us-la/regulation/lac/50

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us-la/regulation/lac/50 — Axiom

(iii)(501)501 Filing Application#

A. The bureau requires an applicant to complete and sign a written application in order to initiate the eligibility determination process for Medicaid benefits. The applicant’s signature on the application affirms that all of the information contained on the form is true and correct or the applicant could be subject to a penalty for perjury. In order to facilitate the application process, the Bureau authorizes the electronic filing of Medicaid applications. Applications may be signed by the following means:

1. the applicant’s signature on a paper application;

2. a personal identification number (PIN); or a digital signature as issued by DHH (in the Louisiana Medicaid Manual).

B. The application may be filed by the applicant or one of the following individuals:

1. a parent;

2. the legal guardian, which is a person legally responsible for the care and management of the person or property of one considered by law to be incompetent to manage his own affairs;

3. a curator, which is any person acting under legal authority for an applicant/recipient who is determined by a court of law to be incompetent to take care of his own person or to administer his estate (an interdict); or

4. someone acting responsibly for the applicant.

C. Assistance with Application

1. The applicant may choose an individual to accompany, assist, and/or represent him/her in the application or renewal process.

2. The bureau must provide assistance if the applicant is unable to participate and has no responsible representation in the application process.

D. Grounds for Accepting/Rejecting Application. The applicant must cooperate in the process of determining eligibility by completing an application form and providing required information. The application may be rejected for non-cooperation only if the applicant, curator, parent or legal guardian is physically and mentally able to make application and provide information and either:

1. does not provide information after being notified; or

2. after being advised of the consequences, has failed to cooperate.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:1483 (July 2004).

(iii)(941)941 Incurred Medical and Remedial Care Expenses#

A. In accordance with 42 CFR Part 435 Subparts H and I, certain medical and remedial care expenses incurred by institutionalized individuals and individuals receiving home and community-based services furnished under a waiver, subject to the reasonable limits specified herein, are deducted from the individual’s income in the calculation of patient liability.

B. Reasonable limits imposed are:

1. For medically necessary care, services, and items not paid under the Medicaid State Plan or, if covered under the Medicaid State Plan, denied due to service limitations.

a. The medical or remedial care must be:

i. recognized under state law;

ii. medically necessary as verified by an independent licensed physician or medical director; and

iii. incurred no earlier than three months preceding the month in which it is reported to the state; and

b. The medical or remedial care cannot be:

i. for cosmetic or elective purposes, except when medically necessary as verified by an independent licensed physician or medical director; and/or

ii. for payment of a medical or dental service plan that has not been approved by the Department of Insurance in accordance with the Louisiana Insurance Code, Title 22 of the Louisiana Revised Statutes.

2. The deduction for medical and remedial care expenses that were incurred as a result of imposition of transfer of assets penalty period is limited to $0.

3. The deduction for medical and remedial care expenses that were incurred as a result of the individual’s equity interest in the home exceeding the limit established under 42 U.S.C. §1396p(f) is limited to $0.

4. The deduction for medical or remedial care expenses that were incurred during a period when the individual is not subject to patient liability is limited to $0.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 50:216 (February 2024).

(iii)(1107)1107 Disclosure of Eligibility Data#

A. Notwithstanding any other provisions of law, Express Lane agencies in possession of data directly relevant to Express Lane eligibility determinations shall convey such data to the department and shall ensure that the individual (or his parent, guardian, caretaker relative, authorized representative) whose circumstances are described in the data has either provided consent to disclosure, or has not objected to disclosure.

1. Such individuals shall be provided with advance notice of disclosure and a reasonable opportunity to object to the disclosure of their information.

B. Express Lane agency sources of data shall include, but is not limited to, the following:

1. eligibility files;

2. unemployment compensation benefits;

3. wages and income information;

4. Social Security Administration and Internal Revenue Service information;

5. employer wage reports to a state agency;

6. vital records information about births in any state; or

7. third party health insurance information.

C. Improper Disclosure Penalties

1. Civil Monetary Penalty. A private entity that publishes, discloses, or makes known in any manner or to any extent not authorized by the department any information obtained for the purposes of Express Lane eligibility may be subject to civil monetary penalties for each unauthorized publication or disclosure, pursuant to §1942 of Title XIX of the Social Security Act.

2. Criminal Penalty. A private entity that willfully publishes, discloses, or makes known in any manner or to any extent not authorized by the department any information under this section shall be fined not more than $10,000 or imprisoned not more than 1 year, or both, for each unauthorized publication or disclosure.

3. The limitations and requirements that apply to Express Lane eligibility data disclosure shall not be construed to prohibit the conveyance or disclosure of data or information otherwise permitted under federal law.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 36:1556 (July 2010).

(iii)(2303)2303 Family Opportunity Act Medicaid Program#

A. The Family Opportunity Act, signed into law by Congress as part of the Deficit Reduction Act of 2005, allows states to offer a Medicaid buy-in program to families with income up to 300 percent of the federal poverty level (FPL) for children with disabilities who are not eligible for Supplemental Security income (SSI) disability benefits due to excess income or resources. The department hereby implements a Medicaid buy-in program called the Family Opportunity Act Medicaid Program to provide Medicaid coverage to children with disabilities.

B. Eligibility Requirements. Children born on or after October 1, 1989, up to age 19, and who meet the following requirements may receive health care coverage through the Family Opportunity Act Medicaid Program.

1. The child must have a disability which meets the Social Security administration’s childhood disability criteria.

2. Gross family income must not be more than 300 percent of the federal poverty level using the income methodologies of the SSI program.

a. For the purpose of determining family income, the family unit shall consist of the following members:

i. child(ren) with disabilities;

ii. natural or legal parent(s); and

iii. siblings under age 19.

b. Step-parents and step-siblings are excluded from the income determination.

3. The child may be uninsured or underinsured.

a. Parents are required to enroll in available employer-sponsored health plans when the employer contributes at least 50 percent of the annual premium costs. Participation in such employer-sponsored health plans is a condition of Medicaid coverage pursuant to the Family Opportunity Act Medicaid Program.

C. Children determined eligible under the Family Opportunity Act Medicaid Program shall receive coverage of medically necessary health care services provided under the Medicaid state plan.

D. Premium Payments. Families with gross income above 200 percent, but not more than 300 percent of the FPL, are required to pay premiums for Medicaid coverage. Families with gross income up to 200 percent of the FPL are not required to pay premiums for Medicaid coverage.

1. The amounts paid for premiums for Medicaid-required family coverage and other cost-sharing may not exceed 5 percent of a family’s income for families with income up to 200 percent of the FPL and 7.5 percent of a family’s income for families with income above 200 percent of the FPL.

2. For families with gross income above 200 percent, but not more than 300 percent of the FPL, the premium amount for Medicaid is determined by whether the natural or legal parent(s) living in the household is paying for other creditable health insurance that covers the child(ren) with disabilities.

a. Families who have other creditable health insurance that provides coverage to the child(ren) with disabilities will pay a family Medicaid premium on a sliding scale as follows:

i. $12 per month for families with income above 200 percent and up to 250 percent of the FPL;

ii. $15 per month for families with income above 250 percent, but not more than 300 percent of the FPL.

b. Families who do not have other creditable health insurance that provides coverage to the child(ren) with disabilities will pay a family Medicaid premium on a sliding scale as follows:

i. no premium is required for families with income from 0 percent and up to 200 percent of the FPL;

ii. $30 per month for families with income above 200 percent and up to 250 percent of the FPL;

iii. $35 per month for families with income above 250 percent, but not more than 300 percent of the FPL.

3. The first premium is due the month following the month that eligibility is established. Prepayment of premiums is not required. A child’s eligibility for medical assistance will not terminate on the basis of failure to pay a premium during the 12-month continuous eligibility period. A child’s eligibility for medical assistance will terminate at the end of the 12-month continuous eligibility period if a failure to pay has continued for at least 60 days from the date on which the premium was past due.

4. The premium may be waived in any case where it is determined that requiring a payment would create an undue hardship for the family. Undue hardships exist when a family:

a. is homeless or displaced due to a flood, fire, or natural disaster;

b. resides in an area where there is a presidential-declared emergency in effect;

c. presents a current notice of eviction or foreclosure; or

d. has other reasons as determined by the department.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:1628 (August 2008), amended LR 35:69 (January 2009), amended by the Department of Health, Bureau of Health Services Financing, LR 51:1857 (November 2025).

(iii)(2308)2308 Former Foster Care Children Group#

A. Pursuant to the Patient Protection and Affordable Care Act of 2010 (collectively referred to as the Affordable Care Act), the Department of Health implemented a Medicaid eligibility group, effective December 31, 2013, to provide health care coverage to youth who are transitioning out of foster care to self-sufficiency upon reaching age 18 or at a higher age selected by the department. This eligibility group is called former foster care children group.

B. Eligibility Requirements

1. For youth who turned age 18 prior to January 1, 2023, the youth must meet all of the following requirements to receive Medicaid health care coverage under this eligibility group:

a. be from age 18 to 26 years old;

b. is not eligible or enrolled in another mandatory eligibility group described in sections 1902(a)(10)(A)(i)(I)-(VII) of the Social Security Act;

c. was in foster care under Louisiana’s custody and receiving Medicaid upon turning age 18 or upon aging out of foster care at a higher age elected by the state in its title IV-E plan (up to age 21); and

d. resides in Louisiana.

2. For youth who turned age 18 on or after January 1, 2023, the youth must meet all of the following requirements to receive Medicaid health care coverage under this eligibility group:

a. be from age 18 to 26 years old;

b. is not enrolled in another mandatory eligibility group described in sections 1902(a)(10)(A)(i)(I)-(VII) of the Social Security Act;

c. was in foster care under the responsibility of any state and receiving Medicaid upon turning age 18 or such higher age (up to 21) as the state has elected in its title IV-E plan; and

d. resides in Louisiana.

C. Income, resources and insurance status are not considered when determining eligibility.

D. Individuals determined eligible in this group shall receive coverage of medically necessary health care services provided under the Medicaid state plan.

1. The assistance unit shall consist of the youth only.

E. Eligibility for the program will continue until the youth reaches age 26 unless the youth:

1. moves out of state;

2. requests closure of the case; or

3. dies.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 40:2260 (November 2014), amended by the Department of Health, Bureau of Health Services Financing, LR 43:1389 (July 2017), LR 49:1728 (October 2023).

(iii)(2311)2311 Louisiana Health Insurance Premium Payment Program#

A. Section 1906 of Title XIX of the Social Security Act mandates that Medicaid recipients enroll, and maintain their enrollment, in cost-effective group health insurance plans as a condition of Medicaid eligibility if such a plan is available. In compliance with section 1906, the department hereby establishes the Louisiana Health Insurance Premium Payment (LaHIPP) Program to provide Medicaid payment of the costs associated with the enrollment of recipients in cost-effective group health insurance plans.

B. Medicaid recipients shall be enrolled in LaHIPP when cost-effective health plans are available through the recipient's employer or a responsible party's employer-based health plan if the recipient is enrolled or eligible for such a health plan.

1. The enrollment period for the LaHIPP Program shall be no less than six months.

C. When coverage for eligible family members is not possible unless ineligible family members are enrolled, the Medicaid Program will pay the premiums for the enrollment of other family members when it is cost-effective.

D. The recipient, or the individual acting on behalf of the recipient, shall cooperate to establish the availability and cost effectiveness of group health insurance.

1. Medicaid benefits of the parent may be terminated for failure to cooperate unless good cause for non-cooperation is established. Medicaid benefits for a child shall not be terminated due to the parent’s or authorized representative’s failure to cooperate.

E. Continued eligibility for this program is dependent upon the individual's ongoing eligibility for Medicaid.

F. LaHIPP recipients shall be entitled to coverage of the patient responsibility amounts for services covered under the group health insurance to the extent allowed under the Medicaid State Plan and for all services that are not covered by the group health insurance but are provided for under the Medicaid State Plan and rendered by Medicaid providers.

G. The department shall be entitled to any rate refund made when the health insurance carrier determines a return of premiums to the policy holder is due because of lower than anticipated claims for any period of time in which the department paid the premiums.

H. The Medicaid Program will make the determination whether the group health insurance plan(s) available to the recipient is cost effective.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 43:664 (April 2017).

(iii)(2313)2313 Medically Needy Program#

A. The Medically Needy Program (MNP) provides Medicaid coverage when an individual's or family's income and/or resources are sufficient to meet basic needs in a categorical assistance program, but not sufficient to meet medical needs according to the MNP standards.

1. The income standard used in the MNP is the federal medically needy income eligibility standard (MNIES).

2. Resources are not applicable to modified adjusted gross income (MAGI) related MNP cases.

3. MNP eligibility cannot be considered prior to establishing income ineligibility in a categorically related assistance group.

B. MNP Eligibility Groups

1. Regular Medically Needy

a. Prior to the implementation of the MAGI income standards, parents who met all of the parent and caretaker relative (PCR) group categorical requirements and whose income was at or below the MNIES were eligible to receive Regular MNP benefits. With the implementation of the MAGI-based methodology for determining income and household composition and the conversion of net income standards to MAGI equivalent income standards, individuals who would have been eligible for the Regular Medically Needy Program are now eligible to receive Medicaid benefits under the parent and caretaker relative eligibility group. Regular medically needy coverage is only applicable to individuals included in the MAGI-related category of assistance.

b. Individuals in the non-MAGI [formerly aged (A-), blind (B-), or disability (D-)] related assistance groups cannot receive Regular MNP.

c. The certification period for Regular MNP cannot exceed six months.

2. Spend-Down Medically Needy

a. Spend-Down MNP is considered after establishing financial ineligibility in categorically related Medicaid programs and excess income remains. Allowable medical bills/expenses incurred by the income unit, including skilled nursing facility coinsurance expenses, are used to reduce (spend-down) the income to the allowable MNP limits.

b. The following individuals may be considered for Spend-Down MNP:

i. individuals who meet all of the parent and caretaker relative group requirements;

ii. non-institutionalized individuals (non-MAGI related); and

iii. institutionalized individuals or couples (non-MAGI related) with Medicare co-insurance whose income has been spent down.

c. The certification period for spend-down MNP begins no earlier than the spend-down date and shall not exceed three months.

3. Long Term Care (LTC) Spend-Down MNP

a. Individuals residing in Medicaid LTC facilities, not on Medicare-coinsurance with resources within the limits, but whose income exceeds the special income limits (three times the current federal benefit rate), are eligible for LTC Spend-Down MNP.

C. The following services are covered in the Medically Needy Program:

1. inpatient and outpatient hospital services;

2. intermediate care facilities for persons with intellectual disabilities (ICF/ID) services;

3. intermediate care and skilled nursing facility (ICF and SNF) services;

4. physician services, including medical/surgical services by a dentist;

5. nurse midwife services;

6. certified registered nurse anesthetist (CRNA) and anesthesiologist services;

7. laboratory and x-ray services;

8. prescription drugs;

9. early and periodic screening, diagnosis and treatment (EPSDT) services;

10. rural health clinic services;

11. hemodialysis clinic services;

12. ambulatory surgical center services;

13. prenatal clinic services;

14. federally qualified health center services;

15. family planning services;

16. durable medical equipment;

17. rehabilitation services (physical therapy, occupational therapy, speech therapy);

18. nurse practitioner services;

19. medical transportation services (emergency and non-emergency);

20. home health services for individuals needing skilled nursing services;

21. chiropractic services;

22. optometry services;

23. podiatry services;

24. radiation therapy; and

25. behavioral health services.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 42:1888 (November 2016).

(iii)(2315)2315 LaMOMS Program#

A. Pursuant to the provisions of the Omnibus Budget Reconciliation Act of 1986, the Department of Health, Bureau of Health Services Financing shall provide health care coverage through the LaMOMS Program to Medicaid eligible pregnant women with low income under the Medicaid state plan.

B. Eligibility Requirements. Eligibility for LaMOMS coverage may begin at any time during a pregnancy, and as early as three months prior to the month of application. Eligibility cannot begin before the first month of pregnancy. The pregnant woman must be pregnant for each month of eligibility, except for the 12-month postpartum period.

C. Financial Eligibility. Effective January 1, 2014, the LaMOMS Program shall provide Medicaid coverage to pregnant women with family income up to 133 percent of the federal poverty level. For applicants with income above 133 percent of the federal poverty level, 5 percent of the federal poverty level shall be disregarded from their income.

1. Changes in income shall be disregarded during the period of pregnancy and for the 12-month postpartum period.

D. The LaMOMS program shall provide Medicaid coverage for:

1. prenatal care;

2. delivery;

3. conditions which may complicate the pregnancy; and

4. postpartum care during the 12-month postpartum period.

E. Certification Period

1. Eligibility for the pregnant women group may begin:

a. at any time during a pregnancy; and

b. as early as three months prior to the month of application.

2. Eligibility cannot begin before the first month of pregnancy. The pregnant women group certification may extend through the calendar month in which the 12-month postpartum period ends.

3. An applicant/enrollee whose pregnancy terminated in the month of application or in one of the three months prior without a surviving child shall be considered a pregnant woman for the purpose of determining eligibility in the pregnant women group.

4. Certification shall be from the earliest possible month of eligibility (up to three months prior to application) through the month in which the 12-month postpartum period ends.

5. Retroactive eligibility shall be explored regardless of current eligibility status.

a. If the applicant/enrollee is eligible for any of the three prior months, she remains eligible throughout the pregnancy and 12-month postpartum period. When determining retroactive eligibility, actual income received in the month of determination shall be used.

b. If application is made after the month her pregnancy ends, the period of eligibility will be retroactive but shall not start more than three months prior to the month of application. The start date of retroactive eligibility is determined by counting back three months prior to the date of application. The start date will be the first day of that month.

6. Coverage during the 12-month postpartum period is only available to an individual who is eligible for medical assistance under the state plan while pregnant, including during a period of retroactive eligibility.

7. Eligibility may not extend past the month in which the 12-month postpartum period ends.

a. The 12-month postpartum period begins on the last day of pregnancy.

b. The 12-month postpartum period ends the last day of the month in which the 12-month postpartum period has expired.

8. The applicant/enrollee must be income eligible during the initial month of eligibility only. Changes in income after the initial month will not affect eligibility.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 39:3299 (December 2013), amended by the Department of Health, Bureau of Health Services Financing, LR 48:499 (March 2022).

(iii)(2327)2327 Modified Adjusted Gross Income (MAGI) Groups#

A. For eligibility determinations effective December 31, 2013 eligibility shall be determined by modified adjusted gross income (MAGI) methodology in accordance with section 1004(a)(2) of the Patient Protection and Affordable Care Act (ACA) of 2010 and section 36B(d)(2)(B) of the Internal Revenue Code, for the following groups:

1. parents and caretaker relatives group which includes adult individuals formerly considered for low income families with children as parents or caretaker relatives;

2. pregnant women;

3. child related groups; and

4. other adult related groups including breast and cervical cancer, tuberculosis (TB) and family planning.

B. A MAGI determination will be necessary for each individual in the home for whom coverage is being requested. The MAGI household resembles the tax household.

1. MAGI Household. The individual’s relationship to the tax filer and every other household member must be established for budgeting purposes. The MAGI household is constructed based on whether an individual is a:

a. tax filer;

b. tax dependent; or

c. non-filer (neither tax filer or tax dependent.

2. For the tax filer the MAGI household includes the tax filer and all claimed tax dependents.

a. Whether claimed or not, the tax filer’s spouse, who lives in the home, must be included.

b. If a child files taxes and is counted as a tax dependent on his/her parent’s tax return, the child is classified as a tax dependent not a tax filer.

3. When taxes are filed for the tax dependent the MAGI household consists of the tax filer and all other tax dependents unless one of the following exceptions is met:

a. being claimed as a tax dependent by a tax filer other than a parent or spouse (for example, a grandchild, niece, or tax filer’s parent);

b. children living with two parents who do not expect to file a joint tax return (including step-parents); or

c. children claimed as a tax dependent by a non-custodial parent.

4. For individuals who do not file taxes nor expect to be claimed as a tax dependent (non-filer), the MAGI household consists of the following when they all live together:

a. for an adult:

i. the individual’s spouse; and

ii. the individual’s natural, adopted, and step-children under age 19; and

b. for a minor:

i. the individual’s natural, adoptive, or step-parents; and

ii. the individual’s natural, adopted, and step-siblings under age 19.

C. Parents and Caretaker Relatives Group

1. A caretaker relative is a relative of a dependent child by blood, adoption, or marriage with whom the child is living, and who assumes primary responsibility for the child’s care. A caretaker relative must be one of the following:

a. parent;

b. grandparent;

c. sibling;

d. brother-in-law;

e. sister-in-law;

f. step-parent;

g. step-sibling;

h. aunt;

i. uncle;

j. first cousin;

k. niece; or

l. nephew.

2. The spouse of such parents or caretaker relatives may be considered a caretaker relative even after the marriage is terminated by death or divorce.

3. The assistance/benefit unit consists of the parent and/or caretaker relative and the spouse of the parent and/or caretaker relative, if living together, of child(ren) under age 18, or age 18 and a full-time student in high school or vocational/technical training. Children are considered deprived if income eligibility is met for the parents and caretaker relatives group. Children shall be certified in the appropriate children’s category.

D. Pregnant Women Group

1. Eligibility for the pregnant women group may begin:

a. at any time during a pregnancy; and

b. as early as three months prior to the month of application.

2. Eligibility cannot begin before the first month of pregnancy. The pregnant women group certification may extend through the calendar month in which the 12-month postpartum period ends.

4. Certification shall be from the earliest possible month of eligibility (up to three months prior to application) through the month in which the 12-month postpartum period ends.

5. Retroactive eligibility shall be explored regardless of current eligibility status.

a. If the applicant/enrollee is eligible for any of the three prior months, she remains eligible throughout the pregnancy and 12-month postpartum period. When determining retroactive eligibility actual income received in the month of determination shall be used.

7. Eligibility may not extend past the month in which the 12-month postpartum period ends.

a. The 12-month postpartum period begins on the last day of pregnancy.

b. The 12-month postpartum period ends the last day of the month in which the 12-month postpartum period has expired.

8. The applicant/enrollee must be income eligible during the initial month of eligibility only. Changes in income after the initial month will not affect eligibility.

E. Child Related Groups

1. Children Under Age 19CHAMP. CHAMP children are under age 19 and meet income and non-financial eligibility criteria. ACA expands mandatory coverage to all children under age 19 with household income at or below 133 percent federal poverty level (FPL). Such children are considered CHAMP children.

2. Children Under Age 19LaCHIP. A child covered under the Louisiana State Children's Health Insurance Program (LaCHIP) shall:

a. be under age 19;

b. not be eligible for Medicaid under any other optional or mandatory eligibility group or eligible as medically needy (without spend-down liability);

c. not be eligible for Medicaid under the policies in the state's Medicaid plan in effect on April 15, 1997;

d. not have health insurance; and

e. have MAGI-based income at or below 212 percent (217 percent FPL with 5 percent disregard) of the federal poverty level.

3. Children Under Age 19–LaCHIP Affordable Plan. A child covered under the Louisiana State Children's Health Insurance Program (LaCHIP) Affordable Plan shall:

a. be under age 19;

b. not be income eligible for regular LaCHIP;

c. have MAGI-based income that does not exceed 250 percent FPL;

d. not have other insurance or access to the State Employees Health Plan;

e. have been determined eligible for child health assistance under the State Child Health Insurance Plan; and

f. be a child whose custodial parent has not voluntarily dropped the child(ren) from employer sponsored insurance within the last three months without good cause. Good cause exceptions to the three month period for dropping employer sponsored insurance are:

i. the premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income;

ii. the child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a qualified health plan (QHP) through the marketplace because the employer-sponsored insurance (ESI) in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B–2(c)(3)(v);

iii. the cost of family coverage that includes the child exceeded 9.5 percent of the household income;

iv. the employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan;

v. a change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under the Consolidated Omnibus Reconciliation Act of 1985 (COBRA));

vi. the child has special health care needs;

vii. the child lost coverage due to the death or divorce of a parent;

viii. involuntary termination of health benefits due to a long-term disability or other medical condition;

ix. the child has exhausted coverage under the COBRA continuation provision (i.e., COBRA expired); or

x. lifetime maximum has been reached.

4. Children Under Age 19-Phase IV LaCHIP (SCHIP). The State Child Health Insurance Program (SCHIP) provides prenatal care services, from conception to birth, for low income uninsured mothers who are not otherwise eligible for other Medicaid programs, including CHAMP pregnant women benefits. This program, phase IV LaCHIP, also covers non-citizen women who are not qualified for other Medicaid programs due to citizenship status only.

F. Regular and Spend Down Medically Needy MAGI. Regular and spend down medically needy shall use the MAGI determination methodology.

G. Former Foster Care Children. Former foster care children are applicants/enrollees under 26 years of age, who were in foster care under the responsibility of the state at the time of their eighteenth birthday, and are not eligible or enrolled in another mandatory coverage category.

1. Former foster care children may also be applicants/enrollees who:

a. have lost eligibility due to moving out of state, but re-established Louisiana residency prior to reaching age 26.

2. Former foster care children must:

a. be at least age 18, but under age 26;

b. currently live in Louisiana;

c. have been a child in foster care in any state’s custody upon reaching age 18; and

d. not be eligible for coverage in another mandatory group.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:945 (May 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 48:499 (March 2022).

(iii)(2331)2331 Act 421 Children’s Medicaid Option (Act 421-CMO/TEFRA)#

A. Pursuant to section 1902(e)(3) of the Social Security Act the state may extend Medicaid eligibility to certain children living in the community, who require the level of care provided in an institution, and who would be eligible for Medicaid if living in an institution.

B. Effective January 1, 2022, the department implemented the Act 421 Children’s Medicaid Option (Act 421-CMO) program to provide Medicaid State Plan services to children with disabilities who, despite parental or household income and resources, meet the eligibility criteria set forth in this Section.

C. Eligibility Criteria. In order to qualify for the 421-CMO program, an applicant/Act 421-CMO beneficiary must meet all of the following criteria:

1. is 18 years of age or younger (under 19 years of age);

2. is a U.S. citizen or qualified non-citizen;

3. is a Louisiana resident;

4. has countable resources that are equal to or less than the resource limits for the Supplemental Security Income (SSI) program;

5. has countable income equal to or less than the special income level for long-term care services (nursing facility, ICF/IID, and home and community-based services);

6. qualifies as a disabled individual under section 1614(a) of the Social Security Act;

7. must meet a level of care, assessed on an annual basis, provided in an intermediate care facility for individuals with intellectual disabilities (ICF/IID), a nursing facility, or a hospital; and

8. care needs are being safely met at home at a lower cost than the cost of services provided in an institutional setting.

D. Act 421 Children’s Medicaid Option (Act 421-CMO/TEFRA) Levels of Care

1. The individual meets Act 421-CMO ICF/IID level of care when demonstrating both of the following:

a. has obtained a statement of approval from the Office for Citizens with Developmental Disabilities, or its designee, or EarlySteps eligibility (depending on age) confirming that he/she has a developmental disability as defined in R.S. 28:451.2; and

b. meets the requirements for active treatment of a developmental disability under the supervision of a qualified developmental disability professional, as prescribed on the Request for Medical Eligibility Determination, Form 90-L.

2. The individual meets Act 421-CMO nursing facility level of care when demonstrating both of the following, assessed in accordance with the Act 421 Children’s Medicaid Option assessment tool:

a. has a diagnosis of a medical/physical condition resulting in needs requiring long term care services of at least six months; and

b. requires skilled nursing interventions and/or has substantial functional limitations (SFLs) requiring hands-on assistance from others throughout the day.

3. The individual meets hospital level of care when demonstrating all of the following, assessed in accordance with the Act 421 Children’s Medicaid Option assessment tool:

a. the need for frequent medical care that requires the use of equipment to prevent life-threatening situations, with skilled medical care required more than once during each 24-hour period;

b. the need for skilled medical interventions that are expected to persist for at least six months; and

c. an overall health condition that is unstable, presenting the constant potential for complications or rapid deterioration, such that he/she requires monitoring by professional nurses, parents, or other properly instructed individuals, in order to detect unstable and life-threatening conditions and respond promptly with appropriate care.

E. Cost Effectiveness

1. On an annual basis, each 421-CMO beneficiary’s expenditures will be measured against the average cost of care in an institution that corresponds to his/her level of care (i.e. hospital, ICF/IID, nursing facility) to ensure that home and community-based care is more cost effective than institutional care.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, 46:977.21-977.25, and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 47:1872 (December 2021), amended by the Department of Health, Bureau of Health Services Financing and the Office for Citizens with Developmental Disabilities, LR 49:1222 (July 2023).

(iii)(2523)2523 Citizenship#

A. Citizenship or Satisfactory Immigration Status

1. The department hereby adopts criteria for the coverage of qualified non-citizens pursuant to the provisions of §401 of the Personal and Work Opportunity Act of 1996 (P.L. 104-193) as amended by the Balanced Budget Act of 1997 (P.L. 105-33). For purposes of this Part, the term qualified noncitizens shall have the same meaning as the term qualified alien as set forth in 8 USC § 1641(b).

2. Effective October 1, 2026, Sections 1903 (v)(5) and 2107(e)(1)(R) of the Social Security Act, as amended by Section 71109 of the Budget Reconciliation Act of 2025 (P.L. 119-21), limits federal financial participation (FFP) for full-benefit Medicaid coverage. Medicaid eligibility is limited to individuals who meet all other eligibility requirements and who are among the classes eligible for FFP pursuant to 42 USC §1396b(v)(5).

3. The department provides Medicaid coverage to qualified non-citizens who were present in the United States before August 22, 1996, if federal law authorizes FFP and the individual meets all eligibility criteria.

4. Qualified non-citizens entering the United States on or after August 22, 1996, are not eligible for Medicaid coverage until five years after entry into the United States.

a. Such qualified non-citizens are eligible for emergency services only.

b. Upon expiration of the five-year period, coverage for regular Medicaid services shall be considered if federal law authorizes FFP and the qualified non-citizen meets all eligibility criteria of a Medicaid eligibility group.

5. This Section does not restrict coverage for emergency medical services, lawfully residing children, pregnant women under the CHIRPA 214 option, or any other coverage category for which federal law authorizes FFP.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 45:44 (January 2019), amended LR 52:1348 (August 2026).

(iii)(2529)2529 Hospital Presumptive Eligibility#

A. Effective December 31, 2013 any hospital designated by Louisiana Medicaid as a hospital presumptive eligibility qualified provider (HPEQP) may obtain information and determine hospital presumptive eligibility (HPE) for individuals who are not currently enrolled in Medicaid and who are in need of medical services covered under the state plan.

1. Coverage groups eligible to be considered for hospital presumptive eligibility include:

a. parents and caretaker relatives;

b. pregnant women;

c. children under age 19;

d. former foster care children;

e. family planning; and

f. certain individuals needing treatment for breast or cervical cancer.

B. Qualified Hospitals. Qualified hospitals shall be designated by the department as entities qualified to make presumptive Medicaid eligibility determinations based on preliminary, self-attested information obtained from individuals seeking medical assistance.

1. A qualified hospital shall:

a. be enrolled as a Louisiana Medicaid provider under the Medicaid state plan or a Medicaid 1115 demonstration;

b. not be suspended or excluded from participating in the Medicaid Program;

c. have submitted a statement of interest in making presumptive eligibility determinations to the department; and

d. agree to make presumptive eligibility determinations consistent with the state policies and procedures.

C. The qualified hospital shall educate the individuals on the need to complete an application for full Medicaid and shall assist individuals with:

1. completing and submitting the full Medicaid application; and

2. understanding any document requirements as part of the full Medicaid application process.

D. Eligibility Determinations

1. Household composition and countable income for HPE coverage groups are based on modified adjusted gross income (MAGI) methodology.

2. The presumptive eligibility period shall begin on the date the presumptive eligibility determination is made by the qualified provider.

3. The end of the presumptive eligibility period is the earlier of:

a. the date the eligibility determination for regular Medicaid is made, if an application for regular Medicaid is filed by the last day of the month following the month in which the determination for presumptive eligibility is made; or

b. the last day of the month following the month in which the determination of presumptive eligibility is made, if no application for regular Medicaid is filed by that date.

4. Those determined eligible for presumptive eligibility shall be limited to no more than one period of eligibility in a 12-month period, starting with the effective date of the initial presumptive eligibility period.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:946 (May 2015).

(iii)(10305)10305 Income Disregards#

A. For recipients in the Family Opportunity Act Medicaid Program, an income disregard of $85 will be applied to total gross (earned and unearned) family income and then half of the remaining income will be disregarded.

B. During the eligibility determination process for home and community-based services, an individual shall be considered eligible under the Medicaid State Plan as though the individual was a resident in a nursing facility or intermediate care facility for persons with developmental disabilities (ICF/DD) and an income disregard shall be applied to gross income over the special income level.

1. The special income level used to determine financial eligibility for long-term care services (nursing facility, ICF/DD, and home and community-based services) is three times the Supplemental Security Income federal benefit rate.

2. Gross income may exceed the special income level but cannot be more than the highest Medicaid facility rate (nursing or ICF/DD, as applicable) in the state at the time of application for home and community-based services.

3. Income disregarded in the initial eligibility determination process will not be disregarded in the post-eligibility process for determining contributions toward the cost of care.

4. The personal care needs amount (the amount of income protected to cover the expense of living in the community) remains capped at the special income level.

5. All income over the special income level shall be contributed towards the cost of care.

C. Effective December 31, 2013, the income of children ages 6 to 19 from 100 percent up to 142 percent of the federal poverty level shall be disregarded.

D. Effective December 31, 2013, the income of parents or siblings of pregnant unmarried minors (PUMs) or pregnant minor unmarried mothers (MUMs) will not be included when determining Medicaid eligibility for a PUM or pregnant MUM.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:1629 (August 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:1898 (September 2009), LR 40:2260, 2261 (November 2014).

(iii)(10307)10307 Modified Adjusted Gross Income (MAGI) Groups#

A. MAGI-based

1. Income shall be calculated in accordance with 42 CFR §435.603 and §457.315.

B. Financial eligibility for the MAGI groups shall be made using income received in the calendar month prior to the month of application or renewal as an indicator of anticipated income. The taxable gross income of each member of the MAGI household shall be used. Income eligibility of the household shall be based on anticipated income and circumstances unless it is discovered that there are factors that will affect income currently or in future months.

1. Income eligibility is determined by prospective income budgeting or actual income budgeting.

a. Prospective income budgeting involves looking at past income to determine anticipated future income. Income earned in the calendar month prior to the month of application or renewal which the applicant/enrollee earned shall be used to determine expected income in the current and future months.

b. Actual income budgeting involves looking at income actually received within a specific month to determine income eligibility for that month. Actual income shall be used for all retroactive coverage. Actual income or the best estimate of anticipated actual income shall be used if:

i. the income terminates during the month;

ii. the income begins during the month; or

iii. the income is interrupted during the month.

2. The net countable income for the individual’s household shall be compared to the applicable income standard for the household size to determine eligibility.

a. If the countable income is below the income standard for the applicable MAGI group, the individual is income eligible.

b. If the countable income is above the income standard for the applicable MAGI group, the individual is income ineligible.

C. Federal Poverty Income Guidelines (FPIG). Eligibility shall be based upon the following guidelines using the federal poverty income guidelines and adjusted to account for the 5 percent disregard:

1. parents/caretakers, income is less or equal to 24 percent FPIG;

2. pregnant women, income is less or equal to 138 percent FPIG;

3. CHAMP (children 0-18), income is less or equal to 147 percent FPIG;

4. LaCHIP, income is less or equal to 217 percent FPIG;

5. LaCHIP IV (unborn option), income is less or equal to 214 percent FPIG;

6. LaCHIP Affordable Plan, income is less or equal to 255 percent FPIG;

7. Adult Group, income is less than or equal to 138 percent FPIG; and

8. Take Charge Plus, income is less than or equal to 138 percent FPIG.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:947 (May 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 46:29 (January 2020).

(iii)(10705)10705 Resource Disregards#

A. In compliance with the Deficit Reduction Act, individuals who are insured under a long-term care insurance policy that meets the requirements of a “qualified state long-term care insurance partnership” policy shall receive a disregard of resources equal to the amount paid under the insurance policy.

1. The Medicaid Program shall accept the certification of the Louisiana Commissioner of Insurance that the long-term care policy meets the requirements of a “qualified long-term care insurance partnership” policy.

B. The resource disregard is determined on a 1:1 ratio. For each $1 of a qualifying long-term care insurance partnership policy benefit amount paid, $1 of countable resources is disregarded or excluded during the eligibility determination process.

1. The disregard is permitted at the time a recipient begins receiving benefits from a qualifying long-term care insurance partnership policy.

C. All resources shall be disregarded in eligibility determinations for the Qualified Medicare Beneficiaries (QMB), Specified Low Income Beneficiaries (SLMB) and Qualifying Individuals (QI) Programs.

D. Modified Adjusted Gross Income (MAGI) Groups. Resources will be disregarded for those groups using the MAGI determinations methodology.

E. Disregard from resources unspent funds received as a class member pursuant to a class settlement in the case of Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson. No. 820-839.

F. Resources accumulated from March 18, 2020 through March 31, 2023, that, but for the continuous enrollment provision at section 6008(b)(3) of the Families First Coronavirus Response Act, would have been paid toward the cost of a beneficiary’s home and community-based services waiver or institutional services based on the application of post-eligibility treatment of income, will be disregarded through the twelfth month following the first full redetermination of the beneficiary’s eligibility conducted after March 31, 2023.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 35:1899 (September 2009), amended LR 36:2867 (December 2010), LR 41:949 (May 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 45:1772 (December 2019), LR 46:1393 (October 2020), LR 49:876 (May 2023), LR 49:1223 (July 2023), repromulgated LR 49:1394 (August 2023).

(iii)(10717)10717 Types of SSI-Related Resources#

A. The following SSI-related resources are considered in determining eligibility for Medicaid coverage.

1. Annuities

a. Any annuity purchases must adhere to the following requirements or the annuity will be considered an available countable resource.

i. The annuity must contain a statement that names the state of Louisiana as the remainder beneficiary in the first position for the total amount of Medicaid assistance paid on behalf of the annuitant unless there is a community spouse and/or a minor or disabled child.

ii. If there is a community spouse and/or a minor or disabled child, the state may be named in the next position after those individuals. If the state has been named after a community spouse and/or minor or disabled child and any of those individuals or their representatives dispose of any of the remainder of the annuity for less than fair market value, the state may then be named in the first position.

iii. If the state is not named as a remainder beneficiary in the correct position, the purchase of the annuity will be considered a transfer for less than fair market value. The full purchase value of the annuity will be considered the amount transferred.

b. In addition to purchases of annuities, certain related transactions which occur to annuities are subject to these provisions. If any action taken by the individual changes the course of payment to be made by the annuity, then the treatment of the income or principal of the annuity is subject to these provisions. This includes additions of principal, elective withdrawals, requests to change the distribution of the annuity, elections to annuitize the contract and similar actions taken by the individual.

i. Routine changes and automatic events that do not require any action or decision after the effective date of the enactment are not considered transactions that would subject the annuity to treatment under these provisions.

c. Refusal to disclose sufficient information related to any annuity will result in denial or termination of Medicaid based on the applicant's failure to cooperate. When an unreported annuity is discovered after eligibility has been established and after payment for long-term care services has been made, appropriate steps to terminate payment for services will be taken, including appropriate notice to the individual of the adverse action.

d. Annuities purchased by or on behalf of an annuitant who has applied for medical assistance will not be treated as a transfer of assets if the annuity meets any of the following conditions:

i. the annuity is considered to be:

(a). an individual retirement annuity; or

(b). a deemed individual retirement account (IRA) under a qualified employer plan; or

ii. the annuity is purchased with proceeds from one of the following:

(a). a traditional IRA;

(b). certain accounts or trusts which are treated as IRAs;

(c). a simplified retirement account; or

(d). a simplified employee pension; or

iii. the annuity:

(a). is irrevocable and non-assignable;

(b). is actuarially sound; and

(c). provides payments in approximately equal amounts with no deferred or balloon payments.

e. Applicants or their authorized representatives shall be responsible for providing documentation from the financial institution verifying qualifying IRS annuities. Absent such documentation, the purchase of the annuity will be considered a transfer for less than fair market value which is subject to penalty. The full purchase value of the annuity will be considered the amount transferred.

f. If an annuity or the income stream from an annuity is transferred, except to or for the spouse's sole benefit, to their child or a trust, the transfer may be subject to penalty.

2. Continuing Care Retirement Community Entrance Fees

a. Continuing care retirement communities (CCRC's) are entities which provide a range of living arrangements from independent living through skilled nursing care. An entrance contract for admission to a continuing care retirement center or life care community must take into account the required allocation of resources or income to the community spouse before determining the amount of resources that a resident must spend on his or her own care.

b. A CCRC entrance fee shall be treated as a resource for the purposes of determining Medicaid eligibility under the following conditions if the entrance fee:

i. can be used to pay for care under the terms of the entrance contract should other resources of the individual be insufficient;

NOTE: It is not necessary for CCRC's or life care communities to provide a full, lump-sum refund of the entrance fee to the resident. If portions of the fee can be refunded or applied to pay for care as required, this condition would be met.

ii. or a remaining portion is refundable when the individual dies or terminates the contract and leaves the CCRC or life care community; and

NOTE: It is not necessary for the resident to actually receive a refund of the entrance fee for deposit. This condition is met as long as the resident could receive a refund were the contract to be terminated, or if the resident dies.

iii. does not confer an ownership interest in the community.

3. Life Estates

a. The purchase of a life estate in another individual's home is considered a countable resource and subject to examination under transfer of asset provisions unless the purchaser resides in the home for a period of at least one year after the date of purchase.

b. The life estate value will be determined using the life estate tables published by the Social Security Administration for the SSI program.

c. For transfer of assets determinations, the amount of the transfer is the entire amount used to purchase the life estate.

i. The amount shall not be reduced or prorated to reflect an individual's residency for a period of time less than one year.

d. If payment for a life estate exceeds the fair market value (FMV) of the life estate, the difference between the amount paid and the FMV will be treated as a transfer of assets.

e. If an individual makes a gift or transfer of a life estate, the value of the life estate will be treated as a transfer of assets.

f. These provisions apply only to the purchase of life estates. They do not apply in situations where an individual transfers real property but retains the life estate and the value of the remainder interest (not the life estate) is used to determine whether a transfer has occurred and to calculate the period of ineligibility.

g. For the purposes of determining eligibility for Medicaid coverage, the terms “life estate” and “usufruct” have the same meaning.

4. Loans, Mortgages, Promissory Notes and Other Property Agreements

a. Countable assets include funds used to purchase a promissory note, or funds used to make a loan or mortgage. These resources are subject to transfer of assets provisions unless the repayment terms are actuarially sound.

b. Loans, mortgages, promissory notes, property agreements or property assignments are countable resources regardless of any non-assignability, non-negotiability or non-transferability provisions contained therein.

c. Instruments containing any of the following provisions are a countable resource and shall be evaluated as a transfer of assets:

i. repayment terms that exceed the holder's life expectancy;

ii. provisions for interest only payments or principal payments that are not to be made in equal amounts during the term of the loan;

iii. deferral or balloon payments; or

iv. cancellation or forgiveness clauses that cancel the balance upon some occurrence such as death of the lender.

d. If there is evidence that there is not a good faith agreement to repay the entire principal of a note, loan or mortgage, the instrument shall not be considered bona fide and shall be evaluated as a transfer of resources.

5. Substantial Home Equity

a. Substantial home equity above the state's established limit is a countable resource which causes ineligibility for long-term care services. If an individual's equity interest in their home exceeds $500,000, that individual is not eligible for Medicaid payment of nursing facility services or other long-term care services.

b. Home equity limitations do not apply if the individual's spouse, the individual's child under the age of 21, or the individual's blind or disabled child is residing in the home.

i. A child is considered disabled if he or she meets the definition of disability as defined by Section 1614(a)(3) of the Social Security Act.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:1410 (July 2008).

(iii)(10905)10905 Transfers#

A. The Deficit Reduction Act of 2005 established new provisions governing the treatment of transfers of assets for individuals and their spouses who apply for or receive long-term care services.

B. The look-back period is lengthened to five years for potential transfers of assets.

C. For transfers of assets for less than fair market value, the period of ineligibility for an individual in a long term care facility begins the later of the first day of the month after which the asset was transferred for less than fair market value or the date on which the individual is eligible for Medicaid and is receiving institutional level of care services (based on an approved application for such services) that, but for the imposition of the penalty, would be covered by Medicaid.

1. Periods of ineligibility cannot occur during any other period of ineligibility; they must be consecutive and not concurrent.

D. For transfers of assets for less than fair market value, the period of ineligibility for an individual applying for, or receiving, home and community-based services (HCBS) waiver services begins the later of the first day of the month after which the asset was transferred for less than fair market value or the date on which it is determined that the individual meets the financial and non-financial requirements for Medicaid eligibility and all other requirements for admission to an HCBS waiver are met.

E. Partial Month Transfers. The department shall impose penalties for transfers in a month that are less than the state’s average monthly cost to a private patient of nursing facility services in the state.

F. Combining Multiple Transfers Made in More Than One Month. These provisions refer to more than one transfer during the look-back period where each transfer results in less than a full month of eligibility.

1. The department shall combine multiple transfers for less than fair market value in more than one month and impose a single period of ineligibility or apply multiple penalty periods.

a. If the department imposes a single period of ineligibility, all transfers will be added together and a single continuous period of eligibility will be imposed. Otherwise, a separate period of ineligibility shall be calculated for each month and the resulting periods of eligibility shall be imposed separately.

G. Undue Hardship. The department shall provide for an undue hardship waiver when application of the transfer of assets provision would deprive the individual of medical care such that the individual’s health, life or other necessities of life would be endangered.

1. Undue hardship provisions shall permit the facility in which the individual is residing to file an undue hardship waiver application on his behalf with the consent of the individual or the personal representative of the individual.

2. Bed hold payments shall not be made while an application for an undue hardship waiver is pending.

3. Terms. The penalty is a period of ineligibility for receiving long term care vendor payments as a result of a transfer of income or assets or both.

a. An undue hardship exception is when a penalty will not be imposed against the applicant/enrollee, either in whole or in part, after findings that an undue hardship exists.

b. The community spouse is not protected by the hardship exception. The exception is for the applicant/enrollee not to be deprived.

4. Undue hardship does not exist:

a. when the application of the transfer of assets provisions merely causes the individual inconvenience or when such application might restrict his or her lifestyle but would not put him/her at risk of serious deprivation; and

b. when property is transferred to one or more of the following:

i. blood relatives to a third degree cousin;

ii. mother-in-law;

iii. father-in-law;

iv. brother-in-law; or

v. sister-in-law;

c. if the individual who transferred the assets or income, or on whose behalf the assets or income were transferred, has not exhausted all lawful means to recover the assets or income or the value of the transferred assets or income; or

d. if the applicant/enrollee’s health or age indicated a need for long term care services was predictable at the time of the transfer.

5. The applicant/recipient shall be advised in writing that an undue hardship exception.

6. If an undue hardship exception is denied the applicant has the right to appeal the denial decision.

7. Determining Undue Hardship. Once a period of ineligibility has been established because of a transfer of assets or income for less than fair market value, or the equity value in the home, an applicant/enrollee may apply for an undue hardship exception.

a. An undue hardship exception request must be made within seven days from the date of notification of the penalty. Documentation supporting the request for the exception of undue hardship must be provided. The department may extend the request periods if it determines that extenuating circumstances require additional time.

b. When undue hardship requests are made for the first time, individuals challenging the penalty must raise all claims and submit all evidence permitting consideration of undue hardship. The individual has to have taken action in law and equity to get the asset back before the department can consider undue hardship.

c. Once the department determines that it has received complete documentation, it shall inform the individual within 10 business days of the undue hardship decision.

d. If no request for undue hardship is received within seven days after notification of a transfer penalty, or if the request is denied, the department shall issue an eligibility determination specifying the applicable penalty period. If the individual is a recipient, the notice shall include the date of the Medicaid long-term care termination. The notice shall also include the right to request a fair hearing and continuing benefits.

8. An undue hardship exception may be requested at any time during the penalty period if new circumstances leading to undue hardship arise during the duration of the penalty period. If granted, the undue hardship request shall be prospective from the date of the request.

9. The department shall have no obligation to pay for long-term care services during the penalty period unless it grants an undue hardship exception or the applicant/enrollee prevails in a fair hearing.

10. The individual must provide to the department sufficient documentation to support, by a preponderance of the evidence, the claim that application of the penalty will result in an undue hardship to the applicant/enrollee (not the community spouse).

11. If undue hardship is determined to exist, the transferred assets or equity value in the home shall not be considered in the eligibility process.

12. If a request for an undue hardship exception is denied, the applicant/enrollee may request a fair hearing.

13. Terminating the Undue Hardship Exception. The department shall terminate the undue hardship exception, if not earlier, at the time an individual, the spouse of the individual, or anyone with authority on behalf of the individual, makes any uncompensated transfer of income or assets after the undue hardship exception is granted.

a. The department shall deny any further requests for an undue hardship exception due to either the disqualification based on the transfer upon which the initial undue hardship determination was based or a disqualification based on the transfer, which required termination of the undue hardship exception.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:1411 (July 2008), amended by the Department of Health, Bureau of Health Services Financing, LR 46:588 (April 2020).

(iii)(20103)20103 Eligibility Criteria#

A. The LaCHIP Medicaid program provides health insurance coverage to low-income, uninsured children who meet the following criteria:

1. are under the age of 19;

2. are from families with income at or below 217 percent of the federal poverty level; and

3. do not meet the state's Medicaid eligibility criteria in effect as of March 31, 1997.

B. The following children are excluded from coverage under the LaCHIP Medicaid expansion:

1. those currently eligible for Medicaid;

2. those currently covered by other types of health insurance;

3. inmates of a public institution; and

4. patients in an institution for mental disease.

C. Children are considered uninsured, for the purpose of determining eligibility for LaCHIP, if they do not have creditable coverage for health insurance.

1. The department is adopting the definition of creditable coverage for health insurance, the definition for health insurance coverage and the exceptions to health insurance coverage as cited in Section 2110 of the Social Security Act which references 42 U.S.C. §300gg(c)(1), §300gg-91(b)(1), and §300 gg-91(c)(1).

D. Children shall not be considered uninsured if their creditable coverage is dropped within the three calendar months prior to application for LaCHIP benefits unless the reason for dropping the coverage is loss of the employment that provided access to insurance coverage.

1. For the purposes of this Rule, the term loss of employment shall include the following:

a. loss of employment due to a lay-off, down-sizing, resignation, firing, etc.;

b. death of the parent whose employment provided access to dependent coverage;

c. change of employment to an employer that does not provide an option for dependent coverage;

d. discontinuation of health benefits for all employees of the applicant's employer;

e. expiration of coverage periods established by the Consolidated Omnibus Reconciliation Act of 1985 (COBRA); or

f. termination of health benefits due to a long term disability of the parent whose employment provided access to dependent coverage.

E. Effective December 31, 2013 eligibility for LaCHIP shall be determined by modified adjusted gross income (MAGI) methodology in accordance with section 1004(a)(2) of the Patient Protection and Affordable Care Act (ACA) of 2010 and section 36B(d)(2)(B) of the Internal Revenue Code.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XXI of the Social Security Act.

HISTORICAL NOTE: Repromulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:659 (April 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:1292 (July 2015).

(iii)(20505)20505 Covered Services#

A. Children covered in phase five of the LaCHIP expansion shall receive health care benefits through an array of covered services offered by health plans participating in the Healthy Louisiana Program, and behavioral health services administered by the statewide management organization under the LBHP. The following services shall be included:

1. inpatient hospital services:

a. pre-certification is required for hospital admissions. Emergency services are covered if, upon review, presentation is determined to be life-threatening, resulting in admission to inpatient, partial hospital or intensive outpatient level of care;

2. outpatient hospital services:

a. the relative therapies require pre-certification;

3. physician services;

4. surgical procedures;

5. clinic services and other ambulatory health care services;

6. prescription drugs;

7. laboratory and radiological services;

8. pre-natal care and pre-pregnancy family services and supplies;

9. inpatient and outpatient behavioral health services other than those listed in any other provisions of §20503:

a. these services include those furnished in a state-operated mental hospital, residential facility or other 24 hour therapeutically-planned structural services. Pre-certification is required for these services. Emergency services are covered if, upon review, presentation is determined to be life-threatening, resulting in admission to inpatient, partial hospital or intensive outpatient level of care;

b. inpatient and outpatient visits are limited to medically necessary services not to exceed a combined 52 visits per plan year for mental health and substance abuse services;

10. durable medical equipment;

11. nursing care services;

12. dental services;

13. inpatient substance abuse treatment services, including residential substance abuse treatment services:

a. inpatient admissions must be pre-certified. Emergency services are covered if, upon review, presentation is determined to be life-threatening, resulting in admission to inpatient, partial hospital or intensive outpatient level of care;

b. inpatient days are limited to medically necessary services not to exceed a combined 45 visits per plan year for mental health and substance abuse services;

14. outpatient substance abuse treatment services:

a. all services must be pre-certified;

b. outpatient visits are limited to medically necessary services not to exceed a combined 52 visits per plan year for mental health and substance abuse services;

15. case management services:

16. physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders:

a. physical and occupational therapy is limited to 50 visits per year and speech therapy is limited to 26 visits per year;

17. hospice care:

18. medical transportation; and

19. any other medically necessary medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative services.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XXI of the Social Security Act.

HISTORICAL NOTE: Repromulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:660 (April 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:1292 (July 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 52:1189 (July 2026).

(iii)(20509)20509 Dental Services Reimbursement Methodology#

A. Services covered in the LaCHIP Affordable Plan Dental Program shall be reimbursed at the lower of either:

1. the dentist’s billed charges minus any third party coverage; or

2. the state’s established schedule of fees, which is developed in consultation with the Louisiana Dental Association and the Medicaid dental consultants, minus any third party coverage.

B. Effective for dates of service on or after July 1, 2012, the reimbursement fees for LaCHIP Affordable Plan dental services shall be reduced to the following percentages of the 2009 National Dental Advisory Service comprehensive fee report 70th percentile, unless otherwise stated in this Chapter:

1. 65 percent for the following oral evaluation services:

a. periodic oral examination;

b. oral examination-patients under 3 years of age; and

c. comprehensive oral examination-new patients;

2. 62 percent for the following annual and periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiographs-periapical, each additional film;

c. radiographs-panoramic film;

d. diagnostic casts;

e. prophylaxis-adult and child;

f. topical application of fluoride, adult and child (prophylaxis not included); and

g. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under 6 years of age);

3. 45 percent for the following diagnostic and adjunctive general services:

a. oral/facial image;

b. non-intravenous conscious sedation; and

c. hospital call; and

4. 56 percent for the remainder of the dental services.

C. Removable prosthodontics and orthodontic services are excluded from the July 1, 2012 rate reduction.

D. Effective for dates of service on or after August 1, 2013, the reimbursement fees for LaCHIP Affordable Plan dental services shall be reduced by 1.5 percent of the rate on file July 31, 2013, unless otherwise stated in this Chapter.

1. The following services shall be excluded from the August 1, 2013 rate reduction:

a. removable prosthodontics; and

b. orthodontic services.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XXI of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 39:1285 (May 2013), amended LR 40:1008 (May 2014).

(iii)Louisiana Administrative Code Title 50 (Public Health - Medical Assistance), Part III: Eligibility#

(iii)(101)101 Fair Hearings#

(iii)Louisiana Administrative Code Title 50 (Public Health - Medical Assistance), Part III: Eligibility#

(iii)(101)101 Fair Hearings#

(iii)(301)301 General Provisions#

(iii)(501)501 Filing Application#

(iii)(503)503 Application Date#

(iii)(939)939 Medically Needy#

(iii)(941)941 Incurred Medical and Remedial Care Expenses#

(iii)(1101)1101 General Provisions#

(iii)(1103)1103 Eligibility Determinations#

(iii)(1105)1105 Automatic Enrollment#

(iii)(1107)1107 Disclosure of Eligibility Data#

(iii)(2303)2303 Family Opportunity Act Medicaid Program#

(iii)(2305)2305 Provisional Medicaid Program#

(iii)(2307)2307 Youth Aging Out of Foster Care#

(iii)(2308)2308 Former Foster Care Children Group#

(iii)(2309)2309 Medicaid Purchase Plan [Formerly LAC 50:III.763-765]#

(iii)(2311)2311 Louisiana Health Insurance Premium Payment Program#

(iii)(2313)2313 Medically Needy Program#

(iii)(2315)2315 LaMOMS Program#

(iii)(2317)2317 New Adult Eligibility Group#

(iii)(2325)2325 Medicare Savings Programs#

(iii)(2327)2327 Modified Adjusted Gross Income (MAGI) Groups#

(iii)(2329)2329 Lawfully Resident Children#

(iii)(2330)2330 Twelve-Months Postpartum Medicaid Coverage#

(iii)(2331)2331 Act 421 Children’s Medicaid Option (Act 421-CMO/TEFRA)#

(iii)(2523)2523 Citizenship#

(iii)(2525)2525 Twelve-Month Continuous Eligibility#

(iii)(2529)2529 Hospital Presumptive Eligibility#

(iii)(10305)10305 Income Disregards#

(iii)(10307)10307 Modified Adjusted Gross Income (MAGI) Groups#

(iii)(10703)10703 General Provisions#

(iii)(10705)10705 Resource Disregards#

(iii)(10717)10717 Types of SSI-Related Resources#

(iii)(10905)10905 Transfers#

(iii)(16101)16101 Spousal Impoverishment#

(iii)(16103)16103 Nursing Facility Private-Pay Cost#

(iii)(20101)20101 General Provisions#

(iii)(20103)20103 Eligibility Criteria#

(iii)(20301)20301 General Provisions#

(iii)(20303)20303 Eligibility Criteria#

(iii)(20305)20305 Services#

(iii)(20501)20501 General Provisions#

(iii)(20503)20503 Eligibility Criteria#

(iii)(20505)20505 Covered Services#

(iii)(20507)20507 Cost Sharing#

(iii)(20509)20509 Dental Services Reimbursement Methodology#