Louisiana Administrative Code
Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE
Part I - Administration
Subpart 3 - Managed Care for Physical and Behavioral Health
Chapter 33 - Coordinated Care Network Shared Savings Model
Section I-3307 - Reimbursement Methodology

a. Interim determinations may be made for less than 12 months of service during the contract year. For dates of service with less than 12 months of elapsed time after the end of the contract period an adjustment for incurred but not reported (IBNR) claims will be made.

b. Final determinations will not be made for less than 12 months of service during the contract year. Final determinations will be made when all dates of service during the contract year have 12 months of elapsed time from the last date of service. Final determinations will use data updated since the interim determination.

a. The health risk of the Medicaid enrollees enrolled in the CCN-S will be measured using a nationally recognized risk-assessment model.

b. Utilizing this information, the PCPBs will be adjusted to account for the health risk for the enrollees in each CCN-S relative to the overall population being measured.

c. The health risk of the enrollees and associated CCN-S risk scores and the PCPBs will be updated periodically to reflect changes in risk over time.

a. nursing facility;

b. dental services;

c. personal care services (children and adults);

d. hospice;

e. school-based individualized education plan services provided by a school district and billed through the intermediate school district;

f. specified Early Steps Program services;

g. specialized behavioral health services (e.g. provided by a psychiatrist, psychologist, social worker, psychiatric advanced nurse practitioner;

h. targeted case management;

i. non-emergency medical transportation;

j. intermediate care facilities for persons with intellectual disabilities;

k. home and community-based waiver services;

l. durable medical equipment and supplies; and

m. orthotics and prosthetics.

a. Shared savings will be limited to five percent of the actual aggregate costs, including the enhanced primary care case management fees paid. Such amounts shall be determined in the aggregate and not for separate enrollment types.

b. The department may make an interim payment to the CCN for savings achieved based on the interim determination. Interim payments shall not exceed 75 percent of the eligible amount.

c. The department will make a final payment to the CCN for savings achieved based on the final determination. The final payment amount will be up to the difference between the amount of the interim payment (if any) and the final amount eligible for distribution.

d. For determination periods during the CCN-S first two years of operation, 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 operation, distribution of savings will be contingent upon the CCN-S meeting department established clinical quality performance measure benchmarks and compliance with the contract.