1. A. Hospital and Practitioner Directed Payments

   1. 1. Subject to written approval by the Centers for Medicare and Medicaid Services (CMS), the Louisiana Department of Health (LDH) shall provide directed payments to qualifying hospitals and practitioner/groups. Practitioners include physicians, physician assistants, certified registered nurse practitioners, and certified nurse anesthetists, as well practitioner groups. These entities must participate in Healthy Louisiana Medicaid managed care program. All directed payments shall be made in accordance with the applicable 42 CFR §438.6(c) preprint(s) approved by CMS, as well as relevant federal and departmental regulations.

   2. 2. Qualifying Hospital or Practitioner—one of the following:

      1. a. an in-state provider of inpatient and outpatient hospital services (excluding freestanding psychiatric hospitals, freestanding rehabilitation hospitals, and long-term acute care hospitals) that meets the criteria specified in the applicable 42 CFR §438.6(c) preprint approved by CMS and departmental regulations;
      2. b. an in-state hospital provider of long-term acute care, psychiatric services, and rehabilitation services for both inpatient and outpatient hospital services that meet the criteria specified in the applicable 42 CFR §438.6(c) preprint approved by CMS and departmental regulations; or
      3. c. an in-state practitioner for professional services, primary care services and specialty physician services that meet the criteria specified in the applicable 42 CFR §438.6(c) preprint approved by CMS and the departmental regulations.

   3. 3. The department shall assign qualifying hospitals or practitioners to provider classes based upon criteria specified in the applicable 42 CFR §438.6(c) preprint(s) approved by CMS, in accordance with departmental regulations.

      1. a. Qualifying hospitals or practitioners shall have no right to an administrative appeal regarding any issue related to provider classification, including, but not limited to, provider class assignment, the effective date of provider class assignment, or qualifying determinations.

   4. 4. The department shall utilize an interim payment process, whereby interim directed payments will be calculated based on provider class assignment utilizing the data and methodology specified in the applicable 42 CFR §438.6(c) preprint(s) approved by CMS, in accordance with departmental regulations.

      1. a. Qualifying hospitals or practitioners shall have no right to an administrative appeal regarding calculation of interim directed payments.
      2. b. The department reserves the right to discontinue the interim directed payments to any hospital or practitioner whose projected recoupment due to shifts in utilization is greater than 50 percent of their estimated interim directed payments or any hospital or practitioner who discontinues operations during or prior to the directed payment contract period.

   5. 5. The department shall cause interim directed payments to be paid on a quarterly basis to the Healthy Louisiana Medicaid managed care organizations (MCOs), in accordance with departmental requirements.

      1. a. The MCOs shall pay interim directed payments to qualified hospitals or practitioners within 10 business days of receipt of quarterly interim directed payment information from LDH. If a barrier exists that will not allow the MCO to pay the interim directed payments within 10 business days of receipt, the MCO shall immediately notify LDH. LDH at its sole discretion will determine if penalties for late payment may be waived.
      2. b. The qualifying hospital or practitioner may request that the MCOs deposit their interim directed payments into a separate bank account owned/held by the qualifying hospital or practitioner. Interim directed payments shall not be deposited into a bank account that is owned/held by more than one qualifying hospital or practitioner.

   6. 6. In accordance with the applicable 42 CFR §438.6(c) preprint(s) approved by CMS, federal regulations, and departmental requirements, directed payments must be based on actual utilization and delivery of services during the applicable contract period.

      1. a. Within 12 months of the end of each state fiscal year (SFY), LDH shall perform a reconciliation of hospital interim payments as specified in the applicable 42 CFR §438.6(c) preprint approved by CMS and departmental regulations.

      2. b. LDH shall reconcile the interim payment for practitioners as specified in the applicable 42 CFR §438.6(c) preprint approval by CMS and departmental regulations.

         1. i. Qualifying hospitals or practitioners shall have no right to an administrative appeal regarding any issue related to reconciliation, including, but not limited to, the timing and process.
      3. c. Qualified hospitals or practitioners are strongly encouraged to submit claims as quickly as possible.

   7. 7. If a qualifying hospital or practitioner that is subject to a reconciliation or adjustment will not be participating in a directed payment arrangement in the future, the qualified hospital or practitioner shall pay all amounts owed to LDH or the MCO, if any, within 30 calendar days’ notice of the amount owed, in accordance with departmental regulations.

      1. a. In addition to all other available remedies, LDH or the MCOs has the authority to offset all amounts owed by a qualifying hospital or practitioner due to a reconciliation or adjustment against any payment owed to the qualifying hospital or practitioner, including, but not limited to, any payment owed by the MCO or LDH..

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:245 and Title XIX of the Social Security Act

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 49:264 (February 2023), amended LR 49:1566 (September 2023), LR 50:1649 (November 2024), LR 51:2096 (December 2025).