Current through Register Vol. 50, No. 9, September 20, 2024
A. The MCO shall be responsible for the
administration and management of its requirements and responsibilities under
the contract with the department and any and all department issued guides. This
includes all subcontracts, employees, agents and anyone acting for or on behalf
of the MCO.
1. No subcontract or delegation
of responsibility shall terminate the legal obligation of the MCO to the
department to assure that all requirements are carried out.
B. An MCO shall possess the
expertise and resources to ensure the delivery of core benefits and services to
members and to assist in the coordination of covered services, as specified in
the terms of the contract.
1. An MCO shall
have written policies and procedures governing its operation as specified in
the contract and department issued guides.
C. An MCO shall accept enrollees in the order
in which they apply without restriction, up to the enrollment capacity limits
set under the contract.
1. An MCO shall not
discriminate against enrollees on the basis of race, gender, color, national
origin, age, health status, sexual orientation, or need for health care
services, and shall not use any policy or practice that has the effect of
discriminating on any such basis.
D. An MCO shall be required to provide
service authorization, referrals, coordination, and/or assistance in scheduling
the covered services consistent with standards as defined in the Louisiana
Medicaid State Plan and as specified in the terms of the contract.
E. An MCO shall provide a chronic care
management program as specified in the contract.
F. The MCO shall establish and implement a
quality assessment and performance improvement program as specified in the
terms of the contract and department issued guides.
G . An MCO shall develop and maintain a
utilization management program including policies and procedures with defined
structures and processes as specified in the terms of the contract and
department issued guides.
H. An MCO
shall develop and maintain effective continuity of care activities which ensure
a continuum of care approach to providing health care services to
members.
I. The MCO must have
administrative and management arrangements or procedures, including a mandatory
compliance plan, that are designed to guard against fraud and abuse.
1. The MCO shall comply with all state and
federal laws and regulations relating to fraud, abuse, and waste in the
Medicaid and CHIP program as well all requirements set forth in the contract
and department issued guides.
J. An MCO shall maintain a health information
system that collects, analyzes, integrates and reports data as specified in the
terms of the contract and all department issued guides.
1. An MCO shall collect data on enrollees and
provider characteristics and on services furnished to members through an
encounter data system as specified in the contract and all department issued
guides.
K. An MCO shall
be responsible for conducting routine provider monitoring to ensure:
1. continued access to care for Medicaid
recipients; and
2. compliance with
departmental and contract requirements.
L. An MCO shall ensure that payments are not
made to a provider who is in non-payment status with the department or is
excluded from participation in federal health care programs (i.e., Medicare,
Medicaid, CHIP, etc.).
M. Medical
records shall be maintained in accordance with the terms and conditions of the
contract. These records shall be safeguarded in such a manner as to protect
confidentiality and avoid inappropriate disclosure according to federal and
state law.
N. An MCO shall
participate on the departments Medicaid Quality Committee to provide
recommendations for the Bayou Health Program.
O. An MCO shall participate on the
departments established committees for administrative simplification and
quality improvement, which will include physicians, hospitals, pharmacists,
other healthcare providers as appropriate, and at least one member of the
Senate and House Health and Welfare Committees or their designees.
P. The MCO shall provide both member and
provider services in accordance with the terms of the contract and department
issued guides.
1. The MCO shall submit member
handbooks, provider handbooks, and templates for the provider directory to the
department for approval prior to distribution and subsequent to any material
revisions.
a. The MCO must submit all
proposed changes to the member handbooks and/or provider handbooks to the
department for review and approval in accordance with the terms of the contract
and the department issued guides.
b. After approval has been received from the
department, the MCO must provide notice to the members and/or providers at
least 30 days prior to the effective date of any proposed material changes to
the plan through updates to the member handbooks and/or provider
handbooks.
Q.
The member handbook shall include, but not be limited to:
1. a table of contents;
2. a general description regarding:
a. how the MCO operates;
b. member rights and
responsibilities;
c. appropriate
utilization of services including emergency room visits for non-emergent
conditions;
d. the PCP selection
process; and
e. the PCPs role as
coordinator of services;
3. member rights and protections as specified
in
42 CFR
§438.100 and the MCOs contract with the
department including, but not limited to:
a.
a members right to disenroll from the MCO, including disenrollment for
cause;
b. a members right to change
providers within the MCO;
c. any
restrictions on the members freedom of choice among MCO providers;
and
d. a members right to refuse to
undergo any medical service, diagnoses, or treatment, or to accept any health
service provided by the MCO if the member objects (or in the case of a child,
if the parent or guardian objects)on religious grounds;
4. member responsibilities, appropriate and
inappropriate behavior, and any other information deemed essential by the MCO
or the department, including but not limited to:
a. immediately notifying the MCO if he or she
has a Workers Compensation claim, a pending personal injury or medical
malpractice law suit, or has been involved in an auto accident;
b. reporting to the department if the member
has or obtains another health insurance policy, including employer sponsored
insurance; and
c. a statement that
the member is responsible for protecting his/her identification card and that
misuse of the card, including loaning, selling or giving it to others could
result in loss of the members Medicaid eligibility and/or legal
action;
5. the amount,
duration, and scope of benefits available under the MCOs contract with the
department in sufficient detail to ensure that members have information needed
to aid in understanding the benefits to which they are entitled including, but
not limited to:
a. specialized behavioral
health;
b. information about health
education and promotion programs, including chronic care management;
c. the procedures for obtaining benefits,
including prior authorization requirements and benefit limits;
d. how members may obtain benefits, including
family planning services, from out-of-network providers;
e. how and where to access any benefits that
are available under the Louisiana Medicaid state plan, but are not covered
under the MCOs contract with the department;
f. information about early and periodic
screening, diagnosis and treatment (EPSDT) services;
g. how transportation is provided, including
how to obtain emergency and non-emergency medical transportation;
h. the post-stabilization care services rules
set forth in
42
CFR 422.113(c);
i. the policy on referrals for specialty
care, including specialized behavioral health services and other benefits not
furnished by the members primary care provider;
j. for counseling or referral services that
the MCO does not cover because of moral or religious objections, the MCO is
required to furnish information on how or where to obtain the
service;
k. how to make, change,
and cancel medical appointments and the importance of canceling and/or
rescheduling rather than being a "no show";
l. the extent to which and how after-hour
crisis and emergency services are provided; and
m. information about the MCOs formulary
and/or preferred drug list (PDL), including where the member can access the
most current information regarding pharmacy benefits;
6. instructions to the member to call the
Medicaid Customer Service Unit toll free telephone number or access the
Medicaid member website to report changes in parish of residence, mailing
address or family size changes;
7.
a description of the MCOs member services and the toll-free telephone number,
fax number, e-mail address and mailing address to contact the MCOs Member
Services Unit;
8. instructions on
how to request multi-lingual interpretation and translation services when
needed at no cost to the member. This information shall be included in all
versions of the handbook in English and Spanish;
9. grievance, appeal, and state fair hearing
procedures and time frames as described in
42
CFR §438.400 through §
438.424
and the MCOs contract with the department; and
10. information regarding specialized
behavioral health services, including but not limited to:
a. a description of covered behavioral health
services;
b. where and how to
access behavioral health services and behavioral health providers, including
emergency or crisis services;
c.
general information on the treatment of behavioral health conditions and the
principles of:
i. adult, family, child, youth
and young adult engagement;
ii.
resilience;
iii. strength-based and
evidence-based practices; and
iv.
best/proven practices;
d. description of the family/caregiver or
legal guardian role in the assessment, treatment, and support for individuals
with an emphasis on promoting engagement, resilience, and the strengths of
individuals and families; and
e.
any limitations involving the provision of information for adult persons who do
not want information shared with family members, including age(s) of consent
for behavioral health treatment, as per 42 CFR part 2.
R. The provider handbook shall
include, but not be limited to:
1. billing
guidelines;
2. medical
management/utilization review guidelines;
3. case management guidelines;
4. claims processing guidelines and
edits;
5. grievance and appeals
procedures and process;
6. other
policies, procedures, guidelines, or manuals containing pertinent information
related to operations and pre-processing claims;
7. description of the MCO;
8. core benefits and services the MCO must
provide, including a description of all behavioral health services;
9. information on how to report fraud, waste
and abuse; and
10. information on
obtaining transportation for members.
S. The provider directory for members shall
be developed in four formats:
1. a hard copy
directory to be made available to members and potential members upon
request;
2. an accurate electronic
file refreshed weekly of the directory in a format to be specified by the
department and used to populate a web-based online directory for members and
the public;
3. an accurate
electronic file refreshed weekly of the directory for use by the enrollment
broker; and
4. a hard copy
abbreviated version, upon request by the enrollment broker.
T. The department shall require
all MCOs to utilize the standard form designated by the department for the
prior authorization of prescription drugs, in addition to any other currently
accepted facsimile and electronic prior authorization forms.
1. An MCO may submit the prior authorization
form electronically if it has the capabilities to submit the form in this
manner.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
