DHH Announces Five Contract Recommendations for Coordinated Care Networks to Improve Health Outcomes for Louisiana Medicaid Recipients
Networks will emphasize preventive care, ensure better access to treatment
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| Monday, July 25, 2011 | Contact: Lisa R. Faust; (225) 342-7913 or (225) 252-3579 (cell) |
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BATON ROUGE - The Louisiana Department of Health and Hospitals today announced the five entities recommended to administer Coordinated Care Networks (CCNs), which will transform the way two-thirds of the State's Medicaid recipients receive health care services.
Medicaid will offer two types of CCNs, prepaid and shared savings, and will implement the networks within three Geographic Service Areas (GSA), enrolling recipients in phases. Entities were allowed to propose networks for a specific GSA, or multiple areas.
All of the CCNs being recommended by the evaluation teams would serve all GSAs. The recommended CCNs are:
CCN-Prepaid
- Louisiana Healthcare Connections, Inc (whose parent company is Centene)
- Amerihealth Mercy of Louisiana, Inc
- AmeriGROUP Louisiana, Inc
CCN-Shared Savings
- UnitedHealthcare of Louisiana, Inc
- Community Health Solutions of America, Inc
"This selection represents an important step in our years of work and research to transform the State's health care delivery model, improving quality of life for recipients, reducing the burdens on providers and giving more value to the taxpayers who fund Medicaid," said DHH Secretary Bruce D. Greenstein. "These selections were made after an extensive, thorough review process, and I want to thank our hardworking staff members who put in so much time and care making these critical recommendations."
Under the prepaid model, CCNs will receive a monthly fee for each enrollee covered to provide core benefits and services, with prior authorizations and claims payment handled directly through the CCN. These networks also are responsible for establishing a robust provider network of primary care physicians, specialists, hospitals and other providers. The CCN-Shared Savings is a managed fee-for-service model that is responsible for coordinating the care of its members. The entity shares in the savings generated by improving health outcomes and reducing costs. In this model, providers will continue being paid on a fee-for-service basis by the state Medicaid program.
CCNs have a two-fold mission in making Louisiana Medicaid better - improving health outcomes and saving money for taxpayers by providing the preventive care and better managing costly and complex cases. In its first full year of implementation, fiscal year 2012-2013, the state is expected to save $135 million through better care coordination.
"Because Louisiana is one of only a few states not already coordinating recipients' care through these kinds of networks, we had the advantage of other states' experience to draw from in creating our CCN model," said Ruth Kennedy, Medicaid Deputy Director and Coordinated Care Networks Project Director. "We studied Medicaid programs in more than two dozen states, looking at what worked and what didn't. Based on these 'lessons learned,' we were able to develop very detailed network requirements that allowed our evaluation team to select the best entities for Louisiana, ones that demonstrated they can deliver the health care improvements our recipients deserve."
DHH used a competitive procurement process to select the CCNs, with a Request for Proposals issued April 11. Twelve entities submitted proposals by the June 30 deadline, with nine proposing a prepaid network and three proposing a shared savings network.
Entities that proposed a CCN-Prepaid but were not selected are:
- Aetna Better Health Inc.
- Children's Hospital Health Plan Inc.
- Coventry Cares of Louisiana Inc.
- Louisiana Cares Health Plan LLC
- United Healthcare of Louisiana Inc.
- Wellcare Health Plans Inc.
An entity that submitted a proposal to be a CCN-Shared Savings but was not selected is:
- LA Physicians Connections LLC
All but two entities proposed networks statewide, for all three GSAs. Two companies proposed networks for a single GSA - United Healthcare (GSA C) and Children's Hospital (GSA A), in both cases proposing a CCN-Prepaid network. Contracts were evaluated by GSA, so United Healthcare and Children's Hospital competed against only other proposers for that specific GSA, not statewide.
All of the proposals, with certain proprietary business information redacted as outlined in State law and in the RFPs, along with the score sheets used to evaluate the proposals, will be available for review by the public at www.MakingMedicaidBetter.com.
DHH used a consensus scoring process to extensively evaluate all proposals. Five teams separately reviewed each proposal to examine a specific aspect of that proposer's ability to provide services for Medicaid recipients:
- Team 1: Qualifications and Experience; Added Value to Louisiana
- Team 2: Planned Approach to Project; Provider Network; Fraud and Abuse
- Team 3: Member Enrollment and Disenrollment; Member Materials; Customer Service; Emergency Management Plan; Grievances and Appeals
- Team 4: Chronic Care/Disease Management; Service Coordination; Utilization Management; EPSDT; Quality Management
- Team 5: Third Party Liability (CCN-P only); Claims Management; Information System
The teams met independently to score their specific areas, and then the review committee combined the five teams' scores to determine each proposal's total score.
A network's operating cost was not a factor in these contract recommendations because DHH pre-determined CCN rates based on spending in the current Medicaid program. A network must reimburse providers at least equal to the Medicaid fee-for-service rate, and the CCNs will be required to spend at least 85 percent on direct patient care.
Because cost was not a factor, the recommendations were based on a potential CCN's qualifications, experience coordinating care for Medicaid recipients, additional benefits or value and how the network would work with patients and providers to improve health outcomes.
Several steps remain before CCN contracts are final and the networks are ready to begin operations. The Division of Administration must approve the evaluation process and the final contracts. Additionally, CCNs will undergo a thorough readiness review before any network can begin providing services to Medicaid recipients. To ensure network adequacy, each CCN must demonstrate it has a robust network of primary care providers (and specialists, hospitals, and other provider types in the case of the prepaid CCNs) in place to treat patients, sufficient support staff to handle administrative processes and provider relations, and the ability to meet all the deliverables specified in its proposals. The Centers for Medicare and Medicaid Services, the federal agency that monitors states' Medicaid programs, will review each CCN's contract and network adequacy, and must approve these before recipient services can begin. Any CCN that cannot meet these rigorous readiness review requirements will not be allowed to operate in Louisiana.
DHH has set a target date to go live in the first GSA (the New Orleans and Northshore areas) on Jan. 1. The other two areas of the state will transition to CCN coverage after this in 60-day increments.
The CCNs will coordinate health care services for nearly 900,000 Medicaid recipients, including 80,000 adults with disabilities who do not receive Medicare, children under age 19, their parents and pregnant women
Medicaid recipients not covered in CCNs include nursing home residents, home and community-based waiver recipients, Medicare dual eligibles and recipients enrolled for some specialty service Medicaid programs. These groups will continue receiving care through the current, strictly fee-for-service system. Additionally, certain available Medicaid services such as dental care, behavioral health treatment, and pharmacy will not be managed through CCNs.
Recipients will be given the opportunity to choose their own CCN, and will be encouraged to make a proactive choice of CCN rather than being auto-enrolled in a network. DHH recently announced contract awards for an enrollment broker and an education and outreach campaign contractor, who will assist in helping eligible Medicaid recipients to select a CCN. The education and outreach contractor will develop materials for enrollees and hold outreach events to provide them with information about the changes and how to take a proactive role in their healthcare decisions. The enrollment broker will act as an unbiased third party to assist Medicaid recipients in selecting a CCN, and will help them find networks that include their preferred medical providers and that best meet their family's health care needs. DHH will offer multiple opportunities for recipients to receive CCN choice counseling, either face-to-face or by phone. The enrollment broker will conduct follow-up phone calls to increase proactive members' choices of a CCN. Recipients who do not make a proactive choice of a CCN will be automatically enrolled in a network based on a detailed formula to place them in a network that meets their needs.
Doctors and other medical providers can sign contracts with as many CCNs as they wish, can participate in both prepaid and shared-savings networks, and may remain Medicaid fee-for-service providers to treat their patients who are not part of the initial CCN implementation. DHH has produced a CCN Resource Guide for Providers to address what medical professionals should expect during the transition to CCNs.
"For too many years, Louisiana has been at the bottom of national health care rankings, and coordinating care effectively is an opportunity to change these unfortunate statistics," Greenstein said. "These CCNs will shoulder a tremendous responsibility in improving health outcomes in Louisiana, which is why this process has been conducted with the highest level of care and attention. We know that better coordinating care will lead to better health, not only for Medicaid recipients, but for the state overall."
For more information on Coordinated Care Networks, including updates on the process and a detailed overview of CCN implementation, please visit www.MakingMedicaidBetter.com.
The Louisiana Department of Health and Hospitals strives to protect and promote health statewide and to ensure access to medical, preventive and rehabilitative services for all state citizens. To learn more about DHH, visit http://www.dhh.louisiana.gov. For up-to-date health information, news and emergency updates, follow DHH's blog, Twitter account and Facebook.
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