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Louisiana Medicaid Eligibility Manual Eligibility Determinations Reissued July 18, 2025 Page 14 of H-1040 Replacing July 31, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

period, a review of the budget must be completed at six (6) month intervals to determine if the beneficiary remains eligible.

Certification for LTC SD MNP/Income over Facility Fee is limited to one (1) month. This is an open/closed certification. The case should again be reviewed in LTC SD MNP/Income over Facility Fee or LTC SD MNP for the subsequent month after each certification for up to 12 months from the application date. If ineligible for LTC SD MNP/Income over Facility Fee, consider eligibility in all other programs, a new application will be required the month following an ineligible month.

H-1041.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary **.

H-1041.8 Form 110-MNP

** Form 110-MNP is only required for LTC SD MNP/Income over Facility Fee certifications when there is an incurred medical expense (IME) on the effective date of the coverage. Form 110 MNP is sent to the IME provider only.