Louisiana LA

Louisiana publishes PA on its own terms via two distinct loci. (1) FFS medical/service PA lives in Gainwell-operated lamedicaid.com Provider Manuals: ~50 service-line manuals each linking a manuals/<X>/<X>.pdf chapter PDF that states PA/precertification requirements inline (no single master code list for medical FFS). (2) Pharmacy/drug PA is LDH-hosted: a Single PDL (statewide, applies across FFS + MCOs since 2024 single-PDL/per-MCO-PBM transition) plus a Drug PA form coversheet, off ldh.la.gov/pharmacy. Managed-care (Healthy Louisiana, 5 MCOs) PA is delegated to each MCO (Humana Healthy Horizons publishes its own Preauthorization & Notification List). Authority split: LDH = policy/PDL owner; Gainwell/lamedicaid.com = FFS provider-manual + portal operator; MCOs = delegated managed-care PA. NOTE: prior pinned ldh.la.gov/page/* URLs (pa_index, pharmacy, provider_manual 3025) now 404 — LDH migrated to /medicaid/* and /pharmacy. The doc-288 repin (rediscover-sources, today) pointed pa_codes_master at a Humana MCO preauth list — an MCO-delegated artifact, not the LDH FFS authority.

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2022-02-11. Next due: 2026-12-31. Contracts extended through: 2026-12-31.

## 1. How LA requires PA Louisiana's Medicaid program requires prior authorization (PA) for a variety of services and medications. The process is managed through two primary loci: the Louisiana Department of Health (LDH) and the fiscal agent Gainwell, which operates the Louisiana Medicaid Provider Portal (lamedicaid.com). For fee-for-service (FFS) providers, PA requirements are detailed in service-line manuals hosted on lamedicaid.com. These manuals cover medical services including bariatric surgery (PA required; effective 10/1/2015) and physician-administered drugs. The physician-administered drug coversheet requires documentation of primary and secondary diagnoses, pain type, surgery date if applicable, and relevant laboratory values; step-therapy is not mentioned. Pharmacy-related PA is managed via documents hosted by LDH. The Pharmacy / PDL documents list medications requiring prior authorization, such as buprenorphine and buprenorphine/naloxone agents (diagnosis-code and quantity-limit requirements), and topical acne agents (non-preferred brands require medical-necessity documentation). ## 2. How LA publishes and reports PA Louisiana publishes its PA requirements through multiple channels. For FFS providers, PA guidance is embedded within service-line manuals on lamedicaid.com. Pharmacy-specific PA requirements are published in the Louisiana Medicaid Prior Authorization List and the PDL on LDH's website — e.g., the 2026 LA Medicaid Prior Authorization List includes Abecma intravenous suspension (idecabtagene vicleucel, HCPCS Q2055), which requires preauthorization from the Humana National Transplant Network, effective Jan. 1, 2026. Reporting of PA decisions is not explicitly detailed in the source documents; it likely follows standard procedures within each MCO and through Gainwell's portal for FFS providers. No centralized cross-MCO reporting mechanism is described. ## 3. LA's CMS-0057-F and PA-reform compliance posture Louisiana's structured publication of PA requirements (service-line manuals + the PA List/PDL) is relevant to CMS-0057-F and PA-reform expectations, though the source documents do not detail how CMS-0057-F compliance is monitored or reported. Louisiana has a Gold Card Law (SB 112) establishing a process for expedited review of certain prior-authorization requests. On carve structure: pharmacy is carved into MCOs (MCOs manage PA for those drugs); behavioral health (BH) uses an integrated approach with a partial carve-out; and long-term services and supports (LTSS) are carved out to state FFS. Louisiana is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Louisiana. The local model's earlier "Workforce Innovation and Opportunity Act" expansion was a hallucination and is incorrect.) No WISeR participation should be inferred for LA. ## 4. How LA runs its own program Louisiana's Medicaid program is structured around a mix of managed care organizations (MCOs) and FFS providers. The MCO procurement cycle occurs roughly every three years; the last award was made on February 11, 2022, with contracts extended through December 31, 2026. The fiscal agent has transitioned from ACS-Inc to Conduent/Gainwell over time. Gainwell operates the Louisiana Medicaid Provider Portal (lamedicaid.com), the hub for FFS providers to access service-line manuals and submit PA requests (the portal is noted as partially functional in the source documents — some manual URLs return Page Not Found). Louisiana has implemented several 1115 waivers, including the Healthy Louisiana SUD 1115 Demonstration Waiver (extension) and a Reentry 1115 Demonstration Waiver. Carve structure (repeated): pharmacy carved into MCOs; BH integrated with a partial carve-out; LTSS carved out to state FFS. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Dual-Locus Management:** PA requirements published through two distinct systems — service-line manuals on lamedicaid.com (FFS) and a separate PA List / PDL hosted by LDH. - **Frequent Updates:** Frequent PA-guideline updates (e.g., the 2026 PDL and revised service-line manuals). - **Carve-In/Out Policies:** A nuanced mix of carve-in and carve-out arrangements. ### What's Missing/Uncertain: - **Centralized Reporting Mechanism:** No centralized cross-MCO/FFS PA reporting described. - **Specific Compliance Measures:** CMS-0057-F monitoring/reporting specifics not provided in the corpus. - **Foster Care Program:** No foster-care MCO program is noted; implications unclear without more context. Overall, Louisiana's PA process is well-documented across multiple channels, with gaps around centralized reporting and specific compliance measures.