La. Admin. Code tit. 22 § XIII-503

Current through Register Vol. 50, No. 9, September 20, 2024

Section XIII-503 - Limits on Awards

A. General

1. There will be a $15,000 limit for awards for all victims with the exception of those primary victims who become totally and permanently disabled as a result of the crime. For those awards, the board may, at its discretion, award up to $25,000, depending on availability of funds, its administrative rule limits for certain award benefits, and the extent, if any, of collateral resources. For purposes of this Section:

a. a victim is "totally and permanently disabled" if the victim has a physical or mental impairment that substantially precludes them from obtaining gainful employment and appears reasonably certain to continue without substantial improvement throughout their life;

b. the board reserves the right to obtain an impartial medical expert, at its expense, if necessary, to assess the degree of disability of the victim.

2. All applications filed as the result of the death of a victim will be assigned one claim number with the deceased listed as the primary victim. Each additional claimant and/or secondary victim must submit a separate application with the appropriate claim form(s) and supporting documents. The aggregate claims arising out of the same crime will be subject to the maximum amount authorized by law.

3. Payments for forensic medical examinations shall not exceed $600 for the healthcare provider, and $1,000 for the healthcare facility.

B. Attorney Fees

1. The board does not reimburse victims for fees charged by an attorney to prepare an application or represent the victim in any way unless the fees result from a hearing ordered by the board.

2. Those reimbursable charges are set at a maximum of $50 per hour for a total of five hours or $250.

3. The appeals process does not constitute a hearing. Thus, any fees charged by an attorney to represent a victim/claimant at an appeal are not compensable.

C. Funeral Expenses

1. The board will reimburse up to a maximum of $5,000 ($6,500 for crimes occurring after May 1, 2023) to cover reasonable expenses actually incurred for the funeral, burial, or cremation.

2. Death and/or burial insurance taken out specifically for the purpose of burial must pay first. The amount of life insurance proceeds paid is no longer considered as a collateral source for funeral expenses.

D. Lost Wages/Earnings

1. When lost wages are part of a claim, lost wages will be considered before out-of-pocket or other medical expenses are considered.

2. The inability to work must be directly related to the victimization and documented by the appropriate medical doctor. That medical opinion is subject to professional review and audit.

3. Violently assaulted victims who do not require medical intervention (i.e., doctor visit, emergency room treatment) will be allowed a reimbursable recuperation period:

a. if no sick time or other compensation is available, the board may grant up to five working days of lost wages;

b. wage verification by the employer is required.

4. The board may reimburse lost wages/earnings as follows:

a. 80 percent of the gross weekly wage of the victim For seasonal or part time wages, the amount shall be calculated at 80 percent of the average weekly wage;

b. for the loss of income from work by the parent or legal guardian of a minor or dependent victim who must miss work to obtain or provide the medically indicated services or care for the personal injury.

5. If workers' compensation or other private disability/income protection insurance is available, those policies must be paid out first before the board considers a claim for lost wages.

6. If the victim cannot return to work, the lost wage period may include future lost wages.

7. If a person is not gainfully employed or is not receiving entitlement at the time of the crime, then no lost wages can be determined nor awarded. However, an award for loss of wages based on seasonal, nonsalaried or intermittent work, or a bona fide offer of employment may be based on an average net anticipated salary for the period of employment.

8. Only the following list of physicians can legally determine physical disability:

a. medical doctor;

b. oral surgeon;

c. psychiatrist;

d. physiatrist;

e. ophthalmologist;

f. surgeon.

g. Nurse practitioner or physician assistant (under supervision of licensed physician)

9. If a victim is initially treated by one doctor and that doctor refers the victim to another doctor, the referral doctor can determine disability from the date of the incident.

E. Loss of Support

1. For loss of support for a surviving spouse or other dependent to be considered, the following documentation must be provided:

a. death certificate signed by the coroner;

b. individual federal and state tax return for year before the crime to show dependency of claimant;

c. employment/wage verification completed and signed by the victim's employer;

d. verification of life insurance claimed by dependent filing application; and

e. documentation that Social Security or other pension benefits are not available to surviving spouse or dependents.

2. Loss of support for a surviving spouse may be awarded at the discretion of the board when no other collateral resources exist and the inability to work exists or the opportunity to find work could be delayed due to age, frailly, and lack of previous work experience.

3. The board will reimburse loss of support up to a maximum award of $ 10,000 ($15,000 for crimes occurring after May 1, 2023).

a. The board may award loss of support up to the maximum amount per week authorized for lost wages in §503.D.4 That amount is based on net, after-tax, or take home pay.

b. When only gross income is provided by a claimant, then the board will award the loss of support at 80 percent of the amount authorized in §503.D.4 for lost wages.

F. Ambulance

1. A maximum of $300 for regular ambulance transport. A maximum of $500 exists for air medical transport.

2. Air transport services are considered ambulance services and reimbursed as such.

3. The medical portion of the ambulance bill is to be considered as a medical cost and paid at the medical per cent consistent with all other claims for that claimant.

4. If the ambulance bill is part of the total hospital bill and the total hospital bill is under $ 15,000, the ambulance transfer bills will be isolated and paid separately. If the total bill is over $ 15,000, the ambulance charges will not be isolated for payment.

G. Medical Expenses.

1. The board reserves the right to audit any and all billings associated with medical care. All treatment must be considered "usual and customary" and be directly related to the victimization.

2. The board will not pay any interest, finance, or collection fees as part of the claim process.

3. The board will pay up to 70 percent of all outstanding charges after any third-party payment sources up to the statutory limits.

4. If the total outstanding charges exceed the maximum award cap, then all providers listed in the claim will be paid out at the actual percentage for those bills in relation to the available case funds.

5. Out-of-pocket paid ironies will be reimbursed to the victim prior to applying this payment schedule.

6. Rates for Reimbursement

a. Physicians, psychiatrists, state-certified or state-licensed psychologists, licensed professional counselors, and board-certified social workers are eligible for reimbursement. In addition, a provisionally licensed mental health provider, who is under the supervision of a licensed mental health provider, is eligible for reimbursement. The session notes submitted to the board for review must be signed by the supervising mental health provider.

b. The board will not reimburse more than one psychological evaluation (as defined in §503.I 5

i. The board will not reimburse for any intake evaluation or psychological testing.

ii. The board will not reimburse for any more than one in-patient treatment, group or individual, per day. Support or family day sessions and "community" meetings are not reimbursable.

iii. All in-patient mental health service charges are reimbursed at the same session rate as out-patient mental health services, that is:

(a). Doctoral Level Providers (e.g. M.D. PhD., PsyD.), $110/session).

(b). Master's Level Providers (e.g., L.P.C., L.C.S.W., L.M.F.T., P.L.P.C, P.L.C.S.W, P.L.M.F.T., D.S.W.) $90/session.

(c). Group Therapy rates (90 minutes)($50/ session).

c. Therapeutic groups outside the per diem charge of the hospital will not be reimbursed.

d. All therapist charges that are outside the per diem charge of the hospital will be limited to no more than one session per day at a rate described in §503.I 8

7. Only those medicines and drugs prescribed by a licensed physician are compensable.

8. Reimbursable providers include licensed medical doctors, dentists, eye doctors, chiropractors, osteopaths, pediatrists, psychiatrists psychologists, physical therapists, etc.

9. Compensable medical services include emergency ambulance service, medical examinations, X-ray and laboratory services, whirlpool baths ordered by a doctor.

10. Only services of a nurse as prescribed by a licensed physician are compensable.

11. Aids such as hearing aids, false teeth, eyeglasses, contact lenses, crutches, and wheelchairs needed as a direct result of the crime or that were damaged or destroyed during the crime are compensable.

12. Tattoo removal for victims of human trafficking:

(a). must be performed by board certified physician; or

(b). non-physician acting under direct supervision of a licensed physician.

H. Travel Expenses. Transportation costs other than the initial ambulance services are reimbursable only when required medical care is not locally available. Certification is required by the physician of record that local medical care is unavailable. Allowable private vehicle mileage for out-of-town travel is reimbursed at the rate published in the current state travel regulations.

I. Mental Health Counseling

1. It is the board's opinion that the majority of those directly victimized by violent crime (e.g., primary victims) can obtain significant improvement within the first six months of qualified counseling. The board recognizes that short-term crisis management counseling may also be needed for secondary victims (defined as primary family members or cohabitors of the victim).

2. Limits on Charges

a. For the life of each claim, reimbursable charges may not exceed $2,500. These limits include the cost of all treatment services and psychological or neuro/psychological evaluations/testing as described in §503.1.8 Victims/claimants may apply for an additional $2,500 in reimbursement when there is a documented need for long-term mental health services.

b. All applications for extended reimbursement of mental health expenses are subject to peer review by a psychiatrist or psychologist, licensed by the state of Louisiana, consulting with the board which will have a peer review of the following:

i. complete progress notes for crime-related conditions(s) being treated;

ii. any psychological evaluations/testing pertaining to the crime-related condition;

iii. description of prior conditions or treatments;

iv. updated treatment plan.

3. Limits on Evaluation/Testing

a. Psychological evaluation/testing may not exceed $800 and neuropsychological evaluation/testing may not exceed $1,500.

b. Any evaluation/testing must be conducted by a licensed psychologist and should include the following:

i. description of any structured interview used;

ii. case formulation and DSM-V diagnoses.

4. Treatment plans completed by the therapist of record (or primary therapist) are required for consideration of mental health expenses. The therapist must show that the psychological condition being treated is a direct result of the crime. Treatment plans must be fully documented in a "problem" and "intervention" format. Detail must be provided for both symptom and intervention. Single word descriptors such as "nightmares" or supporting counseling" will not suffice. Insufficient treatment plans will be returned to the originating therapist and the case may be deferred or denied until revised.

5. Payments for services are subject to review and audit by the board.

6. Rates for Reimbursement

a. Only physicians, psychiatrists, state certified or state licensed psychologists, licensed professional counselors, or board-certified social workers are eligible for reimbursement.

b. The rates for reimbursement shall be the same as authorized in §503 Limits on Awards G.6.b.

i. - iii. Repealed.

7. It is the board's assessment that psychiatric inpatient hospitalization of a crime victim is rarely required. If under unusual circumstances such treatment is required, compensation will be subject to a peer review as previously described. Reimbursement for such treatment is limited in amounts and procedures listed under "medical" services.

8. Any claim for injuries sustained may be denied if prescribed or preempted as a matter of law.

J. Catastrophic Property Loss

1. A maximum award up to $ 10,000 ($15,000 for crimes occurring after May 1, 2023) may be awarded if a victim's abode is owned by them and destroyed by criminal act.

2. This loss must produce a "verifiable" overwhelming financial effect for that person.

3. This is considered when no insurance exists or the ability to rehabitate the structure is precluded due to lack of personal resources.

K. Vehicular Incidents

1. Eligible expenses include those resulting from death or personal injury as outlined in the statute if they are incurred resulting from DWI or hit and run offenses, fleeing felon incidents, or injuries intentionally inflicted with a motor vehicle, boat or aircraft.

2. Vehicular accident related injuries, other than those caused by the above are not compensable.

L. Child Care Expenses

1. Pre-existing child care costs are not reimbursable if those same costs were being incurred prior to the crime.

M. Crime Scene Evidence

1. Expenses associated with the collection and securing of crime scene evidence are limited to:

a. reasonable replacement costs for clothing;

b. bedding; or

c. property seized as evidence or rendered unusable as a result of a criminal investigation or lab test.

2. Medical Examination of Sexual Assault Victims

a. Costs of the forensic medical examination are reimbursable by the Crime Victims Reparations Board (CVR Board) under this Section and payable directly to the healthcare provider who provides the service. All other expenses related to victims of sexual assault are reimbursable by the board subject to the maximum permitted by law and the provisions of the Crime Victims Reparations Act and its administrative rules.

b. In instances where the sexual assault victim assigns his or her rights to collect reparations for reimbursable medical expenses beyond those associated with the forensic medical examination to the hospital/health care facility, the hospital/health care facility must submit the following items directly to the CVR Board within one year of the date of service in order to receive reimbursement:

i. victim of sexual assault assignment of rights form, signed by the victim;

ii. hospital/health care CVR application;

iii. itemized bill for services rendered.

c. The sexual assault victim may submit these expenses to his or her private insurance or other third-party payor. If these expenses are paid by insurance or other third -party payor, the hospital/health care facility may file an application with the CVR Board for any unreimbursed expenses.

d. Nothing in this Section shall preclude a sexual assault victim or claimant from filing a regular or emergency application for additional benefits.

3. Healthcare providers shall be reimbursed for expenses associated with providing a forensic medical exam in the same amount as provided for in the fee schedule in §503.M.4 The total amount reimbursable to all providers per forensic medical exam (FME) is limited to $1000. All x-rays, ultrasounds, CT scans, extensive dental work, and lab/diagnostic test not listed in the schedule below related to the sexual assault must have supporting documentation to support testing.

4. Non scheduled FME expenses will be reimbursed at a rate of 55 percent. (eff. 1/1/22).

5. Forensic Medical Exam Reimbursement for Sexual Assault Cases

Examination Fee	Maximum Reimbursement
Forensic Medical Exam Incl. Rate Kit, MD/SANE Nurse Exam, Anogenital Exam, Supplies, Toxicology Kit, Facility Fee	$1000
Physician Fees	Maximum Reimbursement
Anogenital Exam	$150
Anoscopy	$120
Follow-Up Office Visit	$150
Mental Health Office Visit-Initial Eval	$150
Mental Health Office Visit-Follow-Up	$90
Laboratory Testing	Maximum Reimbursement
CBC	$65
Chlamydia	$110
CMP	$90
Gonorrhea	$80
Hepatitis Panel	$160
Herpes	$30
HIV	$80
Lab Pregnancy Test	$30
Syphilis/RPR/Treponema Pallium	$25
Trichomonas	$40
Urinalysis	$30
Urine Culture	$50
Venipuncture	$50
Wet Mount	$50
Medications	Maximum Reimbursement
Antimicrobials	$100
Antiretroviral/HIV/nPEP	$500/5 Doses
Emergency Contraception	$50.00
Hepatitis B Vaccine	$70/Dose {up to 3 doses}
HPV Vaccine-Females age 9-26 and Males age 9-21	$150/Dose {up to 3 doses}
Injection Fee	$50
Tetanus Vaccine with injury	$40

6. Repealed.

N. Medical Examination of Sexual Assault Victims

1. A healthcare provider can submit a claim for reimbursement for a forensic medical exam performed on a victim of a sexually-oriented criminal offense. The direct reimbursement claim form must be accompanied by the attestation form signed by the forensic medical examiner. The healthcare provider who performs the forensic medical exam will be reimbursed an amount as provided by law. The healthcare facility at which the forensic medical exam was conducted will be reimbursed an amount as provided by law.

2. The reimbursement amounts for the forensic medical exam will cover the services (listed by R.S. 40:1216.1).

3. Healthcare services or expenses ancillary to a forensic medical examination and directly related to the crime may be reimbursed.

O. Crime Scene Cleanup

1. Crime scene cleanup means the removal or attempted removal of blood, stains, odors, broken glass, impurities or other debris caused by the crime or the processing of the crime scene where the crime occurred.

2. Expenses submitted for cleaning the residential crime scene of the victim may not exceed $2500.

3. Types of allowable expenses for clean up include:

a. equipment rental;

b. disinfecting and cleaning supplies;

c. professional cleaning services insured for that purpose.

4. Expenses for crime scene cleanup cannot be used for:

a. repair of property damaged in the crime

b. replacement of personal property;

c. costs not directly billed to victim and/or claimant.

P. Loss of Support for Victim in Sexual Crimes

1. Loss of support may be paid on behalf of a child victim of a sexual offense if the offender was providing support through employment or a benefits program before the date the crime was committed.

2. Claimant qualifications:

a. must be a parent, or legal guardian of the minor child(ren);

b. must provide documented proof that offender supported the home and minor child victim;

c. is only eligible if the offender is incarcerated.

3. The board may award loss of support up to $10,000 maximum ($15,000 for crimes occurring after May 1, 2023).

Q. Relocation. Payment for relocation expenses is for those claimants who must relocate as a result of the crime for reasons of imminent danger, personal safety, or threat of injury.

1. "Threat of injury" is:

a. where a victim/claimant is directly threatened and there is a reasonable probability that physical and/or emotional injury would result if the threat were carried out, and/or

b. a victim was within sight and range of proximity of a person brandishing a weapon or other dangerous instrument and who felt reasonably threatened for their own safety.

2. Reimbursement for relocation expenses is limited up to $5,000 per household of the claimant.

3. A police and/or incident report should be submitted with the claim to verify the basis for relocation.

La. Admin. Code tit. 22, § XIII-503

Promulgated by the Office of the Governor, Crime Victims Reparations Board, LR 20:539 (May 1994), amended LR 22:710 (August 1996), LR 24:328 (February 1998), LR 25:26 (January 1999), LR 26:1019 (May 2000), LR 29:577 (April 2003), LR 31:1330 (June 2005), LR 32:242 (February 2006), LR 35:65 (January 2009), LR:37:1605 (June 2011), LR 39:1042 (April 2013), LR 41:1668 (September 2015), Amended LR 42570 (4/1/2016), Amended LR 42743 (5/1/2016), Amended LR 44270 (2/1/2018), Amended LR 4840 (1/1/2022), Amended LR 49922 (5/1/2023), Amended LR 501274 (9/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:1801 et seq.