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Louisiana’s Medicaid Managed Care Quality

Strategy

Prepared by: The Bureau of Health Services Financing

Louisiana Medicaid

Quality Improvement, Population Health, and Health

Equity Section

September 2023

Louisiana Medicaid Managed Care Quality Strategy

Table of Contents

1. INTRODUCTION – MANAGED CARE GOALS, OBJECTIVES AND OVERVIEW..........1

1.1 History of Managed Care in Louisiana .......................................................... …..... 1

1.2 Quality Strategy Aims, Goals, and Objectives ............................................. .......... 2

1.3 Quality Management Structure................................................................................. 4

2. DRIVING IMPROVEMENT AND MONITORING PROGRESS ........................................... 5

2.1 Goals and Objectives for Continuous Quality Improvement ................................. 5

2.2 MCO Performance Measures .................................................................................... 5

2.3 Performance Measures and Performance Improvement Projects (PIPs) ............. 5

2.4 Other Medicaid Quality Interventions .................................................................... 10

2.5 Annual External Independent Reviews .................................................................. 12

2.6 Procedures for Identifying, Evaluating, and Reducing Health Disparities ......... 13

2.7 Use of Sanctions ........................................................................................................ 15

3. STATE STANDARDS FOR ACCESS AND CLINICAL POLICIES AND GUIDELINES 17

3.1 Provider Network Adequacy Standards and Availability of Services ................. 17

3.2 Adoption & Dissemination of Evidence-Based Clinical Practice Guidelines .....29

3.3 Transition of Care Policy ......................................................................................... 29

3.4 Mechanisms Used to Identify Persons with Special Health Care Needs (SHCN)

.................................................................................................................................... 30

3.5 Non-Duplication Strategy ........................................................................................ 31

4. EVALUATING, UPDATING, AND DISSEMINATING THE QUALITY STRATEGY .... 33

4.1 Quality Strategy Development and Public Comment ........................................... 33

4.2 Quality Strategy Review, Update, and Evaluation ................................................ 33

5. APPENDIX A: Louisiana Medicaid MCO Performance Measures (Measurement Year 2023

and Subsequent Years) ..............................................................

.................................................. 35

Louisiana Medicaid Managed Care Quality Strategy

1 Introduction – Managed Care Goals, Objectives and

Overview

1.1 History of Managed Care in Louisiana

Louisiana’s Medicaid managed care program is responsible for providing high-quality, innovative, and

cost-effective health care to Medicaid enrollees. Guided by the Triple Aim, the Louisiana Department of

Health (LDH) partners with enrollees, providers, and health plans to continue building a Medicaid

managed care delivery system that improves the health of populations (better health), enhances the

experience of care for individuals (better care) and effectively manages costs of care (lower costs).

More specifically, the Department’s Medicaid managed care objectives include:

 advancing evidence-based practices, high-value care and service excellence;

 supporting innovation and a culture of continuous quality improvement (CQI) in Louisiana;

 ensuring enrollees ready access to care, including through innovative means such as medical

homes and telehealth;

 improving enrollee health;

 decreasing fragmentation and increasing integration across providers and care settings,

particularly for enrollees with behavioral health needs;

 using a population health approach, supported by health information technology, to advance

health equity and address social determinants of health (SDOH);

 reducing complexity and administrative burden for providers and enrollees;

 aligning financial incentives and building shared capacity to improve health care quality through

data and collaboration; and,

 minimizing wasteful spending, unnecessary utilization, and fraud.

Today, Louisiana Medicaid serves over 1.8 million Louisianans, approximately 39% percent of the state’s

population. Six (6) statewide Managed Care Organizations (MCOs), one (1) Behavioral Health Prepaid

Inpatient Health Plan (PIHP) and two (2) Dental Prepaid Ambulatory Health Plan (PAHP) pay for

healthcare services for more than 90 percent of the Louisiana Medicaid population, including more than

481,000 new adults since Medicaid expansion took effect in July 2016. These managed care entities

(MCOs) pay for Medicaid benefits and services included in the Louisiana Medicaid state Plan, state

statutes and administrative rules, Medicaid policy and procedure manuals. In addition, these MCOs also

provide specified value-added Medicaid benefits and services. Accreditation information for Louisiana’s

MCOs are posted to the Medicaid Quality Initiatives website and can be accessed at

https://ldh.la.gov/index.cfm/subhome/47. Accreditation information for Louisiana’s PIHP is posted to the

Behavioral Health Coordinated System of Care (CSoC) website and can be accessed at

https://ldh.la.gov/index.cfm/page/1342. Accreditation information for Louisiana’s PAHPs are posted to

the Dental Services website and can be accessed at https://ldh.la.gov/index.cfm/page/2067 or directly at

https://ldh.la.gov/assets/docs/BayouHealth/Dental/DBPM_Accreditation_Web_Posting_11.3.22.pdf.

On February 1, 2012, the Louisiana Department of Health (LDH) transitioned nearly 900,000 Medicaid

enrollees from the state’s 45-year-old fee-for-service (FFS) program to a Medicaid managed care model.

Rollout occurred in phases based upon designated geographic service areas, with the statewide rollout

Louisiana Medicaid Managed Care Quality Strategy

completed on June 1, 2012. In transitioning from fee-for-service to a Medicaid managed care model,

Louisiana sought to:

 Improve access to care

 Improve care coordination

 Increase emphasis on disease prevention and the early diagnosis and management of chronic

conditions

 Improve health outcomes and quality of care

 Provide for a more financially stable Medicaid program

In 2014, LDH issued a request for proposal (RFP) for its second-generation, full-risk Medicaid managed

care contracts, with a start date of February 1, 2015. The RFP provided for an initial three-year contract

term and the option to extend the contracts up to 24 months. Subsequently, the Louisiana Legislature

approved a 23-month extension to these contracts, from February 1, 2018 through the contract expiration

date of December 31, 2019.

In December 2015, LDH integrated specialized behavioral health services into the managed care

program in an effort to improve care coordination for enrollees and facilitate provision of whole-person

health care. Louisiana also continues to administer the Coordinated System of Care (CSoC), a single

behavioral health PIHP to help children with behavioral health challenges that are at risk for out of home

placement. Wraparound support and other services are provided to assist children with staying in or

returning to their home.

In 2021, LDH initiated procurement for its third-generation, full-risk Medicaid managed care contracts.

The new third-generation, full-risk Medicaid managed care contracts with six (6) MCOs went into effect

on January 1, 2023.

1.2 Quality Strategy Aims, Goals, and Objectives

This Quality Strategy establishes clear aims, goals, and objectives to drive improvements in care delivery

and health outcomes as well as metrics by which progress will be measured. It articulates priority

interventions, and details the standards and mechanisms for holding MCOs accountable for desired

outcomes. The Quality Strategy is a roadmap by which LDH will use the managed care infrastructure to

facilitate improvement in health and health care through programmatic interventions.

Guided by the Triple Aim and the broad aims of the National Quality Strategy – Better Care, Healthy

People, Healthy Communities, and Affordable Care – Louisiana’s Quality Strategy framework defines

and drives the overall vision for advancing health outcomes and quality of care provided to Louisiana

Medicaid enrollees. Described in Table 1, these broad aims link to Louisiana specific goals and

objectives, intended to highlight key areas of quality focus for the Louisiana Medicaid managed care

program.

Table 1: Louisiana Quality Strategy Aims, Goals, and Objectives

Aims Goals Objectives

Better Care. Make

health care more

Ensure access to care to

meet enrollee needs

Ensure timely and approximate access to primary

and specialty care

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives

person-centered,

coordinated, and

accessible so it occurs

at the “Right care, right

time, right place.”

Improve coordination

and transitions of care

Ensure appropriate follow-up after emergency

department visits and hospitalizations through

effective care coordination and case management

Ensure appropriate hospice onboarding and

transitioning from palliative care to hospice

Facilitate patient-

centered, whole-person

care

Engage and partner with enrollees to improve

enrollee experience and outcomes

Integrate behavioral and physical health

Healthier People,

Healthier

Communities. Improve

the health of

Louisianans through

better prevention and

treatment and proven

interventions that

address physical,

behavioral, and social

needs.

Promote wellness and

prevention

Ensure maternal safety and appropriate care during

childbirth and postpartum

Prevent prematurity and reduce infant mortality

Promote healthy development and wellness in

children and adolescents

Promote oral health in children

Improve immunization rates

Prevent obesity and address physical activity and

nutrition in children and adults

Prevent prematurity and reduce infant mortality

Improve cancer screening

Improve HIV and Hepatitis C virus infection

screening

Promote early initiation of palliative care to improve

quality of life.

Promote healthy development and wellness in

children and adolescents

Promote use of evidence-based tobacco cessation

treatments

Improve chronic

disease management

and control

Improve hypertension, diabetes, and cardiovascular

disease management and control

Improve respiratory disease management and

control

Improve HIV control

Improve quality of mental health and substance use

disorder care

Partner with

communities to

improve population

health and address

Stratify key quality measures by race/ethnicity and

rural/urban status and narrow health disparities

Advance specific interventions to address social

determinants of health

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives

health disparities

Smarter Spending.

Demonstrate good

stewardship of public

resources by ensuring

high-value

, efficient

care.

Pay for value and

incentivize innovation

Advance value-based payment arrangements and

innovation

Minimize wasteful

spending

Ensure members that are improving or stabilized in

hospice are considered for discharge

Reduce low value care

*High value services, as defined by the Institute of Medicine, represent the “best care for the patient, with the optimal result for

the circumstances, delivered at the right price.” Low-value services represent care that does not meet these criteria.

Underpinning these aims, objectives and goals are a robust set of quality interventions/strategies and

quality performance measures that MCOs are required to measure and report progress against, as

described in Section 2, Driving Improvement and Monitoring Progress.

1.3 Quality Management Structure

The day-to-day operations of the Medicaid managed care program are the responsibility of the Bureau of

Health Services Financing within LDH, with support from all LDH “program offices” – Office of

Behavioral Health (OBH), Office of Public Health (OPH), Office of Aging and Adult Services (OAAS),

and Office for Citizens with Developmental Disabilities (OCDD). The Medicaid Quality Improvement,

Population Health, and Health Equity Section, in collaboration with these program offices, the Medicaid

Chief Medical Officer and Medicaid Executive Management Team, is responsible for the development,

implementation and evaluation of the Medicaid Managed Care Quality Strategy.

The Louisiana Medical Care Advisory Committee fulfills the role required by 42 CFR 431.12. The

Committee provides focus and direction for Medicaid program quality improvement activities to promote

access and utilization of quality, evidence-based healthcare that is designed to meet the health needs of all

Louisiana Medicaid and Children’s Health Insurance Program enrollees.

Members of the Committee and its subcommittees provide advisory insight to the Medicaid program.

This Committee provides recommendations for the delivery of high quality care. It is interdisciplinary and

includes representatives who are familiar with quality improvement and the medical needs of Medicaid

enrollees.

Louisiana Medicaid Managed Care Quality Strategy

2 DRIVING IMPROVEMENT AND MONITORING

PROGRESS

2.1 Goals and Objectives for Continuous Quality Improvement

LDH is committed to a culture of Continuous Quality Improvement (CQI). We require MCOs to engage

in and support CQI on clinical and administrative metrics, and work with providers and the Department to

bring innovation to all aspects of health care. We expect MCOs to evaluate the effectiveness of program

interventions and adjust continuously to optimally support whole-person centered care and improved

health outcomes for enrollees.

2.2 MCO Performance Measures

Louisiana requires MCOs to report annually on patient outcome performance measures, including the

Healthcare Effectiveness Data and Information Set (HEDIS®) quality metrics, CMS Adult and Children

Core Set, Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators, Consumer

Assessment of Healthcare Providers and Systems (CAHPS) measures, and state-specified quality

measures. The state may add or remove performance measure reporting requirements prior to the start of

a measurement year. Current MCO performance measure reporting requirements are described in

Appendix A. All performances measures listed in Appendix A are listed on the Louisiana Medicaid

Managed Care Quality Dashboard, which can be accessed at http://qualitydashboard.ldh.la.gov/.

Currently, one percent of each MCO’s monthly capitated payment is withheld to incentivize a core set of

quality and health outcomes (denoted in Appendix A with “$$”). The MCO may earn back the quality

withhold for the measurement year based on its performance on incentive-based measures relative to

targets as established by LDH. LDH aligns HEDIS benchmarks to NCQA Quality Compass Medicaid

National 50th percentile. Targets for non-HEDIS incentive-based measures are equal to the best

performance reported to LDH by any MCO for the prior measurement year. To earn back the full

withhold amount associated with each incentive-based measure, MCO performance must either meet the

target for that measure or improve by at least two points from the prior measurement year.

2.3 Performance Measures and Performance Improvement Projects

(PIPs)

In accordance with 42 CFR 438.340 and 42 CFR § 438.330(d), MCOs must have an ongoing program of

PIPs that focus on clinical and non-clinical areas. A PIP is intended to improve the care, services or

enrollee outcomes in a focused area of study. In addition to any CMS specified PIPs, LDH requires

MCOs to perform two LDH-approved PIPs, a minimum of one additional LDH-approved behavioral-

health PIP each contract year, and may require up to two additional projects for a maximum of five PIPs.

PIPs are designed to achieve, through ongoing cycles of enrollee input, planned intervention, and

measurement, significant improvement on priority health outcomes sustained over time.

LDH-approved MCO, PIHP, and PAHP PIPs are listed below in Tables 2 and 3.

Louisiana Medicaid Managed Care Quality Strategy

Table 2: Medicaid MCO Performance Improvement Projects

2021-2023 Ensuring access to the

COVID-19 vaccine among

Healthy Louisiana vaccine-

eligible enrollees

Implement interventions to achieve the following

objectives:

 Enrollee Interventions

o Refer and facilitate making appointments for

eligible enrollees engaged in case

management to COVID-19 vaccination sites.

o Refer and facilitate making appointments for

eligible enrollees NOT engaged in case

management to COVID-19 vaccination sites.

o Educate and inform enrollees on vaccine

merits, safety and accessibility with

comprehensive and clear communication in

accordance with the State of Louisiana

communication plan for the COVID-19

vaccine [e.g., LDH COVID-19 website:

Louisiana Coronavirus COVID-19 |

Department of Health | State of Louisiana

(la.gov) ].

o Provide enrollees with second dose reminders

for those overdue.

 Provider Interventions

o Distribute listings of COVID-19 vaccine-

eligible enrollees, as well as listings of

pharmacy vaccination sites and other LINK-

enrolled providers, to PCPs.

o Conduct training and education of providers,

when necessary, using LINKS training videos

and CDC/ACIP evidence-based guidance in

collaboration with the Tri-Regional LINKS

Outreach Coordinators.

 Collaborate with state and local partners

o Outreach to racial/ethnic minority enrollees.

Utilize COVID-19 vaccination coverage

reports generated in LINKS to track and

monitor COVID-19 vaccination rates and to

determine pockets of need (e.g., zip code and

region level). Collaborate and coordinate with

the Louisiana Department of Health

Vaccination Strike Teams to vaccinate hard-

to-reach target populations in Louisiana.

o Collaborate with the Office of Public Health

on vaccine education materials.

Louisiana Medicaid Managed Care Quality Strategy

2023 Cervical Cancer Screening

Implement interventions to achieve the following

objectives:

 Member Objective: Improve the HEDIS

Cervical Cancer Screening performance indicator

by developing and implementing interventions for

the following eligible populations ages 21-64

years:

o Eligible population of women who are in

case management.

o Eligible population of women who are not

in case management and have at least one

PCP or OB/GYN visit during the

measurement year.

o Eligible population of women who are not

in case management and have not had any

PCP or OB/GYN visits during the

measurement year. Interventions must

address provider linkage.

o Disparity subpopulations identified using

the Analysis of Disproportionate Over-

Representation (cervical cancer

prevalence) and Under-Representation

(cervical cancer screening).

 Provider Objective: Improve the HEDIS

Cervical Cancer Screening performance indicator

by developing and implementing provider

interventions (must include Gaps-In-Care Report

and Provider Education).

2023 HIV Screening

Implement interventions to achieve the following

objectives:

 Member Objective: Improve the HIV screening

rate by developing and implementing member

interventions for the following eligible adolescent

and adult with populations 1 through 3 screened

during the measurement year, and the last eligible

population ever screened:

o Pregnant persons or persons with

encounters for labor and delivery

o Persons with past or present injection

drug use

o Persons with contact with and (suspected)

exposure to infections with a

Louisiana Medicaid Managed Care Quality Strategy

predominantly sexual mode of

transmission or to human

immunodeficiency virus or persons with

high-risk heterosexual behavior, high-risk

homosexual behavior, or high-risk

bisexual behavior; This would also

include persons diagnosed with infections

with a predominantly sexual mode of

transmission

o All others aged 15 to 65 years (without a

current or past HIV diagnosis)

 Provider Objective: Improve the HIV screening

rate for the total eligible population by implement

provider interventions for PCP providers and

OB/GYN/prenatal care providers

2022-2023 Dental: Fluoride Varnish

Application to Primary

Teeth of All Enrollees

Aged 6 Months through 5

Years by Primary Care

Clinicians

Implement interventions to:

 Perform member outreach

 Perform provider education

 Prepare Member Fluoride Varnish Care Gap

Report

2022-2023 Behavioral Health

Transitions in Care

Implement interventions to improve performance

improvement of the following measures:

 Follow-Up after Hospitalization for Mental Illness

 Follow-Up After Emergency Department Visit for

Mental Illness

 Follow-Up After Emergency Department Visit for

Alcohol and Other Drug Abuse or Dependence

Table 3: Dental (PAHP) and CSoC (PIHP) Performance Improvement Projects

2021-2023 Dental: Improving the

percentage of children with

their 10th birthdate in the

measurement year who

have ever received sealants

on permanent molar teeth:

 at least one sealant

and

 all four molars

sealed

Implement interventions to:

 Improve member access to preventive dental

visits

 Educate parents about the importance of dental

sealants to prevent cavities

 Educate dental providers about evidence-based

clinical recommendations regarding sealants.

Louisiana Medicaid Managed Care Quality Strategy

2023 CSoC: Increase the

Effectiveness of Plans of

Care in Addressing

Actionable Clinical Needs

of Youth Enrolled in CSoC

CSoC enrollees are deemed at risk for or are currently in

out-of-home placement and often have cross-system

involvement (e.g., juvenile justice, child welfare, or

special education). Services are administered using the

Wraparound model, an intensive, structured, team-based

care coordination process that prioritizes the preferences

and perspectives of the youth and family throughout the

design and implementation of the plan of care (POC).

This project aims to improve the integration and

incorporation of clinical interventions and evidence-based

treatment (EBT) in addressing the actionable clinical

needs of youth enrolled in CSoC. This will be measured

through Plan of Care (POC) Reviews completed by the

CSoC Contractor’s Care Managers to monitor POC

submissions to assess adherence to practice standards and

verify that required program activities are completed.

Specifically, Care Managers will review members’ POCs

to determine the extent to which member needs are linked

to the assessment, evidence-based practices are considered

to address member needs where appropriate, and strategies

reflect member strengths and needs (and the effectiveness

of strategies).

2019-2022 CSoC: Monitoring

Hospitalization Follow Up

Practices

Implement the following interventions with the objective

to drive improvement in the rate of Coordinated System of

Care (CSoC) enrollee discharges from a mental health

hospitalization with appropriate follow up:

 Utilize PST services of members to increase

engagement with families while the youth is

hospitalized with purpose of providing additional

support to family and educating family about the

importance of FUH process.

 Expand the accessibility and availability of

Licensed Mental Health Professional (LMHP)

providers by increasing the reimbursement rates

to incentivize qualified providers to schedule

appointments within 7 days of discharge.

 Magellan will conduct clinical rounds for youth

while hospitalized in order to identify risks, need

for specialized services, supports available to

family during times of crisis, exchange

information between the care and utilization

management teams and facilitate coordination of

care between the WAA and the inpatient provider.

 Wraparound facilitators will conduct a crisis CFT

during the inpatient hospitalization or no later

than three business days from the date of the

Louisiana Medicaid Managed Care Quality Strategy

discharge with a goal of revising the Plan of Care

and crisis plan

2.3.1 PIP Topics and Processes

Each PIP must be completed in a reasonable time period so as to generally allow information on the

success of PIPs in the aggregate to produce new information regarding quality of care every year. Quality

improvement project topics should:

 Include aims that are expressed as a Specific, Measureable, Actionable, Realistic, and Time-bound

(SMART)

 Connect to the specific health outcomes prioritized in the LDH Quality Strategy

 Use key driver diagrams (or other cause-and-effect diagrams) to show the theory of improvement or

how the interventions being tested are thought to impact the project goal (SMART aim)

 Incorporate enrollee voice and concerns into topic choice and/or theory of improvement

 Use clear descriptions of methods used to identify key drivers, associated interventions, and

prioritization of interventions (e.g., process mapping, Pareto analyses, root cause analyses, Failure

Mode & Effects Analysis, Gemba walk)

 Reflect examples of intervention tests (PDSAs) and lessons learned

 Use objective quality indicators to measure performance including: whether the measure is a process

measure, an outcome measure, or balancing measure, data source(s) for the measure, the intervention

or driver to which the measure is linked, the frequency of measurement, the frequency of review of

longitudinal (time series) measurement data, stratification of key data by race and other demographic

factors to assess for disparities, and, mention of methods used to draw conclusions from the data (e.g.,

identification of special cause or the degree of variance in processes)

 Use longitudinal (trended) depictions (run charts, control charts, line graphs) of the MCO’s

improvement project outcomes over time with annotation of intervention periods and special cause

identification

 Include results and lessons learned from performance and quality improvement projects and describe

how these are communicated within and across the organization, as well as integrated into the overall

MCO QAPI program

 Define processes or procedures that have been or will be put in place to sustain and spread successful

interventions

LDH facilitates regular PIP meetings with MCOs to provide guidance and clinical leadership and allow

for MCO collaboration. The EQRO validates MCO PIPs and related performance measures each year and

produces a report, reviewed and approved by LDH prior to release to MCOs, which summarizes the PIP

results and findings for each MCO and recommendations for improvement.

2.4 Other Medicaid Quality Interventions

LDH has developed a series of interventions aligned closely with the Quality Strategy, designed to build

an innovative, whole-person centered, well-coordinated system of care that addresses both medical and

non-medical drivers of health. These interventions drive progress towards the Quality Strategy aims,

goals, and objectives described in Section 1, Introduction – Managed Care Goals, Objectives and

Overview. Progress against these aims, goals, and objectives, and the role of interventions in achieving

those goals, will be assessed using the measures defined in Appendix A of this document.

Louisiana Medicaid Managed Care Quality Strategy

2.4.1 MCO Withhold of Capitation Payments for Increasing Use of Value-Based

Payments (VBP) and Improving Health Outcomes

Effective February 2018, Medicaid introduced a two percent (2%) withhold requirement into its MCO

contracts to incentivize quality, health outcomes, and VBP. Effective January 2023, health equity was

introduced as a third component of the two percent (2%) withhold.

 Half of the total withhold (i.e., 1%) is tied to the achievement of quality and health outcomes,

specifically on MCOs’ performance on the Medicaid managed care incentive-based quality

measures identified in Appendix A.

 Half of the remaining total withhold amount (i.e., 0.5%) is linked to increasing the use of VBP.

The MCO’s VBP strategy must pertain to measurable outcomes that are meant to improve

quality, reduce costs, and increase patient satisfaction. The VBP strategy placed emphasis on the

establishment of provider payment arrangements designated as categories 3 and 4 and the

evolution of providers along the APM model continuum (i.e. from less sophisticated to more

advanced categories) with consideration of provider readiness to take on financial risk.

 The remaining withhold (i.e., 0.5%) is linked to MCO reporting and performance relative to the

MCO’s health equity strategies, including health equity deliverables such as the MCO’s Health

Equity Plan.

2.4.2 Managed Care Incentive Payment (MCIP) Program

Effective January 2019, the MCIP program is designed to provide incentive payments to Medicaid MCOs

for achieving quality reforms that increase access to health care, improve the quality of care, and/or

enhance the health of MCO enrollees. Current quality reforms focus on increasing enrollees’ access to

primary health care, improving health outcomes for pregnant women, newborns, and enrollees with

chronic conditions, as well as reducing inefficiencies and costs by reducing unnecessary utilization,

promoting evidence-based practices, and reducing low-value care.

2.4.3 Health Information Technology (HIT)

LDH’s approach to the long-term sustainability of its current and future HIT and health information

exchange (HIE) statewide infrastructure began with the creation of its 2018 - 2021 Louisiana HIT

Roadmap. The Roadmap and concepts developed since it was published provide provides a foundational

framework to achieve ubiquitous, interoperable health care data sharing among participants throughout

the broader Louisiana health care community. LDH continues to support current opportunities and build

upon statewide initiatives with the collective purpose of improving the health of individuals, families and

communities. LDH is currently working on its’ future sustainability plan and reviewing several of the

initiatives outlined in the current Roadmap. These reviews will result in the updating of the Louisiana

Department of Health Roadmap with future state goals that will support sustainability of current projects

and statewide interoperability development.

2.4.4 Other LDH Department-Wide Quality Initiatives

Integral to this Quality Strategy and related aims, goals, and objectives are LDH-wide quality strategies

and initiatives supported by the Medicaid managed care program, such as:

 Taking Aim at Cancer in Louisiana: a statewide initiative that brings together leaders across

sectors in healthcare, business, government, community, advocacy, philanthropy and other

sectors to work toward the common goal of improving cancer outcomes in Louisiana.

 Louisiana Perinatal Quality Collaborative: a voluntary network of perinatal care providers,

public health professionals and patient and community advocates who work to advance equity

Louisiana Medicaid Managed Care Quality Strategy

and improve outcomes for parents, families, and newborns in Louisiana, supported by LDH and

authorized by the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality.

 Opioid Strategy: Through expanded federal grants from the Centers for Disease Control and

Prevention and the Substance Abuse and Mental Health Services Administration, LDH will

continue to work to expand access to opioid use disorder treatment in primary care settings.

 Hepatitis C Elimination Strategy: LDH executed an innovative payment model for direct-acting

antivirals in Medicaid with the goal of eliminating hepatitis C virus infection in Louisiana.

2.5 Annual External Independent Reviews

The MCOs’ adherence to federal and state regulatory requirements and performance standards will be

evaluated annually, in accordance with 42 CFR 438.340, by an independent EQRO. This will include a

review of the services for timeliness, outcomes, and accessibility, using definitions contained in 42 CFR

438.320.

The scope of the annual EQR conducted by the state for MCOs, as outlined in 42 CFR 438.310(b),

includes: a) criteria used to select entities to perform the reviews, b) specification of activities to be

performed by the EQRO, c) the circumstances in which the EQR may use other accreditation review

results and d) standards for availability of review results. The annual EQR will be conducted each

calendar year, with the first EQR report including any months prior to the first full calendar year of

operation.

The activities to be performed by the EQRO broadly include: measurement of quality and appropriateness

of care and services; synthesis of results compared to the standards, and recommendations based on the

findings. The EQRO will meet these obligations by utilizing the EQR protocols developed by CMS to

perform the mandatory activities required of EQROs, as mentioned in 42 CFR 438.352 and 438.358,

including data to be gathered, data sources, activities to ensure accuracy, validity and reliability of data,

proposed data analysis and interpretation methods and documents and/or tools necessary to implement the

protocol.

The state ensures the EQRO has sufficient information for the review from the mandatory and optional

EQR-related activities described in the regulation, as outlined in 42 CFR 438.350. This information will

be obtained through methods consistent with established protocols, include the elements described in the

EQR results section, and results will be made available, as specified in the regulation.

Requirements of MCOs include the following:

 The MCO shall provide all information requested by the EQRO and/or LDH including, but not

limited to, information concerning timeliness of, and enrollee access to, benefits and services.

 The MCO shall cooperate with the EQRO during the review (including medical records review),

which will be done at least one (1) time per calendar year.

 A description of the performance improvement goals, objectives, and activities developed and

implemented in response to the EQRO findings will be included in the MCO's QAPI program. LDH

may also require separate submission of an improvement plan specific to the findings of the EQRO.

If an MCO is deemed non-compliant during any aspect of the EQR process, a corrective action plan may

be developed to address areas of noncompliance, including a timeline for achieving compliance. LDH

provides ongoing monitoring of the corrective action plan.

Louisiana Medicaid Managed Care Quality Strategy

If the EQRO indicates that the quality of care is not within acceptable limits set forth in the Contract,

LDH may sanction the MCO in accordance with the provisions of the MCO contract and may suspend

automatic assignment until the MCO attains a satisfactory level of quality of care as determined by the

EQRO.

The EQRO produces, at least, the following information, as required in 42 CFR 438.364(a), without

disclosing the identity of any patient, as mentioned in 42 CFR 438.364(c):

 A detailed technical report describing data aggregation and analysis and the conclusions

(including an assessment of strengths and weaknesses) that were drawn as to the quality,

timeliness, and access to care furnished by the MCO. For each activity conducted, the report does

include objectives, technical methods of data collection and analysis, description of data obtained

and conclusions drawn from the data;

 Recommendations for improving the quality of health care services furnished by the MCO; and,

 An assessment of the degree to which the MCO effectively addressed previous EQRO review

recommendations.

EQR results and technical reports are reviewed by LDH. Ongoing EQR status reports and final technical

and project reports are communicated through the Louisiana Medicaid Provider and Plan Resources,

Reporting and Accountability website (http://ldh.la.gov/index.cfm/page/1582). Report results, including

data and recommendations, are analyzed and used to identify opportunities for process and system

improvements in LDH and MCO quality management programs, improvements to PIPs and Medicaid

managed care quality performance measures, and determination of regulatory compliance of the MCOs.

LDH will provide copies of the EQRO results and reports, upon request, to interested parties through

print or electronic media or alternative formats for persons with sensory impairments, as mentioned in 42

CFR 438.364(c). LDH will also provide copies of the EQRO results and reports to CMS. In addition,

summary results and findings will be included in reports to the legislature and to the public, as

appropriate.

2.6 Procedures for Identifying, Evaluating, and Reducing Health

Disparities

2.6.1 Diversity and Inclusion

LDH characterizes diversity as representing the differences and similarities of all of us that include, for

example, individual characteristics (e.g., disability, age, education level, poverty status, rural/urban

setting, race, ethnicity, and sexual orientation), values, beliefs, experiences and backgrounds. LDH also

characterizes inclusion as creating a work environment in which all individuals are treated fairly and

respectfully, have equal access to opportunities and resources, and can contribute fully to the work of our

agency. This is inclusive of LDH also building its capacity to create, support and/or fund (i.e., via

programming projects and contracts) efforts that do not discriminate against people, populations, and/or

communities due to disability, age, education level, poverty status, rural/urban setting, race, ethnicity, and

sexual orientation. LDH believes that diversity and inclusion aid in more equitably achieving its mission

– “…protect and promote health and to ensure access to medical, preventive and rehabilitative services

for citizens of the State of Louisiana.”

2.6.2 Data Collection

In compliance with the requirements set forth in 42 CFR 438.340 (b)(6), and described in Section 2,

Driving Improvement and Monitoring Progress, MCOs must report select measures outlined in Appendix

A based on select strata such as age, race, ethnicity, sex, primary language, rural/urban status and

Louisiana Medicaid Managed Care Quality Strategy

disability status, where feasible. This information is provided to MCOs upon enrollee enrollment and will

be used by LDH to better understand disparities of care within and across MCOs.

The five racial categories for which data are gathered by the MCOs are: American Indian/Alaskan Native,

Asian, Native Hawaiian/Pacific Islander, Black/African American and White. The two ethnic categories

are: Hispanic or Latino and Non-Hispanic or Latino. When individuals do not self-identify their race and

ethnicity, alternative system checks and follow-up with households are performed. If a racial and/or

ethnic category cannot be obtained, the identification defaults to “Unknown.” Medicaid enrollees, who

are a member of any federally recognized American Indian or Alaskan Native tribe, may voluntarily elect

to enroll in the Medicaid managed care program.

During the Medicaid application process, the applicant may identify race, ethnicity, and primary spoken

language. The data collected for race and language is processed through the Louisiana Medicaid

Eligibility Determination System and downloaded nightly into the Medicaid Management Information

System (MMIS). The applicant’s preferred language is also identified and forwarded to the MMIS.

Because this is a voluntary disclosure, LDH relies on demographic updates to the eligibility system.

Although this method does not collect 100 percent of the required data, there are data for a significant

portion of Medicaid enrollees.

2.6.3 Communications with MCOs

LDH contracts with an Enrollment Broker that is responsible for Medicaid managed care program

enrollment and disenrollment. Daily, the Enrollment Broker provides updates on those newly enrolled

into the Medicaid managed care program. In addition, at specified times each month, the Enrollment

Broker notifies each MCO regarding those that will be enrolled, re-enrolled or disenrolled to/from their

MCO for the following month. The Enrollment Broker provides LDH a listing of current enrollees, via

electronic media, on a monthly basis. MCOs, or their administrators, must be capable of uniquely

identifying each enrollee across multiple systems within its span of control. To facilitate care delivery

appropriate to client needs, the enrollment file includes race/ethnicity, primary language spoken, and

selective health information. MCOs utilize this information to provide interpreter services and facilitate

enrollee needs in the context of their cultural and language requirements.

MCOs are required to ensure that translation services are provided for written marketing and enrollee

education materials for any language that is spoken as a primary language for 200 or more MCO enrollees

within the geographic service area. The state requires that MCOs and any contractors have interpretation

services for those who speak any language other than English. The Enrollment Broker will provide multi-

lingual interpreters and enrollment material in other alternate formats (large print, and/or Braille) as

needed.

2.6.4 Evaluating Health Disparities

LDH is committed to ensuring that improvements in health outcomes lead to equitable improvements in

all groups. As a first step, LDH is requiring routine reporting of quality measures stratified by

race/ethnicity as well as urban/rural status. LDH will support MCOs in including measures of health

disparities in all quality improvement activities. Based on their results over time, LDH will develop (or

require MCOs to develop) targeted interventions and/or other strategies to address identified disparities.

In addition, beginning in 2018, LDH’s EQRO conducts a Health Disparities Survey of each MCO and

includes the results in the Annual Technical Reports (ATR).

Louisiana Medicaid Managed Care Quality Strategy

In 2020, LDH formed a Medicaid Health Equity Action Team to review Medicaid policy, procedures and

processes to advance health equity initiatives and strategic goals.

Furthermore, LDH has strategies to address health disparities identified through data collection, data

stratification, and analysis. Strategies include, but are not limited to leveraging managed care contracts to

address disparities, health equity and SDOH; stratification of Medicaid performance measures; utilizing

performance improvement projects to create targeted interventions for subpopulations experiencing health

disparities; track and monitor improvements; publish quality measure data for public review; administer

health disparities surveys to the MCOs to identify gaps in care; stakeholder engagement and collaboration

with internal and external entities; and implementing the LDH Health Equity Framework.

2.7 Use of Sanctions

LDH may impose any or all sanctions, including requiring an MCO to take remedial action, imposing

intermediate sanctions, and/or assessing liquidated damages due to non-compliance with contract

requirements or applicable federal or state laws.

2.7.1 Acts or Failures to Act Subject to Intermediate Sanctions

Pursuant to 42 CFR §438.700, et seq., LDH may impose on the MCO intermediate sanctions if it

determines that an MCO acts or fails to act as follows:

 Fails substantially to provide medically necessary services that the MCO is required to provide, under

law or under the Contract, to an enrollee covered under the Contract;

 Imposes on enrollees premiums or charges that are in excess of the premiums or charges permitted

under the Louisiana Medicaid MCO Program;

 Acts to discriminate among enrollees on the basis of their health status or need for health care

services; this includes termination of enrollment or refusal to reenroll an enrollee, except as permitted

in Contract Section 2.3.13.3, or any practice that would reasonably be expected to discourage

enrollment by recipients whose medical condition or history indicates probable need for substantial

medical services.

 Misrepresents or falsifies information that it furnishes to CMS or to LDH;

 Misrepresents or falsifies information that it furnishes to an enrollee, potential enrollee, or a health

care provider;

 Fails to comply with the requirements for physician incentive plans, as set forth (for Medicare) in 42

CFR §422.208 and §422.210;

 Distributes directly, or indirectly through any agent or independent contractor, marketing materials

that have not been approved by LDH or that contain false or materially misleading information; or

 Violates any of the other applicable requirements of Section 1903(m), 1905(t)(3) or 1932 of the

Social Security Act and any implementing regulations.

2.7.2 Other Misconduct Subject to Intermediate Sanctions

LDH also may impose sanctions against any MCO if it finds any of the following non-exclusive

actions/occurrences:

Louisiana Medicaid Managed Care Quality Strategy

 The MCO has failed to correct deficiencies in its delivery of service after having received written

notice of these deficiencies from LDH;

 The MCO has been excluded from participation in Medicare because of fraudulent or abusive

practices pursuant to Public Law 95-142;

 The MCO or any of its owners, officers or directors has been convicted of a criminal offense relating

to performance of the Contract with LDH or of fraudulent billing practices or of negligent practice

resulting in death or injury to the MCO’s enrollee;

 The MCO has presented, or has caused to be presented, any false or fraudulent claim for services or

has submitted or has caused to be submitted false information to be furnished to the state or the

Secretary of the federal Department of Health and Human Services;

 The MCO has engaged in a practice of charging and accepting payment (in whole or part) from

enrollees for services for which a PMPM payment was made by LDH;

 The MCO has rebated or accepted a fee or portion of fee or charge for a patient referral;

 The MCO has failed to repay or make arrangements for the repayment of identified overpayments or

otherwise erroneous payments;

 The MCO has failed to keep or make available for inspection, audit or copying, such records

regarding payments claimed for providing services;

 The MCO has failed to furnish any information requested by LDH regarding payments for providing

goods or services;

 The MCO has made, or caused to be made, any false statement or representation of a material fact to

LDH or CMS in connection with the administration of the Contract;

 The MCO has furnished goods or services to an enrollee which at the sole discretion of LDH, and

based on competent medical judgment and evaluation are determined to be 1) insufficient for his or

her needs, 2) harmful to the enrollee, or 3) of grossly inferior quality.

2.7.3 Sanction Types

The types of intermediate sanctions that LDH may impose on the MCO shall be in accordance with §1932

of the Social Security Act (42 U.S.C. §1396u-2) and 42 CFR §438.702-708 and may include any of the

following:

 Civil monetary penalties in the amounts specified in 42 CFR §438.704

 Appointment of temporary management for an MCO as provided in 42 CFR §438.706;

 Granting enrollees the right to terminate enrollment without cause and notifying the affected

enrollees of their right to disenroll;

 Suspension of all new enrollments, including automatic assignment, after the effective date of the

sanction;

 Suspension of payment for enrollees enrolled after the effective date of the sanction and until

CMS or LDH is satisfied that the reason for imposition of the sanction no longer exists and is not

likely to recur in accordance with 42 CFR §438.730; and

 Additional sanctions allowed under state statutes or regulations that address areas of

noncompliance described above.

Louisiana Medicaid Managed Care Quality Strategy

3 State Standards for Access and Clinical Policies and

Guidelines

3.1 Provider Network Adequacy Standards and Availability of

Services

Louisiana’s MCO contracts include robust requirements to ensure that MCOs meet federal and state

requirements and standards for adequate Medicaid enrollee access to covered services. All standards for

network adequacy and availability of services are in accordance with the access and network adequacy

standards set forth in the applicable federal regulations.

The following tables summarize provider network standards, as indicated in LDH’s Medicaid MCO

Contract Attachment F: Provider Network Standards, and other access performance standards.

Table 4: Provider Access and Distance Standards

Type

Network Ratio

(Provider:

Member)

Rural Parishes

(miles)

Urban Parishes

(miles)

Primary Care

Adult

PCP (Family/General

Practice; Internal Medicine;

FQHC; RHC)

1:1,000 30 10

Pediatric

PCP (Pediatrics;

Family/General Practice;

Internal Medicine; FQHC;

RHC)

1:1,000 30 10

Hospitals

Acute Inpatient Hospitals 30 10

Ancillary

Laboratory 30 20

Radiology 30 20

Pharmacy 30 10

Hemodialysis Centers 30 10

Specialty Care

OB/GYN

1:10,000 30 15

Allergy/Immunology 1:100,000 60 60

Cardiology 1:20,000 60 60

Dermatology 1:40,000 60 60

Endocrinology and Metabolism

1:25,000 60 60

Gastroenterology 1:30,000 60 60

Hematology/Oncology 1:80,000 60 60

Nephrology 1:50,000 60 60

Neurology

1:35,000 60 60

Ophthalmology 1:20,000 60 60

Orthopedics

1:15,000 60 60

Otorhinolaryngology/

Otolaryngology

1:30,000 60 60

Urology 1:30,000 60 60

Louisiana Medicaid Managed Care Quality Strategy

Type

Network Ratio

(Provider:

Member)

Rural Parishes

(miles)

Urban Parishes

(miles)

Other Specialty Care 60 60

Type

Rural

Parishes

(miles)

Urban Parishes

(miles)

Psychiatrists 30 15

Specialty Care

Physicians and LMHPs

who specialize in pregnancy-related

and postpartum depression or related mental health disorders

and pregnancy-related

60 60

Physicians and LMHPs who specialize in pregnancy-related

and postpartum substance use disorders

60 60

Other Specialty Care 60 60

Licensed Mental Health Specialists

7, 9

Advanced Practice Registered Nurse (Nurse Practitioners and

Clinical Nurse Specialists with a behavioral health specialty)

30 15

Medical or Licensed Psychologist 30 15

Licensed Clinical Social Worker 30 15

Psychiatric Residential Treatment Facilities (PRTFs) (pediatric

)

Psychiatric Residential Treatment Facility 200 200

Psychiatric Residential Treatment Facility Addiction (ASAM

Level 3.7)

200 200

Psychiatric Residential Treatment Facility Other

Specialization

200 200

Substance Abuse and Alcohol Abuse Center - Outpatient

ASAM Level 1 30 15

ASAM Level 2.1 30 15

ASAM Level 2WM 60 60

Substance Use Residential Treatment Facilities (adult

)

ASAM Levels 3.1 30 30

ASAM Levels 3.3 30 30

ASAM Levels 3.5 30 30

ASAM Levels 3.2 –Withdrawal Management 60 60

ASAM Level 3.7 60 60

ASAM Level 3.7-Withdrawal Management 60 60

Substance Use Residential Treatment Facilities (pediatric

)

ASAM Level 3.1 60 60

ASAM Level 3.2 Withdrawal Management 60 60

ASAM Level 3.5 60 60

Psychiatric Inpatient Hospital Services

Hospital, Free Standing Psychiatric Unit 75 60

Hospital, Distinct Part Psychiatric Unit 75 60

Behavioral Health Rehabilitation Services

Mental Health Rehabilitation Agency (Legacy MHR) 30 15

Louisiana Medicaid Managed Care Quality Strategy

Behavioral Health Rehab Provider Agency (Non-Legacy

MHR)

30 15

For the purposes of assessing Network Adequacy, the MCO shall consider only those

Providers who are actively providing services to enrollees, which shall be defined as (1)

physical health providers who have submitted at least twenty-five (25) claims in an office

setting within the prior six (6) calendar months; (2) behavioral health providers who have

submitted at least twenty-five (25) claims within the prior six (6) calendar months; or (3)

any providers who were newly contracted within the prior six (6) calendar months,

regardless of claim submissions.

The network ratio is a calculation of the MCO’s Network Providers relative to the MCO’s

members.

Unless otherwise specified in this Attachment, the Contractor must demonstrate that one

hundred percent (100%) of applicable members (adult or pediatric) have access to

Network Providers for the type of service specified within the identified distance standard

from the Enrollee’s residence, based on a driving route versus a straight line calculation.

For purposes of assessing Network Adequacy for OB/GYN specialty services, access

standards are established based on female members age 21 and over. The Contractor

shall not include OB/GYN providers in its assessment of Network Adequacy for Primary

Care Services.

For purposes of reporting Network Adequacy for both physical and behavioral health

services, adult is defined as an Enrollee age 21 and over and pediatric is defined as an

enrollee under age 21.

In order to be included in the calculation, the Provider must work as a PCP at least 24

hours per week. The MCO may use physician extenders to meet PCP network ratios and

distance standards. Physician extenders include nurse practitioners and physician

assistants linked to a physician group who provide Primary Care Services. For calculation

of the network ratio, each physician extender is counted with a factor of 0.5 while physician

PCPs are counted with a factor of 1.0.

For these specialties, the travel distance standards shall be applied separately to the

Contractor’s adult and pediatric member populations and to specialists serving the

applicable age group(s).

The linkage ratio is a calculation of the MCO’s network provider to his/her patients who are

Louisiana Medicaid managed care enrollees, regardless of MCO. The linkage ratios

specified are applicable to providers who work as PCPs at least 24 hours per week.

Network standards are applied across the provider types listed collectively within the

identified distance standard from the Enrollee’s residence, based on a driving route versus

a straight line calculation from the applicable members (adult or pediatric) residences.

Louisiana Medicaid Managed Care Quality Strategy

Table 5: Provider Access and Timeliness Standards

Type of Visit/Admission/Appointment Access/Timeliness Standard

Emergency care 24 hours, 7 days/week within 1 hour of request

Urgent non-emergency care 24 hours, 7 days/week within 24 hours of request,

Non-urgent sick primary care 72 hours

Non-urgent routine primary care 6 weeks

After hours, by phone

Answer by live person or call-back from a

designated medical practitioner within 30 minutes

Ob/Gyn care for pregnant women

1st Trimester 14 days

2nd Trimester 7 days

3rd Trimester 3 days

High risk pregnancy, any trimester 3 days

Family planning appointments 1 week

Specialist appointments 1 month

Scheduled appointments Less than a 45 minute wait in office

Non-urgent routine behavioral health care 14 days

Urgent non-emergency behavioral health care 24 hours

Psychiatric inpatient hospital (emergency

involuntary)

4 hours

Psychiatric inpatient hospital (involuntary) 24 hours

Psychiatric inpatient hospital (voluntary) 24 hours

ASAM Level 3.3, 3.5 & 3.7 10 business days

Residential withdrawal management 24 hours when medically necessary

Psychiatric Residential Treatment Facility

(PRTF)

20 calendar days

Table 6: Dental Access to Care and Network Availability Standards

Network Capacity and Geographic Access Standards

 The Primary Dental Provider (PDP) may practice in a solo or group practice or may practice in a clinic

(i.e. Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) or outpatient clinic). The

Dental Benefit Program Manager (DBPM) shall contract with a sufficient number of PDPs needed to

meet the geographic access, appointment, and wait time standards outlined in this contract.

 The DBPM shall provide access to dentists that offer extended office hours (before 8:00 a.m., after 4:30

p.m., and/or on Saturdays) at least one (1) day per week.

 Network providers must offer office hours at least equal to those offered by commercial dental

insurance plans.

 If an enrollee requests a provider who is located beyond access standards, and the DBPM has an

appropriate provider within the DBPM network who accepts new patients, it shall not be considered a

violation of the access requirements for the DBPM to grant the enrollee’s request. The DBPM shall not

Louisiana Medicaid Managed Care Quality Strategy

submit encounters for travel outside of the access standards if an appropriate provider was available

within the access standards.

 The DBPM shall comply with the following maximum distance requirements, as determined by

mapping software (e.g. MapQuest, Google Maps, ArcGIS). Requests for exceptions as a result of

prevailing community standards must be submitted in writing to LDH for approval.

Distance to Primary Dental Services

 Travel distance from enrollee’s place of residence shall not exceed thirty (30) miles one-way for rural

areas and ten (10) miles one way for urban areas.

Distance to Specialty Dental Services

 Travel distance shall not exceed sixty (60) miles one-way from the enrollee’s place of residence for at

least seventy-five (75) percent of enrollees and shall not exceed ninety (90) miles one-way from the

enrollee’s place of residence for all enrollees.

 The DBPM shall ensure, at a minimum, the availability of the following specialists and other

providers for enrollees under the age of twenty-one (21) years:

 Endodontists;

 Maxillofacial Surgeons;

 Oral Surgeons;

 Orthodontists;

 Pedodontists;

 Periodontists;

 Prosthodontists; and

 Special Needs Pedodontists.

Timely Access Standards

 Urgent care services – within twenty-four (24) hours of a request for services that do not require prior

authorization and within forty-eight (48) hours for a request for services that do require prior

authorization;

 Primary Dental Care – within thirty (30) days; and

 Follow-up Dental Services – within thirty (30) days after assessment.

Table 7: Access Performance Standards

Access Performance Standards

Delivery Network

Contracted network of appropriate providers (42 CFR 438.206(b)(1))

Each MCO must meet the following requirements.

 Maintains and monitor a network of appropriate providers that is supported by written agreements and is

sufficient to provide adequate access to all services covered under the contract. In establishing and

maintaining the network, each MCO must consider the anticipated Medicaid enrollment, the expected

utilization of services, and take into consideration the characteristics and health care needs of specific,

Medicaid populations enrolled. The MCO must also consider the numbers and types (in terms of

training, experience, and specialization) of providers required to furnish the contracted Medicaid

services, the number of network providers who are not accepting new Medicaid patients, and the

geographic location of providers and Medicaid enrollees. Distance, travel time, the means of

transportation ordinarily used by Medicaid enrollees, will be considered and whether the location

provides physical access for Medicaid enrollees with disabilities.

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

 The MCO networks must be comprised of hospitals, physicians and specialists in sufficient numbers to

make available all covered services in a timely manner.

 The primary care network of the MCO must have at least 1 full time equivalent PCP for every 2,500

patients. Physicians with physician extenders (nurse practitioner/physician assistant, certified nurse

midwife or OB/GYNs only) may increase the physician ration by 1,000 per extender. The maximum

number of extenders shall not exceed two extenders per physician.

 The MCO shall ensure the availability of timely access to hospital care. Transport time will be usual and

customary, not to exceed 30 miles, except in rural areas where distance may be greater. If greater, the

standard shall be the community standard for accessing care. Exceptions must be justified, documented,

and submitted to LDH for approval. The MCO shall include, at a minimum, access to the following:

o One (1) hospital that provides emergency room services, inpatient, and outpatient care in each

parish in the state, provided the parish has such a hospital (free standing psychiatric hospitals

and distinct part psychiatric hospitals do not meet this requirement). The MCO must establish

access to the following within their network of hospitals:

 Level III Obstetrical services;

 Level III Neonatal Intensive Care (NICU) services;

 Pediatric services;

 Trauma services;

 Burn services; and

 A Children’s Hospital that meets the CMS definition in 42 C.F.R. §495.302 and

§412.23(d).

o Tertiary care is defined as health services provided by highly specialized providers, such as

medical sub-specialists; these services frequently require complex technological and support

facilities. The MCO shall provide tertiary care services including trauma centers, burn centers,

level III (high-risk) nurseries, rehabilitation facilities, and medical sub-specialists twenty-four

(24) hours per day. If the MCO does not have a full range of tertiary care services, the MCO

shall have a process for providing such services including transfer protocols and arrangements

with out-of-network providers.

Timely services for enrollees 438.3(q)(3)

 Each MCO must provide for arrangements with, or referrals to, sufficient numbers of physicians and other

practitioners to ensure that services under the contract can be furnished to enrollees promptly and without

compromise to quality of care.

Direct Access to Women’s Health Specialist (42 CFR 438.206(b)(2)

 Provides female enrollees with direct access to women’s health specialist within the network for covered

care, necessary to provide women’s routine and preventive health care services. This is in addition to the

enrollee’s designated source of primary care if that source is not a women’s health specialist.

 Contractors must ensure that the network procedures for accessing family planning services are convenient

and easily comprehensible to enrollees.

 A women's health specialist may serve as a primary care provider.

Adequate and Timely Second Opinion (42 CFR 438.206(b)(3))

 Provides for a second opinion from a qualified health care professional within the network, or arranges for

the enrollee to obtain one outside the network, at no cost to the enrollee.

Adequate and Timely Out-of-Network Providers (42 CFR 438.206(b)(4) & (b)(5))

 If the provider network is unable to provide necessary services, covered under the contract, to a particular

enrollee, the MCO must adequately and timely cover these services out of network for the enrollee, for as

long as the MCO provide

network is unable to provide them.

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

 Requires out-of-network providers to coordinate with the MCO with respect to payment and ensures that

cost to the enrollee is no greater than it would be if the services were furnished within the network.

Provider Credentialing as required in regulation (42 CFR 438.206(b)(6))

 Demonstrates that its providers are credentialed as required by § 438.214

Timely Access (42 CFR 438.206(c)(1)(i-vi))

 Each MCO must meet and require its network providers to meet State standards for timely access to care

and services, taking into account the urgency of the need for services. Standards for access and timeliness

are identified in the Provider Network Companion Guide.

 Ensure that the network providers offer hours of operation that are no less than the hours of operation offered

to commercial enrollees or comparable to Medicaid fee-for-service, if the provider serves only Medicaid

enrollees.

 Make services included in the contract available 24 hours a day, 7 days a week, when medically necessary.

 Establish mechanisms to ensure compliance by network providers, take corrective action if there is a failure

to comply.

 Monitor network providers regularly to determine compliance

 Take corrective action if there is a failure to comply by a network provider.

Reasonable and Adequate Hours of Operation 438.3(q)(1)

 Each MCO must provide for reasonable and adequate hours of operation, including 24-hour availability of

information, referral, and treatment for emergency medical conditions.

Cultural Considerations (42 CFR 438.206(c)(2))

 Each MCO participates in the state’s efforts to promote the delivery of services in a culturally competent

manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic

backgrounds.

o The MCO is required to have available interpretive services for all languages other than English upon

request.

o The MCO will encourage and foster cultural competency in its employees.

Assurances of Adequate Capacity 438.207

Documentation and Assurances of Adequate Capacity and Services (42 CFR 438.207 (b), (c))

 Each MCO must give assurances to the state and provide supporting documentation that demonstrates that it

has the capacity to serve the expected enrollment in its service area and in accordance with the State’s

standards for access to care including § 438.68 and § 438.206(c)(1)

o Nature of supporting documentation: Each MCO must submit documentation to the state, in a format

specified by the state to demonstrate that it complies with the requirements below.

o Offers an appropriate range of preventive, primary care, and specialty services that are adequate for

the anticipated number of enrollees for the service area.

o Maintains a network of providers that is sufficient in number, mix, and geographic distribution to

meet the needs of the anticipated number of enrollees in the service area.

o Timing of documentation: Each MCO must submit the required documentation, no less frequently than:

o at the time it enters into a contract with the state or at any time there has been a significant change

(as defined by the state) in the MCO operations that would affect adequate capacity and services,

including changes in Contractor services, benefits, geographic service area, payments or enrollment

of a new population with the MCO.

Coordination and Continuity of Care 438.208

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

Except as specified below, the State must ensure that through its contracts, each MCO complies with the

requirements of this section.

 Exception for MCOs that serve dually eligible enrollees.

o For a MCO that serves enrollees who are also enrolled in and receive Medicare benefits from a

Medicare+Choice plan, the state determines to what extent that a MCO must meet the primary care

coordination, identification, assessment, and treatment planning provisions of this section.

o The state bases its determination on the services it requires the MCO to furnish to dually eligible

enrollees.

Primary care and coordination of health care services for all MCO enrollees.

Each MCO must implement procedures to deliver primary care to and coordinate health care services for all

MCO enrollees. These procedures must meet state requirements and must do the following:

 Ensure that each enrollee has an ongoing source of primary care appropriate to his or her needs and a person

or entity designated as primarily responsible for coordinating the health care services furnished to the

enrollee.

 Coordinate the services the MCO furnishes to the enrollee with the services the enrollee receives from any

other MCO, PIHP, or PAHP, with services the enrollee receives in FFS; and with the services the enrollee

receives from community and social support providers.

 Provide that the MCO makes a best effort to conduct an initial screening of each enrollee’s needs, within 90

days of the effective date of enrollment for all new enrollees, including subsequent attempts if the initial

attempt to contact the enrollee is unsuccessful.

 Share with the State or other MCOs serving the enrollee the results of any identification and assessment of

that enrollee’s needs to prevent duplication of those activities.

 Ensure that in the process of coordinating care, each enrollee’s privacy is protected in accordance with the

privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to the extent that they are applicable.

MCO contract §6.39 (Case Management)

 The MCO shall maintain a case management program through a process which provides appropriate and

medically-related services, social services, and basic and specialized behavioral health services that are

identified, planned, obtained and monitored for identified members who are in the special healthcare needs

(SHCN) population and identified members who have high risk or have unique, chronic, or complex needs.

 The process shall integrate the member’s and case manager’s review of the member's strengths and needs

resulting in a mutually agreed upon appropriate plan that meets the medical, functional, social and

behavioral health needs of the member.

Identification and Assessment (42 CFR 438.208(c)(1)(2))

 Identification. The State must implement mechanisms to identify persons who need LTSS or persons with

SHCN needs to MCO, as those persons are defined by the State. These identification mechanisms:

o Must be specified in the State’s quality strategy in § 438.340;

and

o May use State staff, the State’s enrollment broker, or the State’s MCOs.

 Assessment: Each MCO must implement mechanisms to comprehensively assess each Medicaid enrollee

identified by the State (through the mechanism specified in paragraph (c)(1) of this section) and identified to

the MCO by the State as LTSS or SHCN in order to identify any ongoing special conditions of the enrollee

that require a course of treatment or regular care monitoring. The assessment mechanisms must use

appropriate providers or individuals meeting LTSS service coordination requirements of the State or the

MCO as appropriate.

Mechanisms for Enrollees with SHCN or who need LTSS (42 CFR 438.208(c)(3))

 Treatment/service plans: MCOs must produce a treatment or service plan meeting the criteria in

paragraphs (c)(3)(i) through (v) of this section for enrollees who require LTSS and, if the State requires,

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

must produce a treatment or service plan meeting the criteria in paragraphs (c)(3)(iii) through (v) of this

section for enrollees with special health care needs that are determined through assessment to need a

course of treatment or regular care monitoring. The treatment or service plan must be:

o Developed by an individual meeting LTSS service coordination requirements with enrollee

participation, and in consultation with any providers caring for the enrollee;

o (ii) Developed by a person trained in person-centered planning using a person-centered process

and plan as defined in § 441.301(c)(1) and (2) of this chapter for LTSS treatment or service

plans;

o (iii) Approved by the MCO, PIHP, or PAHP in a timely manner, if this approval is required by

the MCO, PIHP, or PAHP;

o (iv) In accordance with any applicable State quality assurance and utilization review standards;

and

o (v) Reviewed and revised upon reassessment of functional need, at least every 12 months, or

when the enrollee's circumstances or needs change significantly, or at the request of the enrollee

per § 441.301(c)(3) of this chapter.

o .

Mechanisms for Enrollees with SHCN: Direct Access to Specialists (42 CFR 438.208(c)(4))

 Direct access to specialists: For enrollees with SHCN determined through an assessment (consistent with §

438.208(c)(2)), to need a course of treatment or regular care monitoring, each MCO must have a mechanism

in place to allow enrollees to directly access a specialist (for example, through a standing referral or an

approved number of visits) as appropriate for the enrollee’s condition and identified needs.

Coverage and Authorization of Services §438.210

 The State must ensure through its contracts with each MCO complies with the requirements of this section.

o Identify, define, and specify the amount, duration, and scope of each service that the MCO, PIHP, or

PAHP is required to offer.

o Require that the services identified in paragraph §438.210 (a)(1) of this section be furnished in an

amount, duration, and scope that is no less than the amount, duration, and scope for the same

services furnished to beneficiaries under FFS Medicaid, as set forth in § 440.230 and for enrollees

under the age of 21, as set forth in subpart B of part 441.

 Provide that the MCO:

o Must ensure that the services are sufficient in amount, duration, or scope to reasonably achieve the

purpose for which the services are furnished.

o May not arbitrarily deny or reduce the amount, duration, or scope of a required service solely

because of diagnosis, type of illness, or condition of the beneficiary.

 The MCO may place appropriate limits on a service based criteria applied under the State plan, such as

medical necessity or for the purpose of utilization control, provided the services furnished can reasonably be

expected to achieve their purpose. The MCO must also specify what constitutes “medically necessary

services” in a manner that:

o is no more restrictive than that used in the State Medicaid program as indicated in State statutes and

regulations, the State plan, and other state policy and procedures manuals; and

o addresses the extent to which the MCO is responsible for covering services related to the following:

 The prevention, diagnosis, and treatment of enrollee’s disease, condition and/or disorder that results

in health impairments and/or disability;

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

 The ability to achieve age-appropriate growth and development

 The ability to attain, maintain, or regain functional capacity and

 The opportunity for an enrollee receiving long-term services and supports to have access to the

benefits of community living, to achieve person-centered goals, and live and work in the setting of

their choice.

Policies and Procedures for Authorization of Services (42 CFR 438.210(b)(1), (2), and (3))

 For the processing of requests for initial and continuing authorizations of services, each contract must

require:

o That the MCO and its subcontractors have in place, and follow, written policies and procedures.

o That the MCO

 Have in effect mechanisms to ensure consistent application of review criteria for authorization

decisions; and

 Consult with the requesting provider when appropriate.

 Authorize LTSS based on an enrollee’s current needs assessment and consistent with the person-

centered service plan.

 That any decision to deny a service authorization request or to authorize a service in an amount,

duration, or scope that is less than requested, be made by an individual who has appropriate

expertise in addressing the enrollee's medical, behavioral health, or long-term services and supports

needs.

Notice of Adverse Action (42 CFR 438.210(c))

 Each contract must provide for the MCO to notify the requesting provider, and give the enrollee written

notice of any decision by the MCO to deny a service authorization request, or to authorize a service in

an amount, duration, or scope that is less than requested. The notice must meet the requirements of

§438.404, except that the notice to the provider need not be in writing. For Medicaid contracts with an

applicable integrated plan, as defined in § 422.561, in lieu of the provisions in this paragraph governing

notices of adverse benefit determinations, the provisions set forth in §§ 422.629 through 422.634 apply

to determinations affecting dually eligible individuals who are also enrolled in a dual eligible special

needs plan with exclusively aligned enrollment, as defined in § 422.2

Timeframe for decisions (42 CFR 438.210(d))(1), (2)&(e)

 Each MCO contract must provide for the following decisions and notices:

o Standard authorization decisions: For standard authorization decisions, provide notice as expeditiously

as the enrollee’s health condition requires and within State-established timeframes that may not exceed

14 calendar days, following receipt of the request for service, with a possible extension of up to 14

additional calendar days, if:

 The enrollee, or the provider, requests extension: or

 The MCO justifies (to the state agency upon request) a need for additional information and the

extent to which the extension is in the enrollee’s interest.

o Expedited authorization decisions: For cases in which a provider indicates, or the MCO determines,

that following the standard timeframe could seriously jeopardize the enrollee’s life or health or ability to

attain, maintain, or regain maximum function, the MCO must make an expedited authorization decision

and provide notice as expeditiously as the enrollee’s health condition requires and no later than 3

working days after receipt of the request for service.

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

o The MCO may extend the 72-hour time period by up to 14 calendar days if the enrollee requests an

extension, or if the MCO justifies (to the State agency upon request) a need for additional information

and how the extension is in the enrollee’s interest.

 Compensation for utilization management activities: Each contract between the State and MCO must

provide that, consistent with §§438.3(i)), and §422.208 of this chapter, compensation to individuals or

entities that conduct utilization management activities is not structured so as to provide incentives for the

individual or entity to deny, limit, or discontinue medically necessary services to any enrollee.

Emergency and Post–Stabilization Care Service (42 CFR 438.114)

The MCOs will comply with the definitions used in this section:

 Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient

severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of

health and medicine, could reasonably expect the absence of immediate medical attention to result in the

following:

o Placing the health of the individual (or for pregnant woman, the health of the woman or her unborn

child) in serious jeopardy;

o Serious impairment to bodily functions; or

o Serious dysfunction of any bodily organ or part.

 Emergency services means covered inpatient and outpatient services that are:

o Furnished by a provider that is qualified to furnish emergency services.

o Needed to evaluate or stabilize an emergency medical condition.

 Post-stabilization care services means covered services, related to an emergency medical condition, that are

provided after an enrollee is stabilized in order to maintain the stabilized condition, or, under the

circumstances described in paragraph (e) of this section, to improve or resolve the enrollee’s condition.

Coverage and payment: MCOs are responsible for coverage and payment of emergency services and post-

stabilization care services.

Coverage and payment: Emergency services.

(1) The entities identified in this section -

 Must cover and pay for emergency services regardless of whether the provider that furnishes the

services has a contract with the MCO; and

 May not deny payment for treatment obtained under either of the following circumstances:

o An enrollee had an emergency medical condition, including cases in which the absence of

immediate medical attention would not have had the outcomes specified in paragraphs (1), (2),

and (3) of the definition of emergency medical condition in this section.

o A representative of the MCO instructs the enrollee to seek emergency services.

Additional rules for emergency services.

(1) The MCOs may not -

 Limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms;

and

 Refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not

notifying the enrollee's primary care provider, MCO or applicable State entity of the enrollee's screening

and treatment within 10 calendar days of presentation for emerg

ency services.

(2) An enrollee who has an emergency medical condition may not be held liable for payment of subsequent

screening and treatment needed to diagnose the specific condition or stabilize the patient.

Louisiana Medicaid Managed Care Quality Strategy

Access Performance Standards

(3) The attending emergency physician, or the provider actually treating the enrollee, is responsible for

determining when the enrollee is sufficiently stabilized for transfer or discharge, and that determination is

binding on the entities identified in paragraph (b) of this section as responsible for coverage and payment.

Coverage and payment: Post-stabilization care services. Post-stabilization care services are covered and paid

for in accordance with provisions set forth in 42 CFR §422.113(c). In applying those provisions, reference to

“MA organization” and “financially responsible” must be read as reference to the entities responsible for

Medicaid payment, as specified in paragraph (b) of this section, and payment rules governed by Title XIX of the

Act and the States.

(2) MA organization financial responsibility. The MA organization -

 Is financially responsible (consistent with § 422.214) for post-stabilization care services obtained within

or outside the MA organization that are pre-approved by a plan provider or other MA organization

representative;

 Is financially responsible for post-stabilization care services obtained within or outside the MA

organization that are not pre-approved by a plan provider or other MA organization representative, but

administered to maintain the enrollee's stabilized condition within 1 hour of a request to the MA

organization for pre-approval of further post-stabilization care services;

 Is financially responsible for post-stabilization care services obtained within or outside the MA

organization that are not pre-approved by a plan provider or other MA organization representative, but

administered to maintain, improve, or resolve the enrollee's stabilized condition if –

o The MA organization does not respond to a request for pre-approval within 1 hour;

o The MA organization cannot be contacted; or

o The MA organization representative and the treating physician cannot reach an agreement

concerning the enrollee's care and a plan physician is not available for consultation. In this

situation, the MA organization must give the treating physician the opportunity to consult with a

plan physician and the treating physician may continue with care of the patient until a plan

physician is reached or one of the criteria in § 422.113(c)(3) is met; and

 Must limit charges to enrollees for post-stabilization care services to an amount no greater than what the

organization would charge the enrollee if he or she had obtained the services through the MA

organization. For purposes of cost sharing, post-stabilization care services begin upon inpatient

admission.

(3) End of MA organization's financial responsibility. The MA organization's financial responsibility for post-

stabilization care services it has not pre-approved ends when -

 A plan physician with privileges at the treating hospital assumes responsibility for the enrollee's care;

 A plan physician assumes responsibility for the enrollee's care through transfer;

 An MA organization representative and the treating physician reach an agreement concerning the

enrollee's care; or

 The enrollee is discharged.

Applicability to PIHPs and PAHPs. To the extent that services required to treat an emergency medical condition

fall within the scope of the services for which the PIHP or PAHP is responsible, the rules under this section

apply.

Louisiana Medicaid Managed Care Quality Strategy

3.2 Adoption & Dissemination of Evidence-Based Clinical Practice

Guidelines

The application of evidence-based clinical practice guidelines has proven to reduce variation in treatment,

resulting in improved quality. The MCO’s development and use of evidence-based clinical practice

guidelines for physical and behavioral health is expected and must be consistent with the requirements of

42 CFR 438.236:

 Are based on valid and reliable clinical evidence or a consensus of providers in the particular

field;

 Consider the needs of enrollees;

 Are adopted in consultation with; and

 Are reviewed and updated periodically as appropriate.

LDH expects MCOs to coordinate the development of clinical practice guidelines with other MCOs and

Louisiana Medicaid clinical leadership team through the process established to create provider manual

updates, to avoid providers receiving conflicting practice guidelines.

MCOs must use clinical care standards and/or practice guidelines to objectively evaluate the care the

MCO delivers or fails to deliver for targeted clinical conditions. These guidelines and/or clinical care

standards must be formally adopted by the MCO’s Quality Assessment and Performance Improvement

(QAPI) Committee and disseminated to all affected providers and, upon request, to enrollees and potential

enrollees. Decisions for utilization management, enrollee education, coverage of services, and other areas

to which the guidelines apply must be consistent with the guidelines. MCOs must monitor adherence to

practice guidelines by medical record reviews and performance measure outcomes.

Examples of evidence-based practices guidelines plans are required to use are in the following categories:

 Federal guidelines (e.g., Agency for Healthcare Research and Quality evidence reviews and

United States Preventive Service Taskforce recommendations)

 Specialty society guidelines (e.g., the Infectious Diseases Society of America/American

Association for the Study of Liver Diseases Hepatitis C treatment guidelines)

 Other clinical practice guidelines produced by other organizations (e.g., Milliman Care

Guidelines)

3.3 Transition of Care Policy

LDH monitors the development and maintenance of effective continuity of care activities to ensure a

continuum of care approach to enrollees. MCOs are 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 MCO contract.

The MCO shall provide active assistance to enrollees when transitioning to another MCO or to Medicaid

FFS. A receiving MCO is responsible for the provision of medically necessary services during the

transition period that shall not exceed thirty (30) calendar days from the effective date of the enrollee’s

enrollment in the receiving MCO unless the enrollee has been identified as an individual with special

health care needs. The MCO shall provide continuation/coordination of services for enrollees identified as

having special health care needs up to ninety (90) calendar days or until the enrollee may be reasonably

transferred without disruption, whichever is less. During the transition period, the receiving MCO shall be

Louisiana Medicaid Managed Care Quality Strategy

responsible for notification to the new primary care provider of the enrollee’s selection, initiation of the

request of transfer for the enrollee’s medical files, and arrangement of medically necessary services.

If an enrollee is to be transferred between MCOs but is hospitalized at the time, the transfer shall be

effective for the date of enrollment into the receiving MCO; however, the relinquishing MCO is

responsible for the enrollee’s hospitalization until the enrollee is discharged. The receiving MCO is

responsible for all other care.

The MCO shall not require service authorization for the continuation of medically necessary covered

services of a new enrollee transitioning into the MCO, regardless of whether such services are provided

by an in-network or out-of-network provider; however, the MCO may require prior authorization of

services beyond thirty (30) calendar days. For the first thirty (30) calendar days of enrollment, the MCO

is prohibited from denying prior authorization solely on the basis of the provider being an out-of-network

provider.

3.4 Mechanisms Used to Identify Persons with Special Health Care

Needs (SHCN)

An enrollee with SHCN is an individual of any age with a mental disability, physical disability, or other

circumstance that places his or her health and ability to fully function in society at risk, and thus requires

individualized health care requirements. Identification mechanisms should include:

 The MCO’s use of historical claims data (if available) to identify enrollees who meet Medicaid

managed care program eligibility criteria for SHCN. Enrollees with Special Health Care Needs is

defined as individuals of any age with a behavioral health disability, physical disability,

developmental disability, or other circumstances that place their health and ability to fully

function in society at risk, requiring individualized care approaches. Enrollees with Special

Health Care Needs shall include any enrollees who:

o have complex needs such as multiple chronic conditions, co-morbidities, and co-existing

functional impairments;

o are at high risk for admission/readmission to a hospital within the next six (6) months;

o are at high risk of institutionalization;

o have been diagnosed with a Serious Emotional Disturbance, a Severe and Persistent

Mental Illness, or a Substance Use Disorder, or otherwise have significant behavioral

health needs;

o are homeless as defined in Section 330(h)(5)(A) of the Public Health Services Act and

codified by the US Department of Health and Human Services in 42 U.S.C. 254(b);

o are women with high-risk pregnancies (i.e., pregnancies that have one or more risk

factors) or who have had an adverse pregnancy outcome during the pregnancy, including

preterm birth of less than thirty-seven (37) weeks;

o have been recently incarcerated and are transitioning out of custody;

o are at high risk of inpatient admission or Emergency Department visits, including certain

enrollees transitioning care across acute hospital, chronic disease and rehabilitation

hospital or nursing facility setting;

o are members of the Department of Justice (DOJ) Agreement Target Population;

o are enrolled under the Act 421 Children’s Medicaid Option; or

o receive care from other state agency programs, including but not limited to programs

through Office of Juvenile Justice (OJJ), Department of Children and Family Services

(DCFS), or Office of Public Health (OPH).

Louisiana Medicaid Managed Care Quality Strategy

 The MCO must identify enrollees with SHCN within 90 days of receiving the enrollee’s historical

claims data.

 Primary care physicians can identify enrollees with SHCN at any time. An appropriate healthcare

professional must conduct an assessment of those enrollees within 90 days of identification. If an

assessment determines a course of treatment or regular care monitoring, referral for case

management will be provided.

 Enrollees may also self-identify as SHCN to either the Enrollment Broker or the MCO.

 MCOs monitor and assess the appropriateness of care furnished to individuals with SHCN

through various means including but not limited to evaluation of the quality assessment and

performance improvement programs, comprehensive care management program reporting, care

coordination, and use of the CAHPS Children with Chronic Conditions survey

 Louisiana implemented Act 421 enacted by the Louisiana Legislature effective January, 1, 2022.

The program is titled the Act 421 Children’s Medicaid Option (“Act 421-CMO”). The Act 421-

CMO extends Medicaid eligibility to children covered by § 1902(e)(3) of the Social Security Act,

i.e., children age 18 and younger who meet institutional level of care (Nursing Facility, Hospital,

Intermediate Care Facility for Individuals with Intellectual/Developmental Disabilities) and are in

families with income that is too high to qualify for Medicaid, who could otherwise become

Medicaid eligible if receiving extended care in an institutional setting.

o The Demonstration option allows these children with disabilities to become Medicaid

eligible based on their own resources in order to receive medical services in less-costly

home-settings instead of an institution.

o The 1115 demonstration waiver authority is to be used to provide coverage to eligible

children but with a condition of coverage that families maintain pre-existing private

major medical health insurance (obtained through employment or the private insurance

market) unless the family demonstrates that maintaining private insurance would create a

financial hardship for the family and meets good cause exception criteria.

o The enrollment cap for 421-CMO is the number of children who can be served based on

annual legislative appropriation. With the exception of children with dual coverage in

Medicare and Medicaid, enrollment in managed care is required of all participants in

order to control costs and enhance budget predictability.

3.5 Non-Duplication Strategy

The CMS External Quality Review (EQR) regulations (42 CFR 438.360) allow for non-duplication of

mandatory EQR activities at the state’s discretion. These regulations permit use of information about an

MCO obtained from a private accreditation review to be used in the annual EQR if certain conditions are

met. These conditions include, but are not limited to, compliance with the standards established by a

national accrediting organization when the organization’s standards are comparable to the federal

standards. For MCOs achieving accreditation, the LDH External Quality Review Organization (EQRO)

can use the toolkits produced by the accrediting organizations and the MCO-specific accreditation

reports/results to identify standards meeting federal and state regulatory requirements. The EQRO can

then use the accrediting organization’s results for those standards.

Beginning with the 2020-2021 EQR reports published in 2022, the Information Systems Capabilities

Assessment (ISCA) mandatory EQR activity is substituted by the system reviews conducted as part of the

MCO’s NCQA HEDIS Compliance Audit, as outlined by CMS. Should the state determine in the future

Louisiana Medicaid Managed Care Quality Strategy

that a private accreditation activity (e.g., National Committee on Quality Assurance [NCQA]

accreditation) is comparable to any other EQR activities, the state will work with the EQRO to identify

any areas in the NCQA accreditation program that may be redundant with the EQR review and deem

these activities accordingly.

Louisiana Medicaid Managed Care Quality Strategy

4 EVALUATING, UPDATING, AND DISSEMINATING

THE QUALITY STRATEGY

4.1 Quality Strategy Development and Public Comment

The Quality Strategy reflects significant stakeholder input as well as thoughtful consideration of the

quality priorities and issues that are most important in Louisiana. Through multiple, ongoing public

stakeholder forums across the state and engagement with the Medical Care Advisory Committee, LDH

specifies a set of measures that represent critical targets to improve the quality of care and health

outcomes for Medicaid enrollees.

In 2017, in preparation for Louisiana’s transition to its VBP program, Medicaid conducted “A Deep Dive

into Quality” through a series of public town hall meetings across the state. Led by Medicaid’s Chief

Medical Officer and Chief Transformation Officer for Quality Improvement, LDH traveled to seven

regions of the state to gain stakeholder input on quality measurement priorities that best reflect the needs

and desired health outcomes of Medicaid enrollees. The results of this effort culminated in the prioritized

set of MCO incentivized and monitored quality performance measures referenced in Section 2, Driving

Improvement and Monitoring Progress, as ratified by the Medical Care Advisory Committee.

Later, in 2018, Medicaid conducted another series of public stakeholder events titled, “Paving the Way to

a Healthier Louisiana: Advancing Medicaid Managed care,” to communicate its future vision for the

Medicaid managed care program and gain stakeholder input on key managed care policies. These events

laid the foundation for managed care policy priorities, including the Quality Strategy Aims, Goals and

Objectives, as described in Section 1, Managed Care Goals, Objectives and Overview.

In preparation for the future Medicaid managed care program effective 2021, LDH updated its MCO

quality performance measures (currently referenced in Section 2, Driving Improvement and Monitoring

Progress) to best align with the priorities and objectives of the Louisiana Managed Care Quality Strategy

and other LDH Department-wide priorities. LDH undertook a broad public stakeholder input process

across major regions of the state in early 2019. As part of this effort, LDH worked in concert with the

Medical Care Advisory Committee to reach consensus on the final set of performance measures.

In accordance with the state’s Tribal consultation policy, tribal notification was also made to request

further input into the Quality Strategy. In parallel, prior to finalizing the Quality Strategy, LDH made the

Quality Strategy available for public comment and incorporated edits as appropriate. LDH made the final

Quality Strategy available on its website.

4.2 Quality Strategy Review, Update, and Evaluation

The Quality Strategy will be reviewed and updated as needed, but no less than once every three years as

required by the CMS Medicaid Managed Care Final Rule or when there is a significant change, defined as

any change to the Quality Strategy that may reasonably be foreseen to materially affect the delivery or

measurement of the quality of health care services. The Quality Strategy review includes an evaluation of

the effectiveness of the quality strategy. Currently, the state’s EQRO conducts an in-depth, independent

evaluation and produces an annual report on the implementation and effectiveness of the Quality Strategy.

This evaluation can include feedback from both internal and external stakeholders. The Quality Strategy

Evaluation report is published on LDH’s website.

Louisiana Medicaid Managed Care Quality Strategy

MCO quality performance measure results, stakeholder input on current issues and barriers to health care

access and quality, and LDH strategic priorities all inform decisions regarding quality goals and

measures. Measures are assessed to determine what, if any, updates should be made, including the

addition and removal of measures and the selection of incentive-based measures. Criteria used to make

decisions regarding measure recommendations includes:

 Relevance: Measures must be relevant to Medicaid enrollees

 Scientific Soundness: Measures must be based on evidence produced through research and

evaluation, ideally at the national level

 Feasibility: Measures initially must meet at least one of three requirements:

o Be retrievable through routinely collected administrative data

o Be collected via survey of enrollees or their caretakers

o Be collected via a medical record review

Additional considerations for decisions regarding quality measures and initiatives include technical

aspects, such as whether:

 The measure has been in operation for a sufficient period of time to demonstrate effectiveness

 The measure has demonstrated success documented through tangible results

 The measure is consistent with current policy and evidence-based practice

Louisiana Medicaid Managed Care Quality Strategy

APPENDIX A: Louisiana Medicaid MCO Performance Measures (Measurement Year 2023 and Subsequent Years)

Aims Goals Objectives $$ Measures Measure Description Steward

Better Care.

Make health

care more

person-

centered,

coordinated,

and accessible

so that

enrollees get

the right care

at the right

time in the

right place.

Ensure access

to care to

meet enrollee

needs

Ensure timely

and approximate

access to primary

and specialty

care

1. Child and Adolescent Well-Care Visits

The percentage of members 3–21 years of age who had at least one

comprehensive well-care visit with a PCP or an OB/GYN practitioner

during the measurement year.

NCQA

2. Well-Child Visits in the First 30 Months of Life

The percentage of members who had the following number of well-

child visits with a PCP during the last 15 months. The following rates

are reported:

1. Well-Child Visits in the First 15 Months. Children who turned 15

months old during the measurement year: Six or more well-child

visits.

2. Well-Child Visits for Age 15 Months–30 Months. Children who

turned 30 months old during the measurement year: Two or more

well-child visits.

3. Inpatient Utilization – General Hospital/Acute Care

(IPU)

This measure summarizes utilization of acute inpatient care and

services in the following categories:

 Maternity

 Surgery

 Medicine

Total inpatient (the sum of Maternity, Surgery and Medicine)

4. Adult Access to Preventive/Ambulatory Services

The percentage of members age 20 years and older who had an

ambulatory or preventive care visit during the measurement year.

Three age stratifications and a total rate are reported:

 20-44 years

 45-64 years

 65 years and older

 Total

Improve

coordination

and

transitions of

care

Ensure

appropriate

follow-up after

emergency

department visits

and

hospitalizations

through effective

care coordination

and case

management

5. Ambulatory Care

This measure summarizes utilization of ambulatory care in the

following categories:

 Outpatient Visits Including Telehealth

 ED Visits

Note: A lower rate indicates better performance for ED visits.

NCQA

6. Follow-Up After Hospitalization for Mental Illness

The percentage of discharges for members 6 years of age and older

who were hospitalized for treatment of selected mental illness or

intentional self-harm diagnoses and who had a follow-up visit with a

mental health practitioner. Two rates are reported:

 $$: The percentage of discharges for which the member received

follow-up within 30 days after discharge.

 The percentage of discharges for which the member received

follow-up within 7 days after discharge.

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

7. Follow-Up After Emergency Department Visit for

Mental Illness

The percentage of emergency department (ED) visits for members 6

years of age and older with a diagnosis of mental illness or intentional

self-harm, who had a follow-up visit for mental illness. Two rates are

reported:

 $$: The percentage of ED visits for which the member received

follow-up within 30 days of the ED visit (31 total days).

 The percentage of ED visits for which the member received

follow-up within 7 days of the ED visit (8 total days).

8. Follow-Up After Emergency Department Visit for

Substance Use

The percentage of emergency department (ED) visits among members

age 13 years and older with a principal diagnosis of substance use

disorder (SUD), or any diagnosis of drug overdose, for which there was

follow-up. Two rates are reported:

 The percentage of ED visits for which the member received

follow-up within 30 days of the ED visit (31 total days)

 The percentage of ED visits for which the member received

follow-up within 7 days of the ED visit (8 total days).

9. Plan All-Cause Readmissions

For members 18 -64 years of age, the risk-adjusted rate of acute

inpatient stays during the measurement year that were followed by an

unplanned acute readmission for any diagnosis within 30 days.

Facilitate

patient-

centered,

whole person

care

Engage and

partner with

enrollees to

improve enrollee

experience and

outcomes

10. Consumer Assessment of Healthcare Providers and

Systems (CAHPS®) Health Plan Survey 5.1H – Child

Version (Medicaid)

This measure provides information on parents’ experience with their

child’s Medicaid organization.

NCQA

11. Consumer Assessment of Healthcare Providers and

Systems (CAHPS®) Health Plan Survey 5.1H, Adult

Version (Medicaid)

This measure provides information on the experiences of Medicaid

members with the organization and gives a general indication of how

well the organization meets members’ expectations.

12. Children with Chronic Conditions

This measure provides information on parents’ experiences of

Medicaid members with the organization and gives a general

indication of how well the organization meets members’ expectations.

Integrate

behavioral and

physical health

13. Depression Screening and Follow-Up for Adolescents

and Adults

(Please note: This is a pilot measure and LDH will

work with the MCO on strategies to collect this

information. This measure is not required for

reporting).

The percentage of members 12 years of age and older who were

screened for clinical depression using a standardized instrument and,

if screened positive, received follow-up care.

 Depression Screening. The percentage of members who

were screened for clinical depression using a standardized

instrument.

 Follow-Up on Positive Screen. The percentage of members

who received follow-up care within 30 days of screening

positive for depression.

NCQA

14. Diabetes Screening for People with Schizophrenia or

Bipolar Disorder Who Are Using Antipsychotic

Medications

The percentage of members 18–64 years of age with schizophrenia,

schizoaffective disorder or bipolar disorder, who were dispensed an

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

antipsychotic medication and had a diabetes screening test during the

measurement year.

15. Diabetes Monitoring for People with Diabetes and

Schizophrenia

The percentage of members 18–64 years of age with schizophrenia or

schizoaffective disorder and diabetes who had both an LDL-C test

and an HbA1c test during the measurement year.

16. Cardiovascular Monitoring for People with

Cardiovascular Disease and Schizophrenia

The percentage of members 18–64 years of age with schizophrenia or

schizoaffective disorder and cardiovascular disease, who had an

LDL-C test during the measurement year.

17. Metabolic Monitoring for Children and Adolescents

on Antipsychotics

The percentage of children and adolescents with ongoing

antipsychotic medication use who had metabolic testing during the

year

Healthier

People,

Healthier

Communities.

Improve the

health of

enrollees

through

evidence-

based

prevention and

treatment

interventions

that address

physical and

behavioral

health needs.

Promote

wellness and

prevention

Improve overall

health

18. Self-Reported Overall Health (Adult and Child)

Note: This measure is from the CAHPS survey.

Reporting will be dependent on availability and

validity of data.

The percentage of members reporting overall excellent or very good

health.

AHRQ

19. Self-Reported Overall Mental or Emotional Health

(Adult and Child)

Note: This measure is from the CAHPS survey.

Reporting will be dependent on availability and

validity of data.

The percentage of members reporting overall excellent or very good

mental or emotional health.

Ensure maternal

safety and

appropriate care

during childbirth

and postpartum

20. Prenatal and Postpartum Care: Timeliness of Prenatal

Care

The percentage of deliveries of live births on or between October 8 of

the year prior to the measurement year and October 7 of the

measurement year that received a prenatal care visit in the first

trimester, on or before the enrollment start date or within 42 days of

enrollment in the organization.

NCQA

21. Cesarean Rate for Low-Risk First Birth Women

$$: The percentage of cesareans in live births at or beyond 37.0

weeks gestation to women that are having their first delivery and are

singleton (no twins or beyond) and are vertex presentation (no breech

or transverse positions).

Note: A lower rate indicates better performance.

TJC

22. Prenatal and Postpartum Care: Postpartum Care

The percentage of deliveries of live births on or between October 8

of the year prior to the measurement year and October 7 of the

measurement year that had a postpartum visit on or between 7 and 84

days after delivery.

NCQA

Reduce infant

mortality

23. Percentage of Low Birthweight Births

Percentage of live births that weighted less than 2,500 grams in the

state during the reporting period.

AHRQ

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

Promote healthy

development and

wellness in

children and

adolescents

24. Developmental Screening in the First Three Years of

Life

The percentage of children screened for risk of developmental,

behavioral, and social delays using a standardized screening tool in

the 12 months preceding or on their first, second, or third birthday.

CMS

25. Lead Screening in Children

The percentage of children 2 years of age who had one or more

capillary or venous lead blood test for lead poisoning by their second

birthday.

NCQA

Promote oral

health in children

26. Topical Fluoride for Children

The percentage of members 1-4 years of age who received at least

two fluoride varnish applications during the measurement year.

Report two age stratifications and a total rate:

 1-2 years

 3-4 years

 Total

NCQA

27. Oral Evaluation, Dental Services

The percentage of members under 21 years of age who received a

comprehensive or periodic oral evaluation with a dental provider

during the measurement year. Report four age stratifications and a

total rate:

 0-2 years

 3-5 years

 6-14 years

 15-20 years

 Total

Improve

immunization

rates

28. Childhood Immunization Status

The percentage of children 2 years of age who had four diphtheria,

tetanus and acellular pertussis (DTaP); three polio (IPV); one

measles, mumps and rubella (MMR); three haemophilus influenza

type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four

pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three

rotavirus (RV); and two influenza (flu) vaccines by their second

birthday. The measure calculates a rate for each vaccine and nine

separate combination rates. ($$: Combo 3)

NCQA

29. Immunizations for Adolescents

Percentage of adolescents that turned 13 years old during the

measurement year and had specific vaccines by their 13th birthday.

Report all individual vaccine numerators and combinations. ($$:

Combo 2)

Prevent obesity

and address

physical activity

and nutrition in

children and

adults

30. Weight Assessment and Counseling for Nutrition and

Physical Activity for Children/Adolescents – Body

Mass Index Assessment for Children/Adolescents

The percentage of members 3–17 years of age who had an outpatient

visit with a PCP or OB/GYN and who had evidence of the following

during the measurement year.

 BMI percentile documentation

 Counseling for nutrition

 Counseling for physical activity

NCQA

31. Contraceptive Care – All Women Ages 15-20

The percentage of women ages 15-20 who are at risk of unintended

pregnancy and were provided a most or moderately effective method

of contraception or were provided a LARC. Two rates are reported.

OPA

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

32. Contraceptive Care – Postpartum Women Ages 15-20

The percentage of women ages 15-20 who had a live birth and were

provided a most or moderately effective method of contraception

within 3 and 90 days of delivery or were provided a LARC within 3

and 90 days of delivery. Four rates are reported.

Promote

reproductive

health

33. Contraceptive Care – All Women Ages 21–44

The percentage of women ages 21-44 who are at risk of unintended

pregnancy and were provided a most or moderately effective method

of contraception or were provided a LARC. Two rates are reported.

34. Contraceptive Care – Postpartum Women Ages 21–44

The percentage of women ages 21-44 who had a live birth and were

provided a most or moderately effective method of contraception

within 3 and 90 days of delivery or were provided a LARC within 3

and 90 days of delivery. Four rates are reported.

35. Chlamydia Screening in Women

The percentage of women 16–24 years of age who were identified as

sexually active and who had at least one test for Chlamydia during

the measurement year.

NCQA

Improve cancer

screening

36. Cervical Cancer Screening

$$: Percentage of women 21–64 years of age who were screened for

cervical cancer:

 Women 21-64 who had cervical cytology performed every 3

years.

 Women 30-64 who had cervical cytology/HPV co-testing

performed every 5 years.

NCQA

37. Colorectal Cancer Screening

$$: The percentage of members 45-75 years of age who had

appropriate screening for colorectal cancer. Report two age

stratifications and a total rate:

 46-49 years.

 50-75 years.

 Total.

Improve hepatitis

C virus infection

screening

38. Hepatitis C Virus Screening

Percentage of eligible individuals screened for hepatitis C virus

infection.

State

Promote use of

evidence-based

tobacco cessation

treatments

39. Medical Assistance With Smoking and Tobacco Use

Cessation

Assesses different facets of providing medical assistance with

smoking and tobacco use cessation.

MCOs will report three components (questions):

 Advising Smokers and Tobacco Users to Quit

 Discussing Cessation Medications

 Discussing Cessation Strategies

NCQA

Improve

chronic

disease

Improve

hypertension,

diabetes, and

cardiovascular

disease

40. Controlling High Blood Pressure

$$: The percentage of members 18-85 years of age who had a

diagnosis of hypertension (HTN) and whose blood pressure (BP) was

adequately controlled (<140/90 mm Hg) during the measurement

year.

NCQA

41. Diabetes Short-Term Complications Admission Rate

Number of discharges for diabetes short term complications per

100,000 member months per Medicaid enrollees age 18 and older.

AHRQ

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

management

and control

management and

control

Note: A lower rate indicates better performance.

42. Statin Therapy for Patients with Cardiovascular

Disease



The percentage of males 21-75 years of age and females 40-75

years of age during the measurement year, who were identified as

having clinical atherosclerotic cardiovascular disease (ASCVD)

and who received statin therapy (were dispensed at least one high

or moderate-intensity statin medication during the measurement

year.)

 The percentage of males 21-75 years of age and females 40-75

years of age during the measurement year, who were identified as

having clinical atherosclerotic cardiovascular disease (ASCVD)

and who had statin adherence of at least 80% (who remained on a

high or moderate-intensity statin medication for at least 80% of the

treatment period.)

NCQA

43. Heart Failure Admission Rate

Percent of population with an admissions for heart failure (reported

by Recipient Parish). The number of discharges for heart failure per

100,000 member months for Medicaid enrollees age 18 and older

(reported by Recipient Parish).

AHRQ

44. Hemoglobin A1c Control for Patients With Diabetes

The percentage of members 18–75 years of age with diabetes

(types 1 and 2) whose hemoglobin A1c (HbA1c) was at the

following levels during the measurement year:

 HbA1c control (<8.0%).

 $$: HbA1c poor control (>9.0%)

Note: A lower rate indicates better performance for HbA1c

poor control (i.e., low rates of poor control indicate better

care).

NCQA

45. Blood Pressure Control for Patients With Diabetes

The percentage of members 18–75 years of age with diabetes

(types 1 and 2) whose blood pressure (BP) was adequately

controlled (<140/90 mm Hg) during the measurement year

NCQA

46. Eye Exam for Patients With Diabetes

The percentage of members 18–75 years of age with diabetes

(types 1 and 2) who had a retinal eye exam

NCQA

Improve

respiratory

disease

management and

control

47. Asthma in Younger Adults Admission Rate

Admissions for a principal diagnosis of asthma per 100,000

population, ages 18 to 39 years. Excludes admissions with an

indication of cystic fibrosis or anomalies of the respiratory system,

obstetric admissions, and transfers from other institutions. Number of

discharges for asthma per 100,000 member months for Medicaid

enrollees ages 18 to 39.

Note: A lower rate indicates better performance.

AHRQ

48. Chronic Obstructive Pulmonary Disease or Asthma in

Older Adults Admission Rate

This measure is used to assess the number of admissions for chronic

obstructive pulmonary disease (COPD) per 100,000 population. The

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

number of discharges for chronic obstructive pulmonary disease

(COPD) or asthma per 100,000 member months for Medicaid

enrollees age 40 and older.

Note: A lower rate indicates better performance.

49. Asthma Medication Ratio

The percentage of members 5-64 years of age who were identified as

having persistent asthma and had a ratio of controller medications to

total asthma medications of 0.50 or greater during the measurement

year. Ages 5-64 as of December 31 of the measurement year. Report

the following age stratifications and a total rate:

 5-11 years

 12-18 years

 19-50 years

 51-64 years

 Total

NCQA

Improve HIV

control

50. HIV Viral Load Suppression

$$: Percentage of patients, regardless of age, with a diagnosis of HIV

with a HIV viral load less than 200.

HRSA

Improve quality

of mental health

and substance

use disorder care

51. Pharmacotherapy for Opioid Use Disorder

The percentage of new opioid use disorder (OUD)

pharmacotherapy episodes that resulted in 180 or more covered

treatment days among members 16 years

of age and older with a diagnosis of OUD

NCQA

52. Initiation and Engagement of Substance Use Disorder

Treatment

The percentage of adolescent and adult members with a new episode

of alcohol or other drug (AOD) abuse or dependence who received

the following.

 Initiation of AOD Treatment. The percentage of members who

initiate treatment through an inpatient AOD admission,

outpatient visit, intensive outpatient encounter or partial

hospitalization, telehealth or medication treatment within 14 days

of the diagnosis.

 Engagement of AOD Treatment. The percentage of members

who initiated treatment and who had two or more additional

AOD services or medication treatment within 34 days of the

initiation visit.

53. Use of First-Line Psychosocial Care for Children and

Adolescents on Antipsychotics

The percentage of children and adolescents 1–17 years of age who

had a new prescription for an antipsychotic medication and had

documentation of psychosocial care as first-line treatment.

54. Adherence to Antipsychotic Medications for

Individuals with Schizophrenia

The percentage of members 18 years of age and older during the

measurement year with schizophrenia or schizoaffective disorder who

were dispensed and remained on an antipsychotic medication for at

least 80% of their treatment period.

55. Follow-Up Care for Children Prescribed Attention-

Deficit/Hyperactivity Disorder Medication

The percentage of children newly prescribed attention-

deficit/hyperactivity disorder (ADHD) medication who had at least

three follow-up care visits within a 10-month period, one of which

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

was within 30 days of when the first ADHD medication was

dispensed. Two rates are reported.

 Initiation Phase. The percentage of members 6–12 years of age as

of the IPSD with an ambulatory prescription dispensed for

ADHD medication, who had one follow-up visit with practitioner

with prescribing authority during the 30-day Initiation Phase.

 Continuation and Maintenance (C&M) Phase. The percentage of

members 6–12 years of age as of the IPSD with an ambulatory

prescription dispensed for ADHD medication, who remained on

the medication for at least 210 days and who, in addition to the

visit in the Initiation Phase, had at least two follow-up visits with

a practitioner within 270 days (9 months) after the Initiation

Phase ended.

56. Antidepressant Medication Management

The percentage of members 18 years of age and older with a

diagnosis of major depression and were newly treated with

antidepressant medication, and who remained on an antidepressant

medication treatment. Two rates are reported.

Improve

population

health and

address health

disparities

Stratify key

quality measures

by race/ethnicity

and rural/urban

status and narrow

health disparities

57. Measures for stratified data:

a. Pregnancy: Percentage of Low Birthweight

Births, Contraceptive Care – Postpartum Women

Ages 21–44

b. Child: Well Child Visits in the First 30 Months

of Life, Childhood Immunizations (Combo 3),

Immunizations for Adolescents (Combo 2)

c. Adult: Colorectal Cancer Screening, HIV Viral

Load Suppression, Cervical Cancer Screening

d. Behavioral Health: Follow-Up After Emergency

Department Visit for Mental Illness (within 30

days), Follow-Up After Emergency Department

Visit for Alcohol and Other Drug Abuse or

Dependence (within 30 days), Follow-Up After

Hospitalization for Mental Illness (within 30

days)

*Refer to individual measures

Various

58. Enrollment by Product Line

The total number of members enrolled in the product line, stratified

by age.

NCQA

59. Language Diversity of Membership

An unduplicated count and percentage of members enrolled at any

time during the measurement year by spoken language preferred for

health care and preferred language for written materials.

Louisiana Medicaid Managed Care Quality Strategy

Aims Goals Objectives $$ Measures Measure Description Steward

60. Race/Ethnicity Diversity of Membership

An unduplicated count and percentage of members enrolled any time

during the measurement year, by race and ethnicity.

Smarter

Spending.

Advance high-

value, efficient

care.

Minimize

wasteful

spending

Reduce low

value care

61. Appropriate Treatment for Children With Upper

Respiratory Infection

The percentage of children 3 months–18 years of age who were given

a diagnosis of upper respiratory infection (URI) and were not

dispensed an antibiotic prescription.

NCQA

62. Avoidance of Antibiotic Treatment in Adults With

Acute Bronchitis

The percentage of adults 18–64 years of age with a diagnosis of acute

bronchitis who were not dispensed an antibiotic prescription.

63. Use of Imaging Studies for Low Back Pain

The percentage of members with a primary diagnosis of low back

pain who did not have an imaging study (plain X-ray, MRI, CT scan)

within 28 days of the diagnosis.

64. Non-recommended Cervical Cancer Screening in

Adolescent Females

The percentage of adolescent females 16–20 years of age who were

screened unnecessarily for cervical cancer.

Note: A lower rate indicates better performance.