reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 21 - General Provisions (Repealed) › Section XXII-2101 - Purpose (Repealed)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› Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 21 - General Provisions (Repealed) › Section XXII-2103 - Enrollment (Repealed)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ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 23 - Eligibility (Repealed) › Section XXII-2301 - Recipient Qualifications (Repealed)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ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 25 - Services (Repealed) › Section XXII-2501 - Covered Services (Repealed)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ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 25 - Services (Repealed) › Section XXII-2503 - Service Limits (Repealed)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ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 25 - Services (Repealed) › Section XXII-2505 - Service Delivery (Repealed)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 XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 27 - Reimbursement (Repealed) › Section XXII-2701 - Reimbursement Methodology (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 XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 41 - General Provisions › Section XXII-4101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. As a result of
				  the devastation caused by Hurricanes Katrina and Rita, many Louisiana health
				  care providers have incurred costs in furnishing medical services and supplies
				  to hurricane evacuees and other affected individuals who do not have health
				  care coverage through insurance or any other financial mechanism. The purpose
				  of the uncompensated care costs (UCC) pool is to provide reimbursement to
				  health care providers through federal financial participation for services
				  rendered for which there is no other source of payment.
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 XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 43 - Eligible Populations › Section XXII-4301 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Affected Individual
-an individual who
					 resided in a designated individual assistance county or parish pursuant to
					 section 408 of the Robert T. Stafford Disaster Relief and Emergency Assistance
					 Act, as declared by the President as a result of Hurricanes Katrina and Rita,
					 and continues to reside in the same state where such county or parish is
					 located.
Evacuee
-an affected individual who has
					 been displaced to another state.
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 XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 43 - Eligible Populations › Section XXII-4303 - Eligibility Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to qualify as a member of the eligible population, an individual must be either
				  a United States citizen or a legal alien who resided in a designated individual
				  assistance county or parish for Hurricane Katrina or Hurricane Rita as declared
				  by the President.
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 XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 45 - Covered Services › Section XXII-4501 - Medicaid State Plan Services

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement is available through the UCC pool for the following services
				  covered under the Louisiana Medicaid State Plan:
1. inpatient and outpatient hospital
				  services, including ancillary services;
2. physician services (inpatient and
				  outpatient);
3. mental health
				  clinic services;
4. inpatient
				  psychiatric services (free-standing psychiatric hospitals and distinct part
				  psychiatric units);
5. emergency
				  ambulance services;
6. home health
				  services;
a. coverage of durable medical
				  equipment and supplies is limited to emergency items;
7. nursing facility services;
8. pharmacy services;
9. laboratory services;
10. x-ray services;
11. hemodialysis services;
12. hospice services;
13. rural health clinic services;
				  and
14. federally qualified health
				  center services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 45 - Covered Services › Section XXII-4503 - Non-Medicaid State Plan Services

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement is available through the UCC pool for methadone and suboxone
				  substance abuse treatments only to the extent that these services are not
				  otherwise reimbursable under other funding sources including, but not limited
				  to, grant or reimbursement programs offered through:
1. the Federal Emergency Management
				  Agency;
2. the Substance Abuse and
				  Mental Health Services Administration;
3. the National Institutes of Health;
				  or
4. any other federal or state
				  program (Medicaid, SCHIP, Medicare), private insurance or any private
				  source.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 47 - Provider Participation › Section XXII-4701 - Participation Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to qualify for reimbursement through the UCC pool for Medicaid State Plan
				  covered services, the provider must have been enrolled to participate in the
				  Louisiana Medicaid Program on or before August 24, 2005.
B. In order to qualify for reimbursement
				  through the UCC pool for methadone and suboxone substance abuse treatments, the
				  provider must be approved by the Office of Addictive Disorders.
C. Qualifying providers may be either a
				  public or a private 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 XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 49 - Requests for Payment › Section XXII-4901 - Submission Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. Requests
				  for payment must be "person specific" for each Hurricane Katrina or Rita
				  evacuee or other affected individual. The request must contain the following
				  data, if known, for the evacuee or other affected individual:
1. last name;
2. first name;
3. middle initial;
4. Social Security number;
5. date of birth;
6. residential address the week prior to
				  Hurricane Katrina or Hurricane Rita;
7. parish of residence the week prior to
				  Hurricane Katrina or Hurricane Rita;
8. date(s) of service; and
9. any other identifying data that would
				  assist in establishing the recipient's identity in the absence of any of the
				  items cited in paragraphs 1-8 above.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 51 - Uncompensated Care Pool Reimbursement › Section XXII-5101 - Allowable Payment

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement through the UCC pool is only available for covered services
				  provided within the State of Louisiana to individuals who meet the requirements
				  to be a member of the eligible population.
B. Payment through the UCC pool for Medicaid
				  State Plan services shall be an interim payment up to 70 percent of the
				  Medicaid fee-for-service rate currently on file for the respective service.
				  Additional payments shall be contingent on the availability of funds in the UCC
				  Pool.
1. UCC pool payments to hospitals that
				  qualify for Medicaid disproportionate share hospital (DSH) payments will be
				  offset from the cost of treating uninsured patients for the state fiscal year
				  to which the DSH payment is applicable to determine the hospital specific DSH
				  limits.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 3 - Family Planning Waiver › Chapter 53 - Administrative Appeals › Section XXII-5301 - Fair Hearings and Appeals

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  There are no provisions under this demonstration waiver for fair hearings for
				  those individuals who have received medical services or supplies and do not
				  have insurance coverage or any other source of payment.
B. There are no provisions under this
				  demonstration waiver for appeals for health care providers who have incurred
				  costs associated with the provision of the uncompensated care.
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 XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 61 - General Provisions › Section XXII-6101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Department
				  of Health, Bureau of Health Services Financing and the Office of Behavioral
				  Health hereby implement a section 1115(a) demonstration waiver called the
				  Healthy Louisiana Opioid Use Disorder/Substance Use Disorder (OUD/SUD) Waiver
				  which is designed to maintain critical access to OUD/SUD services and continue
				  delivery system improvements for these services to provide more coordinated and
				  comprehensive OUD/SUD treatment for Medicaid recipients. This demonstration
				  waiver provides the state with the authority to provide high-quality,
				  clinically appropriate OUD/SUD treatment services for residents in residential
				  and inpatient treatment settings that qualify as an institution for mental
				  disease (IMD).
B. The Healthy
				  Louisiana OUD/SUD Waiver is a 59-month demonstration project which was approved
				  by the U.S. Department of Health and Human Services, Centers for Medicare and
				  Medicaid Services (CMS) effective February 1, 2018 and will span five years,
				  through December 31, 2022. Louisiana may request an extension of this
				  demonstration project through CMS prior to the expiration date.
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 XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 61 - General Provisions › Section XXII-6103 - Program Design (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 XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 63 - Eligibility › Section XXII-6301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Healthy Louisiana OUD/SUD Waiver services shall be available to individuals
				  who:
1. meet the eligibility criteria for
				  Medicaid set forth in the State Plan;
2. meet clinical criteria, including having a
				  SUD diagnosis; and
3. receive
				  OUD/SUD treatment services in residential and inpatient treatment settings that
				  qualify as an IMD, which are not otherwise matchable expenditures under §1903
				  of the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 63 - Eligibility › Section XXII-6303 - Recipient Qualifications (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 XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 65 - Services › Section XXII-6501 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The coverage
				  of OUD/SUD residential treatment and withdrawal management services during
				  residential stays under the scope of this demonstration project are:
1. inpatient services provided to recipients
				  in IMDs;
2. residential treatment
				  provided to recipients in IMDs;
3.
				  clinically managed withdrawal management provided to recipients in
				  IMDs;
4. medically
				  monitored/managed withdrawal management provided to recipients in IMDs;
				  and
5. medication-assisted
				  treatment (MAT) provided to recipients in IMDs.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 65 - Services › Section XXII-6503 - Service Delivery

Current through Register Vol. 50, No. 6, June 20, 2024
A. All Healthy
				  Louisiana OUD/SUD Waiver services are to be provided to recipient groups
				  through a managed care delivery system, except for the following:
1. spend-down medically needy
				  population.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 67 - Provider Participation › Section XXII-6701 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				  providers participating in the delivery of services covered under the Healthy
				  Louisiana OUD/SUD Waiver shall adhere to all of the applicable federal and
				  state regulations, policies, rules, manuals and laws.
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 XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 67 - Provider Participation › Section XXII-6703 - Reporting Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. MCOs and
				  their contracted providers of OUD/SUD services under this demonstration project
				  shall be required to provide data as outlined or requested by the Department of
				  Health.
B. Data shall be provided
				  in the format and frequency specified by the department including any
				  additional data requests as identified by the department.
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 XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 69 - Reimbursement › Section XXII-6901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. MCOs and
				  their contracted IMD providers shall ensure that reimbursement for services
				  covered under the Healthy Louisiana OUD/SUD Waiver is requested and paid only
				  for those recipients who meet the eligibility criteria and for whom services
				  were rendered:
1. providers/IMDs shall retain
				  any and all supporting financial information and documents that are adequate to
				  ensure that payment is made in accordance with applicable federal and state
				  laws;
2. any such documents shall
				  be retained for a period of at least six years from the date of service, or
				  until the final resolution of all litigation, claims, financial management
				  reviews or audits pertaining, whichever is the longest time period;
				  and
3. there shall not be any
				  restrictions on the right of the state and federal government to conduct
				  inspections and/or audits as deemed necessary to assure quality,
				  appropriateness or timeliness of services and reasonableness of
				  costs.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 7 - Healthy Louisiana Opioid Use Disorder/Substance Use Disorder Waiver › Chapter 69 - Reimbursement › Section XXII-6903 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. For
				  recipients enrolled in one of the MCOs, the department or its fiscal
				  intermediary shall make monthly capitation payments to the MCOs inclusive of
				  coverage for the provision of residential and inpatient substance use services
				  for recipients. The capitation rates paid to the MCOs shall be actuarially
				  sound rates and the MCOs will determine the rates paid to its contracted
				  providers. No payment shall be less than the minimum Medicaid rate.
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 XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 81 - General Provisions › Section XXII-8101 - Purpose (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 81 - General Provisions › Section XXII-8103 - Effective Date and Administration (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 81 - General Provisions › Section XXII-8105 - Enrollee Qualifications and Admissions Criteria (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 81 - General Provisions › Section XXII-8107 - Admission Denial or Discharge Criteria (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 81 - General Provisions › Section XXII-8109 - Allocation of Act 421 Children's Medicaid Option Opportunities (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 81 - General Provisions › Section XXII-8111 - Eligibility and Enrollment (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 83 - Services › Section XXII-8301 - Covered Services (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 83 - Services › Section XXII-8303 - Service Delivery (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXII - 1115 Demonstration Waivers › Subpart 9 - Act 421 Children's Medicaid Option › Chapter 85 - Reimbursemen › Section XXII-8501 - Reimbursement Methodology (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 1 - General Provisions › Section XXIII-101 - Purpose and Scope

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Department
				of Health, Bureau of Health Services Financing implemented the Program of All
				Inclusive Care for the Elderly (PACE) in accordance with federal regulations at
				42 CFR 460 et seq. These regulations set forth:
1. the requirements that an entity must meet
				to be approved as a PACE organization that operates a PACE program under
				Medicare and Medicaid;
2. how
				individuals may qualify to enroll in a PACE program;
3. how Medicare and Medicaid payments will be
				made for PACE services;
4.
				provisions for federal and state monitoring of PACE programs; and
5. procedures for sanctions and
				terminations.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 1 - General Provisions › Section XXIII-103 - Organization Application and Evaluation

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE organization shall be licensed as
				an adult day health care (ADHC) provider.
B. If a PACE organization uses their own
				staff to provide personal care attendant (PCA) services to PACE participants,
				the PACE organization shall acquire a home and community-based services (HCBS)
				license under the PCA module.
C.
				The Department of Health (LDH) shall grant appropriate waivers of ADHC and HCBS
				PCA licensing requirements in instances where licensing regulations conflict
				with federal PACE requirements and when such waivers are determined to have no
				adverse effect on participants' health, safety, and quality of life.
D. A PACE organization shall not be required
				to be licensed as a health maintenance organization under the Louisiana
				regulations for risk-based entities.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254, Title XIX of the Social Security Act,
				  and 42 CFR 460 et seq.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 1 - General Provisions › Section XXIII-105 - Administrative Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization must have a fiscally sound operation, as demonstrated by:
1. total assets greater than total
				unsubordinated liabilities;
2.
				sufficient cash flow and adequate liquidity to meet obligations as they become
				due; and
3. a net operating surplus
				or a financial plan for solvency that is satisfactory to the Centers for
				Medicaid and Medicare Services (CMS) and the Department of Health.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 3 - Services › Section XXIII-301 - Medicare and Medicaid Coordination

Current through Register Vol. 50, No. 6, June 20, 2024
A. If a Medicare beneficiary or Medicaid
				participant chooses to enroll in a PACE program:
1. the participant, while enrolled in a PACE
				program, must receive Medicare and Medicaid benefits solely through the PACE
				organization; and
2. Medicare and
				Medicaid benefit limitations and conditions relating to amount, duration, scope
				of services, deductibles, co-payments, coinsurance, or other cost-sharing do
				not apply.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 3 - Services › Section XXIII-303 - Services Provided

Current through Register Vol. 50, No. 6, June 20, 2024
A. The PACE
				benefit package for all participants, regardless of the source of payment, must
				include:
1. all Medicaid-covered services, as
				specified in the state's approved Medicaid plan;
2. interdisciplinary assessment and treatment
				planning;
3. primary care,
				including physician and nursing services;
4. social services;
5. behavioral health services;
a. - c. Repealed.
6. restorative therapies, including:
a. physical therapy;
b. occupational therapy; and
c. speech-language pathology
				services;
7. personal
				care and supportive services;
8.
				nutrition counseling;
9.
				recreational therapy;
10.
				transportation;
11. meals;
a. - y. Repealed.
12. medical specialty services including, but
				not limited to:
a. anesthesiology;
b. audiology;
c. cardiology;
d. dentistry;
e. dermatology;
f. gastroenterology;
g. gynecology;
h. internal medicine;
i. nephrology;
j. neurosurgery;
k. oncology;
l. ophthalmology;
m. oral surgery;
n. orthopedic surgery;
o. otorhinolaryngology;
p. plastic surgery;
q. pharmacy consulting services;
r. podiatry;
s. psychiatry;
t. pulmonary disease;
u. radiology;
v. rheumatology;
w. general surgery;
x. thoracic and vascular surgery; and
y. urology;
13. laboratory tests, x-rays, and other
				diagnostic procedures;
14. drugs
				and biologicals;
a. - d. Repealed.
15. prosthetics, orthotics,
				durable medical equipment, corrective vision devices, such as:
a. eyeglasses and lenses;
b. hearing aids;
c. dentures;
d. repair and maintenance of these items;
				and
e. wheelchairs, including
				custom wheelchairs that are medically necessary;
f. - l. Repealed.
16. acute inpatient care, including:
a. ambulance;
b. emergency room care and treatment room
				services;
c. semi-private room and
				board;
d. general medical and
				nursing services;
e. medical
				surgical/intensive care/coronary care unit;
f. laboratory tests, x-rays, and other
				diagnostic procedures;
g. drugs and
				biological;
h. blood and blood
				derivatives;
i. surgical care,
				including the use of anesthesia;
j.
				use of oxygen;
k. physical,
				occupational, recreational therapies, and speech-language pathology
				services;
l. social services; and
				m. psychiatric treatment;
17. nursing facility care, including:
a. semi-private room and board;
b. physician and skilled nursing
				services;
c. custodial
				care;
d. personal care and
				assistance;
e. drugs and
				biologicals;
f. physical,
				occupational, recreational therapies, and speech-language pathology, if
				necessary;
g. social services;
				and
h. medical supplies and
				appliances;
18. other
				services determined necessary by the interdisciplinary team to improve and
				maintain the participant's overall health status.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 3 - Services › Section XXIII-305 - Excluded Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Services
				excluded from coverage are:
1. any service
				that is not authorized by the interdisciplinary team, even if it is a required
				service, unless it is an emergency service;
2. private room and private duty nursing
				services in an inpatient facility (unless medically necessary), and nonmedical
				items for personal convenience such as telephone charges and radio or
				television rental (unless specifically authorized by the interdisciplinary team
				as part of the participant's plan of care);
3. cosmetic surgery, which does not include
				surgery that is required for improved functioning of a malformed part of the
				body resulting from an accidental injury or for reconstruction following
				mastectomy;
4. experimental
				medical, surgical or other health procedures;
5. services furnished outside of the United
				States except as follows:
a. in accordance
				with
				42
				CFR 424.122 -
				424.124;
				or
b. as permitted under the
				state's approved Medicaid plan.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 3 - Services › Section XXIII-307 - Conditions of Service

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization must establish and implement a written plan to furnish care that
				meets the needs of each participant in all care settings 24 hours a day, every
				day of the year.
B. The PACE
				organization must furnish comprehensive medical, health, and social services
				that integrate acute and long-term care.
C. These services must be furnished in, at
				least, the PACE center, the home, and inpatient facilities.
D. The PACE organization may not discriminate
				against any participant in the delivery of required PACE services based on
				race, ethnicity, national origin, religion, sex, age, mental or physical
				disability or source of payment.
E.
				The frequency of a participant's attendance at a center is determined by the
				interdisciplinary team, based on the needs and preferences of each
				participant.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254, Title XIX of the Social Security Act,
				  and 42 CFR 460 et seq.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 3 - Services › Section XXIII-309 - Emergency Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization must establish and maintain a written plan to handle emergency
				care. The written plan must ensure that CMS, the state, and PACE participants
				are held harmless if the PACE organization does not pay for emergency
				services.
B. Emergency care is
				appropriate when services are needed immediately because of an injury or sudden
				illness and the time required to reach the PACE organization or one of its
				contract providers would cause risk of permanent damage to the participant's
				health. Emergency services include inpatient and outpatient services that:
1. are furnished by a qualified emergency
				services provider, other than the PACE organization or one of its contract
				providers, either in or out of the PACE organization's service area;
2. are needed to evaluate or stabilize an
				emergency medical condition.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 5 - Participant Enrollment › Section XXIII-501 - Eligibility

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to be
				eligible for services from a PACE site an applicant must:
1. be 55 years of age or older;
2. be determined by the state administering
				agency to meet nursing facility level of care, as established by the Department
				of Health;
3. reside in the service
				area of the PACE organization; and
4. at the time of enrollment, an individual
				must be able to live in a community setting without jeopardizing his or her
				health or safety.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 5 - Participant Enrollment › Section XXIII-503 - Enrollment

Current through Register Vol. 50, No. 6, June 20, 2024
A. Enrollment
				Period
1. A participant's enrollment in the
				program is effective on the first day of the calendar month following the date
				the PACE organization receives the signed enrollment agreement.
2. Enrollment continues until the
				participants' death, regardless of changes in health status, unless either of
				the following actions occurs:
a. the
				participant voluntarily disenrolls; or
b. the participant is involuntarily
				disenrolled (see
				§505. B
				below).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 5 - Participant Enrollment › Section XXIII-505 - Disenrollment

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization shall submit proposed denial of enrollment determinations of
				applicants for health and safety reasons and all involuntary disenrollments of
				participants to LDH for review prior to notifying applicants/participants of
				such adverse decisions. The Department shall review denials of PACE enrollment
				eligibility and disenrollments in a timely manner.
B. Involuntary Disenrollment
1. A participant may be involuntarily
				disenrolled for any of the following reasons:
a. a participant fails to pay, or to make
				satisfactory arrangements to pay, any premium due to the PACE organization
				after a 30 calendar day grace period;
b. the participant engages in disruptive or
				threatening behavior, as described in Paragraph 2 below;
c. the participant moves out of the PACE
				program service area or is out of the service area for more than 30 consecutive
				days, unless the PACE organization and/or LDH agrees to a longer absence due to
				extenuating circumstances;
d. the
				participant is determined to no longer meet the state Medicaid nursing facility
				level of care requirements and is not deemed eligible;
e. the PACE program agreement with CMS and
				LDH is not renewed or is terminated;
f. the PACE organization is unable to offer
				health care services due to the loss of state licenses or contracts with
				outside providers; or
g. the
				participant who is permanently placed in a nursing facility fails to pay, or to
				make satisfactory arrangements to pay, the amount of patient liability that
				would be required to be paid by a Medicaid eligible resident of a nursing
				facility if he/she was not a participant in a PACE organization.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 7 - Quality Assessment and Performance Improvement › Section XXIII-701 - Organization Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				PACE organization must develop, implement, maintain, and evaluate an effective,
				data-driven quality assessment and performance improvement program.
B. The program must reflect the full range of
				services furnished by the PACE organization.
C. A PACE organization must take actions that
				result in improvements to its performance in all types of care.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254, Title XIX of the Social Security Act,
				  and 42 CFR 460 et seq.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 7 - Quality Assessment and Performance Improvement › Section XXIII-703 - Quality Assessment and Performance Improvement Plan

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE organization must have a written
				quality assessment and performance improvement plan.
B. The PACE governing body must review the
				plan annually and revise it, if necessary.
C. At a minimum, the plan must specify how
				the PACE organization proposes to meet the following requirements:
1. identify areas to improve or maintain the
				delivery of services and care of the participants;
2. develop and implement plans of action to
				improve or maintain quality of care;
3. document and disseminate to PACE staff and
				contractors the results from the quality assessment and performance improvement
				activities.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 7 - Quality Assessment and Performance Improvement › Section XXIII-705 - Minimum Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization's quality assessment and performance improvement program shall
				include, but is not limited to, the use of objective measures to demonstrate
				improved performance with regard to:
1.
				utilization of PACE services, such as decreased inpatient hospitalizations and
				emergency room visits;
2. caregiver
				and participant satisfaction;
3.
				outcome measures that are derived from data collected during assessments,
				including data on the following:
a.
				physiological wellbeing;
b.
				functional status;
c. cognitive
				ability;
d. social/behavioral
				functioning; and
e. quality of life
				of participants;
4.
				effectiveness and safety of staff-provided and contracted services, including:
a. competency of clinical staff;
b. promptness of service delivery; and
c. achievement of treatment goals
				and measurable outcomes;
5. nonclinical areas, such as grievances and
				appeals, transportation services, meals, life safety, and environmental
				issues.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 7 - Quality Assessment and Performance Improvement › Section XXIII-707 - Internal Activities

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization must do the following:
1. use a
				set of outcome measures to identify areas of good or problematic
				performance;
2. take actions
				targeted at maintaining or improving care based on outcome measures;
3. incorporate actions resulting in
				performance improvement into standards of practice for the delivery of care and
				periodically track performance to ensure that any performance improvements are
				sustained over time;
4. set
				priorities for performance improvement, considering prevalence and severity of
				identified problems, and give priority to improvement activities that affect
				clinical outcomes; and
5.
				immediately correct any identified problem that directly or potentially
				threatens the health and safety of a PACE participant.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 7 - Quality Assessment and Performance Improvement › Section XXIII-709 - Additional Activities

Current through Register Vol. 50, No. 6, June 20, 2024
A. A PACE
				organization must meet external quality assessment and reporting requirements
				as specified by CMS or the state administering agency, in accordance with
				Section 460.202 of the Social Security Act.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254, Title XIX of the Social Security Act,
				  and 42 CFR 460 et seq.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 7 - Quality Assessment and Performance Improvement › Section XXIII-711 - Committees with Community Input

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				PACE organization must establish one or more committees with community input
				to:
1. evaluate data collected pertaining to
				quality outcome measures;
2.
				address the implementation of, and results from, the quality assessment and
				performance improvement plan; and
3. provide input related to ethical
				decision-making, including end-of-life issues and implementation of the Patient
				Self-Determination Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 9 - Sanctions › Section XXIII-901 - Violations

Current through Register Vol. 50, No. 6, June 20, 2024
A. Sanctions may be
				imposed against a PACE organization if it commits one of the following
				violations:
1. fails to provide medically
				necessary items and services to a participant that are covered PACE services,
				and that failure has adversely affected (or has substantial likelihood of
				adversely affecting) the participant;
2. involuntarily disenrolls a participant in
				violation of 42 CFR
				460.164;
3. discriminates in the enrollment or
				disenrollment of Medicare beneficiaries or Medicaid participants, or both, who
				are eligible to enroll in a PACE program on the basis of a participant's health
				status or need for health care services;
4. engages in any practice that would
				reasonably be expected to have the effect of denying or discouraging
				enrollment, except as permitted by Section 460 150, by Medicare beneficiaries
				or Medicaid participants whose medical condition or history indicates a need
				for substantial future medical services;
5. imposes charges on participants enrolled
				under Medicare or Medicaid for premiums in excess of the premiums
				permitted;
6. misrepresents,
				falsifies, or fails to disclose information that is furnished to:
a. CMS or the state under this Part XXIII;
				or
b. an individual or any other
				entity under this Part XXIII;
7. prohibits or otherwise restricts a covered
				health care professional from advising a participant who is a patient of the
				professional about the participant's health status, medical care, or treatment
				for the participant's condition or disease, regardless of whether the PACE
				program provides benefits for that care or treatment, if the professional is
				acting within his or her lawful scope of practice;
8. operates a physician incentive plan that
				does not meet the requirements of Section 1876(i)(8) of the Social Security
				Act; or
9. employs or contracts
				with any individual who is excluded from participation in Medicare or Medicaid
				under Section 1128 or Section 1128A of the Social Security Act (or with any
				entity that employs or contracts with that individual) for the provision of
				health care, utilization review, medical social work, or administrative
				services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 9 - Sanctions › Section XXIII-903 - Imposition of Sanctions by CMS

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				CMS may impose the following sanctions for violations specified in §901:
1. suspend enrollment of Medicare
				beneficiaries;
2. suspend Medicare
				payment to the PACE organization;
3. deny payment to the state for medical
				assistance for services furnished under the PACE program agreement. The state
				will suspend payments to the PACE organization when payment of the federal
				portion of PACE reimbursement is denied;
4. impose civil money penalties as specified
				in federal regulations.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIII - Program of All Inclusive Care for the Elderly › Chapter 11 - Appeals › Section XXIII-1101 - Participant Rights, Grievances, and Appeals

Current through Register Vol. 50, No. 6, June 20, 2024
A. The PACE organization must have a formal
				written appeals process in accordance with
				42 CFR
				460.122, with specified timeframes for
				response, to address noncoverage or nonpayment of a service, and involuntary
				disenrollment.
B. Additional appeal
				rights under Medicare or Medicaid are available to the participant if an
				adverse decision is made in the PACE organization appeal process, or if the
				participant is involuntarily disenrolled from the PACE program. A PACE
				organization must inform a participant in writing of additional appeal rights
				available under Medicare or Medicaid.
C. Medicaid-eligible participants who appeal
				through Medicaid shall be heard by the Division of Administrative Law (DAL)
				within the timeframes applicable to processing Medicaid appeals except in cases
				where federal PACE requirements require a more expeditious decision. The PACE
				organization shall prepare the Summary of Evidence in preparation for the
				appeal.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254, Title XIX of the Social Security Act,
				  and 42 CFR 460 et seq.