reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-701 - Introduction (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-703 - Medical Necessity (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-705 - Exclusionary Criteria (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-707 - Prior Authorization (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-709 - Intradialytic Parenteral Nutrition (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-711 - Additional Documentation (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-713 - Equipment and Supplies (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 7 - Parenteral Nutrition Therapy (Repealed) › Section XXIX-715 - Reimbursement (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Title XIX of the Social Security
				  Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter A - General Provisions › Section XXIX-901 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Average Acquisition Cost
					 (AAC)
-Repealed.
Average Wholesale Price
-Repealed.
Brand Name-
any registered trade name
					 commonly used to identify a drug.
Legend Drugs-
drugs which bear the federal
					 legend: "Caution: federal law prohibits dispensing without a
					 prescription."
Multiple Source Drug--
a drug marketed or
					 sold by two or more manufacturers or labelers or a drug marketed or sold by the
					 same manufacturer or labeler under two or more different proprietary names or
					 both under a proprietary name and without such a name.
National Average Drug Acquisition Cost
					 (NADAC)
-a national pricing benchmark that is reflective of actual
					 invoice costs that pharmacies pay to acquire prescription and over-the-counter
					 drugs. It is based upon invoice cost data collected from retail community
					 pharmacies and reflects actual drug purchases.
Professional Dispensing Fee-
the fee paid
					 by the Medicaid Program to reimburse for the professional services provided by
					 a pharmacist when dispensing a prescription. Per legislative mandate, the
					 provider fee assessed for each prescription filled in the state of Louisiana,
					 or shipped into the state of Louisiana, will be reimbursed separately.
Single Source Drug-
a drug mandated or sold
					 by one manufacturer or labeler.
Usual and Customary Charge
-the lowest
					 price the pharmacy would charge to a particular customer if such customer were
					 paying cash for the identical prescription drug or prescription drug services
					 on the date dispensed.
Wholesale Acquisition Cost
(
WAC
)-the manufacturers published catalog price for a drug
					 product to wholesalers as reported to Medicaid by one or more national
					 compendia on a weekly basis.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter A - General Provisions › Section XXIX-903 - Claims Documentation

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  manufacturer number, product number, and package number for the drug dispensed
				  shall be listed on all claims. This information shall be taken from the actual
				  package from which the drug is usually purchased by a provider, from a supplier
				  whose products are generally available to all pharmacies and reported in one or
				  more national compendia. Repackaged drug products supplied through co-ops,
				  franchises, or other sources not readily available to other providers shall not
				  be used. In such instances, the manufacturer number, product number, and
				  package number for the largest package size, as reported in one or more
				  national compendia for the drug shall be listed.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter B - Professional Dispensing Fee › Section XXIX-915 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  professional dispensing fee shall be set by the department and reviewed
				  periodically for reasonableness, and when deemed appropriate by the Medicaid
				  Program, may be adjusted considering such factors as fee studies or surveys.
Adjustment Factors
-Repealed.
Base Rate
-Repealed.
Base Rate Components
-Repealed.
Maximum Allowable Overhead
					 Cost
-Repealed.
Overhead Year
-Repealed.
B. Provider participation in the Louisiana
				  cost of dispensing survey shall be mandatory. A providers failure to cooperate
				  in the survey shall result in his/her removal from participation as a provider
				  of pharmacy services in the Medicaid Program. Any provider removed from
				  participation shall not be allowed to re-enroll until a professional dispensing
				  fee survey document is properly completed and submitted to the
				  department.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter B - Professional Dispensing Fee › Section XXIX-917 - Maximum Allowable Overhead Cost Calculation (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter B - Professional Dispensing Fee › Section XXIX-919 - Parameters and Limitations (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter B - Professional Dispensing Fee › Section XXIX-921 - Interim Adjustment to Overhead Cost (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter B - Professional Dispensing Fee › Section XXIX-923 - Cost Survey (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter B - Professional Dispensing Fee › Section XXIX-925 - Dispensing Fee (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter C - Estimated Acquisition Cost › Section XXIX-935 - Estimated Acquisition Cost Formula

Current through Register Vol. 50, No. 6, June 20, 2024
A. Estimated acquisition cost (EAC) is the
				  national average drug acquisition cost (NADAC) of the drug dispensed. If there
				  is not a NADAC available, the EAC is equal to the wholesale acquisition cost,
				  as reported in the drug pricing compendia utilized by the departments fiscal
				  intermediary/pharmacy benefits manager (PBM).
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter D - Maximum Allowable Costs › Section XXIX-945 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Maximum
				  Pharmaceutical Price Schedule
1. The maximum
				  payment by the agency for a prescription shall be no more than the cost of the
				  drug established by the state plus the established professional dispensing
				  fee.
2. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter D - Maximum Allowable Costs › Section XXIX-947 - Payments to Dispensing Physician

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Payment will be made for medications dispensed by a physician on a continuing
				  basis only when his main office is more than five miles from a facility which
				  dispenses drugs.
1. Under the above
				  circumstances, vendor payments (when the treating prescriber dispenses his own
				  medications and bills Medical Assistance Program under his own name will be
				  made on the same basis as a pharmacist as specified in
				  §945. A
				  1-2.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter D - Maximum Allowable Costs › Section XXIX-949 - Fee for Service Cost Limits

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Brand Drugs. The department shall make payments for single source drugs (brand
				  drugs) based on the lower of:
1. national
				  average drug acquisition cost (NADAC) plus the professional dispensing fee:
a. if no NADAC is available, use the
				  wholesale acquisition cost (WAC) plus the professional dispensing fee;
				  or
b. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter E - 340B Program › Section XXIX-963 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Self-administered drugs that are purchased by a covered entity through the 340B
				  program and dispensed to patients who are covered by Medicaid shall be billed
				  to Medicaid at actual acquisition cost (can be no more than the 340B ceiling
				  price) unless the covered entity has implemented the Medicaid carve-out option,
				  in which case 340B drugs should not be billed to Medicaid. All other drugs
				  shall be billed in accordance with existing Louisiana Medicaid reimbursement
				  methodologies. Indian Health Service, tribal and urban Indian pharmacy claims
				  will be reimbursed in the encounter rate.
B. Contract Pharmacies. Contract pharmacies
				  are not allowed to bill 340B drugs to Medicaid; therefore, they should carve
				  out.
C. Professional Dispensing
				  Fees. The covered entity will be reimbursed at the appropriate ingredient cost
				  plus the maximum allowable professional dispensing fee or the usual and
				  customary charge, whichever is less.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter F - Antihemophilia Drugs › Section XXIX-971 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Anti-hemophilia
				  drugs purchased by a covered entity through the 340B program and dispensed to
				  Medicaid recipients shall be billed to Medicaid at actual acquisition cost and
				  the professional dispensing fee.
B.
				  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 XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter H - Vaccines › Section XXIX-991 - Vaccine Administration Fees

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement to pharmacies for immunization administration (intramuscular,
				  subcutaneous or intranasal) performed by qualified pharmacists, is a maximum of
				  $15.22. This fee includes counseling, when performed.
B. Administration of vaccines related to a
				  declared public health emergency shall be reimbursed at up to 100 percent of
				  the Louisiana Region 99 Medicare rate for the duration deemed necessary by the
				  Medicaid Program to ensure access. If providers are required to purchase
				  vaccines, then the vaccines will be reimbursed.
AUTHORITY
					 NOTE: Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 9 - Methods of Payment › Subchapter H - Vaccines › Section XXIX-993 - Vaccine Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Vaccines
				  for beneficiaries aged 19 and over shall be reimbursed at wholesale acquisition
				  cost (WAC) or billed charges, whichever is the lesser amount.
B. Vaccines related to a declared public
				  health emergency shall not be reimbursed if furnished at no cost to providers.
				  When providers are responsible for purchasing the vaccine, the Medicaid Program
				  shall reimburse.
AUTHORITY
					 NOTE: Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXIX - Pharmacy › Chapter 11 - Value-based Agreement Programs › Section XXIX-1101 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				Centers for Medicare and Medicaid Services approved LDH to enter into state
				supplemental rebate agreements with pharmaceutical manufacturer(s). LDH may
				enter into an agreement with a pharmaceutical manufacturer to obtain a
				rebate(s) in addition to federal rebates pursuant to
				42 U.S.C.
				1396r. Participation by a pharmaceutical
				manufacturer in a state supplemental rebate agreement with the department is
				voluntary.
B. LDH may enter into an
				agreement with a pharmaceutical manufacturer for outcomes-based contracts.
				Participation by a pharmaceutical manufacturer in an outcomes-based agreement
				with the department is voluntary.
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 XXXI - Refugee Medical Assistance › Chapter 1 - Refugee Medical Assistance Program › Section XXXI-101 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				Immigration and Nationality Act of 1952, Public Law 82-414, allows states to
				provide medical assistance, during the one-year period after entry, to any
				refugee who does not qualify for assistance under a State Plan approved under
				Title XIX of the Social Security Act. The Refugee Medical Assistance (RMA)
				Program provides medical assistance to refugees and asylees in Louisiana who
				are not otherwise eligible for Medicaid/SCHIP coverage. Under the authority of
				the U.S. Department of Health and Human Services, Administration for Children
				and Families, the Department of Health and Hospitals hereby assumes
				responsibility for the administration of the RMA Program.
B. The Refugee Medical Assistance Program is
				a short-term, federally funded program designed to ensure that refugees receive
				the medical care they need while transitioning to life in the United
				States.
C. Refugee medical
				assistance is available to all individuals with the immigration status of
				refugee or asylee.
D. All
				recipients who receive refugee cash assistance through the Office of Refugee
				Resettlement, and who are not eligible for a regular Medicaid/SCHIP program,
				shall be certified for RMA.
1. Receipt or
				application for refugee cash assistance is not a requirement of the RMA
				program.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXI - Refugee Medical Assistance › Chapter 1 - Refugee Medical Assistance Program › Section XXXI-103 - Eligibility Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Individuals who meet the following requirements may receive health care
				coverage through the Refugee Medical Assistance Program.
1. The individual must be a refugee or asylee
				who is not eligible to receive benefits through a regular Medicaid or SCHIP
				program.
2. Application for RMA
				benefits must fall within the established time limit of eight months from the
				date of arrival in the United States for refugees or from the date asylees are
				granted asylum.
3. The individual
				must not be enrolled as a full-time student in an institution of higher
				education unless it is a one-year recertification program which is part of the
				refugee's comprehensive resettlement plan.
4. The individual must provide the name of
				the sponsoring Refugee Resettlement Agency.
a. Asylees are exempt from this
				requirement.
5.
				Applicants for refugee medical assistance must meet income and resource
				guidelines.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXI - Refugee Medical Assistance › Chapter 1 - Refugee Medical Assistance Program › Section XXXI-105 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Recipients
				of RMA are eligible to receive the full range of Medicaid covered
				services.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  36:254 and Public Law 82-414, 8 U.S. Code
				  1522 (e)(5).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXI - Refugee Medical Assistance › Chapter 1 - Refugee Medical Assistance Program › Section XXXI-107 - Certification Period

Current through Register Vol. 50, No. 6, June 20, 2024
A. Refugee
				medical assistance coverage begins the month of application.
B. The certification period shall not exceed
				eight months from the date of entry. For Afghan Special Immigrants, the
				certification period shall not exceed six months from the date of entry.
1. The date of entry for asylees is the date
				the individual is granted asylum.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 1 - Managed Care Organizations and the Coordinated System of Care Contractor › Section XXXIII-101 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program hereby adopts provisions to establish a comprehensive system
				  of delivery for specialized behavioral health and physical health services.
				  These services shall be administered through the Healthy Louisiana and
				  Coordinated System of Care (CSoC) Waiver under the authority of the Department
				  of Health (LDH), in collaboration with managed care organizations (MCOs) and
				  the coordinated system of care (CSoC) contractor, which shall be responsible
				  for the necessary operational and administrative functions to ensure adequate
				  service coordination and delivery.
B. The provisions of this Rule shall apply
				  only to the services provided to Medicaid recipients/enrollees by or through an
				  MCO or the CSoC contractor.
C.
				  Managed care organizations shall operate as such, and the CSoC contractor shall
				  operate as a prepaid inpatient health plan (PIHP). The MCOs and the CSoC
				  contractor were procured through a competitive request for proposal (RFP)
				  process. The MCOs and CSoC contractor shall assist with the states system
				  reform goals to support individuals with behavioral health and physical health
				  needs in families homes, communities, schools and jobs.
D. Through the utilization of MCOs and the
				  CSoC contractor, it is the departments goal to:
1. increase access to a broad array of
				  evidence-based home and community-based services that promote hope, recovery
				  and resilience;
2. improve quality
				  by establishing and measuring outcomes;
3. manage costs through effective utilization
				  of State, federal, and local resources; and
4. foster reliance on natural supports that
				  sustain individuals and families in homes and communities.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 1 - Managed Care Organizations and the Coordinated System of Care Contractor › Section XXXIII-103 - Recipient Participation

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  following Medicaid recipients shall be mandatory participants for integrated
				  specialized behavioral health and physical health services:
1. children who are blind or have a
				  disability and related populations, under age 18;
2. aged and related populations, age 65 and
				  older who are not blind, do not have a disability, and are not members of the
				  §1931 adult population;
3. children
				  who receive foster care or adoption assistance (title IV-E), or who are in
				  foster care or who are otherwise in an out-of-home placement;
4. children with special health care needs as
				  defined in §1932(a);
5. Native
				  Americans;
6. full dual eligibles
				  (for behavioral health services only and non-emergency medical transportation
				  (NEMT);
7. children residing in an
				  intermediate care facility for persons with intellectual disabilities (for
				  behavioral health services only and NEMT);
8. all enrollees of waiver programs
				  administered by the LDH Office for Citizens with Developmental Disabilities
				  (OCDD) or the LDH Office of Aging and Adult Services (OAAS) (mandatory for
				  behavioral health services only and NEMT);
9. all Medicaid children functionally
				  eligible for the CSoC;
10. adults
				  residing in a nursing facility (for behavioral health services only and
				  NEMT);
11. supplemental security
				  income/transfer of resources/long-term care related adults and children (for
				  behavioral health services only and NEMT); and
12. transfer of resources/long-term care
				  adults and children (for behavioral health services only and NEMT).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 1 - Managed Care Organizations and the Coordinated System of Care Contractor › Section XXXIII-105 - Enrollment Process

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCOs and
				  the CSoC contractor shall abide by all enrollment and disenrollment policies
				  and procedures as outlined in the contract entered into by
				  department.
B. The MCOs and the
				  CSoC contractor shall ensure that mechanisms are implemented to assess each
				  Medicaid enrollee identified as having special health care needs in order to
				  identify any ongoing conditions that require a course of treatment or regular
				  care monitoring. The assessment mechanism shall incorporate appropriate health
				  care professionals.
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 XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 1 - Managed Care Organizations and the Coordinated System of Care Contractor › Section XXXIII-107 - Enrollee Rights and Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. The enrollees rights shall include, but
				  are not limited to the right to:
1.
				  participate in treatment decisions, including the right to:
a. refuse treatment;
b. seek second opinions; and
c. receive assistance with care coordination
				  from the primary care providers (PCPs) office or the enrollee's behavioral
				  health provider;
d.
				  Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 3 - Managed Care Organizations and the Coordinated System of Care Contractor Participation › Section XXXIII-303 - Benefits and Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Benefits
				  and services shall be rendered to Medicaid recipients/enrollees as provided
				  under the terms of the contract and department-issued guidelines.
B. The MCO and CSoC contractor:
1. shall ensure that medically necessary
				  services are sufficient in amount, duration, or scope to reasonably be expected
				  to achieve the purpose for which the services are being furnished and shall not
				  be more restrictive than services provided under the Medicaid State
				  Plan;
2. may not arbitrarily deny
				  or reduce the amount, duration, or scope of a required service because of
				  diagnosis, type of illness, or condition of the member;
3. may place appropriate limits on a service:
a. on the basis of medical necessity;
				  and
b. for the purpose of
				  utilization control, provided the services furnished can reasonably be expected
				  to achieve their purpose;
4. shall provide benefits and services as
				  outlined and defined in the contract and shall provide medically necessary and
				  appropriate care to enrollees; and
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 3 - Managed Care Organizations and the Coordinated System of Care Contractor Participation › Section XXXIII-305 - Service Delivery

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCOs and
				  CSoC contractor shall ensure that services rendered to enrollees are medically
				  necessary, are authorized or coordinated, and are provided by professionals
				  according to their scope of practice and licensing in the state of
				  Louisiana.
B. Access to emergency
				  services and family-oriented services shall be assured within the
				  network.
C. MCOs shall offer a
				  contract to all federally qualified health centers (FQHCs), rural health
				  clinics (RHCs), and tribal clinics. Enrollees shall have a choice of available
				  providers in the plans network to select from. The CSoC contractor shall be
				  required to contract with at least one FQHC in each medical practice region of
				  the state (according to the practice patterns within the state) if there is an
				  FQHC which can provide substance use disorder services or specialty mental
				  health services under state law and to the extent that the FQHC meets the
				  required provider qualifications.
D. MCOs and the CSoC contractor shall ensure
				  that the recipient is involved throughout the planning and delivery of
				  services.
1. Services shall be:
a. delivered in a culturally and
				  linguistically competent manner; and
b. respectful of the individual receiving
				  services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 5 - Reimbursement › Section XXXIII-501 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For
				  recipients enrolled in one of the MCOs or with the CSoC contractor, the
				  department or its fiscal intermediary shall make monthly capitation payments to
				  the MCOs or CSoC contractor.
1. The
				  capitation rates paid to the MCOs or CSoC contractor shall be actuarially sound
				  rates.
2. The MCOs or CSoC
				  contractor will determine the rates paid to its contracted providers.
a. No payment shall be less than the minimum
				  Medicaid rate.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 7 - Grievance and Appeals Process › Section XXXIII-701 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCOs
				  and the CSoC contractor shall be required to have an internal grievance system
				  and internal appeal process. The appeal process allows a Medicaid
				  recipient/enrollee to challenge a decision made, a denial of coverage, or a
				  denial of payment for services.
B.
				  An enrollee, an enrollees authorized representative or a provider on behalf of
				  an enrollee, with the enrollees prior written consent, has 60 calendar days
				  from the date on the notice of action in which to file an appeal.
C. An enrollee, an enrollees authorized
				  representative or a provider on behalf of an enrollee, with the enrollees prior
				  written consent, may file a grievance at any time after an occurrence or
				  incident which is the basis for the grievance.
D. An enrollee must exhaust the MCO or the
				  CSoC contractor grievance and appeal process before requesting a state fair
				  hearing.
E. The MCO and CSoC
				  contractor shall provide Medicaid enrollees with information about the state
				  fair hearing process within the timeframes established by the department and in
				  accordance with the state fair hearing policies.
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 XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 7 - Grievance and Appeals Process › Section XXXIII-703 - Provider Grievance and Appeal Process

Current through Register Vol. 50, No. 6, June 20, 2024
A. If the provider is filing a grievance or
				  appeal on behalf of the member, the provider shall adhere to the provisions
				  outlined in
				  §701 of this Chapter.
B. The MCO and CSoC contractor must have a
				  grievance and appeals process for claims, medical necessity, and contract
				  disputes for providers in accordance with the contract and department issued
				  guidance.
1. The MCO and CSoC contractor
				  shall establish and maintain a procedure for the receipt and prompt internal
				  resolution of all provider initiated grievances and appeals as specified in the
				  contract and department issued guidance.
2. The grievance and appeals procedures, and
				  any changes thereto, must be approved in writing by the department prior to
				  their implementation.
3.
				  Notwithstanding any MCO, CSoC contractor, or department grievance and appeal
				  process, nothing contained in any document, including, but not limited to Rule
				  or contract, shall preclude a provider's right to pursue relief through a court
				  of appropriate jurisdiction.
4. The
				  MCO and CSoC contractor shall report on a monthly basis all grievance and
				  appeals filed and resolutions in accordance with the terms of the contract and
				  department issued guidance.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 9 - Monitoring Activities › Section XXXIII-901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  contracted MCOs and the CSoC contractor shall be accredited by an accrediting
				  body that is designated in the contract, or agrees to submit an application for
				  accreditation at the earliest possible date as allowed by the accrediting body.
				  Once accreditation is achieved, it shall be maintained through the life of this
				  agreement.
B. The MCOs and CSoC
				  contractor shall be required to track grievances and appeals, network adequacy,
				  access to services, service utilization, quality measure and other monitoring
				  and reporting requirements in accordance with the contract with the
				  department.
C.- G. 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 XXXIII - Behavioral Health Services › Subpart 2 - General Provisions › Chapter 17 - Behavioral Health Services Reimbursements › Section XXXIII-1701 - Physician Payment Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  The reimbursement rates for physician services rendered under the Louisiana
				  Behavioral Health Partnership (LBHP) shall be a flat fee for each covered
				  service as specified on the established Medicaid fee schedule. The
				  reimbursement rates shall be based on a percentage of the Louisiana Medicare
				  Region 99 allowable for a specified year.
B. Effective for dates of service on or after
				  April 20, 2013, the reimbursement for behavioral health services rendered by a
				  physician under the LBHP shall be 75 percent of the 2009 Louisiana Medicare
				  Region 99 allowable for services rendered to Medicaid recipients.
C. Effective for dates of service on or after
				  September 1, 2013, the reimbursement for procedure codes 90791, 90792, 90832,
				  90834 and 90837 shall be excluded from the January 2013 Medicare rate changes
				  and shall remain at the Medicaid fee schedule on file as of December 31,
				  2012.
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 XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 21 - General Provisions › Section XXXIII-2101 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid
				  Program hereby adopts provisions to provide coverage under the Medicaid State
				  Plan for mental health services rendered to children and youth with behavioral
				  health disorders. These services shall be administered under the authority of
				  the Department of Health (LDH), in collaboration with managed care
				  organizations (MCOs) and the coordinated system of care (CSoC) contractor,
				  which shall be responsible for the necessary operational and administrative
				  functions to ensure adequate service coordination and delivery. The CSoC
				  contractor shall only manage specialized behavioral health services for
				  children and youth enrolled in the coordinated system of care.
B. The specialized behavioral health services
				  rendered to children with emotional or behavioral disorders are those services
				  necessary to reduce the disability resulting from the illness and to restore
				  the individual to his/her best possible functioning level in the
				  community.
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 XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 21 - General Provisions › Section XXXIII-2103 - Recipient Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Individuals under the age of 21 with an identified mental health diagnosis, who
				  meet Medicaid eligibility and clinical criteria, shall qualify to receive home
				  and community-based behavioral health 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 XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 23 - Services › Section XXXIII-2301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				  specialized behavioral health services must be medically necessary. The medical
				  necessity for services shall be determined by a licensed mental health
				  practitioner (LMHP) or physician who is acting within the scope of his/her
				  professional license and applicable state law.
B. Services provided to children and youth
				  must include communication and coordination with the family and/or legal
				  guardian and custodial agency for children in state custody. Coordination with
				  other child-serving systems should occur as needed to achieve the treatment
				  goals. All coordination must be documented in the childs medical record.
1. The agency or individual who has the
				  decision making authority for a child or youth in state custody must request
				  and approve the provision of services to the recipient.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 23 - Services › Section XXXIII-2303 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  following behavioral health services shall be reimbursed under the Medicaid
				  Program:
1. therapeutic services delivered by
				  licensed mental health professionals (LMHP), including diagnosis and
				  treatment;
2. rehabilitation
				  services, including community psychiatric support and treatment (CPST) and
				  psychosocial rehabilitation (PSR);
3. crisis intervention services;
				  and
4. crisis stabilization
				  services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 25 - Provider Participation › Section XXXIII-2501 - Provider Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. Each
				  provider of specialized behavioral health services shall enter into a contract
				  with one or more of the managed care organizations (MCOs) and with the
				  coordinated system of care (CSoC) contractor for youth enrolled in the
				  Coordinated System of Care program in order to receive reimbursement for
				  Medicaid covered services.
B.
				  Providers shall deliver all services in accordance with their license and scope
				  of practice, federal and state laws and regulations, the provisions of this
				  Rule, the provider manual, and other notices or directives issued by the
				  department. The provider shall create and maintain documents to substantiate
				  that all requirements are met.
C. -
				  D.6. 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 XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 27 - Reimbursement › Section XXXIII-2701 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For
				  recipients enrolled with one of the managed care organizations (MCOs) or
				  coordinated system of care (CSoC) contractor, the department or its fiscal
				  intermediary shall make monthly capitation payments to the MCOs or the CSoC
				  contractor.
1. The capitation rates paid to
				  MCOs or the CSoC contractor shall be actuarially sound rates.
2. The MCOs or the CSoC contractor will
				  determine the rates paid to its contracted providers.
a. No payment shall be less than the minimum
				  Medicaid rate.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 3 - Children's Mental Health Services › Chapter 27 - Reimbursement › Section XXXIII-2703 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after July 1, 2012, the reimbursement
				  rates for the following behavioral health services provided to
				  children/adolescents shall be reduced by 1.44 percent of the rates in effect on
				  June 30, 2012:
1. therapeutic
				  services;
2. rehabilitation
				  services; and
3. crisis
				  intervention services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 5 - School-Based Behavioral Health Services › Chapter 41 - General Provisions › Section XXXIII-4101 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid
				  Program hereby adopts provisions to provide coverage under the Medicaid state
				  plan for school-based behavioral health services rendered to children and youth
				  with behavioral health disorders. These services shall be administered under
				  the authority of the Department of Health.
B. The school-based behavioral health
				  services rendered to children with emotional or behavioral disorders are
				  medically necessary behavioral health services provided to Medicaid recipients
				  in accordance with an individualized education plan (IEP), a section 504
				  accommodation plan pursuant to
				  34 C.F.R. §
											104.36, an individualized health care plan or
				  are otherwise medically necessary.
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 XXXIII - Behavioral Health Services › Subpart 5 - School-Based Behavioral Health Services › Chapter 41 - General Provisions › Section XXXIII-4103 - Recipient Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Individuals at least 3 years of age and under the age of 21, who meet Medicaid
				  eligibility and clinical criteria, shall qualify to receive behavioral health
				  services in a setting determined by the IEP.
B. Qualifying children and adolescents must
				  have been determined eligible for Medicaid and behavioral health services
				  covered under Part B of the Individuals with Disabilities Education Act (IDEA),
				  with a written service plan [an IEP, section 504 plan or individualized health
				  care plan (IHP)] which contains medically necessary services recommended by a
				  physician or other licensed practitioner, within the scope of his or practice
				  under state law.
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 XXXIII - Behavioral Health Services › Subpart 5 - School-Based Behavioral Health Services › Chapter 43 - Services › Section XXXIII-4301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program shall provide coverage for behavioral health services pursuant
				  to §1905(a) of the Social Security Act which are addressed in the IEP, section
				  504 plan, IHP or otherwise medically necessary, and that correct or ameliorate
				  a child's health condition.
B.
				  Services must be performed by qualified providers who provide school-based
				  behavioral health services as part of their respective area of practice (e.g.
				  psychologist providing a behavioral health evaluation and/or services).
				  Services rendered by certified school psychologists must be supervised
				  consistent with
				  R.S.
				  17:7.1.
1.
				  Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 5 - School-Based Behavioral Health Services › Chapter 43 - Services › Section XXXIII-4303 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. School-based
				  behavioral health services shall include Medicaid-covered services, including
				  treatment and other services to correct or ameliorate an identified mental
				  health or substance use diagnosis. Services are provided by or through a local
				  education agency (LEA) to children with, or suspected of having, a disability
				  and who attend public school in Louisiana.
B. The following school based behavioral
				  health services shall be reimbursed under the Medicaid Program:
1. therapeutic services, including diagnosis
				  and treatment; and
2. substance
				  use.
3. - 4. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 5 - School-Based Behavioral Health Services › Chapter 43 - Services › Section XXXIII-4305 - Service Limitations and Exclusions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid Program shall not cover
				  school based behavioral health services performed solely for educational
				  purposes (e.g. academic testing). Only services that are reflected in the IEP,
				  section 504 plan, IHP (as determined by the assessment and evaluation) or
				  otherwise medically necessary shall be covered.
B. Social needs, educational needs, or
				  habilitative services are not covered school based behavioral health
				  services.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.