Current through Register Vol. 50, No. 9, September 20, 2024
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.
1. - 2.
Repealed.
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.
1. - 2.b.iii.(c).
Repealed.
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);
a. - b.
Repealed.
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.
