reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 13 - Reimbursement › Section XXIII-1301 - Payment

Current through Register Vol. 50, No. 6, June 20, 2024
A. Participants
				shall be eligible for Medicaid payment of the PACE premium on their behalf if
				they meet the categorically needy income and resource criteria for Medicaid
				eligibility for nursing facility and Home and Community Based Services waiver
				services.
B. Participants are
				eligible for Medicare payment of the PACE premium on their behalf if they are
				covered by Medicare. The amount of Medicare premiums is calculated by the
				Centers for Medicare and Medicaid Services, the federal oversight
				agency.
C. Medicaid payment to a
				PACE organization on behalf of a Medicaid-eligible participant shall be a
				prospective monthly capitated amount that is equal to or less than the amount
				that would otherwise have been paid under the State Plan if the participant was
				not enrolled under the PACE program.
1.
				Initially, each site specific upper payment limit shall be calculated for each
				state fiscal year using service area data, by zip code, from actual paid
				fee-for-service claims for populations who are age 55 or older in nursing
				facilities and in home and community based waiver and state plan services that
				utilize nursing facility level of care and serve people age 55 or
				older.
2. Site specific upper
				payment limits and Medicaid premiums for PACE shall be periodically calculated
				in accordance with the approved State Plan methodology for such calculation,
				including trending of historical data. Premiums for every PACE organization in
				the state will be based on upper payment limits.
3. Premium amount shall be a negotiated rate,
				not to exceed 95 percent of the upper payment limit.
4. No retroactive capitated payments shall be
				made.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXV - Adult Dentures › Chapter 1 - General Provisions › Section XXV-101 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. Only
				those services specified as covered under the Adult Denture Program are
				reimbursable and then only as allowed by this Part XXV.
B. Prior authorization is required for all
				adult denture services except for denture repairs. Items requiring prior
				authorization are noted with an asterisk in §501
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 XXV - Adult Dentures › Chapter 3 - Provider Participation and Recipient Criteria › Section XXV-301 - Participation Requirement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Provider
				participation is limited to those dentists who are duly licensed and authorized
				to practice dentistry in the state of Louisiana and who are enrolled in the
				Medicaid Program as a dental provider.
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 XXV - Adult Dentures › Chapter 3 - Provider Participation and Recipient Criteria › Section XXV-303 - Recipient Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Medicaid recipients who are 21 years of age and older and whose Medicaid
				coverage includes the full range of Medicaid services are eligible for denture
				services. Recipients who are not eligible for adult denture services include,
				but are not limited to, recipients who are certified as Qualified Medicare
				Beneficiary only (QMB only), adult recipients who are certified for Medicaid in
				the Medically Needy Program and pregnant women who are certified with
				presumptive eligibility.
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 XXV - Adult Dentures › Chapter 5 - Covered Services › Section XXV-501 - Adult Denture Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Only the
				following services are reimbursable under the Adult Denture Program and only in
				accordance with program policy and guidelines:
1. comprehensive oral examination*;
2. intraoral radiographs, complete
				series*;
3. complete denture,
				maxillary*;
4. complete denture,
				mandibular*;
5. immediate denture,
				maxillary*;
6. immediate denture,
				mandibular*;
7. maxillary partial
				denture, resin base (including clasps)*;
8. mandibular partial denture, resin base
				(including clasps)*;
9. repair
				broken complete denture base;
10.
				replace missing or broken tooth, complete denture, per tooth;
11. repair resin denture base, partial
				denture;
12. repair or replace
				broken clasp, partial denture;
13.
				replace broken teeth, partial denture, per tooth;
14. add tooth to existing partial
				denture;
15. add clasp to existing
				partial denture;
16. reline
				complete maxillary denture (laboratory)*;
17. reline complete mandibular denture
				(laboratory)*;
18. reline maxillary
				partial denture (laboratory)*;
19.
				reline mandibular partial denture (laboratory)*;
20. unspecified removable prosthodontic
				procedure, by report*.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXV - Adult Dentures › Chapter 5 - Covered Services › Section XXV-503 - Denture Replacement and Denture Reline

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
				January 22, 2010, only one complete or partial denture per arch is allowed in
				an eight-year period. The eight-year time period begins from the date that the
				previous complete or partial denture for the same arch was delivered. A
				combination of two complete or partial denture relines per arch or one complete
				or partial denture and one reline per arch is allowed in an eight-year period,
				as prior authorized by the bureau or its designee.
B. For relines, at least one year shall have
				elapsed since the complete or partial denture was delivered or last
				relined.
C. Cast partial dentures
				continue to be a noncovered service in the Adult Denture Program.
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 XXV - Adult Dentures › Chapter 7 - Reimbursement › Section XXV-701 - Fees

Current through Register Vol. 50, No. 6, June 20, 2024
A. Fees for these
				services shall be reimbursed as established in the Adult Denture Program fee
				schedule.
B. Effective for dates of
				service on or after July 1, 2012, the reimbursement fees on file for the
				following adult denture services shall be reduced to the following percentages
				of the 2009 National Dental Advisory Service comprehensive fee report 70th
				percentile, unless otherwise stated in this Chapter:
1. 65 percent for the comprehensive
				evaluation exam; and
2. 56 percent
				for full mouth x-ray.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 3 - Emergency Medical Transportation › Subchapter B - Ground Transportation › Section XXVII-325 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid
				  reimbursement for ground ambulance services is the rate established in the
				  state fee schedule for emergency ambulance transport, basic life support,
				  advanced life support and mileage, oxygen, intravenous fluids, and disposable
				  supplies administered during the emergency ambulance transport minus the amount
				  paid by any liable third party coverage.
B. For dates of service on or after September
				  1, 2006, the base rate for emergency ambulance transportation services is
				  increased by 5 percent of the rates in effect on August 31, 2006.
C. For dates of service on or after September
				  1, 2006, the ground mileage reimbursement rate for emergency ambulance
				  transportation services is increased by 17 percent of the rates in effect on
				  August 31, 2006.
D. For dates of
				  service on or after September 1, 2007, the ground mileage reimbursement rate
				  for emergency ambulance transportation services in effect on August 31, 2007 is
				  increased by $2.50.
E. For dates of
				  service on or after September 1, 2007, the ancillary services rate for
				  emergency ambulance transportation services is increased by 70 percent of the
				  rate in effect on August 31, 2007.
F. Effective for dates of service on or after
				  August 4, 2009, the reimbursement rates for the following supplies shall be
				  reduced by 36 percent of the rate on file as of August 3, 2009:
1. advanced life support special service
				  disposable intravenous supplies; and
2. advanced life support routine disposable
				  supplies.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 3 - Emergency Medical Transportation › Subchapter B - Ground Transportation › Section XXVII-327 - Supplemental Payments for Ambulance Providers

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
				  September 20, 2011, quarterly supplemental payments shall be issued to
				  qualifying ambulance providers for emergency medical transportation services
				  rendered during the quarter if the department has received an appropriation
				  from the legislature for these payments.
B. Qualifying Criteria. Ambulance service
				  providers must meet the following requirements in order to qualify to receive
				  supplemental payments. The ambulance service provider must be:
1. licensed by the state of
				  Louisiana;
2. enrolled as a
				  Louisiana Medicaid provider; and
3.
				  a provider of emergency medical transportation or air ambulance services
				  pursuant to
				  42
				  CFR 440.170 and a provider of the
				  corresponding medical and remedial care and services in the approved Medicaid
				  state plan.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 3 - Emergency Medical Transportation › Subchapter B - Ground Transportation › Section XXVII-331 - Enhanced Reimbursements for Qualifying Emergency Ground Ambulance Service Providers

Current through Register Vol. 50, No. 6, June 20, 2024
A. Emergency
				  Medical Transportation
1. Qualifying
				  emergency ambulance service providers assessed a fee as outlined in LAC
				  48:I.4001.E.1.a-b shall receive enhanced reimbursement for emergency ground
				  ambulance transportation services rendered during the quarter through the
				  Supplemental Payment Program described in the Medicaid State Plan if the
				  department has received an appropriation from the legislature for these
				  payments.
2. Effective for dates of
				  service on or after July 1, 2019, qualifying emergency ambulance service
				  providers assessed a fee as outlined in LAC 48:I.4001.E.1.a-d shall receive
				  enhanced reimbursement for non-emergency ground ambulance transportation
				  services rendered during the quarter through the Supplemental Payment Program
				  described in the Medicaid State Plan if the department has received an
				  appropriation from the legislature for these payments.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 3 - Emergency Medical Transportation › Subchapter C - Aircraft Transportation › Section XXVII-351 - Standards for Participation

Current through Register Vol. 50, No. 6, June 20, 2024
A. Rotor
				  winged (helicopters) and fixed winged emergency aircraft must be certified by
				  the Department of Health, Bureau of Health Services Financing in order to
				  receive Medicaid reimbursement. All air ambulance services must be provided in
				  accordance with state laws and regulations governing the administration of
				  these services.
B. All air
				  ambulance services must comply with state laws and regulations governing the
				  personnel certifications of the emergency medical technicians, registered
				  nurses, respiratory care technicians, physicians and pilots as administered by
				  the appropriate agency of competent jurisdiction.
C. Prior Approval. Prior approval shall not
				  be required for emergency air ambulance transportation services, including
				  mileage. Approval shall be done during post payment review and shall not be
				  completed prior to service delivery. Claims for payment of emergency air
				  ambulance transportation services are received and reviewed retrospectively.
				  The clinical documentation for each emergency air ambulance transportation
				  service shall not be required for submission concurrent with the claim. If
				  required, clinical documentation shall be required post claim submission.
1. Air ambulance claims will be reviewed and
				  a determination will be made based on the following requirements. Air ambulance
				  services are covered only if:
a. speedy
				  admission of the beneficiary is essential and the point of pick-up of the
				  beneficiary is inaccessible by a land vehicle; or
b. great distance or other obstacles are
				  involved in getting the beneficiary to the nearest hospital with appropriate
				  services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 3 - Emergency Medical Transportation › Subchapter C - Aircraft Transportation › Section XXVII-353 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Fixed Winged Air
				  Ambulance. The reimbursement for fixed winged air ambulance services is the
				  Medicare base rate plus mileage in effect as of January 1, 1995.
1. Payment for air mileage is limited to
				  actual air mileage from the point of pick-up to the point of delivery of the
				  patient.
2. Payment for a round
				  trip transport on the same day between two hospitals is the base rate plus the
				  round trip mileage.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 3 - Emergency Medical Transportation › Subchapter C - Aircraft Transportation › Section XXVII-355 - Supplemental Payments for Ambulance Providers

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
				  September 20, 2011, quarterly supplemental payments shall be issued to
				  qualifying ambulance providers for emergency medical air transportation
				  services rendered during the quarter if the department has received an
				  appropriation from the legislature for these payments.
B. Qualifying Criteria. Ambulance service
				  providers must meet the following requirements in order to qualify to receive
				  supplemental payments. The ambulance service provider must be:
1. licensed by the state of
				  Louisiana;
2. enrolled as a
				  Louisiana Medicaid provider; and
3.
				  a provider of emergency medical transportation or air ambulance services
				  pursuant to
				  42
				  CFR 440.170 and a provider of the
				  corresponding medical and remedial care and services in the approved Medicaid
				  state plan.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter A - General Provisions › Section XXVII-501 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Non-emergency
				  medical transportation (NEMT) is provided to Medicaid beneficiaries to and/or
				  from a medically necessary Medicaid covered service. NEMT is intended to
				  provide transportation only after all reasonable means of free transportation
				  have been explored and found to be unavailable.
NOTE: Non-emergency ambulance transportation (NEAT) is a
					 form of NEMT; NEAT provisions are located in LAC 50:XXVII. Chapter 7.
B. Medicaid covered transportation
				  is available to Medicaid beneficiaries when:
1. the beneficiary is enrolled in a Medicaid
				  benefit program that explicitly includes transportation services; and
2. the beneficiary or their representative
				  has stated that they have no other means of transportation.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter A - General Provisions › Section XXVII-503 - Prior Approval and Scheduling

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  department or its designee will review and approve or deny the transportation
				  requests, prior to scheduling, for beneficiary eligibility and verification of
				  the following:
1. that the originating or
				  destination address belongs to a healthcare provider or facility; or
2. that the service is a prior authorized
				  Medicaid covered service performed in the community.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter A - General Provisions › Section XXVII-505 - Requirements for Coverage

Current through Register Vol. 50, No. 6, June 20, 2024
A.Payment
				  shall only be authorized for the least costly means of transportation
				  available. The least costly means of transportation shall be determined by the
				  department or its designee and considered the beneficiary's choice of
				  transportation, the level of service required to safely transport the
				  beneficiary (e.g., ambulatory, wheelchair, transfer), and the following
				  hierarchy:
1. public providers;
2. gas reimbursement providers who are
				  enrolled in the Medicaid Program;
3. non-profit providers who are enrolled in
				  the Medicaid Program; and
4.
				  for-profit providers enrolled in the Medicaid Program.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter B - Beneficiary Participation › Section XXVII-511 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Beneficiaries shall participate in securing transportation at a low cost and
				  shall agree to use public transportation or solicit transportation from family
				  and friends as an alternative to costlier means of transport.
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 XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter C - Provider Responsibilities › Section XXVII-517 - Provider Enrollment

Current through Register Vol. 50, No. 6, June 20, 2024
A. All NEMT
				  providers must comply with all applicable federal, state, and local laws and
				  regulations, including, but not limited to, those pertaining to enrollment and
				  participation in the Medicaid Program.
B. Non-emergency medical transportation
				  profit providers shall have a minimum liability insurance coverage of $25,000
				  per person, $50,000 per accident and $25,000 property damage policy.
1. The liability policy shall cover:
a. any autos, hired autos, and non-owned
				  autos; or
b. scheduled autos, hired
				  autos, and non-owned autos.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter D - Reimbursement › Section XXVII-523 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement for NEMT services shall be based upon the current fee
				  schedule.
B. Reimbursement will not
				  be made for any additional person(s) who must accompany the beneficiary to the
				  medical provider.
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 XXVII - Medical Transportation Program › Chapter 5 - Non-Emergency Medical Transportation › Subchapter E - Non-Emergency Medical Transportation American Rescue Plan Act › Section XXVII-531 - Non-Emergency Medical Transportation Bonus Payments

Current through Register Vol. 50, No. 6, June 20, 2024
A. General Provisions
1. Non-emergency medical transportation
				  (NEMT) providers that are fully credentialed in the Medicaid Program may be
				  eligible to receive a bonus payment under the Department of Health's (LDH)
				  American Rescue Plan Act (ARPA) NEMT Program until the program's federal funds
				  are exhausted or through the conclusion of the program.
2. Fully credentialed NEMT providers who meet
				  all eligibility requirements are entitled to a monthly disbursement of $500 per
				  vehicle, for up to three vehicles per month, totaling a maximum payment of
				  $1,500 per month per transportation provider. The managed care organization
				  (MCO) will determine eligibility for monthly payments based on the NEMT
				  provider's ongoing compliance for all provider, driver, and vehicle
				  requirements set forth by the Medicaid Program and the LDH ARPA NEMT
				  Program.
3. A NEMT provider is a
				  provider of NEMT services and for the purpose of this bonus payment, includes
				  nonprofit and for-profit providers.
4. The MCO will provide a weekly report to
				  LDH containing all newly acquired NEMT providers. LDH will assign each active
				  NEMT provider to an affiliated MCO.
5. The MCO will administer all payments for
				  the LDH ARPA NEMT Program.
a. - e.
				  Repealed.
6. In order to
				  receive payments under the LDH ARPA NEMT Program, the NEMT provider shall do
				  the following:
a. accede to all provisions of
				  the LDH ARPA NEMT Program and execute a contractual agreement with the MCO,
				  solely for the distribution of ARPA funds;
b. maintain ongoing compliance for all
				  provider, driver, and vehicle requirements set forth by the Medicaid
				  Program;
c. submit reporting and
				  credentialing documentation for all drivers and vehicles within their
				  individual company used for NEMT services on a monthly basis. Failure to meet
				  both LDH and the MCO's time requirements shall result in loss of the monthly
				  bonus payment; and
d. submit a
				  monthly attestation to the MCO which certifies the accuracy of the submitted
				  supporting and credentialing documentation.
7. NEMT services are ineligible and shall not
				  be submitted as a completed service if the status of the NEMT service rendered
				  results in one of the following:
a. the
				  provider is a no-show;
b. no NEMT
				  vehicle is available;
c. no NEMT
				  driver is available; or
d. the NEMT
				  provider is late which causes the beneficiary to miss his or her scheduled
				  Medicaid covered service.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 7 - Non-Emergency Ambulance Transportation › Section XXVII-701 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Non-emergency
				ambulance transportation (NEAT) is ground or air ambulance transportation
				provided to Medicaid beneficiaries to and/or from a medically necessary
				Medicaid covered service when the beneficiary-us condition is such that use of
				any other method of transportation is contraindicated or would make the
				beneficiary susceptible to injury.
B. Medicaid covered transportation is
				available to Medicaid beneficiaries when:
1.
				the beneficiary is enrolled in a Medicaid benefit program that explicitly
				includes transportation services; and
2. the beneficiary or their representative
				has stated that they have no other means of transportation.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 7 - Non-Emergency Ambulance Transportation › Section XXVII-703 - Provider Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				ambulance providers must be licensed by the Department of Health, Bureau of
				Emergency Medical Services.
B. All
				NEAT providers must comply with all applicable federal, state, local laws, and
				regulations, including, but not limited to, those pertaining to enrollment and
				participation in the Medicaid Program.
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 XXVII - Medical Transportation Program › Chapter 7 - Non-Emergency Ambulance Transportation › Section XXVII-705 - Prior Approval and Scheduling

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				department or its designee must review and approve or deny the transportation
				requests, prior to scheduling, for beneficiary eligibility and verification of
				the following:
1. that the originating or
				destination address belongs to a healthcare provider or facility; and
2. that a completed certification of
				ambulance transportation form is received for the date of service.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXVII - Medical Transportation Program › Chapter 7 - Non-Emergency Ambulance Transportation › Section XXVII-707 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Reimbursement
				for NEAT services shall be based upon the current Medicaid fee
				schedule.
B. Reimbursement for NEAT
				claims shall be allowed only when accompanied by the certification of ambulance
				transportation form justifying the need for ambulance services.
C. Reimbursement will not be made for any
				additional person(s) who must accompany the beneficiary to the medical
				provider.
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 XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-105 - Medicaid Pharmacy Benefits Management System Point of Sale-Prospective Drug Utilization Program

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				Louisiana Medicaid Pharmacy Benefits Management System (LMPBM) includes a
				Point-of-Sale/Prospective Drug Utilization Review component.
B. The Louisiana Department of Health
				reserves the right for ultimate decision making relative to certain drug class
				information and drug contraindications or interactions.
C. Covered Drug List. The list of covered
				drugs is managed through multiple mechanisms. Drugs in which the manufacturer
				entered into the Medicaid Drug Rebate Program with CMS are included in the list
				of covered drugs. National average drug acquisition cost (NADAC) and usual and
				customary charges assist in managing costs on the covered drug list. Federal
				upper limits provide for dispensing of multiple source drugs at established
				limitations unless the prescribing practitioner specifies that the brand
				product is medically necessary for a patient. Establishment of co-payments also
				provides for management.
D.
				Reimbursement Management. The cost of pharmaceutical care is managed through
				NADAC of the ingredient or through wholesale acquisition cost (WAC) when no
				NADAC is assigned, and compliance with FUL regulations, the establishment of
				the professional dispensing fee, drug rebates and copayments. Usual and
				customary charges are compared to other reimbursement methodologies and the
				"lesser of" is reimbursed.
E.
				Claims Management. The claims management component is performed through the
				processing of pharmacy claims against established edits. Claim edit patterns
				and operational reports are analyzed to review the effectiveness of established
				edits and to identify those areas where the development of additional edits are
				needed.
F. Pharmacy Program
				Integrity. Program integrity is maintained through the following mechanisms:
1. retrospective drug utilization
				review;
2. Lock-In Program for
				patient education;
3. Surveillance
				and Utilization Review Systems (SURS) Program processes which provide for
				on-going review for mis-utilization, abuse and fraud and audits of the pharmacy
				providers.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-107 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				medication must be prescribed by a practitioner who is authorized to prescribe
				under state law. The national drug code (NDC) must be identified on each
				pharmacy claim for reimbursement. Prescription drugs considered for payment are
				subject to rebates from manufacturers as mandated by federal law and
				regulations.
B. Covered Drugs.
				Coverage of drugs shall be limited to specific drug products authorized for
				reimbursement by therapeutic category and listed by generic name,
				strength/unit, NDC, and brand name. Those drug products subject to mandatory
				coverage as a result of a rebate agreement with the federal government will be
				covered until written notice is received from the Centers for Medicare and
				Medicaid Services that coverage will be terminated. Providers will be given
				notice of termination of coverage.
C. Prior Authorization with a Preferred Drug
				List
1. A prior authorization process is
				established which utilizes a preferred drug list (PDL) for selected therapeutic
				classes. Drugs in selected therapeutic classes that are not included on the PDL
				shall require prescribers to obtain prior authorization. Lists of covered drug
				products, including those that require prior authorization, will be maintained
				on the Louisiana Medicaid web site.
2. The prior authorization process provides
				for a turnaround response by either telephone or other telecommunications
				device within 24 hours of receipt of a prior authorization request. In
				emergency situations, providers may dispense at least a 72-hour supply of
				medication.
3. The Pharmaceutical
				and Therapeutics Committee will make recommendations to the Department
				regarding drugs to be considered for prior authorization. The composition of
				and appointment to the Pharmaceutical and Therapeutics Committee complies with
				R.S.
				46:153.3(D) and 42
				U.S.C.s1396r-8.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-109 - Medicare Part B

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Department
				of Health, Bureau of Health Services Financing pays the full co-insurance and
				the Medicare deductible on outpatient pharmacy claims for services reimbursed
				by the Medicaid Program for Medicaid recipients covered by Medicare Part
				B.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  46:153 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-111 - Copayment

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payment Schedule
1. A copayment requirement in the Pharmacy
				Program is based on the following payment schedule.
a. For dates of service April 1, 2019 through
				December 31, 2019, recipients with a household income of less than or equal to
				$800 per month will not be subject to copay.
Calculated
State Payment
Copayment
$10.00 or less
$0.50
$10.01 to $25.00
$1.00
$25.01 to $50.00
$2.00
$50.01 or more
$3.00
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-113 - Prescription Limit

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective
				February 1, 2011, the Department of Health and Hospitals will pay for a maximum
				of four prescriptions per calendar month for Medicaid recipients.
B. The following federally mandated recipient
				groups are exempt from the four prescriptions per calendar month limitation:
1. persons under 21 years of age;
2. persons who are residents of long-term
				care institutions, such as nursing homes and ICF-DD facilities; and
3. pregnant women.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-115 - Drug Coverage Limits

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Reimbursement for multi-source prescription drugs shall be limited in
				accordance with state and federal law and rules pertaining thereto, with the
				following exception: reimbursement shall be provided for any drug prescribed by
				a prescribing provider that, in his professional judgment and within the lawful
				scope of his practice, he considers appropriate for the diagnosis and treatment
				of the patient with the following limitations.
1. The prescribed drug has been approved and
				designated as safe and effective by the Food and Drug Administration.
2. The prescribed drug is not classified as a
				DESI drug (drugs which have been identified by the FDA as lacking evidence of
				safety/effectiveness).
3. The
				prescribed drug is not a compounded prescription (mixtures of two or more
				ingredients).
4. The prescribed
				drug is not methadone prescribed only for narcotic addiction.
5. The prescription is not for medications
				which are included in the reimbursement to Title XIX facilities, including, but
				not limited to:
a. hospitalized
				recipients;
b. recipients receiving
				benefits under Part A of Title XVIII in a skilled nursing facility;
				or
c. resident/patients at Villa
				Feliciana or any state mental hospital.
6. The prescribed drug is an excluded or
				otherwise restricted drug.
7. The
				prescribed drug is not an experimental or investigational drug which are
				generally labeled:
Caution-limited by federal law to investigational use, unless
				  a specific exception has been granted by the federal government.
8. The prescribed drug is not an
				immunosuppresant drug prescribed and billed to Medicare for a Title XIX
				transplant recipient who has Medicare Part B coverage.
9. The prescribed drug is not an
				immunosuppressant drug covered by Medicare Part B which is prescribed for a
				nontransplant patient with Medicare Part B coverage and identified in the Title
				XIX provider manual as subject to special billing procedures.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-117 - Time Limits

Current through Register Vol. 50, No. 6, June 20, 2024
A. Filling
				Prescriptions. Prescriptions for drugs covered by Medicaid other than a
				controlled substance shall expire one year after the date prescribed by a
				licensed prescriber.
These prescriptions shall not be refilled more than 11 times
				  in one year. A prescription for a controlled dangerous substance listed in
				  schedule II shall expire 90 days after the date written, and no refills are
				  allowed. A prescription for a controlled dangerous substance listed in schedule
				  III, IV or V shall expire six months after the date written. Expired
				  prescriptions shall not be refillable or renewable. Payment shall be made for
				  prescriptions refilled for controlled substances in schedule III, IV and V not
				  more than five times or more than six months after issue date and only to the
				  extent indicated by the prescriber on the original prescription, and is
				  restricted by state and federal statutes.
B. Transferring Prescriptions. Transfer of a
				prescription from one pharmacy to another is allowed if less than one year has
				passed since the date prescribed and in accordance with the Louisiana Board of
				Pharmacy requirements. Transfer of a prescription for a controlled substance in
				schedule III, IV and V from one pharmacy to another is allowed if less than six
				months has passed since the date prescribed, and transfer of a prescription for
				a controlled substance in Schedule II is not allowed. Transfers of
				prescriptions shall be allowed in accordance with the Louisiana Board of
				Pharmacy regulations.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  46:153 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-119 - Maximum Quantity

Current through Register Vol. 50, No. 6, June 20, 2024
A. For all
				prescriptions, the maximum quantity payable shall be a month's supply or 100
				unit doses, whichever is greater. The quantity billed shall be that prescribed,
				unless it exceeds the maximum quantity payable in which case the maximum
				quantity payable shall be filled.
B. When maintenance drugs are prescribed and
				dispensed for chronic illnesses they shall be in quantities sufficient to
				effect economy in dispensing and yet be medically sound. Maintenance type drugs
				should be prescribed and dispensed in at least a month's supply after the
				initial fill. A 90-day supply is allowed on maintenance drugs after a
				beneficiary has been on the same drug and strength for 60 days. Contraceptives
				should be dispensed in a six-month supply, after a beneficiary has been on the
				same drug and strength for six months, unless the beneficiary or prescriber
				requests a smaller supply.
C. For
				patients in nursing homes, the pharmacist shall bill for a minimum of a month's
				supply of medication unless the treating physician specifies a smaller quantity
				for a special medical reason. A 90-day supply is allowed on maintenance drugs
				after a beneficiary has been on the same drug and strength for 60
				days.
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 XXIX - Pharmacy › Chapter 1 - General Provisions › Section XXIX-123 - Medication Administration

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Vaccine Administration. The department shall provide coverage for
				administration of vaccines by a qualified pharmacist when:
1. the pharmacist has been credentialed by
				the Louisiana Board of Pharmacy to administer medications; and
2. the pharmacist is
				Medicaid-enrolled.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-301 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Recipients shall
				have free choice of pharmacy unless subject to the agency's Lock-In
				program.
B. Lock-in is a mechanism
				for restricting Medicaid recipients to a specific physician and/or a specific
				pharmacy provider. The lock-in mechanism does not prohibit the recipient from
				receiving services from providers who offer services other than physician and
				pharmacy benefits. The lock-in mechanism:
1.
				ensures appropriate use of Medicaid benefits by recipients and/or providers;
				and
2. serves as an educational and
				monitoring parameter in instructing recipients in the most efficient method of
				using Medicaid services to ensure maximum health benefits.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-303 - Recipient Placement in the Lock-In Mechanism

Current through Register Vol. 50, No. 6, June 20, 2024
A. Potential lock-in recipients will be
				identified through review of various reports or by referral from other
				interested parties. Department of Health designee(s) who are medical
				professionals examine data for a consistent pattern of misuse/overuse of
				program benefits by a recipient. Contact with involved providers may be
				initiated for additional information. The medical professionals render a
				recommendation to place a recipient in the Physician/Pharmacy Lock-In Program
				or Pharmacy-Only Lock-In Program. The decision making authority rests solely
				with the Department of Health, Bureau of Health Services Financing.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  46:153 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-307 - Notification Directives

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				department's contract designee shall notify the recipient of the decision to
				lock-in providers and shall include the following additional information:
1. the department's intention to allow the
				recipient to choose one primary care provider, one pharmacy provider, and up to
				three specialist providers, if warranted;
2. that Medicaid will make payments only to
				the physician and pharmacy providers chosen by the recipient and subsequently
				approved by the department;
3. that
				the recipient is advised to contact the department's contract designee to
				discuss the Pharmacy Lock-In Program; and
4. that the recipient has the right to appeal
				the initial lock-in decision.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-309 - Restrictions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Recipients shall
				be prohibited from choosing physicians and pharmacists who overprescribe or
				oversupply drugs. When the agency cannot approve a recipients choice of
				provider(s), the Lock-In recipient shall be required to make another selection.
1. In order to be approved as a Lock-In
				provider, the physician or pharmacy shall accept Medicaid as reimbursement for
				services rendered. Recipients are prohibited from paying cash for services
				rendered.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-311 - Appeals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Administration
				Reconsideration. A recipient may request an administrative reconsideration of
				the departments determination to place the recipient in the Lock-In Program. An
				administrative reconsideration is an informal telephone discussion among the
				Bureau of Health Services Financing staff, the LDH contract designee, and the
				recipient. An explanation of the reason for recommending the recipient to be
				placed in the Lock-In Program will be provided to the recipient. An
				administrative reconsideration is not in lieu of the administrative appeals
				process and does not extend the time limits for filing an administrative appeal
				under the provisions of the Administrative Procedure Act. The designated
				official shall have the authority to affirm the decision, to revoke the
				decision, to affirm part or revoke in part, or to request additional
				information from either the department or the recipient.
B. Administrative Appeal Process. Upon
				notification of LDHs determination to place the Medicaid recipient into the
				Lock-In Program, the recipient shall have the right to appeal such action by
				submitting a written request to the Division of Administrative Law within 30
				days of said notification. If an appeal is timely made, the decision to Lock-In
				is stayed pending the hearing of the appeal.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  46:153 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-313 - Changing Lock-In Providers

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Recipients may change lock-in providers every year without cause. With good
				cause, they may change lock-in providers only with the bureaus approval.
				Recipients may change providers for the following "good cause" reasons:
1. a recipient relocates;
2. a recipient's primary diagnosis
				changes;
3. the Lock-In provider(s)
				request(s) that the recipient be transferred; or
4. the Lock-In provider(s) stop(s)
				participating in the Medicaid Program and does not accept Medicaid as
				reimbursement for services.
a. The recipient
				may still receive other program services available through Medicaid such as
				hospital, transportation, etc., which are not controlled or restricted by
				placing a recipient in Lock-In for pharmacy and physician services. No
				recipient on Lock-In status shall be denied the service of a physician or
				pharmacist on an emergency basis within program regulations. In instances in
				which a recipient is referred by his Lock-In physician to another enrolled
				Medicaid physician who is accepting Medicaid recipients, reimbursement shall be
				made to the physician to whom the recipient was referred.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 3 - Lock-In Program › Section XXIX-315 - Recipient Profile Review

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Recipients profiles are to be reviewed periodically as described in the Lock-In
				Procedure Manual (for determination of continuance or discontinuance of
				lock-in). The department's medical designee(s) examine(s) a recipient's profile
				for a continued pattern of misuse or overuse of program benefits. Periods of
				ineligibility for Medicaid will not affect the lock-in status of the
				individual. A review at the end of the first four months of ineligibility of
				lock-in closure will be made to determine if lock-in should be continued. Based
				upon a recommendation of the department's medical designee, a decision may be
				made to restore unrestricted benefits and appropriate notification will be
				provided to the recipient.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  46:153 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 5 - Narcotics and Controlled Substances › Section XXIX-501 - Schedule II Narcotic Analgesic Prescriptions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Schedule II narcotic analgesic
				prescriptions covered under the Louisiana Medicaid Program shall be filled
				within 90 days of the date prescribed by a physician or other prescribing
				practitioner. Also, in accordance with guidance from the drug enforcement
				agency, the prescriber has the ability to issue multiple prescriptions for the
				same schedule II medication to the same patient on the same day. All
				prescriptions must be dated and signed on the date issued. The prescriber may
				issue dispensing instruction, e.g., "do not dispense until a specified
				date."
B. Repealed.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.