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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued February 3, 2026

Page 3 of H-3900

Revised/added text indicated by underscore

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• Copay Wrap Costs • Administrative Costs • Benefits Wrap Costs 2. The Medicaid amount is either: • The Per Month Per Member (PMPM) rate if the member is in an Managed Care Organization (MCO) or • The FFS claims cost if the member is in Fee-for-Service (FFS) (excluding waiver services) 3. The case is cost-effective when the Medicaid amount is higher than the total cost of ESI/IHI participation.

H-3905 Renewals

Renewal is the process of verifying that the beneficiary continues to meet all eligibility factors of the program. Periodical reviews are conducted to ensure cost-effectiveness to ensure continued eligibility and fiscal benefit to the Medicaid program.

Renewal packets are sent 30 Calendar days prior to the first Calendar Day of the policyholder’s Open Enrollment and process renewals prior to the end of the policyholder’s Open Enrollment.

H-3906 Changes

Participants are required to report the following changes within 10 days: • Changes in employment status or access to insurance; • Changes in premium amount or policy coverage; and • Termination of employer-sponsored insurance.

Failure to report changes may result in termination of LaHIPP participation or overpayment recovery.

A cost-effectiveness review is required when any of the following occur during the eligibility period.

• Change in employment or access to employer-sponsored coverage. • Change in premium amount, cost-sharing, or insurance plan benefits. • Change in household composition or Medicaid eligibility status. • Change in projected Medicaid expenditures that affects the cost- effectiveness calculation.