Nursing Facility Transition Services in Louisiana assist eligible Medicaid participants in moving from nursing homes or other institutional settings into community-based residences. These services are part of Louisiana’s Home and Community-Based Services (HCBS) waivers and federal initiatives like Money Follows the Person (MFP). The goal is to ensure that individuals have the necessary resources and coordination to successfully relocate to the least restrictive, most integrated setting possible.

1. GOVERNING AGENCIES

Agency: Louisiana Cabinet for Health and Family Services (CHFS) — Department for Medicaid Services (DMS)
Role: Oversees eligibility, waiver enrollment, and Medicaid funding for transition services

Agency: Louisiana Department for Aging and Independent Living (DAIL)
Role: Provides oversight, monitors transition activities, and ensures participant rights during the move

Agency: Centers for Medicare & Medicaid Services (CMS)
Role: Administers federal oversight and funding for transition programs like MFP

Agency: Managed Care Organizations (MCOs)
Role: Authorize transition services, coordinate provider reimbursement, and track outcomes

2. SERVICE OVERVIEW

Nursing Facility Transition Services are person-centered supports designed to help individuals plan and execute their move from institutional care to a private home or community-based residence.

Covered transition services include:

• Transition planning and readiness assessments
• Coordination with case managers, facility discharge teams, and family members
• Identification and securing of housing and supports
• Development of a Person-Centered Service Plan (PCSP) for post-transition care
• Assistance with arranging home modifications, community supports, and service authorizations
• Moving logistics and household setup (may overlap with Community Transition Services)
• Short-term follow-up to ensure stability and safety
• Transitions must be voluntary, and the individual must meet the criteria for HCBS waiver eligibility.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

• Register business with the Louisiana Secretary of State
• Obtain IRS EIN and Type 2 NPI
• Enroll through the Medicaid Partner Portal Application (MPPA)
• Maintain liability and workers’ compensation insurance
• Employ Transition Coordinators or case managers with experience in community integration
• Develop a Nursing Facility Transition Policy & Procedure Manual
• Ensure HIPAA-compliant documentation and participant tracking systems

4. LOUISIANA PROVIDER ENROLLMENT PROCESS

Step 1: Medicaid Enrollment via MPPA

• Apply as a provider of Nursing Facility Transition or Community Transition Coordination under applicable waivers
• Identify intended geographic service areas and targeted populations

Step 2: MCO Credentialing

• Complete enrollment with MCOs managing Medicaid waiver services in your region

Step 3: Documentation Submission

• Submit business license, insurance, staffing credentials, and transition protocols

Step 4: Begin Services Post Authorization

• Receive participant referral
• Develop transition plan with the waiver case manager and participant
• Coordinate all pre-discharge and post-move supports
• Submit documentation and invoices for approved services

5. REQUIRED DOCUMENTATION

• Articles of Incorporation or Louisiana business license
• IRS EIN and NPI verification
• Proof of liability and workers’ comp insurance

Nursing Facility Transition Policy & Procedure Manual, including:

• Participant intake and housing readiness assessment
• Transition timeline and service tracking logs
• Coordination forms with case managers, discharge planners, and MCOs
• Consent forms, HIPAA policies, and safety protocols
• Housing resource tools and stabilization follow-up checklists
• Medicaid billing logs and service outcome documentation
• Critical incident response and participant feedback forms

6. STAFFING REQUIREMENTS

Role: Transition Coordinator / Community Integration Specialist
Requirements: Experience in case management, housing navigation, or disability support services, background check; transportation capability preferred

Role (optional): Peer Support Specialist
Requirements: Trained in participant advocacy and post-transition support

All staff must complete:

• HIPAA and participant confidentiality training
• Person-Centered Planning and waiver compliance education
• Abuse, neglect, and exploitation prevention protocols
• Transition planning, emergency response, and housing stability training
• Ongoing professional development in community-based long-term services and supports (LTSS)

7. MEDICAID PROGRAMS & HCBS WAIVERS

Nursing Facility Transition Services are available through:

• Supports for Community Living (SCL) Waiver
• Michelle P. Waiver (MPW)
• Acquired Brain Injury (ABI & ABI-LTC) Waivers
• Home and Community Based (HCB) Waiver
• Money Follows the Person (MFP) — federal program that funds transition efforts

Service delivery settings include:

• Participant’s current nursing facility (for discharge planning)
• Community-based homes or apartments (for follow-up services)
• Coordination offices and virtual meetings

8. TIMELINE TO LAUNCH

Phase: Business Registration and Manual Development
Timeline: 1–2 months

Phase: MPPA Enrollment and MCO Credentialing
Timeline: 60–90 days

Phase: Staff Hiring and Documentation Setup
Timeline: 1 month

Phase: Service Launch Based on Waiver and MFP Referrals
Timeline: Ongoing

9. CONTACT INFORMATION

Louisiana Department for Medicaid Services (DMS)
Website: https://chfs.ky.gov/agencies/dms

​Medicaid Provider Enrollment (MPPA): https://mppa.ky.gov

​Louisiana Department for Aging and Independent Living (DAIL)
Website: https://chfs.ky.gov/agencies/dail

​Money Follows the Person Program (KY MFP)
Website: https://chfs.ky.gov/agencies/dms/dca

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10. SCOPE OF WORK

• MPPA Medicaid enrollment and MCO credentialing
• Transition Policy & Procedure Manual development
• Intake forms, assessment tools, and discharge planning templates
• Coordination protocols with nursing facilities, housing agencies, and waiver teams
• HIPAA and billing documentation setup
• Post-transition stabilization tools and reporting templates