reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 1 - General Provisions › Section XIII-105 - Provider Responsibilities [Formerly LAC 50:XIX.105]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Home health agencies must comply with the
				  following requirements as condition for participation in the Medicaid Program.
1. The home health agency must provide to the
				  bureau, upon request, the supporting documentation verifying that the recipient
				  meets the medical necessity criteria for services.
2. Home health services shall be terminated
				  when the goals outlined in the plan of care have been achieved, regardless of
				  the number of days or visits that have been approved.
3. The home health agency must ensure that
				  the family is instructed on a home maintenance exercise program which has been
				  established by the treating physical therapist.
4. T he home health agency shall discharge a
				  patient once it has been determined that the patient or his/her legally
				  responsible caregiver is noncompliant with the treatment regimen, keeping
				  medical appointments and/or assisting with medication compliance and med-pack
				  setups.
5. The home health agency
				  must report complaints and suspected cases of abuse or neglect of a home health
				  recipient to the appropriate authorities if the agency has knowledge that a
				  minor child, a non-consenting adult or a mentally incompetent adult has been
				  abused or is not receiving proper medical care due to neglect or lack of
				  cooperation on the part of the legal guardians or caretakers. This includes
				  knowledge that a recipient is routinely taken out of the home by a legal
				  guardian or caretaker against medical advice or when it is obviously medically
				  contraindicated.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 1 - General Provisions › Section XIII-121 - Cost Reporting Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective July 1, 2012, the department
				  shall implement mandatory cost reporting requirements for providers of home
				  health services. The cost reports will be used to verify expenditures and to
				  support rate setting for the services rendered to Medicaid
				  recipients.
B. Each home health
				  agency shall complete the DHH approved cost report and submit the cost
				  report(s) to the department no later than five months after the state fiscal
				  year ends (June 30).
Chapter 3. Medical Necessity
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 XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 3 - Medical Necessity › Section XIII-301 - General Provisions [Formerly LAC 50:XIX.301]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medical necessity for home health services
				  is determined by the recipient's illness and/or injury and functional
				  limitations. All home health services shall be medically reasonable and
				  appropriate. To be considered medically reasonable and appropriate, the care
				  must be necessary to prevent further deterioration of a recipient's condition
				  regardless of whether the illness or injury is acute, chronic or terminal. The
				  services must be reasonably determined to:
1.
				  diagnose, cure, correct or ameliorate defects, physical and mental illnesses,
				  and diagnosed conditions of the effects of such conditions; or
2. prevent the worsening of conditions, or
				  the effects of conditions, that:
a. endanger
				  life or cause pain;
b. result in
				  illness or infirmity; or
c. have
				  caused, or threatened to cause, a physical or mental dysfunction, impairment,
				  disability, or developmental delay; or
3. effectively reduce the level of direct
				  medical supervision required or reduce the level of medical care or services
				  received in an inpatient or residential care setting; or
4. restore or improve physical or mental
				  functionality, including developmental functioning, lost or delayed as the
				  result of an illness, injury, or other diagnosed condition or the effects of
				  the illness, injury or condition; or
5. provide assistance in gaining access to
				  needed medical, social, educational and other services required to diagnose,
				  treat, or support a diagnosed condition or the effects of the condition, in
				  order that the recipient might attain or retain:
a. independence;
b. self-care;
c. dignity;
d. self-determination;
e. personal safety; and
f. integration into all natural family,
				  community, and facility environments and activities.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 3 - Medical Necessity › Section XIII-303 - Provisions for Infants and Toddlers [Formerly LAC 50:XIX.303]

Current through Register Vol. 50, No. 6, June 20, 2024
A. For the purpose
				  of this Subpart 1,
Infants or Toddlers
are defined as young
				  children, up to age 3, who have not learned to ambulate without
				  assistance.
B. Home health services
				  are considered to be medically necessary for an infant or toddler when the
				  primary care physician has advised against removing the infant or toddler from
				  the home because it would:
1. place the
				  infant or toddler at serious risk of infection;
2. greatly delay or hamper the recovery
				  process;
3. cause significant
				  further debilitation of an existing medical condition or physical
				  infirmity;
4. seriously threaten to
				  cause or aggravate a handicap or a physical deformity or malfunction;
5. cause great suffering or pain;
6. seriously endanger the well-being of the
				  infant or toddler; or
7. otherwise
				  be considered medically contraindicated.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 3 - Medical Necessity › Section XIII-305 - Extended Nursing Services for Ages 0-21

Current through Register Vol. 50, No. 6, June 20, 2024
A. Extended nursing services may be provided
				  to a Medicaid recipient who is age birth through 21 when it is determined to be
				  medically necessary for the recipient to receive a minimum of three continuous
				  hours per day of nursing services. Medical necessity for extended nursing
				  services exists when the recipient has a medically complex condition
				  characterized by multiple, significant medical problems that require nursing
				  care as defined by the Louisiana Nurse Practice Act.
B. Multiple nursing visits on the same date
				  of service may be provided to a recipient who is age birth through 21 when the
				  medical necessity criteria for extended nursing services are met and these
				  services cannot be provided during the course of one visit.
C. Extended and multiple daily nursing
				  services must be prior authorized in accordance with the certifying physician's
				  orders and home health plan of care. All nursing services shall be provided in
				  accordance with the Louisiana Nurse Practice Act.
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 XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 5 - Retrospective Review › Section XIII-501 - Home Health Visits [Formerly LAC 50:XIX.501]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Home health services provided to
				  recipients are subject to post-payment review in order to determine if the
				  recipients condition warrants high utilization.
B. - C. Repealed.
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 XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 7 - Reimbursement Methodology › Section XIII-701 - Nursing and Home Health Aide Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
				  July, 20, 2007, the reimbursement rates for extended nursing services are
				  increased as follows:
1. nurse care in home
				  performed by a registered nurse (RN) is increased to $34 per hour;
2. nurse care in home performed by a licensed
				  practical nurse (LPN) is increased to $32 per hour;\
3. multiple visits - nurse care in home
				  performed by an RN is increased to $17 per hour; and
4. multiple visits - nurse care in home
				  performed by an LPN is increased to $16 per hour.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 8 - American Rescue Plan Act Funding › Section XIII-801 - Nursing Recruitment and Retention Payments

Current through Register Vol. 50, No. 6, June 20, 2024
A. General Provisions
1. Nurses that provide extended home health
				  (EHH) services may be eligible to receive recruitment and retention bonuses
				  through March 2025.
2. A nurse is
				  defined as an individual who possesses and maintains a valid license as a
				  licensed practical nurse (LPN) or registered nurse (RN).
3. All payments shall be administered by the
				  home health agency (HHA) that employs the nurse. If a nurse is employed at
				  multiple agencies, only one HHA may pay the recruitment and retention
				  payment.
4. HHAs shall submit an
				  invoice and supporting documentation for each nurse that meets the requirements
				  outlined in this Chapter on a monthly basis and shall comply with all other
				  requirements established by LDH to receive a payment.
5. HHAs shall disburse the entire payment to
				  the nurse and are prohibited from reducing the payment for any purpose other
				  than required state or federal withholdings.
6. HHAs that provide the required
				  documentation, comply with all applicable requirements, and have at least one
				  nurse a month receiving a bonus payment will be eligible to invoice LDH for an
				  administrative fee of $2,500 each month.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 9 - Rehabilitation Services › Section XIII-901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program provides coverage for rehabilitation services rendered in the
				  Home Health Program. Home Health rehabilitation services include:
1. physical therapy;
2. occupational therapy; and
3. speech/language therapy.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 9 - Rehabilitation Services › Section XIII-905 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program provides reimbursement for physical therapy, occupational
				  therapy and speech/language therapy covered under the Home Health
				  Program.
B. Effective for dates of
				  service on or after February 13, 2014, reimbursement for physical and
				  occupational therapy services shall be 85 percent of the 2013 Medicare
				  published rate. There shall be no automatic enhanced rate adjustment for
				  physical and occupational therapy services.
C. Speech/language therapy services shall
				  continue to be reimbursed at the flat fee in place as of February 13, 2014 and
				  in accordance with the Medicaid published fee schedule for speech/language
				  therapy services provided in the Home Health Program.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 3 - Medical Equipment, Supplies and Appliances › Chapter 85 - Provider Participation › Section XIII-8501 - Accreditation Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after August 1, 2011, all providers
				  seeking reimbursement for medical equipment, supplies and appliances must be
				  accredited by one of the following Medicare deemed accreditation organizations:
1. The Joint Commission (JC);
2. National Association of Boards of Pharmacy
				  (NABP);
3. Board of
				  Certification/Accreditation International;
4. The Compliance Team, Inc.;
5. American Board for Certification in
				  Orthotics and Prosthetics, Inc. (ABC);
6. The National Board of Accreditation for
				  Orthotic Suppliers (NBAOS);
7.
				  Commission on Accreditation of Rehabilitation Facilities (CARF);
8. Community Health Accreditation Program
				  (CHAP);
9. HealthCare Quality
				  Association on Accreditation (HQAA); or
10. Accreditation Commission for Health Care,
				  Inc. (ACHC).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 3 - Medical Equipment, Supplies and Appliances › Chapter 85 - Provider Participation › Section XIII-8503 - Provider Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Providers shall not initially deliver more than a one month allotment of
				  approved supplies. All subsequently approved supplies must be delivered in
				  increments not to exceed a one month allotment.
B. It is the provider's responsibility to
				  verify that the recipient is Medicaid eligible on the date of service in order
				  for payment to be made. The date of service is the date of delivery, unless the
				  item is delivered through a mail courier service.
1. The date of shipping will be considered
				  the date of service for all items delivered through a mail courier
				  service.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 3 - Medical Equipment, Supplies and Appliances › Chapter 103 - Reimbursement Methodology › Section XIII-10301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Unless
				  otherwise stated in this Part XIII, the reimbursement for all medical
				  equipment, supplies and appliances is established at:
1. 70 percent of the 2000 Medicare fee
				  schedule for all procedure codes that were listed on the 2000 Medicare fee
				  schedule and at the same amount for the Health Insurance Portability and
				  Accountability Act (HIPAA) compliant codes which replaced them; or
2. 70 percent of the Medicare fee schedule
				  under which the procedure code first appeared; or
3. 70 percent of the manufacturer's suggested
				  retail price (MSRP) amount; or
4.
				  billed charges, whichever is the lesser amount.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 1 - General Provisions › Section XV-101 - Program Description and Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. Applied behavior analysis-based (ABA)
				  therapy is the design, implementation, and evaluation of environmental
				  modification using behavioral stimuli and consequences to produce socially
				  significant improvement in human behavior, including the direct observation,
				  measurement, and functional analysis of the relations between environment and
				  behavior. ABA-based therapies teach skills through the use of behavioral
				  observation and reinforcement or prompting to teach each step of targeted
				  behavior. ABA-based therapies are based on reliable evidence and are not
				  experimental.
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 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 1 - General Provisions › Section XV-103 - Recipient Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to
				  qualify for ABA-based therapy services, a Medicaid recipient must meet the
				  following criteria. The recipient must:
1. be
				  from birth up to 21 years of age;
2. exhibit the presence of excesses and/or
				  deficits of behaviors that significantly interfere with home or community
				  activities (examples include, but are not limited to aggression, self-injury,
				  elopement, impaired development in the areas of communication and/or social
				  interaction, etc.);
3. be diagnosed
				  by a qualified health care professional with a condition for which ABA-based
				  therapy services are recognized as therapeutically appropriate, including
				  autism spectrum disorder; and
4.
				  have a comprehensive diagnostic evaluation that prescribes and/or recommends
				  ABA services that is conducted by a qualified health care
				  professional.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 3 - Services › Section XV-301 - Covered Services and Limitations

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Medicaid covered ABA-based therapy services must be:
1. medically necessary;
2. prior authorized by the Medicaid Program
				  or its designee; and
3. delivered
				  in accordance with the recipients treatment plan.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 3 - Services › Section XV-303 - Treatment Plan

Current through Register Vol. 50, No. 6, June 20, 2024
A. ABA-based
				  therapy services shall be rendered in accordance with the individuals treatment
				  plan. The treatment plan shall:
1. be
				  person-centered and based upon individualized goals;
2. be developed by a licensed behavior
				  analyst;
3. delineate both the
				  frequency of baseline behaviors and the treatment development plan to address
				  the behaviors;
4. identify long,
				  intermediate, and short-term goals and objectives that are behaviorally
				  defined;
5. identify the criteria
				  that will be used to measure achievement of behavior objectives;
6. clearly identify the schedule of services
				  planned and the individual providers responsible for delivering the
				  services;
7. include care
				  coordination involving the parents or caregiver(s), school, state disability
				  programs, and others as applicable;
8. include parent/caregiver training,
				  support, and participation;
9. have
				  objectives that are specific, measureable, based upon clinical observations,
				  include outcome measurement assessment, and tailored to the individual;
				  and
10. ensure that interventions
				  are consistent with ABA techniques.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 5 - Provider Participation › Section XV-501 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  ABA-based therapy services must be provided by or under the supervision of a
				  behavior analyst who is currently licensed by the Louisiana Behavior Analyst
				  Board, or a licensed psychologist, or a licensed medical
				  psychologist.
B. Licensed behavior
				  analysts that render ABA-based therapy services shall meet the following
				  provider qualifications:
1. be licensed by
				  the Louisiana Behavior Analyst Board;
2. be covered by professional liability
				  insurance to limits of $1,000,000 per occurrence, $1,000,000
				  aggregate;
3. have no sanctions or
				  disciplinary actions on their Board Certified Behavior Analyst (BCBA) or Board
				  Certified Behavior Analyst-Doctoral (BCBA-D) certification and/or state
				  licensure;
4. not have
				  Medicare/Medicaid sanctions, or be excluded from participation in federally
				  funded programs (i.e., Office of Inspector Generals list of excluded
				  individuals/entities (OIG-LEIE), system for award management (SAM) listing and
				  state Medicaid sanctions listings); and
5. have a completed criminal background check
				  to include federal criminal, state criminal, parish criminal and sex offender
				  reports for the state and parish in which the behavior analyst is currently
				  working and residing.
a. Criminal background
				  checks must be performed at the time of hire and at least five years
				  thereafter.
b. Background checks
				  must be current, within a year prior to the initial Medicaid enrollment
				  application. Background checks must be performed at least every five years
				  thereafter.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 7 - Reimbursements › Section XV-701 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program shall provide reimbursement for ABA-based therapy services to
				  enrolled behavior analysts who are currently licensed and in good standing with
				  the Louisiana Behavior Analyst Board. Reimbursement shall only be made for
				  services billed by a licensed behavior analyst, licensed psychologist, or
				  licensed medical psychologist.
B.
				  Reimbursement for ABA services shall not be made to, or on behalf of services
				  rendered by, a parent, a legal guardian or legally responsible
				  person.
C. Reimbursement shall only
				  be made for services authorized by the Medicaid Program or its
				  designee.
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 1 - Applied Behavior Analysis-Based Therapy Services › Chapter 7 - Reimbursements › Section XV-703 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement for ABA-based therapy services shall be based upon a percentage
				  of the commercial rates for ABA-based therapy services in the state of
				  Louisiana.
B. Effective for dates
				  of service on or after January 1, 2017, ABA rates and codes in effect on
				  December 31, 2016 may be realigned to be consistent with Louisiana commercial
				  rates or ABA codes adopted by the American Medical Association via current
				  procedural terminology (CPT) codes.
1. Prior
				  authorizations already in effect on the promulgation date of these provisions
				  will be honored. Those services shall be paid at the rate in effect on December
				  31, 2016.
2. New prior
				  authorizations with a begin date after the promulgation date of these
				  provisions must use the codes in effect prior to January 1, 2017 for those
				  services provided and to be delivered prior to January 1, 2017, and for any
				  services provided after January 1, 2017, the codes in effect at the time of
				  service delivery.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 31 - General Provisions › Section XV-3101 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hospice care is
				  an alternative treatment approach that is based on a recognition that impending
				  death requires a change from curative treatment to palliative care for the
				  terminally ill patient and supporting family. Palliative care focuses on
				  comfort care and the alleviation of physical, emotional and spiritual
				  suffering. Instead of hospitalization, its focus is on maintaining the
				  terminally ill patient at home with minimal disruptions in normal activities
				  and with as much physical and emotional comfort as possible.
B. The bureau terminates the pilot project
				  for hospice care and establishes hospice as a covered service under the
				  Medicaid State Plan.
C. The bureau
				  will continue to make Medicaid payments under certain circumstances for
				  specified services provided in conjunction with Medicare hospice care for
				  dually eligible individuals who reside in Medicaid reimbursed nursing
				  facilities as provided in 4307 of this Subpart and in accordance with
				  §1905(o)(3) of the Social Security Act.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 33 - Provider Participation › Section XV-3301 - Conditions for Participation

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Statutory Compliance
1. Coverage of Medicaid
				  hospice care shall be in accordance with:
a.
												42
				  USC 1396d(o); and
b. the Medicare Hospice Program guidelines as
				  set forth in 42 CFR Part 418.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 35 - Recipient Eligibility › Section XV-3501 - Election of Hospice Care

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to be eligible to elect hospice care under Medicaid, a recipient must be
				  terminally ill. An individual is considered to be terminally ill if the
				  individual has a medical prognosis that his or her life expectancy is six
				  months or less if the illness runs its normal course.
B. An election statement must be filed with a
				  particular hospice for the individual who meets the eligibility requirements as
				  set forth in
				  §3501. A above.
1. The election must be filed by the eligible
				  individual or by a person authorized by law (legal representative) to consent
				  to medical treatment for such individual.
a.
				  A legal representative does not have the authority to elect, revoke, or appeal
				  the denial of hospice services if the recipient is able to and wishes to convey
				  a contrary choice.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 35 - Recipient Eligibility › Section XV-3503 - Waiver of Payment for Other Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hospice providers must provide services to
				  beneficiaries that are comparable to the Medicaid-covered services that could
				  have been received prior to the election of hospice. This requirement refers to
				  all Medicaid-covered services including, but not limited to, durable medical
				  equipment, prescription drugs, and physician-administered drugs.
1. pharmaceutical and biological
				  services;
2. durable medical
				  equipment; and
3. any other
				  services permitted by federal law;
4. the services listed in
				  §3503. A 1-3 are for
				  illustrative purposes only. The hospice provider is not exempt from providing
				  care if an item or category is not listed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 35 - Recipient Eligibility › Section XV-3505 - Revoking the Election of Hospice Care/Discharge

Current through Register Vol. 50, No. 6, June 20, 2024
A. An individual or his/her representative
				  may revoke the individual's election of hospice care for a particular election
				  period at any time during an election period.
1. Required Statement of Revocation. To
				  revoke the election of hospice care, the individual or his/her representative
				  must file a statement with the hospice that includes:
a. a signed statement that the individual or
				  his/her representative revokes the individual's election for Medicaid coverage
				  of hospice care for the remainder of that election period;
b. the date that the revocation is to be
				  effective. (An individual or his/her representative may not designate an
				  effective date earlier than the date that the revocation is made.)
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 35 - Recipient Eligibility › Section XV-3507 - Change of Designated Hospice

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  An individual or his/her representative may change, once in each election
				  period, the designation of the particular hospice from which hospice care will
				  be received. The change of the designated hospice is not a revocation of the
				  election for the period in which it is made. To change the designation of
				  hospice programs, the individual or his/her representative must file, with the
				  hospice from which care has been received and with the newly designated
				  hospice, a statement that includes:
1. the
				  name of the hospice from which the individual has received care and the name of
				  the hospice from which he or she plans to receive care; and
2. the date the change is to be
				  effective.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 37 - Provider Requirements › Section XV-3701 - Requirements for Coverage

Current through Register Vol. 50, No. 6, June 20, 2024
A. To be
				  covered, a certification of terminal illness must be completed as set forth in
				  §3703, the election of hospice care form must be completed in accordance with
				  §3501, and a plan of care must be established in accordance with
				  §3705. A written
				  narrative from the referring physician explaining why the patient has a
				  prognosis of six months or less must be included in the certificate of terminal
				  illness.
B. Prior authorization
				  requirements stated in Chapter 41 of these provisions are applicable to all
				  election periods.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 37 - Provider Requirements › Section XV-3703 - Certification of Terminal Illness

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  The hospice must obtain written certification of terminal illness for each of
				  the periods listed in
				  §3501 C, even if a single election
				  continues in effect for two, three, or more periods.
1. For the first 90-day period of hospice
				  coverage, the hospice must obtain a verbal certification no later than two
				  calendar days after hospice care is initiated. If the verbal certification is
				  not obtained within two calendar days following the initiation of hospice care,
				  a written certification must be made within 10 calendar days following the
				  initiation of hospice care. The written certification and notice of election
				  must be obtained before requesting prior authorization for hospice care. If
				  these requirements are not met, no payment is made for the days prior to the
				  certification. Instead, payment begins with the day certification, i.e., the
				  date all certification forms are obtained.
2. For the subsequent periods, a written
				  certification must be included in an approved prior authorization packet before
				  a claim may be billed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 37 - Provider Requirements › Section XV-3705 - Plan of Care

Current through Register Vol. 50, No. 6, June 20, 2024
A. A written plan
				  of care must be established and maintained for each individual admitted to a
				  hospice program in accordance with the provisions set forth in the Licensing
				  Standards for Hospices (LAC 48:I.Chapter 82), and the care provided to an
				  individual must be consistent with the plan and be reasonable and necessary for
				  the palliation or management of the terminal illness as well as related
				  conditions.
B. The plan of care
				  must be established before services are provided.
C. When developing the plan of care (POC),
				  the hospice provider must consult with, and collaborate with the recipient,
				  his/her caregiver, and his/her long-term personal care services provider, and
				  if the recipient is under age 21, his/her extended home nursing provider and/or
				  pediatric day health care provider. If the recipient is receiving any of these
				  services at the time of admission to hospice, the hospice provider must ensure
				  that the POC clearly and specifically details the services and tasks, along
				  with the frequency, to be performed by the non-hospice provider(s), as well as
				  the services and tasks, along with the frequency, that are to be performed by
				  the hospice provider to ensure that services are non-duplicative and that the
				  recipients needs are being met.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 37 - Provider Requirements › Section XV-3707 - Record Keeping

Current through Register Vol. 50, No. 6, June 20, 2024
A. The hospice
				  must maintain and retain the business and professional records sufficient to
				  document fully and accurately the nature, scope, and details of the health care
				  provided.
B. In accordance with the
				  provisions set forth in the Licensing Standards for Hospices (LAC 48:I.Chapter
				  82), the hospice must establish and maintain a clinical record for every
				  individual receiving care and services.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 37 - Provider Requirements › Section XV-3709 - Self Assessment

Current through Register Vol. 50, No. 6, June 20, 2024
A. In
				  accordance with the provisions set forth in the Licensing Standards for
				  Hospices (LAC 48:I.Chapter 82) the hospice must conduct an ongoing,
				  comprehensive, integrated, self-assessment of the quality and appropriateness
				  of care provided, including inpatient care, home care and care provided under
				  arrangements.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 41 - Prior Authorization › Section XV-4101 - Prior Authorization of Hospice Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Prior authorization is required for all
				  election periods as specified in
				  §3501. C of this
				  Subpart. The prognosis of terminal illness will be reviewed. A patient must
				  have a terminal prognosis and not just certification of terminal illness.
				  Authorization will be made on the basis that a patient is terminally ill as
				  defined in federal regulations. These regulations require certification of the
				  patients prognosis, rather than diagnosis. Authorization will be based on
				  objective clinical evidence contained in the clinical record which supports the
				  medical prognosis that the patients life expectancy is six months or less if
				  the illness runs its normal course and not simply on the patients diagnosis.
1. The Medicare criteria found in local
				  coverage determination (LCD) hospice determining terminal status (L34538) will
				  be used in analyzing information provided by the hospice to determine if the
				  patient meets clinical requirements for this program.
2. Providers shall submit the appropriate
				  forms and documentation required for prior authorization of hospice services as
				  designated by the department in the Medicaid Programs service and provider
				  manuals, memorandums, etc.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4301 - General

Current through Register Vol. 50, No. 6, June 20, 2024
A. With the
				  exception of payment for physician services, Medicaid reimbursement for hospice
				  care is made at one of four predetermined rates, as detailed in §4305, for each
				  day in which a Medicaid recipient is under the care of the hospice. The four
				  rates are prospective rates; there are no retroactive adjustments other than
				  the limitation on payments for inpatient care. The rate paid for any particular
				  day varies depending on the level of care furnished to the recipient. The
				  limitation on payment for inpatient care is described in §4309
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4303 - Levels of Care for Payment

Current through Register Vol. 50, No. 6, June 20, 2024
A. Routine
				  Home Care. The routine home care rate is paid for each day the patient is under
				  the care of the hospice and not receiving one of the other categories of
				  hospice care. This rate is paid without regard to the volume or intensity of
				  routine home care services provided on any given day and is also paid when the
				  patient is receiving hospital care for a condition unrelated to the terminal
				  condition. This rate is also paid in the following situations:
1. if the patient is in a hospital that is
				  not contracted with the hospice; or
2. if the patient is receiving outpatient
				  services in the hospital; or
3. for
				  the day of discharge alive from general inpatient care or respite care level of
				  care.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4305 - Payment Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement for hospice services is made to a designated hospice provider
				  based on the Medicaid rates published annually in a memorandum issued by the
				  U.S. Department of Health and Human Services, Centers for Medicare and Medicaid
				  Services (CMS), Center for Medicaid and CHIP Services. These rates are
				  effective from October 1 of each year through September 30 of the following
				  year.
1. Payment for hospice care will be
				  made at predetermined rates for each day in which a beneficiary is under the
				  care of the hospice provider. The daily rate is applicable to the type and
				  intensity of services furnished to the beneficiary for that day.
a. - b. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4307 - Payment for Long Term Care Residents

Current through Register Vol. 50, No. 6, June 20, 2024
A. Pursuant to Section 1902(a)(13)(B) of the
				  Social Security Act, an additional amount will be paid to hospice providers for
				  routine home care and continuous home care to take into account the room and
				  board furnished by a long term care facility for a Medicaid recipient:
1. who is residing in a nursing facility or
				  intermediate care facility for persons with intellectual disabilities
				  (ICF/ID);
2. who would be eligible
				  under the state plan for nursing facility services or ICF/ID services if he or
				  she had not elected to receive hospice care;
3. who has elected to receive hospice care;
				  and
4. for whom the hospice agency
				  and the nursing facility or ICF/ID have entered into a written agreement in
				  accordance with the provisions set forth in the licensing standards for hospice
				  agencies (LAC 48:I.Chapter 82), under which the hospice agency takes full
				  responsibility for the professional management of the individuals hospice care
				  and the facility agrees to provide room and board to the individual.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4309 - Limitation on Payments for Inpatient Care

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payments to a hospice for inpatient care
				  are limited according to the number of days of inpatient care furnished to
				  Medicaid patients.
1. A hospice cap period is
				  a 12-month period beginning November 1 of each year and ending October 31 of
				  the following year.
2. Once each
				  year at the end of the hospices' "cap period" the bureau calculates a
				  limitation on payment for inpatient care to ensure that Medicaid payment is not
				  made for days of inpatient care in excess of 20 percent of the total number of
				  days of hospice care furnished to Medicaid patients.
a. Medicaid recipients afflicted with
				  acquired immunodeficiency syndrome (AIDS) are included in the calculation of
				  this inpatient care limitation.
b.
				  Any excess reimbursement is refunded by the hospice.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4311 - Coinsurance for Medicare

Current through Register Vol. 50, No. 6, June 20, 2024
A. For
				  dually eligible recipients for whom Medicare is the primary payer for hospice
				  services, Medicaid will also provide for payment of any coinsurance amounts
				  imposed under ' 1813(a)(4) of the Social Security Act.
1. Drugs and Biologicals. The coinsurance
				  amount for each prescription approximates 5 percent of the cost of the drug or
				  biological to the hospice, determined in accordance with the drug copayment
				  schedule established by the hospice, except that the coinsurance amount for
				  each prescription may not exceed $5. The cost of the drug or biological may not
				  exceed what a prudent buyer would pay in similar circumstances.
2. Respite Care. The coinsurance amount for
				  each respite care day is equal to 5 percent of the payment made under Medicare
				  for a respite care day. The amount of the individual's coinsurance liability
				  for respite care during a hospice coinsurance period may not exceed the
				  inpatient hospital deductible applicable for the year in which the hospice
				  coinsurance period began.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4313 - Services Not Related to Terminal Illness

Current through Register Vol. 50, No. 6, June 20, 2024
A. Any covered Medicaid services not related
				  to the treatment of the terminal condition for which hospice care was elected,
				  that are provided during a hospice election period, are billed to the bureau
				  for non-hospice Medicaid payment. Prior authorization is required for any
				  covered Medicaid services not related to the treatment of the terminal
				  condition if such prior authorization is required by the bureau for non-hospice
				  recipients.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 3 - Hospice › Chapter 43 - Reimbursement › Section XV-4315 - Life-Prolonging Treatments for Beneficiaries under the Age of 21

Current through Register Vol. 50, No. 6, June 20, 2024
A. Reimbursement
				  for life-prolonging treatments is separate from hospice payments and is made to
				  the providers furnishing the services.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254.
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 65 - General Provisions › Section XV-6501 - Screening Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				  providers of early and periodic screening, diagnosis and treatment (EPSDT)
				  preventive screening services shall be required to submit information to the
				  Medicaid Program regarding recipient immunizations, referrals, and health
				  status.
B. Screening services
				  rendered to Medicaid-eligible children under 21 years of age and reimbursable
				  under the EPSDT Program shall include:
1.
				  health education (including anticipatory guidance) as a minimum component in
				  addition to a comprehensive health and development history (including
				  assessment of both physical and mental health development);
2. a comprehensive unclothed physical
				  exam;
3. appropriate immunizations
				  according to age and health history; and
4. laboratory tests (including blood lead
				  level assessment appropriate for age and risk factors).
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 65 - General Provisions › Section XV-6503 - Service Limit Exemptions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  following limitations on services shall not apply to Medicaid-eligible
				  recipients under the age of 21:
1. inpatient
				  hospitalization stay limits;
2.
				  outpatient hospital emergency room limits;
3. physician office visit limits;
4. physician hospital visit limits;
5. home health annual visit limits;
6. home health daily limits on nursing and
				  nurse aide 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 65 - General Provisions › Section XV-6505 - Provider Restrictions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medical Assistance Program of Louisiana prohibits Medicaid providers from
				  charging a fee to Medicaid beneficiaries for completing referral forms to
				  obtain services from other state or federally funded programs.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.