reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 69 - Direct Dental Services › Section XV-6901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medicaid
				  recipients who are under 21 years of age are eligible to receive services
				  covered by the EPSDT Dental Program.
B. 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.
C. Prior authorization is
				  required for certain dental services covered in the EPSDT Dental Program.
				  Services requiring prior authorization are identified in the Dental Services
				  Manual, EPSDT Dental Program Fee Schedule.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 69 - Direct Dental Services › Section XV-6903 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The dental
				  services covered under the EPSDT Dental Program are organized in accordance
				  with the following 11 categories:
1.
				  diagnostic services which include oral examinations, radiographs and
				  oral/facial images, diagnostic casts and accession of tissue - gross and
				  microscopic examinations;
2.
				  preventive services which include prophylaxis, topical fluoride treatments,
				  sealants, fixed space maintainers and re-cementation of space
				  maintainers;
3. restorative
				  services which include amalgam restorations, composite restorations, stainless
				  steel and polycarbonate crowns, pins, core build-ups, pre-fabricated posts and
				  cores and unspecified restorative procedures;
4. endodontic services which include pulp
				  capping, pulpotomy, endodontic therapy on primary and permanent teeth
				  (including treatment plan, clinical procedures and follow-up care),
				  apexification/recalcification, apicoectomy/periradicular services and
				  unspecified endodontic procedures;
5. periodontal services which include
				  gingivectomy, periodontal scaling and root planning, full mouth debridement,
				  and unspecified periodontal procedures;
6. removable prosthodontics services which
				  include complete dentures, partial dentures, denture repairs, denture relines
				  and unspecified prosthodontics procedures;
7. maxillofacial prosthetics service, which
				  is a fluoride gel carrier;
8. fixed
				  prosthodontics services which include fixed partial denture pontic, fixed
				  partial denture retainer and other unspecified fixed partial denture
				  services;
9. oral and maxillofacial
				  surgery services which include non-surgical extractions, surgical extractions,
				  other surgical procedures, alveoloplasty, surgical incision, temporomandibular
				  joint (TMJ) procedure and other unspecified repair procedures;
10. orthodontic services which include
				  interceptive and comprehensive orthodontic treatments, minor treatment to
				  control harmful habits and other orthodontic services; and
11. adjunctive general services which include
				  palliative (emergency) treatment, anesthesia, professional visits,
				  miscellaneous services, and unspecified adjunctive procedures.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 69 - Direct Dental Services › Section XV-6905 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Services covered
				  in the EPSDT Dental Program shall be reimbursed at the lower of either:
1. the dentist's billed charges minus any
				  third party coverage; or
2. the
				  state's established schedule of fees, which is developed in consultation with
				  the Louisiana Dental Association and the Medicaid dental consultants, minus any
				  third party coverage.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 71 - Health Services › Section XV-7101 - Recipient Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. Health
				  services for children are covered if they are included on the individualized
				  family service plan (IFSP) for ages 0 to 3 years of age, and on the
				  individualized education plan (IEP) for ages 3 to 21 years of age.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 71 - Health Services › Section XV-7103 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Audiology
				  services are for the identification of children with auditory impairment, using
				  at risk criteria and appropriate audiologic screening techniques. Audiology
				  services include:
1. determination of range,
				  nature and degree of hearing loss and communications, by use of audiological
				  procedures;
2. referral for medical
				  and other services necessary for the rehabilitation of children with auditory
				  impairment; and
3. provision of
				  auditory training, aural rehabilitation, speech reading and listening device
				  orientation and training, and other services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 71 - Health Services › Section XV-7105 - Professional Staffing Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. Audiological Services. Audiological
				  services must be provided by an audiologist or physician licensed in Louisiana
				  to provide these services. A referral must be made by the child's physician,
				  preferably the primary care physician, at least annually in accordance with
				  federal Medicaid regulations. The audiologist must meet one of the following
				  criteria:
1. a certificate of clinical
				  competence from the American Speech and Hearing Association;
2. completion of the equivalent educational
				  requirements and work experience necessary for certification; or
3. completion of the academic program and is
				  acquiring supervised work experience to qualify for a certificate.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 71 - Health Services › Section XV-7107 - EarlySteps Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after January 1, 2011, the reimbursement
				  for certain Medicaid-covered health services rendered in the EarlySteps Program
				  shall be reduced by 2 percent of the rate in effect on December 31, 2010.
1. The following services rendered in the
				  natural environment shall be reimbursed at the reduced rate:
a. audiology services;
b. speech pathology services;
c. occupational therapy;
d. physical therapy; and
e. psychological services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7301 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Early Periodic
				  Screening, Diagnosis and Treatment (EPSDT) Personal Care Services (PCS)
1. Personal Care Services are services which
				  prevent institutionalization and enable the beneficiary to live in the
				  community. PCS are tasks which are medically necessary when physical or
				  cognitive limitations due to illness or injury necessitate assistance with:
a. eating;
b. toileting;
c. bathing;
d. bed mobility;
e. transferring;
f. dressing;
g. locomotion;
h. personal hygiene; or
i. bladder or bowel requirements.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7303 - Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The beneficiary
				  shall be allowed the freedom of choice to select an EPSDT PCS
				  provider.
B. EPSDT personal care
				  services include:
1. basic personal care,
				  including toileting, grooming, bathing and assistance with dressing;
2. assistance with bladder and/or bowel
				  requirements or problems, including helping the beneficiary to and from the
				  bathroom or assisting the beneficiary with bedpan routines, but excluding
				  catheterization;
3. assistance with
				  eating and food, nutrition, and diet activities, including preparation of meals
				  for the beneficiary only;
4.
				  performance of incidental household services essential to the beneficiary's
				  health and comfort in her/his home. Examples of such activities are changing
				  and washing bed linens and rearranging furniture to enable the beneficiary to
				  move about more easily in his/her own home;
5. accompanying, not transporting the
				  beneficiary to and from his/her physician and/or other medical appointments for
				  necessary medical services; and
6.
				  assistance with locomotion in their place of service, while in bed or from one
				  surface to another. Assisting the beneficiary with transferring and bed
				  mobility.
7. - 8.
				  Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7305 - Beneficiary Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Conditions for Provision of EPSDT Personal Care Services
1. The person must be a
				  categorically-eligible Medicaid beneficiary birth through 20 years of age
				  (EPSDT eligible) and have been prescribed medically necessary, age appropriate
				  EPSDT PCS by a practitioner (physician, advance practice nurse, or physician
				  assistant).
2. An EPSDT-eligible
				  shall meet medical necessity criteria as established by the Bureau of Health
				  Services Financing (BHSF) which shall be based on functional and medical
				  eligibility and impairment in at least two activities of daily living (ADL), as
				  determined by BHSF or its designee.
3. EPSDT PCS shall be prescribed if medically
				  necessary by the beneficiary's attending practitioner initially and every 180
				  days thereafter (or rolling six months), and when changes in the plan of care
				  occur. The plan of care shall be acceptable only after the practitioner signs
				  and dates the completed form. The practitioners signature must be an original
				  signature and not a rubber stamp.
4. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7307 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT
				  personal care services are subject to prior authorization (PA) by BHSF or its
				  designee. A face-to-face medical assessment shall be completed by the
				  practitioner. The beneficiary's choice of a personal care services provider may
				  assist the practitioner in developing a plan of care which shall be submitted
				  by the practitioner for review/approval by BHSF or its designee. The plan of
				  care shall specify:
1. the specific personal
				  care service(s) to be provided (i.e., activities of daily living for which
				  assistance is needed); and
2. the
				  minimum and maximum frequency and the minimum duration of each of these
				  services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7309 - Place of Service

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT PCS
				  shall be provided if medically necessary in the beneficiary's home or in
				  another location outside of the beneficiary's home. The beneficiary's home is
				  defined as the beneficiary's own home, which includes the following:
1. an apartment;
2. a custodial relative's home;
3. a boarding home;
4. a foster home; or
5. a supervised living facility.
6. - 6.a. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7311 - Service Limits

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT PCS
				  are not subject to service limits. The units of service approved shall be based
				  on the physical requirements of the beneficiary and medical necessity for the
				  covered services.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7313 - Standards for Payment

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT PCS
				  shall only be provided to EPSDT beneficiaries and only by a staff member of a
				  licensed personal care services agency enrolled as a Medicaid provider. A copy
				  of the current PCS license must accompany the Medicaid application for
				  enrollment as a PCS provider and copies of current licenses shall be submitted
				  to Provider Enrollment thereafter as they are issued, for inclusion in the
				  enrollment record. The provider's record shall always include a current PCS
				  license at all times. Medicaid enrollment is limited to providers located in
				  Louisiana and certain out-of-state providers located only in the trade areas of
				  Arkansas, Mississippi, and Texas.
B. The unit of service billed by EPSDT PCS
				  providers shall be one-quarter hour, exclusive of travel time to arrive at the
				  beneficiary's home. The entire 15 minutes of the unit of time shall have been
				  spent providing services in order to bill a unit.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7315 - Provider Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Personal care services shall be provided by a licensed personal care services
				  agency which is duly enrolled as a Medicaid provider. Staff assigned to provide
				  personal care services to a beneficiary shall not be a member of the
				  beneficiary's immediate family. Immediate family is defined as the father,
				  mother, sister, brother, spouse, child, grandparent, in-law, or any individual
				  acting as parent or guardian of the beneficiary. Personal care services may be
				  provided by a person of a degree of relationship to the beneficiary other than
				  immediate family, only if the relative is not living in the beneficiary's home,
				  or, if she/he is living in the beneficiary's home solely because her/his
				  presence in the home is necessitated by the amount of care required by the
				  beneficiary.
B. An unrelated staff
				  member of a licensed personal care services provider may not live in the same
				  home as the beneficiary.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7317 - Provider Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  licensed PCS agency is responsible for ensuring that all direct service workers
				  providing EPSDT PCS meet all training requirements applicable under state law
				  and regulations. The direct service worker must successfully complete the
				  applicable examination for certification for PCS. Documentation of the direct
				  service workers completion of all applicable requirements shall be maintained
				  by the EPSDT PCS provider.
B. The
				  agency shall use an electronic visit verification (EVV) system for time and
				  attendance tracking and billing for EPSDT PCS.
1. EPSDT PCS providers identified by BHSF
				  shall use:
a. the (EVV) system designated by
				  the department; or
b. an alternate
				  system that:
i. has successfully passed the
				  data integration process to connect to the designated EVV system; and
ii. is approved by the
				  department.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7319 - EPSDT PCS Provider Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. Documentation
1. Documentation for EPSDT PCS provided shall
				  include at a minimum, the following:
a.
				  documentation of approval of services by BHSF or its designee;
b. daily notes by PCS provider denoting date
				  of service and services provided (checklist is adequate);
c. total number of hours worked;
d. time period worked;
e. health condition of beneficiary;
f. service provision difficulties;
g. justification for not providing scheduled
				  services; and
h. any other
				  pertinent information.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 73 - Personal Care Services › Section XV-7321 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Reimbursement
				  for EPSDT PCS shall be the lesser of billed charges or the maximum unit rate
				  set by the department. The maximum rate is a flat rate for each approved unit
				  of service provided to the beneficiary. This rate shall be adjusted as
				  necessary by the department.
1. One quarter
				  hour (15 minutes) is the standard unit of service, exclusive of travel time to
				  arrive at the beneficiary's home.
2. The entire 15 minutes shall have been
				  spent providing personal care services in order to be reimbursed for a
				  unit.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 85 - Durable Medical Equipment-Eyeglasses › Section XV-8501 - Eye Care

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT eyeglasses
				  are limited to three per year with provision for extending if medically
				  necessary.
B. Billing and
				  Reimbursement. The Health Care Common Procedure Coding System (HCPCS) shall be
				  used to bill for EPSDT eyewear. Claims for EPSDT eyewear shall be reimbursed in
				  accordance with the Louisiana Medicaid eyewear fee schedule.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 87 - Durable Medical Equipment-Hearing Devices › Subchapter A - Hearing Aids › Section XV-8701 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hearing
					 aids and related services are only covered for EPSDT recipients up to the age
					 of 21. Approval is granted only when there is significant hearing loss as
					 documented by audiometric or electrophysiologic data from a licensed
					 audiologist and medical clearance and prescription from an ear specialist
					 (otologist).
B. The audiologist
					 must furnish a report, including an audiogram (if applicable) and all test
					 results, indicating the degree and type of hearing loss. A hearing loss greater
					 than 20 decibels with an average hearing level in the range 250-2000 Hz is
					 considered significant. Additional required medical and social information
					 shall include:
1. the recipient's
					 age;
2. expected benefit of the
					 hearing aid;
3. previous and
					 current use of a hearing aid;
4.
					 additional disabilities expected to influence the use of a hearing aid;
					 and
5. referrals made on the
					 recipient's behalf to early intervention programs, special education programs
					 or other habilitative services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 87 - Durable Medical Equipment-Hearing Devices › Subchapter A - Hearing Aids › Section XV-8703 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT
					 reimbursement is reduced 15 percent for providers for the following procedure
					 codes.
1. X-1092;
2. V5030;
3. V5040;
4. V5050;
5. V5060;
6. V5070;
7. V5080;
8. V5100;
9. V5120;
10. V5130;
11. V5140;
12. V5150;
13. V5170;
14. V5180;
15. V5190;
16. V5210;
17. V5220;
18. V5230; and
19. V5299.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 87 - Durable Medical Equipment-Hearing Devices › Subchapter B - Cochlear Device › Section XV-8717 - Eligibility and Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. Coverage is available for cochlear
					 implantation for recipients 1 year of age through 20 years of age with profound
					 bilateral sensorineural hearing loss.
B. Prior Authorization. All implantations
					 (CPT Code 69930) must be prior authorized. The request to perform surgery shall
					 come from the cochlear implant team (made up of professionals as described in
					 §8721 who assessed the recipient's
					 hearing.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 87 - Durable Medical Equipment-Hearing Devices › Subchapter B - Cochlear Device › Section XV-8719 - Recipient Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. Recipient
					 Criteria (General). The following criteria apply to all candidates. Recipient
					 must:
1. have a profound bilateral
					 sensorineural hearing loss which is a pure tone average of 1,000, 2,000, and
					 4,000 Hz of 90 dB HL or greater;
2.
					 be a profoundly deaf child, age 1 year or older or be a post-linguistically
					 deafened adult through the age of 20 years;
3. receive no significant benefit from
					 hearing aids as validated by the cochlear implant team;
4. have high motivation to be part of the
					 hearing community as validated by the cochlear implant team;
5. have appropriate expectation;
6. have had radiologic studies that
					 demonstrate no intracranial anomalies or malformations which would
					 contraindicate implantation of the receiver-stimulator or the electrode
					 array;
7. have no medical
					 contraindications for undergoing implant surgery or post-implant
					 rehabilitation; and
8. show that he
					 and his family are well-motivated, possess appropriate post-implant
					 expectations and are prepared and willing to participate in and cooperate with
					 pre and post implant assessment and rehabilitation programs as recommended by
					 the implant team and in conjunction with Federal Drug Administration (FDA)
					 guidelines.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 87 - Durable Medical Equipment-Hearing Devices › Subchapter B - Cochlear Device › Section XV-8721 - Cochlear Implant Team

Current through Register Vol. 50, No. 6, June 20, 2024
A. Team
					 Minimum Requirements. The implant team shall be composed of the following
					 members at a minimum:
1.
					 physician/otologist;
2.
					 audiologist;
3. speech/language
					 pathologist;
4. psychiatrist;
					 and
5. educator of the deaf with
					 experience in oral/auditory instruction.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 87 - Durable Medical Equipment-Hearing Devices › Subchapter B - Cochlear Device › Section XV-8723 - Expenses Covered/Noncovered

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Covered Expenses. The following expenses related to the maintenance of the
					 cochlear device will be covered if prior authorized:
1. all costs for upgrades and repairs to the
					 component parts of the device; and
2. all costs for cords and
					 batteries.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter A - General Provisions › Section XV-9101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Adolescent
					 School Health Initiative Act of 1991 authorized the development of an
					 adolescent school based health initiative to facilitate and encourage the
					 provision of comprehensive health centers in public middle and secondary
					 schools. Such health centers are referred to in this Chapter as "School Based
					 Health Centers" (SBHCs).
B. A SBHC
					 is a health center that:
1. is located on a
					 school campus (including mobile units);
2. is organized through school, community,
					 and health provider relationships;
3. is administered by a sponsoring
					 facility;
4. provides health
					 services (including, but not limited to, both behavioral and physical health)
					 to children and adolescents through health professionals in accordance with
					 state and local law, including laws related to licensure and
					 certification;
5. provides, at a
					 minimum, health services during school hours to children and adolescents by
					 health professionals in accordance with established standards of care,
					 evidence-based practice, laws, regulations and requirements, including parental
					 consent.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter A - General Provisions › Section XV-9103 - Registry of School Based Health Centers

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Louisiana Department of Health, Office
					 of Public Health will establish and maintain a registry of all SBHCs. This
					 registry shall be publicly available on the website of the Louisiana Department
					 of Health.
B. SBHCs are required to
					 submit the following information to the registry:
1. name of sponsoring agency;
2. name of school(s) where the SBHC is
					 located;
3. additional schools
					 served by the SBHC (*feeder schools);
4. location of the SBHC (address, including
					 parish);
5. services provided at
					 facility; and
6. point of contact,
					 including name, phone number, and email.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter B - Provider Participation › Section XV-9111 - Provider Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 SBHC classification must be verified by the Office of Public Health, Adolescent
					 School Health Program when applying for a Medicaid provider number.
1. Documentation of this verification must be
					 provided upon request.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter B - Provider Participation › Section XV-9113 - Standards of Participation

Current through Register Vol. 50, No. 6, June 20, 2024
A. School
					 based health centers must comply with the applicable licensure, certification
					 and program participation standards for all services rendered. The SBHC shall:
1. maintain an acceptable fiscal record
					 keeping system that readily distinguishes one type of service from another type
					 of service that may be rendered;
2.
					 retain all records necessary to fully disclose the extent of services provided
					 to recipients for five years from the date of service and furnish such records,
					 and any payments claimed for providing such services, to the Medicaid Program
					 upon request; and
3. abide by and
					 adhere to all federal and state regulations and policy manuals.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter C - Services › Section XV-9121 - Scope of Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid
					 Program provides reimbursement for medically necessary preventive health care
					 services provided by school based health centers.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254,
						R.S.
						40:31.3 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter D - Staffing Requirements › Section XV-9131 - Minimum Staffing Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. School based health centers shall have one
					 or more primary care providers on staff, including a:
a. physician;
b. physician assistant; or
c. nurse practitioner.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 91 - School Based Health Centers › Subchapter E - Reimbursement › Section XV-9141 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medicaid
					 reimbursement is limited to medically necessary services that are covered by
					 the Medicaid State Plan.
B.
					 Medicaid covered services provided by SBHCs shall be reimbursed at the lower of
					 either:
1. the providers billed charges minus
					 any third party coverage; or
2. the
					 states established schedule of fees for the service rendered, minus any third
					 party coverage.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 93 - Substance Abuse Services › Section XV-9301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program shall provide coverage of substance abuse services rendered to
				  Medicaid eligible recipients, under the age of 21.
B. Medicaid reimbursement for medically
				  necessary substance abuse services shall only be provided to the Office of
				  Behavioral Health for recipients under the age of 21 who receive outpatient
				  treatment only. The Medicaid Program shall not provide reimbursement for
				  inpatient services under these provisions.
C. Substance abuse services covered under the
				  EPSDT Program shall include medically necessary clinic services and other
				  medically necessary substance abuse services rendered to EPSDT
				  recipients.
D. Medicaid recipients
				  shall be the sole recipients of Medicaid covered substance abuse services and
				  these services shall only be billed for the Medicaid recipient despite the
				  presence of others who may be group or family participants.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 93 - Substance Abuse Services › Section XV-9303 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The medical
				  necessity for these rehabilitative services must be determined by, and services
				  recommended by, a licensed mental health practitioner, or as ordered by a staff
				  physician.
B. Outpatient Treatment
				  Program
1. Professionally directed assessment,
				  diagnosis, treatment, and recovery services are provided in an organized
				  non-residential treatment setting by licensed mental health practitioners
				  (LMHPs) and non-licensed professionals under the supervision of a
				  LMHP.
2. Outpatient treatment
				  program hours range from one hour to nine hours/week. The maximum level of
				  hours may be exceeded based on medical necessity.
3. Outpatient treatment program services
				  include, but are not limited to:
a.
				  individual, group, and family counseling;
b. medication compliance;
c. relapse prevention; and
d. disease concept.
4. Outpatient treatment program services
				  offer comprehensive, coordinated, and defined services that may vary in level
				  of intensity.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 93 - Substance Abuse Services › Section XV-9305 - Provider Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Outpatient clinical services shall be provided by Louisiana licensed mental
				  health practitioners within the scope of the State Practice Act and licensing
				  requirements.
B. A mental health
				  practitioner may include a:
1. licensed
				  professional counselor (LPC);
2.
				  licensed clinical social worker (LCSW);
3. licensed addiction counselor (LAC);
				  and
4. licensed marriage and family
				  therapist (LMFT).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 93 - Substance Abuse Services › Section XV-9307 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program shall provide reimbursement to the Office of Behavioral Health
				  for substance abuse services rendered to EPSDT recipients. Under the provisions
				  of this Rule, payments to OBH for these services shall sunset as of February
				  29, 2012.
B. Reimbursement for
				  these services shall be based on the most recent actual cost to OBH. Cost data
				  shall be derived from the department's ISIS reporting of costs for the period.
				  The cost period shall be consistent with the state fiscal year. Costs are
				  determined by selecting the expenditures paid from state and local funds for
				  the state fiscal year.
C. OBH
				  encounter data from their database shall be used to identify allowable
				  services. Encounter data for recipients under the age of 21 shall be extracted
				  and used in calculations to determine actual cost to OBH.
D. Costs shall be calculated by using the
				  cost-weighted amount and include Medicaid eligibles under 21 database costs
				  divided by total database costs times OBH's expenditures for the program which
				  were derived from the state's ISIS data.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter A - School-Based Health Service Program Guidelines › Section XV-9501 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. EPSDT
					 school-based medical services are provided pursuant to a written plan of care
					 and provided by licensed medical providers within a local education agency
					 (LEA) to Medicaid beneficiaries ages 3 to 21 with or suspected of having a
					 disability. The goal of these services is to prevent or mitigate disease,
					 enhance care coordination, and reduce costs by preventing the need for tertiary
					 care. Providing these services in the school increases access to health care
					 for children and youth resulting in a more efficient and effective delivery of
					 care.
B. School-based medical
					 services shall be covered for all beneficiaries in the school system who are
					 eligible according to Subsection A above. Medical necessity criteria shall be
					 determined according to the provisions of LAC 50:I.Chapter 11.
C. Medically necessary services are defined
					 as those health care services that are in accordance with generally accepted
					 evidence-based medical standards or that are considered by most physicians (or
					 other independent licensed practitioners) within the community of their
					 respective professional organizations to be the standard of care.
1. In order to be considered medically
					 necessary, services must be:
a. deemed
					 reasonably necessary to diagnose, correct, cure, alleviate, or prevent the
					 worsening of a condition or conditions that endanger life, cause suffering or
					 pain, or have resulted or will result in a handicap, physical deformity or
					 malfunction; and
b. those for which
					 no equally effective, more conservative and less costly course of treatment is
					 available or suitable for the beneficiary.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter A - School-Based Health Service Program Guidelines › Section XV-9503 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 following medically necessary services provided by local education agencies
					 (LEAs) are reimbursable when included on a beneficiary's individualized service
					 plan (IEP), a section 504 accommodation plan, an individualized health care
					 plan, or a medical need based written plan of care:
1. medical and remedial behavioral health
					 care including applied behavior analysis (ABA);
a. - c. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter A - School-Based Health Service Program Guidelines › Section XV-9505 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Cost
					 Reporting. Settlement payments for EPSDT school-based medical direct, therapy,
					 behavioral health, and PCS services shall be based on the most recent school
					 year's actual costs as determined by desk review and/or audit for each LEA
					 provider.
1. Each LEA shall determine cost
					 annually by using LDH's cost report for medical service cost form based on the
					 direct services cost report.
2.
					 Direct costs shall be limited to the amount of total compensation (salaries,
					 vendor payments and fringe benefits) of current medical service providers as
					 allocated to medical services for Medicaid beneficiaries. There are no
					 additional direct costs included in the rate.
3. ...
4. To determine the amount of EPSDT services
					 costs that may be attributed to Medicaid; the ratio of total Medicaid students
					 in the LEA is multiplied by total direct (direct plus indirect) cost. Cost data
					 are subject to certification by each LEA. This serves as the basis for
					 obtaining federal Medicaid funding.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter A - School-Based Health Service Program Guidelines › Section XV-9507 - Local Education Agency Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. The LEA shall ensure that its licensed and
					 unlicensed EPSDT service professionals are employed or contracted according to
					 the requirement specified under the Individuals with Disabilities Education Act
					 (IDEA).
B. LEAs shall ensure that
					 individual professional requirements are in compliance with Medicaid
					 qualifications, Department of Education Bulletin 746, and Louisiana Standards
					 for State Certification of School Personnel prior to an LEA billing for any
					 services of a clinician under Medicaid.
C. Anyone providing EPSDT services must
					 operate within their scope of practice license or certification under the
					 supervision of a licensed practitioner. Licensed practitioners assume
					 professional liability for unlicensed/certified practitioners under their
					 supervision and within their scope of practice. The provider shall create and
					 maintain documents to substantiate that all requirements are met.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter B - School-Based EPSDT Transportation Services › Section XV-9511 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
					 special transportation trip is only billable to Medicaid on the same day that a
					 Medicaid-eligible child is receiving a Medicaid Service included in the child's
					 individualized service plan (IEP). Transportation shall be provided on a
					 specially adapted bus. The need for transportation must be documented in the
					 child's IEP.
B. School-based EPSDT
					 transportation services shall be covered for all recipients in the school
					 system who are eligible for the service.
C. Local education agency responsibilities
					 shall be followed in accordance with §9507
D. Service Exclusion. Transportation services
					 are not covered if performed for educational purposes (e.g., academic testing)
					 or, as the result of the assessment and evaluation, it is determined the
					 service is not reflected in an IEP. Medicaid does not reimburse for social or
					 educational needs.
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 XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter B - School-Based EPSDT Transportation Services › Section XV-9515 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Medically necessary specialized transportation that is included on the
					 student's IEP, provided by LEAs to beneficiaries under age 21 is reimbursed
					 based on the most recent school year's actual cost as determined by desk review
					 and/or audit for each LEA provider. Each LEA shall determine cost annually by
					 using LDH's specialized transportation cost report form. There is no time study
					 for the transportation program.
1. Direct
					 cost shall be the cost of fuel, repairs and maintenance, rentals, contracted
					 vehicle use cost and the amount of total compensation (salaries, vendor
					 payments, and fringe benefits) of specialized transportation employees or
					 contract cost for contract drivers, as allocated to special transportation
					 services for Medicaid beneficiaries. There are no additional direct costs
					 included in the rate.
2. Indirect
					 cost is derived by multiplying the direct cost by the cognizant agency's
					 unrestricted indirect cost rate assigned by the Department of Education to each
					 LEA by the allowable costs. There are no additional indirect costs
					 included.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 5 - Early and Periodic Screenings, Diagnosis, and Treatments › Chapter 95 - School-Based Health Services › Subchapter C - School-Based Medicaid Personal Care Services › Section XV-9521 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. General
					 provisions shall be followed in accordance with §9501
B. Early and periodic screening, diagnosis
					 and treatment personal care services must be prescribed by a licensed
					 practitioner within the scope of their practice initially and every 180 days
					 thereafter (or rolling six months) and when changes in the plan of care
					 occur.
C. Local education agency
					 responsibilities shall be followed in accordance with §9507
D. Repealed.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.