Louisiana Department of Health & Hospitals | Bruce Greenstein, Secretary

Unless it is an emergency, the patient should be referred to the PCP the Health Plan has assigned him/her, if the patient knows who the PCP is. If not, the patient can be referred to the Health Plan’s Member Services toll-free number. The name of the patient's Health Plan can be determined by the eligibility verification system, which will be maintained for providers by Molina.

During the first 30 days BAYOU HEALTH is implemented, the non-network provider can contact the recipient's Plan for authorization.  The Plan will contact that PCP to offer a contract. If that PCP chooses not to contract with the Plan, the Plan will notify the recipient to determine if they wish to transfer to a new PCP.  If so, the Plan will ask them to choose a new PCP.  If they wish to stay with the previous PCP, the Plan will direct them to BAYOU HEALTH so they can choose a plan in which that PCP participates.

Providers do not directly link patients to a Health Plan. Medicaid and LaCHIP enrollees select their Health Plans and indicate their preferred provider or, if no choice is made, they are assigned to a Plan. Once enrollees choose a Plan or are automatically assigned, they have 90 days to change Plans for any reason. After 90 days, the patients are locked into that Health Plan until the next open enrollment, unless they have good cause to change Plans. Patients wishing to change Health Plans should be referred to the Enrollment Center’s toll-free number, 1-855-BAYOU-4U. Patients wishing to change doctors should be referred to their Health Plan’s Member Services toll free number.

Medicare Dual eligibles are excluded from Health Plan enrollment. For members with commercial insurance as the primary payer, Medicaid via the BAYOU HEALTH Plan will be the payer of last resort. Those members enrolled in LaHIPP (DHH is paying the employee’s share of the premium for employer sponsored insurance) are excluded.

Eligibility can be verified in the same manner as it is today, with the Web, phone and swipe card options in the eligibility verification system operated by Molina.

Anyone enrolled in a Health Plan is eligible for full Medicaid benefits. Enrollees in Take Charge (Family Planning only) are excluded from enrolling in a Health Plan.

Health Plans will pay RHC claims based on the Medicaid PPS rate for that RHC in effect on the date of service. In addition, the existing cost settlement methodology will not change.

The “not more than 90%” reimbursement rate is based on the Medicaid fee schedule or the Health Plans fee-schedule if greater than Medicaid.

The minimum fee schedule is in the Medicaid fee schedule in effect on the date of service. Differences in a Prepaid Health Plan’s fee schedule (if applicable) can be obtained directly from that Health Plan.

This will be determined by each prepaid Health Plan and approved by DHH. Shared Savings Plans cannot require Prior Authorization for services that are not Prior Authorized by fee-for-service Medicaid. However, Prior Authorization policies for those services can be different than fee-for-service Medicaid.

If in the Shared Savings model, there will be no change. In the Prepaid model, it is dependent on the contract between the Health Plan and the lab.

Health Plans can ensure better coordination of member services, and will ease the burden on providers by assuming responsibility for referrals, care management services and disease management services. Health Plans have more flexibility than the current Medicaid program to restructure resources. The Plans will be better able than the current Medicaid program to support providers by assisting with issues such as transportation, referrals and patient compliance that can be problematic in the current program. The networks will better support providers in dealing with problematic patients so doctors do not have to expend the time and resources to do so.

Please refer to the  Health Plans' Provider Handbooks or direct this question to the Health Plans' Provider Relations, as each Plan will  establish their own authorization policies. (which do require approval from DHH).

Any prior authorizations issued by DHH will be honored within the first 30 calendar days of BAYOU HEALTH implementation in each GSA. There will be no need during this time to resubmit to a Health Plan. In addition, DHH will provide a file of all known prior authorizations to each Health Plan at the BAYOU HEALTH go-live date.

DHH's Contract with the Health Plans includes language that Health Plans can allow members to have a specialist as their PCP if the specialist is willing to perform the responsibilities of a PCP.

The member should contact member services for the Health Plan in which they are enrolled to request a specialist be assigned as their PCP, as this preference is not an option when enrolling through the Enrollment Center.

Prior authorizations are not required for any outpatient surgical procedures. However, if the procedure is performed on the 1st or 2nd day of the inpatient’s stay a pre-cert is needed.

If someone is a member of a shared savings plan, all hospitals enrolled in Louisiana Medicaid can be reimbursed for services (non-emergency services subject to authorization and approval of the Plan).

 If someone is a member of a prepaid plan, the Plan will pay out-of-network hospitals as well as network hospitals for emergency care (that meets the definition of an emergency - not just received at the ER). For non-emergencies (surgery for example) the hospital would need to be in-network unless the Plan has made special arrangements with the out-of-network hospital in order to be reimbursed.

Please contact the Health Plans' Provider Relations departments for clarification on their prior authorization requirements. They may differ between the Plans.

According to the contract, the Health Plan is financially responsible for post-stabilization care services rendered out of network when pre-approved by a Health Plan representative or provider; or not pre-approved but administered within one hour of requesting prior authorization to maintain the patient's stabilized condition.

For the shared-savings plans, Molina will continue to handle claims processing and payment. For the prepaid plans, the plans will handle claims directly. The Health Plans, not the providers, will be responsible for making patient referrals and ensuring access to specialty care, reducing the burden on providers.

Yes. The three Prepaid plans are contracting with home health agencies. The two Shared Savings plans will work with Louisiana Medicaid home health providers.

All members of a GSA where BAYOU HEALTH has been implemented should be linked (either by their own choice or auto assignment) to a health plan. If the aforementioned programs indicate that there is no linkage, the member would fall in one of the categories that is excluded from participation in BAYOU HEALTH, or is in the voluntary population.