reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 59 - Rehabilitation Services › Subchapter B - Reimbursement Methodology › Section V-5913 - Non-Rural, Non-State Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after February 20, 2009, the reimbursement
					 paid to non-rural, non-state hospitals for outpatient rehabilitation services
					 provided to recipients over the age of three years shall be reduced by 3.5
					 percent of the fee schedule on file as of February 19, 2009.
B. Effective for dates of service on or after
					 August 4, 2009, the reimbursement paid to non-rural, non-state hospitals for
					 outpatient rehabilitation services provided to recipients over the age of three
					 years shall be reduced by 5.65 percent of the fee schedule on file as of August
					 3, 2009.
C. Low Income and Needy
					 Care Collaboration. Effective for dates of service on or after January 1, 2010,
					 quarterly supplemental payments will be issued to qualifying non-rural,
					 non-state hospitals for rehabilitation services rendered during the quarter.
					 Maximum aggregate payments to all qualifying hospitals in this group shall not
					 exceed the available upper payment limit per state fiscal year.
1. Qualifying Criteria. In order to qualify
					 for the supplemental payment, the non-rural, non-state hospital must be
					 affiliated with a state or local governmental entity through a Low Income and
					 needy care collaboration agreement.
a. A
					 non-state hospital is defined as a hospital which is owned or operated by a
					 private entity.
b. A Low Income and
					 Needy Care Collaboration Agreement is defined as an agreement between a
					 hospital and a state or local governmental entity to collaborate for purposes
					 of providing healthcare services to low income and needy patients.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 59 - Rehabilitation Services › Subchapter B - Reimbursement Methodology › Section V-5915 - Non-Rural, Non-State Public Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
					 July 1, 2013, quarterly supplemental payments may be issued to qualifying
					 non-rural, non-state public hospitals for rehabilitation services rendered
					 during the quarter. Payment amounts may be reimbursed up to the Medicare
					 outpatient upper payment limits as determined in accordance with
					 42 CFR §
												447.321
1.
					 Qualifying Criteria. In order to qualify for the quarterly supplemental
					 payment, the non-rural, non-state public acute care hospital must be designated
					 as a non-teaching hospital by the department and must:
a. be located in a MSA per
					 42 CFR
					 413.231(b)(1);
b. provide inpatient obstetrical and neonatal
					 intensive care unit services; and
c. per the cost report period ending in SFY
					 2012, have a Medicaid inpatient day utilization percentage in excess of 21
					 percent and a Medicaid newborn day utilization percentage in excess of 65
					 percent as documented on the as filed cost report.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 59 - Rehabilitation Services › Subchapter B - Reimbursement Methodology › Section V-5917 - Childrens Specialty Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after September 1, 2009, the reimbursement
					 amount paid to children's specialty hospitals for rehabilitation services shall
					 be as follows.
1. Qualifying hospitals shall
					 receive an interim payment equal to the Medicaid fee schedule amount on file
					 for each service.
2. Final
					 reimbursement shall be 97 percent of allowable cost as calculated through the
					 cost report settlement process.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 59 - Rehabilitation Services › Subchapter B - Reimbursement Methodology › Section V-5919 - State-Owned Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective
					 for dates of service on or after February 10, 2012, medical education payments
					 for outpatient rehabilitation services which are reimbursed by a prepaid
					 risk-bearing managed care organization (MCO) shall be reimbursed by Medicaid
					 annually through the Medicaid cost report settlement process.
1. Qualifying medical education programs are
					 defined as graduate medical education, paramedical education, and nursing
					 schools.
2. Final payment shall be
					 determined based on the actual MCO covered outpatient rehabilitation services
					 and Medicaid medical education costs for the cost reporting period per the
					 Medicaid cost report.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 59 - Rehabilitation Services › Subchapter B - Reimbursement Methodology › Section V-5921 - Rehabilitation Services for Recipients Ages 0 up to Age 3

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following are reimbursement rates for
					 rehabilitation services provided to Medicaid recipients up to the age of 3,
					 regardless of the type of provider performing the services:
1. initial speech/language
					 evaluation-$70;
2. initial hearing
					 evaluation-$70;
3. initial
					 occupational therapy evaluation-$70;
4. occupational therapy, 15
					 minutes-$15;
5. occupational
					 therapy, 30 minutes-$30;
6.
					 occupational therapy, 45 minutes-$45;
7. occupational therapy, 60
					 minutes-$60;
8. physical therapy
					 and rehab evaluation-$75;
9.
					 physical therapy, one modality-$37;
10. physical therapy, two or more
					 modalities-$56;
11. physical
					 therapy, one or more procedures, and/or modalities, 15
					 minutes-$18.50;
12. physical
					 therapy with procedures, 30 minutes-$37;
13. physical therapy with procedures, 75
					 minutes-$92.50;
14. procedures and
					 modalities, 60 minutes-$74;
15.
					 speech and hearing therapy, 15 minutes-$14;
16. speech and hearing therapy, 30
					 minutes-$28;
17. speech and hearing
					 therapy, 45 minutes-$42;
18. speech
					 and hearing therapy, 60 minutes-$56;
19. speech/language/hearing therapy, 60
					 minutes-$56;
20. visit with
					 procedure(s), 45 minutes-$56;
21.
					 visit with procedure(s), 60 minutes-$74; and
22. visit with procedure(s), 90
					 minutes-$112.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 59 - Rehabilitation Services › Subchapter B - Reimbursement Methodology › Section V-5923 - Rehabilitation Services for Recipients Ages 3 and Above (Reserved)

Current through Register Vol. 50, No. 6, June 20, 2024
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter A - General Provisions › Section V-6101 - Payment for Other Outpatient Hospital Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Interim payment for outpatient hospital
					 services other than clinical diagnostic laboratory services, outpatient surgery
					 services, rehabilitation services, and outpatient hospital clinic services
					 shall be at a hospital-specific cost to charge ratio. Final payment shall be a
					 percentage of cost amount as detailed for each type of hospital in Subchapter B
					 of this Chapter. The percentage shall be applied to cost for these services as
					 calculated based on the finalized cost report.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter A - General Provisions › Section V-6105 - Radiology Utilization Management (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter B - Reimbursement Methodology › Section V-6113 - Small Rural Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective
					 for dates of service on or after July 1, 2008, the reimbursement amount paid to
					 small rural hospitals for outpatient hospital services other than clinical
					 diagnostic laboratory services, outpatient surgeries, rehabilitation services,
					 and outpatient hospital facility fees shall be as follows.
1. Small rural hospitals shall receive an
					 interim payment for claims which shall be 110 percent of each hospital's cost
					 to charge ratio as calculated from the latest filed cost report.
2. Final reimbursement shall be 110 percent
					 of allowable cost as calculated through the cost report settlement
					 process.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter B - Reimbursement Methodology › Section V-6115 - Non-Rural, Non-State Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after February 20, 2009, the reimbursement
					 paid to non-rural, non-state hospitals for outpatient hospital services other
					 than clinical diagnostic laboratory services, outpatient surgeries,
					 rehabilitation services and outpatient hospital facility fees shall be reduced
					 by 3.5 percent of the rates effective as of February 19, 2009. Final
					 reimbursement shall be at 83.18 percent of allowable cost through the cost
					 settlement process.
B. Effective
					 for dates of service on or after August 4, 2009, the reimbursement paid to
					 non-rural, non-state hospitals for outpatient hospital services other than
					 clinical diagnostic laboratory services, outpatient surgeries, rehabilitation
					 services and outpatient hospital facility fees shall be reduced by 5.65 percent
					 of the rates effective as of August 3, 2009. Final reimbursement shall be at
					 78.48 percent of allowable cost through the cost settlement process.
C. Low Income and Needy Care Collaboration.
					 Effective for dates of service on or after January 1, 2010, quarterly
					 supplemental payments will be issued to qualifying non-rural, non-state
					 hospitals for outpatient hospital services other than clinical diagnostic
					 laboratory services, outpatient surgeries and rehabilitation services rendered
					 during the quarter. Maximum aggregate payments to all qualifying hospitals in
					 this group shall not exceed the available upper payment limit per state fiscal
					 year.
1. Qualifying Criteria. In order to
					 qualify for the supplemental payment, the non-rural, non-state hospital must be
					 affiliated with a state or local governmental entity through a low income and
					 needy care collaboration agreement.
a. A
non-state hospital
is defined as a hospital which is owned or
					 operated by a private entity.
b. A
low income and needy care collaboration agreement
is defined
					 as an agreement between a hospital and a state or local governmental entity to
					 collaborate for purposes of providing healthcare services to low income and
					 needy patients.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter B - Reimbursement Methodology › Section V-6117 - Non-Rural, Non-State Public Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
					 July 1, 2013, quarterly supplemental payments may be issued to qualifying
					 non-rural, non-state public hospitals for outpatient services other than clinic
					 services, diagnostic laboratory services, outpatient surgeries and
					 rehabilitation services rendered during the quarter. Payment amounts may be
					 reimbursed up to the Medicare outpatient upper payment limits as determined in
					 accordance with 42 CFR §
												447.321
1.
					 Qualifying Criteria. In order to qualify for the quarterly supplemental
					 payment, the non-rural, non-state public acute care hospital must be designated
					 as a non-teaching hospital by the department and must:
a. be located in a MSA per
					 42 CFR
					 413.231(b)(1);
b. provide inpatient obstetrical and neonatal
					 intensive care unit services; and
c. per the cost report period ending in SFY
					 2012, have a Medicaid inpatient day utilization percentage in excess of 21
					 percent and a Medicaid newborn day utilization percentage in excess of 65
					 percent as documented on the as filed cost report.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter B - Reimbursement Methodology › Section V-6119 - Childrens Specialty Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after September 1, 2009, the reimbursement
					 amount paid to children's specialty hospitals for outpatient hospital services
					 other than clinical diagnostic laboratory services, outpatient surgeries,
					 rehabilitation services, and outpatient hospital facility fees shall be as
					 follows.
1. Qualifying hospitals shall
					 receive an interim payment that is equal to 97 percent of the hospital's cost
					 to charge ratio as calculated from the latest filed cost report.
2. Final reimbursement shall be 97 percent of
					 allowable cost as calculated through the cost report settlement
					 process.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 61 - Other Outpatient Hospital Services › Subchapter B - Reimbursement Methodology › Section V-6127 - State-Owned Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Cost Based
					 Services. The reimbursement methodology for state-owned outpatient hospital
					 services are determined by a hospital cost to charge ratio based on each state
					 hospital's latest filed cost report. These cost-to-charge ratio calculations
					 will be reviewed on an ongoing basis as cost reports are filed and will be
					 adjusted as necessary. Final reimbursement shall be the allowable cost as
					 determined from the Medicare/Medicaid cost report for each state
					 hospital.
B. Effective for dates of
					 service on or after February 10, 2012, medical education payments which are
					 reimbursed by a prepaid risk-bearing managed care organization (MCO) shall be
					 reimbursed by Medicaid annually through the Medicaid cost report settlement
					 process to state-owned hospitals for outpatient hospital services other than
					 outpatient surgery services, clinic services, laboratory services, and
					 rehabilitation services.
1. Qualifying
					 medical education programs are defined as graduate medical education,
					 paramedical education, and nursing schools.
2. Final payment shall be determined based on
					 the actual MCO covered outpatient services and Medicaid medical education costs
					 for the cost reporting period per the Medicaid cost report.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 63 - Diabetes Education Services › Subchapter A - General Provisions › Section V-6301 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for
					 dates of service on or after February 20, 2011, the department shall provide
					 coverage of diabetes self-management training (DSMT) services rendered to
					 Medicaid recipients diagnosed with diabetes.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 63 - Diabetes Education Services › Subchapter A - General Provisions › Section V-6303 - Scope of Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. DSMT
					 services shall be comprised of one hour of individual instruction and nine
					 hours of group instruction on diabetes self-management.
B. Service Limits. Recipients shall receive
					 up to 10 hours of services during the first 12-month period beginning with the
					 initial training date. After the first 12-month period has ended, recipients
					 shall only be eligible for two hours of individual instruction on diabetes
					 self-management per calendar year.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 63 - Diabetes Education Services › Subchapter A - General Provisions › Section V-6305 - Provider Participation

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
					 to receive Medicaid reimbursement, outpatient hospitals must have a DSMT
					 program that meets the quality standards of one of the following accreditation
					 organizations:
1. the American Diabetes
					 Association;
2. the American
					 Association of Diabetes Educators; or
3. the Indian Health Service.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 63 - Diabetes Education Services › Subchapter B - Reimbursement › Section V-6311 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after February 20, 2011, the Medicaid
					 Program shall provide reimbursement for diabetes self-management training
					 services rendered by qualified health care professionals in an outpatient
					 hospital setting.
B. Reimbursement
					 for DSMT services shall be a flat fee based on the appropriate Healthcare
					 Common Procedure Coding (HCPC) code.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 67 - Public-Private Partnerships › Section V-6701 - Baton Rouge Area Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Qualifying
				  Criteria. Effective for dates of service on or after April 15, 2013, the
				  department shall provide supplemental Medicaid payments for outpatient hospital
				  services rendered by non-state privately owned hospitals that meet the
				  following conditions.
1. Qualifying Criteria.
				  The hospital must be a non-state privately owned and operated hospital that
				  enters into a cooperative endeavor agreement with the Department of Health and
				  Hospitals to increase its provision of outpatient Medicaid and uninsured
				  hospital services by:
a. assuming the
				  management and operation of services at a facility where such services were
				  previously provided by a state owned and operated facility; or
b. providing services that were previously
				  delivered and terminated or reduced by a state owned and operated
				  facility.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 67 - Public-Private Partnerships › Section V-6703 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payments
				  to qualifying hospitals shall be made on a quarterly basis in accordance with
				  42
				  CFR 447.321.
B. Effective for dates of service on or after
				  April 15, 2013, a major teaching hospital that enters into a cooperative
				  endeavor agreement with the Department of Health and Hospitals to provide acute
				  care hospital services to Medicaid and uninsured patients, and which assumes
				  providing services that were previously delivered and terminated or reduced by
				  a state owned and operated facility shall be reimbursed as follows.
1. Outpatient Surgery. The reimbursement
				  amount for outpatient hospital surgery services shall be an interim payment
				  equal to the Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost.
2. Clinic Services. The reimbursement amount
				  for outpatient clinic services shall be an interim payment equal to the
				  Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost.
3. Laboratory Services. The reimbursement
				  amount for outpatient clinical diagnostic laboratory services shall be the
				  Medicaid fee schedule amount on file for each service.
4. Rehabilitative Services. The reimbursement
				  amount for outpatient clinic services shall be an interim payment equal to the
				  Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost.
5. Other Outpatient Hospital Services. The
				  reimbursement amount for outpatient hospital services other than clinical
				  diagnostic laboratory services, outpatient surgeries, rehabilitation services
				  and outpatient hospital facility fees shall be an interim payment equal to 95
				  percent of allowable Medicaid cost.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 69 - Out-of-State Hospitals › Subchapter B - Reimbursement › Section V-6901 - Qualifying Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to
					 qualify as an urban metropolitan statistical area (MSA) facility, the hospital:
1. has a facility type code of acute and
					 opened subsequent to the March 12, 2020 presidential declaration of a national
					 emergency due to COVID-19 to provide availability of additional beds and
					 services for COVID-19 patients;
2.
					 must have been licensed and certified no later than June 30, 2020, and located
					 in zip code 70806, east of I-110, north of I-10, and south of Business Highway
					 190;
3. is located in an urban
					 metropolitan statistical area (MSA) as defined by the United States Office of
					 Management and Budget;
4. has an
					 operational emergency room and is located greater than five miles in distance
					 from the closest hospital emergency room; and
5. is located on a single site.
a. The addition of any off-site campus
					 location to the license of this hospital will invalidate the provisions of this
					 reimbursement methodology.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 69 - Out-of-State Hospitals › Subchapter B - Reimbursement › Section V-6903 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after July 1, 2022, payments for
					 outpatient services to qualifying urban MSA hospitals who meet all of the
					 criteria in
					 §6901 shall be made as follows.
1. Outpatient Surgery. The reimbursement
					 amount for outpatient hospital surgery services shall be an interim payment
					 equal to the Medicaid fee schedule amount on file for each service, and a final
					 reimbursement amount of 95 percent of allowable Medicaid cost as calculated
					 through the cost report settlement process.
2. Clinic Services. The reimbursement amount
					 for outpatient clinic services shall be an interim payment equal to the
					 Medicaid fee schedule amount on file for each service, and a final
					 reimbursement amount of 95 percent of allowable Medicaid cost as calculated
					 through the cost report settlement process.
3. Laboratory Services. The reimbursement
					 amount for outpatient clinical diagnostic laboratory services shall be the
					 Medicaid fee schedule amount on file for each service.
4. Rehabilitation Services. The reimbursement
					 amount for outpatient rehabilitation services shall be an interim payment equal
					 to the Medicaid fee schedule amount on file for each service, and a final
					 reimbursement amount of 95 percent of allowable Medicaid cost as calculated
					 through the cost report settlement process.
5. Other Outpatient Hospital Services. The
					 reimbursement amount for outpatient hospital services other than clinical
					 diagnostic laboratory services, outpatient surgeries, rehabilitation services,
					 and outpatient hospital facility fees shall be an interim payment equal to 95
					 percent of allowable Medicaid cost as calculated through the cost report
					 settlement process.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 69 - Out-of-State Hospitals › Subchapter B - Reimbursement › Section V-6915 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Reimbursement for all Louisiana Medicaid recipients who receive outpatient
					 services in an out-of-state hospital, including those recipients up to the age
					 of 21, shall be calculated as follows:
1.
					 Outpatient services provided in out-of-state hospitals that are subject to a
					 fee schedule in-state shall be paid at the fee schedule amounts utilized for
					 in-state non-rural, non-state hospitals.
2. Outpatient services provided in
					 out-of-state hospitals that are not subject to a fee schedule in-state shall be
					 paid at the annual average cost to charge ratio calculated from the filed
					 Medicaid cost reports for in-state non-rural, non-state hospitals multiplied by
					 the percent of allowable cost as specified in
					 §6115 that is in effect for the applicable
					 time period for in-state non-rural, non-state hospitals. This ratio shall be
					 applied to the billed charges for covered claims submitted by out-of-state
					 hospitals to determine payment for non-fee schedule services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 71 - Medicare Part B Claims for Medicaid Eligible Recipients › Subchapter B - Reimbursement › Section V-7115 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. To
					 determine the amount that Medicaid will reimburse on a claim for a Medicaid
					 recipient who is also eligible for Medicare Part B, the Medicare claim payment
					 is compared to the Medicaid rate on file for the revenue or procedure codes on
					 the Medicare Part B claims for outpatient hospital services. If the Medicare
					 payment exceeds the Medicaid rate, the claim is adjudicated as a paid claim
					 with a zero payment. If the Medicaid rate exceeds the Medicare payment, the
					 claim is reimbursed at the lesser of the co-insurance and deductible or up to
					 the Medicaid maximum payment. If the Medicaid payment is reduced or eliminated
					 as a result of the Medicare/Medicaid payment comparison, the amount of the
					 Medicare payment plus the amount of the Medicaid payment, if any, shall be
					 considered to be payment in full for the service.
B. The recipient does not have any legal
					 liability to make payment for the service.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 73 - Urban Metropolitan Statistical Area (MSA) Facility › Section V-7301 - Qualifying Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to
				  qualify as an urban metropolitan statistical area (MSA) facility, the hospital:
1. has a facility type code of acute and
				  opened subsequent to the March 12, 2020 presidential declaration of a national
				  emergency due to COVID-19 to provide availability of additional beds and
				  services for COVID-19 patients;
2.
				  must have been licensed and certified no later than June 30, 2020, and located
				  in zip code 70806, east of I-110, north of I-10, and south of Business Highway
				  190;
3. is located in an urban
				  metropolitan statistical area (MSA) as defined by the United States Office of
				  Management and Budget;
4. has an
				  operational emergency room and is located greater than five miles in distance
				  from the closest hospital emergency room; and
5. is located on a single site.
a. The addition of any off-site campus
				  location to the license of this hospital will invalidate the provisions of this
				  reimbursement methodology.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 73 - Urban Metropolitan Statistical Area (MSA) Facility › Section V-7303 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after July 1, 2022, payments for
				  outpatient services to qualifying urban MSA hospitals who meet all of the
				  criteria in
				  §7301 shall be made as follows.
1. Outpatient Surgery. The reimbursement
				  amount for outpatient hospital surgery services shall be an interim payment
				  equal to the Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost as calculated
				  through the cost report settlement process.
2. Clinic Services. The reimbursement amount
				  for outpatient clinic services shall be an interim payment equal to the
				  Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost as calculated
				  through the cost report settlement process.
3. Laboratory Services. The reimbursement
				  amount for outpatient clinical diagnostic laboratory services shall be the
				  Medicaid fee schedule amount on file for each service.
4. Rehabilitation Services. The reimbursement
				  amount for outpatient rehabilitation services shall be an interim payment equal
				  to the Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost as calculated
				  through the cost report settlement process.
5. Other Outpatient Hospital Services. The
				  reimbursement amount for outpatient hospital services other than clinical
				  diagnostic laboratory services, outpatient surgeries, rehabilitation services,
				  and outpatient hospital facility fees shall be an interim payment equal to 95
				  percent of allowable Medicaid cost as calculated through the cost report
				  settlement process.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 75 - Urban Metropolitan Statistical Area (MSA) Facility-New Orleans Area › Section V-7501 - Qualifying Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to
				  qualify as an urban metropolitan statistical area (MSA) facility-New Orleans
				  area, effective October 5, 2022, a hospital must:
1. be designated a non-rural hospital service
				  district located in LDH region 1, with a facility type code of acute, Medicaid
				  enrolled, with an original hospital license date before July 13, 2014, but
				  after July 1, 2014, located in zip code 70127;
2. be a hospital that is located in an MSA as
				  defined by United States Office of Management and Budget;
3. have an operational emergency room;
				  and
4. not add additional locations
				  under this license, without prior written approval of the department.
a. The addition of any off-site campus,
				  beyond an outpatient primary care clinic, to the license of this hospital will
				  invalidate the provisions of this reimbursement methodology.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part V - Hospital Services › Subpart 5 - Outpatient Hospital Services › Chapter 75 - Urban Metropolitan Statistical Area (MSA) Facility-New Orleans Area › Section V-7503 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payments
				  for outpatient services to qualifying urban MSA hospitals-New Orleans area who
				  meet all of the criteria in
				  §7501 shall be made as follows:
1. Outpatient Surgery. The reimbursement
				  amount for outpatient hospital surgery services shall be an interim payment
				  equal to the Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost as calculated
				  through the cost report settlement process.
2. Clinic Services. The reimbursement amount
				  for outpatient clinic services shall be an interim payment equal to the
				  Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost as calculated
				  through the cost report settlement process.
3. Laboratory Services. The reimbursement
				  amount for outpatient clinical diagnostic laboratory services shall be the
				  Medicaid fee schedule amount on file for each service.
4. Rehabilitation Services. The reimbursement
				  amount for outpatient rehabilitation services shall be an interim payment equal
				  to the Medicaid fee schedule amount on file for each service, and a final
				  reimbursement amount of 95 percent of allowable Medicaid cost as calculated
				  through the cost report settlement process.
5. Other Outpatient Hospital Services. The
				  reimbursement amount for outpatient hospital services other than clinical
				  diagnostic laboratory services, outpatient surgeries, rehabilitation services,
				  and outpatient hospital facility fees shall be an interim payment equal to 95
				  percent of allowable Medicaid cost as calculated through the cost report
				  settlement process.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 301 - General Provisions › Section VII-30101 - Foreword

Current through Register Vol. 50, No. 6, June 20, 2024
A. The ICF/MR
				  standards for payment specify the requirements of federal and state law and
				  regulations governing services provided by intermediate care facilities for the
				  mentally retarded and persons with other developmental disabilities
				  (ICF/MR).
B. The Medicaid Program
				  is administered by the Louisiana Department of Health and Hospitals (DHH) in
				  cooperation with other federal and state agencies.
C. Standards are established to ensure
				  minimum compliance under the law, equity among those served, provision of
				  authorized services, and proper disbursement. If there is a conflict between
				  material in these standards and the federal and state laws or policies
				  governing the program, the state laws or policies governing the program have
				  precedence. These standards provide the ICF/MR with information necessary to
				  fulfill the provider enrollment contract with the agency. It is the ICF/MR
				  facility's responsibility to keep these standards current. The standards are
				  the basis for surveys by federal and state agencies, are part of the enrollment
				  contract, and are necessary for the ICF/MR to remain in compliance with federal
				  and state laws.
D. Monitoring of an
				  ICF/MR's compliance with state and federal regulations is the responsibility of
				  DHH's Bureau of Health Services Financing (BHFS).
E. The Bureau of Health Services Financing
				  (BHSF) Health Standards Section (HSS) is responsible for determining an
				  ICF/MR's compliance with state licensing requirements and compliance with
				  specific Title XIX certification requirements which include physical plant,
				  staffing, dietary, pharmaceuticals, active treatment, and other standards.
				  Minimum licensure requirements for ICF/MRs are covered in the booklet entitled
Licensing Requirements for Residential Care Providers
and
				  Subpart I of the
Code of Federal Regulations
, Chapter
				  42:483.400-483.480.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 303 - Provider Enrollment › Section VII-30301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Scope
1. The standards set forth in this and
				  subsequent sections comply with the Title XIX requirements of the amended
				  Social Security Act. That Act sets the standards for the care, treatment,
				  health, safety, welfare and comfort of Medical Assistance clients in facilities
				  providing ICF/MR services.
2. These
				  standards apply to ICF/MRs certified and enrolled by the Louisiana Department
				  of Health and Hospitals (DHH) for vendor participation.
3. These standards supplement current
				  licensing requirements applicable to ICF/MRs. Any infraction of these standards
				  may be considered a violation of the provider agreement between DHH and the
				  ICF/MR.
4. In the event any of
				  these standards are not maintained, DHH will determine whether facility
				  certification will continue with deficiencies as is allowed under Title XIX
				  regulations or whether termination of the provider agreement is warranted.
				  Although vendor payment will not be suspended during the determination period,
				  deficiencies which may affect the health, safety, rights and welfare of Medical
				  Assistance clients must be corrected expeditiously in order for the ICF/MR to
				  continue to participate.
5. If a
				  certified ICF/MR is found to have deficiencies which immediately jeopardize the
				  health, safety, rights and welfare of its Medical Assistance clients, DHH may
				  initiate proceedings to terminate the ICF/MR's certification. In the event of
				  less serious deficiencies, DHH may impose interim sanctions (see Chapter 323,
				  Sanctions).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 303 - Provider Enrollment › Section VII-30303 - General Admission and Funding

Current through Register Vol. 50, No. 6, June 20, 2024
A. Capacity. The ICF/MR will admit only the
				  number of individuals that does not exceed its rated capacity as determined by
				  the BHSF's HSS and its capacity to provide adequate programming.
B. Admission Requirements. Except on a short
				  term emergency basis, an ICF/MR may not admit individuals as clients unless
				  their needs can be met and an interdisciplinary professional team has
				  determined that admission is the best available plan for them. The team must do
				  the following:
1. conduct a comprehensive
				  evaluation of each individual that covers physical, emotional, social and
				  cognitive factors; and
2. perform
				  the following tasks prior to admission:
a.
				  define the individual's need for service without regard to the availability of
				  those services; and
b. review all
				  appropriate programs of care, treatment, and training and record the
				  findings;
3. ensure that
				  the ICF/MR takes the following action if admission is not the best plan but the
				  individual must nevertheless be admitted:
a.
				  clearly acknowledges that admission is inappropriate; and
b. initiates plans to actively explore
				  alternatives.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 303 - Provider Enrollment › Section VII-30305 - Program Enrollment

Current through Register Vol. 50, No. 6, June 20, 2024
A. An
				  ICF/MR may enroll for participation in the Medical Assistance Program (Title
				  XIX) when all the following criteria have been met:
1. the ICF/MR has received Facility Need
				  Review approval from DHH;
2. the
				  ICF/MR has received approval from DHH/OCDD;
3. the ICF/MR has completed an enrollment
				  application for participation in the Medical Assistance Program;
4. the ICF/MR has been surveyed for
				  compliance with federal and state standards, approved for occupancy by the
				  Office of Public Health (OPH) and the Office of the State Fire Marshal, and has
				  been determined eligible for certification on the basis of meeting these
				  standards; and
5. the ICF/MR has
				  been licensed and certified by DHH.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 303 - Provider Enrollment › Section VII-30307 - Ownership

Current through Register Vol. 50, No. 6, June 20, 2024
A. Disclosure. All
				  participating Title XIX ICF/MRs are required to supply the DHH Health Standards
				  Section with a completed HCFA Form 1513 (Disclosure of Ownership) which
				  requires information as to the identity of the following individuals:
1. each person having a direct or indirect
				  ownership interest in the ICF/MR of 5 percent or more;
2. each person owning (in whole or in part)
				  an interest of 5 percent or more in any property, assets, mortgage, deed of
				  trust, note or other obligation secured by the ICF/MR;
3. each officer and director when an ICF/MR
				  is organized as a corporation;
4.
				  each partner when an ICF/MR is organized as a partnership;
5. within 35 days from the date of request,
				  each provider shall submit the complete information specified by the BHSF/HSS
				  regarding the following:
a. the ownership of
				  any subcontractor with whom this ICF/MR has had more than $25,000 in business
				  transactions during the previous 12 months; and
b. information as to any significant business
				  transactions between the ICF/MR and the subcontractor or wholly owned suppliers
				  during the previous five years.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 303 - Provider Enrollment › Section VII-30309 - Provider Agreement

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to
				  participate as a provider of ICF/MR services under Title XIX, an ICF/MR must
				  enter into a provider agreement with DHH. The provider agreement is the basis
				  for payments by the Medical Assistance Program. The execution of a provider
				  agreement and the assignment of the provider's Medicaid vendor number is
				  contingent upon the following criteria.
1.
				  Facility Need Review Approval Required. Before the ICF/MR can enroll and
				  participate in Title XIX, the Facility Need Review Program must have approved
				  the need for the ICF/MR's enrollment and participation in Title XIX. The
				  Facility Need Review process is governed by Department of Health and Hospitals
				  regulations promulgated under authority of Louisiana
				  R.S.
				  40:2116.
a.
				  The approval shall designate the appropriate name of the legal entity operating
				  the ICF/MR.
b. If the approval is
				  not issued in the appropriate name of the legal entity operating the ICF/MR,
				  evidence shall be provided to verify that the legal entity that obtained the
				  original Facility Need Review approval is the same legal entity operating the
				  ICF/MR.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 305 - Admission Review › Section VII-30501 - Admission Process

Current through Register Vol. 50, No. 6, June 20, 2024
A. ICF/MRs will
				  be subject to a review of each client's need for ICF/MR services.
B. Interdisciplinary Team (ID Team). Before
				  admission to an ICF/MR, or before authorization for payment, an
				  interdisciplinary team of health professionals will make a comprehensive
				  medical, social and psychological evaluation of each client's need for care in
				  the ICF/MR.
1. Other professionals as
				  appropriate will be included on the team, and at least one member will meet the
				  definition of Qualified Mental Retardation Professional (QMRP) as stated in
				  these standards.
2. Appropriate
				  participation of nursing services on this team should be represented by a
				  Louisiana licensed nurse.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part VII - Long Term Care › Subpart 3 - Intermediate Care Facilities for Persons with Intellectual Disabilities › Chapter 305 - Admission Review › Section VII-30503 - Certification Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  following documentation and procedures are required to obtain medical
				  certification for ICF/MR Medicaid vendor payment. The documentation should be
				  submitted to the appropriate HSS regional office.
1. Social evaluation:
a. must not be completed more than 90 days
				  prior to admission and no later than date of admission; and
b. must address the following:
i. family, educational and social history
				  including any previous placements;
ii. treatment history that discusses past and
				  current interventions, treatment effectiveness, and encountered negative side
				  effects;
iii. current living
				  arrangements;
iv. family
				  involvement, if any;
v.
				  availability and utilization of community, educational, and other sources of
				  support;
vi. habilitation
				  needs;
vii. family and/or client
				  expectations for services;
viii.
				  prognosis for independent living; and
ix. social needs and recommendation for
				  ICF/MR placement.