§1253.2. Medicaid managed care program; reporting

A. The Louisiana Department of Health shall submit an annual report concerning the Louisiana Medicaid managed care program and, if not included within that program, any managed care program providing dental benefits to Medicaid enrollees to the senate and house committees on health and welfare. The department shall submit the report by June thirtieth every year, and the applicable reporting period shall be for the previous state fiscal year except for those measures that require reporting of health outcomes which shall be reported for the calendar year prior to the current state fiscal year. The report shall include:            (1) Except when inapplicable due to the types of healthcare benefits administered by the particular managed care organization, the following information related to the managed care organizations contracted with the state to provide Medicaid-covered healthcare services to Medicaid enrollees:

(a) The name of each managed care organization that has contracted with the Louisiana Department of Health to provide healthcare services to Medicaid enrollees.

(b) The total number of employees employed by each managed care organization which is based in Louisiana and the average salary paid to those employees.

(c) The amount of the total payments and average per member per month payment paid by the state to each managed care organization delineated monthly.

(d) The total number of healthcare providers contracted to provide healthcare services for each managed care organization delineated by provider type, provider taxonomy code, and parish.

(e) The total number of providers contracted to provide healthcare services for each managed care organization that provides primary care services and submitted at least one claim for payment for services rendered to an individual enrolled in the health plan delineated by provider type, provider taxonomy code, and parish.

(f) The total number of providers contracted to provide healthcare services for each managed care organization that has a closed panel for any portion of the reporting period delineated by provider type, provider taxonomy code, and parish.

(g)(i) The medical loss ratio of each managed care organization and the amount of any refund to the state for failure to maintain the required medical loss ratio.

(ii) With respect to the monies comprising the managed care organization's medical loss ratio, the report shall include the following information:

(aa) Total expenditures on patient care.

(bb) Total expenditures on healthcare quality improvements.

(cc) Total expenditures on healthcare information technology.

(dd) Total expenditures on goods and services other than patient care, healthcare quality improvements, and healthcare information technology.

(h) A copy of the annual external quality review technical report produced pursuant to 42 CFR 438.364.

(i) A copy of the member and provider satisfaction survey report for each managed care organization.

(j) A copy of the annual audited financial statements for each managed care organization. The financial statements shall be those of the managed care organization operating in Louisiana and shall not be those financial statements of any parent or umbrella organization.

(k) A brief factual narrative of any sanctions levied by the Louisiana Department of Health against a managed care organization.

(l) For managed care organizations that administer dental benefits, a comparison of oral health outcomes that includes but is not limited to the percentage of eligible patients that saw a dentist in that fiscal year as well as the following rates of procedures performed on those who saw a dentist:

(i) Adult oral prophylaxis.

(ii) Child oral prophylaxis.

(iii) Dental sealants.

(iv) Fluoride varnish.

(v) Amalgam fillings.

(vi) Composite fillings.

(vii) Stainless steel crowns.

(viii) Extractions of primary teeth.

(ix) Extractions of permanent teeth.

(x) Pulpotomies performed on primary teeth.

(xi) Root canals performed on permanent teeth.

(2) The following information regarding Medicaid enrollees receiving healthcare services from a managed care organization:

(a) The total number of unduplicated enrollees enrolled during the reporting period, and the monthly average of the number of members enrolled in each managed care organization delineated by eligibility category of the enrollees.

(b) The number of members who proactively chose the managed care organization, and the number of members who were auto-enrolled into each managed care organization, delineated by managed care organization.

(c) The total number of enrollees who received unduplicated Medicaid services from each managed care network, broken down by provider type, provider taxonomy code, and place of service.

(d) The total number and percentage of enrollees of each managed care organization who had at least one visit with their primary care provider during the reporting period.

(e) The following information concerning hospital services provided to Medicaid enrollees:

(i) The number of members who received unduplicated outpatient emergency services, delineated by managed care organization.

(ii) The number of total inpatient Medicaid days delineated by managed care organization.

(iii) The total number of unduplicated members who received outpatient emergency services and had at least one visit to a primary care provider within the past year of receiving the outpatient emergency services.

(f) The number of members, delineated by each managed care organization, who filed an appeal, the number of members who accessed the state fair hearing process, and the total number and percentage of appeals that reversed or otherwise resolved a decision in favor of the member. For purposes of this Subparagraph, "appeal" means a request for review of an action.

(3) The following information related to healthcare services provided by healthcare providers to Medicaid enrollees enrolled in each of the managed care organizations:

(a) The total number of claims submitted by healthcare providers to each managed care organization. The total number shall also be delineated by claims for emergency services and claims for nonemergency services.

(b) The total number of claims submitted by healthcare providers to each managed care organization which were adjudicated by the respective managed care organization and payment for services was denied. This item of the report shall include a delineation between emergency and nonemergency claim denials. Additionally, this item of the report shall include the number of denied claims for each managed care organization delineated by the standard set of Claim Adjustment Reason Codes published by the Washington Publishing Company.

(c) The total number of claims submitted by healthcare providers to each managed care organization which meets the definition of a clean claim as it is defined in the contract executed between the state and the managed care organization, and the percentage of those clean claims that each of the managed care plans has paid for each provider type within fifteen calendar days and within thirty calendar days. In addition, the report shall include the average number of days for each managed care organization to pay all claims of healthcare providers delineated by provider type.

(d) The total number and percentage of regular and expedited service authorization requests processed within the time frames specified by the contract for each managed care organization. In addition, the report shall contain the total number of regular and expedited service authorization requests which resulted in a denial for services for each managed care organization.

(e) The total number and dollar value of all claims paid to out-of-network providers by claim type categorized by emergency services and nonemergency services for each managed care organization by parish.

(f)(i) The total number of independent reviews conducted pursuant to R.S. 46:460.81 et seq., delineated by claim type for each managed care organization.

(ii) The total number and percentage of adverse determinations overturned as a result of an independent review conducted pursuant to R.S. 46:460.81 et seq., delineated by claim type for each managed care organization.

(g) The following information concerning pharmacy benefits delineated by each managed care organization and by month:

(i) Total number of prescription claims.

(ii) Total number of prescription claims subject to prior authorization.

(iii) Total number of prescription claims denied.

(iv) Total number of prescription claims subject to step therapy or fail first protocols.

(v) The average and range of times for responding to prior authorization requests.

(vi) The number of prior authorization requests denied, delineated by the reasons for denial.

(vii) The number of claims denied after prior authorization was approved, delineated by the reasons for denial.

(h) The report shall include the following information concerning Medicaid drug rebates and manufacturer discounts delineated by each managed care organization and the prescription benefit manager contracted or owned by the managed care organization and by month:

(i) Total dollar amount of the Medicaid drug rebates and manufacturer discounts collected and used.

(ii) Total dollar amount of Medicaid drug rebates and manufacturer discounts collected and remitted to the Louisiana Department of Health.

(4) For managed care organizations that administer dental benefits, the following information concerning prior authorization requests, delineated by type of procedure:

(a) The number of prior authorization requests.

(b) The average and range of times for responding to prior authorization requests.

(c) The number of prior authorization requests denied, delineated by the reasons for denial.

(d) The number of claims denied after prior authorization was approved, delineated by the reasons for denial.

(5) Any other metric or measure which the Louisiana Department of Health deems appropriate for inclusion in the report.

B.(1) The Louisiana Department of Health shall submit quarterly reports to the Senate and House committees on health and welfare concerning the Medicaid expansion population and service utilization. The reports shall include all of the following:

(a) Medicaid expansion population data which shall include the following:            (i) Number of individuals enrolled in Medicaid for the reporting period who are eligible as part of the expansion population.

(ii) Number of individuals in the expansion population age nineteen to forty-nine and number of individuals age fifty to sixty-four.

(iii) Number of individuals in the expansion population in each age category with earned income.

(iv) Number of individuals in the expansion population in each age category assigned to a Medicaid managed care organization, identified by each individual managed care organization.

(v) The per-member per-month cost paid to each managed care organization to manage the care of the individuals in the expansion population assigned to their plan, identified by each individual managed care organization.

(b) Medicaid expansion population utilization data shall include the following:

(i) Comparison of individuals age nineteen to forty-nine, age fifty to sixty-four, and those who are covered by Medicaid who are not part of the expansion population utilizing the following services during the reporting period:

(aa) Emergency department.

(bb) Prescription drugs.

(cc) Physician services.

(dd) Hospital services.

(ee) Nonemergency medical transportation.

(ii) Expenditures associated with each service for individuals in the expansion population age nineteen to forty-nine, age fifty to sixty-four, and those who are covered by Medicaid who are not part of the expansion population during the reporting period.

(2) The quarterly reports required in this Subsection shall be submitted on the twentieth day of July, October, January, and April of each year, to include the data required in this Subsection, identified by month for the prior three months, with a collective chart of all data submitted to be included in the annual report provided for in Subsection A of this Section.

C.(1) The Louisiana Department of Health shall submit quarterly reports to the Senate and House committees on health and welfare encompassing the following data regarding the Medicaid managed care organizations' pharmacy benefit managers:

(a) The name of each pharmacy benefit manager, identified as contracted or owned by the Medicaid managed care organization.

(b) Whether the pharmacy benefit manager is a subsidiary of the parent company of the Medicaid managed care organization.

(c) The total dollar amount paid to the pharmacy benefit manager by the Medicaid managed care organization as a transaction fee for each processed claim.

(d) The total dollar amount of the Medicaid drug rebates and manufacturer discounts collected and retained by the Medicaid managed care organization and pharmacy benefit manager.

(e) The total dollar amount of the Medicaid drug rebates and manufacturer discounts collected by the Medicaid managed care organization and pharmacy benefit manager and remitted to the Louisiana Department of Health.

(f) The total dollar amount retained by the pharmacy benefit manager through spread pricing. For purposes of this Subparagraph, "spread pricing" means the actual amount paid as reimbursement to a pharmacist as compared to the amount the pharmacy benefit manager charged to and was reimbursed by the Medicaid managed care organization to identify the excess amount paid to the pharmacy benefit manager above what was paid to the pharmacist.

(g) Identification of any other monies retained by the pharmacy benefit manager not otherwise provided for in this Subsection that are not reimbursed to pharmacists.

(2) The quarterly reports required in this Subsection shall be submitted on the twentieth day of July, October, January, and April of each year, to include the data required in this Subsection, identified by month for the prior three months, with a collective chart of all data submitted to be included in the annual report provided for in Subsection A of this Section.

D. To the greatest extent possible, the Louisiana Department of Health shall include in the report at least three years of historical data for each of the measures set forth in Subsection A of this Section.

Acts 2013, No. 212, §1; Redesignated from R.S. 40:1300.362 by HCR 84 of 2015 R.S.; Acts 2015, No. 158, §1, eff. June 23, 2015; Acts 2017, No. 349, §1; Acts 2018, No. 482, §1, eff. May 25, 2018.