Louisiana Administrative Code

A. This document has been prepared by the Louisiana Workforce Commission, Office of Workers' Compensation (OWCA) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Louisiana Workers' Compensation Act as injure…

A. The principles summarized in this section are key to the intended implementation of all Office of Workers' Compensation medical treatment guidelines and critical to the reader's application of the guidelines in this document. 1. Application of Guidelines. The OWCA provides pro…

A. The OWCA recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers’ compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures, that should be utilized when init…

A. One diagnostic imaging or testing procedure may provide the same or distinctive information as does another procedure. Therefore, prudent choice of a single diagnostic procedure, a complement of procedures, or a sequence of procedures will optimize diagnostic accuracy; and max…

A. All treatment plans begin with shared decision making with the patient. Before initiation of any therapeutic procedure, an authorized treating healthcare provider, employer, and insurer should consider these important issues in the care of the injured worker. B. First, patient…

A. All operative interventions must be based upon positive correlation of clinical findings, clinical course, and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). It is imper…

1. The statewide direct care and care related price shall be apportioned between the per diem direct care component and the per diem care related component using percentages that result in the lowest overall rate. 2. No property tax and insurance pass-through reimbursement shall …

B. State-owned or operated nursing facilities will be paid a prospective per diem rate. The per diem payment rate for each of these facilities will be calculated annually on July 1, using the nursing facility’s allowable cost from the most recently filed Medicaid cost report tren…

F. Effective for dates of service on or after January 22, 2010, the reimbursement paid to non-state nursing facilities shall be reduced by 1.5 percent of the per diem rate on file as of January 21, 2010 ($1.95 per day). G. Effective for dates of service on or after July 1, 2010, …

A. Definitions Active Assessment—a resident MDS assessment is considered active when it has been accepted by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). The assessment will remain active until: a. a subsequent minimum data s…

A. Nursing facility providers under Title XIX are required to file annual cost reports as follows. 1. Providers of nursing facility level of care are required to report all reasonable and allowable cost on a regular nursing facility cost report. Effective for periods ending on or…

a. The direct care/care-related floor will be effective on the date of transition to the case mix reimbursement system. b. For purposes of this initial floor calculation, direct care and care-related spending will be determined by apportioning cost report period costs based on ca…

A. Effective for dates of service on or after January 1, 2004, for state fiscal year 2003-2004 only, each private nursing facility's per diem case mix adjusted rate shall be reduced by $0.67. B. In the event the department is required to implement positive adjustments in the nurs…

A. The Resource Utilization Groups-III (RUG-III) Version 5.20, 34-group, index maximizer model shall be used as the resident classification system to determine all case-mix indices, using data from the minimum data set (MDS) submitted by each facility. Standard Version 5.20, or i…

A. Non-state, government-owned or operated nursing facilities will be paid a case-mix reimbursement rate in accordance with

A. Effective for dates of service on or after September 1, 2007, Medicaid participating nursing facilities that convert a semi-private room to a Medicaid-occupied private room are eligible to receive an additional $5 per diem payment. Facilities that participate will have their f…

A. New facilities are those entities whose beds have not previously been certified to participate, or otherwise participated, in the Medicaid program. New facilities will be reimbursed in accordance with this rule using the statewide average case mix index to adjust the statewide…

A. On or after July 20, 2007, a Louisiana Medicaid participating nursing facility [buyer(s)] that purchases and closes an existing Louisiana Medicaid participating nursing facility (seller) will be eligible to receive fair rental value, property tax and property insurance incenti…

A. The department shall provide each nursing facility provider with the preliminary case-mix index report (PCIR) by approximately the fifteenth day of the second month following the beginning of a calendar quarter. The PCIR will serve as notice of the MDS assessments transmitted …

A. If the facility disagrees with the CMDR findings, a written request for an informal reconsideration must be submitted to the department within 15 business days of the facility’s receipt of the CMDR findings in the SRR letter. Otherwise, the results of the CMDR findings are con…

A. All nursing facilities are required to be protected throughout by a fire sprinkler system by January 1, 2008. Where means of egress passes through building areas outside of a nursing facility, those areas shall be separated from the nursing facility by a two-hour rated wall or…

A. Nursing facilities required to participate in an evacuation, as directed by the appropriate parish or state official, or which act as a host shelter site may be entitled to reimbursement of its documented and allowable evacuation and temporary sheltering costs. 1. The expense …

A. For each Medicaid recipient, nursing facilities shall be reimbursed for up to seven hospital leave of absence days per occurrence and 15 home leave of absence days per year. B. The reimbursement for hospital leave of absence days is 75 percent of the applicable per diem rate. …

A. A state owned or operated nursing facility that changes ownership (CHOW) in order to transition to a private nursing facility will be exempt from the case-mix direct care and care-related spending floor for a period of 12 months following the effective date of the CHOW under t…

A. Any private nursing facility that undergoes a change of ownership (CHOW) to a state-owned or operated nursing facility will be exempt from the prospective reimbursement system for public nursing facilities during the transitional period. 1. The transitional period will be effe…

A. Effective for dates of service on or after November 1, 2011, quarterly supplemental payments shall be issued to qualifying nursing facilities for services rendered during the quarter. Maximum aggregate payments to all qualifying nursing facilities shall not exceed the availabl…

Note: The provisions of this Section shall be subject to approval by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) of a State Plan amendment authorizing such payment. A. Effective for dates of service on or after July 1, 2019, …

A. A specialized care reimbursement rate shall consist of a nursing facility’s Medicaid case-mix reimbursement rate plus an add-on amount. These rates can be established by the department for a specialized care unit. B. Nursing Facility Specialized Care Unit Reimbursement 1. Effe…

A. Non-State Governmental Organization Nursing Facilities 1. Effective for dates of service on or after January 20, 2016, any nursing facility that is owned or operated by a non-state governmental organization (NSGO), and that has entered into an agreement with the department to …

A. A “638” facility’s participation in the Medicaid Program may be cancelled if it is determined that the facility is not providing care in compliance with Medicaid regulations and/or state laws. B. The Department of Health and Hospitals may, at its discretion, cancel the partici…

A. Section 4901 of the Balanced Budget Act of 1997, Public Law 105-33, established provisions under Title XXI of the Social Security Act to provide health insurance coverage to uninsured, low-income children through an expansion of existing Medicaid Programs, creation of stand-al…

A. The LaCHIP Medicaid program provides health insurance coverage to low-income, uninsured children who meet the following criteria: 1. are under the age of 19; 2. are from families with income at or below 217 percent of the federal poverty level; and 3. do not meet the state's M…

A. For the purposes of Regulation 125, the following terms are defined as follows: Commissioner—the Commissioner of Insurance of the state of Louisiana. Department—the Department of Insurance of the state of Louisiana. Fund—the self-insurance fund established pursuant to R.S. 12:…

A. The fund shall maintain excess insurance or reinsurance in the amount approved by the commissioner, based on an actuarially sound catastrophe model that limits the fund’s exposure on any one loss occurrence to 20 percent of its members distribution payable/surplus or an amount…

A. At inception and thereafter, the fund shall either: 1. Provide evidence satisfactory to the commissioner that it possesses surplus in excess of $3,000,000, or 2. Submit a current audited financial statement, audited by an independent certified public accountant, of at least tw…

A. Pursuant to R.S. 12:1862(D)(1), the fund is subject to delinquency proceedings that shall be governed by the applicable provisions of R.S. 22:731, et seq., pertaining to administrative supervisions, or the applicable provisions of R.S. 22:2001, et seq., pertaining to receivers…

A.1 After notice and opportunity for a hearing, the commissioner may issue an order requiring a person or group to cease and desist from engaging in an act or practice found to be not in compliance with R.S. 12:1851, et seq. or with any rule promulgated by the department pursuant…

A. General Statement. The legislature of Louisiana recognizes the right of people with significant physical disabilities to lead independent and productive lives and further recognizes that persons with significant disabilities require personal assistance to meet tasks of daily l…

A. House Bill Number 1198, Act 939 of the 2010 Regular Session, LAC Title 48, Chapter 201, Revised Statute 46:2116.2.

A. The following terms, when used in this manual, shall have the meaning, unless the context clearly indicates otherwise. Self-Directed—the participant or legal/personal representative will direct, supervise, hire and discharge his/her personal attendant and be able to self-direc…

A. Cost-Effective Service Provision. All services shall be provided in a cost-effective manner. B. This program shall be considered as a source of last resort for personal assistance services after private and governmental sources have been expended. C. Case File Documentation. A…

A. Any individual whose request is denied for goods/services, denied eligibility or discharged from the program may appeal said decision in accordance with the provisions of R.S. 46:107. Such appeal shall be conducted in accordance with the Administrative Procedure Act and shall …

A. An individual can be determined eligible for services as set forth in R.S. 46:2116.2 if that individual meets all of the following criteria: 1. is an individual with significant disabilities; 2. is age 18 or older; 3. needs goods and/or personal assistance services from this p…

A. In determining an individual's financial need for services, the management contractor will use a system based upon the current federal poverty guidelines. The economic need status of each participant for the SPAS Program shall be considered in the initial determination of elig…

A. Following a determination of eligibility for services, an appropriate individualized assessment will be completed to determine the scope of services. After a case-by-case assessment of needs, a service plan will be developed, implemented, and updated as appropriate. The servic…

A. Prior Authorization. A participant shall obtain prior authorization from contract manager for goods and/or services before they can begin. Failure to obtain prior authorization will result in a denial of goods or services. If an emergency situation exists where goods or servic…

A. The management contractor shall keep a waiting list of individuals wanting to apply for the SPAS Program. B. The management contractor shall take a pre-application on participants who will be placed on the waiting list for services and shall use criteria developed by OAAS. C. …

A. The following may result in termination of services and/or closure: 1. the participant no longer meets eligibility criteria; 2. the participant intentionally falsified information; 3. the participant has shown consistent failure to cooperate with the service plan and managemen…

A. Regulation 131 is issued pursuant to the authority vested in the commissioner pursuant to the provisions of Act 2024, No. 9 of the Regular Session of the Louisiana Legislature and in accordance with the Administrative Procedure Act, R.S. 49:950 et seq. R.S. 22:11, and 22:1265(…

A. The purpose of Regulation 131 is to implement the provisions of Act 2024, No. 9 of the Regular Session of the Louisiana Legislature, which allows an insurer to notify the commissioner of its plan to nonrenew or cancel up to five percent of its insureds’ homeowners policies in …