Current through Register Vol. 50, No. 9, September 20, 2024
A.
Payments to an MCO. The department, or its fiscal intermediary, shall make
monthly capitation payments to the MCO based on a per member, per month (PMPM)
rate.
1. The department will establish
monthly capitation rates within an actuarially sound rate range certified by
its actuaries. Consistent with all applicable federal rules and regulations,
the rate range will initially be developed using fee-for-service claims data,
Bayou Health shared savings claims data, Bayou Health managed care organization
encounter data, Louisiana Behavioral Health Partnership (LBHP) encounter data,
financial data reported by Bayou Health managed care organizations and the LBHP
statewide management organization, supplemental ad hoc data, and actuarial
analyses with appropriate adjustments.
2. As the Bayou Health managed care program
matures and fee-for-service, shared savings and LBHP data are no longer
available, there will be increasing reliance on Bayou Health managed care
organization encounter data and/or financial data to set future rates, subject
to comparable adjustments.
3.
Capitation rates will be set for all MCOs at the beginning of each contract
period and will be periodically reviewed and adjusted as deemed necessary by
the department.
4. Capitation rates
will be risk-adjusted for the health of Medicaid enrollees enrolled in the MCO
as appropriate.
a. The health risk of the
Medicaid enrollees enrolled in the MCO will be measured using a
national-recognized risk-assessment model.
b. Utilizing this information, the capitation
rates will be adjusted to account for the health risk of the enrollees in each
MCO relative to the overall population being measured.
c. The health risk of the members and
associated MCO risk scores will be updated periodically to reflect changes in
risk over time.
d. The department
will provide the MCO with advance notice of any major revision to the
risk-adjustment methodology.
5. Kick Payments. MCOs may be reimbursed a
onetime supplemental lump sum payment, hereafter referred to as a "kick
payment", for the provision of certain services that meet specific conditions,
in an amount determined by the departments actuaries.
a. The kick payment is intended to cover the
cost of a specific care event or treatment. Payment will be made to the MCO
upon submission of satisfactory evidence of the event or treatment.
b. Only one kick payment will be made per
event or treatment.
c.
Repealed.
6. Capitation
rates related to pharmacy services will be adjusted to account for pharmacy
rebates.
7. The department, or its
fiscal intermediary, may reimburse an MCOs monthly capitation payments or kick
payments in the aggregate on a lump sum basis when administratively
necessary.
B. As Medicaid
is the payor of last resort, an MCO must agree to accept the PMPM rate as
payment-in-full from the department and agree not to seek additional payment
from a member for any unpaid cost.
C. The MCO rate does not include graduate
medical education payments or disproportionate share hospital payments. These
supplemental payments will be made to applicable providers outside the PMPM
rate by the department according to methodology consistent with existing
Rules.
D. An MCO shall assume 100
percent liability for any expenditure above the PMPM rate.
E. The MCO shall meet all financial reporting
requirements specified in the terms of the contract.
F. An MCO shall have a medical loss ratio
(MLR) for each MLR reporting year, which shall align with the capitation rating
period, except in circumstances in which the MLR reporting period must be
revised to align to a CMS-approved capitation rating period.
1. Following the end of the MLR reporting
year, an MCO shall provide an annual MLR report, in accordance with the
financial reporting guide issued by the department.
2. The annual MLR report shall be limited to
the MCOs medical loss ratio for services provided to Medicaid enrollees and
payment received under the contract with the department, separate from any
other products the MCO may offer in the state of Louisiana.
3. An MLR shall be reported in the aggregate,
including all services provided under the contract, unless the department
requires separate reporting and a separate MLR calculation for specific
populations.
a. The aggregate MLR shall not
be less than 85 percent using definitions for health care services, quality
initiatives and administrative cost as specified in 45 CFR Part 158 . If the
aggregate MLR is less than 85 percent, the MCO will be subject to refund the
difference, within the timeframe specified, to the department. The portion of
any refund due the department that has not been paid, within the timeframe
specified, will be subject to interest at the current Federal Reserve Board
lending rate or in the amount of 10 percent per annum, whichever is
higher.
b. The department may
request MLR reporting that distinguishes physical and basic behavioral health
from specialized behavioral health. Neither the 85 percent minimum nor the
refund applicable to the aggregate shall apply to distinct MLRs
reported.
4. The
department shall provide for an audit of the MCOs annual MLR report and make
public the results within 60 calendar days of finalization of the
audit.
G . Any cost
sharing imposed on Medicaid members must be in accordance with the federal
regulations governing cost sharing and cannot exceed the amounts reflected in
the Louisiana Medicaid State Plan, but the amounts can be less than the cost
sharing levels in the State Plan.
H. The department may adjust the PMPM rate,
during the term of the contract, based on:
1.
changes to core benefits and services included in the capitation
rate;
2. changes to Medicaid
population groups eligible to enroll in an MCO;
3. changes in federal requirements;
and/or
4. legislative
appropriations and budgetary constraints.
I. Any adjusted rates must continue to be
actuarially sound and will require an amendment to the contract.
J. The MCO shall not assign its rights to
receive the PMPM payment, or its obligation to pay, to any other entity.
1. At its option, the department may, at the
request of the MCO, make payment to a third party administrator.
2. - 3.a. Reserved.
K. In the event that an incorrect payment is
made to the MCO, all parties agree that reconciliation will occur.
1. If an error or overcharge is discovered by
the department, it will be handled in accordance with the terms and conditions
of the contract.
L.
Network Provider Reimbursement
1.
Reimbursement for covered services shall be equal to or greater than the
published Medicaid fee-for-service rate in effect on the date of service,
unless mutually agreed by both the plan and the provider in the provider
contract to pay otherwise.
a. The MCO shall
pay a pharmacy dispensing fee, as defined in the contract, at a rate no less
than the minimum rate specified in the terms of the
contract.
2. The MCOs
subcontract with the network provider shall specify that the provider shall
accept payment made by the MCO as payment-in-full for core benefits and
services provided and shall not solicit or accept any surety or guarantee of
payment from the department or the member.
a.
The term "member" shall include the patient, parent(s), guardian, spouse or any
other legally responsible person of the member being
served.
3. The MCO shall
pay federally qualified health centers (FQHCs) and rural health clinics (RHCs)
at least the amount LDH would pay for such services through fee-forservice or
defined by the prospective payment system (PPS) rate or the alternative payment
methodology rate in effect on the date of service for each
encounter.
M.
Out-of-Network Provider Reimbursement
1. The
MCO is not required to reimburse more than 90 percent of the published Medicaid
fee-for-service rate in effect on the date of service to out-of-network
providers to whom they have made at least three documented attempts to include
the provider in their network as per the terms of the contract.
2. If three attempts to contract with the
provider prior to the delivery of the medically necessary service have not been
documented, the MCO shall reimburse the provider the published Medicaid
fee-for-service rate in effect on the date of service.
3. The MCO is not required to reimburse
pharmacy services delivered by out-of-network providers. The MCO shall maintain
a system that denies the claim at the point-of-sale for providers not
contracted in the network.
N. Reimbursement for Emergency Services for
In -Network or Out-of-Network Providers
1. The
MCO is financially responsible for ambulance services, emergency and urgently
needed services and maintenance, and post-stabilization care services in
accordance with the provisions set forth in
42
CFR §422.113.
2. The reimbursement rate for medically
necessary emergency services shall be no less than the published Medicaid
fee-for-service rate in effect on the date of service, regardless of whether
the provider that furnished the services has a contract with the MCO.
a. The MCO may not concurrently or
retrospectively reduce a providers reimbursement rate for these emergency
services, including ancillary and diagnostic services, provided during an
episode of care.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
