La. Admin. Code tit. 50 § I-3501

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-3501 - Participation Requirements

A. In order to participate in the Bayou Health Program, a managed care organization must be a successful bidder, be awarded a contract with the department, and complete the readiness review.

B. An MCO must:

1. meet the federal definition of an managed care organization as defined in federal regulations;

2. meet the requirements of R.S. 22:2016 and be licensed or have a certificate of authority from the Louisiana Department of Insurance (DOI) pursuant to title 22 of the Louisiana Revised Statues at the time a proposal is submitted;

3. be certified by the Louisiana Secretary of State to conduct business in the state;

4. meet solvency standards as specified in federal regulations and Title 22 of the Louisiana Revised Statutes;

5. meet NCQA health plan accreditation or agree to submit an application for accreditation at the earliest possible date as allowed by NCQA and once achieved, maintains accreditation through the life of this agreement;

6. have a network capacity to enroll a minimum of 250,000 Medicaid and LaCHIP eligibles; and

7. not have an actual or perceived conflict of interest that, in the discretion of the department, would interfere or give the appearance of possibly interfering with its duties and obligations under this Rule, the contract and any and all appropriate guides. Conflict of interest shall include, but is not limited to, being the fiscal intermediary contractor for the department; and

8. establish and maintain a performance bond in the amount specified by the department and in accordance with the terms of the contract.

9. Except for licensure and financial solvency requirements, no other provisions of title 22 of the Revised Statutes shall apply to an MCO participating in the Louisiana Medicaid Program.

C. An MCO shall ensure the provision of core benefits and services to Medicaid enrollees as specified in the terms of the contract.

D. Upon request by the Centers for Medicare and Medicaid Services, the Office of Inspector General, the Government Accounting Office, the department or its designee, an MCO shall make all of its records pertaining to its contract (services provided there under and payment for services) with the department available for review, evaluation and audit. The records shall include, but are not limited to the following:

1. pertinent books and documents;

2. financial records;

3. medical records and documents; and

4. provider records and documents involving financial transactions related to the contract.

E. An MCO shall maintain an automated management information system that collects, analyzes, integrates and reports data that complies with department and federal reporting requirements.

1. The MCO shall submit to the department for approval the MCOs emergency/contingency plan if the MCO is unable to provide the data reporting specified in the contract and department issued guides.

F. An MCO shall obtain insurance coverage(s) including, but not limited to, workmans compensation, commercial liability, errors and omissions, and reinsurance as specified in the terms of the contract. Subcontractors, if any, shall be covered under these policies or have insurance comparable to the MCOs required coverage.

G. An MCO shall provide all financial reporting as specified in the terms of the contract.

H. An MCO shall secure and maintain a performance and fidelity bond as specified in the terms of the contract during the life of the contract.

I. I In the event of noncompliance with the contract and the departments guidelines, an MCO shall be subject to the sanctions specified in the terms of the contract including, but not limited to:

1. corrective action plans;

2. monetary penalties;

3. temporary management; or

4. suspension and/or termination of the MCOs contract.

La. Admin. Code tit. 50, § I-3501

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:1583 (June 2011), Amended by LR 41933 (4/1/2015), Amended LR 412366 (11/1/2015).

AUTHORITY NOTE: Promulgated in accordance with R. S. 36:254 and Title XIX of the Social Security Act.