Did Louisiana Medicaid managed care have to pay advanced practice nurses the same rate as other providers?

Plain-English summary

Senator Don Hines asked whether advanced practice registered nurses (APRNs) treating patients through Louisiana's Medicaid managed care arrangements had to receive the same reimbursement as other providers. In Opinion 03-0135, the Attorney General concluded that the Medicaid Managed Care Program fell within the then-existing definition of a qualified plan. The statute barred that plan from paying an APRN less than another provider for the same service.

The opinion distinguished CommunityCARE, which linked Medicaid patients to doctors, from the broader Medicaid Managed Care Program and its public insurance coverage. The AG said CommunityCARE by itself was not a qualified plan, but the program that included it was. He also said APRNs did not have to be listed as primary care physicians in CommunityCARE; the statute addressed reimbursement for services they provided under a physician's direction.

Currency note

This opinion was issued in 2003. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

What the opinion meant at issuance

Advanced practice registered nurses

Under the statute the AG applied, an APRN providing covered basic-benefit services under a physician's direction could receive direct reimbursement. For the same services, the qualified plan could not pay the APRN less than another health care provider. The opinion did not make APRN enrollment as a CommunityCARE primary care physician a condition.

Medicaid managed care administrators

The AG treated the Medicaid Managed Care Program as a qualified plan even though its coverage was public insurance. His conclusion rested on the program's basic benefits, its state and federal funding arrangement, the federal waiver, and the statute's express inclusion of Medicaid recipients in the definition of an enrollee.

Common questions

Q: Did the equal-rate rule apply only to private health plans? A: The AG said no. He found no public-insurer exclusion in the statute and applied it to the Medicaid Managed Care Program described in the request.

Q: Was CommunityCARE itself the qualified plan?
A: No. The opinion described CommunityCARE alone as a link between patients and doctors; the broader Medicaid Managed Care Program, including Medicaid insurance, satisfied the qualified-plan definition.

Q: Did an APRN need to be registered as a primary care physician to receive payment? A: The AG said no. He read the statute to require direct reimbursement for covered services provided under a physician's direction, without making APRN listing as a CommunityCARE primary care physician necessary.

Q: Did the opinion require equal payment for different services? A: No. The statute's comparison was with other providers performing the same services.

Background and statutory framework

The opinion quoted LA. R.S. 40:2212, as amended by Act 704 of 2001, on direct reimbursement and equal rates for APRNs. It quoted LA. R.S. 40:2211's definitions of a qualified plan and enrollee. The AG considered the Medicaid program's basic benefits, the federal approval of CommunityCARE's waiver through February 29, 2004, and the state's payment of the stated enrollment fee. Those dated program details were part of his 2003 reasoning.

Citations and references

Statutes in the opinion: LA. R.S. 40:2211 and LA. R.S. 40:2212. Legislation discussed: Act 704 of 2001.

Source

• Landing page: https://www.ag.state.la.us/Opinions
• Original PDF: https://www.ag.state.la.us/Opinion/Download/03-0135

Original opinion text

DEPARTMENT OF JUSTICE
One American Place
301 Main Street, Suite 600
c,w, DW S,ON
P.O. Box 94005
BATON ROUGE
TEL.: (225) 342-7013
FAX: (225) 342-2090
RICHARD P. IEYOUB
70804-9005
ATTORNEY GENERAL

,APR 2003
OPINION NUMBER 03-0135

75A NURSES
Honorable Don Hines 49 HEALTH - Louisiana State Board of Health
including parish boards of health.
Louisiana State Senate, District 28 53 HOSPITALS - Blood tests, etc.
P.O. Box 262
LA. R.S. 40:2212 applies to both public and private
insurance programs, in that it requires that advanced
Bunkie, Louisiana 71322
practice registered nurses get reimbursed at the same
rate as other health care providers who perform the same services.
Dear Mr. Hines:

You have requested an opinion from our office on whether Advanced Practice Registered Nurses (APRNs) working under the Medicaid Managed Care Program should be reimbursed at the same rates as other health care providers.
More
specifically your request inquires about the applicability of LA. R.S. 40:2212 to situations where APRNs are treating medicaid patients in a Medicaid Managed Care Program clinic.

In 2001, the legislature amended LA. R.S. 40:2212 with Act No. 704, which mandates that APRNs get paid the same rate as other healthcare providers when performing the exact same services. LA. R.S. 40:2212 now reads: "[a]ny qualified plan shall not exclude from direct reimbursement health care services provided by an advanced practice registered nurse who provides health care services under the direction of a physician for basic benefit services covered by the basic health plan." LA. R.S.
40:2212. The statute goes further to state that, "[a]ny qualified plan shall not reimburse health care services provided by an advanced practice registered nurse at a rate less than the rate paid to other health care providers who perform the same services." LA.
R.S. 40:2212.

In order to determine whether reimbursement is warranted under LA. R.S. 40:2212, it must first be determined whether we are dealing with a "qualified plan." In the definitions section of this statute, a "qualified plan" is defined as a "basic benefits plan that may be established under a health maintenance organization, health insurance organization, or managed care organization that contracts with the state to provide or coordinate the provision of health care services to an enrollee." LA. R.S. 40:2211.

It is important to discuss the nature of the Louisiana Community Care Program ("CommunityCARE") and the Community Care Clinics you mentioned in your letter.
Department of Health and Hospitals (DHH) has maintained that CommunityCARE is nothing more than a link between medicaid patients and providers, and that Community CARE does not meet the aforementioned definition of a "qualified plan." However, CommunityCARE patients are provided health care services through a public health care insurance plan, medicaid. While the definition for a "qualified plan" does not refer to public or private insurers, it does contain suggestive elements that meet the characteristics of medicaid.

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OPINION NUMBER 03-0135
Don Hines
Page - 2-

The intent of the legislature is clear by the language of the preamble of Act 704, which states its purpose is, "[t]o enact R.S. 40:2212(C), relative to basic benefit plans provided under a health care cost control program; to prohibit the basic benefit plan from excluding direct reimbursement for [APRNs]; to require reimbursement for [APRNs] at a rate equal to that paid other health care providers for performance of the same services..." It is the opinion of this office that there is no intent to differentiate between public and private health care providers, and absent such intent, it is assumed that all APRNs will be reimbursed according to the statute.

Moving from the intent of the legislature to the exact language of the statute, we can still find no evidence that R.S. 40:2212(C) is only applicable to private insurers. Hence, the crux of the question hinges on whether the Medicaid Managed Care Program, under which CommunityCARE is created, meets the definition of a "qualified plan." As mentioned above, the elements of a qualified plan are that it must be a basic benefits plan. Title XlX of the Social Security Act requires certain basic services to medicaid recipients such as: inpatient hospital services, outpatient hospital services, physician services, medical and surgical dental services, rural health clinic services, etc. www.cms.hhs..qov/medicaid/mservice.asp.

Therefore Medicaid provides a basic benefits plan through a public insurance program, just as private insurers do (i.e., Blue Cross and Blue Shield of Louisiana). Next the statute goes on to suggest that this plan may, not shall, be established under a health maintenance organization, health insurance organization, or managed care organization. Again this is merely suggestive language under which the plan may be established. Medicaid is however, a "health insurance organization," despite the fact that it is public. This is evident by the language of Louisiana’s Department of Health and Hospital website, which states that, "[m]edicaid is the public insurance program that reimburses for health care services provided to low-income elderly, disabled and families with children." http://www.dhh.state.la.us/MEDICAID/

The statute further states the plan would be one which contracts with the state. According to the Federal Medical Assistance Percentages (FMAP) from Louisiana’s Medicaid Program, Medicaid is approximately 70% federal funded and 30% state funded. Furthermore, the federal government has approved Louisiana’s request to expand the CommunityCARE Medicaid Managed Care Program. According to a March 8, 2002 letter to Mr. Ben Beardon, Director of Louisiana’s Department of Health and Hospitals, the federal government states that its approval for the CommunityCARE program "provides for the waiver of the following Sections of Title XlX of the Act: Section 1902(a)(10)(B) (Comparability of Services), and Section 1902(a)(23) (Freedom of Choice)." The letter states the approval is for a two-year period from March 1, 2002 to February 29, 2004. This is clearly a contract between the federal government and the state, which distributes funding for CommunityCARE and medicaid insurance, to, as R.S. 40:2211 states, "provide or coordinate the provisions of health care services to an enrollee."

Our last element of the definition for a "qualified plan" involves the definition of an "enrollee," according to the statute. An enrollee under this definition section is defined

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OPINION NUMBER 03-0135
Don Hines
Page - 3 -

as "any Medicaid recipient or indigent, uninsured, or underinsured person enrolled in a qualified plan for the provision of health care services whose enrollment costs are paid wholly or in part by the state under a federal waiver to the Medicaid program." LA. R.S. 40:2211. Since the enrollment fee of $3.00 for CommunityCARE patients is paid by the state, and CommunityCARE operates under the aforementioned federal waiver, these
CommunityCARE medicaid
patients meet the definition of an enrollee.
www.dhh.state.la.us/NEWS/faqconcerninqcc.htm. (question #9 regarding enrollment fee).

While CommunityCARE by itself does not meet the definition of a "qualified plan," because it simply links medicaid patients to doctors, the Medicaid Managed Care Program under which it operates does meet this definition. It is therefore our conclusion that since Act 704 makes no distinction between public and private insurance programs, APRNs are to be paid equally. These APRNs do not need to be listed as a Primary Care Physician (PCP) under the CommunityCARE program. All R.S. 40:2212(C)(1) mandates is that the "qualified plan" (Medicaid coverage)"shall not exclude from direct reimbursement health care services provided by an advanced practice registered nurse who provides health care services under the direction of a physician for basic benefit services covered by the basic health plan." LA. R.S. 40:2212. It is irrelevant whether these APRNs are registered as PCPs, since the physicians under whom they are working should be registered. Further analysis of R.S. 40:2212(C)(2) dictates that these APRNs should be paid the same when performing the same procedures.

While it has been addressed by previous correspondence regarding this opinion that CommunityCARE is not a "qualified plan," we are of the opinion that it is the public insurance it offers that is a "qualified plan." It is the Medicaid Managed Care Program, which includes both CommunityCARE and medicaid insurance, that makes R.S. 40:2212 applicable to the situation described in your opinion request. If it was intended to exclude public insurers from having to reimburse APRNs at an equal rate, new legislation should be enacted in order to make that distinction. We trust this answers your inquiry. Please contact our office if you have any further questions or concems.

Very truly yours,

RICHARD P. IEYOUB
ATTORNEY GENERAL

By:
CHARLES H. BRAUD, JI
Assistant Attorney Genera

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