Contents december 2010 I. Emergency rules

A. Effective December 1, 2010, the Department of Health and Hospitals will pay for a maximum of four prescriptions per calendar month for Medicaid recipients.

B. The following federally mandated recipient groups are exempt from the four 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 four 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, or its successor, diagnosis code that is directly related to each drug prescribed that is over the four prescription limit (no ICD-9-CM, or its successor, 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 four prescriptions per calendar month is required by the recipient.

E. ...

F. An acceptable statement and ICD-9-CM, or its successor, diagnosis code are required for each prescription in excess of four for that month.

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 35:1901 (September 2009), LR 37:

Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required.

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.

Interested persons may submit written comments to Don Gregory, 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, January 26, 2011 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.

Bruce D. Greenstein

Secretary

I. ESTIMATED IMPLEMENTATION COSTS (SAVINGS) TO STATE OR LOCAL GOVERNMENT UNITS (Summary)

It is anticipated that the implementation of this proposed rule will result in estimated programmatic savings to the state of $437,961 for FY 10-11, $997,749 for FY 11-12 and $1,033,680 for FY 12-13. It is anticipated that $410 ($205 SGF and $205 FED) will be expended in FY 10-11 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

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 $1,297,629 for FY 10-11, $2,067,531 for FY 11-12 and $2,123,558 for FY 12-13. It is anticipated that $205 will be expended in FY 10-11 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The

numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized and appropriated by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional and appropriated enhanced federal match would be available after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

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

This proposed rule, which continues the provisions of the December 1, 2010 emergency rule, amends the provisions governing the Pharmacy Benefits Management Program to reduce the number of prescriptions covered by the Medicaid Program from 5 to 4 prescriptions within a calendar month. It is anticipated that implementation of this proposed rule will decrease program expenditures in the Medicaid Program by approximately $1,736,000 for FY 10-11, $3,065,280 for FY 11-12 and $3,157,238 for FY 12-13.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule will not have an effect on competition. However, we anticipate that the implementation may have a negative effect on employment as it will reduce the payments made to some providers of pharmacy services. The reduction in payments may adversely impact the financial standing of pharmacy providers and could possibly cause a reduction in employment opportunities.

Pregnant Women Extended Services

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to amend LAC 50:XV.16107 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 11 of the 2010 Regular Session of the Louisiana Legislature which states: “The secretary is directed to utilize various cost containment measures to ensure expenditures in the Medicaid Program do not exceed the level appropriated in this Schedule, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations, drug therapy management, disease management, cost sharing, and other measures as permitted under federal law.” This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq.

As a result of a budgetary shortfall in state fiscal year 2010, the Department of Health and Hospitals, Bureau of Health Services Financing amended the provisions governing the reimbursement methodology for dental services to reduce the reimbursement rates for services rendered to Medicaid eligible pregnant women (Louisiana Register, Volume 36, Number 9).

As a result of a budgetary shortfall in state fiscal year 2011, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for dental services to reduce the reimbursement rates for services rendered to Medicaid eligible pregnant women (Louisiana Register, Volume 36, Number 8). The August 1, 2010 Emergency Rule was amended to revise the formatting of LAC 50:XV.16107 as a result of the promulgation of the September 20, 2010 final Rule governing the Pregnant Women Extended Services Dental Program (Louisiana Register, Volume 36, Number 11).

Due to a continuing budgetary shortfall, the department promulgated an Emergency Rule which further reduced the reimbursement rates for dental services rendered to Medicaid eligible pregnant women (Louisiana Register, Volume 36, Number 12). This proposed Rule is being promulgated to continue the provisions of the November 20, 2010 and the December 1, 2010 Emergency Rules.

Title 50

PUBLIC HEALTHMEDICAL ASSISTANCE

Part XV. Services for Special Populations

Subpart 13. Pregnant Women Extended Services

Chapter 161. Dental Services

§16107. Reimbursement

A. - D.3.q. …

E. Effective for dates of service on or after August 1, 2010, the reimbursement fees for dental services provided to Medicaid eligible pregnant women 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. 69 percent for the comprehensive periodontal evaluation exam;

2. 65 percent for the following diagnostic services:

a. intraoral-periapical first film;

b. intraoral-periapical, each additional film; and

c. panoramic film and prophylaxis, adult; and

3. 58 percent for the remaining diagnostic services and all periodontic procedures, restorative and oral and maxillofacial surgery procedures which includes the following dental services:

a. intraoral, occlusal film;

b. bitewings, two films;

c. amalgam (one, two or three surfaces) primary or permanent;

d. amalgam (four or more surfaces);

e. resin-based composite (one, two or three surfaces), anterior;

f. resin-based composite (four or more surfaces) or involving incisal angle, anterior;

g. resin-based composite crown, anterior;

h. resin-based composite (one, two, three, four or more surfaces), posterior;

i. prefabricated stainless steel crown, primary or permanent tooth;

j. prefabricated resin crown;

k. periodontal scaling and root planning (four or more teeth per quadrant);

l. full mouth debridement to enable comprehensive evaluation and diagnosis;

m. extraction, coronal remnants-deciduous tooth;

n. extraction, erupted tooth or exposed root (elevation and/or forceps removal);

o. surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth;

p. removal of impacted tooth, soft tissue; and

q. removal of impacted tooth, partially bony.

F. Effective for dates of service on or after December 1, 2010, the reimbursement fees for dental services provided to Medicaid eligible pregnant women 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. 67.5 percent for the comprehensive periodontal evaluation exam;

2. 63.5 percent for the following diagnostic services:

a. intraoral-periapical first film;

b. intraoral-periapical, each additional film; and

c. panoramic film and prophylaxis, adult; and

3. 57 percent for the remaining diagnostic services and all periodontic procedures, restorative and oral and maxillofacial surgery procedures which includes the following dental services:

a. intraoral, occlusal film;

b. bitewings, two films;

c. amalgam (one, two or three surfaces) primary or permanent;

d. amalgam (four or more surfaces);

e. resin-based composite (one, two or three surfaces), anterior;

f. resin-based composite (four or more surfaces) or involving incisal angle, anterior;

g. resin-based composite crown, anterior;

h. resin-based composite (one, two, three, four or more surfaces), posterior;

i. prefabricated stainless steel crown, primary or permanent tooth;

j. prefabricated resin crown;

k. periodontal scaling and root planning (four or more teeth per quadrant);

l. full mouth debridement to enable comprehensive evaluation and diagnosis;

m. extraction, coronal remnants-deciduous tooth;

n. extraction, erupted tooth or exposed root (elevation and/or forceps removal);

o. surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth;

p. removal of impacted tooth, soft tissue; and

q. removal of impacted tooth, partially bony.

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 30:434 (March 2004), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:1902 (September 2009), amended LR 36:2044 (September 2010), LR 37:

Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required.

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.

Interested persons may submit written comments to Don Gregory, 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, January 26, 2011 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

I. ESTIMATED IMPLEMENTATION COSTS (SAVINGS) TO STATE OR LOCAL GOVERNMENT UNITS (Summary)

It is anticipated that the implementation of this proposed rule will result in estimated programmatic savings to the state of $37,161 for FY 10-11, $70,994 for FY 11-12 and $73,551 for FY 12-13. It is anticipated that $656 ($328 SGF and $328 FED) will be expended in FY 10-11 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

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 $110,715 for FY 10-11, $147,114 for FY 11-12 and $151,100 for FY 12-13. It is anticipated that $328 will be expended in FY 10-11 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general

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

This proposed rule, which continues the provisions of the November 20, 2010 and the December 1, 2010 emergency rules, amends the provisions governing the reimbursement methodology for dental services to reduce the reimbursement rates for services rendered to Medicaid eligible pregnant women. It is anticipated that implementation of this proposed rule will decrease program expenditures in the Medicaid Program by approximately $148,532 for FY 10-11, $218,108 for FY 11-12 and $224,651 for FY 12-13.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule will not have an effect on competition. However, we anticipate that the implementation may have a negative effect on employment as it will reduce the payments made for dental services to Medicaid eligible pregnant women. The reduction in payments may adversely impact the financial standing of dentists and could possibly cause a reduction in employment opportunities.

Don Gregory	Robert E. Hosse
Medicaid Director	Staff Director
1012#094	Legislative Fiscal Office

NOTICE OF INTENT

Department of Health and Hospitals

Bureau of Health Services Financing

Professional Services Program

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to amend LAC 50:IX.15113 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act. This Emergency Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:953(B)(1) et seq., and shall be in effect for the maximum period allowed under the Act or until adoption of the final Rule, whichever occurs first.

As a result of a budgetary shortfall in state fiscal year 2010, the Department of Health and Hospitals, Bureau of Health Services Financing amended the provisions governing the Professional Services Program to further reduce the reimbursement rates paid for physician services and to clarify the provisions governing physician reimbursement for services rendered to recipients 16 years of age or older (Louisiana Register, Volume 36, Number 10).

To maintain access to obstetric delivery services and encourage the continued participation of physicians in the Medicaid Program, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for physician services to increase the reimbursement rates for obstetric delivery services (Louisiana Register, Volume 36, Number 12). This proposed Rule is being promulgated to continue the provisions of the December 1, 2010 Emergency Rule.

A. - H. …

I. Effective for dates of service on or after December 1, 2010, reimbursement shall be 90 percent of the 2009 Louisiana Medicare Region 99 allowable for the following obstetric services when rendered to recipients 16 years of age and older:

1. vaginal-only delivery (with or without postpartum care);

2. vaginal delivery after previous cesarean (VBAC) delivery; and

3. cesarean delivery following attempted vaginal delivery after previous cesarean delivery. The reimbursement for a cesarean delivery remains at 80 percent of the 2009 Louisiana Medicare Region 99 allowable when the service is rendered to recipients 16 years of age and older.

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 36:1252 (June 2010), amended LR 36:2282 (October 2010), LR 37:

Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required.

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 will have a positive impact on family functioning, stability and autonomy as described in R.S. 49:972 by helping to stabilize provider participation in the Medicaid Program and improving access to obstetric services.

Interested persons may submit written comments to Don Gregory, 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, January 26, 2011 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 an estimated programmatic increase to the state of $241,656 for FY 10-11, $687,378 for FY 11-12 and $712,132 for FY 12-13. However, the cost is expected to be offset by an indeterminable amount from the anticipated savings realized in the Professional Services Program from prior reductions to obstetric delivery services. It is anticipated that $328 ($164 SGF and $164 FED) will be expended in FY 10-11 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

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

It is anticipated that the implementation of this proposed rule will increase federal revenue collections by approximately $715,456 for FY 10-11, $1,424,381 for FY 11-12 and $1,462,980 for FY 12-13. It is anticipated that $164 will be expended in FY 10-11 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

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

This proposed rule, which continues the provisions of the December 1, 2010 emergency rule, amends the provisions governing the reimbursement methodology for physician services to increase the reimbursement rates for obstetric delivery services. It is anticipated that implementation of this proposed rule will increase expenditures in the Medicaid Program by approximately $956,784 for FY 10-11, $2,111,759 for FY 11-12 and $2,175,112 for FY 12-13.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule will not have an effect on competition. However, it is anticipated that the implementation of this proposed rule may have a positive effect on employment as it will increase the payments for obstetric delivery services. The increase in payments may improve the financial standing of physicians and could possibly cause an increase in employment opportunities.

Physical Therapy (LAC 46:LIV.Chapters 1–5)

Notice is hereby given that the Physical Therapy Board, pursuant to the authority of the Louisiana Physical Therapy Practice Act, R.S. 37:2401–2424, and in accordance with the provisions of the Louisiana Administrative Procedure Act, R.S. 49:950 et seq., intends to amend its administrative rules governing the practice of physical therapy.

The Physical Therapy Board is proposing a comprehensive revision of the current rules to clarify the application of the newly revised PT Practice Act. The Physical Therapy Board is completely repealing in its entirety Chapters 1 through 3. The proposed new rules include term definitions, board operations, defining provisional licensees and supervised clinical practice for foreign educated physical therapists, requirements of credentialing agencies for foreign educated physical therapists, setting a limit on the number of attempts applicants may sit for the national physical therapy examination prior to remediation, changing the renewal period from annual to biennial, requirement for background checks, and criteria for continuing competence. Act 139 of the 2010 Legislative session changed supervision of physical therapist assistants thusly requiring rule changes. The proposed rules also include alternatives to disciplinary action for licensees who self-report first time, substance abuse issues, cease and desist authority, further defining violations and unprofessional conduct, and describes the adjudication process/appeal.

The proposed rules incorporate the holdings of Declaratory Statements which have been issued by the Board since the last revision. The changes support the Board in the execution of its duty to regulate the industry for the protection of the public.

Title 46

PROFESSIONAL AND OCCUPATIONAL STANDARDS