MedicaidCoverageMedium impact
Personal Care Services for Adults with Serious Mental Illness - MEDICAID - LOUISIANA (Revised)
Humana·LA · Psychiatry, Geriatrics, Occupational Therapy +1 more·Medicaid
Effective date
Jul 20, 2026
We identified it
Jul 16, 2026
Summary
This is a revised Medicaid policy for Personal Care Services (PCS) for adults with serious mental illness in Louisiana, effective July 20, 2026. The policy establishes coverage criteria, service limitations (20 hours/week maximum, 30-day annual per diem limit), and prohibits direct medication administration by personal care workers. Billing teams must ensure claims comply with eligibility requirements, service hour limits, and exclude prohibited activities like medication setup or services during facility admissions.
Action Required
Before July 20, 2026: Billing team must update claim processing rules in billing software to enforce the following for Louisiana Medicaid (Humana Healthy Horizons) PCS claims: (1) Verify member age ≥21 years and transition/diversion from nursing facility via My Choice Louisiana program; (2) Enforce 20-hour weekly maximum (1 unit = 15 minutes); allow per diem only up to 30 calendar days per year; (3) Reject claims for medication administration, setup, or insertion of catheters/sterile procedures; (4) Deny claims for services during hospitalization, nursing facility, or residential facility stays (except admission/discharge days); (5) Verify service plan is in place before processing any claim; (6) Reject duplicate billing when member attends programs providing ADL/IADL assistance; (7) Require LMHP or physician recommendation documentation in medical record before payment. Update encounter forms to capture service plan dates and weekly hour totals. Train billing staff to flag claims exceeding limits for medical director review. Failure to enforce these limits will result in claim denials and potential overpayments.