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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 3 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” If the Form 142 expires before admission to the nursing home, a new Form 142 is required. Medicaid vendor payment shall not begin prior to the date that medical and financial eligibility is established, and shall only begin once the individual is actually admitted to the facility.

An approved Form 142 is required each time there is a change in LOC or when there is a change in ICF/IID facility.

The Form 142 is issued by the OAAS, OCDD or its designee.

The Form 142 documents the:

● Approval or disapproval of the level of care;

● Effective date of the level of care approval; and

● Expiration date, if applicable.

NOTE: For nursing facility residents needing services beyond the expiration date on the Form 142, the nursing facility must submit a continued stay request to the OAAS NFA Unit in accordance with the timelines set by OAAS. H-810.3 Patient Liability

After determining the applicant/beneficiary is financially eligible for payment of nursing home or ICF/IID services, the applicant/beneficiary becomes subject to the post-eligibility treatment of income (PETI) calculation rules.

Patient liability (PLI) is a post-eligibility calculation used to determine the amount the applicant/beneficiary must pay the LTC facility towards their monthly cost of care. It is based on the amount of monthly income remaining after allowable deductions. Refer I-1536 Deductions and to I-1538 Patient Liability-Post Eligibility Treatment of Income (PETI).

H-810.4 Optional State Supplement The Optional State Supplement (OSS) is a state funded payment**, which is made to certain LTC beneficiaries to help meet their personal care needs. Refer to J-300 Optional State Supplement (OSS) Payments and MEM Table Z-700.