La. Admin. Code tit. 50 § XXIII-1301

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

Section XXIII-1301 - Payment

A. Participants shall be eligible for Medicaid payment of the PACE premium on their behalf if they meet the categorically needy income and resource criteria for Medicaid eligibility for nursing facility and Home and Community Based Services waiver services.

B. Participants are eligible for Medicare payment of the PACE premium on their behalf if they are covered by Medicare. The amount of Medicare premiums is calculated by the Centers for Medicare and Medicaid Services, the federal oversight agency.

C. Medicaid payment to a PACE organization on behalf of a Medicaid-eligible participant shall be a prospective monthly capitated amount that is equal to or less than the amount that would otherwise have been paid under the State Plan if the participant was not enrolled under the PACE program.

1. Initially, each site specific upper payment limit shall be calculated for each state fiscal year using service area data, by zip code, from actual paid fee-for-service claims for populations who are age 55 or older in nursing facilities and in home and community based waiver and state plan services that utilize nursing facility level of care and serve people age 55 or older.

2. Site specific upper payment limits and Medicaid premiums for PACE shall be periodically calculated in accordance with the approved State Plan methodology for such calculation, including trending of historical data. Premiums for every PACE organization in the state will be based on upper payment limits.

3. Premium amount shall be a negotiated rate, not to exceed 95 percent of the upper payment limit.

4. No retroactive capitated payments shall be made.

D. There shall be a minimum of two Medicaid upper payment limits calculated annually:

1. one for participants who are eligible for both Medicare and Medicaid; and

2. one for participants who are eligible only for Medicaid.

E. Medicaid payment to a PACE organization shall be made for each Medicaid-eligible participant who is identified on Medicaid files as linked to the PACE provider and is enrolled for the subsequent month.

1. Enrolled participants are those who have signed an enrollment agreement and who have been linked by Medicaid to the PACE provider.

2. Medicaid-eligible participants are those who have been determined to be eligible for Medicaid payment effective as of or before the first day of the month, including those who are retroactively eligible, when such date is on or before the first day of the month.

F. The amount of the Medicaid premium is a fixed amount regardless of changes in the participant's health status.

G. A PACE organization may not charge a premium to a participant who is eligible for both Medicare and Medicaid, or who is only eligible for Medicaid.

H. Participants who are not eligible for Medicaid must pay a premium to the PACE organization equal to the amount of the Medicaid premium, except that a different negotiated amount may be paid as a governmental premium on behalf of participants whose care is financed by governmental agencies such as Veterans Administration.

I. Participants who are not eligible for Medicaid and are also not eligible for either Medicare Part A or Medicare Part B must pay a premium to the PACE organization equal to the amount of the Medicaid premium and also amount(s) equal to the Medicare premium for Part A or Part B, or both.

J. A Medicaid PACE participant, who is in a nursing facility reimbursed by PACE on his/her behalf, shall be responsible for payment of patient liability.

1. The amount of patient liability is the same amount that would be required to be paid by a Medicaid eligible resident of a nursing facility if he/she was not a participant in a PACE organization.

2. The patient liability obligation for Medicaid participants begins the day it is determined by the PACE provider that the nursing facility stay is permanent.

3. The PACE organization shall determine whether the patient liability is to be paid to the PACE organization or the nursing facility.

K. Effective for dates of service on or after August 1, 2010, the monthly capitated amount paid to a PACE organization shall be reduced by 2 percent of the capitated amount on file as of July 31, 2010.

L. Effective for dates of service on or after January 1, 2011, the monthly capitated amount paid to a PACE organization shall be reduced by 3.09 percent of the capitated amount on file as of December 31, 2010.

M. Effective for dates of service on or after July 1, 2012, the monthly capitated amount paid to a PACE organization shall be reduced by 2 percent of the capitated amount on file as of June 30, 2012.

La. Admin. Code tit. 50, § XXIII-1301

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:250 (February 2004), amended LR 33:850 (May 2007), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 37:1572 (June 2011), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 37:1572 (June 2011), LR 39:316 (February 2013).

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