Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 35 - Managed Care Organization Participation Criteria › Section I-3509 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payments
				  to an MCO. The department, or its fiscal intermediary, shall make monthly
				  capitation payments to the MCO based on a per member, per month (PMPM) rate.
1. The department will establish monthly
				  capitation rates within an actuarially sound rate range certified by its
				  actuaries. Consistent with all applicable federal rules and regulations, the
				  rate range will initially be developed using fee-for-service claims data, Bayou
				  Health shared savings claims data, Bayou Health managed care organization
				  encounter data, Louisiana Behavioral Health Partnership (LBHP) encounter data,
				  financial data reported by Bayou Health managed care organizations and the LBHP
				  statewide management organization, supplemental ad hoc data, and actuarial
				  analyses with appropriate adjustments.
2. As the Bayou Health managed care program
				  matures and fee-for-service, shared savings and LBHP data are no longer
				  available, there will be increasing reliance on Bayou Health managed care
				  organization encounter data and/or financial data to set future rates, subject
				  to comparable adjustments.
3.
				  Capitation rates will be set for all MCOs at the beginning of each contract
				  period and will be periodically reviewed and adjusted as deemed necessary by
				  the department.
4. Capitation rates
				  will be risk-adjusted for the health of Medicaid enrollees enrolled in the MCO
				  as appropriate.
a. The health risk of the
				  Medicaid enrollees enrolled in the MCO will be measured using a
				  national-recognized risk-assessment model.
b. Utilizing this information, the capitation
				  rates will be adjusted to account for the health risk of the enrollees in each
				  MCO relative to the overall population being measured.
c. The health risk of the members and
				  associated MCO risk scores will be updated periodically to reflect changes in
				  risk over time.
d. The department
				  will provide the MCO with advance notice of any major revision to the
				  risk-adjustment methodology.
5. Kick Payments. MCOs may be reimbursed a
				  onetime supplemental lump sum payment, hereafter referred to as a "kick
				  payment", for the provision of certain services that meet specific conditions,
				  in an amount determined by the departments actuaries.
a. The kick payment is intended to cover the
				  cost of a specific care event or treatment. Payment will be made to the MCO
				  upon submission of satisfactory evidence of the event or treatment.
b. Only one kick payment will be made per
				  event or treatment.
c.
				  Repealed.
6. Capitation
				  rates related to pharmacy services will be adjusted to account for pharmacy
				  rebates.
7. The department, or its
				  fiscal intermediary, may reimburse an MCOs monthly capitation payments or kick
				  payments in the aggregate on a lump sum basis when administratively
				  necessary.