Part XV. Services for Special Populations

A. - C.3. …

D. Effective for dates of service on or after February 1, 2009, the reimbursement rate for long term personal care services shall be reduced by 3.5 percent of the rate on file as of January 31, 2009.

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 29:913 (June 2003), amended by the Department of Health and Hospitals, Office of Aging and Adult Services, LR 34:253 (February 2008), LR 34:2581 (December 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 35:

Family Impact Statement

In compliance with Act 1183 of the 1999 Regular Session of the Louisiana Legislature, the impact of this proposed Rule on the family has been considered. It is anticipated that this proposed Rule may have an adverse impact on family functioning, stability and autonomy as described in R.S. 49:972 in the event that provider participation in the Medicaid Program is diminished as a result of reduced reimbursement rates.

Implementation of the provisions of this Rule is contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Interested persons may submit written comments to Jerry Phillips, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030. He is responsible for responding to inquiries regarding this proposed Rule. A public hearing on this proposed Rule is scheduled for Wednesday, May 27, 2009 at 9:30 a.m. in Room 118, Bienville Building, 628 North Fourth Street, Baton Rouge, LA. At that time all interested persons will be afforded an opportunity to submit data, views or arguments either orally or in writing. The deadline for receipt of all written comments is 4:30 p.m. on the next business day following the public hearing.

Secretary

It is anticipated that the implementation of this proposed rule will result in estimated savings to the state of $553,791 for FY 08-09, $1,592,299 for FY 09-10, and $1,640,068 for FY 10-11. It is anticipated that $328 ($164 SGF and $164 FED) will be expended in FY 08-09 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on the "hold harmless" Federal Medical Assistance Percentage (FMAP) as allowed in the American Recovery and Reinvestment Act of 2009 (72.47%). Additional federal funds are projected to be available in the current year through December 2010. To the extent that DHH utilizes federal match, up to the allowable match (estimated to be 80.01% in the current year) for the eligibility period (through December 2010), state general fund match could be reduced. In FY 10-11, the FMAP is projected to drop below the hold harmless rate by an unknown amount. In the event of this decrease, the state general funds will increase to the federally required match.

II. ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary)

It is anticipated that the implementation of this proposed rule will reduce federal revenue collections by approximately $1,458,068 for FY 08-09, $4,191,569 for FY 09-10, and $4,317,316 for FY 10-11. It is anticipated that $164 will be expended in FY 08-09 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on the "hold harmless" Federal Medical Assistance Percentage (FMAP) as allowed in the American Recovery and Reinvestment Act of 2009 (72.47%). Additional federal funds are projected to be available in the current year through December 2010. To the extent that DHH utilizes federal match, up to the allowable match (estimated to be 80.01% in the current year) for the eligibility period (through December 2010), state general fund match could be reduced. In FY 10-11, the FMAP is projected to drop below the hold harmless rate by an unknown amount. In the event of this decrease, the state general funds will increase to the federally required match.

III. ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS OR NONGOVERNMENTAL GROUPS (Summary)

This proposed rule is being promulgated to continue the provisions of the February 1, 2009 emergency rule which amended the provisions governing the reimbursement methodology for long term personal care services to reduce the reimbursement rate (approximately 10,847 recipients). It is anticipated that implementation of this proposed rule will decrease program expenditures in the Medicaid Program by approximately $2,012,187 for FY 08-09, $5,783,868 for FY 09-10 and $5,957,384 for FY 10-11.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule may have a negative effect on competition and employment as it will reduce the payments made for long term personal care services. The reduction in payments may adversely impact the financial standing of LT-PCS providers and could possibly cause a reduction in employment opportunities.

Pharmacy Program―Prescription Limit Reduction

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to amend LAC 50:XXIX.113 under the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act, and as directed by Act 19 of the 2008 Regular Session of the Louisiana Legislature which states: "The secretary shall, subject to the review and approval of the Joint Legislative Committee on the Budget, implement reductions in the Medicaid program as necessary to control expenditures to the level appropriated in this schedule. Notwithstanding any law to the contrary, the secretary is hereby directed to utilize various cost-containment measures to accomplish these reductions, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations and other measures as allowed by federal law." This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq.

The Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing repromulgated all of the Rules governing the Pharmacy Benefits Management Program in a codified format for inclusion in the Louisiana Administrative Code (Louisiana Register, Volume 32, Number 6). As a result of a budgetary shortfall, the bureau promulgated an Emergency Rule to amend the provisions governing prescription limits to reduce the number of prescriptions covered by the Medicaid Program within a calendar month for certain recipients (Louisiana Register, Volume 35, Number 4). This proposed Rule is being promulgated to continue the provisions of the May 1, 2009 Emergency Rule.

Title 50

PUBLIC HEALTH—MEDICAL ASSISTANCE

Part XXIX. Pharmacy

Chapter 1. General Provisions

§113. Prescription Limit

A. Effective May 1, 2009, the Department of Health and Hospitals will pay for a maximum of five prescriptions per calendar month for Medicaid recipients.

B. The following federally mandated recipient groups are exempt from the five prescriptions per calendar month limitation:

1. persons under 21 years of age;

2. persons who are residents of long-term care institutions, such as nursing homes and ICF-DD facilities; and

3. pregnant women.

C. The five prescriptions per month limit can be exceeded when the prescriber determines an additional prescription is medically necessary and communicates the following information to the pharmacist in his own handwriting or by telephone or other telecommunications device:

1. "medically necessary override;" and

2. a valid ICD-9-CM diagnosis code that directly related to each drug prescribed that is over the five prescription limit (no ICD-9-CM literal description is acceptable).

D. The prescriber should use the Clinical Drug Inquiry (CDI) internet web application developed by the fiscal intermediary in his/her clinical assessment of the patient’s disease state or medical condition and the current drug regime before making a determination that more than five prescriptions per calendar month is required by the recipient.

E. Printed statements without the prescribing practitioner’s signature, check-off boxes or stamped signatures are not acceptable documentation.

F. An acceptable statement and ICD-9-CM are required for each prescription in excess of five for that month.

G. Pharmacists and prescribers are required to maintain documentation to support the override of a prescription limitation.

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 32:1055 (June 2006), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:

Family Impact Statement

In compliance with Act 1183 of the 1999 Regular Session of the Louisiana Legislature, the impact of this proposed Rule on the family has been considered. It is anticipated that this proposed Rule may have an adverse impact on family functioning, stability and autonomy as described in R.S. 49:972 in that it may be necessary for individuals and families to use their own funds or to rely on others in order to purchase medications in excess of the reduced prescription limit.

Implementation of the provisions of this Rule is contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Interested persons may submit written comments to Jerry Phillips, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030. He is responsible for responding to inquiries regarding this proposed Rule. A public hearing on this proposed Rule is scheduled for Wednesday, May 27, 2009 at 9:30 a.m. in Room 118, Bienville Building, 628 North Fourth Street, Baton Rouge,

LA. At that time all interested persons will be afforded an opportunity to submit data, views or arguments either orally or in writing. The deadline for the receipt of all written comments is 4:30 p.m. on the next business day following the public hearing.
Alan Levine

Secretary

It is anticipated that the implementation of this proposed rule will result in an estimated savings to the state of $167,905 for FY 08-09, $1,008,662 for FY 09-10, and $1,038,922 for FY 10-11. It is anticipated that $410 ($205 SGF and $205 FED) will be expended in FY 08-09 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on the “hold harmless” Federal Medical Assistance Percentage (FMAP) as allowed in the American Recovery and Reinvestment Act of 2009 (72.47%). Additional federal funds are projected to be available in the current year through December 2010. To the extent that DHH utilizes federal match, up to the allowable match (estimated to be 80.01% in the current year) for the eligibility period (through December 2010), state general fund match could be reduced. In FY 10-11, the FMAP is projected to drop below the hold harmless rate by an unknown amount. In the event of this decrease, the state general funds will increase to the federally required match.

II. ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary)

It is anticipated that the implementation of this proposed rule will reduce federal revenue collections by approximately $442,329 for FY 08-09, $2,655,202 for FY 09-10, and $2,734,858 for FY 10-11. It is anticipated that $205 will be collected in FY 08-09 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on the “hold harmless” Federal Medical Assistance Percentage (FMAP) as allowed in the American Recovery and Reinvestment Act of 2009 (72.47%). Additional federal funds are projected to be available in the current year through December 2010. To the extent that DHH utilizes federal match, up to the allowable match (estimated to be 80.01% in the current year) for the eligibility period (through December 2010), state general fund match could be reduced. In FY 10-11, the FMAP is projected to drop below the hold harmless rate by an unknown amount. In the event of this decrease, the state general funds will increase to the federally required match.

III. ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS OR NONGOVERNMENTAL GROUPS (Summary)

This rule, which continues the provisions of the May 1, 2009 emergency rule, proposes to amend the provisions governing prescription limits to reduce the number of prescriptions covered by the Medicaid Program within a calendar month for certain recipients (approximately 24,000 recipients per month). It is anticipated that implementation of

this proposed rule will decrease program expenditures in the Medicaid Program by approximately $610,644 for FY 08-09, $3,663,864 for FY 09-10 and $3,773,780 for FY 10-11.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule may have a negative effect on competition and employment as it may reduce the payments made to some providers of pharmacy services. The reduction in payments may adversely impact the financial standing of providers and could possibly cause a reduction in employment opportunities

Jerry Phillips	Robert E. Hosse
Medicaid Director	Staff Director
0904#097	Legislative Fiscal Office

NOTICE OF INTENT

Department of Health and Hospitals

Bureau of Health Services Financing

Professional Services Program―Anesthesia Services

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to adopt LAC 50:IX.15111 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act and as directed by Act 19 of the 2008 Regular Session of the Louisiana Legislature which states: "The secretary shall, subject to the review and approval of the Joint Legislative Committee on the Budget, implement reductions in the Medicaid program as necessary to control expenditures to the level appropriated in this Schedule. Notwithstanding any law to the contrary, the secretary is hereby directed to utilize various cost-containment measures to accomplish these reductions, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations and other measures as allowed by federal law.” This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R. S. 49:950, et seq.

The Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing promulgated a Rule amending the provisions governing the billing and reimbursement methodology for anesthesia services (Louisiana Register, Volume 30, Number 5).

As a result of a budgetary shortfall and to avoid a budget deficit in the medical assistance programs, the department promulgated an Emergency Rule to amend the provisions governing the reimbursement methodology for anesthesia services to reduce the reimbursement rates paid to certified registered nurse anesthetists (CRNAs) for services rendered to Medicaid recipients (Louisiana Register, Volume 35, Number 3). This proposed Rule is being promulgated to continue the provisions of the February 26, 2009 Emergency Rule.

A. The most appropriate procedure codes and modifiers shall be used when billing for surgical anesthesia procedures and/or other services performed under the professional licensure of the physician (anesthesiologist or other specialty) or certified registered nurse anesthetist (CRNA).

B. Formula-Based Reimbursement. Reimbursement is based on formulas related to 100 percent of the 2003 Medicare Region 99 payable.

C. Flat Fee Reimbursement

1. Reimbursement for maternity related anesthesia services is a flat fee, except for general anesthesia related to a vaginal delivery which is reimbursed according to a formula.

2. Other anesthesia services that are performed under the professional licensure of the physician (anesthesiologist or other specialty) or CRNA are reimbursed a flat fee based on the appropriate procedure code.

D. Effective for dates of service on or after February 26, 2009, the reimbursement rates paid to CRNAs will be reduced by 3.5 percent of the reimbursement as of February 25, 2009.

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 35:

Family Impact Statement

In compliance with Act 1183 of the 1999 Regular Session of the Louisiana Legislature, the impact of this proposed Rule on the family has been considered. It is anticipated that this proposed Rule may have an adverse impact on family functioning, stability and autonomy as described in R.S. 49:972 in the event that provider participation in the Medicaid Program is diminished as a result of reduced reimbursement rates.

Implementation of the provisions of this Rule is contingent upon the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Interested persons may submit written comments to Jerry Phillips, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030. He is responsible for responding to inquiries regarding this proposed Rule. A public hearing on this proposed Rule is scheduled for Wednesday, May 27, 2009 at 9:30 a.m. in Room 118, Bienville Building, 628 North Fourth Street, Baton Rouge, LA. At that time all interested persons will be afforded an opportunity to submit data, views or arguments either orally or in writing. The deadline for receipt of all written comments is 4:30 p.m. on the next business day following the public hearing.

Secretary

It is anticipated that the implementation of this proposed rule will result in estimated savings to the state of $19,108 for FY 08-09, $108,276 for FY 09-10, and $111,524 for FY 10-11. It is anticipated that $328 ($164 SGF and $164 FED) will be expended in FY 08-09 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on the "hold harmless" Federal Medical Assistance Percentage (FMAP) as allowed in the American Recovery and Reinvestment Act of 2009 (72.47%). Additional federal funds are projected to be available in the current year through December 2010. To the extent that DHH utilizes federal match up to the allowable match (estimated to be 80.01% in the current year) for the eligibility period (through December 2010), state general fund match could be reduced. In FY 10-11, the FMAP is projected to drop below the hold harmless rate by an unknown amount. In the event of this decrease, the state general funds will increase to the federally required match.

II. ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary)

It is anticipated that the implementation of this proposed rule will reduce federal revenue collections by approximately $50,569 for FY 08-09, $285,025 for FY 09-10, and $293,576 for FY 10-11. It is anticipated that $164 will be expended in FY 08-09 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on the "hold harmless" Federal Medical Assistance Percentage (FMAP) as allowed in the American Recovery and Reinvestment Act of 2009 (72.47%). Additional federal funds are projected to be available in the current year through December 2010. To the extent that DHH utilizes federal match, up to the allowable match (estimated to be 80.01% in the current year) for the eligibility period (through December 2010), state general fund match could be reduced. In FY 10-11, the FMAP is projected to drop below the hold harmless rate by an unknown amount. In the event of this decrease, the state general funds will increase to the federally required match.

III. ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS OR NONGOVERNMENTAL GROUPS (Summary)

This proposed rule is being promulgated to continue the provisions of the February 26, 2009 emergency rule which amended the provisions governing the reimbursement methodology for anesthesia services to reduce the reimbursement rates paid to certified registered nurse anesthetists (CRNAs) for services rendered to Medicaid recipients (approximately 82,412 services per year). It is anticipated that implementation of this proposed rule will decrease program expenditures in the Professional Services Program by approximately $70,005 for FY 08-09, $393,301 for FY 09-10 and $405,100 for FY 10-11.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule may have a negative effect on competition and

employment as it will reduce the payments made to CRNAs for anesthesia services. The reduction in payments may adversely impact the financial standing of providers and could possibly cause a reduction in employment opportunities.

Jerry Phillips	Robert E. Hosse
Medicaid Director	Staff Director
0904#098	Legislative Fiscal Office

NOTICE OF INTENT

Department of Health and Hospitals

Bureau of Health Services Financing

Prosthetics and Orthotics—Reimbursement Rate Reduction

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to amend LAC 50:XVII.501 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act and as directed by Act 19 of the 2008 Regular Session of the Louisiana Legislature which states: "The secretary shall, subject to the review and approval of the Joint Legislative Committee on the Budget, implement reductions in the Medicaid program as necessary to control expenditures to the level appropriated in this schedule. Notwithstanding any law to the contrary, the secretary is hereby directed to utilize various cost-containment measures to accomplish these reductions, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations and other measures as allowed by federal law.” This proposed Rule is promulgated in accordance with the Administrative Procedure Act, R.S. 49:950 et seq.

The Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing amended the provisions governing the reimbursement for prosthetic and orthotic devices to repeal the reimbursement methodology for specific items and to increase the reimbursement rates (Louisiana Register, Volume 34, Number 5).

As a result of a budgetary shortfall, the bureau promulgated an Emergency Rule to amend the provisions governing the reimbursement methodology for prosthetic and orthotic devices to reduce the reimbursement rates (Louisiana Register, Volume 35, Number 3). This proposed Rule is being promulgated to continue the provisions of the March 7, 2009 Emergency Rule.