Helping People Live Healthier Lives

2.10.1 Executive Summary

The Proposer should provide an executive summary, which demonstrates its understanding of LDH’s vision for…
“Helping enrollees live healthier lives” is not just our mission; our enrollees are at the core of
everything we do. We put our enrollees first in many ways, not just through our care
management model and approach, but in how we address social determinants of health,
integrate medical and behavioral health and in how we approach value-based payments. We
align this mission with Louisiana Department of Health’s (LDH’s) vision to work with all
stakeholders in the Medicaid system — enrollees, providers, community-based
organizations and other health plans — to reach the Triple Aim of better health and better
care while successfully lowering costs.
We are proud to submit our proposed solution for LDH’s Louisiana Request for Proposal. LDH
has shown commitment to establish principles to support high-quality care and promote health
to Louisianans and the Medicaid Managed Care Program. We see LDH’s transformative vision
and we have worked side-by-side with LDH to pave a way to a healthier Louisiana for our
enrollees and the communities in which they live. One of the ways in which we support LDH’s
mission is through our reinvestment of more than $5.6 million in recent years to make a
difference in the lives of the enrollees we serve. We are especially proud to show our
community support through our investments with Woman’s Hospital Guiding Recovery and
Creating Empowerment (GRACE) program, Louisiana Research Center “Taking Aim at Cancer”
and Daughters of Charity Partners in Health program, to name a few. As you will see outlined
below and throughout our RFP response, we continued with new investments that will make a
difference in improving the lives of Louisianans.
Our tenure in Louisiana has provided us with a deep
understanding of the needs of the population, and we are
committed to applying our experience to helping LDH achieve
the goals outlined in Section 1.3 of this RFP. The strategy
medallion is one you will see throughout our response. This
medallion highlights the specific ways we are committed to a
Healthier Louisiana. While we will present many ways to align to
LDH’s vision, below are some highlights.

Improve Enrollee Health

We are enhancing our care management program by
incorporating innovative and enrollee-focused resources to continue protecting and promoting
health among Louisiana’s most vulnerable populations.
 Hospital Care Transitions Program (HCT): Our new direct embedded HCT program
helps an enrollee’s move to their next level of care easier and their hospital discharge go
as smoothly as possible. In December 2018, we placed four HCT coordinators within
Our Lady of the Lake Regional Medical Center in Baton Rouge and the Louisiana
Children’s Medical Center (LCMC) Health University Medical Center in New Orleans to
reach high-risk enrollees pre-discharge and provide specialized supports to address
each enrollee’s post-discharge needs. We support the HCT coordinators with an RN, a
clinical pharmacist who addresses medication gaps and issues, and a licensed social
worker with behavioral health expertise who addresses behavioral health concerns. In
2019, we plan to place a perinatal HCT coordinator in Louisiana Woman’s Healthcare
clinic affiliated with Woman’s Hospital in Baton Rouge. The HCT coordinator will address
the prenatal needs of inpatient high-risk women to ensure the best health outcomes for
mother and baby and address social determinants of health needs.

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 Improving the Health of Pregnant Women with Opioid Use Disorder (OUD):
Pregnant women who have OUD are more likely to have a high-risk pregnancy and face
disparately higher rates of maternal and infant mortality. In August 2018, we provided a
$1.2 million grant to Baton Rouge Woman’s Hospital to implement its GRACE program.
By partnering with GRACE at Baton Rouge Woman’s Hospital, an area with a
proportionally high rate of infant mortality, we have been able to overcome health
disparities and reduce the effects of substance use disorder (SUD)/OUD on pregnant
women and their newborns.

Population Health Approach to Maximize Enrollee Health

Our population health efforts are bidirectional, being both informed by and informing our work
across the state. Not only do we use our data aggregation and analysis tools to inform our
population health approach, but we also use population health principles to inform our work
across the organization.
 Social Determinants of Health (SDOH): We recognize the importance of population
health management in identifying and addressing the social, behavioral, medical and
functional needs of our enrollees to improve their health outcomes and reduce health
disparities. We know our enrollees face unique challenges,
such as food insecurity; unsafe or unstable housing; lack
of transportation; unemployment and financial instability.
Our population health approach takes into account these
SDOH that often impede our enrollees from receiving care.
 Supportive Housing: Access to safe and affordable
housing, along with supports necessary to thrive there is a
most basic health-related resource need. We are
committed to addressing housing in Louisiana through the
work of our Permanent Supportive Housing (PSH) liaison Figure 1. We received the Community
who has supported over 50 enrollees in housing and our Champions award at the LHC Housing
Conference on April 3, 2019.
new housing navigator. In 2018, we worked with
Louisiana Housing Corporation (LHC) and LDH to develop strategies to continue
reducing homelessness and supporting individuals in housing, including offering bridge
financing at no interest to LHC to support their HUD $11.5 million Continuum of Care
PSH grant.
 Partners in Health with Daughters of Charity: We further develop SDOH interventions
through our Partners in Health program launched in April 2018 with Daughters of
Charity. Through a $2.5 million grant, we supported the
hiring and training of 15 Daughters of Charity
community health workers (CHWs) who assess at-risk
individuals, identify social barriers, and refer and
connect enrollees to appropriate community programs
and resources. In 2018, CHWs at Daughters of Charity
reached 8,234 unique individuals, encompassing both
our enrollee and non-enrollee population. Of those
individuals, 5,195 completed referrals to receive
Figure 2: Care fellowship team at Daughters medical, dental and behavioral health services through
of Charity with UnitedHealthcare employees
Daughters of Charity health centers.

Advance Evidence-based Practices and High-value Care

We use a systematic approach to seek and evaluate promising and evidence-informed
practices. We have adopted multiple evidence-based practices within our current service

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delivery array and we are committed to expand to include additional best practices and clinical
practice guidelines to meet the needs of Medicaid Managed Care Program populations. Some
of the innovations we bring to advancing evidence-based practices include:
 Hotspotting is the strategic use of data to identify enrollees with complex needs.
Typically, these individuals have high utilization of services and social and behavioral
complexities. Using our Hotspotting Tool, we can identify enrollees who are most likely
to benefit from our CHW approach — a direct, evidence-based, in the community
approach to service delivery. CHWs engage enrollees directly in place-based
interventions, whether it is at the hospital bedside, at a homeless shelter or another
location.
 Parent Child Interaction Therapy (PCIT) is an evidence-based, specialized behavior
management identified by LDH as needed to strengthen the network of available
therapeutic services for children, adolescents and their families in Louisiana. We were
the first managed care organization in Louisiana to offer MCO-sponsored PCIT training.
We helped the LSU Center from Evidence to Practice and MCO Healthy Blue identify
potential provider candidates to receive PCIT training and shared information regarding
potential expansion locations in the state.

Support Innovation and Continuous Quality Improvement

Our culture of innovation is driven by our mission to help people live healthier lives, and
emphasizes continuous exploration and testing of new ideas, while collaborating with diverse
partners to develop a simpler, more intelligent and cost-effective health care system for
everyone.
 Dedication to Quality Improvement: Over the past 5 years,
we have achieved year-over-year improvement in our
HEDIS, CAHPS and overall NCQA scores. Our goal of
reaching an ‘Excellent’ NCQA score is well within reach.
 NextHealth Technologies (NextHealth): In 2019, we are
partnering with NextHealth to implement its artificial
intelligence platform, which predicts opportunities to address risk and prescribes
personalized actions to improve outcomes for enrollee sub-populations. NextHealth
offers powerful, subtle suggestions that alter behavior without harsh consequences and
provide subtle cues to each sub-population to make the right choice desirable.
 Ready Responders: Ready Responders is a network of trained, licensed and fully
insured EMTs, paramedics and nurses who visit high-risk enrollees with inappropriate
ED utilization to help divert them from the ED. Since its launch in July 2018, our
preliminary results show a 25% decrease in ED PMPM costs and a 38% decrease in
inpatient PMPM costs among enrollees engaged in the program, driven by decreased
utilization.

Decrease Fragmentation and Increase Integration

Over the past decade, the integration of behavioral health and general medical services has
improved patient outcomes, reduced stigma related to mental health and reduced health care
costs. We decrease fragmentation and increase integration in the following ways:
 Medical/Behavioral Health Integration: Our integrated care team model facilitates a
comprehensive approach to assessing our enrollees’ physical health, behavioral health
and SDOH, such as housing and employment, for linkage to community resources.

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 Cross-functional Opioid and Substance Use Disorder (OUD/SUD) Strategy: Our

pharmacy and utilization management (UM) teams collaborate to identify enrollees at
potential risk of SUD/OUD and our provider relations team has expanded our available
medication-assisted treatment (MAT) network. We train our case management teams to
offer specialized care that promotes recovery, such as referrals to GRACE and ACER
for pregnant women with SUD/OUD.
 Integration With Utilization Management: Our UM activities support our population
health program by providing objective and systematic monitoring and evaluation of
enrollee care and services. Inputs from our UM program provide critical evidence about
health care patterns and practices and provide information that shapes our population
health programs. For example, using UM data analysis, our team is able to identify
patterns of high ED use and deploy programs, such as UHC Doctor Chat and Ready
Responders to support sub-populations with high utilization.

Ensure Enrollees Ready Access to Care

We evaluate our network through the eyes of enrollees and confirm they are able to receive the
right care from their preferred provider in the right location at the right time.
Telehealth Solutions: Our strategy is to expand our delivery of care to underserved Louisiana
Medicaid enrollees through three modes of telehealth access: direct to enrollee, enrollee to
specialist through the PCP, and doctor to doctor. From 2017 to 2018, we have seen a 34%
increase in telehealth claims received. Telehealth adoption is critical to provide access to
specialties currently in short supply. We are committed to advancing telehealth options and
continuous improvement with incentives and offerings to further the continuum and adoption.

Reduce Complexity and Administrative Burden for Providers and

Enrollees
We continuously monitor our program, conduct surveys, and review complaints or direct
feedback from providers and enrollees regarding burdensome or unnecessary policies and
processes. As we learned in 2017, while we have focused processes to drive positive results,
we always have room for improvement. We worked closely with providers along with LDH to
improve and make systematic and meaningful changes to enhance the overall experience by
removing complexity for providers and LDH. We made many improvements and supported
efforts to find common MCO policies. We remain committed to help be the MCO of choice with
providers.
Provider Scorecards: For value-based payment (VBP) programs to work, providers need
timely and easy to understand reporting. We have engaged significantly with our provider
community to become trusted partners to reward them for their great work. This comes with
continuous outreach, education and support. For example, when we see that a provider is not
achieving their targeted improvement metrics, we modify our support and identify solutions to
address their challenges. We provide each participating provider with scorecards showing
trends in rates relative to baselines and targets for clinical quality measures, utilization metrics
and total cost of care, depending upon contracted parameters. Outreach is conducted via in-
person meetings, webinars, lunch and learn sessions, and email. In fact, LDH adopted our
provider scorecard template as the standard format across MCOs.

Align Financial Incentives and Build Shared Capacity

Demonstrating a culture of innovation and continuous quality improvement,
UnitedHealthcare has continued to evolve our approach to VBP programs for Louisiana’s
Medicaid Managed Care providers in support of the “triple aim” over the last seven years.

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Louisiana Children’s Medical Center: In 2019, we furthered our commitment to helping

Louisiana providers move along the Health Care Payment Learning and Action Network
Alternative Payment Model (APM) continuum, receiving a letter of intent from LCMC to begin
participating in fully clinical integrated population health data sharing. This engagement will
allow LCMC to use data sharing to learn case management and build the foundation for a
capitation model that we plan to launch by 2021. The outcomes of our successful collaboration
with LCMC will continue to guide our strategic plan for the state, as outlined in Section
2.10.12.3. While we focus our 3-year strategy on our VBP programs, we remain committed to
moving up the APM continuum. We are excited about our first major step toward achieving our
first Level 4 APM agreement.

Minimize Wasteful Spending, Abuse and Fraud

Since 2012, UnitedHealthcare has safeguarded Louisiana’s Medicaid funds, ensuring they are
used efficiently and judiciously to provide enrollees with the care they need to improve their
health and wellbeing in alignment with the Triple aim. We have exceeded LDH referral goals
and achieved $1 million in recoveries since 2015. Examples of best practices include
screening tips prior to assignment to SIU, re-routing non-fraud cases to our Waste and Error
Team and enabling our SIU to refer cases to LDH independently.
We are committed to improving access to care, improving the overall quality of care, and
creating efficiencies within the health care system in Louisiana. We understand how the
integration of benefits and operational structures can benefit the health care system and
fundamentally improve convenience and satisfaction of the system’s stakeholders. We provide
local commitment by building community in Louisiana; and we are committed to high
satisfaction, better quality and lower cost. We look forward to continuing the journey we have
begun together, helping people live healthier lives.

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2.10.2 Organizational Experience

2.10.2.1 Proposer Experience
2.10.2.1.1 The Proposer should provide a brief summary of the organizational history of the Proposer and its…

Organizational History/Volume and States of Medicaid Business

UnitedHealthcare is proud of our 7-year partnership with the
citizens of Louisiana and the Louisiana Department of
Health (LDH). As of February 2019, we serve more than
442,000 Louisiana enrollees and are the largest organically
grown managed care organization (MCO) in Louisiana.
Through our commitment to enrollee health, strong brand
recognition and local community partnerships, we are the
enrollees’ MCO of choice for the past 7 years, with the
highest proactive choice rate. UnitedHealthcare has
provided Medicaid managed care services for 44 years and we serve more than 6 million
enrollees in 25 states in government-sponsored programs for low income and medically needy
populations. These states include Arizona, California, Colorado, Florida, Hawaii, Iowa, Kansas,
Louisiana, Maryland, Michigan, Missouri, Mississippi, Nebraska, Nevada, New Jersey, New
York, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, Washington and
Wisconsin.

Organizational Goals
We base our organizational goals on our core values of Integrity, Compassion,
Relationships, Innovation and Performance. Our core values
translate to: honoring our commitments and never compromising
our ethics; walking in the shoes of the people we serve and those
with whom we work; building trust through collaboration; inventing
the future and learning from the past; and demonstrating
excellence in everything we do. These values are the overarching
basis of how we serve the people of Louisiana by connecting them
to better health, one person at a time. This approach aligns with
LDH’s vision for the future of Medicaid Managed Care as outlined
in their white paper “Paving the Way to a Healthier Louisiana:
Advancing Medicaid Managed Care.”
 Advancing Evidence-based Practices: We are enhancing evidence-based practices
and improving discharge planning with new processes to embed behavioral health,
physical health and pharmacy staff in hospitals to improve access and care.
 Population Health: We are addressing social determinants of health (SDOH) in our
programs and solutions to serve Medicaid enrollees better, particularly those
experiencing homelessness, poor nutrition, unemployment and other factors that
negatively affect health and well-being.
 Reducing Complexity and Administrative Burden for Providers: We are supporting
providers through a combination of data, analytics, and targeted consulting — reducing
complexity and easing administrative burden to ensure they succeed. For example, we
have worked hard to remove barriers identified in early 2017 and are committed to
continuous quality improvement. We engage and work with LDH on common policies
and systems to improve the overall provider experience.

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 Aligning Financial Incentives: We are actively working with LDH to transform payment
incentives to encourage population-based care, as evidenced by our joint focus on
LDH’s vision on value-based payment (VBP). Our shared vision has helped transform
our VBP to drive quality scores and increased provider incentive payouts year over year,
ultimately resulting in better care and access for our enrollees.
 Commitment to the Louisiana Community and Health: We are strengthening local
programs in Louisiana. For example, we invested more than $5.6 million in community
initiatives since 2015, including Daughters of Charity Partners in Health program,
Woman’s Hospital Guiding Recovery and Creating Empowerment (GRACE) program,
Louisiana Research Center “Taking Aim at Cancer” and Baton Rouge Area Foundation ‒
Flood Relief.

Relevance of Medicaid Managed Care to our Mission

At UnitedHealthcare, our mission — to help people live healthier lives and to help the health
care system work better for everyone — drives and guides us to meet the needs of our
enrollees. At the core is a commitment to person-centeredness, which focuses on the enrollee’s
expressed needs, goals, desired outcomes, preferences and choices. We empower enrollees
using person-centered principles that support our care management programs, processes, tools
and approach to working with our enrollees. We are committed to our partnership with the LDH
and the relationships that allow us to deliver seamless and appropriate care to our enrollees to
achieve the goals of the Triple Aim; better health, better care and lower costs.
2.10.2.1.2 It is preferred, though not mandatory, that Proposers meet the following qualifications prior to the…
2.10.2.1.2.1 Have a minimum of seven (7) years of experience in providing health care services for a Medicaid…
UnitedHealthcare has more than 7 years of experience providing health care services in
Louisiana; we first contracted with LDH in 2012. Nationally, we have spent 44 years providing
health care services for Medicaid managed care programs.
2.10.2.1.2.2 Have, within the last twelve (12) months, been engaged in a contract or awarded a new contract as a
Within the last 12 months, UnitedHealthcare has engaged in or been awarded new contracts in
25 states. Some of the contracts we were awarded with Medicaid populations equal to or
greater than that of Louisiana in the past 12 months include:
 Arizona: Our recent contract execution date for the Arizona Complete Care program
started October 2018 and runs through September 2021, serving more than 371,000
enrollees out of 1.7 million Medicaid eligible individuals as of December 2018. We serve
TANF, children with special health care needs and ABD populations in Arizona. This
new integrated system will join physical and behavioral health services.
 North Carolina: Our recent contract execution date for the North Carolina Health
Choices Program will start November 2019 and continue in a phased implementation to
2022. We anticipate serving more than 360,000 enrollees out of 2 million Medicaid
eligible individuals by November 2019; we will serve TANF, CHIP, ABD and non-dual
LTSS populations in North Carolina. North Carolina’s program design seeks to advance
high-value care, improve population health, engage and support providers.
 Washington: Our recent contract execution date for the Washington Fully Integrated
Managed Care program started July 2018 and runs through December 2019 (annual
renewal). Serving more than 208,000 enrollees out of 1.8 million Medicaid-eligible
individuals as of December 2018; we serve TANF, CHIP, Expansion and ABD
populations in Washington. We provide the full continuum of physical health and
behavioral health.

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2.10.2.2 Staff Experience and Organizational Structure

2.10.2.2.1 For each individual appointed to a key personnel role, the individual’s name, résumé, key personnel…
We select key personnel after an extensive review of UnitedHealthcare resources and national
Medicaid and managed health care experts. Our resulting leadership team are experts in the
management of large health care delivery enterprises including leadership in managed care
systems, Medicaid program and operations. When recruiting, we first consider Louisiana
residents that have qualified experience in our roles. We have provided the names of the
individuals, their resumes, the key personnel role they fill and their role in the governance and
operating structure herein.

Scott Waulters, Interim Chief Executive Officer

Scott Waulters has full binding authority and autonomy over the operational management of the
Medicaid program and remains fully accountable to the Department for every aspect of program
administration. Mr. Waulters reports to UnitedHealthcare’s regional Medicaid CEO.

Karl Lirette, Chief Operating Officer

Karl Lirette reports to Mr. Waulters and is responsible for the operations business unit, which
includes grievance and appeals, claims administration, enrollee services, call centers, provider
services, information services and encounter data. Mr. Lirette has oversight of Dental Benefit
Providers, MARCH Vision, National MedTrans and our Hudson Veteran subcontractors.

Dr. Julie Morial, Chief Medical Officer

Dr. Julie Morial reports to Mr. Waulters as part of our operating structure. Dr. Morial is
responsible for the clinical business unit, which includes medical management, case
management and quality management. She has oversight of CareCore and Optum Health Care
Solutions.

Dr. Jose Calderon-Abbo, Behavioral Health Medical Officer

Dr. Jose Calderon reports to Dr. Morial as part of our operating structure. Dr. Calderon is
responsible for the behavioral health business unit, which includes behavioral health services.
He has oversight of United Behavioral Health.

Tatyana Kotlovskiy, Interim Chief Financial Officer

Tatyana Kotlovskiy reports to Mr. Waulters as part of our operating structure. Ms. Kotlovskiy is
responsible for the financial business unit, which includes budgeting and forecasting, accounting
system management, financial reporting and audit management.

Shana Bush, Interim Pharmacy Director

Shana Bush reports to Mr. Waulters as part of our operating structure. Ms. Bush is responsible
for the pharmacy business unit, with oversight of OptumRx.

Larry Smith, Contract Compliance Officer

Larry Smith reports to Mr. Waulters and our Board of Directors. He is responsible for
implementing the UnitedHealthcare compliance business unit, which includes program integrity;
contract compliance; and fraud, waste and abuse. He oversees OptumInsight.

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SCOTT WAULTERS, INTERIM CHIEF EXECUTIVE OFFICER

Professional Experience
Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Interim Chief Executive Officer (CEO)

Time Frame: February 2019 – Present

 Provides executive oversight and leadership for UnitedHealthcare to
meet the needs of our enrollees and achieve contractual compliance
 Develops, translates and executes strategies or functional/operational
objectives for UnitedHealthcare
 Provides leadership to and is accountable for the performance and
results through multiple layers of management and senior level
professional staff
Role and  Confirms appropriate prioritization of initiatives and good personnel
Responsibilities: management
 Develops policies and procedures for operational processes to verify
optimization and compliance with established standards and regulations
 Effectively develops strategic goals and turns those goals into specific
operating and business plans that are executed at UnitedHealthcare
 Validates regulatory compliance
 Reviews medical expense drivers and creates plans to reduce waste
and maximize the affordability of our programs

Company: UnitedHealthcare Community & State – Nationwide

Title: Executive Network Sponsor – all states

Time Frame: June 2018 – February 2019

Role and  Conducted market reviews and network strategy for multiple states
Responsibilities: across UnitedHealthcare Community & State

Company: UnitedHealthcare Community & State – Edison, New Jersey

Title: Chief Operating Officer – myConnections

Time Frame: February 2017 – June 2018

 Led all startup and growth strategies focused on the social
determinants of health and operations across multiple states and
services lines
 Operationalized a flexible and scalable housing and social service
Role and solution for enrollees identified as persistent, frequent utilizers of
Responsibilities: health care services
 Instrumental in new strategic partnerships to develop, test and scale
new models of care for enrollees with complex health, behavioral
and social needs

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UnitedHealthcare Community Plan of New Jersey – Edison, New

Company: Jersey
Title: President/Chief Executive Officer

Time Frame: September 2010 – February 2017

 Led a team of over 250 direct associates serving 730,000 members
with revenues in excess of $3.5 billion
 Operated a strong performing, NCQA Commendable organization
that consistently met its fiduciary responsibilities to its customers
Role and  Managed New Jersey product expansion and organic growth from
Responsibilities: 264,000 to 500,000 enrollees
 Implemented premium rate advocacy plan and legislative rounds
with key appointed state leaders
 Specialized in risk management, affordability and network
management

Education/Licensure/Credentials
 Bachelor of Arts – Industrial and Organizational Psychology, California University of
Pennsylvania

Awards and Recognitions

 Named 2015 UnitedHealthcare Cultural Values Award winner for Performance
 Received 2014 Innovation Leadership Award
 Named 2013 UnitedHealthcare Cultural Values Award winner for Compassion
 Named 2013 New Jersey Humanitarian of the Year

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KARL LIRETTE – CHIEF OPERATING OFFICER

Professional Experience
Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Chief Operating Officer (COO)

Time Frame: May 2013 – Present

 Manages over $1 billion in medical expenses and oversees 400+
employees
 Completed UnitedHealthcare Executive Training Program 2016,
Stanford University
 Manages marketing, network and operations teams for
UnitedHealthcare
 Led Louisiana implementation team for Medicaid expansion and served
as guest panelist for LDH Medicaid expansion tour and Media Day with
UnitedHealthcare CEOs
 Louisiana “Core Team” leader for writing 2015 Louisiana Medicaid RFP,
first place score out of five MCOs
 Managed build-out of new Baton Rouge facility, staffing/training of 300+
Role and FTEs in 2015
Responsibilities:  Created and rolled out statewide provider quality value-based
contracting model
 Responsible for go-live implementation of 2015 full-risk RFP and 2015
behavioral health carve-in
 Leads quarterly business reviews with LDH and Louisiana plan monthly
town halls
 Built strong relationship with State’s third-party payer, mitigating
payment issues
 Redesigned provider service model to handle full end-to-end issues and
complaints
 Executive sponsor for local employee engagement team
 Emergency plan coordinator for UnitedHealthcare with State Medicaid
program

Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Chief Financial Officer

Time Frame: December 2011-April 2013

 Successfully led team through first year startup, assisted with PCP
network build
Role and  Led build-out of newly created gain share financial model with LDH
Responsibilities: along with Mercer for “Bayou Health” program
 Active on go-live team resulting in first place State enrollment at 30%
out of five plans

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 Led team creating onboarding and training documents

 Recipient of 2012 inaugural UnitedHealthcare Community & State
President’s Culture Award ‒ Performance

Company: The Shaw Group – Baton Rouge, Louisiana

Controller – Air Quality Systems (AQCS)/Natural Gas – Fossil Power
Title: Division/Senior Finance Manager
Time Frame: April 2007 – December 2011
 Financial lead on over $2.5 billion on six active projects, five domestic
and one international
 Financial lead on Shaw’s most financially successful project of $1.2
Role and billion
Responsibilities:  Created quarterly internal financial position papers for various complex
project issues on revenue recognition or other significant financial
issues

Company: McKesson Specialty Pharmacy Services – New Orleans, Louisiana

Title: Controller (McKesson Specialty/BioTech Pharmacy)

Time Frame: November 2000 – April 2007

 Successfully coordinated build-out of backup Specialty Pharmacy in
Pittsburgh, PA
 Managed the financial and systems integration of VitaRx to McKesson,
SAP
 Led the design and implementation of a new SAP/Business Warehouse
inventory/profitability system enabling measurement of profit margin by
Role and product line
Responsibilities:  Instilled and reorganized processes enabling revenue growth from $35
million to $250 million
 Redesigned medical billing processes that led to decreased days sales
outstanding (DSO) from 120 to 24 days
 Created annual strategic plans and budgets for specialty pharmacy
($250 million)

Education/Licensure/Credentials
 UnitedHealthcare Executive Development Program
 Bachelor of Science ‒ Accounting, University of New Orleans

Professional and Community Affiliations

 Current Advisory Board member with NextHealth National Executive Advisory Council
 Current Panel member of LDH Independent Review Panel
 Current Commissioner for St. Charles Parish Housing Authority Board
 Current Board member, Ormond Civic Association, Community Board

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 Completed 2017 Baton Rouge Leadership Academy with Baton Rouge Business Report
 Recipient of 2012 inaugural UnitedHealthcare President’s Culture Award ‒ Performance
 Recipient of 2006 McKesson National FinanceRx ICARE Award

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JULIE MORIAL, M.D., MPH, FACP – CHIEF MEDICAL OFFICER

Professional Experience
Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Chief Medical Officer

Time Frame: November 2017 – Present

 Drives strategy and clinical value focused on quality, affordability and
service while ensuring the voice of Louisiana’s enrollees and
providers. Focuses on the effective use of data to drive transformation.
 Works in concert with UnitedHealthcare and United Clinical Services
(UCS) clinical operations and national affordability teams to ensure total
medical PMPM performance targets and value-based risk sharing
purchasing. Activities include Joint Operations Committee (JOC), data
sharing, health care affordability initiatives and ensuring appropriate
levels of inpatient/outpatient and ED utilization.
 Delivers clinical excellence. Assists with HEDIS® data collection
process, CAHPS® improvement while driving UnitedHealthcare
accreditation activities and quality rating initiatives for the local CMS
plan. Assists in the implementation of value-based and risk-sharing
Role and purchasing models with the integration of these models across quality,
evidence-based guidelines of care, utilization and strategic goals.
Responsibilities:
 Uses and maintains strong working knowledge of all government
mandates and provisions for the local UnitedHealthcare health plan to
ensure compliance and engagement of all stakeholders across the
health care spectrum.
 Leads transformation of health system through clinical interface and
communication with care providers and UnitedHealthcare network
management.
 Creates strategies and relationships that drive Triple Aim for patient-
centered medical home access, quality and affordability.
 Identifies new opportunities by participating in regional and local
Medical Cost Operating Teams (MCOTs), national MCOT and JOCs.
Oversees performance of United Behavioral Health including behavioral
health and medical care integration and OptumHealth.

Company: Peoples Health – Baton Rouge, Louisiana

Title: Corporate Market Medical Director

Time Frame: May 2010 – October 2017

 Served as market medical director for the Capital Region of Peoples
Health, a Medicare Advantage MCO that provides patient-centered
Role and medical care to seniors and the dually-eligible population. Charged with
Responsibilities: building the infrastructure and relationships that inform and educate
physicians across the Baton Rouge community about quality initiatives
— and virtual navigation — related to chronic disease management,

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long-term acute care, care coordination, risk adjustment and adherence.

 Built system that ensured correct physician documentation, preventive
measures and patient assessment.
 Implemented initiatives that took Star scores from poor performance
(2.5) to excellent (4.0), while markedly improving Risk Scores to No. 1
performer (compared to seven other established markets) in the
Peoples Health.
 Significantly improved overall financial performance through progressive
cost containment efforts with physicians, physician practices and
partner health care institutions.
 Established a face-to-face presence with membership, and on a
business level that did not exist previously. Significantly improved
collaboration and alignment and created impetus to deliver timely and
appropriate care.

Company: Blue Cross Blue Shield (BCBS) of Louisiana – Baton Rouge, Louisiana

Title: Associate Medical Director/Medical Director

Time Frame: June 2006 – April 2010

 Grew disease management (DM) program from a group limited
to diabetes and heart failure for a small segment of the population
(2006) to highly successful, highly populated, whole person DM model
focusing on a suite of conditions — COPD, asthma, coronary heart
disease and diabetes
 Drove improved communication and collaboration across team,
significantly improving return on investment for this fledgling
organization created in parallel to company vision
 Recognized by the Federal Employee Program Director's office (2011)
as a “best practice among the other 39 BCBS state plans”
 Collaborated with DM manager and analytics team to develop program
Role and evaluation measures that monitored clinical outcomes and program
Responsibilities: success
 Designed and launched enrollee assessments that allowed health
coaches to capture demographic data to address health disparities and
health literacy
 Facilitated hiring of nationally recognized physician, Dr. Villagra, to
perform third-party clinical review of diabetes program, adding
significant credibility to the program, especially for the physician
community
 Led review and assessment of nine local and national DM vendors,
leading to decision to offer an internal program rather than outsourcing
— a highly efficient and effective decision

Education/Licensure/Credentials
 Doctor of Medicine, University of Pennsylvania
 Master of Public Health, University of California Berkeley
 Bachelor of Arts – Biological Sciences, Yale University

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Professional and Community Affiliations

 Board Member, Louisiana Policy Institute for Children, 2016 – Present
 Board Member, National Diversity Advisory, Louisiana State University, 2011 – Present
 Chair Healthcare Outreach Committee, Smoking Cessation Trust for Louisiana, 2011 –
Present
 Member, American College of Physicians 1990 – Present
 Member, Board of Directors, Cancer Services of Greater Baton Rouge, Executive
Committee, 2010 – 2016
 Member, American Society of General Internal Medicine 2003-2006
 Professional Awards:
 Healthcare Hero Award, New Orleans CityBusiness, May 2018
 The American Health Strategy and Quality Institute, The Right Track Quality in Care
Award, October 2015
 Ursuline Academy Ursuline Update, Alumnae Spotlight, August 2008
 Disease Management Awards:
 Annual Forum of Healthcare Effectiveness 2005 Statewide Public Hospital and
Ambulatory Centers Initiatives, Medical Center of Louisiana, New Orleans
– First Place-Cancer Strategy: Cancer Screening Clinical Improvement
– Third Place-Cancer Strategy: Cancer Screening Clinical Excellence
– Second Place-Congestive Heart Failure Strategy Group: CHF Clinical
Improvement
– Third Place-HIV Strategy Group: Clinical Improvement

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JOSE CALDERON-ABBO, M.D. – BEHAVIORAL HEALTH MEDICAL

DIRECTOR
Professional Experience
Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Behavioral Health Medical Director

Time Frame: March 2018 – Present

 Provides oversight to and direction of the behavioral health programs at
UnitedHealthcare
 Interacts directly with psychiatrists, behavioral health providers and
other clinical professionals who consult on various processes and
programs
 Expands and manages development and implementation of evidence-
Role and based treatments and medical expense initiatives and will advise
Responsibilities: leadership on health care system improvement opportunities
 Maintains the clinical integrity of the program, including timely peer
reviews, appeals and consultations with providers and other community-
based clinicians, including general practitioners
 Works collaboratively with the medical director, clinical, network and
quality staff

Company: University Medical Center of Louisiana – New Orleans, Louisiana

Title: Associate Medical Director, Co-occurring Disorders Program

Time Frame: August 2015 – February 2018

 Oversaw program development, clinical and quality integrity of the co-
occurring disorders unit at University Medical Center
 Served as liaison to the Louisiana State University School of Medicine
Role and teaching and supervising medical students, residents in training and
Responsibilities: other health-allied professionals
 Participated in hospitals quality improvement, compliance and other
administrative functions

Company: University Hospital Calhoun Campus – New Orleans, Louisiana

Title: Medical Director, Co-occurring Unit Interim

Time Frame: 2009 ‒ July 2015

 Oversaw program development, clinical and quality integrity of the co-
occurring disorders unit at University Medical Center
Role and
 Served as liaison to the LSU School of Medicine teaching and
Responsibilities: supervising medical students, residents in training and other health-
allied professionals

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 Participated in hospitals quality improvement, compliance and other

administrative functions

Education/Licensure/Credentials
 Professional certification, Center for Mind-Body Medicine, Washington, D.C.
 Addiction Medicine fellow, American Society of Addiction Medicine
 Present Fellow, American Board of Psychiatry and Neurology
 Adult Psychiatry residency, Sinai Hospital, Wayne State University
 Internal Medicine Transitional Internship, Sinai Hospital, Wayne State University
 Medical Diploma, National Autonomous University of Mexico
 Active unrestricted medical license, Louisiana M.D.14816R
 Inactive unrestricted medical license, Michigan

Professional and Community Affiliations

 American Society of Addiction Medicine
 Member of American Academy of Actuaries, 2014 – Present
 Member of the Board, Anti-defamation League South Region, starting August 2019
 Climate Change Psychiatry Alliance
 Host: Whole Body Mental Health podcast on iTunes, and community radio show at 102.3
FM New Orleans and whivfm.org

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TATYANA KOTLOVSKIY, INTERIM CHIEF FINANCIAL OFFICER

Professional Experience
Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Interim Chief Financial Officer

Time Frame: March 2019 – Present

 Provides financial expertise to ensure that the health plan is operating
effectively, with sound financial analysis, and with appropriate financial
and operating controls
 Manages the day-to-day development of financial models and
performance as it relates to the Medicaid managed care, goals and
Role and objectives
Responsibilities:  Drives data analytics to cultivate and execute innovative solutions in
concert with clinical and operational peers to achieve better care, better
health, and lower costs for Louisiana’s most vulnerable citizens
 Designs value-based Purchasing arrangements to reward and incent
provider partners for improving access to care, focusing on population
health concerns, and addressing disparities in health outcomes

Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Director of Actuarial Services/Associate Director of Actuarial
Title: Services/Senior Actuarial Analyst
February 2014 – March 2019 (Director of Actuarial Services)
Time Frame: February 2013 – February 2014 (Associate Director of Actuarial Services)
September 2011 – February 2013 (Senior Actuarial Analyst)
 Partnered with Medicaid plans including Louisiana plan to drive health
care quality and support strategic state priorities
 Ensured cohesion in the development and execution of the financial
strategy in support of corporate objectives
 Reported directly to the chief actuary and provided executive and board
level financial and strategic planning intelligence
Role and  Supported Medicaid plans to provide a variety of functions, including
Responsibilities: pricing, financial forecasting and affordability initiatives
 Communicated with other teams providing guidance to accounting,
regulatory and other functional groups
 Worked with state agencies to assess impact of program and policy
changes and ensure soundness of capitation rates
 Provided oversight of complex actuarial issues related to analyzing and
implementing changes that affect pricing and risk assumptions

Education/Credentials
 Bachelor of Science, Major: Mathematics, Minor: Economics, Specialization: Actuarial
Science – The University of Minnesota

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Professional Affiliations
 Society of Actuaries ASA designation, 2014 – Present
 Member of American Academy of Actuaries, 2014 – Present

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SHANA BUSH, PHARM.D. – INTERIM PHARMACY DIRECTOR

Professional Experience
Company: UnitedHealthcare of Louisiana, Inc. – Metairie, Louisiana

Title: Interim Pharmacy Director

Time Frame: April 2019 – Present

 Builds and maintains client relationships and serves as the primary
point of contact for overall and day-to-day service locally
 Assists the health plan on all pharmacy-related activities including
clinical program development and improving member satisfaction
 Understands and assures compliance with the state contract and the
rules governing pharmacy (formulary/PDL, utilization management
(UM), member communications)
 Creates and maintains state-specific policies
 Serves as the subject-matter-expert single point of contact for benefit
and coding requirements and communicates to appropriate internal
stakeholders for implementation
 Develops a strong working knowledge of health plan operations
(compliance, finance, encounters, claims adjudications, networks,
clinical, case management, HEDIS measures)
Roles and  Collaborates with internal partners to complete projects and to address
Responsibilities: ongoing pharmacy service needs of the plan
 Analyzes, reviews, forecasts, trends and presents information for
operational and business planning
 Communicates pharmacy program changes with the assigned health
plans key departments
 Supports short- and long-term operational/strategic business activities
by maintaining operational information
 Attends State pharmacy meetings
 Submits timely and accurate pharmacy reports and deliverables
 Supports the assigned health plans’ grievances department in the
processing of grievances, appeals, fair hearings, as defined by the
health plans’ process to ensure a timely decision by the medical director
 Supports assigned health plans’ health services, case management and
behavioral health areas regarding targeted enrollees with specific
pharmacy concerns

Company: UnitedHealthcare Network Pharmacy – Brentwood, Tennessee

Title: Regional Pharmacy Director

Time Frame: January 2008 – April 2019

Roles and  Oversaw financial and utilization trend monitoring and management,
Responsibilities: State and regulatory interface

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 Managed relationship and projects with the pharmacy benefit manager

(PBM), key constituents with the State and within the health plan itself
 Implemented clinical and UM programs and benefit designs
 Supported DM initiatives and medical management via network
physician interactions
 Supported State audits and NCQA accreditation reviews
 Interfaced with the P&T Committee
 Provided drug information concerning medications and formulary
updates with care management

Education/Licensure/Credentials
 Doctor of Pharmacy, Mercer University School of Pharmacy ‒ Magna Cum Laude
 Bachelor of Science in Biology, University of Tennessee ‒ Cum Laude

Community Affiliations
 Academy of Managed Care Pharmacy
 Tennessee Pharmacy Association
 Mississippi Pharmacy Association
 TennCare Pharmacy Advisory Committee

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LARRY SMITH – CONTRACT COMPLIANCE OFFICER

Professional Experience
Company: UnitedHealthcare Community Plan – Baton Rouge, Louisiana

Title: Contract Compliance Officer

Time Frame: April 2013 – Present

 Implement and oversee the UnitedHealthcare Compliance Program
 Monitor fraud, waste and abuse compliance
Role and  Monitor compliance to LDH contract requirements and federal and State
Responsibilities: regulations
 Act as principal point of contact between LDH business owners and
UnitedHealthcare resources

Company: United Medical Healthcare – Hammond, LA

Title: Compliance Officer

Time Frame: February 2008 – March 2013

 Monitored compliance to corporate integrity agreement
Role and  Provided education to staff on CMS and federal regulations for
Responsibilities: Medicare
 Defended denied claims up to the administrative law judge level

Company: Touro Infirmary – New Orleans, Louisiana

Title: Director, Touro At Home

Time Frame: August 2001 – December 2007

 Managed the operations of this home health unit of a major hospital in
Role and New Orleans, including staffing, business development, financial
Responsibilities: management and survey readiness

Education/Licensure/Credentials
 Bachelor of Arts – Liberal Arts, Loyola University
 Masters of Health Administration, College of St. Francis
 Certified in Healthcare Compliance

Professional and Community Affiliations

 Health Care Compliance Association since 2009

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2.10.2.2.2 The following information about the Proposer’s operating structure:

2.10.2.2.2.1 A description of the operating structure’s leadership and how this leadership reports to and otherwise…
Our operating structure consists of a key personnel team who are accountable for the overall
performance of the plan and all subcontractors and closely monitors enrollees’ needs and health
plan’s issues. Our interim CEO, Scott Waulters, reports to Timothy Spilker, regional CEO, and
holds quarterly business reviews to report on operational issues. He conducts key personnel
and operations meetings on a daily, weekly and monthly basis and all-staff meetings quarterly.
The key personnel team meeting reports on financial performance, medical management,
membership, quality initiatives and health care affordability initiatives and creates the direction
for the health plan at a strategic level. In addition, he is a member of UnitedHealthcare
Community & State’s national Medicaid leadership team comprising senior leaders and
functional leads from across the organization. This national Medicaid leadership team serves as
our governance structure; they review key deliverables for our state partners to share best
practices and measure performance at least once a month. On a quarterly basis, Mr. Waulters
leads executive reviews of Louisiana compliance metrics and performance results with national
leadership. By leveraging many shared best practices, our local Louisiana team is able to bring
innovations to LDH that have proven results in other states.
2.10.2.2.2.2 An organizational chart of the Proposer’s operating structure, depicting the key teams or units…
These organizational charts show our leadership and functional teams supporting the Medicaid
Managed Care program, including staff types, reporting relationships and key functional roles.
Our organizational structure provides the framework for appropriate staffing levels and roles
needed to administer the Medicaid Managed Care program successfully and coordinate the
delivery of high quality, best-value health care services for enrollees and their families.

Key Personnel Organizational Chart

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Operating Unit Organizational Chart

Integrated Clinical and Behavioral Health Organizational Chart

Financial Unit Organizational Chart

Pharmacy Unit Organizational Chart

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Compliance Unit Organizational Chart

2.10.2.2.2.3 For each such team or unit, a brief description of the role the team or unit plays, the operating…
The team leads from each business unit, including senior leadership, operations, clinical,
behavioral health, finance, pharmacy and compliance, participate in daily executive leadership
meetings, which result in feedback that informs decisions for leadership. These meetings are in
addition to individual business unit periodic meetings, as described herein.

Senior Leadership
Scott Waulters, our interim CEO, directs our key personnel leadership team in the strategic
development, growth and operations of the Medicaid Managed Care Program. He participates in
bi-weekly national CEO meetings to report the plan operations updates. The key personnel
team is responsible for improving enrollee health; ensuring optimal operating performance of
the health plan to meet the needs of its enrollees and providers; developing appropriate provider
networks/contracts to deliver access to enrollees through a high-quality network; meeting
contract and regulatory requirements; implementing contract changes;; and driving innovation.
He holds quarterly business reviews with Louisiana key personnel and national executives to
review all aspects of our program. Mr. Waulters provides key metrics and updates to our LDH
performance review as required by the Model Contract Section 2.3.8.

Operations Unit
UnitedHealthcare’s operations staff, led by COO, Karl Lirette, formulates business strategies
and operational plans to ensure the optimal health plan performance. The unit is responsible for
developing appropriate provider networks; ensuring ready access to care; reducing complexity
and administrative burden; fulfilling contract and regulatory requirements; and achieving
operating performance objectives. He works closely with Mr. Waulters to address strategic
issues and chart the direction for the organization’s future. He establishes operating metrics and
daily, weekly and monthly scorecards to manage the ongoing operations that maintain
contractual compliance. Mr. Lirette conducts weekly operational meetings, including all Medicaid
plan leaders, and reports all operational concerns to the CEO. He conducts a monthly
operational call with all functional leads under operations to report on key operational metrics.
The report includes grievance and appeals, claims administration, enrollee services, provider
services, call centers, information services and encounter data. In addition, he receives
oversight report outs on Dental Benefit Providers, MARCH Vision, National MedTrans and our
Hudson Veteran subcontractors. Mr. Lirette will provide key metrics and operational updates
related to our LDH performance review as stated in our Model Contract Section 2.3.8.

Clinical Unit
Our clinical staff, led by Dr. Julie Morial, establishes and executes utilization, quality and case
management strategies to meet and exceed LDH’s goals and requirements. She advances
evidence-based practices and population health. She provides medical oversight, expertise,

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leadership and direction for the administration of the Medicaid Managed Care Program to
deliver quality health care services as defined by LDH’s contract and organizational standards.
She oversees and directs health services and quality departments and serves as a liaison with
LDH’s medical leadership and other stakeholders. Dr. Calderon, Behavioral Health Medical
Director, collaborates with Dr. Morial; together they ensure compliance with LDH Medicaid
regulations, advance behavioral-medical integration, appropriate utilization of medical
resources, and monitor quality of care and quality services. Our clinical personnel monitor and
take action for continuous clinical quality improvement and patient safety. Dr. Morial is the head
of the Quality Management Committee and is ultimately responsible for the implementation,
coordination and integration of all quality management activities. She chairs the Provider
Advisory and Healthcare Quality and Utilization Management Committee. Dr. Morial is
responsible for providing clinical updates and key metrics related to our LDH performance
review as stated in our Model Contract Section 2.3.8.

Behavioral Health Unit

Dr. Calderon collaborates with Dr. Morial and the pharmacy director to facilitate the integration
of physical and behavioral health services for our Medicaid Managed Care enrollees. He
oversees our quality improvement initiatives regarding the appropriate use of psychotropic
medications and coordinates the day-to-day operations to achieve LDH’s goals. Dr. Calderon
leads and directs the development of appropriate risk management strategies in collaboration
with LDH, other behavioral health staff, providers and stakeholders.

Finance Unit
Our finance team, led by Interim Chief Financial Officer Tatyana Kotlovskiy, oversees our
financial operations, including standardization of items to measure and related tools and
processes for encounter data, analysis and reporting. Ms. Kotlovskiy is responsible for
collaborating with Mr. Waulters and our corporate financial team to establish a disciplined
approach to financial performance management. She conducts medical economic analyses to
support joint projects with clinical teams and cost management initiatives, including aligning
financial incentives with providers. Ms. Kotlovskiy maintains the pro forma for the health plan
and manages operational investment capital. She performs monthly trend analytics to evaluate
unit and volume cost trends. She is also responsible for setting incurred but not reported and
monthly financial closes. Managing state enrollee capitation and reconciliation and validating the
timely completion and accuracy of all encounter submissions is a key part of her job. Ms.
Kotlovskiy will participate in providing financial updates and key metrics related to our LDH
performance review as stated in our Model Contract Section 2.3.8.

Pharmacy Unit
The pharmacy team, led by Interim Pharmacy Director Dr. Shana Bush, oversees all clinical and
administrative pharmacy activities, including the proper provision of pharmaceutical services to
enrollees. She also develops and maintains pharmacy practice standards, policies and
procedures. She collaborates with Dr. Morial, Dr. Calderon and other UnitedHealthcare staff to
ensure the integration of pharmacy data into UnitedHealthcare’s management and quality
improvement efforts in Louisiana. She provides pharmacy trend analysis and review to deliver
multiple regulatory and ad hoc pharmacy reports. As the dedicated pharmacy resource for the
Louisiana health plan, she is the direct contact person for Louisiana pharmacy providers and a
resource for our Louisiana health plan and national clinical and pharmacy staff. Dr. Bush will
participate in providing key metrics and pharmacy updates related to our LDH performance
review as stated in our Model Contract Section 2.3.8.

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Compliance Unit
Our Contract Compliance Officer Larry Smith collaborates with business leaders to promote the
UnitedHealthcare Compliance Program, ensuring operational accountability and compliance
with the contract. He serves as the point of contact for LDH and other regulatory agencies
regarding compliance issues and regulatory audits. Mr. Smith reports to the Board of Directors
and, with Mr. Waulters, co-chairs the Compliance Oversight Committee meetings. One of his
main goals is to address ways to minimize wasteful spending, abuse and fraud. Mr. Smith
oversees: fraud, waste and abuse program; compliance and ethics reporting; all regulatory
audits; the risk assessment process; and verifies that compliance risks are proactively identified
and addressed through prevention, detection, correction and monitoring strategies. He
coordinates implementation of compliance training and education programs; development and
implementation of appropriate corrective action; and with legal counsel, compliance
investigations. In addition, he maintains compliance-related policies and procedures; verifies
timely communication and education of the compliance program; works with operational leaders
to validate understanding and communication regulatory contractual requirements; confirms
appropriate delegated entity oversight; and verifies established processes and procedures meet
regulatory and contract requirements, including a dedicated special investigations team, as
stated in our Model Contract Section 2.3.8.
2.10.2.2.2.4 For each such team or unit, the number of full-time equivalents (FTEs) on the team or unit, a brief…
We outline, for each business unit, the number of FTEs in the unit, the typical qualifications or
competencies of staff in the unit and the role of the unit lead. We have aligned our current
staffing level to an estimated level of 472,283 members based upon current market share in
combination with a signaled reduction in contract awards from five to four. We plan for staffing
based upon enrollment increases or decreases the following ways:
 Workforce Planning: We use a standardized Workforce Management Projection Model
that can accommodate membership changes and can project the number of FTE
personnel required by functional area to support membership growth. For example, we
have metrics and planning models for enrollee and provider call center, claims, appeals
and disputes to calculate workforce projections. These models allow us to plan for the
hiring, training and location of each required FTE, verifying we have the resources we
need, when and where we need them.
 National Resources: We can deploy our national team to assist locally while we hire
and train local staff. These national resources enable our local executives and staff to
focus on the day-to-day activities to provide services and support to Medicaid Managed
Care members. We have dedicated national leadership resources that we make
available to support plan leaders at the local level in key roles such as medical director,
pharmacy, behavioral health, health services director and operations director.

Senior Leadership Unit

 FTEs: There are seven FTEs in the senior leadership unit, inclusive of our CEO, chief
operating officer, chief medical officer, behavioral health medical director, chief financial
officer, pharmacy director and contract compliance officer.
 Description of Major Qualifications and Competencies: We list the qualifications of
our senior leadership team later as unit leads under each major functional area.
 Description of Team Lead: Mr. Waulters provides overall direction, including strategic
development, growth and operations of UnitedHealthcare to provide innovative care to
our enrollees. He provides executive oversight and leadership to meet the needs of our
enrollees and achieve contractual compliance.

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Operations Unit
 FTEs: There are 459.6 FTEs in the operations unit (approx. 354 FTEs based on 375,000
enrollees).
 Description of Major Qualifications and Competencies: Staff in the operations unit
have multiple years of experience in managed care plans and with providers relevant to
their respective roles — grievances and appeals, claims administration, enrollee
services, information management, encounter data and provider services.
 Description of Team Lead: Mr. Lirette is our operations unit lead and serves as the
primary point-of-contact for all UnitedHealthcare operational issues. He is responsible for
managing and administering multiple functions and general business operations. He
manages daily staffing operations across multiple levels and departments in
UnitedHealthcare to meet performance requirements. He is responsible for formulating
sound business strategies and operational plans and is accountable for operational
results.

Clinical Unit
 FTEs: There are 245.2 FTEs in the clinical unit (approx. 189 FTEs based on 375,000
enrollees).
 Description of Major Qualifications and Competencies: The key qualifications for this
unit of personnel include clinical staff comprising RNs, LPNs and some non-clinical
personnel. This staff has multiple years of experience in managed care plans and with
providers in their respective roles: case management, quality management, SDOH and
clinical transformation.
 Description of Team Lead: Dr. Morial is our clinical unit lead and is actively involved in
all major clinical and quality management components of UnitedHealthcare’s operations,
including the integration of physical, behavioral and social health. She oversees clinical
operations initiatives that focus on clinical excellence and performance improvement.

Behavioral Health Unit

 FTEs: There are 77.2 FTEs in the behavioral health unit (approx. 59 FTEs based on
375,000 enrollees).
 Description of Major Qualifications and Competencies: Our behavioral health team
includes licensed behavioral health clinicians with experience serving the Medicaid
population and assisting individuals with complex behavioral and emotional needs.
 Description of Team Lead: Dr. Calderon is the behavioral health medical lead and
maintains the clinical integrity of behavioral health programs, including peer reviews,
appeals and consultations with providers and other community-based clinicians,
including general practitioners. He works collaboratively with clinical, network and quality
staff and interacts directly with psychiatrists, prescribers, state officials and other clinical
professionals who consult on various processes and programs.

Finance Unit
 FTEs: There are 4.5 FTEs in the finance unit (approx. 4.5 FTEs based on 375,000
enrollees).
 Description of Major Qualifications and Competencies: Staff in the financial unit
have multiple years of experience in managed care plans and in the provider community
relevant to budgeting and forecasting; accounting system management; financial
reporting; and audit managment.

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 Description of Team Lead: Tatyana Kotlovskiy is our finance unit lead and oversees all
aspects for strategic financial planning, analysis and operations for UnitedHealthcare.
She oversees the budget, accounting systems, financial reporting and audit activities.

Pharmacy Unit
 FTEs: There are 6.6 FTEs in the pharmacy unit (approx. 5 FTEs based on 375,000
enrollees).
 Description of Major Qualifications and Competencies: Staff in the pharmacy unit
has experience in managed care pharmacy either in a health plan or PBM including
experience with Medicaid; an understanding of state contract language; experience
building and maintaining client relationships and networking; experience developing and
implementing clinical programs to reduce trend or improve member experience; and the
ability to develop tactical plans, drive performance and achieve targets.
 Description of Team Lead: Dr. Shana Bush is our pharmacy unit lead. She manages
the contract requirements; creates and maintains state-specific policies; and conducts
pharmacy benefit analysis to support the provision of clinically appropriate, high quality,
cost-effective pharmaceutical care for our enrollees. She analyzes, reviews, forecasts,
trends and presents information to leadership for operational and business planning.

Compliance Unit
 FTEs: There are 15.1 FTEs in the compliance unit (approx. 13 FTEs based on 375,000
enrollees).
 Description of Major Qualifications and Competencies: Staff in this unit have
multiple years of experience in managed care plans and the provider community
relevant to their respective roles — program integrity; compliance; and fraud, waste and
abuse.
 Description of Team Lead: Mr. Smith is the compliance unit lead who oversees the
UnitedHealthcare Compliance Program and serves as the primary point-of-contact for all
UnitedHealthcare contract compliance issues. He provides oversight to the program
integrity functions, including the special investigations unit (SIU) and payment integrity.
He executes policies developed to prevent, detect and report fraud, waste and abuse to
meet contract compliance. He manages the logistics of contract deliverables and ad hoc
requests for information from LDH.

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2.10.2.3 Material Subcontractors

Please refer to Attachment 2.10.2.3 Appendix F – Material Subcontractors including the
executed agreement, for each of our material subcontractors that provide behavioral health,
pharmacy, vision, transportation and dental services. These subcontractors are Dental Benefit
Providers, MARCH Vision Group, National MedTrans, OptumRx and United Behavioral Health,
respectively.

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2.10.2.4 Proposer Reference Contact Information

2.10.2.4.1 The Proposer shall provide contact information (name, title, phone number and email) for the lead…
2.10.2.4.2 For each reference, the Proposer should provide a brief description of the types and numbers of …
The tables herein outline our contact information for the lead state-program manager, a brief
description of the types and numbers of individuals served, our key responsibilities and any
compliance actions taken by the State.

Louisiana
Medicaid Program: Acute Care (Medicaid)
Licensed Entity: UnitedHealthcare of Louisiana, Inc.
Name of Lead State Program Manager: Jen Steele
Title: Director of Medicaid
Phone: 337-233-9627
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD 27,996
Behavioral Health Only 26,310
Expansion 142,938
TANF** 245,719
Total 442,963
Key Responsibilities
This Medicaid program provides health care coverage throughout the state for traditional Medicaid
beneficiaries, to include the chronically ill, ABD, Families and Children, LaHIPP, Expansion, Coordinated
System of Care (CSOC) and TANF. Benefits include core benefits and services, such as audiology services, in-
patient and out-patient hospital services, ambulatory surgical and ancillary medical services, laboratory and
x-ray services, surgical dental services, diagnostic services, organ transplant, behavioral health medication
management, EPSDT, emergency medical services, communicable disease services, durable medical
equipment, prosthetics, orthotics and certain supplies, emergency dental, emergency and non-emergency
medical transportation, home health and personal care services, hospice services, pregnancy-related services,
nurse midwife services, pediatric and family nurse practitioner services, chiropractic services, rural health
services, immunizations, end stage renal disease, optometrist services, pharmacy, podiatry, and rehabilitative
and therapy services. The contract is integrated with behavioral health and transportation. The contract
covers children and youth with medical complexity. As of Feb. 1, 2015, the health plan became a full risk plan.
 State-funded program for traditional Medicaid populations, such as ABD, Families and Children and TANF
beneficiaries
 Available in all parishes
 Originated in 2015; current contract duration: Feb. 1, 2015 – Jan. 31, 2018 plus a 23-month extension from
Feb. 1, 2018 – Dec. 31, 2019. Coordinated Care Network-Shared Savings contract (originated 2011) phased
into this statewide Medicaid contract on Feb. 1, 2015.
**All Families and Children enrollees are included in TANF count.
Compliance Actions

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Louisiana Inc. Corrective Action Request Apr 2016 Claims
UHC Community Plan of Louisiana Inc. Corrective Action Request May 2017 Prior Authorization; FWA-FWAE
Operations; Network
Operations; Outreach Activities;
Member Materials; Care
Management; Provider
Experience; Network
Management; Quality; High
Level Oversight – Governance;
Appeal & Grievance; Written
Standards, Policies and
Procedures
UHC Community Plan of Louisiana, Inc. Corrective Action Request April 2016 Pharmacy Reimbursement
UHC Community Plan of Louisiana, Inc. Corrective Action Request Apr 2016 CEO Attendance at PI Meetings
UHC Community Plan of Louisiana, Inc. Corrective Action Request Jan 2017 Standing and Ad Hoc Reports
UHC Community Plan of Louisiana, Inc. Corrective Action Request Jan 2017 Standing and Ad Hoc Reports
UHC Community Plan of Louisiana, Inc. Corrective Action Request Feb 2017 Daily File Update
UHC Community Plan of Louisiana, Inc. Fine April 2017 Pharmacy Fees
UHC Community Plan of Louisiana, Inc. Corrective Action Request May 2017 EQRO Audit; Multiple Functional
Areas
UHC Community Plan of Louisiana, Inc. Corrective Action Request Aug 2017 TPL File Load (an email from
Stacy Guidry)
UHC Community Plan of Louisiana, Inc. Corrective Action Request Nov 2017 Provider Directory
UHC Community Plan of Louisiana, Inc. Corrective Action Request Dec 2017 IT Connectivity
UHC Community Plan of Louisiana, Inc. Corrective Action Request Apr 2018 Prior Authorization
UHC Community Plan of Louisiana, Inc. Fine June 2018 Behavioral Health Access
UHC Community Plan of Louisiana, Inc. Fine June 2018 Provider Directory
UHC Community Plan of Louisiana, Inc. Corrective Action Request July 2018 NEMT Claims Payment,
Credentialing
UHC Community Plan of Louisiana, Inc. Corrective Action Request Aug 2018 Pharmacy Copays
UHC Community Plan of Louisiana, Inc. Fine Aug 2018 Subcontractor Oversight
UHC Community Plan of Louisiana, Inc. Corrective Action Request Oct 2018 Provider Directory
UHC Community Plan of Louisiana, Inc. Corrective Action Request Oct 2018 Recoupment of Retro-
disenrollment
UHC Community Plan of Louisiana, Inc. Corrective Action Request Oct 2018 Standing and Ad Hoc Reports
UHC Community Plan of Louisiana, Inc. Corrective Action Request Oct 2018 Standing and Ad Hoc Repots
UHC Community Plan of Louisiana, Inc. Corrective Action Request Nov 2018 Claims Processing Turnaround
Time
UHC Community Plan of Louisiana, Inc. Corrective Action Request Nov 2018 RFI Timeliness
UHC Community Plan of Louisiana, Inc. Corrective Action Request Nov 2018 Standing and Ad Hoc Reports
UHC Community Plan of Louisiana, Inc. Fine Dec 2018 Performance Measures
UHC Community Plan of Louisiana, Inc. Corrective Action Request Dec 2018 Inappropriate Claim Denial
UHC Community Plan of Louisiana, Inc. Corrective Action Request Jan 2019 NEMT Call Center
UHC Community Plan of Louisiana, Inc. Corrective Action Request Jan 2019 RFI Timeliness
UHC Community Plan of Louisiana, Inc. Fine Jan 2019 Provider Directory
UHC Community Plan of Louisiana, Inc. Fine Feb 2019 Claims Processing Turnaround
Time
UHC Community Plan of Louisiana, Inc. Corrective Action Request Apr 2019 Mental Health Rehab Staff NPI
Numbers

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Arizona
Medicaid Program: AHCCCS Complete Care Integrated Services
Licensed Entity: Arizona Physician's IPA, Inc. (APIPA)
Name of Lead State Program Manager: Jami Snyder
Title: Director of Medicaid
Phone: 602-417-4111
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD 40,922
CHIP 7,824
Expansion 89,246
TANF 233,302
Total 371,294
Key Responsibilities
This Medicaid program provides statewide coverage to low-income pregnant women, families, children; ABD
SSI individuals; and uninsured children in families at other income levels through the KidsCare State
Children’s Health Insurance Program (SCHIP) program. Services cover Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) medical check-ups, occupational therapy, audiology, speech therapy,
hospital clinic services — as appropriate, regular examinations, immunizations, child delivery and newborn
care, substance use and behavioral health services, laboratory and X-ray services, including tests to prevent
birth defects, expanded vision care, podiatry, asthmatic care, dental services and other specialty care benefits.
The contract is integrated with transportation. The contract covers children and youth with some medical
complexity. Most medically complex cases are covered with the inclusion of the Children’s Rehabilitation
Services.
 State-funded program for ABD, CHIP, Expansion and TANF beneficiaries
 Available in Gila, Maricopa, Pima and Pinal counties, excluding ZIP codes: 85542, 85192 and 85550
 Originated in 1982; current contract duration: Oct. 1, 2018 – Sept. 30, 2021 with two 2-year options to
extend, not to exceed a total contracting period of 7 years
 Please note: On Oct. 1, 2018, the Children’s Rehabilitative Services (CRS) contract integrated with the Acute
Care/Uninsured Children contract, to create the newly formed AHCCCS Complete Care Integrated Services
contract.
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Arizona Corrective Action Request May 2016 Care Management;
Exclusions/Sanctions; Claims;
Network Management; Provider
Experience; Utilization Management
UHC Community Plan of Arizona Fine May 2016 Encounters
UHC Community Plan of Arizona Fine May 2016 Encounters
UHC Community Plan of Arizona Fine May 2016 Encounters
UHC Community Plan of Arizona Fine May 2016 Encounters
UHC Community Plan of Arizona Corrective Action Request Oct 2016 Claims; Utilization Management;
Care Management; Encounters
UHC Community Plan of Arizona Fine Nov 2016 Encounters
UHC Community Plan of Arizona Corrective Action Request Jan 2017 Appeal & Grievance;
Care Management
UHC Community Plan of Arizona Corrective Action Request May 2017 Network Operations; Provider
Experience; Utilization Management;
Quality;
Credentialing/Recredentialing;
Care Management

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Arizona Corrective Action Request May 2017 Claims; Provider Experience;
Utilization Management;
Credentialing/Recredentialing
UHC Community Plan of Arizona Corrective Action Request Jun 2017 Network Operations; Provider
Experience; Utilization Management;
Prior Authorization
UHC Community Plan of Arizona Fine Jul 2017 Encounters
UHC Community Plan of Arizona Corrective Action Request Sep 2017 Care Management; Provider
Experience
UHC Community Plan of Arizona Corrective Action Request Sep 2017 Provider Experience; Call Center
Member; Care Management
UHC Community Plan of Arizona Fine Nov 2017 Encounters
UHC Community Plan of Arizona Corrective Action Request Dec 2017 Claims
UHC Community Plan of Arizona Fine Mar 2018 Encounters
UHC Community Plan of Arizona Fine Mar 2018 Encounters
UHC Community Plan of Arizona Corrective Action Request Apr 2018 Quality
UHC Community Plan of Arizona Fine May 2018 Encounters
UHC Community Plan of Arizona Fine May 2018 Encounters
UHC Community Plan of Arizona Corrective Action Request May 2018 Quality
UHC Community Plan of Arizona Corrective Action Request May 2018 Quality
UHC Community Plan of Arizona Corrective Action Request May 2018 Quality
UHC Community Plan of Arizona Corrective Action Request Aug 2018 Quality
UHC Community Plan of Arizona Fine Oct 2018 Encounters
UHC Community Plan of Arizona Corrective Action Request Oct 2018 Provider Experience; Prior
Authorization
UHC Community Plan of Arizona Fine Oct 2018 Encounters
UHC Community Plan of Arizona Fine Nov 2018 Encounters
UHC Community Plan of Arizona Fine Dec 2018 Quality
UHC Community Plan of Arizona Fine Dec 2018 Quality

California
Medicaid Program: Medi-Cal Managed Care – Geographic Expansion
Licensed Entity: UnitedHealthcare Community Plan of California, Inc.
Name of Lead State Program Manager: Stephanie Issertell
Title: Contract Manager, Department of Health Care
Phone: 916-633-0193
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD 437
CHIP 2,263
Expansion 4,078
TANF 1,166
Total 7,944
Key Responsibilities
This Medicaid program provides health care coverage for eligible ABD, CHIP, expansion and TANF
beneficiaries in California. Medically necessary services cover mild to moderate behavioral health, physical
and vision care, and long-term services and supports in San Diego county. Other benefits include free health
risk assessments (HRA), EPSDT screening and a Healthy First Steps Pregnancy Program — with member
incentives for maintaining appropriate pre- and post-natal care and well-child immunization visits. The
contract is integrated with behavioral health, transportation and LTSS (i.e., covers all LTSS in San Diego). The
contract covers children under the age of 21 with specific high complexity diagnoses who enroll in the state’s
California Children’s Services (CCS) program.
 State-funded program for ABD, CHIP, expansion and TANF beneficiaries

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 Available in all counties, with LTSS in a select few

 Originated in 2017; current contract duration: Oct. 1, 2017 – Sept. 30, 2022
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of California Corrective Action Request Jul 2018 Network Management
UHC Community Plan of California Corrective Action Request Jul 2018 Prior Authorization; Appeal &
Grievance
UHC Community Plan of California Corrective Action Request Dec 2018 Network Operations
UHC Community Plan of California Corrective Action Request Jan 2019 Claims; Finance; Appeal &
Grievance

Colorado
Medicaid Program: Accountable Care Collaborative Program (ACC) and RMHP Prime and Child Health
Plus (Prime/CHP)
Licensed Entity: Rocky Mountain Health Maintenance Organization, Inc.
Name of Lead State Program Manager: Laurel Karabatsos
Title: Deputy Medicaid Director – Interim
Phone: 303-866-3058
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD 6,454
CHIP 10,527
Expansion 19,570
TANF 9,637
ASO/BH 144,222
35,661 (RMHP – Prime)
Total 10,527 (CHIP+)
144,222 (RAE/Health First Colorado)
Key Responsibilities
The Rocky Mountain Health Plan (RMHP) – Prime and Child Health Plan Plus (CHP) contracts provide public
low-cost health insurance for children and pregnant women. They offer benefits to those whose income is too
high to qualify for Health First Colorado (Medicaid) program and do not earn enough to pay for private health
insurance. Covered services include medical behavioral, vision and oral health care services, such as
asthmatic care, audiology, hospital clinic services — as appropriate, immunizations, laboratory services,
maternity care, medical checkups, newborn care, occupational therapy, pharmacy, regular examinations,
speech therapy, X-ray services, vision care and other specialty care benefits.
The Rocky Mountain Health Plan (RMHP) – Health First Colorado (Medicaid) is part of a regional
organization, and it helps enrollees residing in Western Colorado and Larimer county. It uses a network of
Regional Accountable Entities (RAEs) to coordinate acute, primary and specialty care; pharmacy; and select
behavioral health services to most Medicaid beneficiaries in the state. Medically necessary services are
provided, to include clinic services, laboratory services, PCP and specialist services, radiology and
prescription drugs. Populations covered include ABD, foster care, LTSS and TANF. All population types are
enrolled mandatorily, including those receiving LTSS services. However, LTSS/HCBS services are carved out
of the agreements and administered as a coordinate fee-for-service (FFS) wrap benefit under the Medicaid
plans.
 State-funded programs for ABD, CHP, foster care, LTSS and TANF beneficiaries
 (Prime/CHP do not include foster care)
 Available in Western Colorado
 Recently, RMHP received an RFP award notice from the Colorado Department of Human Services, Office of
Behavioral Health to operate a Crisis Services ASO in the 22 county Region 1 service area, effective July 1,
2019

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 Originated in 1974; current contract duration: May 11, 2011 – June 2019. Acquired by UnitedHealthcare ‒
March 2017. Contracts listed, including newly formed RAE contract – effective July 1, 2018 – June 30, 2019
Compliance Actions
Nothing Reported

Florida
Medicaid Program: Statewide Medicaid Managed Care (SMMC)
Licensed Entity: UnitedHealthcare of Florida, Inc.
Name of Lead State Program Manager: Kimberly Turner
Title: Contract Manager and Program Analyst
Phone: 850-412-4325
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD 37,405
LTSS 8,421
SSI 26,274
TANF 206,431
Total 278,531
Key Responsibilities
This program provides health care coverage to LTSS, SSI and TANF and chronically ill Medicaid beneficiaries.
Additional benefits include other expanded services (e.g., adult and children’s dental, over-the-counter
medications, personal hygiene items and circumcision). The elderly, chronically ill and disabled people living
in community and nursing home environments are enrollees of this program — enabling those in the
community to remain in the community, while avoiding nursing home placement. A wide range of community
supports are provided, such as home health aide services, respite care, adult day care, personal
assistance/care, housekeeping and chore services
 Medicaid; state-funded program for ABD, LTSS, SSI and TANF beneficiaries
 Available in 67 counties
 Originated in 2013; current contract duration: Jan. 1, 2019 – Dec. 31, 2023. Five programs (i.e., M* Plus:
origination 1974; Florida Diversion: origination 1999; Frail Elderly: origination 1996; Medica: organization
2009 and CareFlorida: origination 2011) phased into the statewide SMMC from August to December 2013.
Medicaid Program: Florida Healthy Kids
Licensed Entity: UnitedHealthcare of Florida, Inc.
Name of Lead State Program Manager: Lindsay Lichti
Title: Deputy Director, Plan Management
Phone: 850-224-5437
850-701-6105 (direct)
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 8,751
Total 8,751
Key Responsibilities
This CHIP program provides health coverage to children in Florida, to include Baker, Clay, Duval, Flagler,
Nassau, St. Johns and Volusia. Its enrollees have access to a full range of CHIP health plan services. For
example, services include primary, specialty, acute and behavioral care; disease and care management;
maternity services and newborn care; outpatient and emergency health care access; home health and
hospice; organ transplant services and comprehensive pharmacy benefits with low copays. Other programs
include Healthy First Steps™ and Dr. Health E. Hound.

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 CHIP; state-funded program for CHIP beneficiaries

 Available in seven counties
 Originated in 1996; current contract duration: Oct. 1, 2015 – Sept. 14, 2017 with “evergreen” annual auto-renewals
through Sept. 30, 2018, plus an amendment dated Oct. 1, 2018 – Dec. 31, 2019. This contract is in procurement
status.
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Florida Fine Mar 2016 Auditing and Monitoring
UHC Community Plan of Florida Fine Apr 2016 Quality
UHC Community Plan of Florida Fine Apr 2016 Network Management
UHC Community Plan of Florida Fine Apr 2016 Care Management
UHC Community Plan of Florida Fine Apr 2016 Care Management
UHC Community Plan of Florida Fine May 2016 Prior Authorization
UHC Community Plan of Florida Fine May 2016 Vendor
UHC Community Plan of Florida Fine Jun 2016 Appeal & Grievance
UHC Community Plan of Florida Fine Jun 2016 Member Materials
UHC Community Plan of Florida Corrective Action Request Aug 2016 Quality
UHC Community Plan of Florida Fine Aug 2016 Prior Authorization
UHC Community Plan of Florida Fine Aug 2016 Appeal & Grievance
UHC Community Plan of Florida Fine Aug 2016 Quality
UHC Community Plan of Florida Fine Sep 2016 Member Materials
UHC Community Plan of Florida Fine Oct 2016 Vendor
UHC Community Plan of Florida Fine Oct 2016 Appeal & Grievance
UHC Community Plan of Florida Fine Oct 2016 Care Management
UHC Community Plan of Florida Fine Oct 2016 Outreach Activities
UHC Community Plan of Florida Fine Nov 2016 Utilization Management
UHC Community Plan of Florida Fine Nov 2016 Quality
UHC Community Plan of Florida Fine Nov 2016 Appeal & Grievance
UHC Community Plan of Florida Fine Nov 2016 Member Materials
UHC Community Plan of Florida Fine Nov 2016 Care Management
UHC Community Plan of Florida Fine Dec 2016 Appeal & Grievance
UHC Community Plan of Florida Fine Jan 2017 Vendor
UHC Community Plan of Florida Fine Jan 2017 Care Management
UHC Community Plan of Florida Fine Mar 2017 Prior Authorization
UHC Community Plan of Florida Fine May 2017 Vendor
UHC Community Plan of Florida Fine May 2017 Vendor
UHC Community Plan of Florida Fine Jul 2017 Prior Authorization
UHC Community Plan of Florida Fine Jul 2017 Claims
UHC Community Plan of Florida Fine Jul 2017 Vendor
UHC Community Plan of Florida Fine Jul 2017 Prior Authorization
UHC Community Plan of Florida Fine Oct 2017 Encounters
UHC Community Plan of Florida Fine Oct 2017 Claims
UHC Community Plan of Florida Fine Oct 2017 Network Operations
UHC Community Plan of Florida Fine Oct 2017 Vendor
UHC Community Plan of Florida Fine Nov 2017 Outreach Activities
UHC Community Plan of Florida Fine Nov 2017 Outreach Activities
UHC Community Plan of Florida Fine Nov 2017 Appeal & Grievance
UHC Community Plan of Florida Fine Nov 2017 Admin/Operations
UHC Community Plan of Florida Fine Dec 2017 Finance
UHC Community Plan of Florida Fine Dec 2017 Network Operations
UHC Community Plan of Florida Fine Dec 2017 Appeal & Grievance
UHC Community Plan of Florida Fine Dec 2017 Appeal & Grievance
UHC Community Plan of Florida Fine Dec 2017 Quality
UHC Community Plan of Florida Fine Dec 2017 Quality
UHC Community Plan of Florida Fine Jan 2018 Network Operations
UHC Community Plan of Florida Fine Jan 2018 Network Operations
UHC Community Plan of Florida Fine Jan 2018 Claims

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Florida Fine Jan 2018 Appeal & Grievance
UHC Community Plan of Florida Fine Jan 2018 Network Management
UHC Community Plan of Florida Fine Jan 2018 Appeal & Grievance
UHC Community Plan of Florida Fine Feb 2018 Care Management
UHC Community Plan of Florida Fine Feb 2018 Care Management
UHC Community Plan of Florida Fine Feb 2018 Network Management
UHC Community Plan of Florida Fine Feb 2018 Care Management
UHC Community Plan of Florida Fine Feb 2018 Claims
UHC Community Plan of Florida Fine Feb 2018 Care Management
UHC Community Plan of Florida Corrective Action Request Feb 2018 Quality
UHC Community Plan of Florida Fine Mar 2018 Credentialing/Recredentialing
UHC Community Plan of Florida Fine Mar 2018 Care Management
UHC Community Plan of Florida Fine Mar 2018 Vendor
UHC Community Plan of Florida Fine Mar 2018 Utilization Management
UHC Community Plan of Florida Fine Mar 2018 Network Operations
UHC Community Plan of Florida Fine Mar 2018 Appeal & Grievance
UHC Community Plan of Florida Fine Apr 2018 Quality
UHC Community Plan of Florida Fine Apr 2018 Provider Experience
UHC Community Plan of Florida Fine Apr 2018 Network Management
UHC Community Plan of Florida Fine Apr 2018 Care Management
UHC Community Plan of Florida Fine Apr 2018 Prior Authorization
UHC Community Plan of Florida Fine Apr 2018 Network Management
UHC Community Plan of Florida Fine Jun 2018 Care Management
UHC Community Plan of Florida Fine Jun 2018 Network Management
UHC Community Plan of Florida Fine Jun 2018 Network Management
UHC Community Plan of Florida Fine Jun 2018 Vendor
UHC Community Plan of Florida Corrective Action Request Sep 2018 Network Management;
Provider Experience;
FWA-FWAE Operations
UHC Community Plan of Florida Fine Sep 2018 Vendor
UHC Community Plan of Florida Fine Sep 2018 Billing and Enrollment
UHC Community Plan of Florida Fine Sep 2018 Claims
UHC Community Plan of Florida Fine Sep 2018 Claims
UHC Community Plan of Florida Fine Sep 2018 Appeal & Grievance
UHC Community Plan of Florida Fine Sep 2018 Claims
UHC Community Plan of Florida Corrective Action Request Sep 2018 Claims
UHC Community Plan of Florida Fine Nov 2018 Quality
UHC Community Plan of Florida Fine Nov 2018 Quality
UHC Community Plan of Florida Fine Nov 2018 Care Management
UHC Community Plan of Florida Fine Dec 2018 Care Management
UHC Community Plan of Florida Fine Feb 2019 Encounters
UHC Community Plan of Florida Fine Feb 2019 Appeal & Grievance
UHC Community Plan of Florida Fine Feb 2019 Vendor

Hawai’i
Medicaid Program: QUEST Integration
Licensed Entity: UnitedHealthcare Insurance Company
Name of Lead State Program Manager: Judy Mohr Peterson, PhD
Title: Med-QUEST Division Administrator
Phone: 808-692-8050
Email: [email protected]

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Medicaid Program: QUEST Integration

Licensed Entity: UnitedHealthcare Insurance Company
Types of Individuals Served Number of Individuals Served
ABD including LTSS 20,365
CHIP 1,520
Expansion 15,889
TANF 10,665
Total 48,439
Key Responsibilities
This state-funded program (with Federal match) provides comprehensive medical, behavioral, LTSS,
pharmacy coverage and other benefits throughout the state of Hawai’i. It combines the earlier separate
programs: QUEST (non-ABD) and QExA (ABD including LTSS). Other benefits include medically necessary
services, such as non-emergent medical transportation, personal care attendants, home delivered meals,
home modifications, personal emergency response system and a 24-hour nurse line. The program covers all
Medicaid eligible including those in long-term care (nursing home or alternative long term care setting),
medically fragile children, and disabled individuals. Physical and behavioral health is provided using an
integrated, member-centric approach. Behavioral health services for the serious mental illness (SMI)
population are carved out to another program and DD/ID populations have certain services provided through
the DDD program at the State of Hawai’i Dept. of Health.
 State-funded program for ABD, CHIP, expansion, other Medicaid categories and TANF beneficiaries
 Available on/in all islands/counties
 Originated in 2015; current contract duration: Jan. 1, 2015 – Dec. 31, 2017 with up to four 1-year
extensions
 Two programs phased into QUEST Integration as of Jan. 1, 2015: QUEST (Medicaid) – 2012 and QUEST
Expanded Access (QExA) – 2009
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Hawai’i Corrective Action Request Sep 2016 Appeal & Grievance; Network
Operations; Member Materials
UHC Community Plan of Hawai’i Corrective Action Request Sep 2017 Credentialing/Recredentialing

Kansas
Medicaid Program: KanCare Managed Care 2.0
Licensed Entity: UnitedHealthcare of the Midwest, Inc.
Name of Lead State Program Manager: Position is vacant.
Title: The State is actively searching for a replacement.
Phone:
Email:
Types of Individuals Served Number of Individuals Served
ABD 15,910
CHIP 16,016
DD 2,319
LTSS 8,669
TANF 98,570
Total 141,485
Key Responsibilities
This Medicaid program provides health care coverage throughout the state for TANF, CHIP, ABD and LTC
populations, to include multiple waiver populations (i.e., frail elderly, physically disabled and DD/ID).

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Medicaid Program: KanCare Managed Care 2.0

Licensed Entity: UnitedHealthcare of the Midwest, Inc.
Services include medical, behavioral health, pharmacy, dental, vision and non-emergent transportation. Care
managers (e.g., RNs, community outreach and behavioral health clinicians) deliver hands-on care
management, including risk assessments and individualized plans of care with monitoring and oversight.
Enrollment is mandatory enrollment for most populations. Enrollment is voluntary for Native Americans. The
contract is integrated with behavioral health, transportation and LTSS. The contract covers children and
youth with medical complexity, if they qualify financially or via the 1115 Waiver (LTSS),
 State-funded program for ABD, CHIP, LTC and TANF beneficiaries
 Available in all counties
 Originated in 2013; current contract duration: Jan. 1, 2019 – Dec. 31, 2021 with two 1-year extensions
Compliance Actions
Nothing Reported

Maryland
Medicaid Program: Medicaid, CHIP, Primary Adult
Licensed Entity: UnitedHealthcare of the Mid-Atlantic, Inc.
Name of Lead State Program Manager: Dennis Schrader
Title: Chief Operating Officer and Medicaid Director
Maryland Department of Health
Phone: 410-767-4139
Email: [email protected]
Types of Individuals Served Number of Individuals Served
Expansion 33,751
TANF including ABD, CHIP and SSI 112,965
Total 146,716
Key Responsibilities
This Medicaid program provides health care coverage throughout the state for the beneficiaries of Maryland’s
HealthChoice program. Services are provided for adults and children, and for children and youth with medical
complexity; they include primary care and specialty physician care, prescription drugs, diagnostic services,
inpatient services, home health, hospice, emergency services, OB/GYN care and eye exams for adults and
children. Our adult value-added benefits include adult dental and vision care (e.g., exams, one pair of glasses
every 2 years and one replacement pair, if needed within a 2-year period). Substance use treatment and
transportation services are carved out of the HealthChoice program. These services are provided by the
State’s FFS program, and the health plan is contractually required to coordinate with the State’s vendors.
 State-funded program for CHIP, expansion, SSI and TANF beneficiaries
 Available in all counties
 Originated in 1997; current contract duration: Jan. 1, 2019 – Dec. 31, 2019
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Maryland Corrective Action Request Jun 2016 Credentialing/Recredentialing;
Prior Authorization; Quality;
Utilization Management
UHC Community Plan of Maryland Corrective Action Request Nov 2016 Quality
UHC Community Plan of Maryland Corrective Action Request May 2017 Credentialing/Recredentialing;
Vendor; Prior Authorization;
Appeal & Grievance
UHC Community Plan of Maryland Corrective Action Request Dec 2017 Quality
UHC Community Plan of Maryland Corrective Action Request Mar 2018 Network Operations
UHC Community Plan of Maryland Corrective Action Request May 2018 Prior Authorization
UHC Community Plan of Maryland Corrective Action Request Jan 2019 Network Operations

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Michigan
Medicaid Program: Michigan Medicaid
Licensed Entity: UnitedHealthcare Community Plan, Inc.
Name Kathleen Stiffler
Title: Director of Medicaid
Phone: 517.284.1129
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD and MME 29,198
CRS/Children’s Special Health Care Services (CSHCS) 2,987
Expansion 68,178
TANF including CHIP 147,907
Total 248,270
Key Responsibilities
This state-funded program provides comprehensive health care coverage in 65 counties throughout Michigan
for ABD, CHIP Children’s Special Health Care Services (CSHCS), expansion, MME and TANF beneficiaries.
Services are those covered by Medicaid and other expanded services, emergency and urgent care, home
health, hospice, inpatient hospital care, outpatient health care, podiatry, skilled nursing facilities, chiropractic
services, outpatient health care, supplies — DME, prosthetic devices, diagnostics, diabetes — self-monitoring
and training, and preventive care (e.g., screenings and blood tests). Medical appointment transportation is
provided for an unlimited number of trips. Enrollees receive an enhanced vision benefit. It covers children
and youth with medical complexity.
 State-funded program for ABD, CHIP Children’s Special Health Care Services (CSHCS), expansion, MME and
TANF beneficiaries
 Available in 65 counties
 Originated in 1996; current contract duration: Jan. 1, 2016 – Dec. 31, 2020. MI CHIP contract (originated
2010) phased into this statewide Medicaid contract on Jan. 1, 2016
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Michigan Corrective Action Request Sep 2016 Quality
UHC Community Plan of Michigan Corrective Action Request Nov 2016 Quality
Network Operations; FWA-FWAE
UHC Community Plan of Michigan Corrective Action Request Mar 2017 Operations
UHC Community Plan of Michigan Corrective Action Request Apr 2018 Network Operations
FWA – FWA Operations/Network
UHC Community Plan of Michigan Corrective Action Request Oct 2018 Operations

Mississippi
Medicaid Program: Mississippi CAN
Licensed Entity: UnitedHealthcare of Mississippi, Inc.
Name of Lead State Program Manager: Drew Snyder
Title: Executive Director
Phone: 601-359-9562
Email [email protected]
Types of Individuals Served Number of Individuals Served
ABD/SSI 27,685
TANF 153,173
Total 180,858

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Key Responsibilities
This state-funded program provides statewide health care coverage throughout Mississippi for Medicaid
beneficiaries, including the most vulnerable ABD/SSI and TANF enrollees of the Medicaid population. It
features full Medicaid benefits and enhanced benefits beyond Medicaid FFS. These enhancements support a
medical home model that connects enrollees with a primary care provider (PCP) and case managers to ensure
enrollees receive the best and most appropriate level care, as and when needed. The contract is integrated
with behavioral health and transportation. The contract covers children and youth with medical complexity.
 State-funded program for ABD/SSI and TANF beneficiaries
 Available in all counties
 Originated in 2011; current contract duration: July 1, 2014 – June 30, 2020 with two 1-year extensions
Medicaid Program: Mississippi CHIP
Licensed Entity: UnitedHealthcare Insurance Company (UHIC)
Name of Lead State Program Manager: Drew Snyder
Title: Executive Director
Phone: 601-359-9562
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 26,927
Total 26,927
Key Responsibilities
This state-funded program provides high quality, accessible health care and customer service throughout the
state of Mississippi for CHIP eligible populations. Medical coverage provides a broad range of services (e.g.,
inpatient and outpatient hospital care, rural health clinic [RHC] and federally qualified health center [FQHC]
visits, laboratory and x-ray, behavioral health services, ambulance/medical transportation, pharmacy
services, and vision and dental services). The program design connects enrollees with a primary care
provider (PCP) and case managers to ensure enrollees receive appropriate levels of care.
 State-funded program for CHIP beneficiaries
 Available in all counties
 Originated in 2010; current contract duration: July 1, 2015 – June 30, 2018; includes a 1-year extension.
Awarded a new CHIP contract with a 2019 start date, but implementation is delayed and currently pending
from the State due to protest proceedings
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Mississippi Fine May 2016 Claims
UHC Community Plan of Mississippi Corrective Action Request May 2016 Provider Experience
UHC Community Plan of Mississippi Corrective Action Request Aug 2016 Quality
UHC Community Plan of Mississippi Corrective Action Request Jan 2017 Credentialing/Recredentialing;
Network Operations;
Member Materials;
Care Management;
Provider Experience;
Appeal & Grievance; Quality
UHC Community Plan of Mississippi Corrective Action Request Jan 2017 Credentialing/Recredentialing;
Provider Experience; Network
Operations; Quality; Member
Materials; Encounters; Appeal &
Grievance; Care Management
UHC Community Plan of Mississippi Corrective Action Request Feb 2017 Claims; Prior Authorization
UHC Community Plan of Mississippi Fine May 2017 FWA ‒ FWAE Operations
UHC Community Plan of Mississippi Corrective Action Request Oct 2017 Care Management
UHC Community Plan of Mississippi Corrective Action Request Dec 2017 Quality
UHC Community Plan of Mississippi Corrective Action Request Jan 2018 Claims
UHC Community Plan of Mississippi Corrective Action Request Mar 2018 Business Intelligence
UHC Community Plan of Mississippi Corrective Action Request Sep 2018 Encounters; Claims

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Mississippi Corrective Action Request Sep 2018 Encounters
UHC Community Plan of Mississippi Corrective Action Request Oct 2018 Credentialing/Recredentialing;
Claims; Appeal & Grievance
UHC Community Plan of Mississippi Corrective Action Request Nov 2018 Network Operations
UHC Community Plan of Mississippi Fine Dec 2018 Claims
UHC Community Plan of Mississippi Corrective Action Request Jan 2019 Prior Authorization
UHC Community Plan of Mississippi Fine Jan 2019 Claims
UHC Community Plan of Mississippi Fine Feb 2019 Vendor

Missouri
Medicaid Program: Missouri’s HealthNet (Medicaid)
Licensed Entity: UnitedHealthcare of the Midwest, Inc.
Name of Lead State Program Manager: Bobbi Jo Garber
Title: Director of Medicaid
Phone: 573-751-6522
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 7,184
Foster Care 9,152
TANF 144,105
Total 160,441
Key Responsibilities
This state-funded program provides statewide health care coverage throughout Missouri for CHIP, foster care
and TANF enrollees of the Medicaid population. General types of services covered include medical, behavioral
health, dental, vision and non-emergent transportation. Care managers (e.g., RNs, community outreach and
behavioral health clinicians) deliver hands-on care management, including risk assessments and
individualized plans of care with monitoring and oversight. Enrollment is mandatory for most populations.
Enrollment is voluntary for Native Americans. The contract is integrated with behavioral health and
transportation.
 State-funded program for CHIP, foster care and TANF beneficiaries
 Available in all counties
 Originated in 2017; current contract duration: May 1, 2017 – June 30, 2018; with four 1-year options to
extend
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Missouri Corrective Action Request Jun 2018 Agents/Brokers; Marketing
Materials

Nebraska
Medicaid Program: Nebraska’s Heritage Health (Medicaid)
UnitedHealthcare of the Midlands, Inc.
Name of Lead State Program Manager: Heather Leschinsky
Title: Deputy Director of Medicaid, HCBS and LTSS
Phone: 402-471-9362
Email: [email protected]

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Types of Individuals Served Number of Individuals Served

ABD and Adults/Children with Disabilities 5,726
CHIP 12,766
Dual Eligible 7,754
I/DD 2,315
Katie Beckett 14
LTSS 4,582
Subsidized Adoption/Foster Care 1,952
TANF 49,190
Traumatic Brain Injury 19
Wards 1,460
Total 81,274
Key Responsibilities
The Nebraska Medicaid Managed Care Program, “Heritage Health,” is an integrated statewide program that
provides health care coverage for Medicaid eligible enrollees. Services include physical health, behavioral
health, pharmacy and transplant benefits.
Services include inpatient and outpatient hospital services; ambulatory surgery service; ED; urgent care;
clinical and anatomical laboratory services, radiology; FQHC and RHC services; Indian Health Services;
EPSDT; physician services; home health care and private duty nursing services; rehabilitation; physical,
occupational and speech therapy; DME and medical supplies; hearing aids and care; family planning; diabetic
supplies; podiatry, chiropractic therapy, vision services; non-emergent ambulance transportation; ambulance
services; skilled/rehabilitative and transitional nursing facility services; hospice services — except when
provided in a nursing facility; and flu vaccinations.
 State-funded program for ABD, adults and children with disabilities, CHIP, dual-eligible, I/DD, Katie
Beckett, subsidized adoption/foster care, TANF, traumatic brain injury and wards beneficiaries
 Available in all counties
 Originated in 1996; current contract duration: Jan. 1, 2017 – Dec. 31, 2021. This is a 5-year contract with
two possible 1-year extensions split between three MCOs
Compliance Actions
Nothing Reported

Nevada
Medicaid Program: Health Plan of Nevada
Licensed Entity: Health Plan of Nevada, Inc.
Name of Lead State Program Manager: Cody Phinney
Title: Deputy Administrator
Department of Health and Human Services
Phone: 775-687-3735
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 14,724
Expansion 103,079
TANF/CHAP 142,305
Total 260,108
Key Responsibilities
This state-funded program provides health care coverage throughout the state for Nevada’s TANF, child
health assurance program (CHAP) and CHIP enrollees. Available through an extensive, stable, provider

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network, medically necessary services are targeted to enrollees’ medical, behavioral and social needs,
ensuring a consistent medical home and continuity of care. Services include a wide range of options, such as
readily accessible obstetrical care, member incentive programs, EPSDT screenings, well-child care,
immunizations, early prenatal/postpartum care, adult preventive care, behavioral health services, and
programs to address social determinants of health, such as transitional and permanent housing. Our health
education-wellness division offers bilingual instruction on pregnancy, asthma, cholesterol, diabetes, high
blood pressure, weight management and smoking cessation. Other benefits include a 24-hour telephone
nurse service, telemedicine access, extended-hour clinics, mobile medical services, supplemental non-
emergency transportation and added non-covered medical benefits. The contract is integrated with
behavioral health, social and transportation — to include myHousing and myRide, both of which are
producing positive results in lowering the cost of medical care.
 State-funded program for CHAP, CHIP and TANF including expansion beneficiaries
 Available in two counties
 Originated in 1997; current contract duration: July 1, 2017 – June 30, 2021
Compliance Actions
Nothing Reported

New Jersey
Medicaid Program: New Jersey Medicaid
Licensed Entity: UnitedHealthcare of New Jersey, Inc.
Name of Lead State Program Manager: Meghan Davey
Title: Director of Division of Medical Assistance and Health
Services
Phone: 609-588-2600
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 17,534
Duals 22,372
Expansion 130,793
LTSS 8,960
SSI 74,866
TANF including DD 231,849
Total 486,374
Key Responsibilities
This state-funded program provides health care coverage throughout the state of New Jersey for CHIP, DD,
duals, expansion, LTSS, SSI and TANF beneficiaries. We offer a broad package of health services that cover
medically necessary care, such as inpatient and outpatient hospital care, physician services, laboratory tests
and x-rays, home health care and nursing facility care. The contract covers children and youth with medical
complexity. Behavioral health benefits are integrated for individuals with LTSS and developmental
disabilities.
 State-funded program (Medicaid) for CHIP, DD, duals, expansion, LTSS, SSI and TANF beneficiaries
 Available in all counties
 Originated in 1995; current contract duration: July 1, 2018 – June 30, 2019 (Bi-annual Renewal)
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of New Jersey Fine Mar 2016 Encounters
UHC Community Plan of New Jersey Fine Mar 2016 Encounters
UHC Community Plan of New Jersey Fine Mar 2016 Encounters

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of New Jersey Corrective Action Request Apr 2016 Network Management; Claims;
Quality; Provider Experience;
Care Management;
Credentialing/Recredentialing;
Appeal & Grievance; Prior
Authorization; Security
UHC Community Plan of New Jersey Corrective Action Request Jun 2016 Network Management; Call Center
Member; Member Materials; Prior
Authorization
UHC Community Plan of New Jersey Corrective Action Request Oct 2016 Quality
UHC Community Plan of New Jersey Fine Oct 2016 Encounters
UHC Community Plan of New Jersey Corrective Action Request Oct 2016 Quality; Care Management;
Utilization Management; Provider
Experience
UHC Community Plan of New Jersey Corrective Action Request Nov 2016 Claims
UHC Community Plan of New Jersey Corrective Action Request Jan 2017 Care Management
UHC Community Plan of New Jersey Corrective Action Request Mar 2017 Care Management
UHC Community Plan of New Jersey Corrective Action Request Apr 2017 Network Management; Quality;
Care Management; Appeal &
Grievance
UHC Community Plan of New Jersey Corrective Action Request May 2017 Quality
UHC Community Plan of New Jersey Corrective Action Request Jun 2017 Care Management
UHC Community Plan of New Jersey Fine Jul 2017 Quality
UHC Community Plan of New Jersey Fine Dec 2017 Appeal & Grievance
UHC Community Plan of New Jersey Corrective Action Request Jan 2018 Care Management
UHC Community Plan of New Jersey Corrective Action Request Jan 2018 Encounters
UHC Community Plan of New Jersey Corrective Action Request Feb 2018 Prior Authorization
UHC Community Plan of New Jersey Corrective Action Request Mar 2018 Care Management
UHC Community Plan of New Jersey Corrective Action Request Mar 2018 Care Management
UHC Community Plan of New Jersey Corrective Action Request May 2018 Care Management
UHC Community Plan of New Jersey Corrective Action Request Jul 2018 Care Management; Network
Management; Quality; Appeal &
Grievance; Call Center Member;
Credentialing/Recredentialing;
Provider Experience; Utilization
Management; Network
Operations; Written Standards,
Policies, and Procedures;
Prior Authorization
UHC Community Plan of New Jersey Corrective Action Request Sep 2018 Care Management
UHC Community Plan of New Jersey Corrective Action Request Sep 2018 Quality; Care Management
UHC Community Plan of New Jersey Corrective Action Request Oct 2018 Provider Experience
UHC Community Plan of New Jersey Corrective Action Request Dec 2018 Care Management
UHC Community Plan of New Jersey Corrective Action Request Jan 2019 Network Operations
UHC Community Plan of New Jersey Corrective Action Request Feb 2019 Care Management

New York
Medicaid Program: New York Medicaid
Licensed Entity: UnitedHealthcare of New York, Inc.
Name of Lead State Program Manager: Jonathan Bick
Title: Director – Division of Health Plan Contracting and
Oversight
Phone: 518-474-5515
Email: [email protected]

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Types of Individuals Served Number of Individuals Served

HARP 9,038
Expansion 40,722
SSI 17,236
TANF including ABD 425,287
Total 492,283
Key Responsibilities
This Medicaid health plan is available in the five boroughs of New York City and 43 additional counties in the
state of New York. Medically necessary covered services are offered. Dental services are provided.
Transportation services are available in some counties and carved out to State Department of Health (SDOH)
in the remainder. The contract is integrated with behavioral health, transportation and LTSS. The contract
covers children and youth with medical complexity.
 State-funded program (Medicaid) for ABD, SSI and TANF beneficiaries
 Available in five boroughs and 43 counties
 Originated in 2005; current contract duration: March 1, 2014 – Feb. 28, 2019
 Services being provided under informal extension pending execution of new contract
Medicaid Program: Child Health Plus
Licensed Entity: UnitedHealthcare of New York, Inc.
Name of Lead State Program Manager: Gabrielle Armenia
Title: Director – Child Health Plus Enrollment
Phone: 518-473-0566
Email: [email protected]
Types of Individuals Served Number of Individuals Served
Children and youth with medical complexity 52,730
Total 52,730
Key Responsibilities
This state-funded health plan is available in five boroughs of New York City, two boroughs in Long Island and
27 additional counties throughout the state of New York for children. Medically necessary services are
provided, including dental and prescription coverage. The contract is integrated with behavioral health,
transportation and LTSS. The contract covers children and youth with medical complexity.
 State-funded program for children
 Available in seven boroughs and 27 counties
 Originated in 1997; current contract duration: Jan. 1, 2016 – Sept. 30, 2019
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of New York Corrective Action Request Mar 2016 Network Management
UHC Community Plan of New York Corrective Action Request Apr 2016 Care Management; Network
Management; Network Operations;
Utilization Management;
Credentialing/Recredentialing
UHC Community Plan of New York Corrective Action Request Apr 2016 Network Management
UHC Community Plan of New York Corrective Action Request May 2016 Claims
UHC Community Plan of New York Corrective Action Request May 2016 Care Management
UHC Community Plan of New York Corrective Action Request Jun 2016 Care Management
UHC Community Plan of New York Corrective Action Request Sep 2016 Finance/Accounting
UHC Community Plan of New York Corrective Action Request Sep 2016 Finance
UHC Community Plan of New York Corrective Action Request Oct 2016 Network Operations
UHC Community Plan of New York Corrective Action Request Oct 2016 Auditing and Monitoring
UHC Community Plan of New York Corrective Action Request Nov 2016 Network Management
UHC Community Plan of New York Corrective Action Request Dec 2016 Care Management

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of New York Corrective Action Request Jan 2017 High Level Oversight ‒
Governance; Quality; Outreach
Activities; Care Management;
Appeal & Grievance; Billing and
Enrollment
UHC Community Plan of New York Corrective Action Request Jan 2017 Network Management; Network
Operations; Appeal & Grievance;
Prior Authorization
UHC Community Plan of New York Corrective Action Request Feb 2017 Agents/Brokers; Network
Operations; Claims; Utilization
Management; Appeal & Grievance
UHC Community Plan of New York Corrective Action Request Feb 2017 Encounters
UHC Community Plan of New York Corrective Action Request May 2017 System
UHC Community Plan of New York Corrective Action Request Jul 2017 Network Management
UHC Community Plan of New York Corrective Action Request Jul 2017 Call Center Member
UHC Community Plan of New York Corrective Action Request Oct 2017 Care Management
UHC Community Plan of New York Corrective Action Request Oct 2017 Encounters
UHC Community Plan of New York Corrective Action Request Nov 2017 Network Operations
UHC Community Plan of New York Corrective Action Request Jan 2018 Prior Authorization
UHC Community Plan of New York Corrective Action Request Jan 2018 Care Management
UHC Community Plan of New York Corrective Action Request Feb 2018 Care Management
UHC Community Plan of New York Corrective Action Request Apr 2018 Member Materials
UHC Community Plan of New York Corrective Action Request May 2018 Network Management; Prior
Authorization
UHC Community Plan of New York Corrective Action Request Jun 2018 Call Center Member
UHC Community Plan of New York Corrective Action Request Aug 2018 Call Center Member
UHC Community Plan of New York Corrective Action Request Aug 2018 Vendor
UHC Community Plan of New York Corrective Action Request Dec 2018 Network Management
UHC Community Plan of New York Corrective Action Request Mar 2019 Care Management

North Carolina
Medicaid Program: Prepaid Health Plan Services
Licensed Entity: UnitedHealthcare of North Carolina, Inc.
Name of Lead State Program Manager: Sarah Gregosky, MSPH
Title: Deputy Director of Standard Plans – North Carolina
Department of Health and Human Services
Phone: 919-527-7027
Email: [email protected]
Types of Individuals Served Number of Individuals Served
Forecast for February 2020
ABD 27,210
CHIP 55,997
LTSS 3,335
TANF 270,940
Total 357,482
Key Responsibilities
This is a statewide Medicaid program, which works closely with the state to improve the overall health and
well-being of North Carolinian Medicaid enrollees, both adults and children. The program provides whole-
person, coordinated care, which addresses both medical needs and social supports and services, such as
access to food, transportation, employment and housing. This includes preventive care, primary care,
hospitalization, prescriptions and other health and wellness services, often at low or no cost.
 State-funded program (Medicaid) for ABD, CHIP, SSI and TANF beneficiaries

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 Available in all counties

 Originated in 2019; current contract duration: Nov. 1, 2019 – June 30, 2020 (Phase I) and Feb. 1 2020 –
June 30, 2020 (Phase II) plus two additional 1-year periods from July 1 – June 30
Compliance Actions
Nothing Reported

Ohio
Medicaid Program: Covered Families/Children (CFC)/Aged, Blind or Disabled (ABD)
Licensed Entity: UnitedHealthcare Community Plan of Ohio, Inc.
Name of Lead State Program Manager: Roxanne Richardson
Title: Interim Deputy Director Managed Care
Department of Medicaid
Phone: 614-752-2600
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD 22,584
Expansion 85,741
TANF including CHIP and Other Children 171,468
279,793
Total
(178,209 CFC/110,917 ABD)
Key Responsibilities
This program provides health care coverage throughout Ohio for ABD, CHIP, expansion and TANF
beneficiaries. The Medicaid program encompasses ABD, Ohio’s Healthy Families eligibles (i.e., TANF-related
Medicaid consumers), Ohio’s Healthy Start eligibles (SCHIP consumers) — referred to as Covered Families
and Children (CFC) and Medicaid expansion beneficiaries. It involves the delivery of all Medicaid-covered
physical health services, including, for example, retail pharmacy, vision and dental, and behavioral health as
of July 1, 2018, to eligible recipients. The program covers short-term nursing facility stays (<100 days) except
in the case of the expansion population where the entire stay is covered. The contract is integrated with
behavioral health and transportation. The contract covers both ABD children and Children in Custody (CIC)
with a unique set of medical complexity.
 State-funded program (Medicaid) for ABD, CHIP, expansion and TANF beneficiaries
 Available in all counties
 Originated in 2005; current contract duration: July 1, 2018 – June 30, 2019 (Annual Renewal)
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Ohio Fine Apr 2016 Network Management
UHC Community Plan of Ohio Corrective Action Request Jun 2016 Care Management
UHC Community Plan of Ohio Fine Jul 2016 Network Management
UHC Community Plan of Ohio Corrective Action Request Sep 2016 Outreach Activities
UHC Community Plan of Ohio Fine Oct 2016 Network Management
UHC Community Plan of Ohio Fine Nov 2016 Quality
UHC Community Plan of Ohio Fine Jan 2017 Network Management
UHC Community Plan of Ohio Fine Feb 2017 Care Management
UHC Community Plan of Ohio Fine Feb 2017 Care Management
UHC Community Plan of Ohio Corrective Action Request Feb 2017 Care Management
UHC Community Plan of Ohio Corrective Action Request Mar 2017 Network Management
UHC Community Plan of Ohio Fine May 2017 Network Management
UHC Community Plan of Ohio Corrective Action Request Jun 2017 Network Operations
UHC Community Plan of Ohio Corrective Action Request Jun 2017 Encounters
UHC Community Plan of Ohio Corrective Action Request Jun 2017 Encounters
UHC Community Plan of Ohio Fine Aug 2017 Network Management

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Ohio Corrective Action Request Sep 2017 Network Management; Care
Management; Utilization
Management; Network Operations;
Member Materials; Appeal &
Grievance; Provider Experience;
Quality; Prior Authorization
UHC Community Plan of Ohio Fine Sep 2017 Quality
UHC Community Plan of Ohio Corrective Action Request Oct 2017 Appeal & Grievance
UHC Community Plan of Ohio Fine Nov 2017 Network Management
UHC Community Plan of Ohio Fine Nov 2017 Network Management
UHC Community Plan of Ohio Fine Dec 2017 Quality
UHC Community Plan of Ohio Fine Feb 2018 Network Management
UHC Community Plan of Ohio Fine Mar 2018 Utilization Management
UHC Community Plan of Ohio Corrective Action Request May 2018 Network Operations
UHC Community Plan of Ohio Fine May 2018 Network Management
UHC Community Plan of Ohio Fine May 2018 Network Management
UHC Community Plan of Ohio Fine May 2018 Vendor
UHC Community Plan of Ohio Corrective Action Request May 2018 Vendor
UHC Community Plan of Ohio Corrective Action Request Jul 2018 Network Management
UHC Community Plan of Ohio Fine Sep 2018 Network Management
UHC Community Plan of Ohio Fine Oct 2018 Quality
UHC Community Plan of Ohio Fine Nov 2018 Network Management
UHC Community Plan of Ohio Fine Nov 2018 Network Management
UHC Community Plan of Ohio Corrective Action Request Dec 2018 Lines of Communication/Reporting
Mechanisms; Utilization
Management; Prior Authorization
UHC Community Plan of Ohio Corrective Action Request Jan 2019 Call Center Member
UHC Community Plan of Ohio Corrective Action Request Feb 2019 Prior Authorization
UHC Community Plan of Ohio Fine Feb 2019 Claims
UHC Community Plan of Ohio Fine Feb 2019 Network Management
UHC Community Plan of Ohio Fine Feb 2019 Network Management
UHC Community Plan of Ohio Corrective Action Request Feb 2019 Care Management; Claims
UHC Community Plan of Ohio Fine Mar 2019 Report Deliverable

Pennsylvania
Medicaid Program: UnitedHealthcare Community Plan for Kids
Licensed Entity: UnitedHealthcare of Pennsylvania, Inc.
Name of Lead State Program Manager: Patricia Allan
Title: Executive Director
Department of Human Services, Office of Children’s
Health Insurance Program (CHIP)
Phone: 717-705-0542
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 36,268
Total 36,268
Key Responsibilities
This is a state-funded program that provides health care coverage in 52 counties in the Commonwealth for
CHIP beneficiaries. It provides free or low-cost health insurance to children under the age of 19 who meet
eligibility requirements. Eligible children are enrolled and provided with all CHIP-covered inpatient,
outpatient, diagnostic, pharmacy, dental, vision and mental health services. Services include immunizations;
DME; well-child exams; laboratory and x-ray; hospital care; physical, occupational and speech therapy; case
management for children with special needs; behavioral health care; vision care, including glasses, frames

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and contact lenses; tobacco cessation benefits; sports physicals and other specialty services. United
Behavioral Health provides the behavioral services covered by the CHIP program. Emergency transportation
is available also. CHIP enrollees with special needs may be transitioned to Medicaid depending on condition.
Pennsylvania Medical Assistance provides extensive medical and mental health coverage for children with
special needs that may not be available or may be limited through CHIP.
 State-funded program (Medicaid) for CHIP beneficiaries
 Available in 52 counties
 Originated in 1999; current contract duration: March 1, 2019 – Feb. 28, 2020
Medicaid Program: UnitedHealthcare Community Plan for Families
Licensed Entity: UnitedHealthcare of Pennsylvania, Inc.
Name of Lead State Program Manager: Laurie Rock
Title: Director ‒Bureau of Managed Care Operations
Phone: 717-772-6197
Email: [email protected]
Types of Individuals Served Number of Individuals Served
Expansion 74,475
TANF including ABD 147,378
Total 221,853
Key Responsibilities
This is a state-funded Medicaid program that provides health care coverage in 32 counties (i.e., Adams,
Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bucks, Butler, Cambria, Chester, Cumberland, Dauphin,
Delaware, Fayette, Franklin, Fulton, Greene, Huntingdon, Indiana, Lancaster, Lawrence, Lebanon, Lehigh,
Montgomery, Northampton, Perry, Philadelphia, Somerset, Washington, Westmoreland and York) in the
Commonwealth for disabled adult, Medicaid expansion and TANF beneficiaries. It covers unlimited visits to
PCP; personal care available 24 hours a day, 7 days a week; ED care, when needed; immunizations;
prescriptions and dental services; EPSDT screenings and treatment, vision exams and eyewear. Specialty care
includes asthma care, cancer awareness, diabetes control and support, healthy heart programs, a well-
mother/well-baby program, teenage pregnancy, AIDS, substance use prevention, smoking cessation and other
community/health supports.
 State-funded health plan (Medicaid) for disabled adult, expansion and TANF beneficiaries
 Available in 32 counties
 Originated in 1989; current contract duration: Jan. 1, 2019 – Dec. 31, 2019 (Annual Renewal)
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Pennsylvania Corrective Action Request Apr 2017 Provider Experience;
FWA ‒ FWAE Operations
UHC Community Plan of Pennsylvania Corrective Action Request Nov 2016 Care Management
UHC Community Plan of Pennsylvania Corrective Action Request Jan 2017 Appeal & Grievance
UHC Community Plan of Pennsylvania Corrective Action Request Jan 2017 Network Operations
UHC Community Plan of Pennsylvania Corrective Action Request Apr 2018 Pharmacy
UHC Community Plan of Pennsylvania Corrective Action Request Apr 2018 Prior Authorization
UHC Community Plan of Pennsylvania Corrective Action Request Oct 2018 Prior Authorization

Rhode Island
Medicaid Program: RIte Care (CHIP/TANF)
Licensed Entity: UnitedHealthcare of New England, Inc.
Name of Lead State Program Manager: Patrick Tigue
Title: Medicaid Program Director
Phone: 401-462-1965
Email: [email protected]

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Types of Individuals Served Number of Individuals Served

TANF including CHIP and CSHCN 54,192
Total 54,192
Key Responsibilities
This is a state-funded program that provides health care coverage throughout the state of Rhode Island for
CHIP, CSHCN and TANF beneficiaries. It covers comprehensive member care for all Rhode Island Medicaid
populations; medical and behavioral health, and pharmacy services are offered. RIte Care Medicaid child
enrollees born after May 2000 are offered dental services by UnitedHealthcare Dental, which is a separate
contract. The contract is integrated with behavioral health and provides preventive services similar to LTSS
(e.g., minor modifications, personal care attendants and homemakers). The contract covers children and
youth with medical complexity.
 State-funded program (Medicaid) for CHIP, CSHCN and TANF beneficiaries
 Available in all counties
 Originated in 1994; current contract duration: March 1, 2017 – June 30, 2022
Compliance Actions
Nothing Reported
Medicaid Program: Rhody Health Partners – Adult SSI
Licensed Entity: UnitedHealthcare of New England, Inc.
Name of Lead State Program Manager: Patrick Tigue
Title: Medicaid Program Director
Phone: 401-462-1965
Email: [email protected]
Types of Individuals Served Number of Individuals Served
ABD including SSI 6,876
Total 6,876
Key Responsibilities
This is a state-funded program that provides health care coverage throughout the state of Rhode Island for
ABD and SSI beneficiaries. It covers comprehensive member care for all Rhode Island Medicaid populations;
medical and behavioral health, and pharmacy services are offered.
 State-funded program (Medicaid) for ABD and SSI beneficiaries
 Available in all counties
 Originated in 1994; current contract duration: March 1, 2017 – June 30, 2022
Compliance Actions
Nothing Reported
Medicaid Program: RIte Care – Expansion
Licensed Entity: UnitedHealthcare of New England, Inc.
Name of Lead State Program Manager: Patrick Tigue
Title: Medicaid Program Director
Phone: 401-462-1965
Email: [email protected]
Types of Individuals Served Number of Individuals Served
Expansion 29,515
Total 29,515
Key Responsibilities
See description above for TANF population. This covers the Medicaid expansion being executed in the State of
Rhode Island, currently. Medicaid Expansion was added as an amendment to the main Medicaid contract on
Jan. 1, 2014.
 State-funded program for expansion beneficiaries
 Available in all counties
 Originated in 1994; current contract duration: March 1, 2017 – June 30, 2022
Compliance Actions
Nothing Reported

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Tennessee
Medicaid Program: TennCare
Licensed Entity: UnitedHealthcare Plan of the River Valley, Inc.
Name of Lead State Program Manager: Gabe Roberts
Title: Director of Medicaid
Phone: 615-507-6444
Email: [email protected]
Types of Individuals Served Number of Individuals Served
LTSS 10,719
SSI 34,057
TANF including ABD 372,988
Total 417,764
Key Responsibilities
This is a state-funded program that provides health care coverage throughout the state of Tennessee for SSI,
TANF and uninsured children beneficiaries. It provides services to all mandatory Medicaid eligibility groups
and some categorically and medically needy voluntary groups, including children, pregnant women, the aged
and individuals with disabilities. TennCare Standard includes children in these eligibility categories:
uninsured, children under age 19 who are TennCare eligible and with family incomes less than 200% of the
federal poverty level; who are TennCare eligible and meet “medically eligible” criteria (e.g., a health condition
that makes the child uninsurable); and who are no longer eligible for TennCare Medicaid and are either
uninsured or medically eligible. Services include, for example, inpatient hospital, physician, outpatient
hospital, ambulance, physical therapy, nursing care, speech therapy, DME, home health care, hospice, hearing,
vision, LTSS, behavioral health and non-emergency transportation. Pharmacy and dental services are
provided but carved out. The contract is integrated with behavioral health, non-emergency medical
transportation and LTSS (i.e., elderly, individuals with physical disabilities, individuals with
intellectual/developmental disabilities in conjunction with Employment Community First (ECF), etc.). We
provide care management and/or care coordination to infants, children, and adolescents, including those
with complex needs or special needs. We provide support for preventive and wellness screenings for those
under 21 years old in accordance with Bright Futures care recommendations.
 State-funded program (Medicaid) for ABD, SSI and TANF beneficiaries
 Available in all counties
 Originated in 1994; current contract duration: Jan. 1, 2014 – Dec. 31, 2017 with four 1-year extensions
 Jan. 1, 2014 – Three main region contracts (i.e., East: origination 1994; Middle Grand: origination 2006;
and West: origination 2008) phased into this statewide TennCare Medicaid contract from January to
December 2014
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Tennessee Fine Mar 2016 Claims
UHC Community Plan of Tennessee Fine Mar 2016 Claims
UHC Community Plan of Tennessee Fine Mar 2016 Care Management
UHC Community Plan of Tennessee Corrective Action Request Mar 2016 Encounters; Claims
UHC Community Plan of Tennessee Fine Mar 2016 Care Management
UHC Community Plan of Tennessee Corrective Action Request Mar 2016 Claims
UHC Community Plan of Tennessee Fine Mar 2016 Claims
UHC Community Plan of Tennessee Fine Mar 2016 Vendor
UHC Community Plan of Tennessee Fine Mar 2016 Vendor
UHC Community Plan of Tennessee Corrective Action Request Mar 2016 Credentialing/Recredentialing
UHC Community Plan of Tennessee Corrective Action Request Apr 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Apr 2016 Network Operations
UHC Community Plan of Tennessee Fine Apr 2016 Care Management
UHC Community Plan of Tennessee Fine Apr 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Apr 2016 Claims

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Tennessee Fine Apr 2016 Vendor
UHC Community Plan of Tennessee Fine Apr 2016 Care Management
UHC Community Plan of Tennessee Corrective Action Request Apr 2016 Appeal & Grievance;
Utilization Management;
Credentialing/Recredentialing
UHC Community Plan of Tennessee Fine Apr 2016 Care Management
UHC Community Plan of Tennessee Fine May 2016 Vendor
UHC Community Plan of Tennessee Fine May 2016 Vendor
UHC Community Plan of Tennessee Fine May 2016 Vendor
UHC Community Plan of Tennessee Fine May 2016 Vendor
UHC Community Plan of Tennessee Corrective Action Request May 2016 Claims
UHC Community Plan of Tennessee Fine Jun 2016 Care Management
UHC Community Plan of Tennessee Fine Jun 2016 Vendor
UHC Community Plan of Tennessee Fine Jun 2016 Network Operations
UHC Community Plan of Tennessee Fine Jul 2016 Appeal & Grievance
UHC Community Plan of Tennessee Fine Jul 2016 Appeal & Grievance
UHC Community Plan of Tennessee Corrective Action Request Jul 2016 Network Operations
UHC Community Plan of Tennessee Fine Jul 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Appeal & Grievance
UHC Community Plan of Tennessee Fine Aug 2016 Claims
UHC Community Plan of Tennessee Fine Aug 2016 Claims
UHC Community Plan of Tennessee Fine Aug 2016 Claims
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Claims
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Aug 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Aug 2016 Claims
UHC Community Plan of Tennessee Fine Aug 2016 Appeal & Grievance
UHC Community Plan of Tennessee Fine Aug 2016 Vendor
UHC Community Plan of Tennessee Fine Sep 2016 Network Operations
UHC Community Plan of Tennessee Fine Sep 2016 Vendor
UHC Community Plan of Tennessee Fine Sep 2016 Quality
UHC Community Plan of Tennessee Fine Sep 2016 Quality
UHC Community Plan of Tennessee Fine Sep 2016 Quality
UHC Community Plan of Tennessee Corrective Action Request Sep 2016 Quality
UHC Community Plan of Tennessee Corrective Action Request Sep 2016 Quality
UHC Community Plan of Tennessee Corrective Action Request Sep 2016 Quality
UHC Community Plan of Tennessee Fine Sep 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Sep 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Sep 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Oct 2016 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Oct 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Oct 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Nov 2016 Claims
UHC Community Plan of Tennessee Fine Nov 2016 Vendor
UHC Community Plan of Tennessee Fine Nov 2016 Vendor
UHC Community Plan of Tennessee Corrective Action Request Nov 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Nov 2016 Quality
UHC Community Plan of Tennessee Fine Nov 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Nov 2016 Claims
UHC Community Plan of Tennessee Corrective Action Request Dec 2016 Claims
UHC Community Plan of Tennessee Fine Dec 2016 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Dec 2016 Claims

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Tennessee Corrective Action Request Dec 2016 Quality
UHC Community Plan of Tennessee Corrective Action Request Dec 2016 Care Management
UHC Community Plan of Tennessee Fine Jan 2017 Care Management
UHC Community Plan of Tennessee Fine Jan 2017 Care Management
UHC Community Plan of Tennessee Fine Jan 2017 Vendor
UHC Community Plan of Tennessee Fine Jan 2017 Care Management
UHC Community Plan of Tennessee Fine Jan 2017 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Jan 2017 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Jan 2017 Claims
UHC Community Plan of Tennessee Fine Jan 2017 Vendor
UHC Community Plan of Tennessee Fine Feb 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Feb 2017 Claims
UHC Community Plan of Tennessee Fine Feb 2017 Care Management
UHC Community Plan of Tennessee Fine Feb 2017 Claims
UHC Community Plan of Tennessee Corrective Action Request Feb 2017 Quality
UHC Community Plan of Tennessee Fine Mar 2017 Vendor
UHC Community Plan of Tennessee Fine Mar 2017 Appeal & Grievance
UHC Community Plan of Tennessee Corrective Action Request Mar 2017 Claims
UHC Community Plan of Tennessee Fine Mar 2017 Claims
UHC Community Plan of Tennessee Fine Mar 2017 Vendor
UHC Community Plan of Tennessee Fine Mar 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Apr 2017 Quality
UHC Community Plan of Tennessee Fine Apr 2017 Quality
UHC Community Plan of Tennessee Fine Apr 2017 Quality
UHC Community Plan of Tennessee Fine Apr 2017 Quality
UHC Community Plan of Tennessee Fine Apr 2017 Quality
UHC Community Plan of Tennessee Fine Apr 2017 Care Management
UHC Community Plan of Tennessee Corrective Action Request Apr 2017 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Apr 2017 Encounters
UHC Community Plan of Tennessee Fine Apr 2017 Vendor
UHC Community Plan of Tennessee Fine Apr 2017 Vendor
UHC Community Plan of Tennessee Fine Apr 2017 Vendor
UHC Community Plan of Tennessee Fine May 2017 Claims
UHC Community Plan of Tennessee Fine May 2017 Claims
UHC Community Plan of Tennessee Fine May 2017 Claims
UHC Community Plan of Tennessee Fine May 2017 Vendor
UHC Community Plan of Tennessee Fine May 2017 Auditing and Monitoring
UHC Community Plan of Tennessee Fine May 2017 Care Management
UHC Community Plan of Tennessee Corrective Action Request May 2017 Encounters
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Corrective Action Request May 2017 Written Standards, Policies and
Procedures; FWA-FWAE
Operations
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Corrective Action Request May 2017 Credentialing/Recredentialing;
Quality
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Fine May 2017 Prior Authorization
UHC Community Plan of Tennessee Corrective Action Request May 2017 Encounters
UHC Community Plan of Tennessee Corrective Action Request May 2017 Encounters
UHC Community Plan of Tennessee Fine May 2017 Vendor
UHC Community Plan of Tennessee Fine May 2017 Vendor
UHC Community Plan of Tennessee Fine May 2017 Vendor
UHC Community Plan of Tennessee Fine May 2017 Vendor

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Tennessee Fine May 2017 Vendor
UHC Community Plan of Tennessee Fine May 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Jun 2017 Network Operations
UHC Community Plan of Tennessee Fine Jun 2017 Network Operations
UHC Community Plan of Tennessee Fine Jun 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Jul 2017 Network Operations
UHC Community Plan of Tennessee Fine Jul 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Jul 2017 Claims
UHC Community Plan of Tennessee Fine Jul 2017 Claims
UHC Community Plan of Tennessee Corrective Action Request Jul 2017 Encounters;
Network Operations
UHC Community Plan of Tennessee Corrective Action Request Aug 2017 Quality
UHC Community Plan of Tennessee Corrective Action Request Aug 2017 Utilization Management
UHC Community Plan of Tennessee Fine Aug 2017 Quality
UHC Community Plan of Tennessee Fine Aug 2017 Vendor
UHC Community Plan of Tennessee Fine Aug 2017 Vendor
UHC Community Plan of Tennessee Fine Aug 2017 Vendor
UHC Community Plan of Tennessee Fine Aug 2017 Encounters
UHC Community Plan of Tennessee Fine Aug 2017 Vendor
UHC Community Plan of Tennessee Fine Sep 2017 Vendor
UHC Community Plan of Tennessee Fine Sep 2017 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Sep 2017 Claims; Network Operations
UHC Community Plan of Tennessee Fine Sep 2017 Claims
UHC Community Plan of Tennessee Corrective Action Request Sep 2017 Claims
UHC Community Plan of Tennessee Corrective Action Request Oct 2017 Network Operations
UHC Community Plan of Tennessee Fine Oct 2017 Vendor
UHC Community Plan of Tennessee Fine Oct 2017 Vendor
UHC Community Plan of Tennessee Fine Oct 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Oct 2017 Claims
UHC Community Plan of Tennessee Fine Oct 2017 Vendor
UHC Community Plan of Tennessee Fine Nov 2017 Claims
UHC Community Plan of Tennessee Fine Nov 2017 Appeal & Grievance
UHC Community Plan of Tennessee Fine Nov 2017 Care Management
UHC Community Plan of Tennessee Fine Nov 2017 Vendor
UHC Community Plan of Tennessee Fine Nov 2017 Auditing and Monitoring
UHC Community Plan of Tennessee Fine Nov 2017 Vendor
UHC Community Plan of Tennessee Fine Nov 2017 Vendor
UHC Community Plan of Tennessee Fine Nov 2017 Vendor
UHC Community Plan of Tennessee Corrective Action Request Nov 2017 Claims
UHC Community Plan of Tennessee Fine Nov 2017 Claims
UHC Community Plan of Tennessee Fine Nov 2017 Claims
UHC Community Plan of Tennessee Fine Dec 2017 Network Operations
UHC Community Plan of Tennessee Fine Dec 2017 Claims
UHC Community Plan of Tennessee Corrective Action Request Dec 2017 Claims
UHC Community Plan of Tennessee Fine Jan 2018 Vendor
UHC Community Plan of Tennessee Corrective Action Request Jan 2018 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Jan 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Feb 2018 Claims
UHC Community Plan of Tennessee Fine Feb 2018 Claims
UHC Community Plan of Tennessee Fine Feb 2018 Claims
UHC Community Plan of Tennessee Fine Feb 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Feb 2018 Claims
UHC Community Plan of Tennessee Fine Mar 2018 Claims
UHC Community Plan of Tennessee Fine Mar 2018 Claims
UHC Community Plan of Tennessee Fine Mar 2018 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Mar 2018 Provider Experience
UHC Community Plan of Tennessee Corrective Action Request Mar 2018 Provider Experience

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Tennessee Corrective Action Request Mar 2018 Provider Experience
UHC Community Plan of Tennessee Corrective Action Request Mar 2018 Claims
UHC Community Plan of Tennessee Fine Apr 2018 Claims
UHC Community Plan of Tennessee Fine Apr 2018 Business Intelligence
UHC Community Plan of Tennessee Corrective Action Request Apr 2018 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Apr 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Apr 2018 Quality
UHC Community Plan of Tennessee Fine Apr 2018 Claims
UHC Community Plan of Tennessee Fine Apr 2018 Vendor
UHC Community Plan of Tennessee Fine May 2018 Encounters
UHC Community Plan of Tennessee Fine May 2018 Encounters
UHC Community Plan of Tennessee Fine May 2018 Vendor
UHC Community Plan of Tennessee Fine May 2018 Vendor
UHC Community Plan of Tennessee Corrective Action Request May 2018 Credentialing/Recredentialing
UHC Community Plan of Tennessee Corrective Action Request May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Claims
UHC Community Plan of Tennessee Fine May 2018 Encounters
UHC Community Plan of Tennessee Corrective Action Request Jun 2018 Claims
UHC Community Plan of Tennessee Fine Jun 2018 Vendor
UHC Community Plan of Tennessee Fine Jul 2018 Vendor
UHC Community Plan of Tennessee Corrective Action Request Jul 2018 Network Operations
UHC Community Plan of Tennessee Fine Jul 2018 Vendor
UHC Community Plan of Tennessee Corrective Action Request Aug 2018 Network Management
UHC Community Plan of Tennessee Corrective Action Request Aug 2018 Care Management
UHC Community Plan of Tennessee Fine Aug 2018 Prior Authorization
UHC Community Plan of Tennessee Corrective Action Request Aug 2018 Claims
UHC Community Plan of Tennessee Fine Aug 2018 Vendor
UHC Community Plan of Tennessee Fine Sep 2018 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Sep 2018 Claims
UHC Community Plan of Tennessee Fine Sep 2018 Vendor
UHC Community Plan of Tennessee Fine Sep 2018 Claims
UHC Community Plan of Tennessee Fine Oct 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Oct 2018 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Oct 2018 Claims
UHC Community Plan of Tennessee Fine Oct 2018 Vendor
UHC Community Plan of Tennessee Corrective Action Request Oct 2018 Network Management
UHC Community Plan of Tennessee Corrective Action Request Oct 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Nov 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Nov 2018 System
UHC Community Plan of Tennessee Corrective Action Request Nov 2018 System
UHC Community Plan of Tennessee Fine Nov 2018 Network Management
UHC Community Plan of Tennessee Fine Nov 2018 Appeal & Grievance
UHC Community Plan of Tennessee Corrective Action Request Nov 2018 Care Management
UHC Community Plan of Tennessee Corrective Action Request Nov 2018 Claims; Network Operations
UHC Community Plan of Tennessee Fine Dec 2018 Claims
UHC Community Plan of Tennessee Fine Dec 2018 Network Operations
UHC Community Plan of Tennessee Corrective Action Request Dec 2018 Claims
UHC Community Plan of Tennessee Corrective Action Request Jan 2019 Network Operations
UHC Community Plan of Tennessee Fine Jan 2019 Vendor
UHC Community Plan of Tennessee Fine Jan 2019 Claims
UHC Community Plan of Tennessee Fine Feb 2019 Vendor
UHC Community Plan of Tennessee Corrective Action Request Feb 2019 Claims

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Tennessee Corrective Action Request Feb 2019 Care Management
UHC Community Plan of Tennessee Corrective Action Request Feb 2019 Claims
UHC Community Plan of Tennessee Fine Mar 2019 Encounters
UHC Community Plan of Tennessee Fine Mar 2019 Encounters
UHC Community Plan of Tennessee Fine Mar 2019 Encounters
UHC Community Plan of Tennessee Fine Mar 2019 Network Operations
UHC Community Plan of Tennessee Fine Mar 2019 Vendor

Texas
Medicaid Program: Texas STAR
Licensed Entity: UnitedHealthcare Community Plan of Texas, LLC
Name of Lead State Program Manager: Stephanie Muth
Title: Director of Medicaid
Phone: 512-707-6096
Email: [email protected]
Types of Individuals Served Number of Individuals Served
TANF 139,872
Total 139,872
Key Responsibilities
This Medicaid program provides health care coverage to Medicaid recipients in 44 counties throughout the
state of Texas. Services cover EPSDT medical checkups, occupational therapy, audiology, speech therapy,
case management for children with special needs, hospital clinic services — as appropriate, regular
examinations, immunizations, child delivery and newborn care, substance use and behavioral health services,
laboratory and X-ray services, including tests to prevent birth defects, expanded vision care, podiatry,
asthmatic care, dental services and other specialty care benefits. The contract is integrated with behavioral
health and transportation. The contract covers adults, children and youth.
 Medicaid; state-funded program for Temporary Assistance for Needy Families (TANF) beneficiaries
 Available in 44 counties
 Originated in 2006; current contract duration: Sept. 1, 2018 – Dec. 31, 2019
Medicaid Program: Texas CHIP
Licensed Entity: UnitedHealthcare Community Plan of Texas, LLC
Name of Lead State Program Manager: Stephanie Muth
Title: Director of Medicaid
Phone: 512-707-6096
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 10,554
Total 10,554
Key Responsibilities
This CHIP provides health care coverage to children in 34 counties throughout the state of Texas.
Services include medical care for children; immunizations; DME; well-child exams; laboratory and X-ray;
hospital care; physical, occupational and speech therapy; case management for children with special needs;
behavioral health care; vision care, including glasses, frames and contact lenses; tobacco cessation benefits;
sports physicals and other specialty services. A CHIP perinatal program is included in this coverage. The
contract is integrated with behavioral health and transportation.
 CHIP; federally funded state program for CHIP beneficiaries
 Originated in 2007; current contract duration: Sept. 1, 2018 – Dec. 31, 2019
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Texas Fine Jun 2016 Encounters

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Health Plan Type Date Issued Area of Non-compliance

UHC Community Plan of Texas Corrective Action Request Jul 2016 Encounters; Claims
UHC Community Plan of Texas Fine Jul 2016 Claims
UHC Community Plan of Texas Corrective Action Request Jul 2016 Care Management
UHC Community Plan of Texas Corrective Action Request Sep 2016 FWA ‒ FWAE Operations
UHC Community Plan of Texas Corrective Action Request Sep 2016 Claims
UHC Community Plan of Texas Fine Sep 2016 Claims
UHC Community Plan of Texas Fine Jan 2017 Encounters
UHC Community Plan of Texas Fine Mar 2017 Reporting
UHC Community Plan of Texas Corrective Action Request Jul 2017 Encounters
UHC Community Plan of Texas Fine Jul 2017 Encounters
UHC Community Plan of Texas Corrective Action Request Jul 2017 Network Management
UHC Community Plan of Texas Fine Aug 2017 Appeal & Grievance
UHC Community Plan of Texas Corrective Action Request Nov 2017 Care Management
UHC Community Plan of Texas Corrective Action Request Nov 2017 Claims
UHC Community Plan of Texas Fine Nov 2017 Encounters
UHC Community Plan of Texas Corrective Action Request Jan 2018 Network Management
UHC Community Plan of Texas Corrective Action Request Feb 2018 Claims
UHC Community Plan of Texas Corrective Action Request Apr 2018 Network Management
UHC Community Plan of Texas Corrective Action Request Apr 2018 Network Management
UHC Community Plan of Texas Fine May 2018 Claims
UHC Community Plan of Texas Corrective Action Request Jun 2018 Vendor; Business Intelligence;
Finance; Claims
UHC Community Plan of Texas Corrective Action Request Jun 2018 Network Management
UHC Community Plan of Texas Corrective Action Request Jun 2018 Response to Identified Issues;
Appeal & Grievance;
Credentialing/Recredentialing;
Vendor; Utilization Management;
Network Operations;
Network Management
UHC Community Plan of Texas Corrective Action Request Aug 2018 Network Operations
UHC Community Plan of Texas Corrective Action Request Dec 2018 Network Management
UHC Community Plan of Texas Corrective Action Request Jan 2019 Network Management
UHC Community Plan of Texas Corrective Action Request Jan 2019 Care Management
UHC Community Plan of Texas Fine Feb 2019 Claims
UHC Community Plan of Texas Corrective Action Request Mar 2019 Network Management

Virginia
Medicaid Program: Medallion 3.0/4.0 – Medicaid
Licensed Entity: UnitedHealthcare Insurance Company
Name of Lead State Program Manager: Karen Kimsey
Title: Chief Deputy
Phone: 804-786-8099
Email: [email protected]
Types of Individuals Served Number of Individuals Served
CHIP 8,103
TANF 64,339
Total 72,442
Key Responsibilities
This state-funded program provides statewide health care coverage throughout Virginia for CHIP and TANF
enrollees. General types of services covered include medical, behavioral health, maternity care, pharmacy and
transportation. The contract is integrated with behavioral health, transportation and pharmacy.
 State-funded program for CHIP and TANF beneficiaries
 Available in all counties

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 Originated in 2005; Medallion 3.0 contract duration: Nov. 1, 2017 – Nov. 30, 2018 (Acquisition)/Medallion
4.0 current contract duration: Aug. 1, 2018 – June 30, 2019, with up to six successive 12-month renewal
periods with rolling “go-live” period through Dec. 1, 2018
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Virginia Fine Feb 2018 Encounters
UHC Community Plan of Virginia Corrective Action Request Feb 2018 Encounters
UHC Community Plan of Virginia Fine Apr 2018 Claims
UHC Community Plan of Virginia Corrective Action Request Apr 2018 Claims
UHC Community Plan of Virginia Fine Jun 2018 Encounters
UHC Community Plan of Virginia Fine Sep 2018 Encounters
UHC Community Plan of Virginia Fine Nov 2018 Care Management
UHC Community Plan of Virginia Fine Dec 2018 Claims
UHC Community Plan of Virginia Corrective Action Request Dec 2018 Claims
UHC Community Plan of Virginia Corrective Action Request Feb 2019 Claims

Washington
Medicaid Program: Washington Apple Health
Licensed Entity: UnitedHealthcare of Washington, Inc.
Name of Lead State Program Manager: Mary Anne Lindeblad
Title: Director of Medicaid
Phone: 360-725-1863
Email [email protected]
Types of Individuals Served Number of Individuals Served
ABP 10,254
BD 1,728
CHIP 8,138
COPES 1,741
Expansion 92,470
TANF 93,896
Total 208,227
Key Responsibilities
This is a state-funded program that provides health care coverage throughout the state of Washington for
ABP expansion, BD, CHIP, COPES and TANF beneficiaries. The program covers disease management, care and
case management, customer service and benefit administration — to include physical, behavioral health and
pharmacy benefit management; implementation of health homes; claims payment; network contracting;
maintenance and reporting; quality improvement and oversight; contract compliance; credentialing; vendor
oversight and program integrity functions. It covers those in the Community Options Program Entry System
(COPES) for adults program. Personal care and case management services are available for eligible adults and
children living in their own home, community-based residential facilities (adult family homes and assisted
living) and skilled nursing facilities. Services are authorized by Home and Community Services, Division of
Developmental Disabilities or Area Agencies on Aging. Eligible persons may be served through home and
community-based waiver programs, such as COPES for adults, who require nursing home levels of care.
Additional services provided by the waiver may include client training, skilled nursing, home-delivered
meals, personal emergency response systems, home modification, specialized medical equipment, home
health aides, transportation, adult day care, community transition services and nurse delegation.
 State-funded program (Medicaid) for ABP expansion, BD, CHIP, COPES, expansion and TANF beneficiaries
 Available in all counties
 Originated in 2012; Current Contract: July 1, 2018 – Dec. 31, 2019 (Annual Renewal)
 Healthy Options (originated 2012) rebranded by the State of Washington as “Apple Health” in January
2014

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Medicaid Program: Washington Health Homes

Licensed Entity: UnitedHealthcare of Washington, Inc.
Name of Lead State Program Manager: Stacey Bushaw
Title: Section Supervisor for Family Health Care Services
Phone: 360-725-1829
Email: [email protected]
Types of Individuals Served Number of Individuals Served
Fee-for-Service (FFS) 182
Managed Care Organization (MCO) 8,098
Total 8,280
Key Responsibilities
Under Washington State’s approach, this statewide Health Homes program provides a bridge to integrate
care within existing health delivery systems. Authorized by Section 2703 of the federal Patient Protection and
Affordable Care Act, the Managed FFS Demonstration model and Substitute Senate Bill 5394 from the 2011
legislative session, it places a designated Health Home provider at the center for directing “patient-centered
care” for high-risk, high-cost beneficiaries in a specified, geographic coverage area. Each designated Health
Home provider is accountable for reducing avoidable health care costs, specifically preventable hospital
admissions/readmissions and avoidable ED visits. It offers timely post-discharge follow up and improves
patient outcomes by mobilizing and coordinating primary medical, specialist, behavioral health and LTSS.
Each member has a care coordinator, who is embedded in a community-based setting to manage the full
breath of beneficiary needs.
 State-funded program (Medicaid) for the FFS and MCO populations
 Available in all counties
 Originated in 2013; current contract duration: July 1, 2018 – Dec. 31, 2020; Washington Health Homes A, B
and C phased into single statewide Washington Health Homes contract, as of July 1, 2016
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Washington Corrective Action Request Jun 2016 Care Management; Appeal &
Grievance; Utilization
Management
UHC Community Plan of Washington Corrective Action Request Mar 2017 Quality
UHC Community Plan of Washington Corrective Action Request Mar 2017 Quality
UHC Community Plan of Washington Corrective Action Request Jul 2017 Care Management; Prior
Authorization; Appeal &
Grievance; Encounters; Quality
UHC Community Plan of Washington Corrective Action Request Oct 2018 FWA ‒ FWAE Operations; Care
Management; Quality; Prior
Authorization; Utilization
Management; Pharmacy;
Training and Education;
Encounters

Wisconsin
Medicaid Program: BadgerCare Plus/Medicaid SSI
Licensed Entity: UnitedHealthcare of Wisconsin, Inc.
Name of Lead State Program Manager: Jim Jones
Title: Director of Medicaid
Phone: 608-266-5151
Email: [email protected]
Gina Anderson – Executive Assistant
Types of Individuals Served Number of Individuals Served
ABD and SSI 18,666

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FHP 31,925
TANF including CHIP 114,264
Total 164,855
Key Responsibilities
The “BadgerCare Plus Standard Health Plan” program provides quality health care to adults, parents or
caretakers with household income at or below 100% of the Federal Poverty Level (FPL) and children and
pregnant women with income at or below 300% of the FPL. This Medicaid fee-for-service program calls for
copayments between $0.50 and $3.00 depending on the service. Copays are waived by the health plan for
medical benefits, but they still apply for some services (e.g., vision benefits, etc.) within service area counties.
Copayments apply for state carved out services like pharmacy, transportation, and chiropractic care and
dental benefits administered by the state Medicaid program. Additional services not requiring copayments
include case management services; crisis intervention services; community support program services;
emergency services; family planning services, including sterilizations; HealthCheck; HealthCheck “other
services”; home care services; hospice care services; immunizations; independent laboratory services;
injections; services for ventilator-dependent enrollees; pregnancy-related services; preventive services with
an A or B rating from the U.S. Preventive Services Task Force; school-based services; substance use day
treatment services and surgical assistance.
The “Medicaid SSI” program provides the same benefits as Medicaid FFS (e.g., medical, dental, mental
health/substance use, vision and prescription drug coverage) at no cost to enrollees through a care
management model. SSI-related Medicaid enrollees receive coverage from Wisconsin Medicaid because of a
disability determined by the Disability Determination Bureau. Enrollees meeting the following criteria are
eligible to enroll in the program:
 Medicaid-eligible individuals living in a service area that has implemented an SSI managed care program
 Individuals ages 19 and older (e.g., individuals enrolled in Wisconsin Medicaid and SSI or receive SSI-
related Medicaid)
 Special provisions, such as prescription drugs, are included for continuity of care purposes
 These programs are offered in 60 counties throughout the state of Wisconsin
 State-funded program (Medicaid) for SSI and childless adult beneficiaries — ABD, FHP and TANF including
CHIP
 Available in all counties
 Originated in 1986 (BadgerCare Plus) and in 2005 (Medicaid SSI); current contract duration: Jan. 1, 2018 –
Dec. 31, 2019
Compliance Actions
Health Plan Type Date Issued Area of Non-compliance
UHC Community Plan of Wisconsin Corrective Action Request May 2017 Network Management
UHC Community Plan of Wisconsin Corrective Action Request Jan 2018 Coordination of Benefits

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2.10.2.5 NCQA Accreditation

2.10.2.5.1 The Proposer should provide a copy of its certificate of accreditation by the National Committee for…
UnitedHealthcare initially achieved NCQA Accredited status
(Standards Only) for its Medicaid program in 2014. This accreditation
was valid from July 22, 2014, through July 22, 2017. In August 2016,
we received Commendable status from NCQA, as evidenced in
Attachment 2.10.2.5.1 NCQA Certificate of Accreditation. Our
organization is committed to quality management and performance in
every aspect of our business by anchoring quality standards to our
corporate values of Integrity, Compassion, Relationships, Innovation
and Performance. This commitment to quality aligns with LDH’s vision
for the future of Louisiana’s Medicaid Managed Care program by
supporting innovation and a culture of continuous quality improvement. Achieving NCQA
accreditation is an indicator of the rigor of our continuous quality
improvement, and is a responsibility we have to our enrollees. As
a trusted steward of the Medicaid program, we are steadfast in
our commitment to provide high-quality health care programs that
set the standard for extraordinary performance while exceeding
the expectations of our state partners.
The process of achieving and maintaining NCQA accreditation
provides us with an infrastructure of industry-recognized quality standards and an independent
evaluation of plan performance against these standards. We have consistently achieved and
maintained NCQA Accreditation for the Medicaid health plans we operate, including our
Louisiana Medicaid plan.
As illustrated in the following table, NCQA accredited UnitedHealthcare in Louisiana for the first
time in July 2015. That accreditation was for 3 years with an annual rescoring of HEDIS and
CAHPS. Based upon our August 2015 scores, those scores in conjunction with our Standards
elevated us to Commendable status. Over the next 3 years, we saw continuous improvement in
our Standards, HEDIS and CAHPS scores because of our commitment to quality improvement,
maintaining our Commendable status.
We use the data collected from our annual CAHPS surveys to assess members’ satisfaction
with their PCPs, specialty care practitioners and the health plan overall, in addition to other
health care components such as transportation and written member materials. Our CAHPS
scores are now at 12.8 out of 13.
Year Survey Type Accreditation Status Standards HEDIS CAHPS Totals
July First (July 2014 Accredited
48.8718 18.6357 12.4150 79.9225
2015 – July 2017)
August Annual Update Accredited
48.8718 18.6357 12.4150 79.9225
2015
August Annual Update Commendable
48.8718 21.4970  12.1330 82.9890 
2016
July Renewal (July Commendable
2017 2017 – July 49.5420 21.4793  12.1330 83.1526 
2020)
August Annual Update Commendable
49.5420 23.1846 12.1911  84.9177 
2017
August Annual Update Commendable
49.5420 23.6421  12.8267  86.0107 
2018

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2.10.2.5.2 Where a Proposer utilizes a material subcontractor to provide behavioral health services, the Proposer…

Behavioral Health Accreditation

Our behavioral health subcontractor, United Behavioral Health, also maintains the
accreditations from NCQA and URAC. They were awarded full NCQA Managed Behavioral
Healthcare Accreditation through Jan. 18, 2021, and full URAC Health Utilization Management
Accreditation through Feb. 1, 2020. We routinely monitor and audit subcontractors, including
United Behavioral Health, for compliance with regulatory requirements, NCQA accreditation
standards, as applicable, and for performance against established goals and quality standards.
Where opportunities to collaborate on quality improvement activities exist, our quality team
works directly with the subcontractor to develop interventions and monitor success, continuing
to obtain feedback and recommendations throughout the process. Our quality team remains
engaged, working with UnitedHealthcare leadership and the subcontractor to develop plans to
improve enrollee outcomes and drive continuous quality improvement activities, as appropriate.
We have provided evidence of Managed Behavioral Healthcare Organizations accreditation as
Attachment 2.10.2.5.2 Material Subcontractor NCQA Accreditation Certificate.

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2.10.3 Enrollee Value-Added Benefits

2.10.3.2 The Proposer should identify whether it proposes to offer any of the following six (6) optional value…
2.10.3.3 For each selected value-added benefit, the Proposer should describe:
2.10.3.4 For each selected value-added benefit, the proposal should indicate the PMPM actuarial value of benefits…
2.10.3.5 The proposal should include a statement of commitment to provide the selected value-added benefits for…
In conformity with Section 2.5.5 and the LDH goal to align with the “Triple Aim” of better health,
better care and lower costs to improve enrollee outcomes, we will offer a comprehensive
package of value-added benefits.

LDH Program Goals: Ensuring ready access to care and improving enrollee
health
Our value-added benefits represent an opportunity to increase health-related
benefits and services and educational, preventive and outreach services. We
design our value-added benefits to encourage enrollee engagement in targeted activities to
build healthy behaviors and improve health outcomes.

UnitedHealthcare will offer the following value-added benefits:

 Dental Benefits for Adults
 Chiropractic Benefits and Mindfulness Exercises for Pain Management in Adults
 Medical Respite Services for Homeless Persons
 Newborn Male Circumcision
 Tobacco Cessation
 Vision Benefits for Adults
The following tables provide the detailed information on each of our value-added benefits. We
include the PMPM actuarial value in each table and the required statement from our actuary,
Interim Chief Financial Officer, Tatyana Kotlovskiy, who is a member of the American Academy
of Actuaries, certifying the accuracy of the information as Attachment 2.10.3.4 Signed Actuarial
Statement.

Dental Benefits for Adults

We recognize the importance of preventive and routine
dental services to the overall health of our enrollees.
People with low incomes have a disproportionately Positive Dental Utilization Trend
higher prevalence of dental disease and tooth loss We currently offer dental benefits to
related to lack of access to dental coverage and care. enrollees in Louisiana. Over the last 2
According to Kaiser Family Foundation, “oral health is a years, utilization increased:
critical but often overlooked component of overall  19% for preventive dental services
health and well-being.” If not treated, oral disease can  5.9% for diagnostic services
have serious secondary impacts, such as nutrition  7.7% and 3.7% in 2017 and
problems, chronic pain and heart disease. Poor oral 2018, respectively, for restorative
health can also exacerbate chronic medical conditions services
such as diabetes and can lead to pregnancy
complications.

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Dental Benefits for Adults

Populations who may receive the Enrollees aged 21 years and older are eligible to receive this
benefit benefit.
Scope of benefit  Description: Our adult dental benefits include routine dental
 Descriptions, where applicable exams, x‐rays, cleanings and fillings. The offerings of this benefit
 Comparison to Louisiana Medicaid with in‐network providers are limited to $500 per year for
 Procedure codes covered dental services. This benefit does not require prior
authorization.
 Comparison to Louisiana Medicaid coverage: Louisiana
Medicaid does not provide dental coverage for Medicaid‐eligible
adults. The promotion of oral health for children is a Medicaid
Managed Care quality measure in Louisiana. We believe
providing a similar benefit to adults supports enrollees to
continue good oral health habits. Using a whole‐person
approach, our case managers promote the dental benefit to
support wellness and preventive health care. Case managers will
assist enrollees to access this benefit, understand coverage and
encourage healthy outcomes through regular dental checkups.
 Procedure codes: D0120, D0140, D0150, D0210, D0220,
D0230, D0270, D0272, D0273, D0274, D1110, D2140, D2150,
D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392,
D2393, D2394
Proposed copayments $0
How the benefit will be provided to Enrollees can access the benefit by visiting an in‐network dental
enrollees (including subcontractor provider as provided through our subcontractor, Dental Benefit
details, if applicable) Providers, Inc. (DBP).
Oversight of the value‐added benefit Under the direction of our Chief Medical Officer Dr. Morial and
Health Services Director Nicole Thibodeaux, our clinical team
conducts oversight of this benefit through monthly reviews of
enrollee‐level utilization reports and crosswalks to case
management referral reporting. We use this information to identify
additional education needs of our case management staff as to the
availability of the benefit. We do this to ensure enrollees who need
the benefits have avenues to access them.
In addition, we conduct Joint Operating Committee (JOC) meetings
with DBP monthly and annually. During this call, we review
compliance strategies and initiatives to support DBP’s
performance. This includes, but is not limited to: reviewing
business performance overall; assessing key
compliance/regulatory issues and risks; escalating issues;
reviewing fraud, waste and abuse prevention efforts; discussing
network adequacy, ensuring recent complaints and grievances are
resolved, and monitoring benefit utilization.


Available for the 36‐month term Yes

Chiropractic Benefits and Mindfulness Exercises for Pain Management in

Adults
Back pain is second only to headaches as the most common neurological ailment in the United
States. In addition, the Centers for Disease Control and Prevention (CDC) identified increased
prevalence of anxiety and depression in those suffering from chronic pain, which adversely

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affects work, social, educational and other aspects of individuals’ lives. We will work proactively
to improve enrollee health and safety by providing non-opioid chronic pain management and
treatment such as chiropractic visits and mindfulness exercises. Evidence-based medicine
supports the use of chiropractic care to improve lower back pain. We also will include evidence-
based mindfulness exercises, through our Live and Work Well resource to reduce chronic pain,
manage stress and improve mental state for enrollees. In some cases, visits to the chiropractor
can reduce or eliminate the need for pain medication, including opioids.
Chiropractic Benefits and Mindfulness Exercises for Pain Management in Adults
Populations who may receive the Enrollees age 21 years and older are eligible to receive this benefit.
benefit
Scope of benefit  Description: We will provide 24 visits per calendar year to an
Descriptions, where applicable in‐network chiropractor. We also will provide access 24 hours a
Comparison to Louisiana Medicaid day, 7 days a week for enrollees to engage in mindfulness
Procedure codes exercises from their home through our enrollee portal. This
additional health benefit does not require a prior authorization.
 Comparison to Louisiana Medicaid coverage: Louisiana
Medicaid does not provide coverage for chiropractic services.
Chiropractic services can be a valuable part of an enrollee’s
pain‐management treatment plan when used in conjunction
with covered services such as physical therapy and behavioral
health services.
 Procedure codes: 98940, 98941, 98942, 98943
Proposed copayments $0
How the benefit will be provided to Enrollees can access the benefit by visiting a chiropractor within
enrollees our contracted network, and may be offered transportation
support to access these services if needed
Oversight of the value‐added benefit Under the direction of Dr. Morial and Ms. Thibodeaux, our clinical
team conducts oversight of this benefit through monthly reviews of
enrollee‐level utilization reports and crosswalks to case
management referral reporting. We use this information to identify
additional education needs of our case management staff as to the
availability of the benefit. We do this to ensure enrollees who need
the benefit have avenues to access them. We screen enrollees who
use the benefit for case management if a referral or current case
management is not already in place. In addition, enrollees can self‐
refer to receive chiropractic visits.


Available for the 36‐month term Yes

Medical Respite Services for Homeless

Persons National Success with Respite
UnitedHealthcare subscribes to the National Health Programs
Care for the Homeless definition of medical respite as Our enrollees will benefit from our
acute and post-acute medical care for homeless experience with the medical respite
programs in Arizona, Nevada and
persons who are too ill or frail to recover from a
Washington. For example, in
physical illness or injury on the streets but are not ill Washington, total ED PMPM costs
enough to be in a hospital. Short-term respite care decreased by 45% for those
allows homeless individuals the opportunity to rest in enrollees who received medical
a safe environment while accessing medical care and respite as an alternative to the ED.

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other supportive services. Our vision aligns to the National Health Care for the Homeless
Medical Respite Standards and guides our engagement with partners and providers who share
this same vision.
Medical Respite Services for Homeless Persons
Populations who may receive the Enrollees in the New Orleans area who are homeless, as defined in
benefit 42 U.S.C. §254b
Scope of benefit  Description: Safe, high quality care and services including safe,
 Descriptions, where applicable temporary housing, post‐acute clinical care, care coordination,
 Comparison to Louisiana Medicaid wraparound support services, including housing/supportive
 Procedure codes housing, identification of community resources, social support,
assistance with applications for SSI/SSDI, food stamps and other
federal/state benefit programs.
 Accessible accommodations: A bed (24 hours a day), on‐site
showering and laundry (facility or service), secure storage for
belongings/medications and three meals a day
 Staff (clinical/non‐clinical): Care coordination services in
addition to: 24‐hour onsite staff and access to 24‐hour on‐call
medical support (NurseLine for non‐emergency medical
inquiries)
 Length of stay: Will be limited to the period necessary for
complete medical recovery. Once the enrollee is medically
stable, we will connect them to safe, affordable housing,
linked to the health and community supports they need to
stabilize and thrive in the community. As our experience with
our partners increases, we also will consider opportunities for
medical respite before surgery as appropriate.
 Comparison to Louisiana Medicaid: There are currently no
formal medical respite programs in Louisiana; therefore,
Louisiana Medicaid does not provide coverage. Instead,
enrollees who are homeless with post‐acute recovery needs may
receive a higher level of care than necessary or be at greater risk
for readmission or ED visits due to the inability to recuperate in
an appropriate environment.
Offering medical respite services allows enrollees who are
otherwise homeless to have a stable environment in which we
can establish a solid case management relationship. Enrollees
will be able to get services in place to support timely healing. In
addition to medical and behavioral health support, we will help
find resources to address social determinants of health (SDOH).
 Procedure Codes: Based upon our experience in other states,
we expect to use G9006, and we will confirm the appropriate
code before implementation
Proposed copayments $0

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Medical Respite Services for Homeless Persons

How the benefit will be provided to We are in the process of identifying the most appropriate hospital
enrollees facilities based upon admission/ED rates for enrollees who are
homeless in New Orleans. Enrollees will access medical respite
through discharge planning staff. We will develop clear protocols
for identifying individuals who can be safely discharged to medical
respite immediately upon release.
We will select a community partner who has the appropriate space
available to create a safe, effective medical respite program and
whose vision aligns with the National Health Care for the Homeless
Medical Respite Standards. Once established, we will make the
program available to all Medicaid members who are homeless
through our provider partner in New Orleans, regardless of their
MCO.
Oversight of the value‐added benefit We have staffed a full‐time housing partner, Felice Hill, who, in
coordination with Dr. Julie Morial, will oversee the service. Dr.
Morial and her clinical team will review utilization reports and
reports on the economic impact of medical respite on utilization
management collectively with medical respite partners and
relevant providers on a quarterly basis, at a minimum.


Available for the 36‐month term Yes

Newborn Male Circumcision

According to the American Academy of Pediatrics, the Newborn Male Circumcision
“health benefits of newborn male circumcision outweigh Utilization
the risks” as circumcision may help prevent urinary tract UnitedHealthcare offered this
infections, penile cancer and transmission of some benefit to our enrollees under our
sexually transmitted infections, including HIV. Providing current contract, with more than
17,000 newborn babies
this benefit helps build enrollee trust in a health system
receiving this benefit in
that is sensitive to their personal and cultural priorities. Louisiana since 2015.

Newborn Male Circumcision

Populations who may receive the Newborn males
benefit
Scope of benefit  Description: We will provide circumcisions for newborn males
 Descriptions, where applicable in the hospital or a physician’s office.
 Comparison to Louisiana Medicaid  Comparison to Louisiana Medicaid coverage: Louisiana
 Procedure codes Medicaid does not provide coverage for circumcisions. We
educate providers on this benefit through the Provider Manual
so they can discuss with the mother, alongside covered
pregnancy‐related and EPSDT services.
 Procedure codes: 54150, 54160, 54161
Proposed copayments $0
How the benefit will be provided to Newborn male infants can receive circumcisions without a prior
enrollees authorization if performed before discharge from a newborn
nursery or in the physician’s office within 30 days after birth. Our
prior authorization staff will review all requests after 30 days of
birth for medical necessity.

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Newborn Male Circumcision

Oversight of the value‐added benefit Dr. Morial and Ms. Thibodeaux, and our clinical team conducts
oversight of this benefit through monthly claims and utilization
reports at the enrollee level.


Available for the 36‐month term Yes

Tobacco Cessation
According to the CDC, “more people in the United States Tobacco Cessation Success
are addicted to nicotine than to any other drug.” Using Our Quit For Life® Program has
nicotine (smoking, smokeless tobacco, electronic proven successful for Medicaid
cigarettes) increases the risk for serious health enrollees:
problems, many diseases and death. Per America’s  Average 6‐month responder quit
Health Rankings, Louisiana’s adult smoking rate in 2018 rate is 26%, more than
was 23.1%. Quit With Us, Louisiana indicates that quadrupling outcomes
smoking kills 6,500 Louisianans each year. compared to when people try to
quit on their own
Smoking during pregnancy can cause additional health  Satisfaction rate is 95% across
problems, including premature birth, certain birth defects Medicaid health plans
and infant death. According to the 2015 Louisiana
Pregnancy Risk Assessment Monitoring System, 4.4% of women said they smoked the same
amount or increased smoking during their pregnancy, and 11.8% kept smoking during the last 3
months of pregnancy.
Tobacco Cessation
Populations who may receive the Enrollees aged 18 years and older are eligible to receive this
benefit benefit.
Scope of benefit  Description: Enrollees will have access to the Quit For Life
 Descriptions, where applicable Program, the nation’s leading tobacco cessation program.
 Comparison to Louisiana Medicaid Enrollees will have access to five telephonic coaching calls (10
 Procedure codes for those who are pregnant, including prenatal and postpartum),
personalized, interactive text messaging, and anytime access to
an interactive, mobile‐friendly online website.
 Comparison to Louisiana Medicaid: Louisiana Medicaid
covers tobacco cessation medications. The State also sponsors
the Louisiana Tobacco Quitline (1‐800‐Quit). Promoting the use
of evidence‐based tobacco cessation treatments is a Medicaid
Managed Care Quality measure in Louisiana. Promoting and
providing an enhanced program will increase the success rate
for our enrollees, with cumulative health and economic benefits
for them. It also will benefit those around them who may have
been exposed to secondhand smoke.
 Procedure Codes: 99406, 99407
Proposed copayments $0
How the benefit will be provided to Our case managers screen all enrollees for tobacco use using the
enrollees SF‐12 screening tool and individual Health Needs Assessment
(HNA). Based upon the results from these screenings, case
managers can provide information on and refer enrollees to the
Quit For Life Program. In addition, enrollees will receive outreach
from the Quit For Life Program for inclusion in the tobacco
cessation program.
Enrollees can also self‐refer to the Quit For Life Program.

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Tobacco Cessation
Oversight of the value‐added benefit Our population health team, under the direction Dr. Morial,
oversees this benefit through review of reports that track:
participation, quit and satisfaction data, demographic information
and self‐referral. We use this information to identify additional
education needs of our case management staff as to the availability
of the benefit. We do this to ensure enrollees who need the benefit
have avenues to access them. Through the SF‐12 assessment, we
will educate enrollees verbally on the availability of the Quit For
Life Program. In addition, we will share the results of the SF‐12
assessments with the Quit For Life Program so they can conduct
outreach to those enrollees and make tobacco cessation reports
available to LDH upon request.


Available for the 36‐month term Yes

Vision Benefits for Adults

According to the CDC, about 11 million Americans over age 12 need their vision corrected.
Providing additional vision benefits to adult enrollees in Louisiana not only improves their overall
quality of life and independence, but also enables early detection of other diseases like
diabetes, multiple sclerosis and high blood pressure.
Vision Benefits for Adults
Populations who may receive the Enrollees aged 21 years and older are eligible to receive this
benefit benefit.

Scope of benefit  Description: Vision services including one routine eye exam
 Descriptions, where applicable every year and $100 allowance for frames/lenses and a $105
 Comparison to Louisiana Medicaid allowance for contacts every year.
 Procedure codes  Comparison to Louisiana Medicaid coverage: Louisiana
Medicaid does not provide coverage for vision services or
allowances for frames/lenses for Medicaid‐eligible adults.
Using a whole‐person approach, our case managers promote the
vision benefit to support wellness and preventive health care.
Case managers will assist enrollees to access this benefit and
encourage healthy outcomes. For diabetic enrollees, this benefit
provides glasses and lenses in addition to existing coverage for
eye exams available based upon diagnosis of diabetes.
 Procedure codes: V2020, V2025, 92002, 920049, 92014,
92012, 92015, S0620, S0621, H5200, H5201, H5202, H5203,
H5210, H5211, H5212, H5213, H52201, H52202, H52203,
H52209, H52211, H52212, H52213, H52219, H52221, H52222,
H52223, H52229, H5231, H5232, H524, H52521, H52522,
H52523, H52529, H52531, H52532, H52533, H52539, H526,
H527, Z0100, Z0101
Proposed copayments $0
How the benefit will be provided to Enrollees can access the benefit by visiting an in‐network vision
enrollees provider as provided through our vision subcontractor, MARCH
Vision.

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Vision Benefits for Adults

Oversight of the value‐added benefit We conduct monthly JOC meetings with MARCH Vision. During this
call, we review compliance strategies and initiatives to support
MARCH Vision’s performance. This includes, but is not limited to,
overall review of the business performance; assessment of key
compliance/regulatory issues and risks; escalation of issues;
review of fraud, waste and abuse prevention efforts; discuss
network adequacy; ensure recent complaints and grievances are
resolved; and monitor benefit utilization.


Available for the 36‐month term Yes

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2.10.4 Population Health

2.10.4.1 Describe its understanding of, and experience with, improving population health for Medicaid…
We recognize the importance of population health management (PHM) in identifying and
addressing the social, behavioral, medical and functional needs of our enrollees to improve their
health outcomes and reduce health disparities. Medicaid enrollees are at increased risk of
developing chronic illnesses and are more likely to require preventive health services in
comparison with the general population. We know our enrollees face unique challenges, such
as food insecurity, unsafe and unstable housing, lack of transportation, unemployment and
financial instability. Our population health approach takes into account these social
determinants of health (SDOH).
Our PHM approach is built upon the principles presented in the following table informs and
guides our overall managed care program for enrollees across Louisiana. This approach
supports LDH’s vision for population health described in Appendix B, Section 2.6, Population
Health and SDOH.
Principles of a Population Health Approach
Evaluating our entire enrollee population and engaging enrollees across the continuum
We establish baseline health‐outcome measures using the performance measures specified in Attachment G,
NCQA Quality Compass Benchmarks and utilization measures. We build upon external data sources, such as
America’s Health Rankings, NCQA Quality Compass Benchmarks and the LDH Office of Population Health
(OPH) priorities to understand the challenges and context in Louisiana. A variety of tools including our health
needs assessment (HNA), referral network, Hotspotting and HealthView Analytics Clinical Dashboard help us
understand our enrollee population and identify subpopulations who may benefit from case management. We
strive to provide programs and services that fit the unique situation of enrollees across the continuum.
Improving enrollee health status and supporting enrollees as they take an active role in managing
their care through health promotion and disease prevention
We encourage enrollees to take action on their health using an array of health promotion and disease
prevention tools provided through websites, mobile apps, texting programs and telephonic support. For
instance, we offer live telephonic access to RNs who educate enrollees about conditions, such as diabetes and
HIV/AIDS. RNs instruct enrollees on health care services through NurseLine, use clinical texting to engage
expectant mothers, offer tobacco cessation, promote medication adherence and provide appointment
reminders and mobile apps to help enrollees locate in‐network and urgent care providers.
Using a data‐driven approach to understand our enrollees’ health risk, needs and circumstances
Our suite of advanced data analytics tools analyzes medical, behavioral and functional needs and the impact
of SDOH on our enrollees’ ability to access needed services. Our predictive modeling algorithms analyze
demographics, medical, behavioral and pharmacy utilization and use more than 300 clinical rules to identify
health risks and design programs that are appropriate to meet a subpopulation’s needs. The next iteration of
our data‐driven approach incorporates ICD‐10 codes that confirm SDOH needs and services are tracked while
avoiding additional administrative work for providers.
Incorporating consideration of the SDOH
There is widespread recognition and evidence that SDOH are primary drivers for health outcomes, health
care costs and quality. Our PHM program identifies social and economic barriers that stand in the way of
enrollees meeting their health care goals. We incorporate SDOH into our PHM program as follows:
 Using data from enrollee screenings to identify barriers that may negatively impact our enrollees’ ability to
meet their goals and frequent SDOH barriers in specific populations and geographies
 Analyzing community capacity and quality to confirm population needs are being met
 Developing internal processes to connect individuals within populations to community‐based
organizations (CBOs) identified for these frequent barriers
 Investing in innovative best practices that build capacity, improve quality and reduce health care costs

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Principles of a Population Health Approach

Implementing targeted interventions for subpopulations experiencing health disparities
Using data from a variety of sources and advanced data analytics, we identify geographies within Louisiana
and subpopulations of enrollees who experience health disparities. Armed with this information, we
collaborate with a variety of CBOs and providers to develop interventions that help address those disparities.
For example, our Northeast Healthy Teen Pregnancy grant targeted teen mothers, who have
disproportionately high rates of pregnancy complications, premature births and low birth weight infants. We
partnered with the Children’s Coalition for Northeast Louisiana to develop and host highly attended school‐
based sessions in six schools. As of 2018, all of the mothers who had given birth had infants of healthy birth
weight with an average of 7 pounds. Additionally, 98%of mothers stayed in school post‐delivery, which
indicates the program can also address inequity in educational achievement.
Addressing LDH’s population health priorities
We have programs to address the LDH population health priorities in Appendix B, Section 2.6.1.1. For
instance, to reduce infant mortality and maternal mortality and morbidity, we have implemented programs to
identify enrollees who are pregnant and evaluate their pregnancy risk. We engage women with high‐risk
pregnancies in our Healthy First Steps (HFS) case management program. Through HFS Rewards, we educate
all pregnant women about their developing baby and provide reminders and rewards for attending
appointments during their pregnancy and the first 15 months postpartum. We continually evaluate the needs
of this population and modify current or develop new programs to address them, such as our identification of
low post‐natal care rates among women with high‐risk pregnancies in Baton Rouge. This identification led to
our partnership with the Louisiana Women’s Healthcare clinic in Baton Rouge where we embedded a case
manager in the clinic to address prenatal needs of the enrollee during their OB visit.

2.10.4.1.1 Identifying baseline health outcome measures and targets for health improvement;
We choose baseline health-outcome measures from a variety of sources, including the quality
performance measures specified in Attachment G and NCQA Quality Compass Benchmarks
that allow us to examine quality improvement and benchmark performance through NCQA
averages and percentiles. We monitor utilization rates; HEDIS-reported rates; and medical,
behavioral, pharmacy and SDOH-related metrics to understand the population health status of
our enrollees and areas for improvement. We currently track the measures required by LDH,
including 45 of the 61 measures in Attachment G for the new contract.
Using data from publicly available sources, we look at our communities and parishes through
the lenses of health, social need and environmental conditions. We identify traditional core
health measures, including tobacco use, adult obesity and diabetes prevalence rates. We build
on this with data on key areas of concern in Louisiana, such as infant mortality rates and the
devastating impact of opioids on our communities. We identify social and environmental
measures to add context to the health and well-being of a local community or parish. In our
experience, food insecurity, severe housing problems, unemployment, and free and reduced
lunch rates provide clarity into the conditions our enrollees’ families face in meeting their needs.
For example, using data from the CDC Diabetes Interactive Atlas, the Behavioral Risk Factor
Surveillance System, CDC WONDER Mortality Data and data from the National Center for
Health Statistics we analyzed adult obesity, tobacco use, diabetes prevalence, infant mortality
and overdose mortality rates in Louisiana as presented in the figure.

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Figure 3. The analysis of baseline health outcomes provides insight into the needs of enrollee populations so we can design appropriate
interventions. For example, the data show that Region 2 has the highest infant mortality rate (10.3%) in the state. Because we are
embedding a case manager to provide support to pregnant women at Louisiana Woman’s Healthcare clinic affiliated with Woman’s
Hospital in Baton Rouge (Region 2), our highest volume maternal provider in Louisiana.

Identifying Targets for Health Improvement

Using the named data sources and mechanisms to identify subpopulations within our enrollee
population, we identify targets for health improvement, develop programs to address them and
evaluate their effectiveness as presented in the figure.

Figure 4. Our population health approach starts with the aggregation of data. We use internal and external data to prioritize the
disparities faced by key sub‐populations, which informs our implementation of programs in our enrollee communities.

Monitoring our Performance against HEDIS and NCQA and Utilization

Through our quality management (QM) program, we identify targets for improvement by
reviewing low performing HEDIS measures, our performance against the NCQA Quality
Compass percentiles and by monitoring utilization. For example, if our enrollees are performing
poorly on a specific measure (e.g., eye exams for enrollees with diabetes), we take action to
address this measure, such as calls to enrollees with gaps in care, educating PCPs, or
developing targeted solutions. In this example, we have enhanced our value-added vision
benefit to annual screenings — versus bi-annual — to improve compliance with diabetic retinal
screens. We also track our performance against the Attachment G measures for which we have
implemented a provider and enrollee incentive program, such as Measure 1. Well-Child Visits in

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the First 15 Months of Life. We describe these provider and enrollee incentive programs in our
response to RFP Section 2.10.4.1.4.

Comparison to State and National Rates and Subpopulations

We compare the health outcome measures of
our enrollees to state and national rates and We collaborate with Mom’s Meals to provide
across subpopulations to identify targets by two meals per day for 7‐14 days delivered to
region, race/ethnicity and educational the enrollee’s place of recovery upon
attainment. We use publically available data discharge. This program has been successful in
such as America’s Health Rankings, the U.S. helping reduce avoidable utilization in other
Census, Robert Wood Johnson Foundation, states. In Wisconsin, total emergency room
and analyses and data from OPH to PMPM decreased by 35% for members after
understand the larger picture into which our joining the program. Implemented in
enrollees fit. We evaluate public health November 2018 in Louisiana, we are seeing
measures in line with LDH priorities, which positive indications of its effectiveness. Ninety‐
five % of enrollees engaged avoided
allow us to identify population health priorities
readmission after discharge from an acute
and shape our responsive programs and hospital setting.
partnerships.

Using a population health approach to address priority SDOH

Addressing SDOH is a vital component of improving population health. To support
Louisiana’s population health goals, we have developed a robust approach to
collecting SDOH data through ICD-10 coding and other external data sources.
Once identified, we are addressing the needs through strategic development of relationships
with CBOs and our enrollee’s communities to expand access to services. Our end-to-end model
is informed by lessons learned as a Center for Medicare and Medicaid Innovation accountable
community of health grantee and through multiple community-focused pilots.
2.10.4.1.2 Measuring population health status and identification of sub-populations within the population;
With our baseline measures established annually, we divide the population into subpopulations
experiencing a disparate level of need. These subpopulations are based upon risk level,
geographic area, access to care and common demographic factors, such as race/ethnicity, age
and gender; for example, pregnant women and their infant children. Our suite of data analytics
tools and strategies to measure population-health status helps us identify enrollee
subpopulations with unique needs and provide targeted interventions accordingly. We stratify
soon after enrollment and re-stratify on an ongoing basis.
Predictive modeling. Each month, we analyze our enrollees and identify subpopulations who
may benefit from case management using algorithms to assess gender, age, other demographic
variables, prior year total cost of care spending, acute inpatient admissions, ED visits,
pharmacy, behavioral conditions and chronic conditions. The analysis applies more than 300
clinical rules to identify enrollees with gaps in care, condition-specific triggering events, high
utilization, risk markers, substance use concerns and the impact of SDOH to their overall risk.
Our predictive modeling algorithms have positive predictive validity of nearly 80%,
allowing us to identify individuals and patterns among those individuals to proactively intervene.
Hotspotting. Hotspotting is a data-driven process to map geographical areas with the highest
concentration of enrollees who use a disparate amount of medical, behavioral and social
resources. Launched in June 2018, our proprietary Hotspotting tool provides the timely
identification and engagement of enrollee subpopulations such as those with inappropriate
utilization patterns, complex social, behavioral or medical needs and high costs within a defined
region of Louisiana. Its dashboard provides a host of filters to segment enrollees by

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demographics, SDOH, utilization, cost, diagnosis, risk factors and enrollment in case
management. The tool provides heat maps and summary statistics that offer our clinical team
an understanding of subpopulations that could benefit from additional community support.
HealthView Analytics/Next-generation behavioral economics. In 2017, we developed our
HealthView Analytics Clinical Dashboard for identifying key metrics, such as avoidable ED use,
ED use per 1,000, NICU admissions or enrollees who are pregnant, enrollees who have HIV
and have opioid use disorder (OUD) at the parish or provider subpopulation. We then apply
behavioral economics to influence human behavior for each subpopulation through customizing
our communications to them, using tailored presentation of choice, framing messages and
designing financial rewards. Proven behavioral economics principles point to new methods for
facilitating, engaging and helping enrollees continue their healthy behaviors.

LDH Program Goal: Supporting innovation and a culture of continuous

quality improvement in Louisiana
We are partnering with NextHealth Technologies to implement its artificial
intelligence platform, which predicts opportunities to address risk and prescribes
personalized actions to improve outcomes for enrollee subpopulations. NextHealth offers
powerful, subtle suggestions that alter behavior without harsh consequences and provide subtle
cues to each sub-population to make the right choice desirable.
2.10.4.1.3 Identifying key determinants of health outcomes and strategies for targeted interventions to reduce…
We understand that access to care, socioeconomic status or
education can influence the physical and mental health of In 2018, nearly 50%of
individuals and the resiliency of communities. Our deep our enrollees responded
understanding of SDOH comes from both our field-based care in their HNA that they
teams who live in the communities we serve and publically had some form of SDOH
available data, such as reports from LDH’s Bureau of Minority need.
Health Access and Promotions. We identify factors that impact
health outcomes through a variety of data sources and analytic methods including demographic
data, geography, our HNA, predictive modeling algorithms and our comprehensive assessment,
which includes 33 questions that identify an enrollee’s SDOH.

LDH Program Goal: Advancing health equity

To better understand a specific subpopulation’s determinants of health, we are
partnering with the Urban League of Louisiana (ULLA) to identify the factors that
lead to poor birth outcomes. The ULLA conducted four listening sessions in Baton
Rouge, New Orleans, Shreveport and Alexandria in early 2019 to assess women’s access to
and methods they use to access health care. In 2019, we are inviting community leaders,
regulatory, political leaders and organizations, such as the March of Dimes, to two symposia in
collaboration with the mayors of New Orleans and Baton Rouge to address the findings from our
ULLA partnership. We plan to examine further indicators of health and well-being, including
disease rates like diabetes and AIDS, and access to health insurance and health screenings. 

Addressing Determinants of Health Disparities

In 2016, we developed our Louisiana Health Disparities Action Plan, which analyzed four areas
against HEDIS performance measures, state goals and NCQA Quality Compass Benchmarks to
determine specific gaps in care by urban and rural locations, member race, ethnicity, gender
and age. We also considered those areas of priorities defined by LDH. We use tools, such as
Healthify, to refer to resources available to each sub-population to address their needs.
Healthify includes 3,929 Louisiana-based resources, including social support, financial support,

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food and housing. Our community health workers (CHWs) work throughout the state to connect
enrollees to community resources. Following are two examples of our work to identify and
support subpopulations facing disparate outcomes due to key determinants of health.

Addressing High Maternal Morbidity and Mortality among African‐Americans

living in East Baton Rouge, Lafayette, Jefferson and Caddo
Analysis of baseline health outcomes provides insight
into the needs of our enrollees so we can design
interventions that address their needs. For example, We match our staffing to the
demographics of the enrollees we serve
we know Region 2 has the highest infant mortality
to help promote trust and increase
rate in the state and our highest volume maternal engagement with our enrollees. For
provider, Woman’s Hospital in Baton Rouge which example, all four of our HFS case
has seen a 67% increase in babies being monitored managers in Region 2 are African
for neonatal abstinence syndrome between 2013 and American and three of the four case
2016. Women who are dealing with OUD/substance managers are of childbearing age and
use disorder (SUD) are less likely to seek perinatal have children of their own.
care due to the stigma, affecting their health and the
health of their babies.
As a result, we are expanding our Hospital Care Transitions (HCT) program, currently in place
at Our Lady of the Lake Regional Medical Center and the LCMC Health University Medical
Center, which facilitates a smooth hospital discharge to the enrollee’s next level of care. In
2019, we will place a perinatal HCT coordinator in Louisiana Women’s Healthcare clinic
affiliated with Woman’s Hospital in Baton Rouge. The HCT coordinator will address the prenatal
needs of inpatient high-risk women to support at-term delivery and confirm continuity of care.
This support includes addressing their SDOH and behavioral health concerns, collaborating with
the HFS case management team to coordinate services and working with our neonatal resource
services team to support a smooth transition for mother and infant after the NICU.

Addressing Access to Care Disparities in Rural Communities

Thirty-five of Louisiana’s 64 parishes are considered rural and some parishes, such as St.
Helena, have large rural populations. We know Louisiana’s rural areas have lower rates of
educational attainment, higher rates of poverty, unemployment, and complex chronic diseases
and fewer and more isolated providers per capita. According to the 2018 America’s Health
Rankings, urban populations have higher average self-reported health status than their rural
counterparts. These factors can lead to disparities among rural enrollees’ access to care and
related health outcomes. To address this disparity, we are implementing a telehealth suite that
improves rural enrollee access to care by providing rural PCPs with access to specialty services
via eConsult and providing enrollees access to services in their homes. Our solution includes:
 Connecting PCPs to specialists in over 120 specialties using RubiconMD (our specialist
eConsultation partner)
 Using UHC Doctor Chat, a chat-first, virtual visit ED diversion program implemented in
March 2019 where enrollees can use the app or web portal to communicate via secure
chat, telephone or video with an RN or a physician who is licensed in Louisiana
 Educating enrollees about telehealth at NOELA Community Health Center, RKM Primary
Care and Children’s Hospital-LCMC
 Providing school-based telehealth in Plaquemines and Tangipahoa
 Providing access to behavioral health visits using a smartphone, computer or tablet to
connect enrollees securely and privately to behavioral health providers

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 Partnering with Genoa Healthcare (our specialized pharmacy partner embedded in

behavioral health practices) to deliver behavioral health pharmacy services, such as
medication adherence support, to enrollees with behavioral health needs
 Providing online cognitive behavioral therapy for prevalent behavioral health conditions
and offering self-management tools, such as the Whole Health Tracker
2.10.4.1.4 How required components of this procurement and other Proposer developed initiatives are integrated…
Our PHM strategy is deeply integrated with several other key components of our managed care
approach. Our population health efforts are bidirectional. Not only do we use our data
aggregation and analytics tools to inform our population health approach, we also use
population health principles to inform our work across the broader organization. Our population
health improvement strategies extend into member-centered case management, disease
management and health promotion activities. We build in technical and program capacity to
meet both population and enrollee-specific needs. We also engage our provider relations team,
enrollee helpline and staff throughout the enterprise and shape our community investments to
meet our population health management targets. Examples of our integrated approach:
Our Louisiana leadership is committed to improving population health and shares this
vision across the local staff. For example, our understanding of the disparities faced by
enrollees with behavioral health needs led our chief medical officer to shape the algorithms that
identify enrollees for case management to elevate those with behavioral health needs.
We provide our care teams with tools, reporting and predictive modeling that give them
the ability to continually monitor every enrollee for indications that their health status, needs or
circumstances have changed and to understand if the enrollee is part of a target sub-population.
Our care teams and providers respond to changing enrollee health status, needs or
circumstances and take action, such as discharge planning for enrollees in the hospital or
engaging the enrollee in case management. Our integrated Case Management Teams connect
enrollees to programs based upon their medical, behavioral or social sub-population status.
Addressing health disparities. To address disparate access to care in Louisiana, we connect
PCPs to top specialists in more than 120 specialties through RubiconMD. Our Behavioral Health
Toolkit for Medical Providers connects PCPs to free screening tools and information about the
treatment of common behavioral health conditions. It helps PCPs link enrollees to treatment,
includes clinical practice guidelines for behavioral health disorders and promotes the use of
behavioral health screening tools, such as the PHQ-9 and the DAST-10 drug screener.
Integration with quality. In addition to using quality metrics promoted by LDH, NCQA and
other thought leaders to provide insight on enrollee and population health outcomes and health
status, we address those population health priorities through provider and enrollee quality
incentives. Our value-based contracting strategy further aligns with our quality improvement and
population health campaign. For example, recognizing that maternal/child health is an area of
focus for LDH, we have developed enrollee and provider incentives to reduce infant mortality
and maternal mortality and morbidity (LDH priorities 2.6.1.1.2 and 2.6.1.1.3) by promoting
healthy perinatal activities related to HEDIS measures, as presented in the table.
Attachment G Measures Covered by a PCP Incentive or Enrollee Incentive Program and the State’s Goal
Attachment G Measure PCP Enrollee Goal
1. Well‐Child Visits in the First 15 Months of Life Yes Annual $20 Gift Card 62.06%
2. Well‐Child Visits in Third, Fourth, Fifth and Sixth Years of Life Yes Annual $20 Gift Card 72.45%
3. Adolescent Well‐Care Visits Yes Annual $20 Gift Card 50.12%
18. Prenatal and Postpartum Care: Timeliness of Prenatal Care Yes HFS Rewards 83.56%
21. Prenatal and Postpartum Care: Postpartum Care Yes HFS Rewards 64.38%

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Integration with utilization management (UM). Our UM activities support our population
health program by providing objective and systematic monitoring and evaluation of enrollee care
and services. Inputs from UM provide critical evidence about health care patterns and practices
and provide information that shapes our population health programs. Using UM data analysis,
our team can identify patterns of high ED use and deploy programs, such as UHC Doctor Chat,
Ready Responders and NurseLine education to support sub-populations with high utilization.
As an example of how our population health efforts are integrated with other efforts
across the organization, we have developed a cross-functional OUD/SUD strategy. Our
Behavioral Health Medical Director Dr. Jose Calderon-Abbo deploys targeted efforts based
upon in-depth information and experience based upon his engagement with external
stakeholders throughout Louisiana, including the HOPE Council and CBOs. Our Pharmacy and
UM Teams collaborate to identify enrollees at risk of SUD/OUD and our Provider Relations
Team has expanded our available medication-assisted treatment (MAT) network. We train our
Case Management Teams to offer specialized care that promotes recovery, such as referrals to
Woman’s Hospital Guiding Recovery and Creating Empowerment (GRACE) and Addiction
Counseling and Educational Resources for pregnant women with SUD/OUD. Our enrollee
education and community grants promote prevention, treatment and community-level resiliency.
2.10.4.1.5 Other considerations the Proposer may seek to present.
We use integrated baseline health outcomes and SDOH data to set targets for key sub-
populations and develop strategic partnerships to address disparities. We understand pregnant
women who have OUD are more likely to have a high-risk pregnancy and face disparately
higher rates of maternal and infant mortality. In August 2018, we provided a $1.2 million grant to
Baton Rouge Woman’s Hospital to implement its GRACE program, which is open to all
Medicaid enrollees. By partnering with GRACE, we have been able to overcome health
disparities and reduce the effects of SUD/OUD on pregnant women and their newborns by:
 Training direct care staff in non-judgmental communication and early detection of
substance misuse to encourage accessing prenatal care
 Connecting newly identified enrollees with OUD to the Pregnancy Substance Misuse
Case Management Program early in their pregnancies
 Providing enrollees with comprehensive case management services and connection to
social resources outpatient recovery services, care planning and one-on-one support
offered by providers trained in obstetrics and addictive disorders
 Continuing support for up to 6 weeks postpartum, with a warm handoff to community
resources, including addiction recovery treatment centers and social services supports

LDH Program Goal: Improving enrollee health

Women enrolled in the GRACE program birthed infants who weighed on average
1.35 pounds more than the comparison group. Their gestational age at delivery
was 5 days greater than the comparison group, and all GRACE deliveries as of
March 2019 were at term compared to 50% preterm deliveries in a comparison group.
2.10.4.2 Describe what the Proposer will do to address population health in the first year of the Contract…
In the first year, we will continue to leverage investments we have already made in
infrastructure, analytics, care management and the provider network. These items are key to
addressing the overall health of the population and our communities. We continually evolve our
strategic approach by evaluating internal and external data sources, establishing measures and
targets for improvement and creating partnerships and solutions to address population health

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disparities. We have developed a population health strategic plan to prepare for NCQA
certification in 2020, and we will work with LDH to confirm that our Strategic Plan meets the
expectations in Appendix B, Section 2.6.1.2 by March 2020. Here, we provide milestones and
timelines that support our plans to address population health in year one of the contract.
Our Strategic Plan incorporates all of the elements required in Section 2.6 of the model contract,
including the identification of key populations, health promotion and disease prevention
programs; interventions to address SDOH and disparities; and working with enrollees, CBOs
and state agencies. The table presents a representative portion of the high-level milestones and
time frames to implement elements of population health in the first year of the contract.
Addressing Population Health in the First Year of the Contract
Milestone Timeframe
Record new baselines measures for population health based upon LDH priorities Q3 & Q4 2019
Conduct a series of meetings with OPH around priorities such as HIV, HCV and syphilis Q3 & Q4 2019
Establish target measures for population health strategy Q4 2019
Hold internal brainstorming session across departments to confirm population health Q4 2019
strategy
Develop and refine population health strategy Q1 2020
Submit population health strategy to LDH March 2020
Meet regularly with Daughters of Charity to discuss the CHW program and SDOH data Ongoing
Update population health SDOH data with new analyses Q2 2020
Incorporate publically available data into new baselines Q2 2020
Update population health baseline data for 2021 with 2020 results Q4 2020
Provide updates to LDH on progress towards Population Health Strategic Plan goals Ongoing

The table presents milestones and time frames to expand our programs to address two key
LDH priorities, infant mortality and maternal morbidity and mortality in year one of the contract.
Infant and Maternal Population Health Programs in the First Year of the Contract
Milestone Timeframe
Evaluate and establish maternal/infant mortality baseline measures Q4 2019
Develop and refine maternal/infant population health strategies Q1 2020
Integrate OB provider support staff in high volume hospital Q1 2020
Launch provider maternal episodes incentive to 40 OB provider groups Q1 2020
ULLA Maternal Health Listening Sessions: Review data and develop work plan Q1 2020
Host New Orleans symposium for maternal child health Q2 2020
Educate providers on the launch of Tulane maternal psychosocial consultation grant and Q2 2020
encourage participation
Launch enhanced Healthy First Steps Rewards program Q2 2020
Review data outcomes from GRACE at Woman’s Hospital Q2 2020
Evaluate Ready Responders Mahmee Program of home visits to maternal members and Q2 2020
consider expansion opportunities
Host Baton Rouge symposium for maternal child health Q3 2020
Aggregate and create an action plan based upon the outcomes of the two symposia Q4 2020
Mail Healthy First Steps educational material to pregnant members Q1, 2, 3, 4 2020
Conduct live outreach calls to expecting moms to address concerns and promote wellness Q1, 2, 3, 4 2020
Refer pregnant women with hypertension to Heart Safe Motherhood remote monitoring Q1, 2, 3, 4 2020
and care coordination program

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Infant and Maternal Population Health Programs in the First Year of the Contract
Assess and pay out incentives for provider‐gap closure on prenatal and postpartum report Q1, 2, 3, 4 2020
Offer Healthy First Steps High‐Risk Case Management Q1, 2, 3, 4 2020
Conduct home visits for our high‐risk pregnant mothers Q1, 2, 3, 4 2020

The table presents milestones and time frames to implement our Housing + Health Pilot
program, described in our response to RFP Section 2.10.4.3 to engage our enrollees who have
the highest utilization and costs and who need housing and services assistance.
Housing + Health Pilot in the First Year of the Contract
Milestone Timeframe
Phase 1: Build Local Socio‐clinical Infrastructure (90‐120 Days) Q3 2019
Build partner relationships, manage approvals and sign contracts; streamline housing
procurement; and align trauma‐informed clinical model.
Phase 2: Begin Serving Members and Deploy Trauma‐Informed Care Q4 2019
Support enrollee identification, work with housing‐health partners and benefit from
external clinical partners. Build local direct care infrastructure, including confirming a
supply of housing vouchers, developing nonprofit partnerships, aligning enrollee resources
(e.g., SNAP) and engaging specialty care, behavioral, medical and social providers.
Phase 3: Review Patient Outcomes: Discuss cases and provide leading and lagging metrics Q1 2020
Phase 4: Expand Care: Establish PCP and hire, train and manage direct care staff Q1 2020
Phase 5: Evaluate success, improve on experience and consider expansion Q3 2020
2.10.4.3 Describe the Proposer’s recent experience with utilizing data regarding social determinants of health…
As discussed in our response to RFP Sections 2.10.4.1 and 2.10.4.1.3, we fully integrate SDOH
data into our population health approach using a variety of data channels, including publicly
available sources, predictive modeling algorithms and our comprehensive assessment, which
includes 33 questions that identify an enrollee’s SDOH. We describe three programs, developed
based upon SDOH data, to improve the health status of targeted populations in this section.

Solutions for Homeless and Housing‐Insecure Enrollees

We know housing insecurity or homelessness significantly affects individuals’ health utilization,
access and costs. On average, enrollees experiencing homelessness have 22 times greater ED
utilization and 17 times more significant total claims costs
compared to average. Our analyses show that Orleans Parish has
the highest concentration of individuals experiencing
homelessness in Louisiana. These enrollees have complex needs
and are the highest cost enrollees in Orleans with claims costs 42
times greater than the average.
Louisiana is recognized as a national leader in its efforts to
support homeless individuals through its Permanent Supportive
Housing (PSH) Program. We are committed to addressing
housing in Louisiana through the work of our PSH liaison, who has Figure 5. On behalf of
UnitedHealthcare, Felice Hill and her
supported over 50 enrollees in housing, and our new housing manager Brad Grudmeyer received the
partner, Felice Hill. In 2018, we worked with Louisiana Housing Community Champions award at the
Corporation (LHC) and LDH to develop strategies to continue LHC Housing Conference on April 3,
2019.
reducing homelessness and supporting individuals in housing,
including offering bridge financing at no interest to LHC to support the HUD $11.5 million
Continuum of Care PSH grant.

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We are implementing two new programs in 2020 in New Orleans to complement the State’s
work by identifying, engaging, and activating UnitedHealthcare enrollees who have the highest
utilization and costs and who need housing and services assistance.
Medical Respite Program. Medical respite is short-term residential care that allows homeless
individuals to rest in a safe environment while accessing medical care and other supportive
services. Our planned program, to be offered as a value-added benefit (discussed in response
to 2.10.3), provides medical respite that includes accessible accommodations, post-acute
clinical care, care coordination and wrap around support services, such as applying for
SSI/SSDI or food stamps. Accessible accommodations include a bed (24 hours a day), on-site
showering, laundry, secure storage and three meals per day. We have begun to identify
members in New Orleans who could benefit from medical respite — 113 members self-identified
as homeless accounted for 20% of our total enrollee inpatient cost, and 22% of inpatient days.
Housing + Health Pilot. We have signed a Letter of Intent with Start Corporation to implement
a Housing + Health Pilot, outlined in our response to 2.10.4.2. Start is licensed by LDH to
provide community-based services, accredited by the Commission on Accreditation of
Rehabilitation Facilities and certified as a Level 3 Patient Centered Medical Home (PCMH). We
will apply their expertise with Housing First to develop 25 PSH units in locations throughout the
state, including New Orleans, Shreveport and Baton
Rouge. Through the pilot program:
Our housing specialist helps
 We engage the enrollee face-to-face in the ED or enrollees develop a housing plan
at the hospital when they are inpatient that outlines steps for achieving
 Working closely with our case management team, stable housing. She meets with
a housing specialist meets our enrollee and builds enrollees to track and assess
a meaningful relationship progress, identify barriers and
troubleshoot solutions that help
 From discharge, the housing specialist helps our them establish goals and access
enrollee move into their home and offers basics, PSH as soon as possible.
such as furniture and food
 Once transitioned, we support our enrollee using evidence-based practices, including
harm reduction, trauma-informed physical-social-behavioral health care, positive
psychology and interventions for adverse childhood experiences (ACEs)

Addressing Diabetes through Healthy Living and Food Smart Families

We understand chronic diseases are an LDH population health priority. Through our state
disease condition and disparities analysis, we found Regions 1, 3, 7 and 8 (including Orleans,
St. Charles, St. Mary, Caddo, Tensas and West Carroll parishes) had the highest diabetes
prevalence and high rates of food insecurity as measured by children receiving free/reduced
lunch. For example, Tensas parish has a food insecurity rate of 26.1% and the highest
statewide diabetes rate at 17.2%. To address these disparities, we partnered with the Louisiana
4-H Healthy Living and Food Smart Families programs.
Food Smart Families provides youth with nutrition, food budgeting and meal preparation
programming, engages families through events and provides referrals to local hunger relief
resources and ingredients for healthy dishes. The program is active in Orleans, Lafayette, St.
Charles, East Baton Rouge and St. Mary parishes. Since 2012, UnitedHealthcare and LSU
AgCenter have delivered 4-H Healthy Living programs to over 52,000 youth and families across
Louisiana, including Tensas neighbor Franklin parish, supporting better diabetes management.

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LDH Program Goal: Improving enrollee health

Among our expansion population with diabetes, ED utilization/1,000 enrollees
decreased 9% between 2017 and 2018, and among TANF enrollees with diabetes,
the decrease was 10% over the same period.

Partners in Health with Daughters of Charity

We are establishing a foundation to develop further SDOH  
interventions through our Partners in Health program
launched in April 2018 with Daughters of Charity. Through a
$2.5 million grant, we supported the hiring and training of 15
Daughters of Charity CHWs who assess at-risk individuals,
identify social barriers, and refer and connect enrollees to
appropriate community programs and resources. CHWs use
the National Association of Community Health Center’s
PRAPARE assessment tool to understand social needs and Figure 6: Care fellowship team at
Daughters of Charity with
barriers to care, such as housing status and stability and UnitedHealthcare employees
education. To connect individuals to resources, CHWs use the
Aunt Bertha resource database and connect individuals to Daughters of Charity’s health centers
to address medical, dental and behavioral health needs. We will use the data from this program
to understand how engaging with these resources affects an enrollee’s health outcomes and
develop partnerships to address SDOH gaps statewide.
In 2018, CHWs at Daughters of Charity reached 8,234 unique individuals, encompassing both
our enrollee and non-enrollee population. Of those individuals, 5,195 completed referrals to
receive medical, dental, and behavioral health services. To address SDOH needs, 3,039
individuals received services through community-based organizations.
2.10.4.4 Describe the Proposer’s approach to contracting with community-based organizations and OPH to…
Our partnerships with OPH and over 35 diverse CBOs in the past 3 years inform and strengthen
our population health improvement strategies. Our contractual arrangement with OPH allows us
to exchange specific data about our enrollees to improve access to preventive services,
including recommended adult wellness visits and screenings for HIV and sexually transmitted
diseases. Developing trust and alignment with CBOs who serve our enrollee communities is
crucial to coordinating effective population-health improvement strategies; these successful
partnerships do not always necessitate formal contracts. We apply local knowledge provided by
our on-the-ground staff, including our Provider Network and Community Outreach Teams, to
identify CBOs aligned with LDH’s population health priorities. We understand each CBO
partner’s unique mission/vision, population served, capabilities and cultural expertise to develop
locally relevant population-health improvement strategies informed by our national expertise.
Our $4.4 million investment in Louisiana CBOs over the past 7 years has helped us better
understand and address our enrollees’ population health needs while simultaneously building
community resilience. To promote young children’s healthy development and prevent ACEs — a
shared priority with LDH — we partnered with the Childhood and Family Learning Foundation,
Caddo Head Start, Christus School-Based Bullying P and sponsored “Booking It with Baby” with
the Glenn “Big Baby” Davis Foundation. To prevent and promote management of chronic
diseases — an LDH shared priority — we have worked with CBOs, such as the American Heart
Association, Second Harvest Food Bank, Whole Kids Foundation and Fit for Life to coordinate
solutions around unhealthy diet and physical inactivity for our enrollees in their communities.

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2.10.4.5 [OPTIONAL] Respond to the following questions to be considered for piloting a Community Health…
2.10.4.5.1 Why is the Proposer interested in this opportunity?
Louisiana faces some of the most significant health challenges in the United States. As a
partner to the State, it is incumbent upon us to help LDH support innovation and a culture of
continuous quality improvement to address these challenges. Sharing LDH’s vision,
UnitedHealthcare is committed to advancing and supporting community-based initiatives to
improve enrollee health outcomes for the residents of Louisiana.
Health care is local and encompasses more than clinical services. Without resources like
healthy food, reliable transportation, stable housing or social connection, a person’s health can
be adversely affected. Left unaddressed, social determinants of health (SDOH) can lead to
higher utilization and higher costs. . By focusing on delivering health care one person at a time
where they live, we know we can meaningfully impact people’s lives. We believe a population
health approach confronting public health issues at the local level with community health
workers (CHWs) will improve enrollee health outcomes and reduce health disparities in
Louisiana.
We are excited to spearhead IMPaCT Louisiana, the demonstration pilot developed by Penn
Center for Community Health Workers (PCCHW) and LDH. We look forward to helping LDH
deploy an effective, evidence-based and financially sustainable CHW-first model that can be
replicated statewide. Participating in IMPaCT Louisiana provides an opportunity to learn from
and draw upon the important work already done by key stakeholders from LDH, PCCHW, and
Center for Healthcare Value and Equity at the LSU Health Sciences Center (CHVE) in
developing this evidence-based CHW initiative and implementing best practices in a deliberate,
step-by-step action plan laid out in the Blueprint.
Aligned with LDH’s vision, we believe in the efficacy of evidence-based, scalable CHW-first
models. Drawing upon our organizational experience in deploying this strategic approach in
other states will bring value to LDH as we invest in IMPaCT Louisiana to improve the lives and
health of our enrollees.
Dr. Jeff Brenner, SVP of Clinical Redesign and the founder and CEO of the Camden Coalition of
Heatlhcare Providers, leads our Clinical Redesign Team, a direct-care delivery unit focused on
the deployment of community-based care models for
our most complex Medicaid enrollees. Early results
show that we can achieve improvement in the quality of Outcomes for the myConnections
care and reduce cost and utilization through the Program in Arizona
Enrollee total cost of care declined
integration of physical health, behavioral health and
55% from $4,403 PMPM pre‐
social services delivered at home and in the community. engagement to $1,941 PMPM post‐
CRT seeks to accelerate the development and engagement. Enrollees’ inpatient
expansion of these kinds of care models, using an and ER utilization decreased
integrated approach that addresses SDOH. dramatically, by up to 80%.
The evolution of our community-based, Housing is We are eager to move beyond
Health Care model started 3 years ago with the pre/post analysis to comparison
groups and to work with PCCHW
myConnections program. Informed and inspired by the
and CHVE on the design and
NUKA Health System, a tribal-owned and managed implementation of a randomized,
system run by the South Central Foundation in Alaska, controlled trial as part of IMPaCT
our myConnections model organizes resources in a Louisiana.
community to address individuals’ SDOH in an
organized and intentional approach rather than as isolated experiences. This model supports
communities and enrollees to improve health outcomes and develop self-sufficiency.

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We understand community-based care models like myConnections, must be embraced by

leadership from the top down to be successful and sustainable. For example, our leadership has
trained at NUKA and they have been engaged in the transformation of our community-based
care model from the beginning. For us, this local approach to health care is embedded in the
DNA of our entire organization. We recognize this same leadership approach and commitment
in LDH’s vision, research and development of IMPaCT Louisiana.
The CHWs play an integral role in myConnections. We have recruited CHW generalists who are
trained, equipped and familiar with community issues to solve for them. Using trauma-informed
care, harm reduction, and motivational interviewing, our CHW generalists deepen relationships
with enrollees by promoting their independence, wellness, recovery and resiliency. In multiple
markets, myConnections provides housing for high cost, complex enrollees experiencing
homelessness through a high fidelity, housing first model. Enrollees receive an apartment and
wraparound services with a focus of supporting individuals to independence. CHWs provide
patient-centered social support to address health inequities and real-life issues.
Implemented in Louisiana in 2018, our Hotspotting Tool identifies enrollees who would benefit
from CHW engagement. Typically, these enrollees have high utilization of services as well as
social and behavioral complexities. With Hotspotting, we can identify enrollees most likely to
benefit from our CHW approach — a direct, evidence-based, in-the-community approach to
service delivery. CHWs engage enrollees directly in place-based interventions, whether it is at
the hospital bedside, at a homeless shelter or other location.

LDH Program Goal: Improve enrollee health

Further emphasizing our support and investment in community-based models and
our belief in the importance of CHWs in improving population health is
UnitedHealthcare’s grant to the Daughters of Charity Health Centers in New
Orleans for $1.5 million in 2018, followed by an additional $1 million in February 2019 for a total
of $2.5 million in funding. Daughters of Charity used the initial grant to hire and train a team of
15 CHWs who assess at-risk individuals, identify social barriers and quickly link these
vulnerable individuals to targeted interventions and resources within the community. CHWs at
Daughters of Charity reached 8,234 unique individuals in 2018. Of these individuals, 5,195
completed referrals to receive medical, dental and behavioral health services through the health
centers, and 3,039 completed referrals to receive services through community-based
organizations, including referrals to address education, employment, food, housing,
transportation, technology/internet and legal needs. In 2019, Daughters of Charity expects to
reach 7,500 individuals using CHWs.

Drawing upon shared experience and a common vision to help Louisianans live healthier lives,
we look forward to collaborating on IMPaCT Louisiana to connect enrollees to the most
appropriate care in the most appropriate setting while reducing low-value care utilization.
2.10.4.5.2 How many CHWs does the Proposer currently employ? In what parts of the state?
In Louisiana, we currently employ 37 CHWs in parishes throughout all nine regions of the state.
We are committed to making incremental investments in the demonstration pilot beginning with
six additional CHWs. This number is based upon a pilot of 600 enrollees (Blueprint) with a
CHW/enrollee ratio of 1:100 as outlined in Appendix B, Model Contract, 2.6.3.2.5.
2.10.4.5.3 What is the Proposer’s CHW/member ratio?
Our CHW to enrollee ratio for this pilot will be 1:100.

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2.10.4.5.4 What are the main activities in which the Proposer’s CHWs are currently engaged?
As trusted members of our field-based care teams, CHWs serve as a link between health and
social services in the community — facilitating access to services and improving the quality and
cultural competence of service delivery to enrollees. CHWs remove barriers to care by
addressing SDOH and linking enrollees to the community and social resources needed to
support healthy outcomes and reduce health disparities. Walking alongside our enrollees,
CHWs help build individual and community capacity by increasing enrollee health knowledge
and self-sufficiency through a range of activities, including outreach, community education,
informal counseling, social support and advocacy. Specifically, our CHWs:
 Locate and engage difficult-to-reach enrollees and build trusted relationships
 Conduct in-person holistic assessments to understand enrollee needs, preferences and
socioeconomic barriers
 Assess barriers to healthy living and accessing health care, including home visits
 Foster relationships with community organizations and link enrollees to social services
(such as housing and AC/heating assistance) and surrounding support services
 Promote sustained, continuous enrollee/provider relationships
 Arrange appointments with medical and behavioral health providers and coordinate
transportation as needed
 Outreach to enrollees when they miss appointments, find out why the appointment was
missed, and problem-solve to address barriers to care
 Provide health promotion, coaching and encouragement to enrollees in the self-
management of chronic conditions while providing the tools and resources to do so
 Provide social support to help boost enrollee’s morale and sense of self-worth
 Serve as a key knowledge source for services and information needed for enrollees to
have healthier, more stable lives
2.10.4.5.5 How are the Proposer’s CHWs currently trained? What are the minimum training requirements?
We embed the culture of trauma-informed care in the training and development of all frontline
staff, including CHWs. Subject matter experts from our CRT provide training on evidence-based
clinical care concepts, such as trauma-informed care and adverse childhood experiences
(ACEs), while incorporating other principles like motivational interviewing, harm reduction,
positive psychology and person-centered care. These training sessions broaden our knowledge
base and help us create a trauma-informed environment to better understand, engage and
support enrollees with complex socio-clinical needs.
As the enrollee’s advocate in the community, CHWs are trained to identify needs and gaps and
link enrollees to resources that promote, maintain, and/or improve health outcomes and reduce
health disparities. CHWs are trained to locate and encourage engagement with social supports
by working directly with the enrollee in their immediate community. CHWs also receive
condition-specific training for a solid understanding of specific conditions supported through our
models of care (e.g., heart failure, chronic kidney disease, sickle cell). Understanding common
health problems, along with issues related to chronic illness and interventions, builds the
foundation for meeting the tailored needs of our enrollees. Our goal is to provide culturally
competent coordination of care with compassion and empathy while building trust and
encouraging enrollees to obtain their short-term and long-term goals.

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2.10.4.5.6 Does the Proposer have a process to ensure that its CHWs are trusted by the communities they serve?
Our process to facilitate trust between CHWs and the communities they serve begins with hiring
CHWs who reside in local parishes, and share sociodemographic and cultural characteristics
(e.g., income, race, education, language) with our enrollees. By working where they live, CHWs
have a close understanding of the cultural and social fabric of their communities. With ties to
their communities, CHWs bring personal knowledge of local needs, cultural competency and
familiarity with social supports and resources, including local community-based organizations
and faith-based groups.. Because of their firsthand knowledge of their communities, shared
cultural/social experiences and ability to relate to enrollees personally, CHWs build trust,
respect and understanding with enrollees. CHWs from local parishes are often aware of and can
solve for social issues that others outside their communities might not see. Understanding
community nuances and building trust through cultural competency allow CHWs to remove
barriers and solve for social determinants of health, maximizing enrollee satisfaction, improving
health outcomes and reducing health disparities.
2.10.4.5.7 What data does the Proposer collect to know if its CHW program(s) is (are) working?
We collect and use data in a number of ways to support the effectiveness of our CHW
programs. CHWs gather data through health needs assessments (HNAs) and comprehensive
assessments, and document enrollee interactions and updates to an enrollee’s plan of care in
CommunityCare, our clinical documentation platform.

LDH Program Goal: Support innovation and a culture of continuous quality

improvement
UnitedHealthcare has partnered with NCQA and the National Association of
Community Health Centers to implement diagnostic codes for services that target
the SDOH. One of the key barriers to expanding access to nonmedical care for social needs is a
lack of coding standardization. In response, we have started to roll out new ICD-10 codes that
providers can use to document these needs.
Our newly announced collaboration with the American Medical Association (AMA) continues to
build on these efforts. We are working with AMA to standardize how data is collected,
processed and integrated for social and environmental factors contributing to an enrollee’s well-
being. UnitedHealthcare is also working with CMS and CDC to facilitate the nationwide adoption
of ICD-10 codes.
In March, UnitedHealthcare received the 2019 Healthcare Innovation Award recognizing our
work on SDOH and our initiatives to implement ICD-10 codes that track key social determinants
of health indicators. UnitedHealthcare is the first health plan to receive this award.

We are also assisting Daughters of Charity in assessing the impact of their CHW interventions
through ongoing data exchanges related to the adoption and expanded use of ICD-10 codes to
identify social barriers to care. We use data capture and analysis to provide a monetary value
for the services their CHWs helped to provide when linking individuals to targeted interventions
and resources within the community. We integrate social and “non-traditional” data at scale,
standardize it and value it — transforming disparate data elements into actionable information in
clinical, enrollee experience and population analytics to help drive better health outcomes for
our enrollees.
We have significant data capture and data analytic capabilities and look forward to collaborating
with LDH, PCCHW and CHVE on ways to make the assessment of the CHW pilot program
more robust by making this data available for tracking, measuring and evaluating outcomes and
cost-savings for IMPaCT Louisiana.

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2.10.4.5.8 How are the Proposer’s CHWs or other care management staff integrated with providers?
As members of our field-based care teams and multidisciplinary Hotspotting teams, our CHWs
are integrated with our case management programs, bridging community and clinic, to help our
enrollees successfully navigate the health care system. They make important contributions to
our care teams, establish and maintain trusting relationships with enrollees outside of a clinic
environment and provide us with a deeper understanding of the communities we serve. We look
forward to working with LDH and exploring ways to expand the integration of our CHWs with
practice sites to foster relationships and better communication with their clinical teams as noted
in the Blueprint (e.g., placing CHWs in one or two hospitals or clinics in the pilot’s hotspot
regions to create “clinical homes” or physical touchdown spaces for CHWs).
2.10.4.5.9 Who is the contact person for this application?
The contact person for this application is Scott Waulters, interim CEO, UnitedHealthcare of
Louisiana, Inc.
2.10.4.5.10 Who is the lead team member who will oversee implementation?
Dr. Jeff Brenner and our CRT will oversee the implementation of LDH’s IMPaCT Louisiana
demonstration pilot. Our local physician leadership of Dr. Julie Morial, Chief Medical Officer and
Dr. Jose Calderon-Abbo, Behavioral Health Medical Director will support Dr. Brenner.

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2.10.5 Care Management

2.10.5.1 The Proposer should describe its anticipated approach to meeting the care management requirements of…
Implemented in 2015 in Louisiana, our comprehensive care management program meets every
enrollee where they are on their health journey and connects them with programs, services and
supports that help them live healthier lives and helps LDH achieve its goals and objectives. It
aligns with Appendix B, Section 2.7, Care Management. Our program has reduced avoidable
utilization, increased enrollee satisfaction and improved health outcomes.

LDH Program Goal: Improving enrollee health

We are committed to the Triple Aim of better care for our enrollees, better health
for populations and lower costs. Comparing utilization from the 1-year period
October 2016 through September 2017 to October 2017 through September 2018,
our care management program has achieved the following:
 A 7.7% decrease in total inpatient admissions per 1,000 across our TANF population
 A 5.3% decrease in emergent emergency room visits for our non-expansion population
 A 4.7% decrease in non-emergent emergency room visits for our non-expansion population

Our care management approach identifies each enrollee’s unique situation, engages them
with locally based care teams, supports enrollees and providers with programs tailored to their
needs and to improve outcomes, and is continually evaluated to confirm its effectiveness.

Figure 7. Our approach identifies enrollee needs, engages through locally based care teams, supports with programs tailored to enrollee
needs and is continually evaluated for effectiveness.

We are enhancing our program by incorporating innovative, enrollee-focused resources to

continue to protect and promote health among Louisiana’s most vulnerable populations. These
include next-generation tools to identify enrollee subpopulations such as HealthView Analytics,
case management programs such as our Hospital Care Transition (HCT) program, strategic
relationships with partners such as BehaveCare, housing resources, and resources that
improve our enrollees’ access to care, such as our UHC Doctor Chat telehealth solution.

LDH Program Goal: Ensuring enrollees ready access to care

To increase each enrollee’s access to care and provide alternatives to ED use, we
implemented UHC Doctor Chat, a chat-first, virtual visit ED diversion program in
Louisiana in March 2019. Enrollees can use an app or web portal to communicate

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via secure chat, telephone or video with an RN or physician licensed in Louisiana. For enrollees
in case management, their case manager is alerted that they have used the tool, which prompts
the case manager to follow up with the enrollee to address acute needs or close gaps in care.
2.10.5.1.1 The Proposer’s process for ensuring that there is success in completing enrollee health needs…
Completing the new enrollee welcome call and HNA are
In 2018, our MSAs made 168,000 critical to identifying enrollees who may benefit from case
phone calls and left 25,000 management and connecting them to resources as soon
messages to reach our enrollees
as possible. The welcome call is often our first live
to conduct the HNA. Our efforts
contact with an enrollee and the HNA is our opportunity
help us connect with and assess
to understand our enrollees in a personal way. We
our enrollees within required recognize that we are asking enrollees to share deeply
time periods — in 2018, we personal information through the HNA, so we train our
completed nearly a third of HNAs
Advocate4Me member services advocates (MSAs) on
within 5 days of enrollment.
enrollee-centered engagement strategies that build trust
and confidence with every enrollee. Among enrollees reached telephonically, we have achieved
monthly HNA completion rates as high as 94%.
Local teams with knowledge of Louisiana develop our welcome call and HNA protocol. A
national interdisciplinary committee confirms our HNA meets nationally recognized NCQA
Population Health Management standards, includes evidence-based social determinants of
health (SDOH) domains and achieves high levels of enrollee engagement. We bring to
Louisiana experience and lessons learned from deploying comprehensive HNAs in 25 states
that address behavioral health and SDOH. We look forward to partnering with LDH to develop
an HNA to identify the needs of all enrollees.
We administer HNAs within the required time frames in Appendix B, Section 2.7.2, Health
Needs Assessment using a variety of methods (print, web-based and telephonic). Within 14
days of enrollment, an Advocate4Me MSA makes at least 3 attempts to complete the new
enrollee welcome call and HNA, calling at different times of the day and on different days of the
week to maximize success. MSAs document each attempt in CommunityCare, our care
management platform. To increase completion rates, we:
 Send a postcard letting enrollees know we are
Since launching our HNA incentive
trying to reach them with directions to call us back
in 2015, we have provided more
 Incentivize enrollees with a $10 gift card for than $730,000 in incentives to
completing their HNA within 90 days of enrollment 73,134 enrollees, helping
 Take advantage of every enrollee interaction to Louisiana achieve the #2 HNA
complete the HNA. For instance, when an enrollee completion rate across
calls Advocate4Me or NurseLine, our systems UnitedHealthcare’s 25 Medicaid
Managed Care plans.
notify our staff when an enrollee needs an HNA, so
they can work with the enrollee to complete it.
 Continuously monitor and improve our process through call audits and coaching,
monthly call reporting, an assessment dashboard and internal performance metrics.
Once we identify an enrollee who may benefit from case management, we make every effort to
engage them and complete an HNA using our team of CHWs who live in the communities they
serve and community partners, such as BehaveCare. We also leverage pharmacy data to
identify the enrollee’s most up-to-date contact information and hospital notification data to try
reach and assess enrollees while they are in an inpatient setting.

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LDH Program Goal: Ensuring enrollees ready access to care

We have signed a letter of intent with BehaveCare, which specializes in locating
and engaging enrollees in New Orleans and Baton Rouge who are homeless or
have limited resources, inconsistent support systems and higher use of emergency
services. BehaveCare’s community-based care specialists complete enrollee HNAs, conduct
comprehensive assessments, provide Tier 3 case management services and facilitate in-home
telemedicine visits to access primary, specialty and behavioral health providers.
2.10.5.1.2 How the Proposer will utilize predictive modeling, referrals and the HNA process to identify…
We use comprehensive data inputs, advanced analytics, clinical expertise and local knowledge
to create a 360-degree view of our enrollees’ and identify individuals who would benefit most
from case management. Our identification and stratification tools identify enrollees who require
intensive clinical intervention, such as those with special health care needs, high-risk
pregnancy, unmanaged complex medical or behavioral conditions or acute social determinants,
such as homelessness. As presented in the figure, our evidence-based process integrates HNA
and predictive modeling results to understand every enrollee’s needs and health risk; and how
they might benefit from case management or other population health programs.

Figure 8. Understanding each enrollee. Our process incorporates an HNA for new enrollees and a monthly analysis of all enrollees
using a variety of data sources and a suite of advanced analytics tools. It delivers a risk score for each enrollee and identifies case
management needs and enrollees with special health care needs, specific conditions or who are experiencing a care setting transition.

Identifying Enrollees – Initial Health Needs Assessment

Our evidence-based pediatric and adult HNAs evaluate each enrollee’s health and wellness and
identify critical information, such as social, behavioral, medical and functional conditions and
needs; PCP and provider relationships; existing treatment plans; current services, including over
and underutilization of services; and barriers to accessing care. The HNA findings lead to
immediate engagement of resources to meet the enrollee’s needs. For instance, we refer
enrollees with high-risk scores or special health care needs for a comprehensive assessment

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and engagement in case management, and connect pregnant enrollees to a maternal support
team to help them access prenatal care and programs, such as Healthy First Steps (HFS) and
HFS Rewards.
When the HNA identifies an enrollee’s behavioral health Identifying members with
condition, it triggers additional assessments to understand special health care needs to
their needs. For example, our adult HNA includes validated engage them in case
tools, such as the Alcohol Use Disorders Identification Test management is a crucial
(AUDIT)-C to screen for risky drinking and the Patient Health priority shared with LDH. In
Questionnaire (PHQ)-2 depression screener. Our pediatric 2018, 37% of enrollees in case
HNA assesses trauma using the Child Stress Disorders management were identified as
having a special health care
Checklist-Screening Form, and depression using the PHQ-9.
need through the HNA.
Identifying Enrollees — Referrals
We accept referrals from enrollees, families, providers, state agencies, such as the Office of
Behavioral Health, and UnitedHealthcare departments, such as our Advocate4Me enrollee
services center, per Appendix B, Section 2.7.5, Referral to Case Management. Our field-based
staff and strong community partners, such as permanent supportive housing (PSH) providers,
also identify enrollees for case management. Through our Shared Savings Value-based
Payment (VBP) Provider Group program, our provider-facing staff works with physician
practices to identify enrollees in the hospital or who have visited the ED, have gaps in care or
may require case management. Through VBP programs, we incentivize providers for
identifying enrollees who may benefit from case management. For instance, our Maternity VBP
includes a Notification of Pregnancy (NOP) incentive, which identifies enrollees early in their
pregnancy and connects them to our HFS program.
Helping an Enrollee with a High ‐Risk Pregnancy
Our enrollee, Jennifer, is a 44‐year‐old woman whose pregnancy had several risk factors, including
two previous pre‐term births, five previous miscarriages and advanced maternal age. We identified
her high‐risk pregnancy via the NOP and reached out to her to enroll her in HFS case management.
After speaking with Jennifer, her OB‐experienced RN case manager also referred her to our OB
Homecare program to provide Jennifer with 17P to reduce her chance of pre‐term birth. Jennifer’s
case manager worked with her OB Homecare RN to schedule weekly home visits. With support
from these homecare visits and face‐to‐face assessments and pregnancy education from her case
manager, Jennifer delivered her healthy baby at 37 weeks.

Identifying Enrollees – Predictive Modeling

Our predictive modeling process complies with the requirements in Appendix B, Section 2.7.3,
Predictive Modeling. Each month, we use Impact ProTM, our predictive modeling tool, to analyze
all enrollees and identify those who may benefit from case management. Our algorithms
analyze gender, age, other demographic variables, prior year total cost of care spending, acute
inpatient admissions, ED visits, pharmacy, behavioral conditions and total chronic conditions.
The analysis applies more than 300 evidence-based clinical rules to identify enrollees with gaps
in care, condition-specific triggering events, high utilization, risk markers, substance use
concerns and the impact of social determinants to their overall risk. Our predictive modeling
algorithms have positive predictive validity of nearly 80%.

Identifying Enrollees – Our Hotspotting Tool

Hotspotting is a data-driven process to map geographical areas with the highest concentration
of enrollees who have high needs and costs and who use a disproportionate quantity of health
care services. Launched in June 2018, Hotspotting provides timely identification and

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engagement of enrollee cohorts with high utilization patterns,

complex social, behavioral or medical needs and high costs
within a defined region of Louisiana. Our dashboard provides
filters to segment enrollees by demographics, region, social
determinants, utilization patterns, cost, diagnosis, risk factors
and enrollment in case management and other programs. The
tool provides heat maps that track utilization patterns across
Louisiana. An individual enrollee view provides frontline staff with
12-months of historical utilization, cost and summary health
statistics. The member summary, presented in the figure, is an
example of information the tool provides on a select cohort of
enrollees with specified characteristics.

Figure 9. Member summary. This view summarizes statistics for cohorts of enrollees using filter criteria determined by the user. The
view provides information such as the top 10 risk factors, SDOH and serious mental illness diagnoses and identifies care management
utilization statistics within the cohort, such as the percentage of enrollees with an opioid prescription and average inpatient admissions.

LDH Program Goal: Improving enrollee health
Our Hotspotting Tool informed the creation of a specialized, field-based Hotspotting
Team, which provides high-touch, trauma-informed Tier 3 case management.
Engagement by our Hotspotting Team has resulted in a 59% decrease in year-
over-year PMPM inpatient costs driven by a decrease in admissions. ED utilization
decreased 36%, resulting in a 38% year-over-year PMPM decrease in costs.
2.10.5.1.3 How the Proposer will engage enrollees who may potentially benefit from case management in the…
Once we identify an enrollee who may benefit from case management, we make every effort to
engage them using evidence-based strategies and to connect in a manner that is culturally
relevant and appropriate to their circumstances. We know from experience that our population
can be difficult to reach given Louisiana’s unique geography and culturally diverse communities.
Acknowledging that 35 of the 64 parishes in the state are considered rural, we locate our field-
based care teams in every region of Louisiana and employ CHWs hired from the communities

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where our enrollees live. In the Baton Rouge area (Region 2), where we have our largest cohort
of enrollees, we staff nine CHWs who each have a deep understanding of the concerns and
resources unique to their neighborhoods.
Our diverse and experienced teams of CHWs use their local knowledge and networks to
outreach to an enrollee telephonically and in-person, traveling across their parish to visit an
enrollee’s last known address at least three times. If the enrollee is not home, the CHW leaves a
door tag with contact information to encourage the enrollee to connect. In 2018, our team of
CHWs across Louisiana completed more than 100,000 phone calls and 10,000 field visit
attempts to engage enrollees in case management. We use a variety of methods to connect
with and engage enrollees who may benefit from case management. For example, we:
 Send a letter to the enrollee to provide information about the availability of services that
may support their needs and encourage the enrollee to contact us
 Benefit from local relationships, such as our partnership with BehaveCare
 Analyze LDH’s historical claims data for new enrollees to identify recent providers and
engage them to help us locate and engage the enrollee
 Conduct specialized outreach for pregnant enrollees through email and web-enabled
maternity assessments and CHW seek-and-engage activities
 Analyze pharmacy data to identify refill dates and service locations. The CHW engages
the enrollee’s pharmacy to help us locate or conduct outreach to engage the enrollee
 Contact local homeless shelters or soup kitchens used by homeless enrollees or
enrollees with a history of using community organizations to meet their needs
 Build relationships with housing resources, such as the Housing Authority of New
Orleans, to help identify locations where we can find the enrollee
 Identify enrollee engagements with the health care system, such as an ED visit or a
hospitalization. CHWs attempt to engage enrollees when they access services
 Build upon our relationships with State agencies, such as our behavioral health liaison
dedicated to supporting the Louisiana Department of Education (LDOE), the Department
of Children & Family Services (DCFS) and Office of Juvenile Justice (OJJ)
 Build upon our provider relationships, such as weekly meetings with Magellan who
delivers Coordinated System of Care (CSoC) services to children and youth
Once we connect with the enrollee, a key component of our engagement is establishing trust
and understanding the goals and capabilities of the enrollee, their family and other natural
supports. We cross-train our case managers in physical and behavioral health and use staff
members with shared knowledge and experience with enrollees, such as our peer support
specialist. Through evidence-based approaches, such as motivational interviewing and trauma-
informed care, our case managers actively listen to every enrollee and prioritize the enrollee’s
voice and choice in discussing the value and benefit of case management; and whether it is
right for them. If the enrollee decides to participate in case management, we enroll them in a tier
of case management aligned with their individual needs, as described next.
 

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2.10.5.1.4 How the Proposer will identify the appropriate tier of case management for an enrollee using objective…
Through our identification process, we
determine each enrollee’s appropriate
tier of support and connect them to
the right services, providers and
resources that meet their needs and
help them achieve their individualized
goals. Our objective measures and
criteria confirm every enrollee
receives information, linkages and
services consistent with their needs,
as defined in Appendix B, Section
2.7.6, Tiered Case Management
Based on Need.
Figure 10. Based upon our understanding of each enrollee, we deliver a range
We identify all enrollees with special of interventions across the care continuum. We connect every enrollee to a PCP
health care needs, comprehensively and deliver programs that empower them as they take responsibility for
assess their needs and goals and managing their health. For at‐risk enrollees, we implement case management
programs aligned with their risk, circumstances and needs.
offer ongoing support in an
appropriate tier of case management per Appendix B, Section 2.7.4, Enrollees with Special
Health Care Needs. The table summarizes our current objective measures and criteria to
identify each enrollee’s appropriate tier of case management. We will continue to assess and
modify criteria in partnership with LDH to ensure we meet enrollees’ changing needs and drive
continuous improvement.
Objective Measures and Criteria for Placing Enrollees in Tiered and Transitional Case Management
Objective Measures and Criteria – Case Management (Low) (Tier 1)
Enrollees of rising risk who, without intervention, are at risk of becoming Tier 2 as determined by their
predictive modeling risk score. They may have 1+ moderately managed or newly diagnosed chronic
condition, and 0‐1 social needs such as social isolation or transportation needs.
Objective Measures and Criteria – Case Management (Medium) (Tier 2)
Enrollees with a midrange predictive modeling risk score signifying an emerging risk for decompensation and
increased utilization. These enrollees may have 1+ ambulatory diagnosis and/or comorbid mild‐moderate
behavioral health diagnoses, and 0‐1 complex social needs, such as food insecurity. Tier 2 may include
enrollees with special health care needs or transitioning from a nursing facility.
Objective Measures and Criteria – Intensive Case Management (High) (Tier 3)
Enrollees with the most significant physical, behavioral, functional and/or social needs and highest persistent
utilization and spend, as measured by a high predictive modeling risk score or as identified through our
Hotspotting Tool. This may include enrollees with special health care needs. These enrollees may have:
 2+ unmanaged complex chronic conditions
 1+ severe behavioral health diagnosis, such as schizophrenia, and/or co‐occurring substance use
disorder/opioid use disorder (SUD/OUD)
 2+ complex social needs such as homelessness or former incarceration
 2+ ED visits or inpatient stays in the previous 6 months
 High‐risk pregnancy, such as SUD history or a history of preterm delivery or low birthweight infant
 Prior institutionalization or transition from a nursing facility
Objective Measures and Criteria – Transitional Case Management
 Enrollees who are transitioning to or from inpatient hospitals, nursing facilities, including the My Choice
Louisiana population, psychiatric facilities, psychiatric residential treatment facilities, therapeutic group
homes, permanent supportive housing, intermediate care facilities, residential SUD settings, and
transitions out of incarceration.

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Objective Measures and Criteria for Placing Enrollees in Tiered and Transitional Case Management
 Enrollees with a high readmission predictive modeling (RPM) risk score or high Readmission Screening
Tool (RST) score. The RPM and RST are used for enrollees transitioning from an inpatient setting to a
lower level of care. The tools incorporate the severity of the condition, diagnosis, medications,
opportunities for health and other factors to determine risk level and eligibility for enrollment in
transitional case management.

Supporting All Enrollees as They Take an Active Role in Their Care

We encourage enrollees to take action on their health using a variety of strategies and tactics to
confirm the engagement with each enrollee is culturally relevant, appropriate for the enrollee’s
age and demographics and tailored to their health needs. We confirm every enrollee has a PCP
and that the enrollee is engaged with their PCP. We refer enrollees for disease management or
specialized programs, such as programs for pregnant women, including Clinical Texting and
HFS Rewards. As presented in the table, we use a multimodal approach and an array of health
promotion tools and resources to engage every enrollee and provide support tailored to each
enrollee’s circumstances. We know approximately 80% of our members have a smartphone and
the other 20% have access to a similar device, so we engage enrollees through websites,
mobile apps, texting programs and telephonic support.
Health Promotion and Disease Prevention Tools and Programs
Telephonic support:
 Our Advocate4Me enrollee services center responds to inquiries and promotes self‐management including
reminders about needed preventive care
 NurseLine, available 24 hours a day, 7 days a week, provides live telephonic access to RNs who educate
enrollees about their conditions and how to use health care services
 MyHealthLine uses the Lifeline free smartphone to deliver Clinical Texting campaign texts and provide
free calls to Advocate4Me and free texting with the care team
 Behavioral Health Crisis hotline supports enrollees and their families with behavioral health experiences
Texting, mobile apps and websites:
 Clinical Texting engages expectant mothers and new parents, adolescents and adults, enrollees with
diabetes and smokers through programs, such as medication adherence and appointment reminders
 NextHealth’s Urgent Care Locator will be able to send a text to enrollees listing nearby urgent care centers
 Mobile apps help enrollees locate in‐network and urgent care providers, provide health benefits and
coverage information and connect enrollees to Advocate4Me or NurseLine
 Available through our enrollee website, myuhc.com, our online health and wellness library provides
education and tools to promote health awareness and prevention of health conditions
Newsletters and mailings:
 Enrollee newsletters and mailed material, such as birthday card reminders about preventive care
 Mailing condition‐specific education materials for targeted conditions, such as cancer or asthma

Support Provided in Tiers 1‐3 Case Management

If the enrollee agrees to participate in case management, an
interdisciplinary, field-based care team provides care
coordination to the enrollee. The team includes an RN, a
licensed behavioral health advocate (BHA) and a CHW. We
assign a care team that lives in the same community as the
enrollee and has appropriate expertise to meet their needs. We
are thoughtful in our initial care team assignment to confirm a
compatible match, including considering cultural background,
primary language, behavioral and/or physical health needs and
Figure 11. Multidisciplinary Care Team.
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enrollee choice. We train case managers to help address the specific concerns enrollees face,
such as person-centered care, recovery and resilience, trauma-informed care, crisis
intervention, motivational interviewing, opioid use, medication-assisted treatment, advanced
illness and grief and identifying readiness through stages of change.
LDH Program Goal: Improving enrollee health
Comparing the 1 year before engagement in case management to 1 year after,
enrollees in case management have achieved*:
 A 40% decrease in total inpatient hospital PMPM costs, driven by decreased utilization
 A 20% decrease in total ED PMPM costs
 A 22% decrease in total claims PMPM for enrollees engaged in our highest-risk case
management program
*Additional cohort analyses planned to understand the impact of case management in context

Each enrollee in case management has a primary case manager with expertise and training
specific to their primary diagnosis. For example, an enrollee with primarily behavioral health
needs is assigned a BHA case manager, and a woman with a high-risk pregnancy is assigned
an OB-experienced RN.

LDH Program Goal: Reducing complexity and administrative burden for

enrollees
To reduce complexity for enrollees in case management and help them navigate the
health care system, we provide a primary case manager who can act as a single
point of contact to coordinate care. The core of our model is the relationship between each
enrollee and their case manager. The local presence and the expertise and experience of the
case manager are critical to allowing the enrollee to develop a level of trust with the case
manager coordinating their care. Establishing trust is the first step in helping the enrollee
participate in and navigate the health care system.
Across all tiers of case management,
our care teams and partners support
enrollee health by confirming every
enrollee receives the right care or
support, at the right time, in the most
appropriate setting, in the most
efficient way. Our care teams
collaborate with the enrollee and their
multidisciplinary care team (MDT) to
create a holistic plan of care,
coordinate their social, behavioral and
medical services and continually
monitor their health status, as
presented in the figure.
Our engagement of these enrollees
aligns with the requirements in
Appendix B, Section 2.7.6, Tiered
Case Management Based on Need,
such as in-person engagement and
frequency of touch points. The table
Figure 12. Case management process. Our field‐based care teams
summarizes the supports provided in coordinate the enrollee’s care and continually monitor progress to
confirm their needs are met and they are achieving their goals.

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each tier of case management, building in intensity and specialized expertise from Tier 1 to our
highest need enrollees in Tier 3.
Supports for Enrollees Engaged in Tiered Case Management
Case Management (Low) (Tier 1)
 In‐person comprehensive assessment and plan of care completed within 90 days of identification
 Confirmation of PCP or assistance finding a PCP
 Disease management education, mailers and program referral for identified chronic conditions
 Timely appointment scheduling and transportation arrangement to close gaps in care
 Access to telehealth or virtual visits
 Referral to state and local offices and programs, such as the Permanent Supportive Housing program,
tobacco cessation and problem gambling
 Support in accessing eligible assistance such as SSI or WIC
 At least quarterly telephonic case management meetings with the enrollee
 Continual monitoring for care gaps and transitions using claims‐based data and real‐time admission,
discharge and transfer (ADT) feeds
 Annual formal in‐person reassessment and updates to the plan of care communicated to the enrollee’s PCP
Case Management (Medium) (Tier 2)
Tier 2 includes Tier 1 supports plus the following:
 In‐person comprehensive assessment and plan of care completed within 30 days of identification
 Identification of, and at least quarterly meetings with, an MDT, including the enrollee, the enrollee’s family
or authorized representative, the enrollee’s PCP, behavioral health provider, specialist or pharmacist(s),
CHW, BHA and RN, plus a peer support specialist, housing partner and/or state staff depending on need
 DME and pharmacy reviews for all medications and medication reconciliation
 At least monthly in‐person or telephonic case management meetings with the enrollee
 Quarterly formal in‐person reassessment and updates to the plan of care
Intensive Case Management (High) (Tier 3)
Tier 3 includes Tier 1 and 2 supports plus the following:
 Daily or weekly contact with the enrollee to close gaps in care within days or weeks of identification
 At least monthly in‐person or telephonic MDT meetings based on the enrollee’s care needs
 Quarterly formal in‐person reassessment and updates to the plan of care
 For our highest‐acuity enrollees, we engage them with our specially trained, interdisciplinary
Hotspotting Team that provides high‐touch, face‐to‐face Tier 3 case management for enrollees identified
by our Hotspotting Tool
We look for every opportunity to apply the expertise of community partners and specialized
teams to meet the needs of our enrollees. This includes coordination with provider-based
resources to ensure collaboration and avoid duplication of services. Our personalized case
management programs extend beyond minimum requirements and meet the specific needs of
priority populations, as presented in the table.
Programs & Partnerships to Provide Tailored Case Management
Healthy First Steps (HFS) Maternity Program
Our comprehensive HFS maternity program provides support for pregnant enrollees and babies at every
stage of the reproductive health cycle and at all risk levels, including:
 HFS Rewards Program: Provides education through a mobile‐enabled website, clinical texting to remind
pregnant enrollees and new moms about important prenatal, postpartum and well‐child visits, and
incentives for achieving important milestones throughout and 15 months after pregnancy. Nationally,
those enrolled in HFS Rewards have a 15% higher physician visit rate. To continually improve the
program, we use enrollee feedback to implement enhanced rewards based upon enrollee preferences.
 HFS Case Management: Specialized case management for high‐risk pregnant enrollees and babies with an
OB‐experienced RN case manager, with case consults provided by a BHA for enrollees with SUD/OUD. The

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Programs & Partnerships to Provide Tailored Case Management

HFS case manager provides support from identification through six weeks postpartum, and evaluates the
enrollee’s needs for ongoing Tier 1, 2 or 3 case management.
 OB Homecare services provide in‐home supports, such as disease management, pre‐term labor support
and nausea and vomiting management for pregnant enrollees with these conditions
 Neonatal Resource Services provides utilization management and transitional case management for
NICU infants for up to 15 months post‐discharge
 Coordination with the Woman’s Hospital Guiding Recovery and Creating Empowerment (GRACE)
program through a unique partnership for pregnant enrollees in Baton Rouge struggling with OUD/SUD.
GRACE provides compassionate Tier 1, 2, or 3 and transitional case management including education on
and connection to MAT services, support for babies with neonatal abstinence syndrome (NAS), and
linkages to community resources.
 In 2019, we will place a perinatal Hospital Care Transition (HCT) coordinator in Louisiana Woman’s
Healthcare Clinic affiliated with Woman’s Hospital in Baton Rouge.
Specialty Program Case Management
Population: All enrollees and families caring for enrollees under age 21 who receive EPSDT personal care
services, private duty nursing and pediatric daily health care
Tailored Support: An RN case manager with specialized expertise provides Tier 3 case management to the
enrollee and family through the life of the authorization(s), and transitional case management 30‐60 days
post service to deliver smooth transitions to other services or community‐based programs dependent on
enrollee and family needs.
Partnership with Children’s Hospital Ventilator Assisted Care Program (VACP)
Population: All enrollees under 21 who are ventilator‐dependent in their home.
Tailored Support: We have contracted with Children’s Hospital VACP to provide family and caregiver
training before enrollee discharge, develop a plan for care in the home and community, coordinate outpatient
care to help the family care for the enrollee at home and provide Tier 1, 2 or transitional case management, as
needed. If the enrollee is also receiving Specialty Program Case Management, their case manager coordinates
with VACP and assists with utilization management (UM) for specialized in‐home services.
Partnership with BehaveCare
Population: Hard‐to‐reach enrollees in New Orleans and Baton Rouge who are experiencing homelessness or
have limited resources, inconsistent support systems and higher use of emergency services
Tailored Support: We are partnering with BehaveCare to expand our targeted Tier 3 outreach and support.
BehaveCare’s community‐based care specialists provide case management services and facilitate in‐home
telemedicine visits to access primary, specialty and behavioral health providers.

LDH Program Goal: Supporting innovation and a culture of continuous
quality improvement in Louisiana
Ready Responders is a network of trained, licensed and fully insured EMTs,
paramedics and nurses who visit high-risk enrollees with inappropriate ED
utilization to help divert them from the ED. During weekly in-home visits, neighborhood-based
health care professionals connect enrollees via a telehealth consult to address their conditions,
make a PCP or behavioral health appointment, provide transport vouchers to their providers,
monitor prescription adherence, evaluate risk factors and answer questions. We are evaluating
the effectiveness of the partnership since its launch in July 2018. Our preliminary results show a
25% decrease in ED PMPM costs and a 38% decrease in inpatient PMPM costs among
enrollees engaged in the program, driven by decreased utilization.

Transitioning Between Tiers of Case Management Intensity

For enrollees in case management, our goal is to implement customized enrollee interventions
for as long as is required to keep or move them to lower risk levels. By engaging enrollees with
an appropriate tier of case management and coordinating the delivery of services and supports

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that meet their needs, enrollees will move to lower intensity tiers or graduate out of case
management altogether. During regular touchpoints, continual monitoring of the enrollee’s
health status, reassessments and care plan updates, our case manager works with the enrollee
and their MDT to look for indications the enrollee can move to a lower tier of case management.
These include evidence that the drivers of the enrollee’s utilization, such as homelessness,
have been addressed; the enrollee is achieving the goals in their care plan; the enrollee is
adhering to their treatment plans, such as taking their medications; and the enrollee is able to
access resources (e.g., transportation or child care).

Support for Enrollees Experiencing Care Setting Transitions

Our transitional case management programs comply with Appendix B, Section 2.7.6.4
Transitional Case Management. They evaluate an enrollee’s social, behavioral and medical
needs and coordinate support services to arrange for safe and appropriate care from one care
setting to another. Our programs include discharge planning for enrollees in the hospital and
specialized transition planning for enrollees moving from a nursing facility to the community and
justice-involved enrollees transitioning to the community.

Enrollees in the Hospital — Discharge Planning

Through discharge planning, we collaborate with the enrollee, the facility and their chosen
planning team to develop a transitional plan of care to ensure progress made during the
inpatient stay continues after discharge. Discharge planning helps confirm the enrollee remains
safe when they transition home, such as reducing potential injury due to pharmacy errors,
procedure complications or falls. The process includes medication reconciliation, patient
education and self-management strategies, addressing any prior authorization needs, and
connection for enrollees experiencing homelessness. It reduces readmissions by anticipating
post-discharge issues, such as gaps in care or barriers to accessing care and identifying
interventions to mitigate them, and following up with enrollees within 72 hours of discharge to
ensure receipt of needed services. The discharge plan builds on the enrollee’s strengths and
identifies the services and supports that meet their needs and help them achieve their goals.
The figure presents our discharge planning process.

Figure 13. Discharge Planning. Discharge planning begins once we become aware of an enrollee’s admission. During their inpatient
stay, we comprehensively assess the enrollee’s post‐discharge needs and goals and support the development of a transition plan that
deploys comprehensive services and supports to meet those needs and goals. The plan helps to prevent readmissions by anticipating
post‐discharge issues and implementing interventions to mitigate them.

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LDH Program Goal: Improving enrollee health

Our HCT program helps enrollees transition safely out of a hospital setting to a
lower level of care. In December 2018, we placed four HCT coordinators within
Our Lady of the Lake Regional Medical Center and the LCMC Health
University Medical Center to better reach high-risk enrollees pre-discharge and provide
specialized supports to address each enrollee’s physical, behavioral, pharmacy and social
needs. We support HCT coordinators with an RN, a pharmacist who addresses medication
gaps and issues, and a licensed social worker with behavioral health expertise who addresses
behavioral health concerns. In 2019, we are expanding this program to address the unique
needs of pregnant women in Baton Rouge by placing a perinatal HCT coordinator in
Louisiana Woman’s Healthcare Clinic affiliated with Woman’s Hospital in Baton Rouge.

Enrollees Transitioning from a Nursing Facility to the Community

Knowing that many individuals living in a nursing
Our My Choice Louisiana liaison, an facility want to return to a community-based setting, we
experienced BHA, coordinates with have implemented a comprehensive program to
the State’s My Choice Louisiana case support enrollees transitioning through the My Choice
manager to provide transitional case Louisiana program. Through this program, we promote
management support for enrollees self-determination and self-direction through person-
transitioning from a nursing facility centered assessment and planning practices to
into a community‐based setting. support the enrollee’s community integration goals. We
assess their needs, strengths, goals and preferences, support the development of their
transition plan, assure the continuity of the enrollee’s care during transition and coordinate the
delivery of an appropriate mix of services and supports to help the enrollee thrive in their new
care setting. The figure provides an overview of our My Choice Louisiana process.

Figure 14. My Choice Louisiana process. We identify enrollees who desire to return to the community from an institutional setting,
support the development of a person‐centered transition plan, assure the continuity of the enrollee’s care during transition, and identify
and deliver an appropriate mix of services and supports to maintain the enrollee in their new care setting. After transition, we engage
them in Tier 2 or Tier 3 of case management for 12 months to help the enrollee maintain community living.

Justice‐involved Enrollees Transitioning to the Community

Justice-involved Louisianans are at increased risk of physical and complex behavioral health
issues, including infectious diseases, co-occurring SUD and significant SDOH. Their return to
the community post-release is frequently marked by high stress as they attempt to re-establish
employment, housing and other relationships, often with limited financial resources and social

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support. Community re-entry, therefore, presents a critical time to support these vulnerable
enrollees in meeting their health care needs. Through our Department of Corrections Case
Management Program, we support these enrollees with specialized transitional case
management from a BHA or RN case manager with experience working with justice-involved
enrollees. Through at least two telephonic pre-release visits, the case manager assesses
physical, behavioral and social needs and confirms appropriate post-release care is in place,
including community-based transition supports. To support successful reintegration into the
community, the case manager follows up with the enrollee at least once post-release and
provides ongoing Tier 2 or 3 case management depending on the enrollee’s needs.

Process for Developing an Individual Plan of Care

Our care planning process, founded on principles of
recovery and enrollee self-determination, In 2018, our case managers completed
encourages and empowers enrollees to lead the more than 30,000 case management
planning process and actively participate in all meetings with enrollees and developed
aspects of care planning. The enrollee’s case or updated more than 9,300 care plans.
manager, supported by the enrollee’s chosen
planning team, advocates for the enrollee to make meaningful decisions about their care and
services. The case manager works with the enrollee to develop a plan of care that includes
services and supports that meet their needs and preferences and help achieve their expressed
goals and desired outcomes.
The plan of care is an integrated, person-centered, enrollee-driven, strengths-based plan. It
highlights the enrollee’s attributes that can serve as a foundation for achieving positive
outcomes based upon their unique situation and needs. It is not static, but continually updated
with the enrollee based upon changing needs and progress toward their goals. Our care
planning process complies with Appendix B, Section 2.7.10, Individual Plan of Care, including
face-to-face enrollee engagement, timeliness of the development of the initial plan of care, the
frequency of required updates and the frequency of MDT care team meetings. We collaborate
with the enrollee to update their plan of care when they show signs of deteriorating health,
experience a change circumstances (e.g., loss of a caregiver) or an acute event, such as a
hospitalization.

Figure 15. Care Planning Process. Using our care planning process, the case manager facilitates plan of care development. The plan of
care includes social, behavioral health, medical and functional services and supports that meet the enrollee’s needs and preferences and
help the enrollee achieve their goals and desired outcomes.

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2.10.5.1.5 How the Proposer will coordinate with providers and state staff that may provide case management…
We align our mission and program development closely with the vision and efforts of LDH and
our provider partners. Our partnerships include clear operational workflows to confirm we align
on details, such as the content of enrollee assessments or the frequency of touchpoints, which
may be adjusted based upon enrollee or enrollee guardian preference. Our clinical team
monitors enrollee outcomes and offers support to our partner case managers through case
rounds and Joint Operating Committees (JOCs). We continue to evaluate and refine these
partnerships to best meet our enrollees’ preferences and match them with programs that are
locally based and in line with enrollees’ desires.
We have experience coordinating with provider and State staff in Louisiana. For example, we:
 Collaborate with Magellan Health to deliver CSoC services to our enrollees who
choose to receive CSoC services. Magellan provides the behavioral health case
management and we provide complementary medical case management. We identify
UnitedHealthcare enrollees served by Magellan and coordinate with Magellan to
manage the care of our enrollees through weekly meetings.
 Have an innovative relationship with LCMC Health to align financial incentives, share
data and enhance coordinated clinical programs. To help LCMC take on case
management responsibilities, we will share data including rosters of enrollees identified
for case management through our predictive algorithms, claims data and HNA results.
We will use JOC meetings to confirm care team coordination and share best practices.
We coordinate with providers and State staff by exchanging enrollee data. Since 2014, we
have been receiving data from approximately 75 participating hospitals through the Health
Information Exchange. In 2018, the Louisiana MCOs along with LDH and Louisiana Hospital
Association began discussions on a new system that would be designed to provide more robust
ED information, readmission and inpatient data offered by Louisiana Health Information
Network. This new technology will allow connected physicians and hospitals to share patient
information and pull reports designed to help improve patient encounters and clinical outcomes.
This initiative would significantly expand participation to most of the state’s hospitals. We are
currently in negotiations with the vendor to have a contract in place by the end of 2019. We
share HNA information, care plans and gaps in care information with the enrollee’s PCP and
other members of the care team, as needed. This coordination helps simplify the enrollee’s
experience and prevents duplication of services.
We identify providers and state agencies through the assessment process. Through the
HNA and the comprehensive assessment process, we work with our enrollees to identify their
providers delivering services to them, State programs in which they are engaged, such as My
Choice Louisiana, and their plans of care or treatment plans. Once identified, our case
managers engage these providers and State agencies to develop the enrollee’s plan of care
and coordinate the integrated delivery of services and supports.
Dedicated staff to develop partnerships with providers and state agencies. We have
dedicated staff that collaborate with State agencies, including our behavioral health liaison who
supports LDOE, DCFS and OJJ; behavioral health liaison who serves as single point of contact
liaison for judicial system; peer support/housing specialist, who serves as our PSH program
liaison; behavioral health consumer and family organizations liaison; intellectual/developmental
disability (I/DD) liaison to work with Office for Citizens with Developmental Disabilities staff;
tribal liaison and My Choice Louisiana liaison who supports the My Choice Louisiana program.

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2.10.6 Case Scenarios

2.10.6.1 Case 1

Like many of our enrollees in Louisiana, our enrollee, Crystal, is managing multiple chronic
conditions and struggling with chronic pain, while faced with limited access to care in a rural
area of St. Helena Parish. Along with our community partners, we must work together to reduce
the likelihood that Crystal, and all our enrollees, will fall through the cracks and promote
wellness and disease prevention. If we do not
thoroughly understand Crystal’s personal If Crystal was enrolled with us during one of
situation and connect her with the appropriate her recent pregnancies, we would have
medical, behavioral and social services engaged her in our Healthy First Steps (HFS)
including high-touch case management, her program, which offers pregnant enrollees
ongoing chronic pain could affect her ability to education and incentives to access regular
care for herself and her family, keep a job and perinatal care. We also would have identified
live a quality life as she defines it. Crystal’s pregnancies as high risk and engaged
her in HFS case management. In Louisiana,
Becoming Aware of Crystal’s HFS case management resulted in year‐
over‐year reductions in low birth weight by
Situation and Initial Engagement 2%, C‐section rate by 3% and premature
As presented in the figure above, we use a birth rate by up to 9%.
variety of case-management engagement
opportunities to become aware of Crystal’s situation. Upon receipt of the request for back
surgery, the utilization management (UM) team refers Crystal to case management. An RN from
our clinical team (described below) immediately begins to engage Crystal and her PCP to
understand her concerns and connect her to services and supports to improve her health and
reduce the need for Crystal to visit the ED. The team reviews Crystal’s follow-up care and
realizes that we have no record of pain management therapy, and attempts to connect Crystal
to appropriate pain management.
At this point, we become aware that Crystal’s PCP has been providing her with pain
management for years. Our medical director initiates a root cause analysis to understand why
and how we did not become aware of her situation earlier. The analysis identifies the causes
and the processes or tools that can be improved to confirm this does not happen to Crystal or

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other enrollees moving forward. For instance, her PCP may be inappropriately coding for pain
management treatment, our pharmacy data may not be reflective of Crystal’s prescription filling
patterns (e.g., she is paying cash for her prescriptions) or her PCP may be providing
inappropriate treatments to meet Crystal’s needs. The team also reviews pharmacy records to
assess prescribing patterns that may be indicative of opioid misuse.
When Crystal’s doctor requests prior authorization for her back surgery, our UM team reviews
the request using evidence-based MCG criteria. We understand back surgery is not always the
best course of action for pain relief and alternative forms of pain management can help Crystal
avoid potentially difficult recovery from invasive surgery. Because the UM team determines the
request for back surgery is not medically necessary until Crystal and her PCP have attempted
non-invasive options to address her pain, our medical director contacts Crystal’s PCP for a
peer-to-peer discussion of pain management therapies Crystal can consider for her plan of care.
During peer-to-peer discussion with her PCP, our
medical director obtains Crystal’s pain management
Specialists can be difficult to access in
Louisiana’s rural areas. RubiconMD’s history, including medications she has used, and if
HIPAA‐compliant eConsult program she has attempted other forms of pain management,
connects Crystal’s PCP to top specialists
such as physical therapy (PT). Our medical director
in more than 120 specialties, including
finds Crystal has not attempted PT to address her
pain management and behavioral
pain and calls her PCP to discuss options for Crystal
health to address the psychosocial
to consider, such as referring her to St. Helena
aspects of and appropriate treatment
for Crystal’s chronic pain. Parish Hospital’s outpatient PT program, which is in
our network. If transportation is a barrier to Crystal
accessing services, our medical director suggests transportation services so she can access PT
in St. Helena or neighboring parishes.
If no in-network providers can meet Crystal’s needs, our medical director discusses with her
PCP available out-of-network PT providers that Crystal can consider and can help her through a
single case agreement. Our medical director and Crystal’s PCP also discuss evidence-based
alternatives for Crystal to evaluate for inclusion in her plan of care, such as our chiropractic
value-added benefit, or mindfulness practices available to Crystal through our enrollee website,
myuhc.com. Once reasonable options are explored, but have not mitigated Crystal’s chronic
pain, our medical director reviews whether she is an appropriate candidate for back surgery.

Connecting Crystal with a Case Manager

As discussed above, we identify Crystal as rising risk and We train case managers to help
enroll her in Tier 3 case management, based upon her enrollees like Crystal. Relevant
multiple health issues, potential substance use, and recent trainings include addiction
recovery, addressing ED
ED use and pregnancies. An RN case manager is assigned
utilization, crisis intervention,
to outreach to Crystal and begin enrolling her in case motivational interviewing, and
management. We support Crystal’s case manager with a identifying readiness through
multidisciplinary care team, including a licensed behavioral stages of change.
health advocate (BHA) to address SUD, a community health
worker (CHW) to address social needs, a pharmacist, our chief medical officer and our
behavioral health medical director. Our BHA, RN and CHW live in or near Crystal’s community,
enhancing our ability to identify and coordinate services available to her.

Initial Engagement and Assessment of Crystal

Getting to know Crystal. Crystal and her case manager have a face-to-face visit to understand
her goals for better health, identify her strengths and begin to develop a comprehensive plan of
care. We know this initial meeting may touch on topics that are personal and uncomfortable,

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which is why establishing a trusted relationship between Crystal and her case manager is so
important. Crystal’s relationship with her case manager becomes a safe haven where the two
can discuss any of her needs. Crystal’s case manager uses motivational interviewing to activate
her interest, acts as a non-judgmental support, and provides insight into how our services can
support her. Crystal shares her priorities, which include getting her pain under control and
managing her conditions. Together, they explore the reasons for her recent pattern of ED visits.
Assessing Crystal’s needs and goals. To understand
Among enrollees enrolled in Crystal’s needs, goals and preferences, her case manager
case management, total per uses shared decision-making tools, evidence-based practices,
member‐per month such as active listening, our Adult Core Comprehensive
emergency room costs Assessment and assessments specific to Crystal’s conditions,
decreased 20% from the such as her diabetes. Understanding depression and anxiety
year before they joined case
are common for individuals dealing with chronic pain or recent
management to a year
following, driven by
pregnancies. Crystal is assessed for depression and anxiety
decreased ED utilization. using the PHQ-2/9 and GAD-2/7 screeners. She is also
assessed for SUD/OUD with the DAST-10.
Crystal’s case manager also assesses her social determinants needs using our Adult Core
Comprehensive Assessment, which includes 33 questions related to social determinants of
health, and our Access to Care assessment that identifies barriers that Crystal may face such
as transportation or access to healthy foods, which may affect her diabetes and hypertension.
Crystal may consider accessing the West St. Helena Food Pantry Dennis Mills, or attending
monthly St. Helena 4-H meetings for education on nutrition. Crystal’s case manager monitors
environmental factors affecting Crystal’s health, such as the condition of her home, and uses
Healthify or local resources to identify and refer her to appropriate services.
Establishing Crystal’s multidisciplinary care team (MDT). Crystal’s case manager asks her
for consent to contact her current and prior providers and request information, such as
treatment plans. Crystal’s providers may include her PCP, a pain management specialist, an
endocrinologist, gastroenterologist and a physical therapist. Crystal identifies participants she
wants on her MDT, including a spouse or partner, friends or family. The MDT has access to
CommunityCare, our care management platform, which shares Crystal’s plan of care,
assessment results and other information, such as case notes with the MDT.

Screening and Treatment for Potential Substance Use Disorder

The challenges Crystal has been facing with Hepatitis C, frequent ED use and history of chronic
pain, may be signs indicating drug misuse, so we
assess her risk for or history of OUD/SUD to inform her We are committed to addressing SUD
care plan. To understand Crystal’s experiences with in Louisiana. Our behavioral health
pain management and SUD history, her case manager medical director serves on the
uses relationship-based communication techniques Advisory Council on Heroin and Opioid
and evidence-based tools, such as the National Prevention and Education (HOPE) and
Institute on Drug Abuse quick screen tool. we are piloting a value‐based payment
model to expand access to high quality
In a review of her pharmacy history, her case manager medication‐assisted therapy (MAT) for
determines if Crystal has exhibited behaviors that enrollees with OUD.
indicate she is at risk of OUD/SUD, such as visiting
multiple prescribers and pharmacies to obtain controlled substances. Our network and quality
teams monitor whether Crystal’s doctor is an outlier in number of opioid prescriptions to confirm
they are not enabling SUD. If screening indicates Crystal has OUD/SUD, her case manager
connects her with evidence-based treatment, such as medication-assisted treatment (MAT), and

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supports her recovery if she is already receiving treatment. Our medical director works with
Crystal’s providers to confirm her chronic pain treatment plan avoids the use of opioids and
other controlled substances that could exacerbate her OUD/OUD.
If Crystal had been diagnosed with SUD/OUD during her pregnancy, we would have connected
her to our perinatal SUD helpline, available 24 hours, 7 days a week. We engaged 650 pregnant
women in SUD treatment in 2017-18 (27% engagement, exceeding statewide average), which
demonstrates our commitment to these high-risk mothers and babies. We would have also
referred Crystal to Addiction Counseling and Educational Resources’ (ACER’s) Slidell office
offering MAT, care coordination, and individual and group counseling.

Developing Crystal’s Plan of Care through Shared Decision‐Making

Developing a plan of care is a collaborative process, taking place over the course of a series of
planning meetings with Crystal, her case manager and her chosen MDT. Crystal’s plan of care
is dynamic and continually updated as she achieves goals, identifies new ones or as her needs
change. During planning, Crystal reviews options and the team documents her choices in her
plan of care. The table presents Crystal’s goals, the expected outcome as she achieves her
goals and the services and supports that may be effective in helping Crystal achieve her goals.
Stated “I want to manage my pain safely.”
Crystal’s
Potential Goal Manage pain safely by avoiding opioid‐based pain therapies and
Measurable
attempting alternative pain management in the next 90 days
Crystal expresses experiencing a reduction in her perception of her pain, while pursuing
Outcome
opioid alternatives for pain management
 Connect Crystal with her preference in alternative pain management therapies/tools: St.
Helena Parish Hospital’s physical therapy and rehabilitation program
 If St. Helena Parish Hospital is not an option for Crystal, connect her to PT providers in
Amite, Albany or Clinton
 Identify an out‐of‐network PT or chiropractic provider and establish a single case
agreement to connect Crystal to care
 If transportation is a concern, connect her to transportation through our Friends and
Family Program which compensates Crystal’s friends or family for providing
transportation or through a traditional transportation provider
 Explore alternatives to PT, such as chiropractic services. Our network includes
chiropractors in Amite and Denham Springs, just across the St. Helena Parish line
 Connect Crystal to peer support and education in pain management skills through the
American Chronic Pain Association
 Refer Crystal to a behavioral health therapist with expertise in treating the psychological
Interventions aspects of chronic pain
 If Crystal is dealing with ongoing depression, anxiety or grief, connect her with local
counseling (available in Greensburg, Roseland or Amite City) and support groups, such
as a NAMI support group, or BetterHelp, which offers online access to licensed,
accredited psychologists, family therapists, clinical social workers and counselors
 Educate Crystal on resources available to her through myuhc.com, such as mindfulness
exercises, comprehensive mental health, and well‐being information and assessments
 Support ED diversion by connecting her with urgent care, NurseLine and UHC Doctor
Chat, which provides Crystal with access to immediate ED triage by an RN or an ED
physician from home via secure chat, telephone or video
If Crystal is dealing with SUD or OUD:
 Connect Crystal with a MAT provider and offer education and support on recovery, such
as our Addiction Recovery Toolkit available online
 Share information on local narcotics anonymous groups, Warmline (a peer support
helpline) and connect her to an OUD peer coach and arrange transportation

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Stated “I want to take care of myself and spend more time with my family.”
Discover ways to integrate healthy behaviors and self‐management tools
Crystal’s for diabetes, hypertension and HCV into her family’s daily life to reach the
Potential Goal Measurable following goals: Reduce HbA1c by 1 percent in the next 90 days; reduce
blood pressure to 130/70 in the next 30 days; approach physician to
discuss HCV treatment options at next appointment
Crystal reports an increase in the number of days she is exercising 20‐30 minutes. She also
Outcome reports discussing her HCV treatment options with her provider during scheduled follow‐
up appointment to manage her chronic conditions in a family‐centered environment.
 Offer Rubicon MD’s eConsult with access to specialty services to Crystal’s providers to
manage her chronic conditions and avoid traveling to multiple specialists
 Connect Crystal with Southeast Community Health Systems’ education and counseling on
nutrition to address her diabetes and hypertension needs
 Encourage Crystal to incorporate healthy eating, meal preparation and exercise habits as
a family activity
 Connect Crystal to monthly Hepatitis C support group at Slidell Memorial Hospital
Interventions  Evaluate Crystal’s Hepatitis C to determine if she meets the criteria for treatment and, if
so, coordinate delivery of services with her PCP. Connect Crystal to the state’s Hepatitis C
subscription program (aka “Netflix Model”) to obtain her medications. Our pharmacist
offers education on adherence and discusses potential side effects and medication
interactions as needed.
 Offer Crystal educational materials and resources, including Help4HEP Support Helpline,
information from the American Diabetes Association and American Heart Association
 Encourage and support medication compliance, addressing any barriers (e.g., price,
transportation) Crystal is facing in adhering to her prescribed medication regimen
Stated “If I get pregnant again, I want to have a normal pregnancy.”
Crystal’s
Potential Goal Define what family planning means to Crystal and have Crystal discuss her
Measurable
ideas with her OB/GYN at her next appointment
Crystal feels confident about her reproductive choices and has the resources she needs to
Outcome
support those choices.
 Connect with family planning education and health‐related social resources such as
Healthy Start or an Office of Public Health (OPH) Reproductive Health Program
 Connect Crystal to the OPH clinic at St. Helena Parish hospital or the St. Helena Parish
rural health clinic for education about pregnancy planning
Interventions
 Engage Crystal with her PCP or OB/GYN to provide education about pregnancy spacing
and the use of long‐acting contraceptives, if she is interested
 Referral to family skills training program such as Positive Parenting Program (PPP), if
Crystal has children in her family

Ongoing Integrated Delivery of Crystal’s Services and Supports

Crystal’s case manager checks in through monthly face-to-
Across Louisiana, our face visits to monitor Crystal’s progress toward her plan of
enrollees with diabetes care goals. As Crystal is able to address her pain, potential
decreased ED use by 10% SUD, and social barriers in line with her articulated goals, she
2017 to 2018. The number gains confidence and feels empowered to better manage her
of preventable hypertension diabetes, hypertension and HCV. Crystal’s case manager
hospital admissions continues to serve as her single point of contact for all of her
decreased by 68% from MDT providers and confirms Crystal receives services to
2016 to 2018.
redirect her back on a path to a healthier and happier life.

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2.10.6.2 Case 2

Our enrollee, Remy, has survived trauma that no child should ever experience. The extreme
stress of repeated trauma, particularly at such a young and critical age, can have long-lasting
effects. Trauma can overwhelm the developing brain’s natural ability to cope, leading to greater
perceived threat and changes to the body. These physiological responses may feel confusing,
uncontrollable and frightening to Remy, making him less able to calm down. Without the
appropriate support and skills to manage these intense experiences, children like Remy,
particularly those with Autism Spectrum Disorder (ASD), often exhibit distressing and harmful
behaviors. Remy’s worsening symptoms are painful and overwhelming for any parent to
manage, let alone Remy’s parents, Jay and Nichole, whose mental health is declining and who
are at risk for experiencing “secondary trauma.”
Sadly, Remy’s story is one that far too many families live through every day in Louisiana. In
many parts of our state, rates of childhood PTSD are three times higher than the national
average and inpatient bed shortages further exacerbate a dangerous situation. Many of these
same challenges affect the lives of the nearly 60,000 Louisiana youth with behavioral health
needs. For these children, we imagine a responsive, trauma-informed and supportive system
that prevents the crises that Remy’s family now faces. We strive to build that system with our
community and state partners, based upon SAMHSA’s Trauma-Informed Care core principles.

Coordinating in Crisis — Securing a Psychiatric Inpatient Bed for Remy

To help Remy recover and thrive, we need to act quickly to address his needs and get him the
right care, at the right place. As soon as the ED submits an authorization request for an
inpatient bed during Remy’s second ED visit, our UM team engages the ED evaluator and
Remy’s Magellan Health Coordinated Services of Care (CSoC) case manager, if he is receiving
CSoC services, to understand what setting would best suit Remy. The UM team also engages
our Provider Advocate Team to educate the ED staff on the availability of community behavioral
health resources as an alternative to discharging him home. Based upon Remy’s worsening
symptoms, the UM team confirms that psychiatric inpatient is the most appropriate setting for
Remy. The team identifies and begins contacting providers with expertise meeting Remy’s
behavioral, physical and developmental needs, such as Children’s Hospital, Lake Charles
Memorial or Brentwood Hospital. If needed, the team locates and authorizes treatment in an
available medical inpatient setting pending transfer to a psychiatric unit. The team may also

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reach out to nearby out-of-network facilities to offer

Building a Better System for a single case agreement, including out-of-state
Children like Remy providers if Remy is clinically authorized to cross
Louisiana has a shortage of crisis and state lines. Once our UM team locates an available
inpatient services for youth. We will
psychiatric inpatient facility, they notify the ED to
continue to work with LDH, providers
facilitate information exchange between facilities,
and other MCOs to facilitate the
creation of services for children like confirm that Remy is stable for transfer and
Remy. For example, we are actively authorize safe transfer. The UM team refers Remy
working with provider partners, such for enrollment in case management.
as Oceans Healthcare to expand
Assigning a case manager to work with Remy
intensive outpatient program services.
We are also approaching LCMC as they and his family. Given the acuity of Remy’s
symptoms, the complex presentation of multiple
expand inpatient capacity for children
and youth. comorbidities, his recent ED visits and the referral
from our UM team, our clinical team identifies Remy
for Tier 3 case management and assigns him a licensed behavioral health advocate (BHA) to
serve as Remy’s case manager. We support the BHA with an RN to address Remy’s medical
needs.
Meeting Remy’s parents and engaging Remy in case management. Remy’s case manager
makes every effort to meet Remy and his family in person in the ED to offer support as they
await transfer. During the visit, Jay and Nichole, Remy’s parents, may express frustration at the
lack of support for their son and their own negative health care system experiences and may be
resistant to the case manager’s engagement. Remy’s case manager uses active listening to
understand Jay and Nichole’s concerns and responds thoughtfully as to how they can help. His
case manager explains how he will serve as a single point of contact to the family and helps Jay
and Nichole understand the benefit of case management by sharing their experience with
adverse childhood experiences (ACEs), crisis management and working with children like
Remy. Remy’s parents agree to enroll him in case management.
Remy’s case manager coordinates his inpatient services with our UM staff and the ED team,
confirms Jay and Nichole know the contact information of the facility and answers any questions
they may have. Given Remy’s history of trauma, we know that having trusted parental figures
involved is essential to his success overcoming this crisis and future resiliency. If the inpatient
setting is far from Remy’s home, his case manager arranges supports for Remy’s parents,
which may include our covered benefit that provides travel and lodging for families, connection
to a local Ronald McDonald House or coordinating transportation services.
We should have become aware of Remy’s situation based upon his conditions and his first visit
to the ED using the case-management engagement opportunities presented in the figure in the
previous section, and immediately identified him as a candidate for case management. Our
clinical team initiates a root cause analysis to understand why and how we did not become
aware of Remy’s situation earlier. The analysis identifies the processes or tools that can be
improved to confirm this does not happen to Remy or other enrollees moving forward.

Supporting Remy and His Parents during His Inpatient Stay

Once Remy, Jay and Nichole have had time to settle and become safely established at his
inpatient setting, Remy’s case manager reaches out to discuss services and supports available
to them. His case manager’s priority is to advocate for Remy and his family to promote the best
possible outcomes for Remy. Remy’s inpatient stay is a crucial period for cultivating a stable
relationship between Remy, his treatment team and the adults in his life, including his case
manager. With the family’s permission, Remy’s case manager stays in close contact, making

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regular telephonic or in-person visits to monitor progress, provide support in addressing their
expressed goals and proactively prepare for Remy’s discharge based upon the family’s needs.
Remy’s case manager helps Remy’s parents stay in contact with others involved in the family’s
life, such as calling his school to notify them of the hospitalization and next steps to address
classes missed, tutoring or Individual Education Plan (IEP) support, and connecting the family
with resources, such as respite care or personal care services in coordination with OCDD.
Advocating for Remy and his family. Remy’s case manager collaborates with the inpatient
facility to confirm Remy receives meaningful treatment within the standard of care and in
alignment with best practices during his inpatient stay and from other providers involved in
Remy’s care. The goal is for Remy to be stabilized so he and his family can develop skills to
allow him to return to and remain at home. Remy’s case manager, our UM team and our
Behavioral Health Medical Director, Dr. Jose Calderon-Abbo, monitor that Remy’s treatment
includes proper evaluation of co-occurring symptoms, self-injurious behaviors,
psychopharmacology and evidence-based treatment, such as Dialectical Behavioral Therapy
(DBT). They confirm Remy’s plan has been developed in collaboration with Remy and his family
and his progress is quantifiable. The UM team conducts concurrent review, monitors Remy’s
response to his treatment plan and works with the inpatient treatment team to authorize
inpatient services and services upon discharge. Remy’s case manager documents his
assessments and case management-related documents in CommunityCare, our care
management platform, which is available to the MDT.

Preparing for Remy’s Discharge

Remy’s case manager and our UM team collaborate with Remy, his family, his outpatient
providers and the inpatient facility to determine the next best steps for Remy once he is stable.
This includes developing a discharge plan and a crisis plan that allows Remy to safely transition
to community life. The services in Remy’s discharge plan build upon Remy’s strengths,
including a low to normal IQ, good language skills, a supportive family and OCDD involvement.
Understanding Remy and his family’s needs for the transition. To identify the family’s
goals, reactions to trauma and social determinant needs, Remy’s case manager uses evidence-
based practices, such as motivational interviewing, and a variety of assessments. They include
our Pediatric Core Comprehensive Assessment, Access to Care assessment, and behavioral
health assessments, such as the Child Stress Disorders Checklist-Short Form, ACE
Questionnaire and PHQ-9 depression screener. His case manager reviews safety assessments
conducted by hospital staff and confirms Remy can safely
return home, reporting any identified safety concerns to the
From 2017‐2018, inpatient
appropriate authorities, such as Child Protective Services.
PMPM decreased 40% for
Identifying the best options for Remy’s placement upon our adolescent enrollees
discharge. Remy may not be ready to return home with behavioral health needs
immediately. If so, his next step may be to receive like Remy’s.
supportive care in a sub-acute or residential treatment
facility. We work with the inpatient team and Remy’s MDT to identify an appropriate step-down
facility that provides family-centered care, such as Methodist Children’s Home in Ruston or one
of 13 statewide therapeutic group homes and rehabilitation facilities for children and
adolescents who may need a step wise approach to return to living at home. If Remy is stable
enough to return home, his transition plan may include an appointment with a local Mental
Health Rehabilitation agency, such as Family Solutions of Louisiana Inc. or connection to the
local government entity in his community for lower-intensity interventions.

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Coordinating CSoC services. Remy’s case manager identifies whether Remy currently
receives CSoC services, such as wraparound facilitation and parent support. If he is not already
receiving them and Jay and Nichole are interested, Remy’s case manager facilitates his referral
to the program. If Remy already has a Magellan CSoC case manager, or once the referral is
made, his case manager coordinates his medical and behavioral needs through weekly case
rounds with Magellan. If the family decides to opt out of CSoC, his case manager engages
Remy and his parents using the same evidence-based approach founded on CSoC’s core
values of individualized, collaborative home and community-based care.
Coordinating other behavioral health services. Remy will benefit from providers with
experience caring for trauma survivors, such as one of the 425 behavioral health clinicians at
750 locations in our Louisiana network who specialize in child and adolescent trauma therapy.
Remy’s case manager confirms the supports Remy receives from OCDD, such as Children’s
Choice Waiver services. If needed, his case manager facilitates referral to one of the more than
300 Applied Behavior Analysis (ABA) therapists in our network, such as the Merakey Louisiana
Shelly Hendrix Autism Center. Remy’s services may also be delivered by one of several
providers throughout Louisiana who we are training
in Parent Child Interaction Therapy (PCIT). Enrollees engaged in behavioral
Establishing Remy’s MDT. Remy’s case manager health transitional case management
have seen a 55% decrease in
works with Remy and his parents to bring together
inpatient PMPM and a 17%
Remy’s post-discharge MDT, which may include a decrease in ED PMPM when
pediatrician, a psychiatrist, therapist specialized in compared to the year before they
complex trauma, ABA therapist, his OCDD case enrolled in case management.
manager, a school representative, his CSoC case
manager, if applicable, and any other natural supports chosen by the family, such as a spiritual
leader. Remy’s MDT will meet monthly, as outlined in his plan of care.
Supporting Remy’s discharge. Recognizing the transition from inpatient can be stressful and
filled with both excitement and apprehension, Remy’s case manager visits him and his family in
person within 24 hours of discharge to confirm the delivery of services and supports in his
discharge plan. For example, Remy’s case manager confirms that Remy has a follow-up visit
with his provider, who may be among the more than 700 behavioral and physical health
providers we are incentivizing through our 7-day follow up after hospitalization (FUH) initiative.

Supporting Remy’s Continued Growth after Discharge

Within 30 days of his enrollment in case management, Remy’s case manager works with the
family to begin developing an integrated, enrollee-driven and strengths-based plan of care to
support Remy’s continued and long-term health. The plan of care highlights Remy’s attributes
that can serve as a foundation for achieving positive outcomes based upon his unique situation
and needs. During planning, Remy and his parents identify achievable short-term goals and his
planning team presents services, supports and provider options for the family to consider to
reach them. Examples are presented in the table. Remy’s plan of care is dynamic and his care
manager continues to update it as Remy achieves his goals and identifies new ones. For
instance, as Remy approaches his teenage years, education about healthy sexual practices and
preventing substance use will be crucial for Remy. We reassess Remy quarterly with face-to-
face meetings to revise and update his plan of care.
Remy: “I don’t want to go to the hospital anymore.”
Stated
Potential Goal Jay and Nichole: “Have a plan to keep Remy and all of us safe.”
for Remy Create a crisis plan for Remy to prevent escalating crises and ED
Measurable
visits/hospitalizations for the next 60 days.

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Remy and his parents express confidence in knowing how to prevent and handle
Outcome
behavioral health crises.
 Crisis resources available 24 hours a day, 7 days a week, such as the Sexual Trauma
Awareness & Response (STAR) Hotline, 211 or the behavioral health crisis text line and
information accessible through myuhc.com, or from the LDH OBH crisis counselor or
area human services district. Support ED diversion through connection with urgent
Suggested
care, NurseLine and UHC Doctor Chat, providing Remy’s family with access to
Interventions
immediate ED triage by an RN via secure chat, telephone or video, with escalation to an
ED physician if needed.
 Develop and practice coping, crisis management and communication skills learned
through DBT, PCIT, or Youth Mental Health First Aid training provided by NAMI.
Remy: “I want to go back to school, play with my friends and have fun.”
Stated Jay and Nichole: “Empower Remy to be a regular kid and help us to be a
Potential Goal
healthy family.”
for Remy
Remy is able to stay in school with fewer missed days over the next 3
Measurable
months and participate in activities that have meaning to him.
Remy’s parents describe feeling more stable and Remy spends more time with his friends
Outcome
and peers.
Connect Remy and his family to:
 PCIT, a 12‐ to 14‐week family‐centered treatment approach, to provide Jay and Nichole
with effective skills for managing and improving Remy’s behavior, and cultivate a
strong relationship between Remy and his parents, or
 The Positive Parenting Program® (PPP), an evidence‐based parenting and family
support system designed to prevent and treat behavioral and emotional problems in
children and teenagers
Suggested
 Family peer support: We are the only MCO nationally approved to conduct “train the
Interventions
facilitator” training of peer support specialists in Seeking Safety group support for
adults and youth who have experienced trauma
 Other parents who have children with special needs, such as Exceptional Lives or
Family to Family meetings with parent peers who could help Jay and Nichole feel
supported, discuss IEPs and school attendance, and connect them to relevant resources
 Supports, such as the Baton Rouge Children’s Advocacy Center which provides children
and families with guidance and trauma‐focused clinical services

Supporting Jay and Nichole. Caregiver well-being is paramount for Remy’s recovery and
resiliency. Fostering strong, responsive relationships between children with ACEs and their
caregivers can buffer against the effects of toxic stress caused by early life trauma. Remy’s
case manager encourages Jay and Nichole to connect to their natural supports and refers them
to services for their own mental health conditions and social needs. This includes helping to
schedule services with their established provider or connecting them to community resources
such as support groups or a credentialed family peer advocate. Remy’s case manager can link
Jay and Nichole to respite care services, if not already connected through OCDD waiver,
available through Remy’s area Human Services District Developmental Disabilities Services.

Achieving a Better Future for Remy

With Remy’s parents’ agreement, we continue to support Remy with Tier 3 case management
and monitor post-discharge outcomes for at least 6 to 12 months to assess his integration back
into the home, progress toward his goals and to prevent or provide support during future
episodes while allowing Remy to remain at home. With the right supports and compassionate
care in place for Remy and his family, we envision a future where Remy and his parents
understand and are able to cope with Remy’s triggers, where Remy feels safe and secure and
has built meaningful relationships with his peers and the adults in his life, and where he can
thrive into young adulthood.

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2.10.6.3 Case 3

Like many seniors, our enrollee, Michael, planned to continue to live in the community as he
aged. However, driven by worsening mental health, chronic pain and weakness, Michael was
placed in a nursing facility, losing his apartment in the process. We understand that the best
care for Michael and many of our other enrollees in My
Choice Louisiana is not institutional but located in the
community where they can sustain their independence, We have 1,246 members with
serious mental illness (SMI) in case
dignity, freedom of choice and be active in their
management today. Michael’s case
communities. Michael may be feeling particularly is very similar to one of our older
overwhelmed at this moment — his excitement is enrollees with schizophrenic
accompanied by stress and apprehension. disorder, who was residing in a
skilled nursing facility. We enrolled
Michael is likely unsure of who to turn to for support, with
him in our case management
multiple state administrators and nursing facility staff program to support his transition
reaching out over the past few weeks. Without home. Since returning to the
appropriate community supports, he is at increased risk community in October 2018, the
for continued ED visits, stroke, debilitating pain, mental enrollee has had no inpatient
instability, heart attacks or further suicidal attempts, all of utilization and only one ED visit.
which will undermine his independence and confidence.
Our goal is to support Michael through collaborative partnerships and help him reach his goals
as he manages daily meals, finances, transportation, making friends, and getting the medical
and behavioral care he needs to live the life he envisions.

Engaging Michael in Case Management

We identify that Michael requires assistance through the methods presented in the figure, such
as referral from the My Choice Louisiana transition coordinator. Once we are aware of Michael,
our clinical team evaluates his situation and refers him for engagement in our transitional case
management program that supports enrollees transitioning through the My Choice Louisiana
program. When we learn about Michael’s situation, we challenge ourselves to think about how
we could prevent this from occurring in the first place. Our clinical team initiates a root cause
analysis to understand whether we identified and reached out to Michael for case management
before his nursing facility stay and why and how we did not become aware of Michael’s situation

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earlier. The analysis identifies the causes and the processes or tools that can be improved to
confirm this does not happen to Michael or other enrollees moving forward.
Due to his primarily behavioral health needs, we assign a licensed BHA case manager to
Michael. His case manager has the appropriate experience and expertise to address Michael’s
needs, and is equipped with clinical skills including motivational interviewing to encourage
treatment adherence, trauma-informed care, stages of change, cultural competency and crisis
management. We support his case manager with a MDT, including an RN to address his
medical needs, our peer support/housing specialist who serves as our permanent supportive
housing (PSH) liaison, who helps identify and coordinate PSH options and waivers for which
Michael may be eligible, and a CHW, who will help address Michael’s social determinants
needs.

Developing a Trusting Relationship with Michael

Michael and his case manager meet during a face-to-face visit at the nursing facility. His case
manager recognizes that enrollees in Michael’s situation may not be inclined to open up to new
people, especially in the face of existing stigma around behavioral health. During this initial
outreach, Michael’s case manager explains their role and uses active listening to build rapport
with Michael by asking him about himself, his experience at the nursing facility, his desire to
transition into the community and other issues important to Michael, such as how he became
estranged from his family.

For enrollees with SMI, like Michael, we Michael shares that he desires to return to an
saw a year‐over‐year decrease of 11% in apartment, preferably the one he was in before
total avoidable emergency room PMPM nursing home placement. His case manager
costs after they were enrolled in case explores Michael’s concerns about a transition to
management. For enrollees with primary the community and identifies services that can
behavioral health needs, we saw a 33% ameliorate his stresses. Recognizing Michael can
reduction in inpatient admits between decline case management, his case manager uses
February 2018 and February 2019. motivational interviewing and builds on the rapport
they have begun to establish with Michael to
explain the opportunities that case management can provide. Michael agrees to participate in
case management. His case manager also meets with Michael’s treatment team in the facility to
identify and link key personnel to Michael’s My Choice Louisiana transition coordinator.

Beginning to Understand Michael’s Needs and Goals: Assessment

During their face-to-face, Michael’s case manager conducts an HNA and uses comprehensive
assessments to determine Michael’s gaps in medical and behavioral care, functional
capabilities, emotional well-being, mental health conditions and social determinant gaps. With
Michael’s permission, his case manager reviews Michael’s history, including his prior ability to
live independently, both what worked well and challenges that contributed to his ED visits. The
case manager conducts a safety assessment to understand his suicide risk, particularly given
his prior suicide attempts and the stress that this transition will likely create.
Michael’s case manager uses additional resources to get a 360-degree perspective of his
present situation and future goals. Michael’s nursing facility shares information with Michael’s
case manager about his needs, functional status and treatment plans. His case manager delves
into Michael’s physical and behavioral concerns, understanding that his mental health
conditions may be affecting his performance with activities of daily living (ADLs), instrumental
ADLs (IADLs) and physical health. Michael’s case manager collaborates with nursing facility
staff to understand Michael’s ability to perform ADLs, such as bathing, and his ability to perform
IADLs, such as preparing meals. Michael’s neuropathy is a concern for his quality of life and

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affects his ability to live independently. His uncontrolled hypertension could cause serious
complications; therefore, timely appointments with a PCP, neurologist and PT/occupational
therapy (OT) are scheduled. Michael’s case manager documents his assessments and case
management-related documents in CommunityCare, our care management platform.
Understanding Michael’s Medicare and waiver eligibility. We know Michael is dual eligible
for Medicare and Medicaid and his case manager confirms whether Michael has enrolled in
Medicare. If he has not enrolled (e.g., he may have only recently become eligible and is unsure
of what to do next) his case manager connects Michael to the Senior Health Insurance
Information Program (SHIIP) for one-on-one guidance on what plan might best fit his needs.
Michael may have multiple options available to him, including Medicare Part A, Part B or
Medicare Advantage, and SHIIP will help Michael choose the program that most appeals to him.
Regardless of his Medicare choices, his case manager coordinates his services with those
provided by his Medicare coordinators and providers. Based upon our understanding of
Michael’s situation, it is unlikely Michael is eligible for the Community Choices or Long-Term
Services waivers, but his case manager refers Michael to the Medicaid Waiver department to
determine his eligibility.

Michael’s Multidisciplinary Transition Team and Transition Plan

Informed by Michael’s priorities and assessments, his case manager convenes Michael’s
transitional MDT within 30 days of enrollment in case management to develop Michael’s
Transitional Treatment Plan. Michael’s MDT includes Michael and people he chooses, such as,
friends, peers, others who support him, such as a spiritual leader, and providers, including
nursing facility staff. With Michael’s agreement, his MDT includes an RN, CHW, pharmacist, our
chief medical officer, our behavioral health medical director, his PT and OT providers, our peer
support/housing specialist, and the My Choice Louisiana transition coordinator. The team
engages in shared decision-making to help Michael develop a transition plan, coordinate among
providers and develop a crisis plan.
The planning process prepares Michael for a transition from nursing facility to the community
and brings together services he needs to be more independent, to receive care and address
barriers to successful community living. Michael’s case manager convenes a series of planning
meetings with Michael and his transitional MDT to identify his strengths and skills (e.g., the
ability to participate in transition planning), and services and supports for his transition plan. We
emphasize the importance of Michael’s self-determination, and encourage and empower him to
lead and actively participate in all aspects of the planning process.

Avoiding Crisis
Michael’s case manager provides information and framing to encourage him to be proactive in
addressing behavioral health concerns before they become crises. In addition to building his
relationship with his case manager and his local providers, Michael’s crisis plan includes
resources, such as our behavioral health crisis line and UHC Doctor Chat. Additionally, we
are partnering with two crisis centers to provide services to enrollees like Michael that help
prevent unnecessary ED use and inpatient admissions. The table presents Michael’s goals and
the interventions included to help Michael avoid crisis and the unnecessary use of the ED.
Stated “I want to stay out of hospitals and nursing homes.”
Michael’s
Potential Goal Minimize Michael’s ED visits to no more than one in the next 90 days by
Measurable
connecting him with behavioral health crisis services
Michael expresses confidence in having a plan to deal with issues before they become
Outcome
emergencies
Interventions  Create a behavioral health crisis plan for Michael that includes the agreed‐upon steps in

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the face of a crisis and people to reach out in case of an emergency and/or when early
warning signs appear. Supports include his behavioral health provider, his case
manager, others, and use of our behavioral health crisis line in Louisiana.
 Connect Michael to regular behavioral health provider appointments, including
cognitive behavioral therapy (CBT) or other evidence‐based therapies, including one of
the 1,209 CBT clinicians in our network with locations throughout the state.
 Share resources such as UHC Doctor Chat which offers in home secure chat, telephone
or video with an RN or an ED physician licensed in Louisiana.
 Offer to link Michael to a local Merakay behavioral health provider for peer support and
treatment (locations in East Baton Rouge, Caddo, Calcasieu, Lafourche, Lafayette,
Orleans, Rapides and Tangipahoa parishes).

Michael’s New Home: Connecting Him to Supportive Housing

Through our national Housing First experience, we know that getting Michael into stable
housing will be an essential foundation for the rest of his care. Our peer support/housing
specialist evaluates available local community housing options through our network of partners
and works with the My Choice Louisiana transition coordinator and the Louisiana PSH program
to identify housing options for Michael. Michael’s case manager arranges day visits for Michael
to visit different housing options. If Michael has made significant improvement in functional
performance and neuropathy, then his case manager collaboratively discusses housing options
with Michael and his MDT. Otherwise, Michael may benefit from an assisted living facility or
group home in the short term, with clearly established steps or goals he needs to take to get to
an independent living situation.
To prepare Michael for living independently and the challenges he is likely to face, his peer
support/housing specialist, case manager, nurses, PT and OT, and other community groups
provide him with opportunities to learn ADL/IADL skills. His case manager helps identify needed
skills, including a stress reduction class at a local community center or church or self-
management skills for individuals with severe mental illness through NAMI’s peer-to-peer
program or a local provider. We also look to Michael’s local Council on Aging for additional
supports. His case manager instructs Michael in the use of non-emergency medical
transportation with his behavioral health provider, and how to access public transportation or
transportation for the elderly to support Michael’s increased integration in his community. With
Michael’s goals articulated, his case manager and MDT facilitate connections to
services/supports that will enable him to meet his goals, as presented in the table.
Stated “I want to live independently in an apartment on my own.”
Michael’s
Potential Goal Michael transitions from the nursing facility in the next 2‐3 months into a
Measurable
supportive housing setting
Outcome Michael selects a setting that fits his preferences and provides him with the care he needs
 Connect Michael with community housing options and select one that best fits his needs
 Assess financial‐medical benefits available to Michael including SSD, Medicaid or Social
Security. Michael’s case manager identifies existing benefits, helps determine his
eligibility and helps Michael apply for benefits.
Interventions  Identify and help Michael select available community resources for transportation, food
security, telephone and other social resource needs using Healthify and Aunt Bertha©
and coordinate to wrap appropriate resources around Michael
 Encourage Michael to be socially involved, including Area Agency on Aging/Council on
Aging senior centers in Michael’s community, and identify community organizations
such as faith‐based groups that Michael might benefit from joining

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Stated “I want to feel good enough to do the things I want to each day.”
Michael’s
Potential Goal Improve self‐management strategies including increasing medication
Measurable
adherence to 5 out of 7 days
Michael is able to meet the goals he sets each day because his chronic physical and
Outcome
behavioral health needs are better managed
 Address Michael’s neuropathy and chronic pain by identifying and scheduling
appointments for him with specialist providers including neurologists, PT and OT.
 Enhance medication adherence by connecting Michael to our pharmacy navigator:
 Genoa, our behavioral health pharmacy partner, delivers medication management
services through trained clinical pharmacists who assess and reconcile his
medications, provide education, resolve drug therapy concerns and set goals in close
Interventions communication with the clinical team.
 Review options that facilitate adherence, such as long‐acting antipsychotics. Our
pharmacist reviews authorization criteria for long acting antipsychotics and works
with Michael’s behavioral health provider to offer education.
 Match Michael with a peer support specialist while at the nursing facility.
UnitedHealthcare is contracting with NAMI St. Tammany and Local Governing Entities
around the state to provide these peer supports to our enrollees.

Managing Michael’s Transition to Community Living

Michael’s transition to his new home is expected to be a stressful time. His case manager and
peer support/housing specialist visit Michael in the nursing facility several times a week in the
time leading up to his transition date. One to 2 weeks before Michael’s transition, his case
manager conducts an in-home assessment to identify and confirm the delivery of services
Michael may require, such as minor home modifications or specific PT or OT that may be
needed for Michael to live in the community.
Michael’s case manager checks on Michael within days of his nursing facility discharge to check
on his transition. Michael and his case manager discuss changes to Michael’s priorities, goals
and preferences for care delivery, any care gaps or barriers to accessing care and social
determinants needs. For example, his case manager offers Michael support if he would like a
new medical provider closer to his apartment. Michael and his case manager develop a daily
routine, and set and maintain measurable goals. Michael’s case manager coaches Michael to
confirm his routine includes self-care and caring for his living space, while managing his
medical/behavioral care, finances, and social and leisure activities. We look forward to Michael
learning not just to survive but also to thrive in his new surroundings.

Looking Forward
Over the next year, Michael starts to take on more IADLs and returns to his old routine. He now
walks to the public library several days a week and attends regular wellness education
programs at his local Council on Aging. Michael and his case manager meet monthly to discuss
his plan of care and confirm progress with Michael and his providers. After 3 months in his new
setting, Michael’s case manager conducts an in-person formal reassessment, repeated
quarterly or as needed when his needs and priorities change. The case manager updates his
plan of care accordingly. Over the next 12 months, case management meetings taper off to a
minimum monthly basis to confirm Michael maintains the support and resources he needs. At
the 1-year anniversary of Michael’s relocation, we evaluate how far he has come since he was
first referred to our case management program. Michael may need ongoing case management,
or may have progressed enough to live independently without this support. In either case,
Michael’s empowerment to lead a self-directed, healthy and meaningful life is a remarkable
achievement, and we are humbled by the opportunity to accompany him along his journey.

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2.10.7 Provider Network

2.10.7.1 The Proposer shall provide an electronic list of all providers within its network, by provider type…
2.10.7.2 The Proposer should submit documentation that its provider network meets or exceeds the time, distance…
Please refer to Attachment 2.10.7.1 Provider Network Listing and Attachment 2.10.7.2 Provider
Network Capacity Response, provided on flash drive.

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2.10.8 Network Management

The Proposer should demonstrate how it will ensure timely access to culturally competent primary and specialty…
Our mission is to help people live healthier lives and to help
make the health care system work better for everyone. To
accomplish our mission in Louisiana, we work hard to evaluate
our network through the eyes of enrollees and confirm they are
able to receive the right care from their preferred provider in the
right location at the right time. As we continue to evolve our
network, we focus on sustaining an environment where enrollees
feel comfortable in the care they receive no matter who they are
or where they live. We recruit providers of all types and make
sure they have tools that enable them to spend more time with
their patients. We place extra focus on providers that serve
particularly underserved populations (e.g., Native American
communities, communities of color, communities with high poverty rates and enrollees
experiencing homelessness).
We apply monitoring techniques (outlined in 2.10.8.5) and real-time insight from
UnitedHealthcare staff, providers and enrollees to verify our enrollees have timely access to
culturally competent care. Our local staff many of whom are native Louisianans, understand
each region’s unique culture and values. We are familiar with geographic distribution of
ethnicities around the state (e.g., we make sure there enough Vietnamese-speaking providers
and provider staff to serve New Orleans East area), and we provide staff sensitivity training on
regional differences. For example, those familiar with the New Orleans area know it could be a
hardship for an enrollee on the Westbank of New Orleans to travel across the Mississippi River
to see a PCP on the Eastbank — regardless of actual distance.
When we identify a network gap, we actively address it through our Network Development Plan,
outlined later. We employ innovative solutions like expansion of our telemedicine offering to
make care available to enrollees regardless of geography. Where capacity is limited by closed
panels or non-participating providers, we meaningfully incent providers through Value-based
Payment (VBP) programs, like our PCP Gap Closure model, which directly and more timely
pays providers who improve outcomes and close HEDIS care opportunities. These initiatives
encourage providers to join our network, open their panels or expand office hours.
We continue to enhance our already deep provider relationships through local engagement and
advisory groups — listening to, collaborating with, and actively supporting them by reducing
complexity and administrative burden (e.g., based upon provider feedback, we added a
feature to our provider service line to help PCPs locate and secure specialist appointments).
Through this combination of local experience, ongoing monitoring, innovation and collaboration,
UnitedHealthcare continues to enhance and maintain a compliant provider network that drives
health care in Louisiana toward the “Triple Aim” and meets all LDH requirements, including
those outlined in Attachments A and D to the Model Contract.
2.10.8.1 Identification of network gaps (time/distance standards, after-hours clinic availability, closed panels, etc.)
2.10.8.2 Strategies that will be deployed to increase provider capacity and meet the needs of enrollees where…
2.10.8.3 Strategies (including a description of data sources utilized) for monitoring compliance with the provider…
Because Questions 2.10.8.1 through 2.10.8.3 are so closely related, our response addresses all
requirements of these questions through a combined response with sections covering:

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 Our approach to identifying network gaps

 Network compliance with Attachment D and known gaps
 Methods to remediate gaps by improving access, capacity and appointment availability

Approach to Identifying Network Gaps

Since 2012, when we partnered with LDH through
a Shared Risk primary care management
program, our culture of innovation and
continuous improvement has informed our
increasingly strategic and proactive network
approach. We have a deep understanding of the
state’s geographic, clinical and cultural needs.
This knowledge and experience guides our
Network Management Team to employ focused
recruitment to enhance our network year over
year. Since moving to a Full Risk Managed Care
Program in 2015, we have developed a full-
service, comprehensive network that includes Figure 16. Network Growth from 2015 to 2018
hospitals, primary and specialty care, behavioral
health, and ancillary service providers. As demonstrated in the figure, our network has grown
approximately 20% over the last 4 years to meet the individual needs of our enrollees.
Our Interdisciplinary Network Team composed of network management, provider relations, the
Quality Management Committee (QMC) and clinical/case management meets at least monthly
to identify and address potential network deficiencies. We coordinate an organization wide
response to accessibility issues or provider trends identified through continuous monitoring,
provider outreach and enrollee feedback.1

Engagement with Providers, Enrollees and Our Community

Through direct interaction with providers and enrollees, we are able to uncover actionable
opportunities for network improvement in real-time that may not be visible purely through data.
Examples of these types of engagement include:
 Our Enrollee Advisory Committee meets quarterly to foster feedback and open dialogue
to assess enrollee satisfaction and remain responsive to enrollees’ needs
 Reviews of provider performance by our provider advocates to identify utilization outliers
and access to care issues
 Face-to-face meetings between our field-based shared savings specialists and providers
engaged in our shared savings VBP model
 Partnership with local faith- and community-based organizations, such as Volunteers of
America, Greater Baton Rouge, which helps identify community-specific network gaps
and offers local providers’ perspective on updates to our network operations
Additional sources of input include quality of service concerns via enrollee complaints and
grievances, provider disputes, and enrollee and provider satisfaction surveys.

                                                            
1
 *PCP includes FQHC/RHC, OB/GYNs and extenders; ** Hospitals include specialty, surgery centers and acute care facilities that
provide BH; ***Ancillary includes HH, DME, vision, dental, PT, OT, ST and chiropractic; ****BH includes outpatient, individually
credentialed clinicians, roster clinicians and group and residential IP facilities. 

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Continuous Network Monitoring

Our Interdisciplinary Network Team meets at least quarterly to assess network adequacy, and
we use the following methods to help us prioritize and identify network gaps and opportunities
for improvement. Through these meetings, we are able to identify specific provider recruitment
opportunities and address the unique cultural, geographic and community-based needs of our
enrollees.
Zelis Network 360® Tool: This tool provides a comprehensive analysis of network strength and
identifies providers targeted for recruitment efforts by type, specialty and geography.
GeoAccess Reporting: We use GeoAccess mapping at least quarterly to evaluate the network
for adequate coverage and compliance with LDH time and distance standards in Attachment D.
QMC Monitoring: Our QMC’s activities include, but are not limited to, reviewing HEDIS data
and network performance against access standards, recommending solutions for network
expansion; monitoring improvement plans, enrollee satisfaction, provider cultural competency,
peer comparison data, quality of care incidents and provider satisfaction; and conducting
appointment and after-hours availability surveys.
Membership and Capacity Reports: We review quarterly enrollee-to-provider counts by
specialty type and PCP capacity to confirm appropriate enrollee access and address any gaps.
Utilization Data: We employ utilization data as part of our annual business planning to identify
and close network gaps. We review out-of-network prior authorization data by specialty type,
location and program to help identify network needs.

Comprehensive Review of Appointment Availability

Timely access to care is essential for our enrollees and their families. Our monitoring and
surveying approach confirms enrollees have access to a contracted provider to meet their
health care needs. We monitor provider compliance with appointment availability requirements,
wait time standards, and after-hours access requirements according to state-specific and NCQA
accreditation requirements.
We use quarterly appointment and availability surveys, annual physical and behavioral provider
satisfaction surveys, provider-level CAHPS surveys and enrollee satisfaction surveys to identify
areas of improvement. We also employ a third-party vendor to conduct regular practitioner
appointment access and availability survey calls to a random sample of PCPs, pediatricians,
specialists, and behavioral health providers to determine compliance with contractual
requirements. During the survey, the vendor solicits appointment availability for emergency,
urgent, routine and preventive visits. When surveys indicate non-compliance, we conduct
targeted training. Non-compliant providers receive additional outreach, face-to-face follow ups
and, when necessary, we develop a corrective action plan. Continued noncompliance may
result in termination. Compliance among PCPs and pediatricians in our network shows the most
improvement year over year compared to other provider types. Nearly nine in 10
PCPs/pediatricians that were non-compliant in 2017 are now complaint in 2018. Our 2018
overall compliance rate for PCPs and pediatricians is 89.5%.
Survey results are presented to our internal Service Quality Improvement Subcommittee
(SQIS), at least annually for review and to develop an action plan to improve overall scores.
This committee is chaired by Chief Operating Officer, Karl Lirette, and is integrally involved in
monitoring and providing feedback to the QMC for systemwide actions, if needed. For example,
after reviewing the concerns for access and availability to behavioral health services, we
initiated the expansion of our behavioral health virtual visits program to include more prescribers

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(e.g., as of April 2019, we have added six MDs to our network). We have seen a steady
increase of utilization and enrollee adoption of virtual visits with over 2,000 claimants in 2018 —
up by over 1,000 units versus 2017.

Compliance with Attachment D and Existing Network Gaps

Current analysis shows we provide a comprehensive network of all provider types to meet the
unique needs of Louisiana enrollees (based on LDH’s Potential Enrollment file). However, as
illustrated in the table, our data indicates the following access challenges for the provider types
listed by LDH in RFP Section 2.10.8.3. Many of these gaps are due to known, statewide
provider shortages in parishes (rural or otherwise) where our enrollees live. We are actively
addressing these challenges. For enrollees with transportation needs, we provide transportation
to and from appointments through our Non-Emergency Medical Transportation program for
Medicaid covered services.
Provider Type Existing Gap Gap Closure Remediation
Adult Cardiologists  Compliant with Attachment D  Compliant with Attachment D
Pediatric  There is a known provider shortage  Telehealth expansion
Cardiologists of pediatric cardiologists. This  Contracting with large hospital systems in
provider specialty is normally nearby parishes such as Lafayette and
associated with large hospital Alexandria; cross‐border contracting
systems.  Single‐Case Agreements (SCA)
Dermatologists  There are no dermatologists in  Telehealth expansion
Beauregard, Calcasieu and Cameron  Contracting with large hospital systems in
parishes. nearby parishes such as Lafayette and
 Enrollee standard access of care is Alexandria
in Lafayette parish  SCAs
Endocrinologists  Known provider shortage in  Seeking contracts with identified
Caldwell, Catahoula, Concordia, East providers
Carroll, Franklin, Grant, LaSalle,  Telehealth expansion
Madison, Morehouse, Sabine,  Currently contracted with large hospital
Tensas, Vernon, West Carroll, Winn, system in the Shreveport area that offers
Ouachita and Rapides parishes this specialty
 Cross‐border contracting
 SCAs
Adult Licensed  Compliant with Attachment D for  Seeking contracts with identified
Mental Health rural areas of the state providers
Specialists  Known provider shortage in urban  Telehealth expansion
areas of the state  SCAs
 Alternative providers available, including
Licensed Professional Counselors (LPC),
Licensed Marriage and Family Therapists
(LMFT), and community‐based providers
Pediatric Licensed  Known provider shortage across  Telehealth expansion
Mental Health the state  Exploring program to provide behavioral
Specialists health consultation to PCPs
 SCAs
 Alternative providers available, including
LPCs, LMFTs, and community‐based
providers

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Provider Type Existing Gap Gap Closure Remediation

Adult Neurologists  There are no neurologists located in  Telehealth expansion
Sabine Parish. Enrollees typically  Currently contracted with large hospital
access care in Alexandria Parish. system in the Shreveport and Alexandria
areas that offer this provider specialty
 Cross‐border contracting
 SCAs
Pediatric  Known provider shortage across  Telehealth expansion
Neurologists the state  Contracting with large health systems
 We currently have providers  Cross‐border contracting
contracted in the following  SCAs
parishes: Caddo, Calcasieu, East
Baton Rouge, Jefferson, Lafayette,
Orleans, Ouachita, Rapides, Saint
Tammany, Tangipahoa, Rapides and
Terrebonne
Obstetricians/  Compliant with Attachment D  Compliant with Attachment D
Gynecologists
Pediatric  Known provider shortage across  Currently contracted with large hospital
Orthopedists the state system in the Shreveport and Alexandria
 Providers only located in Ascension, areas that offer this specialty
Caddo, Calcasieu, East Baton Rouge  Cross‐border contracting
Franklin, Jefferson, Lafayette,  SCAs
Orleans, Ouachita, Rapides,
Richland, St. Tammany and Vernon
Parishes
Adult and Pediatric  We currently have an adequate  Contracted with 90% of school based
PCPs network of adult and pediatric health clinics (SBHC) and all FQHCs
physicians across the state to serve  PCP care in the home via Homedica
the potential Medicaid membership; partnership
however, there are known gaps  Telehealth partnership between
within specific parishes in rural UnitedHealthcare, Metropolitan Human
areas near the Texas, Mississippi Services District, Louisiana State
and Arkansas borders University Department of Psychiatry, and
Plaquemines Parish School Board
(described later)
Adult Psychiatrists  Compliant with Attachment D for  Telehealth expansion, including six adult
rural areas of the state psychiatrists available via virtual visits
 Known provider shortage in urban  Seeking contracts with identified
areas of the state providers
 SCAs
 Enrollees may also use other prescriber
types (e.g., APRNs and PAs with
prescription authority or medical
psychologists)
Pediatric  Known provider shortage across  Telehealth expansion
Psychiatrists the state  Exploring program to provide behavioral
health consultation to PCPs
 Seeking contracts with identified
providers
 SCAs
 Enrollees may also use other prescriber

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Provider Type Existing Gap Gap Closure Remediation

types (e.g., APRNs and PAs with
prescription authority or medical
psychologists)
Pulmonologists  Known provider shortage across  Telehealth expansion
(Adult and the state  Contracting with large hospital systems in
Pediatric)  Providers are located in only 19 nearby parishes such as Lafayette and
parishes; this provider specialty is Alexandria
normally associated with large  Cross‐border contracting
hospital systems.  SCAs

Addressing Gaps in Access, Capacity and Appointment Availability

Here we outline our strategy for addressing network gaps by improving enrollee access,
improving provider and network capacity, and improving appointment availability.

Improving Enrollee Access to Care

Given the geographic locations of enrollees and their need to access primary and specialty
care, we have implemented the following solutions (e.g., telemedicine, home-based care and
community partnerships) to bring the right care to enrollees at the right time and place. In
addition to providing transportation for enrollees that require specialized care or extended travel
(in state or out of state), we partner with the Ronald McDonald house charities for housing, and
local hotels.

Expanding Access to Care through Telehealth

Telehealth is one of our most innovative strategies to provide enrollees with virtual access to
behavioral health, substance use services, and primary and specialty care in the communities
where enrollees live. These solutions not only address gaps in underserved areas, they enable
enrollees to access care regardless of scheduling or transportation challenges.
Our strategy to deliver care to underserved Louisiana Medicaid enrollees through telehealth
addresses three modes of access: direct to enrollee, enrollee to specialist through PCP, and
doctor to doctor. From 2017 to 2018, we have seen a 34% increase in telehealth claims
received. Today, as we continue to expand our telehealth programs, we are guided by a four-
tier strategy for delivering high quality, accessible care to enrollees in Louisiana by focusing on
providing access, capacity, innovation and quality.
As we look to further expand access for enrollees, we are exploring additional telehealth
applications. We continue to identify PCPs statewide and FQHCs in rural parishes interested in
expanding their capacity to serve as a host site for telemedicine services and we are leveraging
our success in VBP programs to offer a telehealth hosting fee to attract providers to participate.
We also will continue to build on our strong network of behavioral health providers, prescribers
and specialty providers throughout Louisiana to deliver these services via mobile telehealth.
Further, to facilitate the expansion of our telehealth programs, we have invested in training with
our Louisiana health plan staff — conducting two sessions with 40 UnitedHealthcare employees
— to help them better communicate options to both enrollees and providers.
The table provides an overview of our existing telehealth program, which has grown in 2019 to
include four new programs. We also support NOELA and Children’s Hospitals by promoting
their ability to connect enrollees to specialist care through their PCP via Skype and smartphone.

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Program Implemented Audience Description

Virtual Visits 2015 Direct to Offers enrollees with behavioral health needs virtual visits
Enrollee via site‐to‐site connectivity and direct‐to‐enrollee
connectivity
UHC Doctor 2019 Direct to Helps patients statewide get the care they need when they
Chat Enrollee need it. With the Dr. Chat app, patients can avoid the ED and
receive on‐demand care via computer or mobile device.
Lower 2019 Direct to In partnership with Metropolitan Human Services District,
Plaquemines Enrollee LSU Department of Psychiatry, and Plaquemines Parish
(Virtual School board, this program expands behavioral health
Visits services to children and adolescents (regardless of MCO) in
Expansion) the underserved area of Lower Plaquemines Parish via
telehealth
Host 2019 Enrollee We are in the process of partnering with Total Family
incentive to PCP to Medical and Children’s International to use a host fee to
program Specialist incentivize PCPs to use telehealth for specialist access while
enrollees are visiting their PCP’s office
RubiconMD 2019 Doctor to PCPs have the ability to connect with specialists for same‐
Doctor day consultations, expanding PCPs’ scope of care, including
TeleMAT

Increasing Access through Community Providers/Partnerships and Care Extenders

We have strategically expanded our network and enrollee access to care by including
community providers (e.g., FQHCs, SBHCs and Indian Health Care providers), care extenders
(e.g., medical assistants, paramedics) and care through home visits and peer support. By
allowing care extenders to operate in expanded roles and provide routine health care services,
we can efficiently improve access for enrollees who may be experiencing access or availability
challenges (e.g., high wait times, provider shortages, low PCP engagement). We engage
provider organizations like the American College of Emergency Physicians, the Louisiana
Academy of Family Physicians and other providers for guidance on preventive care and
required health care screenings in accordance with HEDIS requirements.
To promote timely appointment access to behavioral health services and minimize non-
emergency medical ER visits, we have implemented the following initiatives:
ExpressAccess Behavioral Health Network: While the industry standard (and our
requirement) for a routine appointment is within 10 business days of request, ExpressAccess
providers are contractually committed to offer an appointment within 5 business days. There are
currently 60 ExpressAccess providers in Louisiana today—including rural parishes (e.g., four
providers in Calcasieu, one MD and one MSW in Vermilion). Growing the ExpressAccess
network is a priority to increase access for enrollees with behavioral health needs.
Ready Responders: We partner with Ready Responders to engage enrollees with high ED
utilization in Orleans and Jefferson Parishes. Ready Responders offers a network of trained,
licensed and fully insured physicians, EMTs, paramedics and nurses who visit the enrollee at
home to conduct a medical assessment where a video telehealth physician consult may occur
and treat the enrollee on the spot. This program has had a very successful ED diversion rate
and a very positive overall enrollee engagement.
FQHCs: We value our strong FQHC relationships and support them in maximizing their capacity
to increase access to care for enrollees. We have contracts with all 233 FQHC locations in the
state and are currently partnering with several of them to expand access through telehealth.

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These centers are critical to expanding access to enrollees in underserved areas, including
Bienville, Bossier, Caddo, Caldwell, Claiborne, East Carroll, Franklin and Jackson parishes.

LDH Program Goal: Ensure enrollees ready access to care, including through
non-traditional means
Investing $2.5 Million to Help Daughters of Charity Expand CHW Program
In 2018, through a $1.5 million grant from UnitedHealthcare, community health
workers (CHW) at Daughters of Charity reached 8,234 unique individuals, encompassing both
our enrollee and non-enrollee population. Of those individuals, 5,195 (63%) completed referrals
to receive medical, dental and behavioral health services through the health centers, and 3,039
(37%) completed referrals to receive services through community-based organizations.
Referrals to community-based organizations include referrals to address the education,
employment, food, housing, transportation, technology/internet, and legal needs of underserved
and uninsured individuals. With an additional $1 million grant disbursed in January 2019,
Daughters of Charity expects that the CHWs will reach 7,500 additional people.

School-based Health Clinics: UnitedHealthcare has contracts with 90% of Louisiana’s

SBHCs, and we are in the contracting process with those remaining. Students and their families
rely on SBHCs to meet their needs for a full range of age-appropriate health care services
including primary medical care, mental health, dental health, substance use counseling, nutrition
services and health education.
Home Visits via Homedica House Calls: UnitedHealthcare partners with Homedica House
Calls to provide primary and palliative care to patients who have limited mobility, who find it
difficult and taxing to travel to and from a physician’s office. Nurse practitioners provide care
under the direction of Board Certified internal medicine and palliative care physicians. The goal
is to decrease hospital admissions and ED visits and improve the enrollee’s experience.
Peer Support: Peer support is an important tool in enrollees’ treatment and long-term recovery.
Our peer support specialist, Denise Smith, offers unique services to Louisiana Medicaid
enrollees and can have a significant positive impact on enrollees’ engagement in care and self-
perception. To encourage the use of peer support specialists within the provider network, we
offer an alternative payment arrangement, provide peer support resources on our website and
have sponsored community training specifically geared for these professionals.

Improving Network Capacity

When we identify opportunities to improve and enhance provider capacity and choice, we
strategically recruit providers based upon the following; feedback received from PCPs regarding
referral patterns for the needed specialties; benefit from existing contractual relationships with
providers contracted with UnitedHealthcare’s Medicare and Commercial lines of business;
claims data received from nonparticipating providers and contracts with cross border providers.
We also use internet searches and the State’s licensing board to identify any newly licensed
providers for recruitment. Once we identify providers, our Network Management Team engages
them to discuss network participation and initiate the contracting and credentialing processes. In
some cases, we may be required to enter into an SCA with an out-of-network or out-of-state
provider to ensure enrollees have access to and receive the appropriate care. We further
discuss recruitment strategies in our response to 2.10.8.4.

Improving Appointment Availability

In our efforts to achieve the appointment availability goals as outlined in Attachment D, we use
our quarterly appointment availability surveys to assist in monitoring and identifying any
opportunities for improvement. Provider compliance with timely appointment access measures

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is essential to providing quality-driven, person-centered care. The goal of meeting the standards
is to afford our enrollees timely access to care and promote improved health outcomes.
Untimely access to care is a serious barrier and contributes to negative health outcomes. When
our comprehensive appointment availability monitoring uncovers non-compliance with
appointment availability or after-hours access to care, we take the following steps to address it:
 Our Provider Advocate Team contacts the provider, reviews the issue and educates
them on the requirements and how they failed to meet them
 We send a follow-up letter to the provider clearly outlining the deficiencies and actions
needed to meet the requirements, and notify them of a follow-up audit
 Our Provider Advocate Team meets in-person with persistently noncompliant providers
to identify the source of the issue, deliver re-education and confirm steps are taken to
address deficiencies (e.g., supplying written scripts to noncompliant network providers to
confirm answering service or voicemail meets standards)
 In the rare instance that a provider is uncooperative and not making the necessary
changes to meet access standards or coverage requirements, we refer them to the
Credentialing Committee for a corrective action plan or possible termination
To improve enrollee access to care, UnitedHealthcare assists enrollees and providers in
arranging appointments. Our member services advocates (MSA) assist enrollees in scheduling
appointments with providers. For PCPs experiencing challenges in scheduling specialty
appointments for enrollees, our provider service line offers assistance locating specialists.
2.10.8.4 Strategies for recruitment and retention efforts planned for each provider type, including quality and/or…
Recruiting, incenting and retaining high-quality providers is essential to sustaining an adequate
network. Our ongoing recruitment and retention strategies begin with continuous
monitoring of the network based upon LDH priority measures, access requirements and
targeted recruitment. We are aware of the geographic, social, cultural and health-status issues
Louisianans face and consider enrollee access in the context of these needs.

Recruitment
We are committed to complying with the Model Contract, including section 2.9.8.1.7, in
managing our network. Our strategy focuses on targeted recruitment in geographic areas and
provider types. We consider patient preferences, language barriers, cultural diversity, health
disparities and disabilities. For example, with the addition of the Medicaid expansion population,
the need for adult substance use services increased dramatically. We focused our recruitment
efforts on providers that could serve these enrollees, increasing substance use residential
facilities and medication assisted treatment (MAT) provider access by 17.2% since 2017.
We use quarterly GeoAccess reports to assist with identifying network gaps. We also collect
ongoing feedback through community outreach, enrollee and provider call center interactions,
provider relations feedback and care management activities to further inform the Network
Management Team of any accessibility needs. Where there are known provider shortages —
such as parishes along the Mississippi state border where there is a lack of endocrinologists,
dermatologists, allergists and immunologists — we focus recruitment on cross-border providers,
providers interested in offering or expanding telehealth services or large health systems. Our
network team engages targeted providers to discuss participation and initiate the contracting
and credentialing processes. Our strategy also includes recruiting providers that qualify as
Veteran and Hudson initiative participants.

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We also use quality data obtained through annual medical chart reviews to identify
concentrations of enrollees experiencing conditions that require access to specialists and target
recruitment to meet those needs. For example, our network includes over 300 applied behavior
analysis providers for enrollees with autism spectrum disorders and we continually work to
identify additional providers to meet this need. To enhance our local network, we also will use
our national contracts to provide key ancillary services, including pharmacy, laboratory and
other non-physician provider types that are able to provide services locally to enrollees.

Retention
Attracting and retaining high-quality providers committed to serving the Louisiana Medicaid
population is essential to sustaining an effective network. Our success in retaining and incenting
providers — as demonstrated by our 95% retention rate — is a reflection of our dedication to
partnership, provider incentives, comprehensive education, and access to actionable data
through technology. Through our 360° Provider Service Strategy, we employ these approaches
to support a positive provider experience, reduce administrative burden, facilitate the best care
to our enrollees, and engage providers as our trusted partners — all of which are critical to
retention. Our strategy continues with responsiveness through our comprehensive provider
support model and includes monitoring and tailored outreach to help providers achieve LDH
priority measures and access requirements, education and streamlining data exchange.

Supporting Achievement of LDH Priority Measures and Access Requirements

We prioritize engagement with qualified Medicaid providers who promote culturally sensitive
environments and embrace the role of the health care provider in minimizing disparities. We
monitor their achievements in meeting LDH access and distance requirements outlined in
Attachment D and LDH’s priority quality metrics in Attachment G, including:
 Well-Child Visits (first 15 months)  Prenatal and Postpartum Care:
 Well-Child Visits (years 3 - -6) Postpartum Care
 Adolescent Well-Care Visits  Initiation of Injectable Progesterone for
Preterm Birth Prevention
 Adult Access to Preventive/Ambulatory
Services  Controlling High Blood Pressure
 Seven-Day Follow-Up after Behavioral  Eye Exam (Retinal) Performed
Health Hospitalization  Percent of enrollees completing initial
 Prenatal and Postpartum Care, health needs assessment within 90
Timeliness of Prenatal Care calendar days of enrollment

We employ the following approaches to monitor provider performance and right size our support
to meet each provider’s unique needs.
Consumer Assessment of Healthcare Providers and Systems (CAHPS): Provides insight
into enrollees’ PCP experience (e.g., appointment availability, access, after-hours care and
cultural competency).
HEDIS-reported Utilization Rates: Our provider support team uses monthly reviews of HEDIS
rates and utilization metrics to educate and support providers in closing any gaps in care.
Inpatient and ER Utilization Rates: Available via in-person meetings and our online provider
portal, these monthly reports give providers a scorecard of their aggregate rates to help guide
them in achieving minimum standards, exceeding peers or meeting provider incentive
agreements. The reports also include gaps-in-care data for enrollees assigned to the practice,

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and relevant utilization patterns for each enrollee. We also monitor internal Louisiana Medicaid
Managed Care utilization rates such as cost-per-enrollee, provider inpatient data and ER rates.
Provider Peer Comparison Reports: These annual reports show PCPs and specialists how
their performance in select performance measures compares to their peers. Our provider-facing
staff reviews utilization patterns with providers to help them improve performance.
Provider Profiling: Annual provider profiles for high-volume PCPs (i.e., providers serving 50 or
more enrollees) verify that providers are complying with LDH requirements for access, provider
responsibility and care management.
Fraud, Waste and Abuse (FWA) Review: We review results of data analytics and algorithms;
referrals from enrollees, staff, the public and the provider communities; and a service verification
program to uncover and investigate potential provider FWA.
The data obtained from these monitoring approaches illustrates the comprehensive support
provided by our clinical staff, who work directly with PCP and OB/GYN providers to improve
performance in clinical metrics. This team reviews performance data and suggests ways to
improve a practice’s results. Each participating practice receives scorecards showing trends
relative to baselines and targets for clinical quality measures (including those listed previously).

Incenting Achievement of Quality Metrics through Value‐based Payments

Our comprehensive suite of VBP models reflects our commitment to LDH’s vision to help
providers close gaps in care and improve quality outcomes in alignment with the state’s priority
measures. Our modular approach allows us to meet providers where they are in terms of
affordability, quality improvement and operational sophistication. VBP arrangements also help
address gaps in care by incenting measures tied to specialties where we have known
shortages. For example, our Behavioral Health VBP model enables PCPs and behavioral
health providers with the largest attributed enrollee base to receive incentives if an enrollee
receives care from a behavioral health provider within 7 days of discharge. This facilitates
integration and incentivizes behavioral health professionals to join and remain in network.

Provider Education and Support

Our 360° Provider Service Strategy supports a positive provider experience by pairing effective
communication and collaboration with technology to enable improved performance, ease
administrative burden, and promote quality care. Facets of the program include:
Provider-facing Technology: UHCprovider.com is our
public web home for provider information, which includes “I wanted to write a note of
connection to our secure provider portal, Link. Link thanks for the work [Provider
provides administrative tools to simplify common clinical Advocate, Julie Sutton] has done
tasks. The My Practice Profile feature, implemented in for us in the past year. Her
December 2018, allows providers to view, update and expertise and insight has helped
attest to provider demographic data — making it easier for us raise the bar since I came to
enrollees to find the right provider. our hospital in January 2018.
Thank you again for having
Provider Education and Training: Timely such a capable, helpful and
communication and education through provider-friendly responsive person representing
tools found on UHCprovider.com and Link are essential to your company and helping us
helping providers interact and transact with us and access better take care of patients.”
free continuing education units on a variety of topics.

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Provider Advocates: We assign our full-time, local provider advocates by parish. Advocates
take a hands-on approach to help providers identify issues early through data analytics and
targeted training. Advocates meet with providers face-to-face and online via webinar to answer
questions, identify issues and work on the provider’s behalf to reach resolutions. In addition to
the provider advocates, our call centers, clinical team and local leadership team are all
dedicated provider support.
Provider Expositions: We arrange biannual provider education expositions that focus on a
broad range of topics that includes, refresher training on billing and claims issues, portal
updates and the introduction of new programs or products. Our staff is available to provide a live
demonstration of Link and answer questions during the exposition.
2.10.8.5 Strategies to ensure that its provider network is able to meet the multi-lingual, multi-cultural and
Our strategy for ensuring enrollees have access to providers competent in providing care to
enrollees with limited language proficiency, diverse cultural and ethnic backgrounds and are
ADA compliant includes customized education, network monitoring, strategic provider
recruitment, and provider support and tools.

Network Monitoring/Recruitment for Cultural & Disability Competency

Provider network diversity facilitates improved access to quality care for Medicaid populations
and promotes better patient-provider interactions. We design our network to meet enrollee
needs, such as taking into consideration language fluency, understanding the values of different
cultural groups, sexual orientation and gender identity, beliefs regarding healing, communication
preferences and family dynamics. For example, we know that 2.3% of our enrollees speak
Spanish (1.84%) or Vietnamese (0.39%) rather than English. Currently, 45% of our providers
are bilingual. We also identify populations that are geographically centralized and then work to
align network providers with the culturally specific needs of that population. For example, we
make sure there is a sufficient number of Vietnamese-speaking providers and provider staff to
serve the substantial Vietnamese population in the New Orleans East area.
Annually, we review multiple data points to assess the disability,
cultural, ethnic, racial and linguistic needs of our enrollees. Data We have 535 attested
behavioral health
sources include 2010 U. S. Census data, CAHPS® 5.0H, Network
providers —
Database reports on practitioner languages and race, American including MDs,
Community Survey Data Set (2014), UnitedHealthcare Ph.D.s, RNs and
interpretation services utilization statistics, and physicians’ MSWs–across all 10
languages to confirm our network aligns with the cultural needs of regions of the state to
our enrollees. We also collect cultural and disability competency treat IDD patients.
data during the credentialing process.
In 2018, we were the first and only MCO to engage with Quality Interactions (QI) in their
Compass Cultural Competency Survey for a sample of our network providers. Through the
study, we discovered at least 60% of providers considered themselves skilled in working with
culturally diverse enrollees. Providers also stated that they either had no training or had limited
training within the past 3 years.

Training and Education

Louisiana Culture Training: Our chief operating officer and director of marketing and
community outreach — both native Louisianans — developed required culture training to help
all UnitedHealthcare staff understand everything from each region’s unique heritage to how to
pronounce common last names. This deep familiarity with the state’s culture and values helps
us pair our enrollees with the right providers in the right location at the right time.

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Provider Education: We support provider understanding of cultural diversity and disability

competency, through provider orientation and refresher training (e.g., provider expositions and
town halls). We also provide educational materials, such as the Care Provider Manual and our
Practice Matters newsletter, which includes articles such as Support for Language Services and
A Member’s Right to Culturally Competent Care. We also offer training via our provider portal,
as well as professional, online continuing education and training related to caring for individuals
with disabilities (live and recorded) through UHC On Air.
“Through Their Eyes” cultural competency training is required for all UnitedHealthcare staff —
in support of the national culturally and linguistically appropriate services (CLAS) standards.
This training helps us meet the individuals in our Louisiana Medicaid population where they are,
calls on each of us to act with compassion, and helps us understand the unique needs of
enrollees, providers and business partners. Current topics include medical interpreters,
LGBTQ+ diversity and health literacy.
NAMI Training: In 2018, we contracted with the executive director of the National Alliance on
Mental Illness (NAMI) in Louisiana to host two in person cultural competency trainings
addressing Louisiana populations including Native Americans, Vietnamese, African American,
and Creole. We offered continuing education units (CEUs) for these trainings.

Assistance with Translation and Interpretation

Real-time Interpreter Services are available for both providers and enrollees via bilingual
provider phone representatives and our interpreter service, with more than 240 supported
languages. We monitor the languages enrollees and providers request for interpretation
services to tailor our support accordingly.
Communication Assistance: We offer provider support for enrollees who are deaf, hard-of-
hearing or speech-impaired using TTY/TDD or a Telecommunications Relay Service (TRS).
Customized Materials: We offer customized materials for enrollees with limited English
proficiency and who speak languages other than English or Spanish. Materials are also
available in alternative formats for specific populations, including Braille, upon request (e.g., our
Picture Recovery Workbook is available in Spanish).

Resources and Operational Requirements

Provider Data: Network providers are required to attest to having ADA-compliant offices. We
list provider languages and accessibility in our provider directories so enrollees can easily
identify practitioners who meet their needs.
CommunityCare Collaboration Platform enables network providers to view an enrollee’s
primary language preference.
I/DD Toolkit: To assist providers in serving enrollees experiencing intellectual or developmental
disability (I/DD), we offer an I/DD tool kit. This toolkit includes resources for physical health and
behavioral and mental health providers. It includes the following information: how to
communicate effectively, management of behavioral crises, crisis prevention and psychotropic
medication. We also offer free CEUs and resources on trauma-informed care and home and
community-based services.
Cultural Competency Resource Guide was created and distributed at recent Louisiana
provider expositions along with handouts on topics such as understanding ADA, and the Agency
for Healthcare Research and Quality (AHRQ) health literacy universal precautions toolkit, We

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also shared the cultural competency resource guide with our clinical practice consultants to
share with PCPs during their office visits.
Liveandworkwell.com allows enrollees to search a community directory for providers that meet
their unique needs, including those experienced in and sensitive to LGBTQ+ issues. We
encourage providers to direct UnitedHealthcare enrollees to this site.

Ensure enrollees ready access to care with culturally competent providers

In 2018, we recognized Dr. Samuel Brown — a pediatrician in Kenner — with an
award for cultural diversity. Dr. Brown serves a significant Spanish-speaking
population and reinvested incentive dollars earned through his VBP contract to hire
Spanish-speaking office staff. His dedication to delivering effective, culturally competent care for
his patients exemplifies UnitedHealthcare’s commitment to supporting and incenting providers
dedicated to delivering the Triple Aim for Louisiana Medicaid enrollees.
2.10.8.6 Details regarding planned protocol for terminating network providers for no cause, including how to…
Our first priority is to offer the best possible provider network, ensuring ready access to high-
quality care aligned with LDH’s goals. Our network strategy focuses on recruitment, retention,
monitoring and provider support. From time to time, we have to make decisions that may
include terminating a provider for no cause. Our policy for provider termination for no cause
complies with sections 2.9.8.3.6 through 2.9.8.3.10 of LDH’s Model Contract, including:
 Timing of Termination for No Cause: Per Model Contract section 2.9.8.3.6,
UnitedHealthcare will coordinate to ensure terminations for no cause coincide with
annual open enrollment. On the rare occasion it would occur outside of open enrollment,
we will comply with 2.9.8.3.6.1 through 2.9.8.3.6.4.
 Provider Notification of Termination: In compliance with the LDH requirements, we
send provider notice of termination via mail within 1 day and via email within 15 days of
the decision. Notification includes the reason for termination, effective date, provider’s
right to appeal and instructions for requesting an appeal. Appeal rights are consistent
with federal and state regulatory requirements and NCQA standards.
 LDH Notification of Termination: Communication is critical in ensuring a seamless
transition for impacted enrollees. UnitedHealthcare will notify LDH, its provider
management contractor and other appropriate parties of terminations per Model
Contract requirements 2.9.8.3.5, 2.9.8.3.6, 2.9.8.3.8 and 2.9.8.3.10. Per Model contract
section 2.9.8.3.7, we will seek LDH approval if the terminated provider is located in a
Health Professional Shortage Area.

Ensuring Uninterrupted Enrollee Care

Above all, UnitedHealthcare is committed to ensuring Louisiana Medicaid enrollees receive
uninterrupted access to high-quality care, regardless of the natural ebbs and flows of provider
contracts. We will sustain continuity of care and minimize the impact of the transition:
 In accordance with Model Contract Section 2.9.8.3.9, when a provider is terminated from
the network, we notify affected enrollees in writing within 15 calendar days of provider
notification and no less than 60 calendar days before the termination effective date.
 We employ our Provider Recommendation Engine (PRE) auto-assignment process to
help locate available PCPs/providers for enrollees affected by a provider termination.
The system tailors selection to the enrollee’s needs, including provider specialty,
enrollee sexual orientation or gender identity, enrollee age and gender, and whether the
provider has open panels and meets specified distance requirements.

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 For all other medical provider types, our Network Strategy and Provider Relations
Teams assess available providers and assign the enrollee to the right qualified,
contracted provider, taking into account criteria including time and distance, cultural and
disability needs, and provider specialty.
 We notify enrollees of their medical provider assignment and, for both behavioral health
and medical providers, advise them to call the enrollee services center should they wish
to make another choice. We make sure enrollee services staff are aware of any large
group termination and are available to assist enrollees in selecting a different provider.
 Member service advocates also assist enrollees with selecting a new PCP, using PRE
and other resources, and they will help schedule an appointment with the new provider.
For enrollees who need assistance through the transition of care, an assigned care manager
helps coordinate the plan of care with the new provider, the enrollee and any other identified
care team enrollees and completes the transition. In the case of medical provider termination
affecting enrollees in an ongoing course of treatment or with a special condition, we allow the
enrollee to remain with their current provider for an additional 90 calendar days to facilitate
continuity of care.

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2.10.9 Provider Support

2.10.9.1 The Proposer should offer support to providers in a number of ways under the Contract to ensure that…
Our providers are our essential partners in improving health outcomes of our enrollees. In fact,
we believe well-served providers are the fourth component of the State’s Triple Aim because the
provider experience is critical to improving the lives of enrollees and optimizing value for the
State. Our provider support approach is founded on the voice of our providers and driven by
innovation creating an industry-leading model. We understand LDH’s vision and agree to
comply with all requirements in Section 2.10.9 of the Model Contract.

Delivering Value-Added Supports to Providers

UnitedHealthcare will deliver value-added supports to our providers to expand
access to care and reduce provider administrative burdens and costs.

We have clearly defined strategies to work with providers to collect their feedback and adjust
processes to ease their administrative burden. We also use data to proactively identify issues
and continuously improve processes. Using data and advanced analytics, we identify emerging
trends and proactively outreach to providers to mitigate possible concerns. We also educate
providers on the benefit of self-service tools and connectivity by moving providers from call-
based inquiries/submissions to online or digital transactions.
Based upon feedback from providers, we know easy access to data allows them to improve
their effectiveness and we know that leveraging known technology and resources reduces the
burden of interacting with us. Knowing this, we expect to enhance Health Information Exchange
(HIE) technology to allow connected providers and hospitals to share patient information and
pull reports designed to help improve patient encounters and clinical outcomes. In addition to
decreased manual work, exchanging clinical data can help close preventive care opportunities,
support achievement of value-based quality of care metrics and support care coordination. To
support the state’s priorities, provider advocates (advocates) deliver education regarding
opportunities to reduce the cost of processing claims, decrease prior authorization turn-around-
times and other savings opportunities.

Processes to Effectively Manage Provider Relations/Communications

We know that supporting providers takes a multilevel approach designed to meet the needs and
preferences of each provider. Our knowledge of Louisiana and our experience listening to
providers helps us to understand their pain points and support opportunities. We know that
there is variation in practice sophistication, patient characteristics, and technology infrastructure
and availability for each provider. This understanding has resulted in the development of our
provider engagement model designed to offer providers 360° service and support.
Provider 360° Service & Support: Our provider engagement model uses effective
communication and collaboration with providers to improve and support the best care to our
enrollees. By putting the provider experience at the center of our process, along with provider
preferences related to electronic, face-to-face, phone support — we can address issues of
importance to providers while leveraging resources and technology that improve their
experience. For example, we have configured our MIS to operate in the same manner as LDH’s
system, helping to create an efficient, effective technology support that improves the provider
experience. As show in the graphic, our Provider 360° Service and Support model includes:
Contracting Support: Our relationship with new providers begins with the provider contracting
and credentialing onboarding process, which leads to a successful introduction to UnitedHealth
Networks. We hold town hall meetings to welcome our providers, introduce our supporting

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programs and tools, solicit ideas, and to

provide a forum for any questions or
concerns they may have. In addition,
we begin education on the integrated
care model, the level of support a new
provider can expect from us; and what it
means to be a participating provider in
our networks.
Provider Advocate Support: By
providing outreach and training for
those providers reluctant or unable
(e.g., lack of internet) to embrace Link,
our secure provider portal, advocates Figure 17. UnitedHealthcare’s Provider 360° Service and Support model
play a critical role in increasing provider wraps around the provider to support their practice needs and maximize
enrollee health outcomes.
adoption of Link enhanced claims
payment and prior authorization. Our advocates take a hands-on approach to provider
education and issue identification. Through data analytics and targeted training, our advocates
encourage providers to use technology to minimize unnecessary manual work and decrease
provider costs associated with practice management activities.
Quality Management Support: In addition to receiving a value-based care incentive
opportunity, we support providers with a clinical model that combines consulting, data and
technology. This support helps drive the activities that will improve quality, reduce avoidable
health care cost and subsequently trigger incentive payments within the shared saving payment
model. Our provider-facing clinical staff shares performance data with providers through on-site
visits and virtual support. They review performance on quality and incentive measure, gaps in
care, utilization of services and suggest ways to improve their practice results.
Practice Transformation Support: The flexibility of our model allows us to meaningfully
engage providers, informed by a provider’s experience, resources and sophistication. We have
used our Accountable Care Organization (ACO) program in Louisiana since 2013 and since
then we have developed the flexibility to use “Non Traditional” ACO engagement models
(<1,000 provider panel) with providers to design reimbursement structures that drive value for
the provider. This value-based transformation model accommodates varying levels of,
preparedness and willingness to enter into alternative payment arrangements. The supports we
offer providers not participating in value-based payment (VBP) arrangements improve program
performance and create a framework that facilitates their shift to VBP, supporting the State’s
broader goals.
Local Plan Leadership Support: Our plan leadership has relationships with providers
throughout Louisiana. Engagement with providers occurs through attendance at Provider
Expositions, Town Halls, or through our Joint Operating Committee (JOC), our Provider
Advisory Committee (PAC) and for escalated issues as requested or needed.
Provider Services Call Center Support: Our Provider Services Call Center is available 24
hours a day, 7 days a week for medical and behavioral health support, prior authorization
service support, claims inquiries or concerns and clinical and pharmacy support. On March 15,
2019, our provider phone representatives (PPRs) expanded their support to locate specialists
for PCPs, confirm appointment times and provide specialist contact information and availability.
Clinical Support: Our provider-facing clinical staff, review performance on quality and incentive
measures, gaps in care, utilization of services and recommendations to improve practice

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results. Our clinical model combines consulting, data and technology in alignment with improved
health and a provider shared saving payment model.
Our provider engagement model is aligned to provide information when providers need it, using
a method they prefer to support their needs proactively. We ask providers for their feedback
after every encounter (e.g., calls, visits and webinars) and use this information to support
continuous program improvement and system efficiencies.

Timely Provider Payment and Support

We promote financial stability for our providers by offering
claims and payment processes that are efficient, timely and In the first 3 months of 2019,
convenient through Link, our secure provider portal, or UnitedHealthcare paid
through the provider’s choice of clearinghouse. Our 4,853,297 claims.
methods are flexible and effective including face-to-face  99.84% of those claims
claims support and weekly reviews of high volume claim were paid within 15
denials through our Claims Provider Early Warning System business days
(CP-EWS) tool to proactively analyze and identify trends.  99.99% of those claims
Our encounters rate of 97.85% exceeds current contract were paid within 30
requirements and positions us to achieve the new contract business days
requirements of 99%. Our claims support includes:
Pre-adjudicating Claims: Smart Edits are a pre-adjudicated claims editing capability we use to
auto-detect claims with potential errors. Part of our electronic data exchange (EDI) workflow,
Smart Edits delivers provider feedback within 24 hours of a claim submission. Using Link,
providers can correct errors, reducing the complexity and provider concerns resulting from
claims denials.
Link Computer Labs: Our Mobile Link computer labs allow our advocates to bring real-time on-
site training opportunities to a facility or physician group. These interactive sessions introduce
the provider to Link, its purpose, resources and functions. The sessions result in increased
adoption to Link and the self-service model/tools. Since introducing in Q4 2018, we have
introduced Mobile Link to Franciscan Missionaries of Our Lady Health System and St. Francis
Health system with additional venues planned through 2019.

Implemented Activities and Approaches to Support Providers

We invest in people, processes and information sharing tools to serve providers quickly and
efficiently. We add value to providers by bringing innovative solutions, meaningful data and
information to reduce their administrative burdens, minimize complaints and to anticipate and
address provider concerns proactively, using a systematic approach to resolution.
Minimizing Provider Complaints
We educate, train, communicate and build upon our relationships with Louisiana providers to
promote understanding, minimize complaints and continually evaluate areas of our processes that
create unnecessary administrative burdens for them. For example:
PRISM: Through our Provider Relationship, Insight and Service Model (PRISM), we quickly resolve escalated
issues for providers. PRISM is a single‐point tracking and monitoring tool for our provider services staff.
PRISM provides visibility into complex provider issues, enabling rapid response and resolution. As a single‐
point intake, PRISM streamlines and integrates information from claims, enrollment, clinical episodes of care
and utilization history, and provides an all‐inclusive picture of provider concerns, root cause analysis and
resolution.
Geographically Assigned Advocates: Our Provider Relations Team, consisting of advocates assigned by
region/parish and provider type, takes a hands‐on approach to identify issues early. We communicate

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Minimizing Provider Complaints

proactively and foster strong, positive relationships with providers. We have implemented a number of
proactive monitoring initiatives (e.g., CP‐EWS, claims payment timelines and utilization management
notifications of denials) to determine issues/trends proactively. We recognize that it is essential for us to
have a strong process in place to address provider complaints and disputes quickly and efficiently.
Complaint/Dispute Tracking: We maintain a process and a system for receiving, tracking and resolving all
provider complaints and disputes. Our Provider Services Call Center is typically the “first contact” for intake,
resolution and tracking of both in‐ and out‐of‐network provider complaints. We staff and train our PPRs to
resolve issues on eligibility, prior authorization, and claim inquiries and other provider concerns. Provider
Services Call Center staff is available 24 hours a day, 7 days a week. Please refer to Question 2.10.9.1.4 for
additional detail.
Provider Satisfaction Survey Feedback: Through our commitment to continuous improvement, we ask
providers for their feedback after every encounter (e.g., advocate visits, town halls, post‐PPR call) and use this
information to improve the provider experience. Please refer to Question 2.10.9.3.5 for further detail on the
critical provider metrics and provider surveys used to measure provider satisfaction.

Minimizing Contracting Issues
We use internal and external resources to minimize provider burden with the application process,
source verification and contract completion activities. We use the Council for Affordable Quality
Healthcare’s ProView, which is available to providers at no charge and streamlines the provider data
collection administrative process for credentialing. This process reduces overall credentialing
turnaround time, which eliminates duplication of application efforts among providers.
Contracting Accuracy: Our contract analysts use our PREDICT tool to perform quality checks on contracts
prior to uploading contract details into our provider data systems. We implemented PREDICT in early 2017
to identify errors during provider contract data entry. We audit our provider contracts for accuracy through
multiple processes, such as end‐to‐end review of claims to the contract, random sample audits and provider
roster comparison to contract setup.
Timely Credentialing: We confirm PCP contracts are loaded accurately and timely into our system. We meet
or exceed LDH’s timely credentialing requirements and load at least 90% of executed provider contracts into
our system within 30 days of Credentialing Committee approval. Advocates closely monitor the contracting
process to quickly resolve issues that may arise.

Minimizing Prior Authorization Concerns
The Prior Authorization and Notification app is available on Link for providers to review
requirements, submit requests, upload medical notes, check status and update cases for providers
preferring self‐service. When we identify providers who need assistance or have difficulties
submitting requests for prior authorization, we engage them in a variety of ways:
Link Adoption and Training: Our secure provider portal, Link, helps reduce the provider’s administrative
burden when requesting service authorizations. Available to providers and facilities 24 hours a day, 7 days a
week, it helps the provider submit all information required for a medical necessity review, provides access to
our guidelines and review criteria and allows the provider to track the status of prior authorization requests.
Provider Services Call Center Support: We combined our prior authorization intake and provider services to
decrease administrative burden on our providers. Our PPRs can help providers determine what services
require authorization and assist them with submitting an authorization request. This reduces provider
burden by decreasing the number of calls needed and reduces the amount of paper forms required.
One‐on‐one Training: Staff educates providers about our prior authorization process and guidelines and
criteria, during initial provider training and whenever UM protocols or criteria/guidelines change through
our Care Provider Manual, on our secure Link provider portal, and in our newsletter, Practice Matters.

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Minimizing Claims Concerns

As mentioned earlier in this response, prompt and accurate claims payment is a key concern among
providers. In 2017, we significantly reduced the amount of claims rework and provider claims
complaints with our CP‐EWS team process. CP‐EWS enables us to catch spikes in claims denial
patterns and assist providers immediately if denials reveal the provider needs additional claim filing
education.
2.10.9.1.1 Its process to determine adequate provider relations staffing coverage for the provider network;
We offer dedicated provider facing teams for each state. Each
team knows what makes the provider unique and uses that
knowledge to service specific provider needs. Staff members
are trained to apply available resources to aid in all servicing
needs. We determine provider type (e.g., hospital versus health
system), complexity (e.g., FQHC/RHC), total medical spend
and geography by parish when establishing service territories
and staffing.
We determined our initial staffing coverage on our national
provider relations staffing model based upon our 44 years of
Medicaid and Medicare provider relations staffing experience
and have continued to evaluate and enhance based upon the specific needs of Louisiana
providers. Because of our PAC and JOC meetings, and in-person interactions with providers,
we have fine-tuned this model for Louisiana provider support.
Our local Louisiana field-based provider relations team includes full-time staff — for both
medical and behavioral health — with clearly defined systems for determining staffing coverage
for the provider network. These activities result in an improved distribution of provider support
by aligning our advocates to the top providers. Our advocates make contact with new providers
a minimum of two times to provide education and support. We continue to monitor provider
relations caseloads, provider outreach, workload and performance metrics through our workflow
management software tool. Metrics and reporting provide immediate accountability, allowing
rapid staff adjustments to meet appropriate staffing and changing provider needs.
We continue to support providers in their use of email and currently have full-time advocates
who monitor the provider relations mailbox. Providers may submit a question, request an
outreach or contact their provider advocate via email. We respond to email within 2 business
days. Please refer to our response to Question 2.10.9.3.1 for additional provider relations
staffing information.
2.10.9.1.2 Strategies to provide effective and timely communications with providers, including the development…
Our Provider 360° Service and Support model recognizes that effective communication and
collaboration with our providers improves the provider experience, and supports the best care to
our enrollees. We also understand that communication is not a “one size fits all” effort and we
customize our approach to fit the needs of each provider. Our strategy is to use a broad
continuum of approaches for education, communication, rapid response — we return calls
within 24 hours — to provider questions, service and support to reduce administrative burden
and build a positive experience for providers.

Provider Education Strategies

Our Provider Relations Team conveys information about LDH requirements, provides guidance
regarding the tools available to providers to effectively meet these requirements and shares
information better enabling providers to conduct business with UnitedHealthcare. We use

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accessible, in-depth provider education to create seamless onboarding of new providers and
ongoing education on new contract requirements. Newly contracted providers receive provider
education using a combination of proven training techniques, including new provider
onboarding/orientation webinars, site visits, town hall sessions, webinar presentations,
educational mailings and telephone outreach. We engage new providers and communicate
effectively with existing providers by:
Offering Provider Training Options: Our training is specific, comprehensive and multimodal. It
combines electronic, face-to-face, written and web-based methods. For example, we have
distributed educational toolkits that are subject-specific for providers to peruse in their own time.
These include toolkits for diabetes care, OB kits related to health disparities initiatives and
telehealth toolkits supporting behavioral health Virtual Visits.
Using Proven Training Techniques: The techniques we use align with industry-standard best
practices, including on-site visits, town hall sessions, expos, webinar presentations, UHC On
Air, educational mailings and telephone outreach.
Responding to Provider Requests: We are attuned to provider requests around improvement
opportunities along with feedback from staff and professional associations. Through these
mechanisms, we identify broad-based communication and training opportunities.

Provider Education Program

Our approach includes high-touch provider interactions via telephone, face-to-face, through
provider town hall meetings or through virtual contact via WebEx. It is through our provider
education program that we provide training on doing business with UnitedHealthcare and share
Louisiana Medicaid managed care program requirements. The following outlines the variety of
methods our Provider Relations Team uses to engage providers in timely and effective
communication:
Onboarding: Our relationship with new providers begins with the provider contracting and
credentialing process, which leads to a successful introduction to the UnitedHealth Network.
Initial Provider Training (Orientation Program): We have a well-developed provider
orientation program that includes procedures for doing business with UnitedHealthcare and a
provider introduction to the educational materials, mailings, online seminars, and on-site
provider visits and group trainings. Our initial provider training covers a number of subjects such
as accessing our online, self-service tools, prior authorizations, policies and protocols, claim
reconsiderations and more. We encourage every new provider to complete UnitedHealthcare
orientation within 30 days of the provider’s contract effective date. Provider orientation is
intended for providers newly contracted to UnitedHealthcare; providers new to a group;
providers that have had a product added to their existing contract; and a practice that has had a
line of business added (e.g., Medicaid, Medicare).
Continuing Provider Education: After initial training, local provider relations staff remains in
frequent communication with our Louisiana contracted providers via phone calls, emails, blast
faxes, town halls and in person visits. Proactively, provider-facing teams visit providers
monthly/quarterly to assist with addressing key provider concerns and obtaining VBP incentives
and gap closures. We communicate information to our providers via our quarterly provider
newsletters developed specifically for our Louisiana providers, to update them on program
changes, answer questions and provide applicable documents released by LDH.
Program Enhancement and Targeted Training: Critical components of any successful
provider engagement model are receptivity to feedback, our own analysis of trends and iterative

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improvement. Through staff feedback, trended claims data, associations and advisory councils,
we identify training opportunities and specific providers for focused retraining. We send mailings
to all providers on relevant training topics and update our training curriculum with the goal of
further improving communication and information, especially on common issues such as
changes in policies and procedures, billing and eligibility verification.
A description of our approach and training frequency for Louisiana providers includes:
Louisiana Provider Training Program
Description of Educational Approach Frequency
Onboarding/Orientation: Newly contracted providers. We provide a full Within 30 days of
UnitedHealthcare overview for Medicaid, Medicare and Commercial contract effective date
businesses.
On‐Site Visits: Frequent engagement to foster relationships, maximize Quarterly, monthly or
performance, issue resolution, promote innovative tools/programs to support as needed by request
administrative and clinical efficiencies.
Teleconference: Topical in nature, associated with an outreach initiative or Monthly and
structured meeting. Providers receive monthly telephonic structured meeting. as needed/by request
Revenue Cycle Service and Education Centers: Mobile revenue cycle service Ongoing education
centers allow providers the convenience of real‐time investigation to root opportunity by request
cause for revenue cycle concerns (e.g., claims, trends) or data integrity. of provider/advocate
Link portal and UHCprovider.com Training Labs: Mobile Link computer labs By location based upon
allow providers to quickly adopt ease of use with Link training. Please refer to Link adoption rates,
Question 2.10.9.1 for additional information. proactive scheduling
Town Halls: Multi‐practice forum designed to educate on multiple or targeted Monthly and ad hoc
topics at various locations throughout the state.
Webinars: Multi‐practice forum designed to educate on multiple topics. Can Monthly and ad hoc
focus on specific agenda items (e.g., new protocol deployment, reference tools,
online on‐demand training modules.) We offer 30+ CEU credit classes.
UHC On Air: Similar to “YouTube” making it accessible and relevant in today’s Available on demand
constantly changing health care environment. Providers can contact us during 24 hours a day, 7 days a
or after UHC On Air trainings, making this an interactive exchange. week
Provider Expositions: Educational event assembling multiple At minimum two times
UnitedHealthcare business units, subcontractors and external partners in one per state per year
venue to educate them on business policies and other useful information.
Operational Meetings/JOCs: Operations meetings focus on operational Operations – Monthly
performance and improvement strategies that ease administrative burdens. JOCs – Quarterly

Our service strategy is comprehensive and all-inclusive. Staff members across functional
departments, such as health services, quality management, provider relations, network
management, community outreach and behavioral health use a high-touch approach to build
and support provider relationships, provide accessibility to key provider information, proactively
address common provider inquiries and increase awareness of programs and services.

Evaluating Education Effectiveness

To make sure our trainings are as effective as possible, we capture real-time feedback on our
training—regardless of the type of training. This feedback loop includes evaluation forms for all
in person training. Videos and training viewed include a post-presentation evaluation, and we
survey participants at the end of every large group presentation and use that feedback to
develop new and better content for future trainings of special interest to providers.

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2.10.9.1.3 The processes that the Proposer will put in place to support providers with high claims denial rates; and
UnitedHealthcare has a dedicated Claims Team to monitor the adjudication and daily claims
processing including monitoring high claims denial trends. The team monitors claim spikes and
trends on a daily basis using a series of algorithms to identify extreme spikes in specific types of
denials. When we identify a trend for a particular provider or provider group, further research is
conducted by determining if the root cause is systemic or if it is a provider billing error. We then
mobilize the Provider Relations Team and contact the provider to discuss the root cause,
provide education on correcting the issue and offer additional resource tools. The team uses a
number of resources to educate providers on successfully submitting claims and to keep them
informed about denial trends. Finally, our CP-EWS is part of the mobilization of provider
outreach offered to providers along with on-site coaching. Other tools and processes include:
Pre-adjudicating Claims: We use Smart Edits, a pre-adjudicated claims editing capability, to
auto-detect claims with potential errors. Using Smart Edits, we can deliver feedback to a
provider within 24 hours of a claim submission so they can proactively correct the error (through
Link, our provider portal) and submit accurate, complete claims.
Provider Communications: We use webinars, town halls, newsletters and information in the
Care Provider Manual and monthly Provider Network Bulletins to educate and build awareness
on claims denials. Advocates also use the Field Aligned Support Team (FAST) as another touch
point for educating providers quickly. The FAST team advocates analyze systemic and provider-
specific alerts regarding claims processing to provide valuable information to providers.
Provider Group Claim Support: To support timely
payment and comply with Act 710, we hold weekly “The Ochsner Managed Care
meetings and review the top five providers in all Department would like to express our
specialties with 10% or higher claim denials. By appreciation to our UnitedHealthcare
analyzing the claims denial reasons, we can Provider Advocates Rhonda Pena,
determine the necessary provider support through Tiffany Bourgeois and Candy Williard
education or a face-to-face outreach. for the exceptional customer service
and support they provide to our team.
Support by Type of Claim and Claim Alert: We Rhonda, Tiffany and Candy are always
hold weekly meetings to review denied claims by professional and a pleasure to work
denial reason and type of claim. Our CP-EWS tool with. They have been instrumental
alerts us proactively to denial anomalies and high in facilitating resolution to our
systemic issues. We value the
denial rates, which we review in our operational
relationship and look forward to
claims meeting with action planning designed to continuing our partnership.”
mitigate issues and support providers.
‒Jeff Mitchener, AVP of Payor Relations,
On-site Claims Event Model: If either the plan or Managed Care, Ochsner Health System
the CP-EWS team identifies a significant outlier or
high percent of denied claims, we visit the provider to review all claims and remediate to support
timely payment. We also conduct a daily audit of OB/GYN claims to investigate high denial rate
trends and to remediate as necessary to support the provider.
2.10.9.1.4 The processes that the Proposer will put in place for evaluating and resolving provider disputes in a…
We have a tiered process in place for investigating and resolving provider disputes in a timely
manner. This includes disputes related to the automatic assignment policy and individual
enrollee assignment. Providers can file a complaint or dispute by phone, in writing or in person
(with any UnitedHealthcare representative). Our provider dispute resolution process is a four
level process to quick resolution. These levels include: 1) Provider Services Call Center
resolution, 2) PPR escalation, 3) first level claims dispute, and, 4) second level appeal.

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We prefer to resolve provider complaints and disputes through the Provider Services Call
Center, which is open 24 hours a day, 7 days a week. Providers can share their concerns with a
well-trained PPR who is able to resolve their dispute during the call. In the event the complaint
cannot be resolved, the PPR will escalate the complaint and our escalation tracking software,
which maintains, records and stores all provider dispute, grievance and appeals activity. It
provides us with significant flexibility to provide reporting based upon multiple data elements,
filters and sorting options. The PPR’s escalation is designed to route the dispute to the
appropriate specialist who will review and resolve the dispute within 30 calendar days. If the
dispute is claims related, it will become a first level claims dispute. If the dispute is not resolved
within 30 days (or to the provider’s satisfaction), the provider may request a second-level
appeal. This is a formal written or verbal path to resolve the concern within 30 days of receipt.
Auto-assignment Disputes: One of the types of complaints we receive are the result of auto
assignment issues. Despite the reduction in these requests, if a provider calls to have an auto
assigned enrollee moved due to geography, or family or the enrollee having a relationship with a
different PCP, the PPR can move the enrollee effective next business day. If a provider wants
enrollee moved for any other reason, we would advise the provider to put the request in writing
(e.g., by mail). A provider specialist will review the request for removal or transfer considering
both the provider and the enrollee’s rights. If LDH approves the enrollee’s removal/transfer, we
call the enrollee to explain why the assistance was provided to select a new PCP. If the
enrollee’s removal/transfer is not approved, the provider advocate calls the PCP with an
explanation. This may require that our Provider Relations Team contact a provider related to
what it means to participate in the LA Medicaid program. However, the PCP is expected to
continue to provide care to the enrollee.
2.10.9.2 The Proposer should describe how it will support the provider to improve quality and reduce costs…
Since 2012, UnitedHealthcare has continued to evolve our approach to VBP for Louisiana’s
Medicaid Managed Care providers in support of the Triple Aim — better care and improved
health for enrollees, and lower costs. We recognize that true health care reform is multifaceted,
and that strong, trusting payer/provider/community relationships are foundational for success.
We realize a one-size-fits-all approach is ineffective — our modular suite of VBP models
enables us to customize our approach with an operational infrastructure that supports providers
based upon their readiness.
We continue to tailor our VBP programs for Louisiana providers, moving toward higher risk
models that focus on LDH priorities to support innovation.

2.10.9.2.1 Strategies to support primary care providers, including but not limited to investments in primary care…
Our goal is to incent both the provider and the enrollee on the same measures when possible.
This alignment creates synergy — with both parties working toward the same goal based upon
services given and received.
Infrastructure Investment: To support both LDH’s Quality Strategy (Attachment G) and
delivery system reform, we continue to build a foundation of relationships and infrastructure with
providers to increase our solutions’ effectiveness. Our innovative partnership with LCMC Health
University Medical Center (New Orleans) and Our Lady of the Lake Regional Medical Center
(Baton Rouge) provides both financial (e.g., value-based incentives) and programmatic support

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(e.g., risk stratification, claims, assessment results) in the form of aligned financial incentives,
shared data and enhanced coordinated clinical programs.
Described in Question 2.10.9.2
Practice Coaching and Scorecards: Our provider-facing clinical staff, review performance on
quality and incentive measure, gaps in care, utilization of services and suggest ways to improve
their practice results. Our provider-facing staff meets with our provider groups — face to face —
on a weekly/monthly/quarterly basis. The team reviews operational interventions, which allows
for improved utilization and gap closures (suggestions on timing of scheduling appointments to
accomplish gap closures, follow up for ED visits). We provide each participating practice with
scorecards showing trending in rates relative to baselines and targets for clinical quality
measures, utilization metrics and total cost of care, depending upon contracted parameters.
During the current contract compliance to have common MCO scorecards and reports, LDH
selected UnitedHealthcare reports as the model format among MCOs.
2.10.9.2.2 Strategies to support behavioral health and other specialty providers to participate in delivery system…
Our modular suite of VBP models enables us to customize our approach with providers based
upon their readiness along the care continuum. We actively support and collaborate with
providers through data, analytics and consulting to enable their success under the contract. If
we see that a provider is not achieving their targeted improvement metrics, we work with them
to modify our support process and to identify alternative solutions to address their challenges.
VBP Type Description
Maternity VBP Adds incentives for obstetrical and maternal fetal medicine providers to help them
Bundle achieve better enrollee health outcomes in pregnancy care and to prevent preterm births.
The bundle includes the 17P (Progesterone) incentive for OB and the Notification of
Pregnancy (NOP) incentive program.
Behavioral Initiative designed to decrease multiple inpatient admissions and ED utilization and meet
Health VBP or exceed the target threshold of 54.13%. This program uses the HEDIS Follow Up After
Program Hospitalization (FUH) measure to incentivize providers to identify hospitalized enrollees
and confirm they receive appropriate care after discharge. The program also encourages
behavioral health providers and PCPs to collaborate on discharge follow up. PCPs and
behavioral health providers receive credit for closing the same gap in care.
Opioid VBP Includes a measure to identify and refer enrollees who may require medication‐assisted
Pilot therapy (MAT). Given the high overdose death rate in the Orleans and Jefferson Parishes,
we initiated a partnership with Daughters of Charity to launch our OUD Quality MAT pilot
(Q1 2019.) The OUD Quality MAT VBP includes a substantial monthly care management
payment, in addition to targeted incentives for monthly MAT refills and a bonus for
enrollees retained in treatment every 6 months.
2.10.9.2.3 Strategies to share provider performance data with providers in a timely, actionable manner.
When provider-facing clinical staff makes on-site visits to providers, they share performance
data on quality and incentive measure, gaps in care, utilization of services and suggest ways to
improve their practice results. Each participating practice receives practice scorecards showing
trends relative to baselines and targets for clinical quality measures, utilization metrics and total
cost of care, depending upon contracted parameters. We also educate providers on data
available to them in our provider portal, Link, such as on-demand reporting on VBP measures
(e.g., HEDIS) and comprehensive EPSDT services. Providers can also receive gap in care
alerts through our CommunityCare platform, enrollee-level detail through our ClaimSphere
HEDIS program and joint clinical action plans for more advanced TCoC models. Our Shared
Savings providers can use the Integrated Patient Care Application (iPCA) online tool to collect a

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360-degree view of enrollee care history of real-time clinical and administrative data and the
ability to track enrollee cohorts for interventional care.
2.10.9.3 The Proposer should describe in detail its provider engagement model. Specifically, the Proposer should…
Through our engagement model, effective communication and collaboration with our providers
not only improves the provider experience but is also the key to assuring the best care to our
enrollees. Since program inception, we have continued to assess new strategy and deploy new
methods to meet the needs of our providers. Using provider feedback, we identified key account
providers where additional focus is required due to the complexity or size of the health system
or FQHC. We developed service territories to promote 100% accountability to each provider
across all 64 Louisiana parishes. Our new onboarding process, UHC On Air, and our secure
provider portal, Link, are all innovations introduced in Louisiana to enhance provider
engagement, improve communication and support the self-service needs of providers.
Our provider 360 service and support model facilitates issue resolution and dissemination of
Louisiana health plan information. We engage care providers as our trusted partners through a
strong service orientation and quality-based performance incentives. We support and reward
providers committed to caring for complex populations, transforming care delivery and engaging
in performance-based programs and reimbursement.
Provider Engagement Staff (2.10.9.3.1): To support and engage providers, we have a local
team of provider relations specialists in medical and behavioral health that facilitate timely follow
up and adequate support in compliance with Medicaid program requirements. Provider
engagement staffs have daily oversight of provider outreach and education program
development through our staff of advocates and provider-facing field-based staff. The majority
of these individuals are locally based with statewide responsibilities.
Local Provider Field Representatives (2.10.9.3.2): Our advocates handle all lines of business
in their daily outreach activities. They are assigned geographically by region/parish, and take a
hands-on approach to the identification of issues early, communicate proactively and foster
strong, positive relationships with providers. Additionally, we support providers through our
provider-facing staffs with clinical and operational skillsets. They are local, field-based “feet on
the street” experts who specialize in clinical, quality and transformation. All provider-facing staff
are responsible for addressing provider issues and working toward solutions.
2.10.9.3.3 The mechanism to track interactions with providers (electronic, physical and telephonic);
As described in our response to Question 2.10.9.1.2, we log and track the status of provider
services center calls, visits and other outreach using our workflow management software tool.
All provider-facing and management staff have access, providing timely accountability. Senior
field-based provider support staff use a workflow tool to track meetings and document their
provider interactions including provider-facing events such as town halls, expos, on-site visits
and webinars. We maintain regular meeting minutes from our Provider Advisory Committee
(PAC) that are approved and reported to the Quality Management Committee (QMC). These
minutes become a component of the quality improvement committee’s regular report to LDH.
Other provider interactions that we track include questions and requests to the Provider
Relations Mailbox and calls to the Provider Services Call Center. Calls are recorded and
tracked, including the use of a call reference number that is supplied to the provider after the
call for prompt reference and follow up.

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2.10.9.3.4 How the Proposer collects and analyzes utilization data and provider feedback, including complaints…
We collect and analyze HEDIS and gaps in care reporting (monthly) and provider satisfaction
and CAHPS data (annually), along with feedback from our comprehensive provider education
program. Our local quality staff collects HEDIS utilization data while a third-party vendor collects
provider satisfaction data. Our Quality Management (QM) Team reviews and analyzes the root
cause of member/provider complaints, identifies barriers, creates interventions and studies
concerns identified through feedback and surveys. To close the loop on the quality of the
interactions with members and providers, our Service Quality Improvement Subcommittee
(SQIS) reviews results at least annually to develop an action plan to improve overall scores.
Our quality management program has oversight and responsibility for provider training initiatives
based upon the results of provider feedback from trainings, surveys and complaints. We take
the feedback verbatim and contact those providers that commented and make direct outreach to
help resolve their issues and concerns. We use that feedback to develop a year-over-year plan
to improve in those specific areas of concern. If we see a trend of low scores in customer
service or contracting, we acknowledge that we have a deficiency then create a plan as an
organization, address concerns, remove barriers, work to notify providers that we understand
their concerns and inform the provider of our plans to correct the issue. We review written
feedback from providers through the evaluation surveys we provide post-training or through the
metrics described in the following table.
Type of Data Description/Link to Training Needs
Healthview Analytical tool used to identify concerns by parish, provider or enrollee. Enables
Analytics identification of key geographic areas for critical health outcomes, concerns. In 2018, we
were able to identify areas with the most ED overutilization by Geo and providers at LDH
request during quarterly business review
Pharmacy Prescribing patterns including review of generic versus brand name prescribing
HEDIS Monthly, we review HEDIS rates/utilization metrics monthly to address gaps in care
Utilization concerns and plan interventions such as calls to enrollees to arrange appointments and
Rates transportation or reviewed with our providers to heighten their awareness
Provider Peer Annually, we share utilization rates with providers on select measures such as average
Comparison cost per patient, ED utilization, hospital admissions, length of stay, high opioid prescribing
Reports and medication adherence. Providers can determine outliers to influence provider
utilization patterns using provider communication and outreach
ED utilization Monthly, we monitor utilization rates such as cost‐per‐enrollee, provider inpatient data
rates and ED rates. This is a high‐level review for developing trends in utilization and our
quality outcome measures
VBP Monthly provider reports via in‐person visits from clinical provider‐facing staff. Provides
Scorecards a snapshot of their aggregate rates (e.g., a scorecard) to guide them in achieving minimum
standards, exceeding peers or meeting provider incentive agreements through gaps in
care data and relevant utilization patterns by enrollee
Inpatient Daily, PCPs receive reporting on their patients seen in ED, admitted or discharged from an
Utilization inpatient stay. This enables the provider to be proactive in reaching out to the enrollee to
Rates ensure continuity and transition of care concerns are addressed

We review written feedback from providers through the evaluation surveys we provide after
each training or through the metrics described in the following table (2.10.9.3.5.)
2.10.9.3.5 The metrics used to measure the overall satisfaction of network providers; and
Provider satisfaction and engagement are crucial components of providing care to our enrollees.
Our approach to assessing and addressing provider satisfaction is to use multiple strategies —

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large-scale surveys, provider-training evaluations, post-call and post-outreach provider

feedback — to obtain feedback and employ progressive solutions to address and prevent
concerns. These measurements, along with a deep understanding of the state’s priorities, drive
our specific actions and the way we implement changes to drive continuous quality
improvement. In addition to these metrics, please refer to Question 2.10.9.4 for specific provider
satisfaction results in the past 3 years.
Operational Area Measured Metric
Provider Call Center Call Abandonment Rate (Goal is <5%) Average Time to Answer (Goal is 90%
answered in 30 seconds or less); Hold Time (Goal is 3 minutes or less)
Claims Processing Time to Pay Clean Claims: Business Days, Calendar Days, Combined Calendar Day
Provider Complaints Our Quality Management Leadership Team analyzes provider complaint data,
identifies barriers and develops interventions and education via provider toolkits,
provider communication/education or innovation.
2.10.9.3.6 The approach and frequency of provider training on MCO and Louisiana Medicaid managed care…
We have provided this information in our response to Question 2.10.9.1.2.
2.10.9.4 The Proposer should provide the results of any provider satisfaction survey reflecting its performance in…
We conduct annual large-scale assessments of provider satisfaction as part of our commitment
to continuous quality improvement. Our surveys — which monitor provider satisfaction for
medical/behavioral health providers, vision, behavioral health, dental and other provider types
— include our Annual Provider Survey, LDH State Results Survey, the Behavioral Health
Clinician Satisfaction Survey and the United Experience Survey (after provider services calls).
Survey Description and Provider Satisfaction Results in a 3‐year Period
Survey Name 2016 (%) 2017 (%) 2018 (%)
Annual Provider Satisfaction Survey 65 63 58
Annual Behavioral Health
81 78 93
Clinician Satisfaction Survey
United Experience Survey (UES)
95.5/99.2 97.4/96.8 94.12/99.28
Satisfaction/Quality Service

LDH State Survey Results

We have received the 2018 LDH survey results monitoring provider satisfaction for
enrollment/onboarding/provider manual and printed materials (73%); provider education and
training (59%); claims processing accuracy (73%); specialist access/network coordination of
care (58%); customer service/provider relations relationship (72%); and utilization management
timeliness (59%).

Lessons Learned
We take the results of our provider satisfaction surveys very seriously. Our Quality Management
(QM) Team reviews and analyzes the root cause of provider issues, identifies barriers, creates
interventions and studies outcomes of concerns identified through provider feedback and
surveys. We monitor feedback data on an ongoing basis and respond through new programs,
enhancements or even clinical education via our provider toolkits. In an effort to close the loop
on the quality of the interactions with providers, we present survey results to our Service Quality
Improvement Subcommittee (SQIS), at least annually for review and development of an action
plan to improve overall scores.
Reviewing our 2018 Annual Provider Satisfaction Survey scores, we know this is not where we
want to be. We were encouraged to see satisfaction scores in our annual survey improve in

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several areas such as provider onboarding (from 72% to 82% between 2016 and 2018); and
satisfaction with timeliness of claims processing increased from 70% to 77% from 2016 to 2018.
We know that there are many areas of growth in provider satisfaction during the contract term
because of listening to the feedback of Louisiana providers. For example, after reviewing
provider feedback from 2017, we introduced UHC On Air to provide an improved provider
education and onboarding experience that addresses their need for information at their
convenience; we added the Link Mobile Computing Labs to spur provider adoption of self-
service thereby improving their ability to process timely claims and prior authorizations. Our
original VBP program solicited many provider complaints about not attaining stated incentive
goals. As a result, our new VBP provides incentive money for every gap in care closed and the
feedback from providers has been positive. The following is an in-depth example of our
commitment to the quality of our program in Louisiana and the additional efforts we have
undertaken to put our values into action.

The Weather Report

We consider provider feedback an integral part of our quality
improvement process to lead to the success of LDH’s Medicaid
Managed Care Program. Following the results of our provider
satisfaction survey in 2017, we wanted to understand the results so we
took a deep dive and developed a focused remediation process to
resolve issues with key providers called “The Weather Report.” The
Weather Report was a direct survey that contained nine simple, focused
questions on issues providers may have experienced and how we could
improve. A leading question was how they would rate us on a scale of 1
to 5 based upon “The Weather” (e.g., with Hurricane=1; Sunny=5). The
initial survey score provided an overall score of “Cloudy.” The
remediation efforts included:
 Identify 45 critical providers (physical and behavioral) and scheduled weekly meetings to
obtain feedback to support identification of trends and root causes
 Engage and support of our leadership team
 Create an escalation team to resolve From Hurricane to Partly Cloudy
issues/provide ongoing support for 90 days Communications from the CEO for
LWHA include:
 Meeting with the LDH section chief and the
provider relations manager to share remediation Nov. 6, 2017: “…breakthroughs in
administrative change, the working
results; updated results moved our Weather
relationship is flowing smoothly and
score to “Partly Cloudy” the trust is strong...issues have been
Louisiana Women’s Healthcare (LWHA), provided an coordinated.”
initial Weather Report score of “Hurricane.” As part of “LWH has been at points of impasse
their remediation, we provided an on-site claims with UHC‐LCP...the improvements
specialist and an expanded claims team via WebEx to are such that we now appreciate the
address their issues and provide additional training. The opportunity to work with you and
your team, and look forward to
support continued with a claims supervisor meeting
continued coordination that
weekly with the providers weekly to address any issues. improves the feasibility of LWH’s
We also designated a nurse to work with LWHA to participation in the Healthy
develop new specialist incentives. A post survey Louisiana Plans.”
response from the CEO, confirmed the turnaround
March 26, 2019: “I think the
efforts resulted in a 4-point improvement to “Partly operational turnaround you all have
Cloudy” on The Weather Report. made over the past couple of years
has really held in place.”

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2.10.10 Utilization Management

2.10.10.1 The Proposer should describe how it will satisfy the requirements for authorization of services set forth…
Our utilization management (UM) program accomplishes four core tasks, including identifying
enrollees who may benefit from case management; confirming the appropriateness of care
delivered to enrollees; confirming the effectiveness of our care management programs; and
monitoring and addressing overutilization, underutilization and inappropriate utilization patterns.
Our UM program meets NCQA standards. It features an integrated clinical, UM and quality
management oversight structure and an interdisciplinary set of care management principles,
policies and systematic processes and workflows that verify we are delivering positive outcomes
in terms of member experience, outcomes and quality of life and the quality and cost of care.

Proposed Workflow from Initial Request to Final Disposition

Our service authorization processes meet the requirements in Appendix B, Section 2.12,
Utilization Management, including the timeliness requirements in Appendix B, Section 2.12.9,
Timing of Service Authorization Decisions. They include policies and procedures consistent with
42 CFR §438.210 and state laws and regulations for initial and continuing authorization of
services. The figure presents our workflow from initial request to final disposition.

Figure 18. Prior authorization workflow from initial request to final disposition. Medical directors, nursing staff and other
professional support teams work closely with providers to determine the medical necessity and appropriateness of care, avoid
inappropriate use or duplication of services, and identify enrollees who may need to be engaged in disease management or care
coordination or may need direction to their provider.

Intake. Providers may submit service authorization requests via phone or our secure Link
provider portal. Enrollees and their representatives can request authorization of services by
calling our Advocate4Me member services center. Intake staff compares the request to LDH’s
list of services that require clinical review. Requests that do not require clinical review can be
administratively approved. If the request requires clinical review, the Intake Team builds a case

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file by obtaining enrollee information, provider information, planned services and the network
status of providers and submits the case for clinical review.
Determining medical necessity. Our UM
program is integrated within medical and In Louisiana in FY 2018, we received:
behavioral health fields and our process to  70,795 requests for standard service
determine medical necessity is consistent for authorization. We completed 95.9% of these
all services and programs. While the process requests within 2 days, which exceeds the
is the same, we make UM decisions using 80% requirement
personnel, policies and guidelines specific to  1,775 requests for expedited authorization.
the service requested and the program We completed 100% of the expedited
benefits. A health care professional who has requests within 72‐hour time frames.
appropriate clinical expertise in treating the
enrollee’s condition determines the medical necessity and appropriateness of care. We
determine medical necessity consistent with LDH’s definition of medically necessary, in
compliance with contractually covered services and based upon clinical practice guidelines;
enrollee eligibility; state and federal mandates; enrollee’s certificate of coverage, evidence of
coverage or summary plan description; UnitedHealth Group medical policy; medical technology
assessment information; and CMS National and Local Coverage Decisions.

Proposed Workflow for Expedited Authorizations

Our expedited prior authorization process complies with the requirements in Appendix B,
Section 2.12.9.2, Expedited Service Authorization, including resolving the request within 72
hours of receipt. Once the provider makes a request for expedited prior authorization, we
implement our expedited prior authorization process presented in the figure.

Figure 19. Expedited prior authorization process. A UM clinician determines if the request meets the criteria for expedited review. If
it does not, a medical director reviews the request to determine if it meets the expedited review criteria and promptly inform the
enrollee and process the request within standard time frames. If it does, we process the request within the expedited time frame.

Following the determination, we notify the provider as expeditiously as possible based upon the
enrollee’s health condition, but no later than 72 hours following receipt of the expedited
authorization request. We may provide an extension of up to 14 calendar days if the enrollee or
provider requests it or we justify the need to LDH and the delay is in the enrollee’s best interest.

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2.10.10.2 The Proposer should describe how it will satisfy the requirements for utilization management set forth…
2.10.10.2.1 The proposed criteria to use in its utilization management process and how such criteria will be…
Our evidence-based health care policies, clinical guidelines and review criteria standardize care
management decisions regarding the most appropriate level and site of care needed to treat an
enrollee’s presenting issues, while providing the flexibility to address individual needs. Our
policies, procedures and workflows for clinical coverage decisions are consistent with
Louisiana’s definition of medically necessary services. They promote quality of care and ensure
adherence to standards of care, including clinical appropriateness, closing gaps in care,
promoting recovery principles and promoting relapse/crisis prevention planning. Our guidelines
and criteria comply with the requirements in Appendix B, Section 2.12.1.
Clinical and behavioral guidelines and criteria: We use evidence-based, nationally
recognized MCG for physical health care services and internally developed behavioral health
guidelines and criteria based upon published references from the American Psychological
Association, the American Academy of Child and Adolescent Psychiatry and the most recent
version of the Diagnostic and Statistical Manual of Mental Disorders. We use American Society
of Addiction Medicine criteria for substance use disorders. Our clinical leadership committees
review our behavioral health guidelines at least annually. They include:
 Mental health conditions: 23-hour observation, crisis stabilization and assessment,
day treatment, inpatient, intensive outpatient program, outpatient, partial hospital
program and residential treatment center
 Substance use disorders (SUDs): 23-hour observation, crisis stabilization and
assessment, detoxification (inpatient, outpatient and residential), intensive outpatient
program, opioid treatment program, office-based opioid treatment, outpatient, partial
hospital program and rehabilitation (inpatient and residential)
 Wraparound services: assertive community treatment, care management, peer
services and supports for enrollee and family, psychosocial rehabilitation, respite care,
sober living arrangement, supervised living arrangement and therapeutic foster care
 Other guidelines: telemental health and transcranial magnetic stimulation
Clinical practice guidelines: We have implemented clinical practice guidelines to inform UM
decisions for conditions prevalent in the Medicaid Managed Care Program population, including
the guidelines for the behavioral health conditions described in Appendix B, Section 2.12.1.4.
Our guidelines cover conditions, such as ADHD, autism, diabetes, eating disorders, jaundice in
the newborn, PTSD, sickle cell disease and neonatal service guidelines, such as neonatal
abstinence syndrome.
Coverage determination guidelines: We follow the American Academy of Pediatrics Bright
Futures recommendations in our preventive services coverage determination guidelines. Clinical
coverage decisions are based upon eligibility of the enrollee; state and federal mandates;
enrollee’s certificate of coverage, evidence of coverage or summary plan description;
UnitedHealth Group medical policy; medical technology assessment information; and CMS
National Coverage Decisions and Local Coverage Decisions.

LDH Program Goals: Advancing evidence-based practices and ensuring

enrollees ready access to care
Parent Child Interaction Therapy (PCIT) is an evidence-based, specialized
behavior management identified by LDH as needed to strengthen the network of
available therapeutic services for children, adolescents and their families in Louisiana. We were
the first MCO in the state to offer MCO-sponsored PCIT training and will train 20 Louisiana

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providers on PCIT initial certification and one provider to Level 1 certification. We helped the
LSU Center from Evidence to Practice and MCO Healthy Blue to understand better which
providers are candidates to receive PCIT training and shared information regarding potential
expansion locations in the state. We anticipate the availability of PCIT to expand by 12 more
clinicians statewide by the end of 2019.

How We Apply Our Proposed Criteria

A UM clinician determines if the service request requires prior authorization and, if so,
processes it through our prior authorization process described in our response to Section
2.10.10.1. If a service authorization request requires clinical review and prior authorization, UM
clinicians with the appropriate clinical experience review the request to determine medical
necessity, verify the service request complies with level of care criteria and promotes alignment
with clinical practice guidelines for the appropriateness of treatment (e.g., a request that could
be considered experimental) and the appropriateness of the site of treatment (e.g., an inpatient
request for services that can be delivered in an outpatient setting).
We verify the consistent application of medical
necessity guidelines through annual inter-rater We conducted staff MCG IRR testing in
2018 to establish the consistency of
reliability (IRR) reviews of all licensed UM
training and guideline application among
personnel. IRR reviews compare decisions among clinical reviewers. The results of our
UM staff for uniform cases and then use statistical assessment, for each MCG product,
measures to assess consistency and identify included:
potential sources of inconsistency. Upon completion
 Inpatient and surgical care: 1,684
of the assessment, management reviews the results participants – 99% passed
and reports them to our Quality Management
 Ambulatory care: 1,084 participants –
Committee for corrective actions. The process 98% passed
includes an evaluation of criteria application,  Recovery facility care: 833
guideline navigation, understanding of workplace participants – 100% passed
policies and procedures and knowledge of
regulatory agencies requiring compliance and timeliness guidelines.
2.10.10.2.2 The Proposer’s process for monitoring and addressing high emergency room utilization;
Through our comprehensive UM monitoring program, we use a broad number of mechanisms to
continually evaluate data at the population, parish, enrollee, provider and facility level to analyze
the effectiveness of our care management programs. We compare our performance to
nationally recognized standards (e.g., HEDIS) and evaluate trends, such as increasing use of
the ED or inpatient utilization. Our Clinical Leadership Team uses these analyses to evaluate
the ongoing effectiveness of our clinical programs, monitor utilization patterns and identify
trends and opportunities for operational improvement.
Monitoring unnecessary ED utilization through advanced data analytics and reporting.
Our Health Care Economics Team integrates and analyzes medical, behavioral and pharmacy
claims, social determinants data and lab test results. They use data analytics and reporting tools
to produce a suite of reports, dashboards and scorecards that help our Clinical Leadership
Team monitor utilization. We use a variety of reports to monitor high utilization of the ED:
 Emergency Department Escalation Report identifies hospitals with the propensity to
admit enrollees from their ED to observation or inpatient level of care compared to peer
hospitals across Louisiana. We share this data with hospital partners during Joint
Operating Committee meetings to discuss opportunities to reduce unnecessary care.

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 Medical Experience Tracking Report (METR) helps our leadership team perform
quarterly trend reviews that identifies outliers, trends and changes by broad category of
service to determine areas of concern. The report helps us evaluate areas of concern
through a deeper review of the data at the enrollee, procedure, provider and claim level.
It analyzes how our hospitals perform compared to national and local benchmarks using
metrics, such as admissions/1,000. Our ability to view this data in different cuts allows
for the development of specific plans for performance remediation.
 Provider Peer Comparison Reports. Annually, we share with providers their utilization
rates on select measures; and how they compare with their peers through Provider Peer
Comparison Reports. Provider-facing staff uses this reporting to discuss utilization
patterns with providers. Our Clinical Leadership Team also reviews the reporting to
identify outliers and providers with unusual utilization patterns.
Monitoring unnecessary ED utilization through our HealthView Analytics Clinical
Dashboard. In 2017, we developed our HealthView
Analytics tool, a clinical dashboard for Hotspotting on In a 2018, LDH quarterly business
key population-level metrics, such as avoidable ED use, review, we were able to interactively
NICU admissions, enrollees who are pregnant or have share with LDH ED overutilization
opioid use disorder. The tool allows us to identify key by region/parish, provider type and
concerns by parish, provider or enrollee. For example, membership.
as presented in the figure, we used the tool to create an
ED hospital dashboard for a key hospital in Lafourche Parish, which had a very high percentage
of avoidable ED use. Using this, and other dashboards, in January 2018, we shared with
hospital leadership detail on why the high ED use was occurring, such as the top diagnoses tied
to those visits, so they could develop effective strategies to reduce it.

Figure 20. HealthView Analytics ED Hospital Dashboard. We used the dashboard to help a key hospital understand the causes of its
high avoidable ED utilization, such as the top 5 diagnoses leading to avoidable ED visits or the enrollees with the highest avoidable ED
utilization. Using this and other dashboards, we helped hospital leadership better target their reduction efforts.

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Addressing High Emergency Department Utilization

Once we have identified high ED utilization, our Clinical Leadership Team uses a variety of
methods to address it. They include:
 Developing corrective action plans (CAPs). We analyze the causes of the utilization
variance and develop enrollee, provider or systemwide solutions to address them
 Identifying and engaging enrollees who may benefit from case management. Core
to helping our enrollees appropriately access services is identifying those enrollees who
may benefit from case management and engaging them in case management programs
appropriate to their needs
 Identifying and engaging enrollees through Through our Shared Saving Provider
Hotspotting. Our Hotspotting Tool provides Group program, our provider‐facing
the timely identification of enrollees who have staff works with physician practices
inappropriate utilization patterns, complex to identify enrollees in the hospital,
social, behavioral or medical needs and high who have visited the ED using
costs within a defined region of Louisiana. admission, discharge and transfer
Once identified, we engage enrollees with our (ADT) feeds. Staff works with the
interdisciplinary Hotspotting Team, which practices to engage these enrollees
to confirm they receive appropriate
provides Tier 3 case management
follow‐up care to address the causes
 Helping enrollees engage in healthy of their hospital or ED visit.
behaviors using behavioral economics. We
are implementing technologies that help us identify enrollees whose behavior can be
“nudged” and deliver interventions that will help enrollees make healthier choices
 Providing tools and programs to help enrollees appropriately access services,
such as providing in-home supports to address the needs of enrollees with inappropriate
ED use, increasing enrollee access to care through telehealth and providing telephonic
support to help enrollees use health care services appropriately

Developing Corrective Action Plans

When the Clinical Leadership Team identifies a utilization concern or a metric does not meet the
established goal, the team identifies opportunities for improvement. The team recruits functional
experts to analyze the data and develop an enrollee- or provider-specific plan to correct the
variance and monitor ongoing performance. If our analysis identifies a systemic problem, we
develop CAPs, such as education for case managers. If the issue is broad enough, we
incorporate the change into our enrollee or Care Provider Manual and newsletters.

Identifying and Engaging Enrollees Who May Benefit from Case Management
Our evidence-based identification process integrates health needs assessment (HNA) results,
referrals and predictive modeling analyses to understand every enrollee’s circumstances and
needs, their health risk score and how they might benefit from tiered case management. Our
process identifies key drivers common to enrollees who require intensive clinical intervention,
such as special health care needs, high-risk pregnancy, unmanaged multiple chronic and
complex medical or behavioral health conditions, or low PCP engagement or acute social
determinants, such as homelessness. Once identified, we engage enrollees in tiered case
management programs, transitional case management or programs tailored to enrollees with
unique needs, such as women experiencing high-risk pregnancy.

LDH Program Goal: Improving enrollee health

We have been successful in helping achieve the Triple Aim for our enrollees
resulting in better care, better health and lower cost. Compared to the 1-year period

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before engagement in case management, enrollees in case management have achieved a 40%
year-over-year decrease in total inpatient hospital PMPM cost and a 20% year-over-year
decrease in total ED PMPM driven by decreased utilization and a 22% year-over-year
decrease in total claims PMPM for enrollees engaged in our highest-risk case management
program.

Identifying and Engaging Enrollees through Hotspotting

Launched in June 2018, our proprietary Hotspotting Tool provides the timely identification and
engagement of cohorts of enrollees who have inappropriate utilization patterns, complex social,
behavioral or medical needs and high costs within a defined region of Louisiana. Our
Hotspotting dashboard provides a host of filters to segment enrollees by demographics, social
determinants, utilization, cost, diagnosis, risk factors and enrollment in case management and
other programs. An individual enrollee view provides a 12-month look back of utilization, cost
and summary health care statistics. We engage enrollees identified by the tool with our
interdisciplinary Hotspotting Team, which provides high-touch, low volume, in-person, local Tier
3 case management. The specially trained team includes RNs, licensed behavioral health
advocates and community health workers.

LDH Program Goal: Improving enrollee health

We deliver each tier of case management through an array of customized services,
unique programs and experienced teams, such as our field-based Hotspotting
Team, which provides high-touch, trauma-informed Tier 3 case management.
Engagement by our Hotspotting Team has resulted in a 59% decrease in year-over-year
PMPM inpatient costs driven by a decrease in admissions. ED utilization decreased 36%,
resulting in a 38% year-over-year PMPM decrease in ED costs.

Helping Enrollees Engage in Healthy Behaviors using Behavioral Economics

Behavioral economics recognizes human behavior can
be influenced through the presentation of choice, framing
of messages and design of financial rewards. Proven The NextHealth platform is driving
behavioral economics principles point to new methods material utilization improvement in
for facilitating, engaging and helping enrollees embrace Medicaid populations. Within 6
months of deploying its
healthy behaviors. In 2019, we are enhancing our suite
NextNudgeTM platform, the average
of enhanced data analytics tools by partnering with
ED visit rate and costs had dropped
NextHealth Technologies to implement its artificial by roughly 26% and 39%,
intelligence platform. The cloud-based platform uses respectively, among nudged
artificial intelligence and scientific methodologies to: compared to historical averages
among the target populations.
 Know WHERE we want to focus to improve
enrollee outcomes, reduce unnecessary
utilization and drive down medical costs
 Know WHO to target by predicting which populations to target for the biggest impact
 Know WHAT programs to suggest by prescribing personalized enrollee-level “nudges”
that change behavior and drive positive outcomes
 Know HOW WELL the programs are working by measuring and optimizing messaging,
channels and outcomes, so limited resources deliver the biggest impact
The platform educates enrollees on alternative care settings using personalized phone calls,
emails or texts and other methods, such as refrigerator magnets. It influences behavior by
targeting enrollees with avoidable ED experiences and deploying personalized messages
through the right channel to help drive lasting enrollee education and behavior change. For

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example, NextHealth’s urgent care or PCP locator texts local urgent care or PCP locations to
enrollees based upon their location. NextHealth’s analytics engine provides precise, ongoing
measurement of campaign and overall program success. With the ability to proactively measure
and optimize a program, we can rapidly understand what works and make changes to best
serve our enrollees.

Providing Tools to Help Enrollees Appropriately Access Services

We provide enrollees with a suite of tools and programs that provide specialized, in-home
supports to address the needs of enrollees with inappropriate ED use; help enrollees
appropriately access health care services, such as NextHealth’s urgent care locator; provide
services to enrollees in their homes using telehealth; improve enrollee access to care by
providing specialist eConsults to their PCPs; and telephonically help enrollees use health care
services appropriately and understand their conditions.

LDH Program Goal: Supporting innovation and a culture of continuous

quality improvement in Louisiana
Ready Responders is a network of trained, licensed and fully insured EMTs,
paramedics and nurses who visit high-risk enrollees with inappropriate ED
utilization to help divert them from the ED. During weekly in-home visits, neighborhood-based
health care professionals connect enrollees via a telehealth consult to address their conditions,
make a PCP or behavioral health appointment, provide transport vouchers to their providers,
monitor prescription adherence, evaluate risk factors and answer questions. We are evaluating
the effectiveness of the partnership since its launch in July 2018. Our preliminary results show a
25% decrease in ED PMPM costs and a 38% decrease in inpatient PMPM costs among
enrollees engaged in the program, driven by decreased utilization.

UHC Doctor Chat. To increase each enrollee’s access to care and provide alternatives to ED
use, we implemented UHC Doctor Chat, a chat-first, virtual visit ED diversion program in
Louisiana in March 2019. Enrollees can use the UHC Doctor Chat app or web portal to
communicate via secure chat, telephone or video with an RN or physician licensed in Louisiana.
Behavioral Health Virtual Visits connect enrollees to a virtual visit with a psychiatrist or
therapist using secure video-conferencing via smartphone, tablet or computer. Clinicians can
evaluate and treat general mental health conditions, provide therapy and prescribe medications.
We are partnering with RubiconMD to implement its eConsult service, which connects PCPs to
top specialists in more than 120 specialties. Its HIPAA-compliant online platform empowers
PCPs to easily request specialist input on a case and receive a specialist opinion within hours.
Advocate4Me and NurseLine. Our Advocate4Me Enrollee Services Center helps enrollees
access services in an appropriate way, such as connecting them or finding an urgent care
center. NurseLine provides live telephonic access to RNs 24 hours a day, 7 days a week who
educate enrollees about their conditions and how to appropriately use health care services.
2.10.10.2.3 The Proposer’s process for pre-admission screening and concurrent reviews;
Pre-admission screening for nursing facility admissions. When an enrollee is
contemplating a move to a facility, we coordinate a pre-admission screening. If the enrollee is in
case management, the enrollee’s case manager works with them to identify facilities that meet
their needs and preferences. Before placement, a qualified assessor performs a Level I PASRR
to identify a serious mental illness or intellectual disability. The assessor submits the findings to
the nursing facility. If the enrollee cannot be determined to have a serious mental illness or
intellectual disability, the assessor also requests a Level II PASRR evaluation. If the enrollee is

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in a nursing facility and determined to have a serious mental illness or intellectual disability, the
Office of Behavioral Health (OBH) refers the enrollee to us for a Level II PASRR evaluation. We
contract with Merakey to conduct these evaluations. Once we receive the findings, we send
them to OBH for a determination of the appropriateness of a nursing facility admission or
continued nursing facility stay. We complete an annual Level II PASRR evaluation of enrollees
residing in a nursing facility to review the most appropriate setting for the enrollee’s needs (in
the community, a nursing facility or an acute care setting) and to determine the enrollee is
receiving the services they need in these settings.
Inpatient admissions. Pre-admission screening and concurrent review promotes the continuity
of the enrollee’s care, confirms appropriate utilization, manages length of stay and facilitates
collaboration among the UM clinician, case manager, inpatient facility and multidisciplinary
team. We perform pre-admission screening and concurrent review for inpatient admissions and
non-inpatient, high-intensity behavioral health services. We do not require prior authorization for
emergencies. As presented in the figure, to perform pre-admission screening, a UM clinician
determines if the admission requires prior authorization and, if so, processes it through our prior
authorization process. Once the enrollee has been admitted, the Inpatient Case Management
Team begins concurrent review to confirm the enrollee is receiving an appropriate level of care.
The team uses MCG criteria to help support the discharge planning process and evaluate an
appropriate level of care for the enrollee upon discharge, such as to long-term acute care. When
Level I PASRR screening is performed by a hospital discharge planner, if the enrollee has
positive indicators of serious mental illness or intellectual disability and does not meet the
conditions of a categorical determination, the hospital discharge planner can request a Level II.

 
Figure 21. Inpatient pre‐admission screening and concurrent review. Upon notification of a non‐emergent inpatient admission, UM
clinicians determine if the admission requires prior authorization. If so, they determine the appropriateness of the admission and the
need for a continued inpatient stay. During the enrollee’s inpatient stay, the UM clinician reviews the treatment plan for appropriateness
and scope and the enrollee’s response to the treatment plan and begins discharge planning.

2.10.10.2.4 How the Proposer complies with mental health parity requirements; and
We have long supported parity for mental health and addiction to help our enrollees live
healthier lives. With behavioral health care available as an essential benefit, we improve
outcomes by reaching additional people with prevention, wellness promotion, early intervention
and treatment of mental health and substance use. We are an industry leader in confirming our
financial and clinical models are compliant with the Mental Health Parity and Addiction Equity
Act (MHPAEA) of 2008 and the Final Rules for commercial group plans and Medicaid. Our
internal MHPAEA compliance workgroup has conducted a thorough review of the impact of

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MHPAEA to all key functions covering our benefits, clinical management processes and network
contracting. We continue to support compliance for all plans subject to parity, including:
 Providing expert consultation and recommendations regarding compliance with
MHPAEA as specified in the benefit plan
 Ensuring medical management techniques applied to mental health or SUD benefits are
comparable to and applied no more stringently than the medical management
techniques that are applied to medical and surgical benefits
 Ensuring that the criteria for medical necessity determinations for mental health or SUD
benefits are available to any current or potential enrollee or contracting provider by
making our level of care and coverage determination guidelines available to the public
24 hours a day, 7 days a week online
 Ensuring the plan benefits include a clear description of the behavioral levels of care and
services covered
 Maintaining a clear and easily accessible process for filing appeals and complaints that
complies with regulatory requirements, including NCQA and URAC accreditation
 Offering robust provider networks
 Monitoring the availability of providers and including an easy way for providers to note in
our online directory that they are not accepting new patients
 Providing a clear reason to enrollees and providers for any denial of reimbursement or
payment with respect to mental health or SUD benefits
We use detailed non-quantitative treatment limitation (NQTL) data collection tools that support
the documentation of the quantitative testing required by parity (substantially all and
predominant testing) and alignment of the NQTL applied to behavioral health benefits. UM staff
validates individuals have transparent access to the necessary information to compare NQTLs
of the medical/surgical benefits and behavioral health benefits under the plan. When applicable,
we align with the plan’s definition and use of medical necessity; fraud, waste and abuse
program; exclusion of unproven services; network standards for provider admission and
reimbursement; exclusions for failure to complete treatment; fail first requirements; formulary
design for prescription drugs and restrictions based upon geographic location. This ensures that
the processes used for mental health and SUD are comparable to and applied no more
stringently than those applied to the medical/surgical benefits.
2.10.10.2.5 How the Proposer identifies and mitigates over-utilization, including any targeted categories.
We identify overutilization using the same methods to monitor and address high ED utilization.
The table presents our targeted categories (e.g., ED utilization), the key populations affected by
the targeted category, the tools we use to identify the overutilization in the targeted category
and our strategy to mitigate the overutilization in each targeted category.
Key Population Tool to Identify Strategy to Mitigate
Targeted Category: ED Utilization
All enrollees with  HealthView Analytics ED  Developing CAPs
high ED utilization dashboards  Identifying and engaging enrollees who may
 Hotspotting benefit from case management
 ED Utilization Report from  Identifying and engaging enrollees through
Orbit Hotspotting
 Helping enrollees engage in healthy behaviors
using behavioral economics
 Providing tools and programs to help enrollees
appropriately access services

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Key Population Tool to Identify Strategy to Mitigate

Targeted Category: Pediatric Day Health Care (PDHC) Utilization (LDH Priority)
Children with  Reports on PDHC utilization PDHC:
special health care  Physical therapy, occupational  Exploring Partnership with HeadStart and
needs currently therapy and speech therapy Early HeadStart to transition medically stable
receiving PDHC, claims for PDHC enrollees children younger than school age
extended home  EHH claims  Case managers work with families who seek
health (EHH),  PCS claims therapy services outside of the PDHC program
EPSDT personal EHH:
care services (PCS)
 Development and utilization of an EHH Acuity
Tool that helps the case manager apply criteria
to support the appropriate level of hours that
have been requested
PCS:
 We request the last well‐check visit for the
child from the PCP to support the need for
hands‐on care versus supervisory care
 We engage the PCP or pediatrician in pre‐
emptive peer‐to‐peer discussion, when needed
PDHC, EHH and PCS:
 Our team of RNs collaborates with the MDT to
coordinate the most appropriate level of care
based upon the enrollee’s unique
circumstances
Targeted Category: Overuse of medications
Members with or at Claims data and pharmacy Interventions, such as:
risk of opioid use reporting  Pharmacy and prescriber lock‐in programs
disorder (OUD)  Pharmacy point‐of‐sale edits/reviews
Targeted Category: Unnecessary tests
Certain providers’  Claims data – aberrant practice Drug testing policy submitted to LDH for
enrollees and analysis consideration based upon outlying physicians
enrollees with  Medical Experience Tracking with extreme testing utilization patterns
OUD/SUD Report (METR) review
 Payment integrity monitoring
Targeted Category: Readmissions
All members METR and claims, ADT feeds,  Follow up after hospitalization (FUH) VBP
Potentially Preventable model (for behavioral health admissions)
Dashboard, Variant Day Analysis  Hospital Care Transitions (HCT) program
(VDA) and Hotspotting  Transitional case management
Targeted Category: Inpatient utilization
All members METR and claims, ADT feeds, Tier 1‐3 case management
Hotspotting and VDA, Target
Monitoring Report, Heads in Beds
reporting
Targeted Category: Physician services and outpatient
All members  Provider view – Network CPCs and CTCs follow up for members who are
Optimization analysis being admitted, readmitted, have high ED use and
 METR and claims high PCP use indicating likely poor management
 ADT feeds
 ED Utilization report for

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Key Population Tool to Identify Strategy to Mitigate

Clinical Transformation
Consultants (CTCs) and Clinical
Practice Consultants (CPCs)
Targeted Category: Residential care use
Members in skilled METR and claims, ADT feeds and My Choice Louisiana transitional case
nursing facility/ VDA skilled nursing facility view management
custodial level of
care
Targeted Category: Back pain
Members with back METR and claims and ADT feeds  Tiers 1‐3 case management
pain and high ED  Connect members to chiropractor visits,
utilization mindfulness, specialists and therapies
Targeted Category: Appropriate diagnosis and treatment of children with ADHD
Children with  HEDIS rates Implemented an ADHD Performance
ADHD  PCP knowledge and use of Improvement Project (PIP) to address
ADD/ADHD screening tool appropriate diagnosis and treatment of children
 Diagnosis codes with ADHD, following pattern of overutilization
identified by Louisiana Bureau of Family Health

LDH Program Goal: Supporting innovation and a culture of continuous
quality improvement in Louisiana
In 2017, we implemented an ADHD PIP to address appropriate diagnosis and
treatment of children with ADHD, following a pattern of overutilization identified by
Louisiana Bureau of Family Health. The quality of care for children with ADHD improved from
2017 to 2018. Using a validated screening instrument by the PCP and using the instrument in
multiple settings increased by 20% and 18.33%, respectively. PCP care coordination almost
doubled from 43.33% to 80%.
2.10.10.3 The Proposer should describe its historical experience with utilization management of comparable…
We implemented our UM program in Louisiana in 2012. Nationally, we have extensive
experience performing UM functions in 25 state Medicaid programs, including integrated
physical and behavioral UM programs in 22 states. This includes performing UM functions in 24
states that serve children, 24 states that serve enrollees receiving TANF and 22 states that
serve ABD enrollees.
2.10.10.3.1 Challenges identified with high utilization and increasing medical trends;
Through our experience in Louisiana, we have learned that to address high utilization and
increasing medical trend, we have to look at underlying drivers of high utilization. This includes
evaluating traditional core health measures, such as tobacco use, adult obesity and diabetes
prevalence rates, areas of concern, such as infant mortality rates and opioids, and the impact of
social and environmental determinants. Two examples of challenges identified with high
utilization and increasing medical trends include the following:
 Pregnant women with OUD. As noted in a July 2017 paper from Louisiana Health
Secretary Dr. Rebekah Gee, the prevalence of infants born with Neonatal Abstinence
Syndrome (NAS) prevalence quadrupled and the cost of care increased six-fold among
Medicaid infants between 2003 and 2013. Woman’s Hospital in Baton Rouge has seen a
67% increase in babies being monitored for NAS between 2013 and 2016. We also
know Region 2 has the highest infant mortality rate (10.3%) in the state.

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 Reducing inpatient readmissions. We look for collaborative partners in metropolitan

areas where there were concerns about discharge planning and confirming enrollees are
receiving the services needed in the community. Two of our larger providers in
metropolitan areas include Our Lady of the Lake Regional Medical Center in Baton
Rouge and the LCMC Health University Medical Center in New Orleans.
2.10.10.3.2 Initiatives undertaken to manage high utilization;
We use a variety of methods to monitor and manage high utilization. In this section, we describe
two initiatives we have undertaken to provide supports to pregnant women with OUD and
reduce inpatient readmissions by integrating HCT coordinators in three of our hospitals.
Reducing NICU utilization by focusing on OUD treatment for pregnant women. We
understand that women who have OUD and are pregnant are more likely to have high-risk
pregnancies, face disparately higher rates of maternal and infant mortality and experience
unnecessary high utilization. In August 2018, we provided a $1.2 million grant to Baton Rouge
Woman’s Hospital to implement its GRACE program. The program is open to all Medicaid
enrollees regardless of their MCO. By partnering with Woman’s Hospital, an area with a
proportionally high rate of infant mortality, we have been able to overcome health disparities and
reduce the effects of SUD/OUD on pregnant women and their newborns by:
 Training direct care staff in non-judgmental communication and early detection of
substance misuse to prevent avoidance of prenatal care
 Connecting newly identified enrollees with OUD to the Pregnancy Substance Misuse
Case Management Program early in their pregnancies
 Providing enrollees with comprehensive case management services and connection to
social resources outpatient recovery services, care planning and one-on-one support
offered by providers trained in obstetrics and addictive disorders
 Continuing support for up to 6 weeks postpartum, with a warm handoff to community
resources, including addiction recovery treatment centers and social services supports

LDH Program Goal: Improving enrollee health

Women enrolled in this high-touch case management program had infants who
weighed an average 1.35 pounds more than the comparison group. Their
estimated gestational age at delivery was 5 days greater than the comparison
group (38.25 versus 37.5 weeks) and all GRACE deliveries were born at term as opposed to the
comparison group where 50% of deliveries were preterm.

Reducing readmissions through our Hospital Care Transitions (HCT) Program. Our HCT
program helps make an enrollee’s move to their next level of care easier and their hospital
discharge go as smoothly as possible. In December 2018, we embedded four HCT
coordinators within Our Lady of the Lake Regional Medical Center in Baton Rouge and the
LCMC Health University Medical Center in New Orleans to reach high-risk enrollees pre-
discharge and provide specialized supports to address each enrollee’s post-discharge needs.
We support HCT coordinators with an RN, a clinical pharmacist who addresses medication
issues and a licensed social worker with behavioral health expertise.
In 2019, we will embed a perinatal HCT coordinator in Louisiana Woman’s Healthcare clinic
affiliated with Woman’s Hospital in Baton Rouge. The HCT coordinator will address the prenatal
needs of inpatient high-risk women to confirm they deliver at term, support neonatal discharge
planning, review social determinants needs and begin to address those issues, work with the
Healthy First Steps Case Management Team to coordinate prenatal services to confirm the

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continuity of the enrollee’s care and work with the Neonatal Resource Services (NRS) Team to
deliver a smooth transition for both the mother and an infant who has been in the NICU.
Building a Trusted Relationship to Help a Member
Luke, a 62‐year‐old enrollee, was admitted to Our Lady of the Lake Regional Medical Center in
Baton Rouge in February 2019 with Osteomyelitis, requiring IV antibiotics. His medical history
includes multiple comorbidities including a history of COPD, chronic tobacco use, diabetes,
rheumatoid arthritis, hepatitis C, a history of multifocal discitis status post 6 weeks of treatment
from October through December. Luke has been readmitted secondary to worsening back pain. The
hospital discharge planner reached out to our HCT coordinator to help them plan for Luke’s
discharge as Luke would not speak to any of the facility discharge planners. Luke was angry and
distrustful of everyone and was refusing to transition to assisted living level of care. Luke is a
Vietnam Veteran and our HCT coordinator who is also a veteran, built on this shared experience to
connect with Luke and build trust. The HCT coordinator worked with Luke to understand his needs
and goals, located a long‐term acute facility for Luke and gained his agreement to transition to the
facility. Our HCT manager received calls from two facility case managers stating what a wonderful
job the HCT coordinator is doing helping them with member transitions.

2.10.10.3.3 Initiatives to address use of low value care;
We have implemented programs and trainings to help providers deliver care that is appropriate
to our enrollees and to connect enrollees to care in appropriate settings. Two examples include:
Meeting with providers to review quality outcomes and
educate providers on clinical practice guidelines and HEDIS
requirements. Our staff used a variety of tools and materials,
such as our HEDIS in a Box toolkit, to identify their enrollees
who have gaps in care and discuss ways we can help get
these enrollees connected to preventive care. Provider-facing
staff identifies enrollees with gaps in care through Patient
Care Opportunity Reports.
Choosing Wisely provides evidence-based
recommendations clinicians and enrollees can discuss, such
as when tests and procedures may be appropriate and the
process used for the recommendation. We have included
Choosing Wisely principles in engagement of providers and
enrollees and educated them on the five principles of the
Choosing Wisely program. We have provided literature to Figure 22. Choosing Wisely wallet card
reminds enrollees to talk to their doctors about
PCPs and enrollees during provider expos, enrollee events tests and treatments they really need to
and in-office provider signage. improve their health.

2.10.10.3.4 Initiatives to address long term stays of enrollees in the ER based on limited availability of mental…
Increasing the availability of mental health/substance use services. We are constantly
working with providers to meet increasing standards of care and the needs of our enrollees due
to the opioid crisis. We are working with LCMC to implement a mental health Intensive
Outpatient Program (IOP) treatment facility. IOP is a structured therapeutic environment that
provides treatment to enrollees while living at home and engaging in their personal lives. While
not a covered benefit, we will provide IOP as a treatment option to our enrollees. We are in
discussions with three other providers to bring their existing IOP facilities into our network.

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Increasing access to Medication-Assisted To reduce long‐term stays of enrollees in

Treatment (MAT). We recognize the need for a the ED, we educate ED providers to call us
comprehensive approach to prevent, identify, treat as soon as the enrollee’s need becomes
and promote ongoing recovery for those with OUD. apparent so that we can begin to
Aligned with the Heroin and Opioid Prevention and coordinate services as soon as possible.
Education (HOPE) Council goals and the Louisiana When needed, we also identify out‐of‐
network providers that can meet our
Pew Charitable Trust Recommendation 2, which
enrollees’ needs and execute a single case
focused on expanding MAT capacity through care agreement to provide necessary services
coordination and enhanced rates, we have as quickly as possible.
developed a value-based payment (VBP) aimed at
increasing access to high-quality MAT and supporting member retention in treatment. Given the
high overdose death rate in the Orleans and Jefferson Parishes, in Q1 2019, we initiated a
partnership with Daughters of Charity to launch our OUD Quality MAT pilot.
We developed our program based upon the experiences and lessons learned in states that
have successfully increased MAT capacity and treatment rates, such as Vermont and Virginia.
Our Senior Medical Director, Dr. Katherine Neuhausen, led the successful Virginia Addiction
and Treatment Services program as the former state Medicaid chief medical officer, and has
provided valuable insight into the model development. Dr. Neuhausen will continue to work
closely with Daughters of Charity as they build upon this VBP to scale up their capacity and
provide comprehensive MAT services integrated with primary care, behavioral health, prenatal
care, and Hepatitis C and HIV treatment for those with OUD.
Providing crisis alternatives to the ED or
Increasing the availability of MAT: hospital. We are partnering with two crisis centers
 Our Behavioral Health Medical to provide services to enrollees age 18 or older that
Director, Dr. Jose Calderon‐Abbo, help prevent unnecessary ED use and inpatient
provides education and discussion admissions. Safe Haven (operated by Start
with providers regarding the Corporation) will serve St. Tammany Parish and
expansion of MAT services at Compass Crisis Receiving Center (operated by
substance use centers Compass Health) will be located in Lafayette and
 We are working with Daughters of will serve a 50-mile radius in the Acadiana region.
Charity to build a MAT program We are partnering with Jefferson Parish Human
 We are adding a MAT treatment Services Authority to connect our enrollees to its
induction code so we can pay the Living Room model, which provides a secure and
induction fee for providers to deliver welcoming environment that helps enrollees find
the first dose of Suboxone and
solutions in times of crisis, avoiding automatic
monitor the effect of the treatment
hospitalization or involuntary detention.
2.10.10.3.5 Initiatives undertaken to support providers with high prior authorization denial rates.
When providers need assistance or have difficulties submitting prior authorization requests, we
engage them in a variety of ways. Link helps reduce the provider’s administrative burden when
authorizations. Available 24 hours a day, 7 days a week, it helps the provider submit all
information required for a medical necessity review, provides access to our guidelines and
review criteria, and allows the provider to track the status of prior authorization requests. Our
provider-facing staff conducts one-on-one training sessions with providers, confirming they
receive the education and support needed to follow the prior authorization process. Staff
educates providers about our prior authorization process and our guidelines and criteria during
initial provider training and whenever UM protocols or criteria change through our Care Provider
Manual, on our secure Link provider portal, and in our provider newsletter, Practice Matters.

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2.10.11 Quality
2.10.11.1 The Proposer should describe its organizational commitment to quality improvement and its overall…
We have contracted with LDH since 2012, and we understand the importance of the Aims,
Goals and Objectives outlined in Attachment G. We are currently working with LDH to achieve
these and to continue our upward trend in Attachment G quality measures. We agree to comply
with all requirements in Section 2.10.11 of the Model Contract.

Organizational Commitment to Quality Improvement

Quality is fundamental to our culture. We embed systematic approaches to evaluate and
improve quality through every level of our organization. These efforts engage the resources of
our entire organization — both national and local — and improve service and health outcomes
of enrollees.

Supporting Innovation and a Culture of Continuous Quality Improvement

Our quality interventions and strategies support LDH’s Aims, Goals and Objectives
while focusing on smarter spending — high-value, efficient care — through local
care management and care delivery. The Quality Assessment and Performance Improvement
(QAPI) program we create for the Medicaid Managed Care Program uses comprehensive
population health analytics to identify trends, develop population-specific plans and apply
individualized interventions, while monitoring the quality of care and service delivered in
parishes statewide.

We weave our Culture of Quality into everything we do. Every UnitedHealthcare employee must
attend a multiday culture retreat to learn how we put our quality and value at the center of our
work. Our values of Integrity, Compassion, Relationships, Innovation and Performance inform
and enhance our mission, to “Help people live healthier lives and help make the health system
work better for everyone.”

Quality Champions in Louisiana

To support our companywide culture of quality and drive innovation locally, Angela Olden, MA,
BSN, RN, Population Health Director, and Deb Junot, BSN, RN, Quality Director, will continue to
act as the quality champions for advancing and administering all Medicaid Managed Care
Program requirements for the State. Ms. Olden and Ms. Junot are lifelong residents of Louisiana
and have 40 years of combined managed care quality experience in the state.

Approach and Specific Strategies to Advance “Healthier Louisiana”

Our quality strategy for the Medicaid Managed Care Program verifies that our enrollees have
access to, and use, an integrated program of primary and specialty health care based upon
evidence-based clinical guidelines that foster better health, better care and lower cost. We
support the LDH’s Aims, Goals and Objectives by implementing provider incentive programs
that support improved enrollee care and continuous quality improvement (CQI) initiatives.

Organizational Commitment to Support LDH Priorities and Innovation

Like quality, innovation is also part of the fabric of our company and woven into our efforts to
align our quality improvement program with the LDH Quality Strategy. Some examples follow:
Delivery System Reform: Listening to providers, we adapted our value-based contracting
(VBP) model to meet providers where they are. In 2019, we moved to a

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Reducing Readmissions: To support LDH’s goal of improved coordination and transition of

care, we offer high-need enrollees support by providing home delivered meals after an acute
inpatient hospital stay due to food insecurity/malnutrition. After a hospital discharge, Mom’s
Meals delivers 14 to 28 healthy meals appropriate to an enrollee’s health condition to the
enrollee’s home. Since starting in November 2018, the innovative pilot program resulted in 95%
of enrollees avoiding readmission after discharge from an acute hospital setting. We will
evaluate this program at a future date for continued successful outcomes.
Innovative Care Coordination: Providing acute to post-acute transition services to enrollees is
part of the evolution of the care continuum and supports LDH’s goal to improve coordination of
care. Our embedded Case Management Program in high-volume inpatient facilities addresses
coordination of care — for medical, behavioral health and pharmacy (e.g., medication review
and reconciliation) and the enrollee’s needs related to social determinants of health (SDOH).
ED Diversion/Access to Care through UHC Doctor Chat: Enrollees can use the UHC Chat
app or web portal to communicate via secure chat, telephone or video with an RN and M.D. if
needed for care, 7 days a week (9 a.m. to 9 p.m.). We implemented UHC Doctor Chat, a chat-
based, virtual visit ED diversion program in March 2019. The program addresses enrollees with
CHF, COPD, sickle cell, chronic pain or asthma who have two or more ED visits in the past 12
months AND one non-emergent ED visit in the past 12 months.
Improved Member Health through Telehealth/Telemental Health: As we continue to focus
on improved access for enrollees, we have several programs implemented and in development
to support enrollees receiving and providers delivering accessible and integrated medical and
behavioral healthcare. These programs connect the enrollee to the provider, the provider to
other providers, and enrollees to specialists. Our expanded capabilities also address access to
care issues with providers after hours to meet enrollee needs and improve chronic disease
management and control.
Enrollee Education Partnerships to Drive HEDIS: We partnered with our vendor, MARCH
Vision, on an initiative to close gaps in HEDIS eye exams by calling enrollees identified with
diabetes that had not had their eye exams and scheduled them for services. The result was a
14.6% improvement in our 2017 HEDIS diabetic eye utilization score.
2.10.11.2 The Proposer’s approach should also include:
2.10.11.2.1 A description of the Proposer’s assessment (using available data sources) of utilization rates and the…
The success of our performance strategy and the potential for improvement is guided by and in
alignment with the Triple Aim and the broad aims of the LDH Quality Strategy — Better Care,
Healthy People, Healthy Communities and Affordable Care. Louisiana’s Quality Strategy
framework defines and drives our overall vision for advancing health outcomes and quality of
care provided to Medicaid Managed Care Program enrollees.
We accomplish this by embedding the Louisiana Quality Strategy into our quality “trilogy
documents” — which consist of the Quality Improvement Program Description, the Quality
Improvement Evaluation and the Quality Improvement Work Plan. These documents articulate
our Quality Strategy, driving overall plan performance while also recognizing areas where
quality initiatives have the potential to drive additional improvement.

Tracking Potential for Improvement

We use data to track a variety of measures that provide insight into the effectiveness of our
programs and the health outcomes of our enrollees. Our measures track reductions in
unnecessary utilization, identify enrollees with gaps in care and provide indications that our

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enrollees are receiving quality care that leads to improved enrollee outcomes, such as
compliance with HEDIS measures. Our Quality Improvement (QI) Program describes the
coordinated and collaborative activities and initiatives UnitedHealthcare provides to meet the
needs of enrollees and to continuously improve service, medical and behavioral health care
outcomes. We use several datasets and reports to assess utilization rates:
Inpatient Utilization Rates Report (Daily): Our PCPs receive a report on their patients that
were seen in the ED, admitted or discharged from an inpatient stay. This allows the provider to
proactively reach out to the enrollee to address continuity of care concerns.
ED Utilization Rates (Monthly): We aggregate and review utilization rates such as cost-per-
enrollee, provider inpatient data and ED rates. This high-level view allows us to identify
developing trends in utilization and quality outcome measures.
HEDIS-reported Utilization Rates Data (Monthly): We review HEDIS rates/utilization metrics
across our entire enrollee population. We actively use this data to inform proactive approaches.
For example, if our diabetic enrollees are having lower-than-recommended rates of eye exams,
we take action, which could entail calls to enrollees with gaps in care or outreach to provider
staff to heighten their awareness of enrollees that need these screenings. In both cases, this
review provides both enrollees and providers with education on addressing these needs and
eliminating gaps in care.
VBP Scorecards Reports (Monthly): Our scorecards illustrate to providers engaged in value-
based contracting the measures where their enrollees have gaps in care. Our clinical provider-
facing staff share these during monthly in-person visits. Scorecards allow the provider to focus
on specific enrollees or measures to support both improved care and meet criteria to earn
practice incentives. VBP scorecard data gives providers a snapshot of their aggregate rates to
guide them in achieving minimum standards, outperforming peers or meeting provider incentive
agreements. This information is also available through our online provider portal.
Provider Peer Comparison
Reports (Annually): We share with
providers their utilization rates on
select measures; and how they
compare with their peers. Medical
plan leadership reviews this group-
level data internally to determine
outliers and to influence provider
utilization patterns. For example, we
use this data to identify the
opioid/high-utilizer peer comparison
rates. This allows the plan’s clinical
leadership to review the data, Figure 23. Our Provider Peer Comparison Reports show utilization rates on
select measures in comparison to their peers, highlighting PCP outliers to drive
proactively monitor any potential both provider education and overall plan performance.
abuse and formulate a plan to
address outlier providers on this metric.

Recognizing Potential for Improvement

The table to follow (“Key HEDIS Measures”) represents a sample of key measures to drive
efforts for a Healthier Louisiana. Monthly, we evaluate both incentive measures and monitor
measures supported by additional interventions and provider/enrollee outreach and
education. Our enhanced value-based incentives — added in 2018-2019 — along with member
incentives targeted to populations identified as having health disparities, further enhance our

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efforts. We continue to look for opportunities to continue to drive improvement in all measures
and for all populations. The proposed new measures are inclusive of the expansion population
and broaden our approach to encompass more adult population needs.
At the Department’s request (Addendum 2), we have included four additional measures from
Attachment G: #27, 35, 37 and 50. Of these four proposed measures, three have available
baseline data at this time (e.g., 27, 35 and 50). In the past, we have not monitored Colorectal
Cancer Screenings (#37) for the Medicaid population. The measure for Initiation and
Engagement of Alcohol and other Drug Abuse or Dependence Treatment (#50) has a
performance improvement project scheduled for 2019.
We have begun research to obtain baseline data on the remaining proposed measures
available at this time. Once we finalize the measures in May 2019 for the 2020 contract, we will
analyze and use this data to develop our quality improvement plan inclusive of integrated
provider/member outreach and education for Attachment G to support all the efforts for Better
Care, Healthier People, Healthier Communities and Smarter Spending for a Healthier Louisiana.

Health Plan Rates on Key HEDIS Measures (Attachment G)

HEDIS HEDIS Improved Included in
Met State
ATT. 2018 2017 from Incentive
Attachment G. Measure Benchmark
G # Rate Rate 2017 to Program?
2018*
(%) (%) 2018 (%) PCP Enrollee
Well‐Child Visits in the First
1. 72.26 57.55 14.71 YES 62.06 YES YES**
15 Months of Life
Well‐Child Visits in the Third,
2. Fourth, Fifth, Sixth Years 68.86 68.19 0.67 NO 72.45 YES YES*

Adolescent Well‐Care Visits

3. 60.34 63.88 ‐3.54 YES 50.12 YES YES*
Adult Access to Preventive &
4. 81.64 86.48 ‐4.84 YES 81.61 YES NO
Ambulatory Services
Seven‐day Follow‐Up After
6. Hospitalization for Behavioral 26.58 42.13 ‐15.55 NO 43.94 YES NO
Health (FUH)
Prenatal and Postpartum Care:
18. Timeliness of Prenatal Care 82.24 85.54 ‐3.3 NO 83.56 YES YES
Prenatal and Postpartum Care:
21. 64.48 64.84 ‐0.36 YES 64.38 YES NO
Postpartum Care
Initiation of Injectable
22. Progesterone for Preterm 18.06 18.01 0.05 NO 20.65 YES NO
Birth Prevention
Childhood immunization
27. 71.29 73.72 ‐2.43 NO 71.58 NO NO
Status Combo #3±
35. Cervical cancer screening± 57.66 62.76 ‐5.1 NO 58.44 NO NO
37. Colorectal cancer screening± NA NA NA NA NA NA NA
Controlling High Blood
42. NA NA 6.32 NO 56.93 YES NO
Pressure
46. Eye Exam (Retinal) Performed 55.23 50.12 14.6 YES 55.17 YES NO
Initiation and engagement of I‐ I‐
‐1.74 YES 40.67 NO NO
50. alcohol and other drug abuse 49.19 50.93
or dependence treatment± E‐ E‐ 2.30
YES 12.34 NO NO
I=initiation E=engagement 16.74 14.44
*HEDIS Rates for 2019 not final. ** $20 Gift Card ***$10 Gift Card
± Four additional measures added by the Department in the response to the Q&A.

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Emergency Department Utilization in Louisiana

Emergency Department (ED) utilization is a continuous improvement priority. In measurement
year 2018, the plan ED utilization rate is — as of January 2019 — 72.26% (currently waiting for
claims lag). This was a decrease in ED utilization rate from 78.36% in 2017. We accomplished
this through several ED Diversion initiatives (described in Question 2.10.11.1) including
telehealth initiatives and enrollee awareness and education — even during one of the nation’s
strongest flu seasons. With the innovative programs slated for 2020, we expect additional
improvement on enrollee ED utilization.
2.10.11.2.2 A description of incentives that will be implemented for providers and enrollees to incentivize…
Since 2012, UnitedHealthcare has continued to evolve our approach to VBP for Louisiana’s
Medicaid Managed Care providers in support of the Triple Aim. Our goal is to incent both the
provider and the enrollee on the same measures when possible. The table in our response to
Question 2.10.11.2.1 illustrates the “crosswalk” between the enrollee and provider incentives
measures for 2020.
This alignment creates synergy — when both parties are working toward the same goal based
upon services given and received. We also have an
incentive program for FUH (Attachment G, #6) for both
medical and behavioral providers. This encourages
coordination of care between PCPs and behavioral health
providers. Our VBP programs help providers successfully
progress along the Health Care Payment Learning and
Action Network (HCP-LAN) continuum to achieve practice
transformation, expand access to care and improve
quality service delivery using a “right care in the right
place at the right time” approach.

Choosing Wisely
Choosing Wisely provides specific, evidence-based
recommendations clinicians and enrollees can discuss,
such as when tests and procedures (e.g., CT scans,
Figure 24. Choosing Wisely wallet card
antibiotics) may be appropriate and the process used for (also in Spanish) reminds enrollees to talk to
the recommendation. To support both enrollee and their doctors about which tests and
provider education in this effort, we have included treatments they really need to improve their
Choosing Wisely principles for both provider and enrollees. We have educated providers and
enrollees on the five principles of the Choosing Wisely program and we have provided literature
to PCPs and enrollees during provider expos, enrollee events and in-office provider signage.
2.10.11.2.3 A description of evidence-based interventions and strategies that will be used to target super-utilizers…
Our strategy for targeting super-utilizers and reducing potentially preventable events (PPEs)
begins with using data and analytics to identify super-utilizers. Our identification and
stratification process generates a risk score and stratifies each enrollee according to predicted
future utilization and cost. The algorithm incorporates medical, behavioral health and pharmacy
claims, lab test results and other data. Our Impact Pro™ predictive modeling tool analyzes the
data to deliver a prospective risk assessment for every enrollee and identify the clinical and
utilization events affecting an enrollee’s health risk. The process analyzes gender, age, other
demographic variables, future inpatient risk and prior year total cost of care spending, acute
inpatient admissions, ED visits, pharmacy, behavioral health and chronic conditions.

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Our strategy also identifies enrollees with emerging risk who, without intervention, would likely
become very high utilizers in the coming year. Our risk stratification engine uses multiple
identification rules to identify enrollees with emerging risk, such as multiple medications, a
behavioral health medication with no behavioral health provider, more than six behavioral health
or medical providers and the presence of social risk factors.
We work with these enrollees to help manage the
 41% of total WPC enrollees health concerns that are leading to very high utilization
enrolled in the Super‐Utilizer PPEs using the care management activities and
program resources discussed in the following section. At a
 Total inpatient hospital PMPM minimum, enrollees identified with emerging risk will
decreased by 43% year‐over‐year be assigned to Tier 2 case management and those
for members after joining the who are identified as having persistent high utilization
WPC ‒ Super‐Utilizer Case will be assigned to Tier 3 case management.
Management program, driven by
decreased utilization Other key elements of our strategy to target super-
 Total ED PMPM decreased by utilizers and reduce PPEs include:
26% year‐over‐year for
members after joining the WPC ‒ Supporting participating PCPs and behavioral
Super‐Utilizer program, driven by health practitioners to target follow up as indicated
decreased utilization by their utilization patterns. These interventions
include provider education, drill-down case review and
potential further action depending on the results of the review. We work with providers to allow
super-utilizers to get priority walk-in appointments and transportation to the PCP or urgent care
by:
Identifying enrollees using advanced data analytics that support our algorithm-based
blended identification and stratification process with emerging risk or persistent high utilization
and allows us to assign these enrollees to an appropriate case management risk level (Level 2
or 3) and engage them in an appropriate intensity of case management.
Managing enrollee care through high-touch, high-engagement case management
interventions delivered through field-based, integrated care teams, comprising an RN case
manager, a licensed-behavioral health advocate and an enrollee advocate. The team
collaborates to manage enrollee care and implement interventions that address the causes of
the persistent high utilization. We target high utilizer enrollees with outreach calls and
community health worker visits to address their specific needs (e.g., transportation, childcare,
work schedules, access to care including scheduling PCP or specialist visits).
We send admissions, discharge and transfer) (ADT) data via the Health Information
Exchange (HIE) to our providers on a daily basis. This enables appropriate follow-up
engagement (e.g., schedule appointment within 7 days of discharge), reducing readmissions
and other PPEs. We are finalizing an agreement with the Louisiana Health Information Network
to expand our access to ADT feeds.
Monitoring enrollee health using technology that enables us to monitor in near-real time
by aggregating data from various sources, such as claims data or ADT from hospitals, and
presenting actionable information to the care team so it can engage enrollees with timely,
targeted interventions and prevent an escalation of their utilization. ADT reports are also shared
with the PCP and this communication allows the PCP to know about an enrollee’s inpatient
occurrence or an ED visit.

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Meeting enrollee needs using an array of care management processes, services, supports and
specialized programs for enrollees with persistent high utilization, such as peer supports,
recovery response centers and tools that help enrollees actively manage their conditions.
Sharing member utilization reporting using high utilizer reports with the providers so they
may concentrate their efforts on these enrollees to address their utilization patterns. We also
place these enrollees in case management.
Conducting multidisciplinary continuum of care rounds and addressing enrollees with high
utilization patterns.
Using Ready Responders, a network of trained, licensed and fully insured EMTs, paramedics
and nurses who are connected via a proprietary mobile app to 911 systems, hospitals and
payers.
Offering telehealth options to the enrollee to address access and after-hours concerns — with
access to both medical and behavioral health providers – UHC Doctor Chat.
Using Hotspotting, the strategic use of data to identify enrollees with complex needs.
Typically, these individuals have high utilization of services and social and behavioral
complexities. Using our Hotspotting Tool, we can identify enrollees who are most likely to
benefit from our community health worker (CHW) approach—a direct, evidence-based, in the
community approach to service delivery.
2.10.11.3 The Proposer should describe how the Proposer’s Medicaid managed care Quality Assessment and…
Quality and value are the shared responsibility of everyone on our team and our partners. Our
goal is to deliver on Louisiana’s three central aims better care, better health and lower costs
while we support the state’s Quality Strategy and corresponding goals and objectives related to
improvements in clinical care (Attachment G.) The QAPI forms the foundation for how we drive
quality improvement statewide and our organizational quality committee structure (Question
2.10.11.4.1) is the mechanism we use to engage the entire organization to meet state goals.
Annually: We formally evaluate and document our QAPI through a trilogy of documents that
help us establish QAPI goals and objectives to drive health care utilization and improve the
health status of covered populations. The trilogy documents that form the QAPI Program — the
QI Program Description, the QI Work Plan and the Quality Program Evaluation — support an
organization wide culture of CQI in Louisiana. Our Board of Directors approves all three
documents and they are submitted to LDH for approval. The findings of our evaluation of the
Quality program provide the plan with the foundation for the upcoming year quality strategies,
which are addressed in the Quality Program Description and Work Plan.
QAPI Evaluation: The key mechanism for verifying adherence to LDH’s Quality Strategy is our
QAPI evaluation, through which we conduct an annual evaluation of the Quality Management
program to assess the overall effectiveness of our quality processes in accordance with our
state contract. The evaluation reviews all aspects of the Quality Management program and
Quality Improvement Work Plan, focusing on whether the program has demonstrated
improvements in the quality of health care service provided to enrollees.
Upon completion of the annual evaluation, the Quality Management Committee (described in
Question 2.10.11.4.1) and the Board of Directors review and approve the annual evaluation. We
use the results of the annual evaluation to develop and prioritize the next year’s annual quality
management program and Quality Improvement Work Plan.

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Quarterly: The Quality Management Committee (QMC) reviews and evaluates the QI Program
Description, QI Work Plan and the QI Program Evaluation. It is during the quarterly QMC review
that we present the elements of the QAPI, obtain committee feedback and approval on all
planned QI activities. We document activities, feedback and follow up in QMC meeting minutes.
For additional information on the role of the QMC, please refer to Question 2.10.11.4.1.
Monthly: After QMC approval, our Quality Improvement Team reviews QAPI priorities in
alignment with the LDH Quality Strategy and builds the QI Work Plan. The QI Work Plan is a
living document and we revise it monthly as we continue to make progress on interventions and
prioritize improvement opportunities. During this time, we also share our QI program goals and
activities with enrollees through our HealthTalk newsletter, social media (e.g., Twitter
@UHCPregnantCare) and through SilverLink live outreach calls. We complete QI Work Plan
activities within the year.
Ongoing: Our quality team incorporates ongoing
monitoring of critical quality indicators, formal
performance improvement projects, ongoing
application of rapid cycle improvement and the Plan-
Do-Study-Act method along with analysis of gaps in
care to identify specific improvement projects such
as:

Data‐driven Example #1: ADHD

Performance Improvement Project
Due to the prevalence of Louisiana youth who have
ADHD diagnoses and medication prescriptions, LDH
tasked the five MCOs to conduct a 3-year Figure 25. Three‐year positive trends for ADHD,
consistently exceeding HEDIS goals for the two‐part
collaborative performance improvement project (PIP) measures.
on ADHD.
For the ADHD initiative, we analyzed gaps in care and found that providers needed additional
education to address barriers. For example, during one clinical visit for ADHD measures (e.g.,
30-day follow up once medication begins) our clinical support staff realized that a provider was
scheduling the enrollee to return on the 29th or 30th day for follow up. This did not allow enough
time to complete the follow up in the case of enrollees needing to reschedule appointment. We
encouraged the provider to write a prescription for the medication for 10-14 days then schedule
the follow-up appointment on the 21st day. This allowed room for rescheduling which still
providing the opportunity to meet the VBP metric.

Data‐driven Example #2: EPSDT

We also monitor our EPSDT scores and
implement strategies to improve, and our
outcomes demonstrate improvement. Along with
our HEDIS/Performance Measure outcomes, our
positive EPSDT screening ratio trends exemplify
our commitment to our most vulnerable Figure 26. Our EPSDT Q1 total screening ratio is 84%,
representing +4% above the Department’s established
population. goal of 80%.

The group with the lowest screening and participation ratios receives no incentive to participate,
as the well-visit incentive stops at age 17. As noted last quarter, this may send a message to
the older adolescents that a well visit is not important. A pattern of not maintaining a relationship
with a PCP then follows into young adulthood. This is evidenced by 21- and 22-year-olds being

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the least compliant for the HEDIS performance measure of Access to Care. Due to these
findings, we continue to emphasize the importance of EPSDT/well visits to parents/guardians,
via incentive programs, such as Baby Blocks through the first 15 months, and well visit gift cards
for annual visits thereafter to try to build healthy habits early on. These benefits are noted in the
Enrollee Handbook.
2.10.11.3.1 Analyzing gaps in delivery of services and gaps in quality of care, areas for improved management of…
Since 2015, we have had a Louisiana Health Disparities Plan to identify and reduce specific
parish-based health disparities along with clinical priorities and action steps to address identified
health disparities. We also use this action plan to assess and improve overall culturally
appropriate programs, services and capabilities within the health plan.
To understand gaps in delivery of services and gaps in quality of care, we evaluated statewide
population data using our HEDIS and Health Plan Manager (HPM) reports. HPM enables us to
identify health care disparities annually associated with enrollee age, gender, race/ethnicity,
language and geographic location, and to monitor and evaluate the effectiveness of the
interventions using an age, gender, race/ethnicity, language and location filter. The HPM uses
claims data to provide information on enrollee compliance based upon race and age, and even
allows for a drilldown based upon compliance of select parishes.
An example of how we analyze gaps in delivery of services and care include the Louisiana
Health Disparities Action Plan — an ongoing clinical priority. In the plan, we analyzed four
parishes against HEDIS performance measures, State goals and NCQA Quality Compass
Benchmarks to determine specific gaps in care by target locations (both urban and rural),
enrollee ethnicity, gender and age. We also considered those areas of priorities defined by LDH.

Reducing Health Outcome Disparities by Parish

The following tables illustrate the clinical priorities and action steps for our focus across
Louisiana to reduce the impact of health disparities based upon yearly analysis of the data in
two of the four parishes analyzed. Our specific efforts to acknowledge and support the impact of
culturally competent care and improved health outcomes in Louisiana are shown in four clinical
areas inclusive of the expansion population.
Clinical Area #1: Adult Health (Attachment G #4)
Parish: East Baton Rouge, Lafayette, Jefferson, Caddo
Ethnicity: African‐American
Gender/Demographics: Male and female, age 21+
Improvement Strategies & Action Planning (2018‐2019): Local provider‐facing staff outreach to PCPs with
high numbers of non‐compliant enrollees in targeted parishes. Reinforce HEDIS guidelines, Care Opportunity
Reports, Link use. Reinforce enrollee and provider education during provider expos, Health Talk, enrollee
welcome calls and VBP Adult Prevention Access measures.
Results: Percentage of Non‐Compliance
 East Baton Rouge: Non‐compliance improved from 16.24% (2016) to 16.05% in 2018.
 Caddo: Non‐compliance improved from 26.26% (2016) to 23.84% in 2018.
Clinical Area #2: Women’s Health (Attachment G #21)
Parish: East Baton Rouge, Lafayette, Jefferson, Caddo
Ethnicity: African‐American
Gender/Demographics: Female, ages 16‐35 years
Improvement Strategies & Action Planning (2018‐2019): Local provider‐facing staff outreach to OB
providers with OB toolkit including Healthy First Steps (HFS). HFS now has one manager and four case
managers in Louisiana. Connect Reducing Premature Births PIP outcomes to drive improvement, promote

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Baby Blocks incentives program (e.g., eight incentives for pregnancy and postpartum.) Targeted live IVR calls
to new mothers to determine postpartum visit status and appointment setting if needed. Use of social media
through Twitter: @UHCPregnantCare (In Spanish: @UHCEmbarazada) and Text for Baby (English/Spanish).
Use of “Baby Showers” program to educate pregnant mothers in geographical areas where we identified high
pregnancy/low prenatal care.
Results: Percentage of Non‐Compliance
 East Baton Rouge: Non‐compliance improved from 51.50% (2016) to 37.46% in 2018.
 Caddo: Non‐compliance improved from 48.97% (2016) to 38.62% in 2018.
Clinical Area #3: HbA1c Testing (Attachment G #46 Comprehensive Diabetes Care/CDC Measure)
Parish: East Baton Rouge, Lafayette, Jefferson, Caddo
Ethnicity: All races
Gender/Demographics: Female, all ages
Improvement Strategies & Action Planning (2018‐2019): Locally based provider‐facing staff continue to
review opportunities for care for HbA1c measures. Updated Diabetes Toolkit, created by the quality team, and
used exclusively in Louisiana with high volume providers. Practitioners with linked, diabetic patients, have
CDC A1c as incentive measure on their VBP scorecard. Diabetic screening initiative noted in the Member
Handbook and $50 voucher toward retail items for those who complete their HbA1c labs within 90 days of
enrollment. In negotiations to collaborate with New Orleans East Hospital for their diabetic program affiliated
with the Cleveland Clinic to generate positive outcomes.
Results: Percentage of Non‐Compliance
 East Baton Rouge: Non‐compliance improved from 26.23% (2016) to 23.01% in 2018.
 Caddo: Non‐compliance improved from 27.23% (2016) to 20.65% in 2018.
Clinical Area #4: Diabetic Eye Exams (Attachment G #46 )
Parish: East Baton Rouge, Lafayette, Jefferson, Caddo
Ethnicity: All races
Gender/Demographics: Female, all ages
Improvement Strategies & Action Planning (2018‐2019): Targeted outreach to Lafayette, Jefferson and
Caddo parishes, from MARCH Vision for Q4, with emphasis on female enrollees. UnitedHealthcare and
MARCH Vision Automated Call Campaign conducted in June 2018 using a list of non‐compliant Louisiana
diabetic enrollees. Claims for 524 unique enrollees (some with multiple dates of service) were received as of
October 2018. Importance of diabetic eye exams emphasized with culturally appropriate flyers addressed at
provider expositions, reaching providers from all four targeted parishes.
Results: Percentage of Non‐Compliance
 East Baton Rouge: Non‐compliance improved from 61.30% (2016) to 52.84% in 2018.
 Caddo: Non‐compliance improved from 50.96% (2016) to 50.36% in 2018.

We continue adjusting our efforts to achieve the desired health outcomes by potentially
implementing initiatives such as Community Health Fairs, and providing continued engagement
of CHW field staff from our enrollees’ communities, and culturally tailored enrollee materials and
resources.
We have a strong presence in the state with enrollees and their families and welcome the
opportunity to enhance our efforts to offer programs and services that reflect an understanding
and appreciation for the cultural diversity of enrollees and the community. This includes
providing enrollee materials that are enrollee-centric, culturally inclusive and accessible to non-
English-speaking enrollees.
2.10.11.3.2 Identifying underlying reasons for variations in the provision of care to enrollees; and
We identify the underlying reasons for variations in care based upon data analytics, culturally
competent services delivery, analyzing enrollee outreach, and supporting and assessing a

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provider’s cultural competence working with enrollees. We also understand the impact of social
determinants of health and health disparities in accounting for variation of care.

Reducing Variations in Care Provision

Our approach to improving member care is local and community-based. We build our programs
focused on supporting our enrollees to achieve better health with an understanding of their
communities, the cultural needs of enrollees, and provider network.
As an organization, we are committed to removing barriers to care for all enrollees. We
recognize the critical importance of culturally appropriate and effective communication to
improve the service experience for enrollees and to reduce/eliminate health disparities that
result in variations in the provision of care. We use effective communication strategies to
support enrollees. This includes assisting enrollees with limited English proficiency through our
language interpretation services, assisting enrollees who are hearing or sight impaired using the
711 National Telecommunications Relay Service (TTY) line or using Braille or large print for
member communications. For enrollees with cognitive deficits related to either disease states
(e.g., Alzheimer’s) or mental illness (e.g., depression, schizophrenia), our member services
associates are trained to assist the member using empathetic listening and if necessary,
engage the assistance of a CHW.
Based upon the feedback we have received from enrollees in Louisiana, culled from enrollee
survey feedback, face-to-face community outreach and analysis of data, we find that
transportation to appointments, childcare and taking time off from work are some of the major
barriers that Louisiana enrollees face.
Reducing care outcomes variation is among the plan’s goals. This is a phased process. As we
implement care delivery/care continuum measures, the provider initially realizes significant cost
of care reductions. As we perfect these measures over time, we can expect a reduction in
variability and improved quality outcomes for our enrollees. This improvement includes access
to care, ED utilization for non-engaged enrollees, inpatient and readmits, discharge planning,
and high risk and non-engaged enrollee care coordination.
2.10.11.3.3 Implementing improvement strategies related to analytical findings pursuant to the two (2) functions…
To eliminate enrollee barriers to health, we use several methods to identify and mitigate issues:
Reminder Calls: By monitoring utilization rates and gaps in care, we initiate outreach to
enrollees to remind them of appointments. Our customer service staff asks the member if there
are any barriers to receiving care. They can then arrange their medical/behavioral appointment
for the enrollee and arrange transportation during the call.
UHC Doctor Chat: To facilitate access to care to meet enrollee needs, we implemented a chat-
based, virtual visit ED diversion program in Louisiana in March 2019. The program addresses
enrollees with CHF, COPD, sickle cell, chronic pain or asthma AND two or more ED visits in the
past 12 months AND one non-emergent ED visit in the past 12 months, prioritized by their risk
for experiencing an inpatient admission as identified by our Hotspotting Tool. Enrollees can also
use the Chat app or web portal to communicate via secure chat, telephone or video with an RN
and M.D. if needed for care, 7 days a week (9 a.m. to 9 p.m.).
Provider Cultural Competency Training: We understand the importance of providing
culturally competent care. In fact, in August 2018, we conducted a provider survey focused
on the cultural competency of our providers (e.g., PCPs, OB/GYNs, specialists and
behavioral health). Seventy percent of providers agreed that unaddressed cultural issues (e.g.,
language barriers, low health literacy or mistrust) resulted in no-adherence, lower quality of care

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or avoidable ED visits. As a result, our QMC created an action plan to revise the Cultural
Competence provider website to include more training options. Many of the trainings include
CEU credits to encourage provider engagement. We also distributed a summary of Cultural
Competency resources at recent Provider Expos along with an Agency for Healthcare Research
and Quality (AHRQ) Health Literacy Universal Precautions Toolkit.
Our approach to quality management (QM)/QI consists of QI projects and studies, clinical
practice guidelines, health promotion/health disparities initiatives, ongoing measurement and
monitoring of key clinical and service indicators, continuity of care, health plan performance
analysis and auditing, service coordination, educating enrollees and physicians, risk
management and compliance with all external regulatory agencies and NCQA accreditation
standards.
2.10.11.4 The Proposer should submit an overview of its proposed approach to Quality Management and Quality…
2.10.11.4.1 The Proposer’s current QM/QI organizational plan description, goals, quality committees, and…
We use an integrated approach to our quality structure and oversight, incorporating physical
health and behavioral health programs holistically to address care and service rendered across
the health care continuum. Our documented quality committee structure delineates clear
accountability and inclusive participation by leaders from all functional areas within our local
health plan. These leaders are empowered to act to address opportunities to improve care and
service. We consider our QM/QI program to be the foundation of our health plan. Our
responsibility requires a vigorous and ongoing process to identify opportunities for improvement
in care practices and in the processes that support our health care delivery system. Our QM/QI
program organizational plan encompasses two primary operating committees and four
subcommittees that oversee and drive quality excellence at every level of the Louisiana
Medicaid Managed Care Program.

Organizational Plan Supporting the QM/QI Program

The QMC is the oversight, decision-making body that is accountable for the implementation,
coordination and integration of all QI/QM activities specific to Louisiana. Our QMC includes both
medical and behavioral health clinical staff and operational leaders who are committed to
supporting a Medicaid managed care delivery system that meets the Department’s Aims, Goals
and Objectives:
 Advance evidence-based practices, high-value care and service excellence
 Support innovation and a culture of CQI in Louisiana
 Provide enrollees ready access to care, including through nontraditional means such as
medical homes and telehealth
 Improve enrollee health
 Decrease fragmentation and increase integration across providers and care settings,
particularly for enrollees with behavioral health needs
 Use a population health approach to maximize enrollee health, supported by health
information technology, to advance health equity and address SDOH
 Reduce complexity and administrative burden for providers and enrollees
 Align financial incentives for plans and providers and building shared capacity to improve
health care quality through data and collaboration
 Minimize wasteful spending, abuse and fraud

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The Louisiana QMC analyzes and evaluates the result of QI activities, recommends policy
decisions, verifies that providers and enrollees are involved in the QI program, institutes needed
action and makes certain appropriate follow up occurs.
Quality Management Description of Quality Committee and Oversight
Operating Committees
Board of Directors The Board has oversight of all QM functions and provides feedback and
recommendations to the QMC. Meeting Frequency: Annual
Quality Management Scott Waulters, interim CEO and Dr. Julie Morial, CMO are co‐chairpersons of the
Committee (QMC) QMC which meets at least quarterly. This decision‐making body is ultimately
responsible for the implementation, coordination and integration of all QM
activities for the health plan inclusive of Board‐delegated decisions. QMC
membership includes a designated representative from each department that is a
voting member. The QMC structure includes four subcommittees that oversee and
drive quality. Each subcommittee chair is a member of the QMC to provide
alignment between the subcommittees and the QMC’s Quality Plan. In all
committees and subcommittees, medical and behavioral health concerns are
integrated. Meeting Frequency: Quarterly and ad hoc
Provider Advisory Dr. Julie Morial is chairperson for the PAC. The PAC is a peer‐review committee
Committee (PAC) with local community and hospital‐based clinicians that support our efforts to
improve quality of care across the care continuum. The PAC is responsible for
performing peer review activities and confirming final decisions by the National
Credentialing Committee (NCC). The PAC is responsible for evaluating and
monitoring the quality, continuity, accessibility, availability, utilization and
network cost of health care. Meeting Frequency: Quarterly
Healthcare Quality and Dr. Morial is chairperson of the HQUM Committee. The committee meets at least
Utilization quarterly and monitors clinical QM and utilization management (UM) activities,
Management including a review of QM activities, progress on clinical performance measures
Committee(HQUM) and effectiveness of PIPs. The committee monitors overutilization and
underutilization issues. Meeting Frequency: Quarterly
Service Quality Karl Lirette, Chief Operating Officer and Dr. Morial, are co‐chairpersons of the
Improvement SQIS. The SQIS meets quarterly to monitor the quality of enrollee and provider
Subcommittee (SQIS) services and our overall service performance levels. The SQIS oversees delegated
service functions to monitor and support improved services to enrollees and
providers. Meeting Frequency: Quarterly
Member Advisory Brad Grundmeyer, Director Of Marketing & Community Outreach, is chairperson
Committee (MAC) for the MAC. The MAC provides enrollee and family representatives the
opportunity to discuss and direct feedback on our QM program and our support
of the Quality Strategy by encouraging meaningful engagement with enrollees.
Our goal is to drive actionable improvements to our delivery model through
member feedback and engagement. Quality is a standing agenda item on the MAC
and enrollee initiatives are discussed at this committee where enrollee input is
sought. This committee reports to our QMC and enrollee input from this
committee is a standing agenda item. The MAC reflects the diversity of our
enrolled membership vis a vis race, gender, special populations and geographic
areas. Meeting Frequency: Quarterly
2.10.11.4.2 A description and organizational chart of its proposed QM/QI program, including a list of the…
The QM/QI program objectively monitors, systematically evaluates and effectively improves the
quality and safety of clinical care and quality of services provided to all enrollees in the health
plan population. The graphic illustrates the QM committee structure.

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To drive clinical and operational performance

improvement, the Louisiana quality team incorporates
ongoing monitoring of critical quality indicators, formal
performance improvement projects, ongoing
application of rapid cycle improvement and Plan-Do-
Study-Act (PDSA) method and compliance with
federal and state regulations and NCQA health plan
accreditation standards.

Quality Management Staffing Resources

We provide health plan leadership, dedicated to a
Culture of Quality. Every employee in our health plan
is part of our overall quality strategy; several enrollees
of the team have direct responsibility for day-to-day
management of our quality initiatives. This includes
interim CEO, Scott Waulters, co-chairperson of the Figure 27. The Louisiana Medicaid Managed Care
QMC, who has administrative oversight of the Program Quality Management organizational chart
Louisiana QAPI program. illustrating local oversight.

Staffing/# Staff Description

Medical Directors (2)  Dr. Morial is a Louisiana licensed physician. Dr. Morial is chairperson of the PAC
 Chief Medical Officer and is co‐chairperson of the QMC as shown in the table.
 Behavioral Health  Dr. Jose Calderon‐Abbo is a Louisiana licensed physician. He reports to Dr.
Medical Director Morial as part of our operating structure. Dr. Calderon is responsible for the
behavioral health business unit and services. He has oversight of United
Behavioral Health, our behavioral health services subcontractor.
 Provider‐facing Staff Our provider‐facing staff includes medical and behavioral clinical and non‐
(25) clinical staff with expertise in utilization patterns, cost analysis, quality
improvement process, reviewing provider performance, identifying gaps in care,
tracking improvement in alignment with our value‐based contracting and drive
QM/QI program initiatives. As part of this staff, 12 individuals are responsible
for QM:
 Deb Junot Quality Management Director: Responsible for the QM program
implementation, development and strategy as it relates to our provider
population and enrollee population. This position is responsible for the day‐to‐
day operations of the program, which is inclusive of quality outcomes (HEDIS),
enrollee surveys (CAHPS) PIPs as designated by the State. This position also
represents the health plan at LDH state quality meetings and follows up on any
State quality initiatives.
 Quality Nurses: RNs with expertise in patient safety and risk management work
as part of our quality team to investigate quality of care, quality of service or
critical incidents, refer and follow up on these issues with the Peer Review
Committee and send patient safety trends to our PAC.
 Quality Managers: These clinicians and public health professionals closely
monitor structure, process and outcomes measures over time and against our
performance goals, conduct barrier analyses and implement programs to
improve care and services rendered.
 Quality Analysts: Our quality analysts support our ongoing reporting needs,
including verifying that our reported rates are reliable and valid and producing
population health analyses to enable segmentation of enrollees based upon
geography, demographics or social determinants.

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2.10.11.4.3 The Proposer should demonstrate its capacity to participate in LDH’s annual HEDIS performance…
We are privileged to have served Louisiana Medicaid recipients since 2012. Currently, we serve
more than 442,000 Louisiana Medicaid Managed Care Program enrollees. As illustrated in the
table, we have continuously improved our HEDIS and CAHPS scores, which demonstrate
outcomes improvement year after year.
Year Survey Type Accreditation Standards HEDIS CAHPS Totals
Status
July 2015 First (July 2014 – Accredited 48.8718 18.6357 12.4150 79.9225
July 2017)
August 2015 Annual Update Accredited 48.8718 18.6357 12.4150 79.9225
August 2016 Annual Update Commendable 48.8718 21.4970  12.1330 82.9890 
July 2017 Renewal (July 2017 Commendable 49.5420 21.4793  12.1330 83.1526 
– July 2020)
August 2017 Annual Update Commendable 49.5420 23.1846  12.1911  84.9177 
August 2018 Annual Update Commendable 49.5420 23.6421  12.8267  86.0107 

Availability of Resources
We are committed to providing the Louisiana Medicaid Managed Care Program with the
resources required to continue improved outcomes and “Commendable” status as an NCQA-
accredited health plan. To drive improved health outcomes we use data analytics from HEDIS,
QOC, CAHPS, peer comparisons, Enrollee Gap Report, Enrollee Quality Gap Report, Utilization
Report, Provider Network Accessibility/Availability Report, Provider After-Hours Report and the
SDOH Report for the State. Please refer to our response to Question 2.10.11.4.2.
2.10.11.4.4 The Proposer should provide an example of a recent successful quality improvement activity; and
We conduct programs to improve the health of enrollees diagnosed with multiple or severe
chronic conditions. The PIPs are a set of interventions affecting both the enrollee and
practitioner that promote better care and service for enrollees who we monitor on an ongoing
basis. We are committed to objectively and systematically monitoring and evaluating the quality
and appropriateness of care and service provided to enrollees. To support this, PIP
interventions are determined based upon the needs of the population and the State. They focus
on identified clinical or non-clinical areas that specifically improve access to preventive services
or health outcomes for vulnerable groups within the Medicaid population.
The table describes a recent PIP for Improving the Quality of Diagnosis, Management and Care
Coordination for Children and Adolescents with Attention-Deficit Hyperactivity Disorder.
Improving the Quality of Diagnosis, Management and Care Coordination for Children and
Adolescents with Attention‐Deficit Hyperactivity Disorder
Due to the prevalence of Louisiana youth who have ADHD diagnoses and medication prescriptions, LDH
tasked the five Medicaid MCOs to conduct a 3‐year collaborative PIP on ADHD.
PIP Focus
To improve diagnosis and evaluation; pharmacologic and non‐pharmacologic management; and care
coordination. We noted evidence of improvement via intervention tracking measures and the HEDIS ADD
two‐part measure, “Follow‐Up Care for Children Prescribed ADHD Medication.” This measure was below
the 95th percentile for all health plans at the start of the PIP in 2016. The third year of the PIP started July
1, 2018; the final report is slated for June 2019.
PIP Analysis
Four main interventions determined by LDH, along with the indicators for performance improvement. The

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Improving the Quality of Diagnosis, Management and Care Coordination for Children and
Adolescents with Attention‐Deficit Hyperactivity Disorder
foundation for our strategies was based upon results from the Integrated Practice Assessment Tool (IPAT)
survey, HEDIS ADD scores and the PCP’s chart reviews.
Barriers to Care
 Lack of PCP knowledge of assessment and intervention resources
 Lack of known trained practitioners in evidence‐based treatments for children with ADHD
 Lack of PCP knowledge of the HEDIS ADHD performance measure
Care Interventions
 Provider‐facing staff educate PCPs on resources such as the MCO sponsored American Academy of
Pediatrics (AAP) ADHD Toolkit website, which includes Vanderbilt and other screening tools
 Parent Child Interaction Therapy classes sponsored by UnitedHealthcare to increase workforce capacity
 PCP education on the HEDIS ADD measure, Whole Person Care case management for children with
special needs, the behavioral health provider search engine and other tools in our ADHD toolkit
Outcomes
As of the interim report in June 2018, examples of performance improvement indicators include:
 Validated ADHD screening instrument: increase from 43.33% to 63.33%
 Assessment of other behavioral health conditions/symptoms: increase from 58.33% to 98.3%
 PCP care coordination: increase from 43.3% to 80%
2.10.11.4.5 The Proposer should describe how it will identify quality improvement plans and projects to put in
place, what potential topics may be, and how the Proposer will monitor the implementation and outcomes of the
activity.
In alignment with the Louisiana’s Quality Strategy, we have an ongoing program of PIPs that
focus on clinical and non-clinical areas. They focus specifically on improvement of access to
services or health outcomes for vulnerable groups within the Medicaid population. For each PIP,
we establish QI work groups facilitated by our quality team and comprise subject matter experts
and functional owners to oversee the PIP. When determining potential quality improvement
topics, we consider the needs of the enrollee population such as health disparities, QI trends
and ongoing cycles of outcomes data (e.g., HEDIS, CAHPS) along with Louisiana Quality
Strategy priorities and requests. Potential topics under review include addressing improvements
in our Initiation and Engagement of Alcohol and other Drug Dependence Treatment (IET) PIP
and concentration on our Maternal Child outcomes and improvements. Using our process, we:
Collect Data: We collect and analyze data in alignment with the Department’s Quality Strategy
to use specific, measurable, actionable, realistic and time-bound (SMART) data clearly
connected to state priorities. We review HEDIS data, utilization data, care management and
disease management data, enrollee satisfaction surveys, CAHPS data and enrollee grievance
data.
Review and Approve: We present the proposed PIPs to the applicable quality committee and
for input and approval as part of our overall QAPI strategy to drive specific health outcomes.
Set Goals: We set valid, reliable indicators that accurately measure the theory of improvement
for the PIP. We assess goals against specific baseline performance and evaluate against state
or national benchmarks. Interim and final performance goals are established, and we track
process metrics to verify that interventions are being implemented and progressing as planned.
Develop Interventions: After completing an analysis to identify barriers to meet performance
goals, the PIP work group develops and implements interventions. The group selects
interventions based upon our knowledge of the population and the effectiveness and
appropriateness for the PIP population. The timing and intervention plan is also determined; the

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number and percent of the population who actually receive the intervention; and, whether the
intervention is conducted as expected or if issues arose that interfered with the implementation.
Analyze Changes: We conduct a quantitative analysis to determine if a rate change occurred in
the original selected measurement, or if we have attained goals and benchmarks. We determine
if changes are statistically significant or if they correlate to the timing of the intervention. Based
upon the findings, we determine if the interventions should continue, be adjusted, or if new
interventions should be developed.
Measure and Remeasure: The PIP work group monitors progress routinely, including regular
re-measurement to determine if actions taken have resulted in meaningful improvement. A 3-
year cycle is common, but may extend longer depending upon the topic, design and results.
Monitor Results: Interventions that result in improvement are standardized and monitored to
foster sustained improvement.
Report Recommendations: We present final project reports and recommendations to the QMC
and review our findings with our state partners and the External Quality Review Organization
(EQRO) prior to closing and QIP activities. Additionally, we document QIPs in the format
required by LDH and the EQRO and submit for regulatory review as required.
Interventions are evaluated and refined to achieve demonstrable improvement. At least
annually, the appropriate QIP committee reviews the results of evaluations and
recommendations.
2.10.11.5 The Proposer should submit a list of clinical practice guidelines relevant to the LDH Medicaid…
The following table provides LDH-specific clinical practice guidelines (CPGs). Please refer to
Attachment 2.10.11.5-1 Sample Clinical Practice Guideline and Attachment 2.10.11.5-2 Sample
Clinical Practice Guideline.
Clinical Practice Guidelines – Louisiana Medicaid Managed Care Program
 Guide to Clinical Preventive Services, 2014: Recommendations of the U.S. Preventive Services Task Force
 2017 Recommendations for Preventive Pediatric Health Care
 Practice Guideline for the Treatment of Patients with Substance Use Disorders, second edition (2006);
Major Depressive Disorder, Third Edition (2010); Schizophrenia, second edition (2004). In process of
approval by Local and National PAC‐ April 2019
 Guidelines for Perinatal Care, Eighth Edition
 2008 Physical Activity Guidelines for Americans
 ASCCP Screening Guidelines for the Prevention and Early Detection of Cervical Cancer
 Primary Care Guidelines for the Management of Persons Infected with HIV: 2013 Update
 Treating Tobacco Use and Dependence: 2008 Update
 2011 AHA/ACC Guidelines for Secondary Prevention and Risk Reduction Therapy for Patients with
Coronary and Other Atherosclerotic Vascular Disease
 Effectiveness‐based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update: A
Guideline from the American Heart Association
 2014 Evidence‐based Guideline for the Management of High Blood Pressure in Adults: Report from the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
 Standards of Medical Care in Diabetes – 2018
 2013 ACC/AHA Guideline for the Management of Heart Failure
 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of
the 2013 ACC/AHA
 2007 National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the
Diagnosis and Management of Asthma

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Clinical Practice Guidelines – Louisiana Medicaid Managed Care Program

 2018 Global Strategy for the Diagnosis, Management and Prevention of COPD
 2007 Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention
Deficit Hyperactivity Disorder*
 2011 AAP ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention‐
deficit Disorder in Children and Adolescents*
 2011 Evidence‐based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of
Degenerative Lumbar Spinal Stenosis
 Final Recommendation Statement
 ASCCP Screening Guidelines for the Prevention and Early Detection of Cervical Cancer
* Listed as a historical parameter
2.10.11.5.1 The proposed process for developing and disseminating clinical practice guidelines to participating…
We adopt evidence-based CPGs, including MCG, which serve as the framework for clinical
decisions and have proven to reduce variation in treatment resulting in optimized enrollee care
and outcomes. We select CPGs from a variety of sources that address physical health and
behavioral health and coordinate their development with other MCOs to avoid conflicting
guidelines.
We select CPGs in consideration of our enrollees’ needs and adopt them in consultation with
providers and by review and approval from our integrated PAC and QMC committee enrollees.
We use CPGs and best practices to select our value-based contracting quality measures. This
drives improved quality and outcomes on value-based contracts and meets the individualized
whole health needs of our enrollees in compliance with mental health and substance use
disorder parity requirements.
The CPGs are available to providers and enrollees via our website; provider and enrollee
newsletters; provider toolkits; our Care Provider Manual and Enrollee Handbook; prior
authorization process and care management outreach; and initial and ongoing education. Our
provider-facing staff disseminates CPGs in the course of medical record reviews, and as part of
specific initiatives. For example, we incorporate the AAP 2011 CPG on ADHD into the ADHD
PIP as mandated by LDH and the Island Peer Review Organization (IPRO), and is the basis for
the AAP ADHD toolkit. UnitedHealthcare has collaborated with the Louisiana Chapter of the
AAP, LDH and the other MCOs to co-sponsor access to the AAP ADHD Toolkit website for
practitioners of any provider type. This allows all Louisiana children to benefit from proper care
for ADHD disorders regardless of which practitioner or MCO provides their care.
2.10.11.5.2 How scientific evidence and the opinions of in-network and out-of-network experts and providers will…
As part of our national quality committees, our Medical Technology Assessment Committee
(MTAC) and Clinical Policy & Operations Committees report to the National Medical Care
Management Committee. MTAC meets at least 10 times each year to develop new policies in
response to emerging technology or new treatments based upon scientific evidence.
Additionally, we take the following actions to incorporate:
Expert Medical Practice: We adopt evidence-based CPGs, including MCG, and select CPGs
from sources that address physical health and behavioral health. Our process for using and
monitoring CPGs complies with NCQA requirements. Our CPGs align with the U.S. Department
of Health & Human Services AHRQ. Our team of national physician experts reviews all new and
existing CPGs at least annually. This includes:
Scientific Evidence/Expert Medical Practice CPG Resources
Disease management program guidelines from organizations, including the American Diabetes

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Scientific Evidence/Expert Medical Practice CPG Resources

Association, Disease Management Association of America, American College of Obstetricians and
Gynecologists (ACOG) and AHRQ
American Society of Addiction Medicine criteria for substance use disorder
Maternal child health guidelines based upon nationally accepted standards of care and key treatment
elements as outlined by ACOG
CDC recommendations for screening of pregnant women infected with HIV/AIDS
Optum physical therapy guidelines
Behavioral health guidelines, which are internally developed and based upon published references from
the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry and the
most recent version of the Diagnostic and Statistical Manual of Mental Disorders
HEDIS Technical Specifications
National Comprehensive Cancer Network guidelines for cancer
Guidelines for the diagnosis and management of asthma from the National Heart, Lung and Blood
Institute
Numerous primary and subspecialty guidelines from national policies and standards, valid and reliable
clinical evidence, and expert consensus in specific fields. For example, we follow the American Academy of
Pediatrics Bright Futures recommendations for EPSDT screens

In-Network Expert/Providers: Our local PAC reviews, adopts and recommend guidelines to
our National Committee to be inclusive of any local clinical practice.
Out-of-Network Experts/Providers: For our comprehensive preventive care guidelines, we
have developed a Preventive Services Coverage Determination Guideline (CDG). The
Preventive Services CDG is based upon guidance from the Guide to Clinical Preventive
Services of the U.S. Preventive Services Task Force, the Advisory Committee on Immunization
Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), the Bright Futures
Periodicity Schedule of the American Academy of Pediatrics and the Health Resources and
Services Administration.
2.10.11.5.3 How the Proposer plans to evaluate providers’ adherence to clinical practice standards and evidence…
Nationwide, we maintain processes for monitoring participating providers against established
CPGs for acute, chronic and preventive care, and we use this same approach in Louisiana. This
enables us to identify opportunities for reducing variation in practice patterns while supporting
our participating providers by providing feedback concerning their practice. For example:
Provider Consultation: Upon implementation of new CPGs or changes to our currently
adopted guidelines, we work with providers on our PAC to identify mechanisms to monitor
implementation. These mechanisms include ad hoc, claims-based analyses of care rendered, or
implementation of medical record review checks performed by our provider-facing staffs.
Provider Evaluation/Profiling: At least annually, we perform a formal evaluation of provider
adherence to CPGs and present this evaluation report to our QMC, who makes
recommendations for actions to improve adherence. Additionally, we profile the performance of
our contracted health care providers to include overutilization and underutilization monitoring.
We use this for quality of care monitoring and determining when a provider is not practicing in
accordance with evidence-based clinical guidelines.
Provider/Practice Analyses: Ongoing, we produce provider- and practice-level analyses of
clinical process and outcome indicators, primarily based upon HEDIS processes as HEDIS
rates are based upon national CPGs. Monitoring this data gives us an opportunity to identify
opportunities to assist our participating providers to improve tracking and outreach, resulting in

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closed gaps in care that align with CPGs. In addition to any requirements outlined by our
Louisiana regulatory partners, our process for using and monitoring clinical practice standards
and guidelines complies with NCQA requirements. We review this process for appropriateness
at least annually, and we communicate any changes promptly to our participating providers via
our provider website.

Provider Interventions to Encourage Adherence

To ensure compliance with established and new clinical guidelines, we use:
HEDIS Outcomes Review: We review our outcomes data on a monthly basis and monitor the
HEDIS utilization data results with our providers. The report demonstrates the gaps in the
metrics and the enrollees to target to close gaps. We currently have a “per gap closed” VBP
program for providers to incent quality outcomes.
Provider Education and Compliance Audit: We educate providers as we audit compliance
through routine reporting and medical record reviews. Our provider-facing staff uses a variety of
tools and materials included in our Clinical Practice Consultant HEDIS Toolkit, including gaps in
care reports, when they meet with providers. At these meetings, the Clinical Practice Consultant
reviews evidence-based quality performance guidelines for preventive and condition-specific
care, reinforces appropriate coding and reviews documentation of care rendered.
Peer-to-Peer Consultation: We implement peer-to-peer consultation with providers when our
clinical review processes indicate that a care plan may not adhere to established guidelines. In
this process, the provider is educated on the guidelines and recommendations.
Provider Advisory Committee Review: If we identify a provider- or practice-specific pattern
that leads to a concern that the provider is rendering care contrary to accepted guidelines and
could potentially lead to adverse outcomes for our enrollees, our PAC reviews these findings for
evaluation and action as needed not excluding termination of the provider.
2.10.11.5.4 The ongoing evaluation process for updating and revising the Proposer’s clinical practice guidelines…
We have adopted multiple evidence-based practices within our current service delivery model.
We are committed to expanding our CPGs to include additional best practices and CPGs to
meet the needs of the Louisiana Medicaid Managed Care Program populations. Throughout the
development and adoption of CPGs and evidence-based practices, we discuss and review with
our integrated PAC and the QMC for any recommendations and approval on an annual basis.
Our national quality committees also work to develop new policies to address emerging
technology or new treatments based upon scientific evidence.
We use a systematic approach to evaluate promising and evidence-informed practices. For
example, we base our Transitional Care Management program upon the Coleman Model of
Care Transitions. Our case managers use evidence-based motivational interviewing skills
during care planning discussions with enrollees and their families. We use peer support
services, evidence-based practice and care plan intervention for behavioral health recovery.
The Quality Department conducts medical records reviews on PCPs with 50 or more linked
enrollees every 2 years. This review addresses CPG elements that the providers are required to
perform. We report the results of these reviews to LDH on a quarterly basis and implement
interventions with the providers when necessary. Additionally, we comply with all requirements
related to fidelity monitoring for behavioral health CPGs (Model Contract 2.16.17.).
2.10.11.6 The Proposer should submit, as an attachment using the Quality Response Template provided in the…
Please refer to Attachment 2.10.11.6 NCQA Health Insurance Plan Ratings (2018-2019).

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2.10.12 Value-Based Payment

The Proposer should propose a Value-Based Payment (VBP) Strategic Plan, including an implementation…
Demonstrating a culture of innovation and continuous
quality improvement, UnitedHealthcare has continued UnitedHealthcare’s
to evolve our approach to value-based payment (VBP) commitment to expanding VBP
programs for Louisiana’s Medicaid Managed Care programs is evident in our
providers in support of the Triple Aim over the last 7 growth in member months tied
years. Through participation in our VBP programs, to providers engaged in VBP
providers overcome barriers to deliver better care to from 50% in 2017 to 91% in
enrollees and move the needle on Louisiana’s overall 2018.
performance in critical health measures. To provide our
enrollees the right care, at the right time, at the right place, we closely align our VBP strategy to
our population health and care management strategies to help even the most vulnerable
enrollees (e.g., high-risk maternal health enrollees) receive the care they need.
The figure outlines our continuous development of VBP programs to meet LDH goals, and our
strategic vision through 2020 and beyond. This, along with the programs discussed in 2.10.12.1
and our expansion plan in 2.10.12.3, is included in our VBP Strategic Plan, submitted to LDH
annually. We will continue to abide by all State, federal and contractual requirements in the
administration of VBP programs.

Through our experience across 25 states where we serve Medicaid enrollees, developing
foundational payer-provider-community relationships and influencing behavior change over time
is critical. As demonstrated in the figure, upon moving to a full risk plan in 2015, we added multi-
level VBP arrangements for providers ready to truly drive change and improve outcomes for
enrollees, based upon their size and level of sophistication.
From there, we continued to develop our offerings and engage providers — performing over
1,000 face-to-face visits in 2018 alone, to educate them about using our VBP programs.

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Based upon feedback from providers, in 2018, we moved from rewarding quality on a PMPM
basis to rewarding providers immediately as they close gaps. Further, though the standard
national approach was to pay out incentives annually, UnitedHealthcare implemented quarterly
incentive payouts in Louisiana. Providers welcomed this change, and we have already seen
improvement in our quality scores. For the targeted measures in our
, we closed an additional 5,916 gaps in 2018 versus 2017 (after normalization). In
addition, 63% of group/measure combinations improved or maintained performance year over
year for those targeted measures.
From 2017 to 2018, we saw a 34% increase in telehealth claims received. With the increase, we
have begun implementing a telehealth hosting incentive for identified provider groups. We will
reimburse host providers for coordination of the patient visit at their facility. We will continue to
explore expansion in our telehealth programs, both VBP and non-VBP related, to support our
providers as further outlined in the Network Management Section (2.10.8).
In 2019, we furthered our commitment to helping Louisiana providers move along the Health
Care Payment Learning and Action Network (HCP-LAN) Alternative Payment Model (APM)
continuum, receiving a letter of intent from Louisiana Children’s Medical Center (LCMC) to begin
participating in population health data sharing. This engagement will allow LCMC to use data
sharing to learn case management and build the foundation for a capitation model that we plan
to launch in 2021. The outcomes of our successful collaboration with LCMC will continue to
guide our strategic plan for the State, as outlined in Section 2.10.12.3. While our 3-year strategy
focuses on our VBP programs, we are always willing to align or discuss alignment with multi-
payer VBP models.

LDH Program Goal: Align financial incentives to meet providers where they
are, improving health care quality through data and collaboration
Acting on Provider Feedback to Improve VBP Engagement
“[UnitedHealthcare] has been a great partner to work with on improving the health
outcomes of our patients, and we look forward to advancing our relationship. The recent change
[UnitedHealthcare] made to their represents a preferred
contracting model. The is easy to understand,
comprehensive, transparent and includes timely payments that are direct results of the quality
care we are providing to our patients. – John Heaton, M.D., President of Clinical and Systems
Operations, LCMC Health
2.10.12.1 The specific models and VBP arrangements the Proposer will implement to ensure that it meets the…
UnitedHealthcare has demonstrated success in, and continues to develop VBP programs that
drive providers along the HCP-LAN APM continuum and has achieved LDH’s vision for a
healthier Louisiana. As outlined in 2.10.8.3, in 2019, we will continue to offer established
programs such as our
, 17-P, and Notice of Pregnancy models and expand our suite to include Hospital
Performance Based Contracting, Behavioral Health, Opioid Use Disorder Quality Medication-
Assisted Treatment, and Maternity Episodes programs. Beyond 2019, as outlined in our
strategic plan, we will continue to push expansion into VBP for new specialties and advanced
VBP models in alignment with state priorities.
We will continue to meet VBP requirements outlined in Section 2.17 of the Model Contract.
Section 2.17.9 of the contract outlines LDH’s preferred VBP arrangements over the next 3
years. Our current slate of programs already meets these criteria.

. We also have preliminary CY2019 estimates. As we list each VBP

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model, we outline the expected and maximum payouts based upon CY2019. The annual
estimated bonus payment could vary in future years depending on program design,
provider feedback and LDH priorities.
We look forward to continued partnership with LDH as we expand our VBP footprint and
programs in line with LDH priorities. In the following sections, we outline the VBP arrangements
we have deployed, including APM category and targeted provider types. Through our provider
support model, detailed in 2.10.12.4, we offer dedicated staff to support providers in reaching
goals and intended outcomes, and provide data analytics and training sessions. We take
provider feedback to heart and continue to evolve our VBP programs to align with provider
needs and LDH priorities.

Performance‐based Incentives (APM 2)

APM category 2 rewards many provider types with bonus payment opportunities, in addition to
their fee-for-service (FFS) reimbursement, for delivering high-quality care in relation a set of
HEDIS quality metrics defined by LDH in Attachment G. Providers can achieve bonuses by
closing gaps in care and/or meeting and exceeding a targeted threshold of gap closure
compliance rates. These incentives allow us to address specific and targeted quality measures
through common incentive program methods, while offering VBP opportunities to a large volume
of providers. This includes those in areas of the state with high rates of health disparities, such
as East Baton Rouge, Orleans and Caddo parishes where health outcomes are consistently the
lowest in the state for several quality metrics.
For many providers, this APM category serves as an entry point to a pay-for-quality
environment, and we see this as a crucial engagement platform to build provider best practices
that can mature into future VBP opportunities that entail greater risk at higher APM categories.
Most of our performance-based incentives across all lines of business share common reporting
platforms, bonus payment structure and field-based quality engagement resources. This
reduces complexity for participating providers so they can focus less on administrative details of
coordinating VBP programs and more on improving the quality of care delivered.

Notification of Pregnancy Incentive (HCP‐LAN Category 2B)



This program rewards high-volume OB providers for submitting a notification of pregnancy

(NOP) form to UnitedHealthcare to identify enrollees who are pregnant and who have
pregnancy risk factors. When providers submit the NOP form, it triggers the enrollee’s
enrollment into case management where we can address prenatal risks.

. Since 2017, we have received over 11,000 NOP forms from providers to help us
identify high risk and pregnant enrollees.
After
program evaluation and feedback from the providers, we expanded it in 2019 to include our top
40 OB provider groups.

(HCP‐LAN Category 2C)



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David Raines Community Health

Center, an FQHC in Shreveport,
was able to use incentive dollars
It earned through the
to add
provides Medicaid enrollees with ready access to
additional enrollee outreach staff.
comprehensive wellness, prevention and care
Outreach staff help close gaps in
coordination services. care by calling enrollees to
schedule follow‐up appointments
— further improving the center’s
quality of care and outcomes for
enrollees.

Participating providers receive FFS reimbursement plus the opportunity to earn incentives for
closing gaps in care.

LDH Program Goal: Reduce complexity and administrative burden for

providers
Increasing VBP participation through timely payment for improvement and
user-friendly, actionable reporting
“[UnitedHealthcare] has been a great partner to work with to improve the health outcomes of our
members. They have implemented the best and most comprehensive value-based incentive
plan. The reports are easy to understand, and the program rewards the provider for incremental
improvements, not just when we meet the target. This approach allows the providers to be
awarded for any improvement in our members’/patients’ outcomes.” – Michael Griffin, President
and CEO, Daughters of Charity

(HCP‐LAN Category 2C)



Implemented in Louisiana in January 2018, our is one

of the ways we work with specialists to facilitate access to comprehensive health, wellness,
prevention and care coordination services for our enrollees. The program rewards qualifying OB
specialist providers for closing care opportunities for certain HEDIS measures and improving
birth outcomes. As part of the program, a provider can earn bonus payments for achieving or
exceeding target scores for select performance measures in alignment with Attachment G. The
bonus is in addition to the provider’s compensation for rendering enrollee services.
We collect data through claims submission, reducing the administrative burden for providers
and UnitedHealthcare. When earned, we send bonus payments to providers quarterly, as we do
with our .

Behavioral Health Value‐based Payment Model (HCP‐LAN Category 2C)



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Beginning in 2019, we incorporated the follow up after hospitalization for mental illness (FUH 7)
HEDIS measure into our

This incentive facilitates integration across

providers and improved care for enrollees by encouraging medical providers to help
enrollees seek behavioral health care. It also encourages the medical provider to establish a
relationship with behavioral health providers in their community so they can have a resource for
future referrals. Through this incentive, PCPs work closely with behavioral health providers to
coordinate vital mental health follow ups as soon as possible following a discharge.

. We believe incenting both medical and

behavioral health providers with incentive dollars tied to the outcome of the same measure
creates mutual incentive to collaborate following discharge. We will continue to expand this
new program based upon feedback from providers and LDH priorities.

Opioid Use Disorder Quality Medication‐Assisted Treatment Value‐based

Payment (HCP‐LAN Category 2C)


We recognize the need for a comprehensive approach to prevent, identify, treat and promote
ongoing recovery for those with opioid use disorder (OUD). Aligned with the Heroin and Opioid
Prevention and Education (HOPE) Council goals and the Louisiana PEW Charitable Trust
Recommendation 2, which focused on expanding medication-assisted treatment (MAT) capacity
through care coordination and enhanced rates, we have developed a VBP program aimed at
increasing access to high quality MAT and supporting enrollee retention in treatment. Given the
high overdose death rate in the Orleans and Jefferson Parishes, in Q1 2019, we initiated a
partnership with Daughters of Charity to launch our OUD Quality MAT pilot.

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We look forward to partnering with additional high quality providers to expand our innovative
OUD VBP pilots, and sharing the results of our pilots with LDH to inform the implementation of
strategies to expand MAT services.

Hospital Performance Based Contracting Model (HCP‐LAN Category 2C)



Our Hospital performance-based contracting (PBC) model is currently available for Louisiana’s
hospital systems. The primary objective of this model is to reward hospitals for improving the
quality of care and the costs associated with that care. Quality and efficiency measures vary by
hospital based upon the greatest areas of opportunity as determined from historical utilization
and cost reporting. The quality measures that are available for inclusion are Hospital CAHPS
(HCAHPS), Early Elective Delivery and Mortality Rate (for three conditions).

17P (Progesterone) Incentive for OB Providers (HCP‐LAN Category 2C)



In January 2017, UnitedHealthcare implemented a 17-P pilot with Woman’s Associates of Baton
Rouge (Woman’s) and Lane Medical to help high-volume OB providers lower preterm birth and
align with LDH quality performance requirements. This pilot was well received by providers and
in 2018, we expanded it to include our top 40 OB providers. They earn incentive payments for
providing this service to our enrollees. We monitor performance through claims submission and
pay the bonus quarterly, minimizing the administrative burden for providers.

Maternity Episodes (HCP‐LAN Category 3a)



This episodic payment model has influenced the use of

elective interventions (e.g., C-sections) and the use of
appropriate support during labor and delivery, thereby
driving a reduction in the likelihood of avoidable

complications and readmissions — ultimately improving

the total cost of perinatal care. In April 2019,
UnitedHealthcare and Green Clinic OB physicians
agreed to partner on an episode incentive program to
improve maternal child outcomes.
To engage with our enrollees, we use our perinatal
program, Healthy First Steps, which emphasizes enrollees’ ongoing engagement with an OB
provider, promotes attendance at regular visits and addresses any barriers to receiving care
including assisting with setting and attending appointments. Further, beginning in May 2019,
UnitedHealthcare is partnering with Louisiana Woman’s Associates for Health to place a nurse
in their practice. This position will address our Medicaid maternal needs and address any

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barriers present for our enrollees (e.g., SDOH, behavioral health needs, appointments, referrals
to our Healthy First Steps program, transportation or needs).
Our OB case managers provide active monitoring and follow up to confirm ongoing compliance
with visits for all enrollees, regardless of risks. We are initially implementing the episodes
program as upside only with plans to incorporate downside risk in the future, and expand the
program to include hospitals.

Shared Savings Programs (HCP‐LAN Category 3a/b)



UnitedHealthcare’s APM Category 3 programs provide financial incentives that supplement core
FFS reimbursement in a way that drives a shift in mindset from volume of care to value of care.
Nationally, these shared savings programs cover over 1.4 million Medicaid enrollees, account
for over $4.5 billion in Medicaid spend, and 300 Medicaid shared savings providers spanning 19
states. Of those, 38% are in Louisiana.
Our shared savings programs assist interested PCP practices to Louisiana providers in
reach Patient Centered Medical Home (PCMH) recognition, drive a shared savings
higher quality of health and care, and seek to lower the cost of program lowered their
care by supporting a model focused on improving the lives and inpatient admit rate
(per 1,000) by 26.8%
health of each enrollee. We encourage groups to have experience
between November
in the upside-only “total cost of care” shared savings model prior
2016 and November
to taking on risk. If a group has maintained sufficient scale (i.e., 2018.
meets LDH membership requirements); shown engagement in
clinical transformation, process improvement, and care coordination; and generated some
financial success under the terms of the shared savings agreement, we will consider them for a
risk model. Outcomes influenced by this program include improve access to the PCP; reduce
avoidable ED visits; reduce avoidable hospitalization; reduce avoidable readmission; more
closely manage the most fragile of each engaged PCP’s patients; and assure quality HEDIS
measures are met.

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In addition to receiving a value-based care incentive opportunity, we support our providers with
a clinical model that combines consulting, data and technology. This support helps drive the
activities that improve quality, reduce avoidable health care cost, and subsequently trigger
incentive payments within the shared savings payment model. The support model is explained
further in Question 2.10.12.4.

Accountable Care Shared Savings (ACSS‐PMPM) Payment Model

Our most popular and preferred shared savings model is the Accountable Care Shared Savings
(ACSS) payment model.

Under our ACSS–PMPM program

alone, we are engaged with over
65 PCP and PCMH practices
across Louisiana. Through this
collaboration, the shared savings
program affects the lives of
approximately 125,000 Louisiana
Medicaid enrollees —
approximately 28% of all
UnitedHealthcare enrollees.

Capitation (HCP‐LAN Category 4)

Level 4 VBP arrangements are the apex of the HCP-LAN APM continuum. One form of a Level
4 program is for groups to take full risk in the form of global capitation. The purpose of the
capitation model is to support a comprehensive, population health approach by giving providers
a monthly cash payment, along with timely clinical data to support proactive patient engagement
and to optimally manage high-risk patients. We make capitation payments each month based
upon the number of enrollees assigned to a provider group. The provider group, in turn, uses
those funds to provide or arrange for the best possible care for each of their patients.
In April 2019, UnitedHealthcare and LCMC entered into a Letter of Intent to ultimately achieve a
Level 4 approach to VBP and have already worked through the initial steps of the agreement.

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We have agreed to a full clinically integrated network with LCMC for their physician-owned
practices.
.
With this direct, universal access to holistic information, LCMC can better serve their
membership and learn care management. The final component is to enter into the final step of
meeting a fully capitated level 4 APM agreement. We are excited with the tremendous
relationship we have built with LCMC as we journey into our first Level 4 partnership in
Louisiana. At this time, we cannot estimate the financial impact of this incentive as we do not
have a final contract or set parameters.

LDH Program Goal: Align financial incentives for plans and providers and
build shared capacity to improve health care quality through data and
collaboration
“We strongly believe [UnitedHealthcare’s] strategy aligns with our mission to
improve the health of our patients. Because of our aligned goals, we are now entering into a
Letter of Intent to fully integrate [UnitedHealthcare’s] data with our systems and set the path for
a more advanced risk sharing agreement. We look forward to a great partnership with UHC.” –
John Heaton, M.D., President of Clinical and System Operations for LCMC Health
2.10.12.2 The quantitative, measurable, clinical outcomes the Proposer seeks to improve through implementation…
We have developed our suite of VBP models to drive clinical
outcomes that achieve measurable and quantitative results.
Providers on any VBP
Our APM approach directly aligns with the HCP-LAN APM arrangement (including
Framework. Our continuum of programs rewards provider quality incentives) averaged
movement from traditional FFS arrangements (Category 1) to an MLR more than 17%
accountability and risk incentive models (Categories 3 and lower than providers not on
4). All our VBP programs link quality to value through metrics a VBP program.
aligned with the LDH’s priorities outlined in Attachment G, as
outlined in Section 2.10.11, Quality. We also place significant emphasis on the program’s top
utilization- and cost-driving conditions.
For all incentive programs, we incorporate State goals as our target measures. If there is no
established State goal, then we refer to NCQA Quality Compass 50th, 75th or 90th percentile
(selecting the next available percentile based upon current outcomes). We offer FFS plus
reimbursement incentives for integrated care coordination for quality and value (APM Category
2), quality with shared savings/shared risk (APM Category 3), and capitated/quality and
performance (APM Category 4) for ancillary providers. We also offer incentives for our providers
to decrease enrollee ED use by offering after-hours or telehealth options.
Our suite of VBP offerings drives improved quality and health outcomes, as demonstrated here:
Accountable Care Shared Savings: This program targets providers committed to clinical
integration and comprehensive population management. We set collaborative goals with
participating providers and measure access to care, ED trends, admissions, readmissions and
adverse event trends for their high-risk target populations, such as complex enrollees who are
super-utilizers. As we mentioned previously, Louisiana providers in a shared savings program
lowered their inpatient admit rate (per 1,000) by 26.8% between November 2016 and November
2018.
ACSS Program Success Example: Altus ACE Collaboration
Altus ACE in Texas has been a highly engaged, dynamic and innovative ACSS partner for the metro‐
Houston area since Jan. 1, 2017. Their four‐pronged approach to closing health care gaps includes:

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1) a proprietary risk stratification algorithm, 2) population health tools, 3) practitioner

performance evaluation and 4) shared savings opportunities for network physicians. Collaborating
with our shared savings specialist, Altus ACE consistently achieves monthly clinical integration
metric goals. For example, they regularly exceed the established goal (85%) for quarterly PCP
engagement with a high‐risk cohort of individuals, as shown in the table.
METRIC GOAL JAN FEB MAR APR MAY JUNE JULY AUG
% high‐risk cohort population seen in 85% 98% 100% 98% 98% 100% 100% 93% 97%
last 90 days

: This model focuses on closing gaps in care and improving

quality outcomes. We make it easy for the provider to enroll in this program; our simplified
approach accelerates our speed-to-market and APM membership growth. Our
is a population-health management program aimed at driving better health
outcomes for our enrollees (children and adults). Membership in an APM Category 2 VBP has
increased significantly because of this program — from 47,000 enrollees in 2017 to over
408,000 enrollees in 2018. Quality measures include the following key HEDIS improvement
metrics aligned with Attachment G:
 ADHD Initiation, MY 2017: State goal is 44.8; our results are 55.26
 Diabetic Eye Exam, MY 2017: State goal is 55.17, our results are 55.23, a 14.6%
increase from the previous year
 Well Child 15, MY 2017: State goal is 62.06, our results are 72.26
Program outcome results during the first year include:
 After normalization, an additional 5,916 gaps were closed in 2018 versus 2017
 Sixty-three percent of group/measure combinations improved or maintained
performance year over year for targeted measures


Behavioral Health Programs: We currently have in place our Behavioral Health FUH VBP
program, which focuses on coordination of care between PCPs and behavioral health providers.
We will continue to evaluate and expand behavioral health VBP programs leveraging results in
other Medicaid states where we have been successful in creating and managing behavioral
health programs that work with providers to achieve measurable outcomes.
For example, we have an APM program deployed with Austin Travis County Integral Care, a
central Texas community mental health center (CMHC). Our mutual goal is to reduce inpatient
hospital care in a clinically appropriate manner. We evaluate the number of inpatient admissions
over a 12-month period for all UnitedHealthcare enrollees treated by a CMHC. If inpatient
admissions fall below the baseline measure, we agree to pay the CMHC a lump-sum bonus.
These arrangements and the bonus payment serve as foundation for the CMHCs to fund their
internal clinical integration activities and assist their progressive efforts in becoming a behavioral
health, health home. Future iterations of the health home APM will include focus on the serious
and persistent mental illness (SPMI) population, with attention to HEDIS measures of 7-day
post-hospital follow up, enrollee engagement in clinic on a monthly basis, diabetes screening
and reduction in adverse events.
OB Programs: Over the past year, we have focused on improving and expanding our maternal
VBP programs (e.g., 17-P, , NOP and Maternity Episodes). These
programs aim to prevent preterm birth, reduce infant mortality, and confirm maternal safety and
appropriate care during childbirth and postpartum. The emphasis of these programs is maternal

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health. Infants are included in our

2.10.12.3 How the Proposer proposes to expand VBP arrangements over the initial years of the contract, and…
Our progress in VBP programs for Louisiana’s Medicaid providers over the last 7 years has
guided our approach to developing the strategic plan illustrated in the chart. This suite of
programs — each of which is described in detail in Section 2.10.12.2 — will help our providers
grow along the APM continuum over the next 3 years, steadily improving the efficiency and
quality of care for our enrollees.
We acknowledge that Louisiana is America’s least healthy state as defined in 2018 by
America’s Health Rankings. Our focus will continue to remain on improving the health of our
enrollees. Our work to date and our strategic VBP expansion over the next 3 years will continue
to improve enrollee health outcomes. LDH’s 2018 Transparency Report ranked
UnitedHealthcare first in five of eight pay for performance measures and first in 14 of 15
measures (per 2017 data).
Through the strategic plan we have outlined here, we will continue to tailor our VBP programs
for Louisiana providers, moving toward higher risk models and focusing on LDH priorities.

Figure 29. UnitedHealthcare Strategy for Expansion of Louisiana Medicaid Managed Care VBP Programs.

While our strategy encourages movement up the VBP risk continuum, we recognize that not all
providers will be ready or able to take on episode-based reimbursement or capitation models.
Therefore, we will continue offering our foundational VBP programs (APM Category 2) to those
groups. This will confirm we meet LDH priorities and our enrollees receive high-quality care.
Each year we will apply the continuous quality improvement (CQI) process to apply the next
evolution of VBP programs in the state. In 2019, we are continuing our flagship
, which includes all provider groups with over 50 UnitedHealthcare
enrollees. We also will continue our shared savings and . Our
2018 pilots, 17-P and NOP, were well received and are being expanded to include the top 40
OB groups in 2019.

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 Helping People Live Healthier Lives

As outlined in our VBP strategic plan submitted to LDH on Aug. 15, 2018, we are on track to
introduce Hospital PBC into the state in 2019. We have contracted with Woman’s Hospital of
Baton Rouge as the first practice in the state to have a Hospital PBC program. Lastly, we
added three programs this year, Behavioral Health, OUD Quality MAT, Quality Care Incentive
and Maternity Episodes. As outlined in Section 2.10.12.1, we will have already met many of the
LDH’s 2022 requirements by the end of CY2019.
In 2020, we will continue to move providers up the APM continuum. We are on track to
implement at least one Accountable Care Organization (ACO) arrangement (as defined by LDH)
by 2020. We will work with LDH to confirm our strategy and approach align with State priorities
and that the targeted group(s) meets the ACO criteria. We will assess our 2019 programs (i.e.,
Behavioral Health, OUD Quality MAT and Maternity Episodes) based upon program
effectiveness, provider feedback and alignment with LDH goals, to better understand expansion
opportunities in 2020. We also will continue to partner with providers and LDH on any ongoing
VBP programs, ensuring they are improving the health of our enrollees and that they continue to
align with LDH priorities.
In 2021 and 2022, we plan to introduce capitation, the top of the VBP continuum, to at least one
provider. To enable provider readiness to enter into full risk, we will offer the identified provider a
shared savings or risk arrangement by 2021, furthering the development of total cost of care
best practices and efficiencies prior to entering into a full risk arrangement. We will continue the
CQI process on our VBP programs and work closely with our providers and LDH to focus on
state priorities.
2.10.12.4 How the Proposer will support providers in successful delivery system reform through these payment…
To meet providers where they are on their VBP journey, we
developed a set of modular incentive models that we can
align with each provider’s appetite for financial risk, level of
integration and unique populations served. Before pairing
providers with the appropriate shared risk program, we
conduct an extensive review of their risk readiness that
includes assessment of the provider’s financial, structural and
cultural capabilities necessary to succeed in a risk-sharing
contract. Some examples of this review include:
 Verifying a provider has maintained sufficient scale to
meet LDH membership requirements
 Confirming provider is engaged in clinical
transformation, process improvement and care coordination
 Ensuring the provider has generated some financial success under the terms of the
shared savings agreement
Next, we require the appropriate safeguards to be in place to facilitate success of the
contract. This includes establishing requirements for provider stop loss and reinsurance, and
establishing financial reserve requirements based upon the level of financial risk and the volume
of services where risk is involved. Once they are engaged in VBP contracts, we provide tools
and support to help providers succeed.

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LDH Program Goal: Reduce complexity and administrative burden for

providers
We are dedicated to supporting providers through a combination of data, analytics
and targeted consulting — reducing complexity and easing administrative burden to
help them succeed. We prepare benchmark and ongoing performance reports and monthly
scorecards, provide enrollee-level detail through our ClaimSphere HEDIS program, develop
joint clinical action plans for more advanced APM models, and conduct in-person provider visits
for high-volume providers to review their data and discuss opportunities for improvement. In
fact, LDH adopted our provider scorecard template as the standard format across MCOs.
If we see that a provider is not achieving their targeted improvement metrics, we modify our
support and identify alternative solutions to address their challenges. We provide each
participating provider with scorecards showing trends in rates relative to baselines and targets
for clinical quality measures, utilization metrics and total cost of care, depending upon
contracted parameters. Outreach is conducted via in-person meetings, webinars, lunch and
learn sessions, and email.

In addition to the IT support outlined in our response to Question 2.10.9.2, timely provider-facing
reporting for our VBP programs includes the following platforms and processes, which will grow
as our VBP solutions evolve to best serve Louisiana providers and achieve LDH priorities. To
develop actionable quality strategies, each of these reports enable providers to roll up or drill
down performance measurements at the shared savings practice, provider or enrollee levels —
each applicable depending on the provider’s needs. Our clinical provider-facing staff quality
support teams work directly with providers to translate reporting into action plans. We also
connect with our enrollees who are experiencing gaps in care to verify their assigned PCP,
arrange for transportation if they need it, review the services they need, and connect them to
their PCP to schedule an appointment. These tools, combined with our partnership, enable
providers to understand the data we collect and employ it to improve performance.

Tools for Receiving/Sharing Data: To

aggregate data and share it meaningfully
with providers and LDH, we must first
establish data connectivity as part of our
VBP engagement plan through
admission, discharge and transfer (ADT),
structured data feeds and other methods.

Figure 30. In 2017, we created a large check campaign to share the success
of our VBP program with providers.

As data is compiled via these tools, our data analytics and Health Care Economics Team uses
the information to conduct aggregate and provider/enrollee level performance reporting based

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upon quality and targeted criteria such as total cost of care readmissions, EPSDT compliance
and other HEDIS measures. These analyses validate that providers submit accurate claims
data, know their assigned panel and enrollees see their assigned PCPs. For example, one of
our contracted providers approached us with a concern that they were closing gaps for certain
HEDIS metrics, but were concerned they were not receiving the appropriate incentive
payment. Through our research, we discovered the provider’s claims clearinghouse was
discarding the codes for the measure, meaning UnitedHealthcare was not receiving the correct
data and the provider was not getting credit for the gap closure. The provider then instructed
their clearinghouse to stop discarding the code. The claims clearinghouse modified their
process, and the provider is now receiving their earned incentives.
Sharing Quality Measurements – Provider Support: We help providers improve
performance, meet targets and build capacity so they can progress to more advanced total cost
of care VBP models and practice maturity. To manage care effectively and lower costs,
providers need to proactively engage their complex-needs patients, keep them out of the
hospital and engage during post-discharge transitions. Our suite of online population health
tools and reports allows providers to see enrollee activity across the continuum of care.


On-demand reporting on VBP/HEDIS measures and comprehensive EPSDT services is

available in our provider portal, Link, and gap in care alerts are available via CommunityCare.
Upon request, we send files to providers via secure web transfer. We meet providers where
they are in technical capability by providing data on their enrollees in a variety of formats —
including raw data feeds for sophisticated providers with their own data and analytics tools, and
reports and analytics platforms for providers looking for actionable recommendations and
performance dashboards. For more advanced Total Cost of Care models, we partner to develop
a joint clinical action plan targeting specific quality metrics and efficiency goals. Shared service
providers receive both and utilization operation reports (e.g., inpatient/ED
admits, high utilizers).
We offer these additional reporting tools to our shared savings partners:
 Monthly Operations Report: Processed analytics provide actionable guidance for
improving cost efficiency. This includes high-level trending and enrollee-specific
opportunities. Guidance is primarily on ED, inpatient and pharmacy, lab and radiology.

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 Performance Reporting: We provide reporting that updates the shared savings

provider on where they stand against cost and quality targets in their incentive contract.
 Claims/Eligibility Data Sharing: Our Monthly Operations Report provides most shared
savings providers with the information they need to support clinical transformation. Some
shared savings providers have invested in advanced data analytics resources or
capabilities, and request raw claims and eligibility data transfers from UnitedHealthcare.
For shared savings providers in Total Cost of Care models, our support is critical and surrounds
the care provider, strengthening the provider/enrollee relationship.
Sharing Cost Measurements: We employ the following reporting tools and data analytics to
track costs. Our consultants work with providers at all Joint Operating Committee (JOC)
meetings to maximize their use of these tools.
 Real-Time Alerts: Pushed to providers through our provider portal, alerts on medical
encounters signal opportunities for the provider to intervene and follow up with enrollees;
alerts help manage cost drivers and manage transitions of care.
 Utilization Reports: In our JOC with providers, we share trend data on their paneled
enrollees, including ED visits/1,000 and admissions/1,000. We show how they are
trending, how they compare to peers and what the major drivers of change include,
enabling providers to see the success of their approaches in advanced VBP models.
 Raw Claims Data: We deliver monthly raw claims data to several participating shared
savings providers and we want to expand to additional shared savings providers when
they are ready to receive and use the data. The data shows providers where utilization is
occurring by services and by providers.

When educating our providers on our ADHD HEDIS measure, we discovered that providers
schedule enrollees return visits on the 29th or 30th day. When the enrollee calls and needs to
reschedule, this results in the enrollee falling out of compliance with the HEDIS requirements.
When asked, providers stated they felt comfortable assessing that medication is working between
10‐14 days of the initiation of the medication. We suggested providers take the following actions: 1)
Write the ADHD prescription for 10‐14 days of medication, and 2) schedule the return appointment
to coincide with the prescription expiration date. This change resulted in an increase of 14.6
points in our HEDIS scores for this measure in 1 year.

Reporting and Reconciling Payouts

As we have done in the past, we will continue to submit our VBP Strategic Plan (2.17.5) on time
and as outlined by LDH. We continuously measure and monitor provider performance, utilization
patterns and program costs to keep our VBP program aligned with the Department’s goals.
Correctly reconciling incentive payouts is critically important to providers and the overall
success of any VBP program. Therefore, we apply industry-accepted accounting principles and
practices to calculate and confirm accuracy of incentive payments. In Louisiana, we will
continue to conduct annual payment reconciliations, to reduce administrative burden and the
risk for calculation errors. Providers will have the right to dispute should they have any
discrepancies with our results. Our health care economics specialist, who is a member of the
Shared Savings Core Team and has financial management oversight and qualifications,
performs initial calculations. The specialist then shares the data with internal stakeholders, and
our network or plan leadership staff presents the findings to the appropriate shared saving
leadership responsible for contract management to audit and confirm payout accuracy.

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2.10.13 Claims Management and Systems and Technical

Requirements
2.10.13.1 The Proposer should demonstrate its understanding of the Louisiana Medicaid program, applicable state…

LDH Program Goal: Reduce Complexity and Administrative Burden for

Providers and Enrollees
We understand the requirements and the passion behind the Louisiana Medicaid
program and comply with all requirements in Section 2.18 and 2.19 of the Model
Contract, which focus on reducing complexity and administrative burden, meaningful provider
engagement and enhanced claims processing standards. We offer the state a Louisiana-
specific platform for claims adjudication that, over time, has evolved into a system that supports
the accurate and efficient flow of data, and plays an essential role in achieving LDH’s guiding
principles of Better Care, Better Health and Lower Costs.

From Feb. 1, 2012 through Jan. 31, 2015, UnitedHealthcare participated in Louisiana Medicaid
as a Shared Savings Plan. During this 3-year collaboration with LDH, we pre-processed
provider claims, and batched them to the state’s Fiscal Intermediary via HIPAA 837 encounter
files for payment consideration. If our 837 files were not perfect, our providers were not paid.
We learned every detail of the State claims processing system to ensure our encounters were
accepted and our provider’s claims were paid.
Our high encounter rates of 97.98% (March 2019) demonstrate that our MIS is configured to
meet LDH requirements. We are exceeding the current requirement of 95% and are in a well
positioned to achieve a 99% encounter rate under the Model Contract.
Upon winning the 2015 bid to continue serving Louisiana Medicaid, this time as a full-risk MCO,
we used our 3 years of acquired knowledge to customize a claims processing system that
emulates the State’s so closely that we have been asked to assist other MCOs to attain the
same levels of encounter acceptance. Our system not only addresses applicable administrative
rules and statutes, but also removes administrative burdens to providers where Louisiana
regulations allow. Through weekly internal meetings with our Claims, Configuration,
Recoupments, Encounters and Provider Data Teams, we collaborated with LDH to continually
evolve our system. As LDH’s needs advanced, we were pushed to improve our ability to be
operationally nimble and responsive to program changes and ultimately, to verify alignment of
our Management Information System (MIS) and technology to the State’s needs. For example:
Program Changes Description
Reimbursement We incorporate LDH‐specific administrative exceptions to our reimbursement
Policies policies to ensure compliance, including: ambulance, anesthesia, CLIA, drug testing,
multiple procedure reductions, new patient visits, obstetric services,
professional/technical and readmission policy
Advisor As good stewards of state resources, we also advise LDH of industry‐standard best
practices to consider for Louisiana Medicaid to streamline claims and encounter
processing, improve LDH data collection and reduce unneeded expenses
Drug Testing We presented an initial proposal and associated savings to LDH, then collaborated
Policy Proposal with all MCOs to present a coordinated proposal that would generate over $1 million
in savings for UnitedHealthcare membership alone, while continuing to provide all
necessary services to affected members. Proposal is currently pending LDH approval
CLIA Policy In response to a negative LDH audit by the Louisiana Legislative Auditors (LLA), in
Proposal an effort to make sure MCOs can provide LDH with the most comprehensive and
positive CLIA‐related claims data possible, UnitedHealthcare proposed an immediate
change in the current LDH strategy that prohibits providers from including CLIA

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Program Changes Description

identification numbers on claims. Proposed — allow MCOs to require CLIA
identification numbers on claims. Result — MCOs can accurately deny
inappropriately billed claims, and educate providers for future claim submissions.
Ultimately, future LLA audits of LDH will find favorable, positive results.
CPT II Code CPT IIs are supplemental tracking codes. While not reimbursable, they can: 1) reduce
Acceptance on chart requests; 2) improve physician and MCO HEDIS performance; 3) improve
Encounters health outcomes; and 4) eliminate unnecessary member mailings/reminders.
Historically, encounters with CPT II codes were rejected. Since this data is valuable
to providers, MCOs and the State, LDH accepted our proposal to accept CPT IIs on
encounters. Additional benefit — increased MCO encounter acceptance rates.
2.10.13.2 The Proposer should describe in detail the Management Information System (MIS) it proposes to use in…
UnitedHealthcare’s MIS is fully compliant with the requirements of the Model Contract.
Led by Susan Mieras, Health Plan Performance Director, and our dedicated Information
Technology (IT) Support Team, consisting of approximately 63 IT professionals, we maintain a
solution that integrates disparate technologies and data sources.
Systems Overview
At the center of our MIS architecture— is the Community Strategic Platform (CSP). Using the
latest Oracle Exadata Database platform, CSP is our TriZetto Facets claims platform and
includes interfaces that optimize the exchange of information to other key systems. The Oracle
Exadata platform is the most advanced hardware for managing database loads, providing for
the fastest in-memory databases with redundant hardware and fastest failure recovery times
possible. With this hardware, we go from measuring time for recovery for system outages to
measuring mean time between zero-outage component failures. The Exadata platform provides
capability for zero planned downtime for hardware maintenance. CSP is co-resident on the
Exadata platform with our SMART data warehouse and our NEMIS encounters reporting
system, improving data freshness for reporting from a day, or weeks to as little as real time.
Using CSP, our IT team configures business rules such as claims payment of specific program
services, authorization requirements, benefit limits and reporting requirements. Our system
captures and reports multiple data elements critical to an effective enrollment process. It
accommodates fee schedules, procedure and types of service coding. CSP validates data fields
including edits to smooth the process for payment and operations. Our managed care
information system applications work in concert with CSP to provide care coordination,
encounter data submission capabilities, online provider and enrollee support solutions, and
reporting and analytics capabilities. Our systems are fully interoperable and fluidly exchange
information, allowing us to adapt to support current and future requirements.
We are dedicated to continuous improvement by investing in information systems — people,
process and technology. Between now and the January 2020 go live, we are making significant
investments in the platform underpinning our MIS to keep us on the leading edge of technology
and capabilities. Here is a summary of planned infrastructure upgrades:
Systems Planned Infrastructure Upgrades
Myuhc.com In January 2019, we implemented upgrades to the digital experience for our
enrollee portal, myuhc.com, offering easier navigation, increased personalization,
dedicated health and wellness content, and many other enhancements. A
significant new convenience feature is the ability for enrollees to easily change
their PCP online. In 2018, we implemented enhancements to our online
registration/login (HealthSafe ID™) and our Provider Search to offer a more robust
enrollee experience. We conduct ongoing website usability testing and make

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Systems Planned Infrastructure Upgrades

regular enhancements to improve the enrollee experience.
Mobile app Mobile app for enrollees went live January 2019
Upgrades to Facets To maintain support and compliance, we upgrade CSP twice a year to the most
recent, leading‐edge version of Facets. In 2019, we will upgrade CSP to Facets 5.6.
Eligibility Enrollment EEMS will go live in Q4 2019 providing greater flexibility for eligibility sources,
Management System improved speed to market for format changes, reduced maintenance costs and
(EEMS) continued top of the line end‐to‐end cycle time for loading eligibility
ClaimSphere™ Cognizant’s NCQA‐certified HEDIS solution for prospective analytics helps us
better and more quickly uncover the root cause for low HEDIS scores and take
action. Care gap and performance reports from ClaimSphere HEDIS summarize
quality of care delivered by providers and highlight any care disparities. Multiple
standard reports and ad hoc analytics are available for follow‐up action planning.
Clinical Platform We currently use ICUE and CommunityCare, delivering clinician‐facing web‐based
platforms that deliver an integrated experience to our enrollees and the health
care communities that support them. Our clinicians can view an enrollee’s entire
engagement with UnitedHealthcare — past and present.
Link Portal We continue to improve the provider experience by enhancing our provider portal,
Link, a cloud‐based platform that offers an array of native applications and a
simplified way of doing business with UnitedHealthcare. This includes the My
Practice Profile (MPP) application, which allows providers to initiate demographic
updates online, and prompts them to attest to the accuracy of demographics every
90 days. In 2019, per the request of LDH, MPP will include an option for providers
to trigger an accepting‐new‐patients indicator by location and product.
2.10.13.2.1 The length of time the Proposer has been utilizing the MIS proposed for the Contract; if for fewer than…
UnitedHealthcare has used our current MIS to support LDH since our transition to a full-risk
MCO in February 2015. We maintain system scalability, stability and performance through a
combination of load balancing software, advanced hardware and cloud and virtualization
capabilities for our systems. A formal and auditable process, including structured submissions,
required artifacts, scheduled review meetings, rigorous testing and approval dates, guides our
change management processes. This allows us to implement high volumes of changes, while at
the same time protecting the integrity and stability of our system environment. Additionally, we
own and manage all of our data centers and rely on internal resources for recovery. We
maintain formal disaster recovery plans for our critical technology and systems infrastructure
and systems components supporting our most critical business functions. We review, assess
and update our disaster recovery plans at least annually or more often as changes to systems
occur. We continue to increase our footprint of virtualized servers and we have implemented a
secure private cloud environment for applications such as our Link provider portal.
2.10.13.2.2 Hardware and system architecture specifications for all systems that would be used to support the…

Hardware and System Architecture Specifications

The following exhibit presents the components of our managed care information system and the
relationship between these systems as are deployed in support of the State’s Medicaid
program. The system uses logging, journaling and audit tables to maintain a record of all
transactions and data within each application. Our platforms actively store a minimum of 6 years
of historical information including membership, eligibility and claims data for audit and reporting
purposes and 10 years in archival systems. Our managed care information system comprises
multiple systems strategically interfaced to support the delivery and management of integrated
health care services. Categorized into main functional areas, the following table provides brief

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descriptions of our main information systems. We have provided data and process flows for all
key business processes within our response to Question 2.10.13.2.4
Information System General Description/Functions Supported by System
1. Area: Clinical Information, Care Coordination, Utilization Management and Electronic Care
Management Systems
CommunityCare
This tool enables care management and coordination, medication management and quality management by
giving providers updated and shared access to patients’ individual plan of care and supports alignment of
clinical problems, goals and interventions. It provides electronic access for the care team, providers,
specialists, caregivers and others. Containing claims information from CSP and authorization data from ICUE,
CommunityCare includes our Population Registry and gives providers and care communities a
comprehensive view of the services used by any given care population. Using the enrollee view within the
Population Registry, providers have the clinical history of the whole person. CommunityCare: Provides
automated notifications of care transitions; receives authorizations from ICUE for reference by the care team;
supports DIRECT for secure clinical data exchange with providers and HIEs; supports import, parsing and
attachment of C‐CDA, ADT, LOINC and other standard format. Hardware Configuration: Web Tier: Vendor
Hosted; App Tier: Vendor Hosted; Presentation: Vendor Hosted; Software: Vendor
ICUE
ICUE (Integrated Clinical User Experience) is our clinician‐facing web‐based clinical platform that delivers a
coordinated, integrated experience to our enrollee and the health care communities that support them. ICUE
features consolidated data, functions and user experience and serves as a single source of truth for clinical
operations transactional data. System users have access to all of the categories of data they need, such as
enrollee eligibility, benefits, provider information, claims data and clinical resources. Hardware
Configuration: Web Tier: UNIX/IHS; App Tier: UNIX/WAS; Presentation: UNIX/Oracle; Software: Java
ClaimSphere HEDIS
ClaimSphere™ HEDIS is Cognizant’s NCQA‐certified HEDIS solution. It provides the foundation for medical
quality management and improvement programs like provider profiling and gaps‐in‐care analysis. It
performs detailed measure analysis with access to enrollee detail and information on specific enrollees
qualified for each measure. Standard system views provide insight through analysis, gaps‐in‐care reporting,
provider scorecards and drill down capabilities. We broadcast gaps in care via our secure provider and
enrollee portals, mobile app, EDI eligibility transactions and CommunityCare.
2. Area: Enrollee and Enrollment Data Management
Consumer Database (CDB)
CDB is a consolidated database of all UnitedHealthcare enrollees that serves as a “master index” of enrollees
across all UnitedHealthcare systems. Hardware Configuration: Web Tier: UNIX/IHS; App Tier: UNIX/WAS;
Presentation: UNIX/Mainframe; Software: Initiate (Vendor)
CSP Customer Call Center – Member
Supports enrollee services center operations in assisting enrollees with common inquiries (e.g., obtaining ID
cards and searches for providers)
Interactive Voice Response (IVR) System and Avaya Dialer
Handles basic enrollee inquiries and directs incoming calls to the most appropriate enrollee services center
professional. Hardware Configuration: Web Tier: Avaya (Vendor); App Tier: Avaya (Vendor); Presentation:
Avaya (Vendor); Software: Avaya (Vendor)
Provider Recommendation Engine (PRE)
PRE is an intelligent rules engine that systematically matches enrollees who have not selected a PCP with
“preferred” PCPs who have the highest quality scores and best outcomes, costs and location for enrollees. It
also references historical enrollee, PCP, family PCP, and claims history to narrow its recommendation of
"preferred" PCPs. PRE supports the State’s “Patient Assignment Initiative,” identifying enrollees who have not
received services from their linked PCP, and transitioning them to the PCP who is actually serving them.

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Information System General Description/Functions Supported by System

Hardware Configuration: Web Tier: Intel/Linux; App Tier: Intel/Linux; Presentation: Intel/Linux/Azure
Pack SQL DB; Software: .NET
Public Enrollee Portal (uhccommunityplan.com)
UnitedHealthcare public web presence used for posting general information, handbooks and bulletins —
common entry point for enrollees. The portal provides flexible search capability by type of provider,
specialty, location and other criteria. Hardware Configuration: Web Tier: Intel/Linux; App Tier: Intel/Linux;
Presentation: None; Software: Adobe (AEM)
Secure Enrollee Portal (myuhc.com)
Secure health and wellness information is available 24 hours a day, 7 days a week through our enrollee
portal. Enrollees register for online access by setting up a secure HealthSafe ID™ and password. The
personalized and easy‐to‐navigate digital experience allows enrollees to search for covered benefits, manage
personal preferences, update contact information (including email addresses for facilitating contacts and
information exchange), view/print and request ID cards, change their PCP and locate providers through a
searchable Provider Directory. The portal also offers personalized health and wellness content such as
seasonal reminders (i.e., flu shots), personalized care recommendations, links to plan programs (e.g., Healthy
First Steps, transportation) and links to online resources, tools and community‐based services. Hardware
Configuration: Web Tier: Intel/Linux; App Tier: Intel/Linux; Presentation: None; Software: Adobe (AEM)
Secure Enrollee Mobile app
The free enrollee mobile app provides personalized care notifications, medication management capabilities,
administrative transactions, access to local resources and connects users with a member services advocate
3. Area: Provider Network Management and Credentialing
CSP Customer Call Center – Provider
Supports enrollee services center operations in assisting providers with common inquiries (e.g., verifying
enrollee eligibility and verifying claims status)
Interactive Voice Response (IVR) System
Enterprise voice portal handles basic provider inquiries (e.g., enrollee eligibility/enrollment status and claims
status) and directs incoming calls to the most appropriate provider services center professional. Hardware
Configuration: Web Tier: n/A; App Tier: Wintel/ICM; Presentation: Unix/AIX/DB2; Software: Cisco/Java
Network Database (NDB)
NDB is our single enterprise repository for provider network management. Hardware Configuration: Web
Tier: Unix/Mainframe; App Tier: Unix/Mainframe; Presentation: Unix/Mainframe DB2; Software: COBOL
Link
Secure provider portal providing a central access point where enrolled providers have access to eligibility
and benefits, claims management, claims reconsiderations, enhanced online authorizations and gaps in care,
and where they can update their practice profile including demographic and “accepting new patient” updates
specific to the Louisiana Medicaid Managed Care Program. Additionally, providers can view and provide
feedback on the health needs assessment and individual plans of care in CommunityCare. Hardware
Configuration: Web Tier: Intel/Linux; App Tier: Intel/Linux; Presentation: UNIX/Oracle; Software: Java
UHCprovider.com
UHCprovider.com is UnitedHealthcare’s home for provider information. With access to Link’s self‐service tools
24 hours a day, 7 days a week, current medical policies and the latest news bulletins, this site also has a
library of resources to support administrative tasks including eligibility, claims and prior authorizations and
notifications. UHCprovider.com includes a powerful internal search tool to help care providers locate the
information they need quickly. The site also offers care providers the opportunity to submit feedback on their
experience to help identify opportunities to improve or enhance how we work together. Hardware
Configuration: Web Tier: Intel/Linux/Apache; App Tier: Intel/Linux/WAS; Presentation: n/a; Software: Java

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Information System General Description/Functions Supported by System

4. Area: Claims Processing and Payment
CSP
CSP is an integrated managed care information system built on the TriZetto Facets platform, which meets all
applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions
include, core health‐plan administration system’s primary functions such as benefits, enrollment and
disenrollment management, claims pricing, adjudication and payment. Comprehensive enrollee database,
using Medicaid state ID numbers, including eligibility begin and end dates. Age‐specific information and
enrollment history. Enrollee TPL coverage, utilization and expenditure information. Integrated claim
processing suite including claim edits, adjudication, COB processing, rules‐based correction/adjustment,
voiding and resubmission. Claim status data including incurred claims, processing status and payment
timeliness data. Documents distribution of capitation payments. Generates explanation of benefits and
remittance advice. Data for provider payment issuance purposes. Hardware Configuration: Web Tier:
Intel/Linux; App Tier: Intel/Linux; Presentation: Exadata LINUX/Oracle; Software: Trizetto (Vendor)
Optum Transaction Validation Manager (OTVM)
Electronic data interchange (EDI) validation that enables us to test and certify HIPAA transaction sets and
verify compliance with standards and regulations on inbound claims
Escalation Tracking System (ETS)
ETS facilitates administration, escalation management and processing of claim disputes, grievances and
appeals. ETS: Manages, provides status, and tracks resolution on submitted grievances and appeals against
policy‐mandated time frames for enrollee contact and appeal or grievance resolution; generates reports
related to the outcomes of grievances, complaints and appeals; provides flexibility to easily customize data
elements according to State needs. Hardware Configuration: Web Tier: Wintel MS Visual Studio; App Tier:
Wintel ASP.NET SSIS; Presentation: Wintel SQL Server; Software: ASP.NET
Care Provider Early Warning System (CP‐EWS)
Tool that scans for unusual patterns in claims receipts, denials, rejections and cash paid at the state and
provider level. CP‐EWS allows immediate/on‐time reaction to sudden changes in claim denial patterns,
initiating immediate outreach to provider, notifying them of reason and remediation opportunities for
incoming claim denials. Allows for proactive provider outreach in support of Act 710.
MACESS
MACESS is a workflow application that facilitates claim processing, including viewing of paper claims and
supporting documentation in EDMS, and routing of claims to claim processors. Hardware Configuration:
Web Tier: Wintel Sunguard; App Tier: Wintel ASP; Presentation: Wintel SQL SVR; Software: FSG (Vendor)
Claims Rule Engine (CRE)
Enables claim edits based upon configurable business rules that are quick to modify and deploy. Edits range
from provider validation to CPT code‐based rules.
WebStrat
WebStrat calculates reimbursement using diagnosis‐related groups (DRGs) and ambulatory procedural
classifications (APCs). Ready for future deployment. Hardware Configuration: Web Tier: Wintel/UNIX; App
Tier: Wintel/NT UNIX WAS; Presentation: Wintel/SQL SVR Unix/Sybase; Software: .NET/Java
5. Area: Information Reporting
Strategic Management Analytic Reporting Tool (SMART)
SMART is a comprehensive, integrated analytical data warehouse, using the latest Oracle Exadata Database
platform that holds all Medicaid relevant information — including claims data (e.g., medical, pharmacy, vision
and lab) and historical enrollee claims data from LDH, enrollee data, provider data, authorizations, external
subcontractor data and predictive modeling information.
SMART: Supports quality management, performance management and compliance reporting and ad hoc
reporting on an “as needed” basis with turnaround times averaging less than 5 business days. Stores service‐
specific data that includes behavioral health, pharmacy, inpatient and outpatient services and includes
consolidated patient census (common store of all patients receiving care). Consolidates relevant data for
ClaimSphere EPSDT and HEDIS reporting and related analysis and monitoring.

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Information System General Description/Functions Supported by System

Hardware Configuration: Web Tier: Unix/AIX; App Tier: Unix/AIX; Presentation: Exadata LINUX/Oracle;
Software: Oracle
Reporting Portal
The reporting portal is an end‐user interface to our custom Medicaid data warehouse, SMART. This feature
has an option that can provide LDH staff access to actionable information including two types of reports: 1)
contractual and “canned” reports that can be downloaded by the user, and 2) downloadable ad hoc reports
that support utilization and trending inquiries
6. Area: Financial, Capitation and Encounter Submission Management
National Encounter Management Information System (NEMIS)
NEMIS is our strategic, internally developed encounter data submission and reporting system that initiates
submission of encounters, tracks responses, provides error correction and resubmission of Medicaid
encounters to LDH in a format specified by the Medicaid Managed Care Program. Hardware Configuration:
Web Tier: Intel/Linux; App Tier: Intel/Linux; Presentation: Intel/LINUX/DB2; Software: Java
PeopleSoft
Enterprise financial management solution containing several modules: general ledger, asset management,
purchasing, accounts payable and accounts receivables, to provide a consolidated view of financial data.
Hardware: Web Tier: Intel/Linux; App Tier: Intel/Linux; Presentation: Intel/Linux; Software: Axway
7. Area: Information Technology Support
B2B/External Customer Gateway (ECG)
Suite of tools supports secure EDI transactions/file transfers between UnitedHealthcare and external parties
ServiceNow
Comprehensive tool that supports our UnitedHealthcare Support Center and information technology service
management processes, including system monitoring and reporting of critical incidents

Systems Used to Support the Contract

The CSP is the claims processing centerpiece of our information system. Our Louisiana
Medicaid program platform is built on our CSP core transaction processing system, which
provides eligibility, enrollment, claims processing, benefits configuration, capitation, reporting
capabilities and the source data for our encounter submissions. CSP includes interfaces that
optimize the transport of information to other key subsystems. These subsystems are fully
interoperable and fluidly exchange information, allowing us to adapt to support current and
future requirements. We present the following key features of our main information systems
components and describe how they support the key organizational functions. They include:
System/Subsystem Description (Correspond to Process Flows in Question 2.10.13.2.4)
Enrollment/Eligibility Subsystem
We process daily/monthly electronic data transmissions from LDH (via Maximus) for Louisiana Medicaid
enrollees, including additions, deletions and modifications to the program’s enrollment. The enrollment
processing establishes begin and end dates for enrollees under their current program eligibility category,
while maintaining the integrity of information and feeding benefits and finance subsystems, among others.
Claims Processing and Encounters (Subsystem)
We capture the claim‐received date and assign a unique claim number for all incoming claims. Data edits are
applied to validate data is compliant, complete, accurate and appropriate under contract terms. Claims with
invalid data points are rejected/denied, and those with valid data are adjudicated. Using our Escalation
Tracking System (ETS), we store all grievance/appeals activity. As presented in the End‐to‐End Encounter
Process Flow diagram (Question 2.10.13.2.4), we extract encounter data from our claims platform and load
the data into NEMIS. We require claims files from all external vendors to submit encounter data to LDH.
We maintain/review reports to reconcile financial fields of a claim with the financial fields of adjudicated
encounters. The Encounter Team is responsible for running reports to confirm all data sent validating the

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System/Subsystem Description (Correspond to Process Flows in Question 2.10.13.2.4)

claims system reconciles to the encounter submission reports and verifying the financial fields of a claim
match the financial fields of adjudicated encounters.
Our CSP transaction processing system, which houses our claims data, serves as the main data source for
encounter data extracts. CSP uniquely identifies claims submitted by the service provider based upon the
submitted NPI and edits claims to make certain all data necessary to identify the pay‐to‐provider and process
the claim to payment are present. CSP details a real‐time history of actions taken on each claim. Based upon
adjudicated claims data from CSP, we collect and format encounters data in HIPAA transaction formats and
code sets through NEMIS, our encounter data submission and reporting system. NEMIS processes encounters
across the breadth of our Medicaid businesses and initiates submission, tracks responses and provides error
correction, reconciliation and resubmission of Medicaid encounters.
Customer Services
 Telephone Management System/Member Services: Call center technologies manage the flow of all
incoming calls to provide timely responses to member inquiries. Automatic call distribution and IVR skill‐
based and priority call routing successfully link Louisiana Medicaid enrollees with member services
advocates (MSAs) trained on the Louisiana program and ready to assist. Our innovative “natural language”
capability recognizes more than 70,000 keywords and can categorize the call based upon the member’s
statement. Collectively, information accessed is used to connect the member with the most appropriate
resource. The system also allows management staff to balance workload among MSRs on a real‐time basis
and facilitate the transfer of calls to other staff to address specific issues or concerns, as appropriate. All
MSRs have desktop access to view information on each family member, including benefits, HEDIS gaps in
care, provider information, claims and utilization. MSRs respond to LDH enrollee questions using relevant
information, including any recent visits to the doctor or ED, interactions with our Care Management Team,
and any recent family member calls.
 Telephone Management System/Provider Services Call Center: Our toll‐free provider services call
center responds quickly to provider inquiries. Provider phone representatives (PPRs), specifically trained
in the Louisiana Medicaid Program, staff the call center. Each time a provider calls, they speak with a
dedicated PPR thoroughly trained in provider processes and the expected caller needs. Our toll‐free call
center is open 24 hours a day, 7 days a week.
Utilization Management/Service Authorization
 Utilization Management/Service Authorization: Through our utilization management (UM) program,
we gather quality measures, prior authorizations, clinical and claims data, and data from providers or
subcontractors. We continuously monitor and manage overutilization/underutilization of services across
our health plan using reporting, dashboards and scorecards developed from data gathered and analyzed by
our SMART data warehouse. SMART links with and receives data from our clinical management system,
ICUE, which provides an integrated, single solution for managing service authorizations for
physical/behavioral health services. Providers can submit prior authorization requests for new or
continuing medical/behavioral health services 24 hours a day, via telephone or through our secure
provider portal. Providers can verify approvals, obtain real‐time online verification of membership through
the portal, view gaps in care using CommunityCare, Link, and within the provider’s practice management
system with 270/271 EDI integration.
 Care Management/Care Coordination: An interdisciplinary care management (CM) approach is central
to our clinical model. We provide the tools to support the enrollee, PCP, case managers and the Care
Coordination Team. CommunityCare, a CM collaboration platform, provides PCP information, enrollee
Medicaid ID, a record of each service event, appointments, immunizations, a listing of the enrollee’s
durable medical equipment (DME) along with the ability to capture notes and store attachments.
CommunityCare integrates evidence‐based medicine gaps in care and hospital admission, discharge and
transfer (ADT) messaging and allows providers to track interactions with enrollees such as post‐ED
discharge follow up and care opportunity outreach. Our UM system, the ICUE platform, is the system of
record for medical service authorization data and coordination of behavioral health services. We use
enrollee and authorization data based upon transactions processed in ICUE and passed back to CSP for
claims management and CommunityCare for CM activities. Our care team uses ClaimSphere to identify gaps
in care based upon EPSDT or HEDIS criteria for age, sex and frequency of services. We share these results

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System/Subsystem Description (Correspond to Process Flows in Question 2.10.13.2.4)

in CommunityCare, so in addition to population wide queries based upon specific measures,
CommunityCare enables viewing of individual enrollee’s gaps in care. For example, during interaction with
an enrollee, a case manager can view an enrollee’s record to identify any gaps in care or other reminders.
Financial Systems (Subsystem)
We configure CSP and the finance subsystems to facilitate prompt payment to providers. We send HIPAA
compliant explanation of benefits (EOB). Our Finance and Management Information Systems Teams monitor
reports through NEMIS and CSP to verify: 1) all data sent to LDH; 2) the CSP claims system reconciles to the
encounter submission reports; and 3) the financial fields of claims match the financial fields of adjudicated
encounters. We create general ledger transactions in CSP and integrate into our enterprise resource
management application, PeopleSoft. All financial transactions are auditable according to generally accepted
accounting principles (GAAP) and supported by Sarbanes‐Oxley (SOX) and SSAE 16 controls.
2.10.13.2.3 All proposed functions and data interfaces;
As demonstrated through our current participation in the Louisiana Medicaid Program, we are
capable of supporting numerous types and levels of information processing and data exchange.
We have provided data interfaces and process flows for all key business processes within our
response to Questions 2.10.13.2.2 and 2.10.13.2.4.
2.10.13.2.4 Data and process flows for all key business processes; and

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Figure 31. Architectural Diagram. Our Louisiana system is customized to meet state requirements. It is fully interoperable
and fluidly exchange information, allowing us to support future needs.

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Figure 32. Enrollment/Eligibility Subsystem Flow. Our end‐to‐end enrollment flow validates inbound 834 files for HIPAA
compliance, and loads the data into our CSP system.

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Figure 33. Claims Processing and Encounters. We receive via EDI, portal and paper, and load the data into CSP.

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Figure 34. Encounters Flow. We gather encounter data from numerous sources and report this information using NEMIS.

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Figure 35. Telephone Management System (Enrollee). When an enrollee contacts our member services center, our interactive voice
response (IVR) systems and intelligent routing technology identify the caller and route the call to the appropriate resource or self‐service
function.

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Interactive Voice Response Platform

1 2 4 6 7
Welcome and Call Routing
Provider Phone Reporting and
Provider Calls Validation (Natural Language
Representative Metrics
(IVR) Technology/IVR)

3 5
Providers Internal Systems
(NDB) (CDB, Clinical)

1 Provider calls our customer service number 5 Automated menu options allow various transactions
such as eligibility verification, claims status which
access data held in our internal systems
2 Welcome member message and provider validation 6 Provider Phone Representatives assist providers with
executes. their request
3 Provider’s data is validated against our internal system 7 Reporting and analytics from our IVR system
real time including NDB.
4 Providers can select various routing options using language
or menu prompts.

Figure 36. Telephone Management (Provider Services Call Center). Our provider call center is one of the “first stops” for providers
to obtain information, education and resolve questions.

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Figure 37. Provider Contracting Subsystem Flow. Our simplified credentialing process through CAQH supports data sharing and
administrative simplification for providers.

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Figure 38. Utilization Management/Service Authorization/Care Management/Care Coordination Flow. Our UM/service
authorization and care management process supports the state’s HIT Roadmap and a coordinated system of care.

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Figure 39. Finance Flow. This flowchart illustrates the claims payment process to enable prompt and timely payment to providers.

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Figure 10: Reporting System Flow. Our integrated reporting and data analytics solution enables us to achieve maximum
plan effectiveness and meet LDH’s reporting requirements.

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2.10.13.2.5 Proposed resources dedicated to Medicaid Management Information System (MMIS) exchanges.
The IT technical support for Louisiana is estimated to require 96,720 hours or 47 FTEs per year.
This includes 20,800 hours or 10 FTEs to monitor infrastructure and technical operations and
66,560 hours or 32 FTEs to provide platform technical support. Six local IT staff will be
dedicated to supporting the Louisiana program. Our dedicated information management and
systems director has accountability for the technology supporting the Louisiana Medicaid
Managed Care Program. The local IT staff dedicated to the Louisiana includes an Information
management and systems director/chief information officer; IT systems analyst, operations
support (four); IT systems analyst and HEDIS reporting manager.
In total, we anticipate the Louisiana Medicaid program to require 63 IT resources to support the
program on an ongoing basis. This represents a small fraction of our overall IT support staff who
can be accessed as needed to assist Louisiana Medicaid. UnitedHealth Group IT has more than
10,000 technology professionals across the United States. Following industry standards, our IT
professionals are geographically dispersed to take advantage of the national labor pool and
mitigate risks of localized disaster and weather events. We outline technical resources in the IT
sections immediately above this section.
2.10.13.3 The Proposer should attest to the availability of the data elements required to produce required…
We have substantial experience aligning our system to meet LDH requirements including the
data elements required to produce required management reports. In support of the Louisiana
Medicaid program, we produce more than 80 weekly, monthly, quarterly and annual reports —
plus ad hoc reports — on topics such as claims timeliness, encounter completeness, provider
network, utilization rates, member roster, behavioral health, medical care coordination and
overall Medicaid plan performance, including critical indicators and performance measures. A
team of skilled analysts submits reports reflecting both data analysis and trending.
SMART, our robust, integrated reporting and data analytics solution enables us to achieve
maximum plan effectiveness and meet LDH’s reporting requirements. We integrate data into our
data repositories from sources external to our core operations systems, including provider and
encounter data from our vision and dental ancillary vendors, and pharmacy encounter data. We
recently upgraded SMART to the latest Oracle Exadata Database platform, which brought
noticeable performance benefits to reporting and analytics users. It also provides us with a
future-ready data platform primed to enable timely, database decision-making across the
business. Developing these composite data sets enables quality analysis such as HEDIS and
others and supplements the medical management of enrollees.
2.10.13.4 The Proposer should describe in detail any system changes or enhancements that the Proposer is…
UnitedHealth Group upgrades and enhances its systems continuously. Comprehensive
enhancements deploy on a monthly schedule or more frequently if possible, coordinated across
platforms as needed. Every quarter, we deploy version upgrades to our CSP Facets platform,
and we work closely with the product developer, Cognizant, to drive their roadmap for new
systems features. We officially notify LDH of any significant updates per current contract
requirements. We schedule change windows to avoid impact on enrollees, providers and other
system users. The Change Management Team works with the system stakeholders and the
Operations Team to determine release timing and change windows when there is no impact on
system availability. If a change affects an enrollee or customer, we communicate through
appropriate customer contacts and adhere to the LDH notification requirements.

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2.10.13.4.1 Enrollment;
Eligibility Enrollment Management System (EEMS): Throughout 2019, we are rebuilding our
enrollment module for CSP to provide greater flexibility for eligibility sources, improved speed to
market for format changes, reduced maintenance costs and continued top-of-the-line end-to-
end cycle time for loading eligibility.
2.10.13.4.2 Claims processing;
We implemented chatbots to automate some functions that our customer service personnel
have to perform as part of their standard operating procedures. These chatbots automatically
look up and populate the data or directions to screens for representatives when required. This
automation improves the efficiency of our representatives in assisting our members/providers
and accuracy of data entries during the calls. We are exploring opportunities to add chatbots to
support our claims processers to improve the accuracy of data entries during claims correction.
2.10.13.4.3 Utilization Management/service authorization; or
We constantly upgrade our UM platform to support increased flexibility in requiring prior
authorizations for services.
2.10.13.4.4 Care Management/disease management.
We actively use our resources to support Medicaid providers in practical and targeted ways to
make progress toward meeting state and federal health information technology (HIT) and Health
Information Exchange (HIE) requirements. UnitedHealthcare was the first MCO to execute and
implement a contract with the Louisiana Health Information Exchange (LaHIE), and established
hospital-specific data exchanges with facilities not actively participating with LaHIE to ensure we
met our goal of providing comprehensive care management, and quality and efficiency of health
care delivery, especially among smaller providers in outlying areas of the state. Work continues
to partner with other Louisiana HIEs to develop relationships that increase enrollee data
available to positively influence care management.
2.10.13.5 The Proposer should describe the capability and capacity of the Proposer’s Information Technology (IT)
As shown in Question 2.10.13.2.2, our system architecture currently interfaces with LDH’s
system and that of its network providers and material subcontractors. These interfaces have
been in place and operational since our 2012 Shared Savings program participation.

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2.10.14 Program Integrity

2.10.14.1 The Proposer should describe its fraud, waste and abuse program and how it addresses the requirements…

UnitedHealthcare Fraud, Waste and Abuse Program Overview

Since 2012, UnitedHealthcare has been dedicated to
safeguarding Louisiana’s Medicaid funds, ensuring they are
used efficiently and judiciously to provide enrollees with the care
they need to improve their health and well-being in alignment
with the Triple Aim. Once we became a full-risk plan in 2015, we
expanded our Fraud, Waste and Abuse Program to include a
robust Special Investigation Unit (SIU) and payment integrity
functions. To expand our ability to combat fraud, waste, abuse
and error, we combined advanced analytic capabilities, deep
industry expertise and flexible infrastructure to help reveal
unusual patterns that require further investigation and action.  
Through innovation and continuous improvement, LDH has recognized our best practices.
We have exceeded LDH referral goals and achieved $1 million in recoveries since 2015.
Examples of best practices include screening tips before assignment to SIU, re-routing non-
fraud cases to our Waste and Error Team and enabling our SIU to independently refer cases to
LDH.
From our parent company, UnitedHealth Group, to our employees, contractors and enrollees,
we support a culture of compliance focused on minimizing wasteful spending, abuse and
fraud. Our Compliance Program is modeled on the seven elements of an effective compliance
program, as outlined in 42 CFR §438.608(a)(1), and is compliant with all requirements of Model
Contract Section 2.20. Supporting policies and procedures include our Fraud Waste and Abuse
Prevention and Detection Plan, which we submit to LDH annually, as well as:
 UnitedHealth Group Code of Conduct
 UnitedHealthcare Government Programs Compliance Program
 UnitedHealth Group False Claims Act Compliance Policy
 UnitedHealthcare Compliance Investigations policy
 UnitedHealthcare Fraud, Waste, and Abuse policy
 Supplemental documentation to address federal and state-specific requirements
Since 2013, Larry Smith has served as our contract compliance officer and program integrity
officer. He works in conjunction with our national and local SIU and payment integrity
department, both of which are supported by our Legal Team. Mr. Smith co-chairs our local
Compliance Oversight Committee with the health plan CEO to oversee the compliance program
and confirm adherence with LDH requirements, policies and procedures. Further, Mr. Smith and
the health plan’s CEO or chief operation officer attend LDH Program Integrity (PI) and Louisiana
Office of Inspector General’s (OIG) Medicaid Fraud Control Unit (MFCU) meetings. During
these PI/MFCU meetings, the Department’s investigative units share schemes and case studies
that influence our investigations. For example, behavioral health audits have been an area of
focus for both the MFCU and UnitedHealthcare. In 2018, we reported 400 audits of behavioral
health providers. At these PI/MFCU meetings, collaboration among investigators from all MCOs
has led to more coordinated, effective provider audits and better data for PI/MFCU on cases the
MCOs refer.

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Prevention, Detection and Correction

A cornerstone of our Compliance Program, our Anti-Fraud, Waste and Abuse Program focuses
on prevention, detection and correction activities undertaken to minimize or prevent
overpayments due to fraud, waste or abuse. Through our operational model, appropriately titled
Prevention, Detection and Correction, we further increase the effectiveness of our local
compliance program by drawing upon our national team that spans 25 states where we serve
Medicaid enrollees. Through information sharing with programs in other states, our national and
state teams can uncover potential schemes, share information with other states, and bring in
additional resources if needed to increase our ability to efficiently avoid or remediate fraud,
waste and abuse in Louisiana. Additionally, we are pleased to have contributed to LDH’s recent
recognition by CMS for increasing referrals by 100% and tripling the number of tips received
since LDH introduced its fraud referral form.

Figure 40. Key Features of UnitedHealthcare's Prevention, Detection and Correction Model

Several aspects of our prevention, detection and correction model are outlined in our response
to Questions 2.10.14.1.1 through 2.10.14.1.5 where we address training and education, enrollee
engagement, data analytics, high-risk claims and provider recoveries. The following are also
critical aspects of our Fraud, Waste and Abuse Program.
Prevention
In accordance with Model Contract Section 2.3.1.4, to determine whether they have been
excluded from participation in Medicare, Medicaid, the Children’s Health Insurance Program
and/or any federal health care programs, all UnitedHealthcare employees undergo annual
criminal background checks. We also perform required database searches on employees,
entities, contract and contingent workers, and customers and business partners per all
requirements of Model Contract Section 2.20.3.6. Further, our contracts with third parties
contain language requiring them to screen their employees as required by applicable state and
federal law. UnitedHealthcare checks the exclusion status of all contracted providers against the
following lists:
 Health and Human Services (HHS) OIG List of Excluded Individuals/Entities (LEIE)
 General Services Administration Excluded Parties List Service
 GSA’s System for Award Management (SAM)
 CMS’s Medicare Exclusion Databank
 State Board of Examiners
 Social Security Administration Death Master File (SSADMF)
 National Plan and Provider Enumeration System (NPPES)
 U.S. Office of Foreign Assets Control (OFAC)
 Louisiana Adverse Actions List and all state licensing boards

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When we discover any entity is excluded, suspended or debarred, we report them to LDH within
3 business days. This includes a director, partner or officer of the health plan, subcontractors,
any consultants or employees with other arrangements to provide services material to the health
plan and network providers.
When LDH informs us of a credible allegation of fraud against a provider, we immediately
suspend payments according to 42 CFR §455.23, alerting network management and claims
processors.

Detection
UnitedHealthcare employs an array of programs that combat fraud, waste and abuse both
prospectively (before claims are paid) and retrospectively (after claims have been paid). We
focus on being good stewards of state and federal dollars and are steadfast in our commitment
to preventing FWA through programs and algorithms that identify problems arising from both
intentional and uninformed practices. Our SIUs are critical to detection efforts. Our Louisiana-
based SIU staff includes one investigator for every 50,000 enrollees and is supported by
investigative teams throughout the company. To increase efficiency, our local SIU builds upon
best practices of our national investigative teams, such as:
 Triaging all tips received to determine credibility before routing to the SIU or Waste and
Error Team. The SIU investigates allegations of fraud, while the Waste and Error Team
investigates non-fraud billing aberrations
 Streamlining the process by enabling SIU investigators to interact directly with LDH,
including submitting referrals and notifications
 Performing pre-payment review by using algorithms to identify aberrant billing patterns
that lead to referrals to the SIU
 Participation in the Healthcare Fraud Prevention Partnership and sharing awareness of
industry trends
Through this collaboration between our national and local investigative staff, we received
recognition from LDH for exceeding the Department’s goal for SIU referrals and notices by
100% in state fiscal year (SFY) 2018.
We make it easy for employees, enrollees or providers to report suspicions of misconduct,
including billing fraud or unethical activities. In addition to the ability to report tips to our
compliance officer or management, we offer and provide education on the following methods for
reporting of suspected fraud, waste or abuse. In compliance with the Model Contract, we are
also implementing and will check weekly, a dedicated email account for employees, enrollees or
providers to submit tips.
 UnitedHealthcare’s Compliance &  Online tip referral form
Ethics Help Center and FWA hotline  Provider and enrollee portals
(both available 24 hours a day, 7 days
 Contact numbers for OIG/HHS
a week)
 Louisiana’s FWA hotline
 HRdirect via toll-free number or our
company’s intranet site

Correction
When FWA investigations reveal the need for corrective action, we may pursue actions,
including, but not limited to, the following:
 Notifying and educating the offending provider or enrollee

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 Creating and implementing new data mining queries/rules to detect if the scheme at
issue is occurring with other providers
 Educating providers on possible changes in the contract and/or policy terms and
procedures
 Issuing a corrective action plan to the provider
 Referring a provider to network management for appropriate disciplinary action
 Referring a provider to any other committees as necessary to remediate the issue (such
as quality, contracting and credentialing)
 Reporting providers to state professional licensing authorities and medical boards
 Referring a matter to outside counsel for civil litigation
 Referring a matter to law enforcement officials or prosecutors for criminal prosecution
If a corrective action plan is issued, our compliance officer along with the business leaders of
the affected functional area(s) monitor and evaluate the implementation of and progress made
under the corrective action plan. They are also responsible for documenting that remediation
activities are effective and address the concerns detailed in the corrective action plan.
When we identify providers who meet a threshold of claims denied through prepay record
review, we provide them with a report describing the patterns of billing practices and encourage
them to review it with one of our certified professional coders. We also employ one-on-one
meetings and establish ongoing dialogue related to the identified coding issues. Prepay
monitoring continues until the provider meets or exceeds the threshold of denied claims. This
approach helps avoid the usual resource intensive pay and chase scenario.
All claims and encounters associated with fraud, waste and abuse are voided, and any money
paid to excluded entities is returned to LDH within 30 days.
2.10.14.1.1 Any training programs that the Proposer uses to train employees, subcontractors, and providers on…
Knowledge is the first line of defense in safeguarding LDH’s Medicaid dollars and preventing
fraud, waste and abuse. Our educational content emphasizes to our employees, providers,
subcontractors and enrollees that they are on the front lines in deterring and detecting Medicaid
FWA and are obligated to report suspicions of unethical or illegal behavior.

Training for Employees and Subcontractors

Compliance training is required for all UnitedHealthcare employees, managers and directors,
applicable company subcontractors, and those employees of other company segments who
perform work on our behalf. In addition to new employee orientation, we provide mandatory
annual and/or periodic employee compliance training, including, but not limited to:
 Code of Conduct, including Enforcement and Disciplinary Guidelines
 Privacy and Security
 Organizational Conflicts of Interest
 Identifying Fraud, Waste and Abuse
 Reporting suspected FWA, unethical conduct or non-compliance
 False Claims Act and Whistleblower Protection
 Contract compliance and FWA training, including:
 Procedures for timely consistent notification, information exchange and collaboration
with LDH

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 Organizational chart including the program integrity officer and full-time program
integrity investigators
 Effective lines of communication between compliance and employees
Our compliance officer conducts annual training on Louisiana-specific contract requirements,
including those in Model Contract section 2.20.2.2.4.2. He also shares relevant publications
from LDH throughout the year via email blasts (e.g., Health Plan Advisories, new legislation).
Mandatory annual retraining requires an attestation and/or a passing test score. All compliance
related trainings are completed within 30 days of hire and annually after that. Adherence is
monitored by tracking training completion and notifying managers if employees do not complete
training on time. Our compliance officer then follows up to verify training was completed.

Training for Providers

We offer initial and ongoing integrity and compliance training to providers through our secure
provider website, UHCprovider.com (available 24 hours a day, 7 days a week). We also convey
information about our FWA program in our Care Provider Manual, our provider newsletter,
Practice Matters, and through targeted provider education letters. Our provider advocates also
conduct in-person training to providers and their staff as needed.
We promote the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely
campaign to providers. This program is aimed at avoiding overutilization of inappropriate
services by providing specific, evidence-based recommendations clinicians and enrollees can
discuss, such as when tests and procedures (e.g., CT scans, antibiotics) may be appropriate
and the process used for the recommendation. Finally, providers have access to multiple
venues for any questions and points of escalation. These venues include provider expositions, a
provider hotline outside of the provider call center, grievances and appeals process, and
provider advocates who address issues face-to-face.

Provider Awareness
Our provider awareness campaigns include proactive outreach to those providers with aberrant
billing patterns in a collaborative, respectful manner to minimize provider tensions. The goal is
to remediate identified behavior that could lead to a focused, potentially contentious audit in the
future if not corrected or addressed. We perform this analysis without any payment delays and
burdensome record requests. This approach allows us to influence billing practices through
tailored provider engagement, including letters, outreach via phone and one-on-one meetings
with the provider and a certified professional coder. The goal is to remediate identified behavior
that could lead to a focused audit in the future. Providers receive a letter tailored to the claims
experience from their practice and a report, which demonstrates the results of their billing
compared to their peers. Providers are encouraged to contact us through their Provider
Advocate to discuss the results in more detail. We monitor the provider’s behavior for
improvement and, if none is identified, we consider next steps such as outreach, audit, formal
education or investigation. In 2018, we submitted letters to 360 Louisiana Medicaid providers
spanning 22 prevention campaigns.

LDH Program Goal: Minimize Wasteful Spending, Abuse and Fraud

Targeted Provider Education through Practice Management
A specialized Practice Management Team of licensed clinicians conducts
systematic reviews of provider practices to identify instances of atypical clinical
patterns of behavior and determine if the behavior warrants intervention. They may make
announced or unannounced on-site field audits. They conduct internal meetings with
appropriate departments to inform them of the identified patterns and gather additional

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information. The team then reviews aberrant claims billing patterns with the provider; provides
education on clinical and billing guidelines; conducts clinical audits with potential performance
improvement plans or network termination, or refers the case to the SIU if they identify
prospective flag or recoupment opportunity. While this work typically leads to targeted education
opportunities, practice specialists in Louisiana made 149 referrals to the SIU through this
program in 2018.

Training for Delegated Entities

Delegated Entities are responsible for adhering to all compliance program elements outlined by
federal regulations, and state regulations and UnitedHealthcare. These requirements are
communicated via methods such as our Delegated Entity Oversight reference website and
Annual Compliance Delegate Notice and Annual Attestation. Program elements include, but are
not limited to, the following:
 Awareness of federal and state laws related to an effective compliance program, to
safeguard against improper payments and utilization of services, and methods of
reporting fraud, waste and abuse
 Code of Conduct upon hire and annually after that
 Document retention for 10 years from the date the activity is performed
2.10.14.1.2 How the Proposer engages enrollees in preventing fraud, waste and abuse;
Enrollees receive education upon enrollment, beginning with their welcome newsletter, which
includes descriptions of fraud, waste and abuse, and instructions on how to report it. Their ID
cards for the health plan and pharmacy include a telephone number to report tips. Additional
education is provided through the Enrollee Handbook including definitions of FWA, how to
identify FWA and examples, the enrollee’s responsibility to prevent FWA and the various
avenues available to report FWA. Enrollees receive additional education through the Getting
Started Guide, HealthTalk newsletter, behavioral health support website (liveandworkwell.com)
and enrollee mobile application.
Materials are designed to encourage appropriate and cost-effective use of health care, including
the importance of the PCP, prior authorizations, emergency care, annual checkups, value-
added services, non-covered services and more. Our compliance officer also presents on topics
related to fraud, waste and abuse prevention at our Member Advisory Committee meetings.
Enrollees are also able to review claims through our enrollee website, myuhc.com and contact
us if they observe evidence of fraud, waste or abuse.
To educate enrollees and help limit overutilization of inappropriate services, we also offer the
ABIM Foundation’s Choosing Wisely campaign via literature provided during enrollee events
and in-office provider signage. The campaign encourages enrollees to ask questions like:
 Do I really need this test or procedure?  What happens if I don’t do anything?
 What are the risks and side effects?  How much does it cost, and will my
 Are there simpler, safer options? insurance pay for it?

Per the Code of Federal Regulations (42 CFR §455.20, Recipient Verification Procedure),
states must have a method of verifying whether or not services billed by providers were
received. UnitedHealthcare uses this requirement as an opportunity to engage enrollees to
identify and report any suspicious activity. Any potential inconsistencies identified by the
enrollees are further reviewed, investigated and reported, if warranted, within 3 days of notice
that services were not received.

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2.10.14.1.3 The data analytic algorithms that the Proposer will use for purposes of fraud prevention and detection;
One of the most efficient methods of detecting fraud, waste and abuse is predictive modeling
and electronic data analysis. These tools identify aberrant and excessive billing practices and
trends, inappropriate treatment, fictitious and unqualified providers, and fictitious and ineligible
enrollees.
We apply automated claim edits based upon correct coding, industry standards for HIPAA, state
and federal regulations, UnitedHealthcare reimbursement, medical and drug policies and
specialty programs to validate accurate claim payment and confirm consistent enrollee and
provider experiences. Programs used to identify potential FWA include, but are not limited to:
Diagnosis to Drug Match (DX/Rx): Data analytics confirms a “drug to diagnosis” match along
with age edits to confirm medication use is appropriate. This program supports the identification
of high-risk behavior by identifying fraudulent schemes such as securing controlled substances
and other high-cost supplies for unlawful distribution.
Coordination of Benefits Smart Utility: This program matches eligibility information from
participating payers across the nation and supplies the results back to the payers on a weekly
basis. This information is used to set flags on the adjudication platform.
Algorithm/Data Mining: UnitedHealthcare can identify evidence of overlapping coverage
through a variety of information resources including eligibility data, enrollee communications,
claims and prior authorization data.
Prior Authorization: We work closely with health care practitioners and providers to determine
the medical necessity and appropriateness of care, avoid inappropriate use or duplication of
services, and identify enrollees who may benefit from care coordination. We also require prior
authorization for services at risk for fraud (e.g., durable medical equipment or controlled
substances).
Machine Learning: We use innovative machine learning, a type of computational science
sometimes referred to as artificial intelligence, to uncover unusual behavior amongst providers.
This science incorporates numerous technologies that actively create algorithms as data is
analyzed and then can make predictions when presented with new data sets. Neural networks,
clustering, network analysis and graph theory are a few technologies that comprise our
collection of machine learning techniques.
Natural Language Processing (NLP): Another type of artificial intelligence, NLP enables a
computer program to understand human language as it is spoken or written. With NLP,
computers can read text, hear speech and interpret a tremendous amount of unstructured data
(e.g., electronic health records, medical records, claims data and call center conversations) and
place it into a usable structure. Using this data that would not be available without NLP,
UnitedHealthcare can more efficiently extract trends and identify root cause issues to combat
FWA. We use NLP to make sure we prioritize leads with allegation details that include fraud
trend key words. We also employ NLP to identify trends in the examination of fraud referrals
from external sources like OIG, DOJ and news articles to identify subject areas of concern.
Lock-in Program: In collaboration with LDH, we provide an administrative lock-in program that
acknowledges the potential harm to an enrollee who misuses high-risk prescription medication,
including controlled substances like opioids and medications that could be misused with opioids,
and allows us to limit an enrollee to one pharmacy but does not limit access to emergency
services. We retrospectively identify enrollees who are misusing and potentially committing
fraud or abuse in two primary ways: reported tips from enrollees, providers or our employees

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and data analytics. During 2018, the Lock-in Program averaged 200 to 250 enrollees.
To investigate reported tips or unusual data patterns, we review an enrollee’s medical claims,
such as ED visits or multiple prescribers, to identify potential drug-seeking behavior. Once the
lock-in assignment occurs, we perform annual utilization reviews of the enrollee’s paid
pharmacy and health care services to determine if the enrollee meets the criteria for an
extended lock-in. When enrollees are affirmatively identified for lock-in programs and when an
enrollee in lock-in transfers to fee-for-service (FFS) or another health plan, we notify LDH
immediately (or at a frequency determined by LDH). We also apply the lock-in program when
notified of enrollees who transferred from the FFS benefit and were in the FFS lock-in program.
Pharmacy Drug Utilization Review (DUR) Program: The DUR program identifies high-risk,
dangerous enrollee utilization patterns or gaps in care, looks at prescribing trends outside of
evidence-based guidelines for educational opportunities, and looks to alert pharmacies of
medication related issues they may not be aware of due to an enrollee’s use of multiple
pharmacies. This program helps detect potential high-risk activity.
Pre-Payment Flags When we believe a provider has engaged in fraud, waste or abuse, a
prospective “flag” can be placed on provider payments. Flags are useful in preventing payments
to providers until we validate their billing patterns and create opportunities for provider education
or investigate billing practices, thus reducing administrative costs.
Prospective Payment Program: As required in the Model Contract, we have a software tool
that includes provider peer-to-peer profiling, claim-centric editing, and predictive modeling tools
that uncover previously undetected aberrant behaviors. We can apply these software tools to
the plan’s daily claim stream to identify fraud and abuse before the claim is paid. Both Provider-
and Claim-centric prepayment flags help identify “complex” cases for review.
Aberrant Billing Patterns (ABP): We maintain libraries of ABPs that include queries and
algorithms designed to identify suspected FWA based upon known or suspected schemes and
practices. These ABPs include general queries and criteria applicable to all health plan claims
and those tailored to common FWA schemes.
Claims Edits: A clinical edit system that analyzes physician health care claims based upon
business rules, which automate reimbursement policy and industry standard coding practices.
Our systems support health care reform mandates, including National Correct Coding Initiative
(NCCI) bundling, medically unlikely event (MUE) and health care acquired conditions. This
system helps identify claims for “automated” reviews. 2.10.14.1.4 Methods the Proposer will use
to identify high-risk claims and its definition of “high-risk claims”; and
UnitedHealthcare’s methods to identify high-risk claims range from individual monitoring of
providers to innovative software for automated data risk scoring. Many of the algorithms,
described earlier are used to identify the defined high-risk claims (e.g., durable medical
equipment, home health aides, inappropriate use of medication or high-cost supplies for
unlawful distribution). These methods include, but are not limited to, pre-pay analytic edits,
aberrant billing patterns, data mining and machine learning.
The schemes used in health care fraud, waste and abuse prevention are continually evolving.
UnitedHealthcare’s definition of high-risk claims evolves with these changes. We keep apprised
of industry trends through participation in national organizations like the National Health Care
Anti-Fraud Association and the annual HHS OIG report, which lists convictions and recoveries
by various categories and our own claims analysis. We share this information with investigative
sources, including the MFCU, in Louisiana and other states.

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LDH Program Goal: Minimizing Wasteful Spending, Abuse and Fraud

UnitedHealthcare used high-risk claims analysis to identify freestanding pathology
laboratories with excessive utilization rates for unnecessary drug tests. Enrollees
with uncomplicated alcohol use disorder, for example, were being tested for other
substances like antidepressants and antipsychotics. UnitedHealthcare’s Behavioral Health
Medical Director, Dr. Jose Calderon, analyzed the data and presented his findings to LDH and
the other MCOs. This data analysis led to a collaboration between LDH and UnitedHealthcare to
create and implement a new statewide policy to control drug testing and establish a
reimbursement code for bundling multiple tests. This innovative policy, planned to go live in the
summer of 2019, will help drive the Triple Aim of better care, better health and lower costs.
2.10.14.1.5 The Proposer’s experience with provider recovery collection.
While we are aggressive in our pursuit of resolving overpayments, we recognize that, at times, it
may be complicated or difficult for providers. We work with them to determine the most
equitable manner possible for a successful resolution. We have a dedicated team that oversees
retrospective recovery activities and handles all actions necessary to enable recovery of
overpayments, which we base upon an established recovery process that includes:
 Use of our Overpayment, Detection and Recovery (ODAR) platform to process the
affected claims. Our team loads suspect claims to ODAR to confirm that no other take-
backs were affected by that particular claim. They then send them through ODAR for
financial processing. Investigators then produce the demand letters.
 The health plan is notified of the recovery opportunity. Approval is required to proceed
with the process, and if approved, overpayment demand letters are sent to providers. In
most cases, the turnaround time for provider response is 30 days.
 Providers are entitled to file an appeal following state and LDH guidelines and published
in our Care Provider Manual.
Through this process, UnitedHealthcare
has recovered $1 million since we became
a full-risk plan in Louisiana in 2015.
Through its FWA program, in 2018 alone,
UnitedHealthcare recovered $653,346 in
overpayments, resulting from over 1,200
provider investigations and audits. These
include work performed by both our SIU
and Waste and Error Teams. Noted as a Figure 41. Louisiana FWA Recoveries
best practice by LDH, our Triage Team
refers all non-fraud cases to our Waste and Error Team, rather than SIU. This step in the
process helps focus SIU resources more efficiently and effectively.
As demonstrated by the graph, our recoveries in 2018 increased by 40% from the previous
year. In part, this success is due to the maturation of audits, but a significant factor in increasing
recoveries is the teamwork among investigators and our Negotiations Team. Together,
investigators and negotiators work with providers to reach workable settlements. This
maximizes recoveries and minimizes the need for litigation while allowing providers to maintain
their business activities. In 2019 and beyond, we expect this year-over-year increase in
recoveries to continue.

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2.10.14.2 The Proposer should provide a detailed description of its capability to produce the required reports…
Since 2015, UnitedHealthcare has worked closely with the LDH Program Integrity Team to
submit timely reports and, in some cases, to help refine the format and process of those reports.
Recently, we submitted innovative recommendations for improving the standing report on FWA
activities to make it easier for all MCOs to prepare the report and for LDH to access the data.
We will continue to provide LDH with all reports required under by the Model Contract, including
the following.

Ad Hoc Reports of FWA Incidents Involving Individuals or Entities

In compliance with the Model Contract, we report any FWA incident or notice concerning
individuals or entities within 3 business days. Additionally, we report all credible allegations to
LDH Program Integrity utilizing its Fraud or Notification referral forms. We immediately report
provider fraud and abuse or enrollee fraud to LDH and local law enforcement, and notify LDH
immediately in the event we are contacted by any investigative authority. We check all required
exclusion databases monthly. We also check all state licensing boards and report, within 3
business days, individuals or entities with sanctions in any state or line of business to LDH if
there is Louisiana Medicaid exposure
We will continue to report on overpayments from LDH to UnitedHealthcare, FWA in the
administration of the Louisiana Medicaid program (within 5 business days), and FWA identified
through the medical and pharmacy utilization management program. We also will begin
reporting, upon receipt, any disclosure by a provider of overpayments in excess of $25,000 in
accordance with all Model Contract requirements.

Standing Reports of FWA Activities

Continued submission of these reports includes our monthly reports on tips audits, , and
exclusion database review attestation; quarterly FWA audits and activities (becoming monthly)
and verification of services; and annual reports of recoveries and overpayments and the FWA
compliance program plan. We also will continue to provide monthly reports on unsolicited
provider refunds and begin reporting upon receipt disclosure by a provider of overpayments in
excess of $25,000 in accordance with the Model Contract.
For both Ad Hoc and Standing reports, UnitedHealthcare uses its proprietary reporting software
and databases and keeps detailed tracking logs to support required reporting. Our reporting
software, such as Serena Business Manager and DETECTS, track and monitor tips, including
those reported through the Recipient Verification of Services process. Another proprietary
database, ODAR, is used to track and reconcile payments to claims including reporting on
unsolicited provider refunds. Our investigators also log and track their cases and associated
investigatory processes. This data, combined with DETECTS and ODAR, forms the basis of our
reports of tips, audits and FWA activities.

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2.10.15 Veteran-Owned and Service-Connected Disabled Veteran-

Owned Small Entrepreneurships (Veteran Initiative) and Louisiana
Initiative for Small Entrepreneurships (Hudson Initiative) Programs
Participation
2.10.15.1 Twelve percent (12%) of the total evaluation points in this RFP are reserved for Proposers who are…
2.10.15.2 If the Proposer is a certified Veterans Initiative or Hudson Initiative small entrepreneurship, the…
2.10.15.3 If the Proposer is not a certified small entrepreneurship, but has engaged one (1) or more Veterans…
2.10.15.4 If multiple Veterans Initiative or Hudson Initiative subcontractors will be used, the above required…
2.10.15.5 For additional information, see Appendix G, Veteran and Hudson Initiatives.

Our Commitment to Economic Development

As one of Louisiana’s largest contractors in the Medicaid Managed Care Program serving the
needs of more than 442,000 enrollees, we are committed to supporting LDH’s efforts to
increase state purchasing and contracting opportunities available to certified Louisiana-based
small entrepreneurships under the Louisiana Veteran and Hudson Small Entrepreneurship
Initiatives (“Certified Businesses”). By strengthening the diverse business community, we
contribute to the overall economic growth and expansion of the nation’s most rapidly expanding
market segments. Delivering high quality services to the residents of Louisiana by using locally
owned businesses has deepened our footprint and commitment to the communities we serve.
We have identified 67 medical and administrative subcontracting opportunities with certified
business entities. We also will encourage our commercial and Medicare Advantage (People’s
Health) lines of business in Louisiana to contract with Veteran/Hudson businesses, which is
additional and separate above our Medicaid certified commitment in this bid. We have a strong
history of using Veteran’s/Hudson entities over the past 5 years, spending over $20 million with
previous and current certified businesses. We plan to remain committed to these partners and
expand over the next 3-year commitment.
. By
engaging with these certified businesses upon contract award, we will ensure that certified
Louisiana-based businesses deliver services related to the Medicaid Managed Care Program
when possible. These services include, but are not limited to:
 Care transitions  Wound care management
 Home health care  Wellness
 Pediatric day health center  Physical therapy/occupational therapy
 Retail pharmacy  Marketing/Advertising
 Durable medical equipment (DME)  Printing
 Rehabilitation  Recruiting/staffing
 Non-emergency medical transportation
(NEMT)

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Continually Expanding Opportunities for Certified Louisiana Small

Entrepreneurships
Our commitment to using certified businesses does not end with the list in this response. We
are committed to not only using businesses LDH identifies through the Department of Economic
Development, we will make every effort to replace active subcontractors, certified and non-
certified, with certified businesses and monitor spend with this vendor population proactively. In
addition, as part of our One United approach, we are encouraging our commercial and People’s
Health lines of business to consider using these vendors as well. This again would be above
and separate from our certified Medicaid offer.

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UnitedHealth Group’s Supplier Diversity Program

In support of Louisiana’s Veteran and Hudson Small
Entrepreneurship Initiatives, we will build upon the
Veteran Employees
UnitedHealth Group was
successful experience of our parent company, UnitedHealth
named a 2019 Military Group, to actively seek and partner with local businesses
Friendly Employer by certified in the following classifications: small business,
Viqtory, a veteran‐owned minority-business enterprise, women-owned business
business that connects the enterprise and veteran-owned business enterprise. We
military community to actively seek to partner with diverse suppliers that reflect the
civilian opportunity. multicultural states we serve. We provide diverse businesses
opportunities to compete for discretionary spend associated
with third-party contracts and order fulfillment with our corporation. In 2018, UnitedHealth Group
spent over $1.14 billion with small and diverse suppliers and providers across the enterprise.
Our sourcing teams actively work to identify opportunities for minority, women-owned and
veteran-owned and other historically underutilized businesses. We also work with state and
local government agencies, minority business groups and advocacy organizations to identify
sourcing opportunities for diverse suppliers where possible.
We are corporate members of the National Minority Supplier Development Council (NMSDC)
and the Women Business Enterprise National Council (WBENC). We also support NMSDC and
WBENC regional affiliate councils throughout the United States.

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