1. A. For newly added procedure codes for beneficiaries age 0 through 15 years old, the Medicaid fee shall be set at 90 percent of the current year’s Louisiana Region 99 Medicare allowable fee. For newly added procedure codes for beneficiaries age 16 years and older, the Medicaid fee shall be set at 75 percent of the current year’s Louisiana Region 99 Medicare allowable fee.

   1. 1. If there is no equivalent Medicare fee, the Medicaid fee shall be set based on the Medicare fee for a similar service. In the absence of any applicable Medicare fee, the fee shall be set at the Medicaid fee for a similar service or the Medicaid fee for other states.
   2. 2. If establishing a Medicaid fee based on Medicare rates results in a fee that is reasonably expected to be insufficient to ensure that the service is available to beneficiaries, an alternate methodology shall be used. The fee shall be set at the Medicaid fee for a similar service or the Medicaid fee for other states.

2. B. Effective for dates of service on or after October 15, 2007, the reimbursement for selected physician services shall be 90 percent of the 2007 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount, unless otherwise stipulated.

   1. 1. The reimbursement shall remain the same for those services that are currently being reimbursed at a rate that is between 90 percent and 120 percent of the 2007 Louisiana Medicare Region 99 allowable.
   2. 2. For those services that are currently reimbursed at a rate above 120 percent of the 2007 Louisiana Medicare Region 99 allowable, effective for dates of service on or after October 15, 2007, the reimbursement for these services shall be reduced to 120 percent of the 2007 Louisiana Medicare Region 99 allowable.

3. C. Effective for dates of service on or after January 1, 2008, the reimbursement for selected physician services shall be 90 percent of the 2008 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount, unless otherwise stipulated.

   1. 1. The reimbursement shall remain the same for those services that are currently reimbursed at a rate that is between 90 percent and 120 percent of the 2008 Louisiana Medicare Region 99 allowable.
   2. 2. For those services that are currently reimbursed at a rate above 120 percent of the 2008 Louisiana Medicare Region 99 allowable, effective for dates of service on or after January 1, 2008, the reimbursement for these services shall be reduced to 120 percent of the 2008 Louisiana Medicare Region 99 allowable.

4. D. Effective for dates of service on or after August 4, 2009, the reimbursement for all physician services rendered to recipients 16 years of age or older shall be reduced to 80 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.

   1. 1. For those services that are currently reimbursed at a rate below 80 percent of the Louisiana Medicare Region 99 allowable, effective for dates of service on or after August 4, 2009, the reimbursement for these services shall be increased to 80 percent of the Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.
   2. 2. The following physician services are excluded from the rate adjustment:
   3. a. preventive medicine evaluation and management;
   4. b. immunizations;
   5. c. family planning services; and
   6. d. select orthopedic reparative services.
   7. 3. Effective for dates of service on or after November 20, 2009, the following physician services are excluded from the rate adjustment:
   8. a. prenatal evaluation and management; and
   9. b. delivery services.
5. E. Effective for dates of service on or after January 22, 2010, physician services rendered to recipients 16 years of age or older shall be reduced to 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.
6. 1. The following physician services rendered to recipients 16 years of age or older shall be reimbursed at 80 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount:
7. a. prenatal evaluation and management services;
8. b. preventive medicine evaluation and management services; and
9. c. obstetrical delivery services.
10. F. Effective for dates of service on or after January 22, 2010, physician services rendered to recipients 16 years of age or older shall be reduced to 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.
11. G. Effective for dates of service on or after January 22, 2010, all physician services that are currently reimbursed below the reimbursement rates in §15113.D-F shall be increased to the rates in §15113.D-F.

12. H. 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. 1. vaginal-only delivery (with or without postpartum care);
    2. 2. vaginal delivery after previous cesarean (VBAC) delivery; and
    3. 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.

13. I. Effective for dates of service on or after July 1, 2012, reimbursement shall be as follows for the designated physician services:

    1. 1. reimbursement for professional consultation services (procedure codes 99241-99245 and 99251-99255) shall be discontinued;
    2. 2. reimbursement for cesarean delivery (procedure codes 59514-59515) shall be reduced to equal reimbursement for vaginal delivery fees (procedure codes 59409-59410); and
    3. 3. reimbursement for all other professional services procedure codes shall be reduced by 3.4 percent of the rates on file as of June 30, 2012.
14. J. Effective for dates of service on or after February 1, 2013, the reimbursement for certain physician services shall be reduced by 1 percent of the rate in effect on January 31, 2013.
15. K. Effective for dates of service on or after February 1, 2018, physicians, who qualify under the provisions of §15110 for services rendered in affiliation with a state-owned or operated entity that has been designated as an essential provider, shall receive enhanced reimbursement rates up to the community rate level for qualifying services as determined in §15110.C.
16. L. Effective for dates of service on or after May 1, 2021, the fee on file for inpatient neonatal critical care services(as specified in CPT) shall be increased by 5 percent.
17. M. Administration of treatments related to a declared public health emergency shall be reimbursed at up to 100 percent of the Louisiana Region 99 Medicare rate for the duration deemed necessary by the Medicaid Program to ensure access.

18. N. Effective for dates of service on or after January 20, 2025, the department allows for the coverage of certain physician administered drugs (specifically biosimilars) by all Mary Bird Perkins (MBP) Cancer Center locations throughout Louisiana. Coverage of biosimilar medications will be made for CPT codes listed on the Louisiana Medicaid MBP biosimilars fee schedule and reimbursement will be determined using the following methodology.

    1. 1. Reimbursement and periodic updates to the rates shall be made in accordance with the approved Louisiana Medicaid State Plan provisions governing physician-administered drugs in a physician office setting:

       1. a. average sales price (ASP) plus 6 percent, for drugs appearing on the Medicare file;

       2. b. reimbursement rates for drugs that do not appear on the Medicare file shall be determined utilizing the following alternative methods:

          1. i. the wholesale acquisition cost (WAC) of the drug, if available;
          2. ii. if there is no WAC available, the reimbursement rate will be 100 percent of the provider’s current invoice for the dosage administered.
19. O. Effective for dates of service on or after July 1, 2025, the Medicaid fee shall be set at 85 percent of the 2024 Louisiana Region 99 Medicare allowable fee for both current and newly added procedure codes.

Authority Note

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

Historical Note

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 37:904 (March 2011), LR 39:3300, 3301 (December 2013), LR 41:541 (March 2015), LR 41:1119 (June 2015), LR 41:1291 (July 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 44:62 (January 2018), LR 47:477 (April 2021), LR 47:887 (July 2021), LR 48:1100 (April 2022), LR 51:71 (January 2025), LR 51:1860 (November 2025).