Page 9

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued June 1, 2026

Page 9 of H-900 Replacing June 08, 2021 Revised/added text indicated by underscore

Deleted text indicated by “” is eligible for participation in a new waiver program.

Documentation of Medical Certification

OAAS or OCDD regional waiver office (or their designee) issues the BHSF Form 142 (Notice of Medical Certification).

The BHSF Form 142 documents the following:

• Approval or disapproval of the level of care; • The effective date of medical certification approval; and • All approved waiver services. Federal financial participation (FFP) is available only to services specified in the approved plan of care.

Note: A change in a support coordination agency does not require a BHSF Form 142.

For CSoC-SED Waiver only

A child/youth must have a mental health diagnosis determined by a physician or licensed mental health professional and qualifying scores on the Child and Adolescent Needs and Strengths (CANS) Comprehensive Multisystem to be clinically eligible for the enrollment in the HCBS CSoC-SED waiver.

Documentation of Medical Certification

The CSoC Contractor Clinical criteria must be met to be eligible for enrollment in the HCBS CSoC-SED waiver. The CSoC contractor is responsible for adding the CSoC-SED segment information to MES.

A medical certification is needed every six (6) months for CSoC-SED.

If a new medical certification is not received for the next six (6) month period, continuous eligibility is applicable to those children under age 19 for coverage of regular Medicaid services. The child can remain in the CSoC-SED waiver case but no segment is added.