Page 5

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued August 29, 2022

Page 5 of I-1000 Replacing January 21, 2022

Deleted text indicated by “” Revised/added text indicated by underscore

I-1020.4 PACE

The medical certification approval or disapproval for enrollment is documented on the BHSF Form 142. Once enrolled, the medical certification remains valid unless the participant is disenrolled from the PACE program.

I-1020.5 ACT 421 Children’s Medicaid Option (TEFRA)

The medical certification for enrollment is documented on the BHSF Form 142, which will indicate the approval or disapproval of the level of care and the effective date of medical certification. After eligibility is established, OCDD LGE assesses the Act 421-CMO beneficiary annually to determine that the level of care requirement continues to be met. **

I-1030 DOCUMENTATION

A copy of the Medical Certification Form 142 is filed in the Enterprise Document Management System (EDMS).