La. Admin. Code tit. 50 § I-2103

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2103 - Participation Requirements

A. In order to participate in the Medicaid Program, a DBPM must be a successful bidder, be awarded a contract with the department, and complete the readiness review.

B. A DBPM must:

1. meet the federal definition of a PAHP as defined in 42 CFR §438 . 2;

2. have a license or certificate of authority issued by the Louisiana Department of Insurance to operate as a Medicaid risk bearing "prepaid entity" pursuant to R.S. 22:1016 and submit with the proposal response;

3. have a certificate from the Louisiana Secretary of State, to conduct business in the state;

4. meet solvency standards as specified in federal regulations and title 22 of the Louisiana Revised Statutes;

5. have a network capacity to enroll a minimum of 1,288,625 Medicaid members into the network;

6. be without an actual or perceived conflict of interest that would interfere or give the appearance of impropriety or of interfering with the contractual duties and obligations under this contract or any other contract with LDH, and any and all applicable LDH written policies. Conflict of interest shall include, but is not limited to, the contractor serving, as the Medicaid fiscal intermediary contractor for LDH;

7. be awarded a contract with LDH, and successfully completed the readiness review prior to the start date of operations; and

8. have the ability to provide core dental benefits and services to all assigned members on the day the Dental Benefits Program is implemented.

C. A DBPM shall ensure the provision of core dental benefits and services to all eligible enrollees when the Dental Benefit Program is implemented.

D. Upon request by the Centers for Medicare and Medicaid Services, the Office of Inspector General, the Government Accounting Office, the department or its designee, a DBPM shall make all of its records pertaining to its contract (services provided thereunder and payment for services) with the department available for review, evaluation and audit. The records shall include, but are not limited to the following:

1. pertinent books and documents;

2. financial records;

3. dental records and documents; and

4. provider records and documents involving financial transactions related to the contract.

E. A DBPM shall maintain an automated management information system that collects, analyzes, integrates, and reports data that complies with department and federal reporting requirements.

F. A DBPM shall obtain insurance coverage(s) as specified in the terms of the contract. Subcontractors, if any, shall be covered under these policies or have insurance comparable to the DBPM's required coverage.

G. A DBPM shall provide all financial reporting as specified in the terms of the contract.

H. In the event of noncompliance with the contract and the department's guidelines, a DBPM shall be subject to the sanctions specified in the terms of the contract including, but not limited to:

1. corrective action plans;

2. monetary penalties; or

3. suspension and/or termination of the DBPM's contract.

I. - I.3. Repealed.

La. Admin. Code tit. 50, § I-2103

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 40:784 (April 2014), Amended by the Department of Health, Bureau of Health Services Financing, LR 461228 (9/1/2020), Amended LR 491066 (6/1/2023).

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