with an entity to perform these functions;
  • provide financial reports as requested by the department;
  • post a surety bond for an amount specified by the department for the at-risk portion of the enhanced care management fee;
  • post a performance bond for an amount specified by the department;
  • not have an actual or perceived conflict of interest that, in the discretion of the department, would interfere or give the appearance of possibly interfering with its duties and obligations under this Rule, the contract and any and all appropriate guides
  • and have network capacity to enroll a minimum of 75,000 Medicaid and LaCHIP eligibles into the network in each DHH designated geographic service area.
Payment
Under a fee-for-service with coordinated care networks shared savings (CCN-S) model, the CCN-S receives monthly enhanced primary care case management fees, as well as lump sum savings payments if it is eligible. The CCN-S in turn reimburses primary care providers a monthly case management fee for each enrollee assigned to the primary care provider.
The state will establish a Per Capita Prepaid Benchmark (PCPB) based on the health risk for Medicaid enrollees in the CCN-S. Periodic reconciliations (for time periods covering at least 12 months of service) are performed by the Department of Health and Hospitals to determine total medical cost incurred by the CCN-S. If the CCN-S exceeds the PCPB, it will be required to refund to the state up to 50 percent of the total amount of enhanced primary care case management fees paid to the CCN-S during the performance period. The CCN-S is eligible to receive up to 60 percent of savings if the actual aggregate costs of authorized services, including enhanced primary care case management fees advanced, are less than the aggregate PCPB.
Due to federally mandated limitations under the Medicaid State Plan, shared savings will be limited to five percent of the actual aggregate costs including the enhanced primary care case management fees paid.
Support for Infrastructure
Each CCN-S is required to provide technical support and appropriate incentives to assist primary care practices with their transition to a patient-centered medical home model. The CCN-S is also required to facilitate the data interchange between the network and the department.
Measurement and Evaluation
The coordinated care networks with shared savings (CCN-S) are contractually required to establish and implement a quality assessment and performance improvement program.
During the CCN Program’s first two years of implementation, any distribution of CCN-S savings will be contingent upon the CCN meeting the established “early warning system” administrative performance measures and compliance under the contract. After the second year of implementation, distribution of savings will be contingent upon the CCN-S meeting department established clinical quality performance measure benchmarks and compliance with the contract.