Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 31 - General Provisions › Section I-3113 - Directed Payments

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hospital
				  Directed Payments
1. Subject to written
				  approval by the Centers for Medicare and Medicaid Services (CMS), the
				  Department of Health (hereafter referred to as "the department" and/or "LDH")
				  shall provide directed payments to qualifying hospitals that participate in the
				  Healthy Louisiana Medicaid managed care program, in accordance with the
				  applicable section 438.6(c) preprint(s) approved by CMS, federal regulations,
				  and departmental requirements. Each CMS approved directed payment arrangement
				  is effective for one Healthy Louisiana Medicaid managed care contract rating
				  period.
2.
Qualifying
				  Hospital
-either of the following:
a.
				  an in-state provider of inpatient and outpatient hospital services (excluding
				  freestanding psychiatric hospitals, freestanding rehabilitation hospitals, and
				  longterm acute care hospitals) that meets the criteria specified in the
				  applicable section 438.6(c) preprint approved by CMS and departmental
				  requirements; or
b. an in-state
				  hospital provider of long-term acute care, psychiatric services, and
				  rehabilitation services for both inpatient and outpatient hospital services
				  that meet the criteria specified in the applicable section 438.6(c) preprint
				  approved by CMS and departmental requirements.
3. The department shall assign qualifying
				  hospitals to provider classes based upon criteria specified in the applicable
				  section 438.6(c) preprint(s) approved by CMS, in accordance with departmental
				  requirements.
a. Qualifying hospitals shall
				  have no right to an administrative appeal regarding any issue related to
				  provider classification, including, but not limited to, provider class
				  assignment, the effective date of provider class assignment, or qualifying
				  determinations.
4. The
				  department shall utilize an interim payment process, whereby interim directed
				  payments will be calculated based on provider class assignment utilizing the
				  data and methodology specified in the applicable section 438.6(c) preprint(s)
				  approved by CMS, in accordance with departmental requirements.
a. Qualifying hospitals shall have no right
				  to an administrative appeal regarding calculation of interim directed
				  payments.
b. The department
				  reserves the right to discontinue the interim directed payments to any hospital
				  whose projected recoupment due to shifts in utilization is greater than 50
				  percent of their estimated interim directed payments or any hospital who
				  discontinues operations during or prior to the directed payment contract
				  period.
5. The department
				  shall cause interim directed payments to be paid on a quarterly basis to the
				  Healthy Louisiana Medicaid managed care organizations (MCOs), in accordance
				  with departmental requirements.
a. The MCOs
				  shall pay interim directed payments to qualified hospitals within 10 business
				  days of receipt of quarterly interim directed payment information from LDH. If
				  a barrier exists that will not allow the MCO to pay the interim directed
				  payments within 10 business days of receipt, the MCO shall immediately notify
				  LDH. LDH at its sole discretion will determine if penalties for late payment
				  may be waived.
b. The qualifying
				  hospital may request that the MCOs deposit their interim directed payments into
				  a separate bank account owned/held by the qualifying hospital. Interim directed
				  payments shall not be deposited into a bank account that is owned/held by more
				  than one qualifying hospital.
6. In accordance with the applicable section
				  438.6(c) preprint(s) approved by CMS, federal regulations, and departmental
				  requirements, directed payments must be based on actual utilization and
				  delivery of services during the applicable contract period.
a. Within 12 months of the end of each state
				  fiscal year (SFY), LDH shall perform a reconciliation as specified in the
				  applicable section 438.6(c) preprint approved by CMS and departmental
				  requirements.
i. Qualifying hospitals shall
				  have no right to an administrative appeal regarding any issue related to
				  reconciliation, including, but not limited to, the timing and
				  process.
b. Qualified
				  hospitals are strongly encouraged to submit claims as quickly as possible after
				  SFY end.
7. If a
				  qualifying hospital that is subject to a reconciliation will not be
				  participating in a directed payment arrangement in the future, the qualified
				  hospital shall pay all amounts owed to LDH, if any, within 30 calendar days'
				  notice of the amount owed, in accordance with departmental requirements.
a. In addition to all other available
				  remedies, LDH has the authority to offset all amounts owed by a qualifying
				  hospital due to a reconciliation against any payment owed to the qualifying
				  hospital, including, but not limited to, any payment owed by the
				  MCOs.