Adult BehaviOilii'HeiithState: Louisiana 1915(i) Hess State plan Services State Plan Attachment 3.1...

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -.

1915(i) State plan Home and Community-Based Services

Administration and Operation

The State implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit for elderly and disabled individuals as set forth below.

1. Services. (SpecifY service title(s) for the HCBS listed in Attachment 4.J9-B that the State plans to cover):

Adult BehaviO~8iHeaIth seiYides~ii.criri;~ii(\WtJ:i; f!ieaehiiYi.otitr~eaith -r?i?(Ii)w.~v.t- . ' under a ~ltated coQ.traCtreimb'W::Semtmt methodology '. . ... ~. , .. ::. .; ... ', . .

2. Statewideness. (Select one):

• The State implements the 1915(i) State plan HCBS benefit statewide, per §1902(a)(I) of the Act.

0 The State implements this benefit without regard to the statewideness requirements in § 1902(a)(I) of the Act. State pIan HCBS will only be available to individuals who reside in the following geographic areas or political subdivisions of the State. (SpecifY the areas to which this option applies):

3 State Medicaid Agency (SMA) Line of Authority for Operating the State plan HCBS Benefit. (Select one):

• The State plan HCBS benefit is operated by the SMA. Specify the SMA division/unit that has line authority for the operation of the program (select one):

0 The Medical Assistance Unit (name of unit): I .' .. : . ' 0.'.·- .

• Another divisionlunit within the SMA that is separate from the Medical Assistance Unit (name of division/unit) Office of Behavioral l:fealth·(OBH}within Dep~~ntof . -.' .

This includes Health and Hospitals(DHH), " " ., ~. : . . r.~ ·: .' ..

. '. administrations/divisions ' . ... , under the umbrella

. "'. ",

agency that have been '" ",

identified as the Single .. .

State Medicaid Agency. ..

0 The State plan HCBS benefit is QPerated by (name of aKency)

a separate agency of the State that is not a division/unit of the Medicaid agency. In accordance with 42 CFR §431.1 0, the Medicaid agency exercises administrative discretion in the administration and supervision of the State plan HCBS benefit and issues policies, rules and regulations related to the State plan HCBS benefit. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this delegation of authority is available through the Medicaid agency to CMS uJX1ll request.

STATE h... auf ~ 1'df.N\..a.

DATEREC'6 ~ - 10 - If DATE APPV'D '2-11-{/ A I)ATE EFF a -\-12

SUPERSEDES: NONE -NEW PAGE HCfA 179 II -l~ __ L....._ " .'

_ .. _:---_ .. _._L_ .....

TN# _11-13. ___ --'Approval Date \ 2.. ' 1<\- II - Effective Date_31112012. _____ _ Supersedes TN# __ None. __ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -. Page I

1915(i) State plan Horne ana Community-Basea Services

.tt.<:tministration ana Operation

The State implements the optional 1915(1) State plan Home and Community-Based Services (HCBS) benefit for elderlY and disabled individuals as set furth below.

1. Services. (SpecifY service titleM for the HeES listed in Attachment 4.19-E that the State plans /JJ cQver):

Adult BehaviOilii'Heiith servi&S:~ii~Dt~ththeaebJYl9IiLHeaith -r91~(b)Wtdv& ,'" ' under a capitated oo$actreimb'W;scment methodology', c,' "': ,:'" ", " ,

1. Statewideness. (Select one):

• The State implements the 1915{i) State plan HCBS benefit statewide, per § 1902(a)(1) of the Act.

0 The State implements this benefit without regard to the statewideness requirements in § 1902(a)(l) of the Act. State plan HCBS will only be available to individuals who reside in the fOllowing geograpbic areas or political subdivisions of the State. (SpecifY the areas 10 which this option applies):

. '

3 State Medicaid Agency (SMA) Line of Authority fur Operating tile State plan If CBS Benefit. (Select one):

The State plan HCBS benefit is operated by the SMA. SpecifY the SMAdivisionlunit thet has line authority for the operation of the program (select one): o The Medical Assistance Unit (name afunit): I

.' .. : .

• Another divisionlunit within the SMA thet is separate :from the Medical Assistance Unlt (name of division/unit) Offioo'of'Behavj.oral fiealth.(OBf!Ywithin D~\lIlfof This includes Health and Hospitals (DHH) :" " "., :.', ' " administrations/divisions ,,' , under the umbrella agency that have been identified as the Single i State Medicaid Agency.

o The State plan HCBS benefit is operated by (name of agency)

a separate agency of the State the! is not a division/unit of the Medicaid agency. In accordance with 42 CPR §431.1 0, the Medicaid agency exercises administrative discretion in the administration and supervision of the State plan HCBS benefit and hames policies, roles and regulatiollS related to the State plan HCBS benefit. The interagency agreement or memorandum of undCllitanding thet sets fOrth the authority and arrangements for this delegation of authority is available through the Medicaid agency to CMS upon request.

STATE __ ~~~OU~I~~~;~~~~a~_ DATE REC'I!, '3 - 10 - I' DATEAPPV'O '2 -\q - t I A OATEEFF 0- 1- 12

HerA 179 I! - 1"3 __ !.......c.._... !It ._ .. -:o---.,.,-.-.L-..... -

SUPERSEDES: NONE· NEW PAGE

TNII_Il-13, ___ --'Approval Date \2..' 11,- II . Eftective Dato_31112012. _____ _ Supersedes TN#_None. __ _

11·13-2008

State: Louisiana § 1915(i) Hess State plan Services State Plan Attachment 3.1 -Ao Page1"

4. Distribution of State plan HCBS Operational Bod Admioistrative Functions.

(;11' (By checking this box the State assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes andlor approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specifY the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies):

(Check all aJtencies and/or entities that peiform each {Unction):

Function

I Individual State plan HeSS enrollment

2 State plan Hess enrollment managed against approved limits, if any

3 Eligtbility evaluation

4 Review of participant service plans

5 Pnor authorization of State plan HeSS

6 Utilization management

7 Qualified provider enrollment

8 Execution of Medicaid provider agreement

9 Establishment of a consistent rate methodology for each State plan HCBS

10 Rules, policies, procedures, and information development governing the State plan HeSS benefit

11 Quality assurance and quality improvement activities

Medicaid Agency

OlberState Operating Agency

Contracted Entity

LocalNon~

Stale Entity

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(Specify. as numbered above, the agencies/entities (other than the SMA) that peiform each function):

J, < < STATE vaul~!AAa

DATE REC'1lI 3 - 10 ~ II DATE APPV'D /2. - I q -1/ A.

SUPERSEDES; NONE - NEW PAGE , ,

I)ATE ~F j\ - I -I?--HCFA 179 II -13

~'"-. -------';-... -=. ~, . .."

TN# _l1 - 13, ___ ----.:Approval Date \2·)9 ~ II Effective Date_3/112012, ___ __ _ Supersedes TN# __ None. _ _ _ _

11-13-2008

State: Louisiana § 1915(i) Hess State plan Services State Plan Attachment 3.1 -Ao Page1"

4. Distribution of State plan HCBS Operational Bod Admioistrative Functions.

(;11' (By checking this box the State assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes andlor approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specifY the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies):

(Check all aJtencies and/or entities that peiform each {Unction):

Function

I Individual State plan HeSS enrollment

2 State plan Hess enrollment managed against approved limits, if any

3 Eligtbility evaluation

4 Review of participant service plans

5 Pnor authorization of State plan HeSS

6 Utilization management

7 Qualified provider enrollment

8 Execution of Medicaid provider agreement

9 Establishment of a consistent rate methodology for each State plan HCBS

10 Rules, policies, procedures, and information development governing the State plan HeSS benefit

11 Quality assurance and quality improvement activities

Medicaid Agency

OlberState Operating Agency

Contracted Entity

LocalNon~

Stale Entity

; :: 'i~( " :'C , ';; ;:,-,~,',: ,_.':'" ' '( : ,'i~r,: 0 ),'... . ,. ' .::. \ . ' ';' .-. ': . _ ..... . : ..

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-, ;". ?l?j' ....

. -.. ... -., :: . ," . .1 .. ' .,. - .

,; , 0 , " , "" , "., ' ~

... :;"'~" ', :0

(Specify. as numbered above, the agencies/entities (other than the SMA) that peiform each function):

J, < < STATE vaul~!AAa

DATE REC'1lI 3 - 10 ~ II DATE APPV'D /2. - I q -1/ A.

SUPERSEDES; NONE - NEW PAGE , ,

I)ATE ~F j\ - I -I?--HCFA 179 II -13

~'"-. -------';-... -=. ~, . .."

TN# _l1 - 13, ___ ----.:Approval Date \2·)9 ~ II Effective Date_3/112012, ___ __ _ Supersedes TN# __ None. _ _ _ _

11-13-2008

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -I:r Page'"

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4.

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. ·· ofOBifan(r¥.~~iC " ,.. , " . . . . .:, ;' '':" '.';' " .. , ,: ' . :.:.

..... J.:: .. '.. . . '". . 'i '\' ." .'. . . '" . ..... . ',''' ' .":.: ' . ' :' ::":':"'::.,;". y~ . " ->:"~: . .

6.UtiIization ~getnen.twiqbc; .cOD"ducted .bY theSMOp~lllIIit!9polici~:~d prqcedur~.set u andsub'eet to the a iovalofOBH aridMedicaia:.· . .... . . . . p . ~ " •. ; '. ' PII. ".'"." .' ." .... . ,,, ". , . '.

7. Q~ed pro~der:~o%#t ~h4r~~lll.i~ ·~~c::~~Ji~g¢(¢~y;i,il~:'~rRMi>l4'~9~iit!p;, ' .. ~ pOlicies.and prOcediu'e's'set lipiirid ~iibject to iheiippio'YaJ. ·9f.OB!I;lirid'MediCiUik ' .' . ., ,f: •. ' . .

.' . ,,', . ;. ' .~-\. . .. . '" . ': ," '", .;.;" . .

8. Execution ofMCdi~d tVideia';" ~eiiisWith HCBSroV1ders ~~;&hdtict~~htfu:·· . • " . .P .. :Q ... ... ,, !ll' ., ".:''''' ' '' ". p '''. '' " " . ..... " . '.'CO· .Y. .... SMO. Execution.ofthc;SMO Coiittact WiJl be Wi!hOBH ~thoverSightfrOmMedi9iiia:'): .

- ', ..... -' \. ' ", -. . "'. . .. ' ~ ~,~:' ':"' " , . , ', . ~ . ' . . . . . .; . ' ..... .'.:: ' ... : ..... i·~~.:·.~ .. .. i... . .' .... ~ . . ... : _ .. <:': :~~~~:";~f .:.; .

9. Establishment of a «onsisteilt~tefo:ethcidolOgy. for,ea~h· State· plan HCBS .i¢ b}'.tlX;Medicaid

a~ency. · . '. . " :";'; .". . ,~;, " ,:;: ~.;~ ' · k: /";;, 10. RuI~. poli~ieS, pi;9<;e<hlres andiiir~~tion .developl!lent g9~~'~~ .S~£ p~HCBS

benefit- RnIes are prCimulgated by the Medicaidag~cy. Policies. p.!'.IiC¢ili-es ilnd.iPiQrmation Will be genenilly ouilined!Ji theSfvIO coIitiact by OBR The SMO Will develOp foi:Jiial provider !;lllUluals. billirig 'guidelin~ imd infonnation subject to .aBH agreement

.~ . ~. ' ;:.~'.' . '.' ' . ;,.:~, ... '!. .:.;~: .:: . .. . . . " .. , .... .' . ~;~ •• ~~ .• .,.:... .. : .. >.: .'. . ...

~UPERSEDES; NONE - NEW PAGE OA-rE REC·B_~3.L-:;."J,l.IOL-:..ILJ'L-_ DATE APPV'o ......... I?"' . .:..-.J..! 1i:L:.,.-!.,!.II_ I)ATE EFF __ .o6c.:-:....J,..:! -:J.I:..:J-~_

W# _1l-13 ___ --'Approval Date Supersedes W# _ _ None. __ _

11-13-2008

A

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -I:r Page'"

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4.

. .'~'.: ' .... . ':.' . ':; ::(';'j~c; :>" : .. ~. :" . -,'J:. :~; :::'f : ". ... ',_ 5. WiIl .jJ~co1Uiu«@.DY;;th~SMQ·.p.~iilIr!t::topo!icies · anll ·

. ·· ofOBifan(r¥.~~iC " ,.. , " . . . . .:, ;' '':" '.';' " .. , ,: ' . :.:.

..... J.:: .. '.. . . '". . 'i '\' ." .'. . . '" . ..... . ',''' ' .":.: ' . ' :' ::":':"'::.,;". y~ . " ->:"~: . .

6.UtiIization ~getnen.twiqbc; .cOD"ducted .bY theSMOp~lllIIit!9polici~:~d prqcedur~.set u andsub'eet to the a iovalofOBH aridMedicaia:.· . .... . . . . p . ~ " •. ; '. ' PII. ".'"." .' ." .... . ,,, ". , . '.

7. Q~ed pro~der:~o%#t ~h4r~~lll.i~ ·~~c::~~Ji~g¢(¢~y;i,il~:'~rRMi>l4'~9~iit!p;, ' .. ~ pOlicies.and prOcediu'e's'set lipiirid ~iibject to iheiippio'YaJ. ·9f.OB!I;lirid'MediCiUik ' .' . ., ,f: •. ' . .

.' . ,,', . ;. ' .~-\. . .. . '" . ': ," '", .;.;" . .

8. Execution ofMCdi~d tVideia';" ~eiiisWith HCBSroV1ders ~~;&hdtict~~htfu:·· . • " . .P .. :Q ... ... ,, !ll' ., ".:''''' ' '' ". p '''. '' " " . ..... " . '.'CO· .Y. .... SMO. Execution.ofthc;SMO Coiittact WiJl be Wi!hOBH ~thoverSightfrOmMedi9iiia:'): .

- ', ..... -' \. ' ", -. . "'. . .. ' ~ ~,~:' ':"' " , . , ', . ~ . ' . . . . . .; . ' ..... .'.:: ' ... : ..... i·~~.:·.~ .. .. i... . .' .... ~ . . ... : _ .. <:': :~~~~:";~f .:.; .

9. Establishment of a «onsisteilt~tefo:ethcidolOgy. for,ea~h· State· plan HCBS .i¢ b}'.tlX;Medicaid

a~ency. · . '. . " :";'; .". . ,~;, " ,:;: ~.;~ ' · k: /";;, 10. RuI~. poli~ieS, pi;9<;e<hlres andiiir~~tion .developl!lent g9~~'~~ .S~£ p~HCBS

benefit- RnIes are prCimulgated by the Medicaidag~cy. Policies. p.!'.IiC¢ili-es ilnd.iPiQrmation Will be genenilly ouilined!Ji theSfvIO coIitiact by OBR The SMO Will develOp foi:Jiial provider !;lllUluals. billirig 'guidelin~ imd infonnation subject to .aBH agreement

.~ . ~. ' ;:.~'.' . '.' ' . ;,.:~, ... '!. .:.;~: .:: . .. . . . " .. , .... .' . ~;~ •• ~~ .• .,.:... .. : .. >.: .'. . ...

~UPERSEDES; NONE - NEW PAGE OA-rE REC·B_~3.L-:;."J,l.IOL-:..ILJ'L-_ DATE APPV'o ......... I?"' . .:..-.J..! 1i:L:.,.-!.,!.II_ I)ATE EFF __ .o6c.:-:....J,..:! -:J.I:..:J-~_

W# _1l-13 ___ --'Approval Date Supersedes W# _ _ None. __ _

11-13-2008

A

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -Sr

(By checking the following boxes the State assures that):

S. 0 Conflict ofInterest Standards. The State assures the independence of persons performing evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum, that persons perfurming these functions are not:

• related by blood or marriage to the individual, or any paid caregiver of the individual • financially responsible for the individual • empowered to make financial or health-related decisions on behalf of the individual • providers of State plan HCBS fur the individual, or those who have interest in or are employed by

a provider of State plan HCBS; except, at the option of the State, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified provider in a geographic area, and the State devises conflict of interest protections. (If the State chooses this option, specifY the conflict of interest protections the State will implement):

mill in&ces.~t~al f.9!$(i}~ilr{)u,in~~;~~~l?illt,y"~~~iSi?gsj . sU1>'~~ctit?'W~'lip~rp~,of<?Blf'· and Medicaid' tiir 'etinlind .clinical rieoos"bliSedCriteriaassessments 'Willb'ci ' "ed'6#Doo If the

~~~al~z.~;~~~;~~~~;~!~~~rP"t;:~~fof~!;~~r~~W~~~~e assessment units lite ~4mini:it$tively:separate from utilizatiQii revievl11,riits' liiidfunctians: · The SMO cIiniCalneeds"b'ilSed:assesSinents will bi:reVlewed purSiuiritto the 1915(i) QIS .. . . reqwrenientslist~ 1#~r'k:biisSt~tePhlnbY'D~staft :' ·i<., . " ., .~,~ . . " , In .addition,the SMO will CQndi!i:t. reviews of all individualsco!Dpleting assc;ssl!lents~d plans of care to enSure thiiithey are riot'proY@erl; whohave.im mt~t iii or are etnplO'yed'by a '· ." . provider who isoD. the pllin of care; . Tlie SMOwiij utilize authority under b;eatment,planning per 42 CFR 438.208(c) to identUY. aSsess and devekip treatrilent pm for individuaiSWith special health care riOOds as defined under this 1915(i) au$>rity,. , ..

' . - '. In particular the following conflict niitjgation strategies will be u~ by OBH: • Assuring that indiViduals .~ advqcllte for .themselves or h8ve an advocate prc;sent in planning meetings. , '.: .:/':; .'. . . .. .. . .. • Documenting that the individuafh8s ~n offered choice am6ng all qualified prdvidersof direct services. '. . : . . • Establishing administrative separation between those doing assessments and service plaim:ing and thoSe delivtiring direct services. '~.' . . " . . . .... • Establishing a consumer Council withlnthi: iirgairlZation to .moMor is~eSofChoic¢: • Establishing clear, well-JaiowD, ~ easily acCessible means for cOhsliIri~ to, inake grievances and/ot'appeaIsto the State for assistance regarding cOllCems about cho'ice, quality, and outcomes. .. . ' ' . ' .. , ' . ., '.. --

• Documenting the number andtypes: o,~appeals and the deciSiOns regarding grievances andIo.r appeals. . ' . ::.. . ..' .'. " .. :.. ." .. J .... . . .... ,. .•• • " . •. ::' " ,.' . . ".. .

• Having State quality maniig!llIientstaff ov.erseetheSMO tpassure Co~er l;hoil;;eand control are not compromised. . .' . . . . .. . . . .. . • Documenting consumer experienceS with measures that capture~e quality of pllin of care development. . .

QUPEBSEDE;S: NONE - NEW PAGE STATE t. au i jS Itvl\4. DAlE REG'IY a -/0 - 11

-=:-:::-:-::~:--___ :--_=-=-:----;-:~;-;:;--:-:-:--::=-::---;::-:::-:-:;-;;-;::= .. !DATE APPV'D I ;z. ~ \ q- II ) .TN# _11-13 ___ ~Approval Date_",12",-°ilq::t...:"'-LI.LC _Effective Date_31112012 I)ATE EFF 3 - I -/ J- _ Supersedes TN# _None ~c:?A 179 ___ I \ - 1'0

1T-'T3'20()a-.:=.L~

State: Louisiana §1915(i) HeBS State plan Services

(Yy checking the following boxes the State assures that):

StatePlanAUachment3,1 -Sr Page 4

5. Ii:! Conflict of Interest Standards. The State assures the independence of persOIlS performing evaIualiO!lll, assessments, and plallS of care. Written conflict of interest standards ensure, lit a minimum, that persO!lll perfurming these functions are not:

.. related by blood or marriage to the individual, or any paid caregiver of the individual

.. financially responsible for the individual

.. empowered to make financial or health-related decisions on behalf of the individual

.. providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HeBS; except, at the option of the State, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified provider in a geograpbic area, and the State devises conflict of interest protections, (If the State chooses this option, specify the conflict of interest protections the State will implement):

In .ad.dition,tbe Sf'40 will cond~!:t reviews of all in!lividualscop:!pleting ass!iS~nts~ plans of care to ensure thitttliey are notproyi:!erswhohavean mt~t iii or are OOlpiO'yedby a' ... . provider who is on the plan of care; . The SMO:wiU utilireauthority under treatment,planning per 42 CFR 438.208(c) to identifY, aSsCss and devekip treatment pllu:is fur individuals With special health care needs as defined undet: this 1915(i) autj1.ority.. . .

In particular the fu llo)Ving Conflict niiligati<?n strategies will be utilizt;d by OBH: • Assuring that indiViduals.~ advQru;te fur .themselves or have an advocate PfliSent in planning meetings. ,':";.... . '. .... . ' • Documenting that the individual has been offured choice anKmg all qualified providersof direct services. . ' . . ., . .. . ; . , . • Establishing administrative separation between those doing assessments and service planniog and thoSe deliveJ:mg dir!lct services. '; -. . . .,.. . ..' . • Establishing a consumer Council withlnthil orgavization tol.llQrutor l,s~esofChoicf;i: • Establishing clear, Well-kn.own, ~ easily accessible means fur oohsum'iml to, inake grievances andJonpp6a1s to the State fur assistance regarlling cOllcerns about choice, quality, and outcomes. .. . . .. . .. .., . . .

• Documenting the number andtypes.o.~l'tppeals and the deciSiOns regarding grievances andIo.r appeals.:. . ":', "'. ' . • Haviog State quality managl'llIitl!ll:staff overseetheSMO~as~ eonsili:llii: qhoipe.and control are not compromised. . ..' .. . .. . . • Documenting consumer experienceS with measures that captUJ::eJhe quality of plan of care development. . .

s;[JJ?EBSEDgi: NONE - NEW PAGE

State: Louisiana § 1915(i) HeSS State plan Services State Plan Attachment 3.1 -&-

6. (;:1 Fair Hearings and Appeals. The State assures that individuals have opportunities for fair hearings and appeals in accordance with 42 CFR 431 Subpart E. Enrollees will exhaust the PIlIP appeals process as outlined in J9J5(b) per 42 CFR 438 subpartF.

7. (;:1 No FFP for Room and Board. The State has methodology to prevent claims for Federal financial participation for room and board in State plan Hess.

8. (;:1 Non-duplicatlon of services. State plan HeSS will not be provided to an individual at the same time as another service that is the same in nature and scope regardless of source, including Federal. State. local. and private entities. For habilitation services. the State includes within the record of each individual an explanation that these services do not include special education and related services defined in the Individuals with Disabilities Improvement Act of 2004 that otherwise are available to the individual through a local education agency. or vocational rehabilitation services that otherwise are available to the individual through a program funded under § 110 of the Rehabilitation Act of 1973.

STATE b.0t< f utan a...

DATEAPPV'D /& ~ Ie:) ~ II A I)ATE EFF :1 - ) - I 6-

S'U"PERSEDES: NONE - NEW PAGE HC;=A 179 !I ~ 1":<\ • __ ~ ....... -.-____ • ____ .. _._,t.._ ... .....J

TN# _1l-13 ___ ---'Approval Datel:l. - J t\ -II Effective Date_3/112012. _____ _

Supersedes TN# __ None,-__

11-13-2008

State: Louisiana §1915(i) HeBS State plan Services State Plan Attachment 3.1 -Qy Page 5

6. Ii!'1 Fair Hearings and Appeals. The State assures that individuals have opportunities for fair hearings and appeals in accordance with 42 ePR 431 Subpart E, Enrollees will exhaust the PIHP appeals process as outlined in J9/5(b) per 42 CFR 438subpartF.

7. Ii!'1 No FFP fur Room and Board. The State has methodology to prevent claims for Federal financial participation for room and board in State plan HeBS.

8. Ii!'1 Non-duplicatlon of services. State plan HeSS will not be provided to an individual at the same time as another service that is the S!\ll1e in nature and scope regardless of source, including Federal, State, local, and private entities. For habilitation services, the State includes within the record of each individual an explanation that these services do nol include special education and relaled services defined in the Individuals with Disabilities Improvement Act of 2004 that otherwise are available to the individual through a local education agency, or vocational rehabilitation services thet otherwise are available to the iodividual througb a program funded under § 110 of the Rehabilitation Act of 1973.

SUJ1'ERSEDES: NONE - NEW PAGE

STATE J"OttI Ma:n a.... DA"fE REC'~ a ~ JQ - II DATEAPPV'D Irk ~ I~ ~ II I)ATEEFF 8- 1~16

f' A

He;::A 179 11-1'2 __ ~ ......... ....-__ ",_ ...... __ ,_._L_ ..... ~

Eflective Dalo_3/112012, _____ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3. I -.

Target Group(s) X Target Group(s). The State elects to target this 1915(i) State plan HCBS benefit to a specific

population. With this election, the State will operate this program for a period of 5 years. At least 90 days prior to the end of this 5 year period, the State may request CMS renewal of this benefit fur additional5-year terms in accordance with 1915(i)(7XC). (SpecifY target group(s):

An Adult over the age of 18 who meets one of-the following criteria iii eligible to receive State Plan HCBS services:

Persons with ACUfE Stabilization Needs- The person with AS needs currently presents with mental health symptoms that are consistent with a diagnosable mental disorder specified within the Diagnostic and Statistical Manual of Mental Disord!=!'s (OSM-IV-TR) or the International Classification of Diseases, Wroth Revision, Clinical Modificaticin{ICD-9-CM), or subsequent revisions of these documents.

• Persons with SM! (federal SAMHSA definition of Serious Mental illness as of 12111201 1)The person with MMD has at least one diagnosable mental disorder, which is commonly associated with higher levels of impairment These diagnoses, per the Diagnostic and Statistical Manu;d of Mental Disorders (OSM-IV -TR) or the IntenuitionRl Classification of Diseases, Wroth Revision, Clinical Modification (ICD-9-CM), include only:

Psychotic Disorders 295.10 - Schizophrenia, Disorganized type 295.20 - Schizophrel!ia, Catatonic type 295.30 - Schizophrenia, Paranoid type 295.60 - Schizophrenia, Residual type 295.70 - Schizoatrective Disorder 295.90 - Schizophrenia, Undifferentiated type 297.1 - Delusional Disorder 298.9 - Psychotic Disorder, NOS

Bipolar Disorders

~-----------------~---. STATE Lou r ~ .. CVh 4

DATE REC'rJ 3 -/0 - U DATEAPPV'D /2.-1q -/ [ I)ATE EFF 3 ~ /~''b He:=A 179 tI - I ~ .__. L....,;,..,..o-. _______ • ___ ........ __..&:..-=--. ..... -...

296.00-Bipoiar Disorder, Single Manic Episode 296.40-Blpolar I Disorder, Most Recent Episode Manic 296.50-Bipolar I Disorder, Most Recent Episode Depressed 296.60-Bipolar I Disorder, Most Recent Episode Mixed 296.7 -Bipolar I Disorder, Most Recent Episode Unspecified

296.80-Bipoiar Disorder NOS SlJP_, _EDSED""c,. NONE _ NEW PAGE 296.89-Bipolar II Disorder - E> """

Depression 296.2x - Major Depressive Disorder, Single Episode 296.3x - Major Depressive Disorder, Recurrent only

• Persons with MMD (Major Mental Disorder)

• An adult who has previously met the above criteria and needs subsequent medically necessary services for stabilization and maintenance.

Note: Individuals eligible for EPSDT will receive these services through the EPSDT State Plan and not under the 1915(i).

Exclusion: diagnosis of a substance use disorder without an additional co-occurring Axis I disorder.

TN# _11-13 ___ ~Approval Datel:l.. -1,,\-11 Effective Date _31112012. _____ _

Supersedes TN# __ None'--__

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3. I -. Page 6

Target Group(s) x Target Group(s). The State elects 10 target this 1915(i) State plan HCBS benefit 10 a specifio

population. With this election, the State will operate this program for a period of 5 years. At least 90 days prior to the end of this 5 year period, the State may requeat CMS renewal of this benefit for additiona15-year terms in accordance with 1915(i)(7XC). (SpecifY target group(s):

An Adult over the age of 18 who meets one of the following criteria is eligible to receive State Plan HCBS services:

Persons with ACUI'E Stabilization Needs· The person with AS needs currently presents with mental health symptoms thet are consistent with a diagnosable mental disorder specified within the Diagnostic and Statistical Manual of Mental Diaord!l1's (OSM-IV-TR) or the International Classification of Diseases, Nmth Revision, Clinical Modification (lCD-9-CM), or subsequent revisions of these documents.

• Persons with SM! (federal SAMHSA definition of Serious Mentallllness as of 121112011) - . The person with MMD has at least one diagnosable mental di~order, which is commonly associated with higher levels of impairment. These diagnoses, per the Diagnostic and Statistical Manu;d ofMenla! Disorders (OSM-IV -TR) or the Interruitional Classification of Diseases, Nmth Revision, Clinical Modification (lCD-9-CM), include only:

Psychotic Disorders 295.10 - Schizophrenia, Disorganized type 295.20 - Schizophrenia, Catatonic type 295.30 - Scbiaophrenia, Paranoid type 295.60 - Schizophrenia, Residual type 295.70 - SchizoaffiJctive Disorder 295.90 - Schizophrenia, Undiffilrentiated type 297.1 - Delusional Disorder 298.9 - Psychotic Disorder, NOS

Bipolar Disorders

STATE Lo'14.. r 1'5 I" et,!'): <'1 DKfE REC'I:) .:3 ~ to ~ U DATE APPV'D 12. -1 q ~ If A. I)ATEFFF .~ .... I-I?.. HC:=A 119 1I ~ 1.:!1 ___. 1......:...:..""-. "" _______ ........... __ ,J:.,~'"--, ......

296.00-Bipolar Disorder, Single Manic Episode 296.40-Bipolar I Disorder. Most Recent Episode Manic 296.50-Bipolar I Disorder, Most Recent Episode Depressed 296.60·Bipolar I Disorder. Most Recent Episode Mixed 296.7-Bipalar I Disorder, Most Recent Episode Unspecified 296.80-Bipolar Disorder NOS 296.89-Bipolar II Disorder SUPERSEDES: NONE -NEW PAGE

Deoression 296.2x - Major Depressive Disorder. Single Episode 296.3x - Major Depressive Disorder. Recorrent only

• Persons with MMD (Major Mental Disorder)

• An adult who has previously met the above criteria and needs subsequent medically necessary services for stabilization and msintenance.

Note: Individuals eligible far EPSDT will receive these services through the EPSDT Stata Plan and not under the 1915(i).

Exclusion: diagnosis of a substance use disorder without an additional co-occurring Axis I disorder.

1N# _11 -13 ___ ~AW;;~;U Date _J:l. - 11 ~ II ElEctive Date _31112012.------Supersedes 1N# __ "V"~ __ _

11-13-2008

State: Louisiana §1915(i) HeBS State plan Services State Plan Attachment 3.1 - &

Because this 1915(i) State Plan Amendment specifically targets psychosocial services to individuals with Mental Illness, Louisiana is requesting five year approval of the State Plan amendment fur comparability and targeting. Prior to January I, 2017, Louisiana will renew its targeted population via a 1915(i) State Plan Renewal for an additional five year period after documenting that federal requirements are met. 1

;;t,iPEBSE.OES: NONE -NEW PAGE

• 1 The August 6, 2010 SMD letter says that five year renewal only applies if a slate targets services and populations: "If a Slate chooses to implement this option to provide State plan HCBS to a targeted population(s), the ACA authorizes CMS to approve such a SPA for a five year period. Slates will be able to renew approved 1915(i) services for additional five year periods ifCMS determines, prior to Ihe beginning oflhe renewal period, that the Slate met Fedeml and Slate requirements and that the Stale's monitoring is in accordance with the Quality Improvement Strategy specified in the State's approved SPA."

1N# _11-13 ____ .ApprovaJ Date I;l, - Itt -I ( Etrective Date_3/1/l0 I 2. _____ _ Supersedes 1N# __ None. __ _

11-13-2008

::lillie: Louisiana § 1915(i) HeBS 81l1te plan Services Sillie Plan Attachment 3.1 - & Page 7

Because this 1915(i) State Plan Amendment specifically targets psychosocial services to individuals with Mental Illness, Louisiana is requesting five year approval of the State Plan amendment fur comparability and targeting. Prior to January I, 2017, Louisiana will renew its targeted population via a 1915(i} State Plan Renewal for an additional five year period after documenting that federal requirements are met. I

;;lJPEBSW~S: NONE -NEW PAGE

"" I The Augusl6. 2010 SMD letter says that live year renewal only applies ifa state targets services and populations: "If II. State chooses to implement this option to provide Sillte plan HCBS to II. targeted population(s). the ACA authorizes CMS to approve such a SPA fur a live yes! period. States will be able to renew approved 1915(1) services fur additional five yes! periods IfCMS determines, prior 10 the beginning of the rene WIll period, that the State met Federal and State requirements and that the State's monitoring is in accordance with the Quality Improvement Strategy specified in the Slate's approved SPA."

1N#_l1-13 ___ -.:ApprovaiDate Ii}, - 11'1 ~ll EffectiveDate_3/112012. ____ _ Supersedes 1N# __ Nonc'--__

11-13-2008

State: Louisiana § 1915(i) HCBS State plan Services

Number Served

State Plan Attachment 3.1 -CPage"§"

1. Projected Number of Un duplicated Individuals To Be Served Annually.

(Specify for year one. Thars 2-5 optional):

Projected Number Projected of Participants in Number of

Annual Period From To tbe Medicaid Participants for Total Number 1915 (i) category 1915(i) only of Projected

category Participants

''lI1 hiit1 . . /,.'''' I'l ,. 32,000 " ..23;,000, '''I:. ' ' '," ., 55;000 Year 1 ' , " '

.: ) '.' .. ...

Year 2 1/117Jii 2 '" " Ij : " " ,,33;600 ·· 24'150- :!~>: , .' 5t.750 .. Year 3 1/117.01 ::I "I..;'R/;nj 4 35.280 25;358 60.638

Year 4 ::1/1/2014 n IS 37044 26.625 63;669'

Year 5 1i1I2OlS "I '''I '1/2016 38896 27.957 66~853

2. 0 Annual Reporting. (By checking this box the Stale agrees to): annually report tbe actual number of unduplicated individuals served and the estimated number of individuals for tbe following year.

STATE t..O'IIIi 0 t a./\Gt i DATE REC'~ 3 -10-1' t' '\ DATEAPPV'D i2.-- ''f~ I' n OAThFF 3 - I - I :2-

HC;:A 179 J ~ :-'_:~ .. ~;:''':=.J..~_J ~ ....... ----""'-. SUPERSEDES: NONE - NEW PAGE

TN# _l1-13 ___ ~Approval Date r 2 - 1 q - t \ Effective Date_31l12012'--____ _ Supersedes TN# _None'--__

11-13-2008


Number Servea

State Plan Attachment 3.1 -CPage 1"

1. Projected Number ofUuduplicated Individuals To Be Served AnnulIlly. (Specify for year Olle. Years 2-5 optlollal);

~&pmoo Projected Number Projected ofPamcipants in Number of

From To !he Medicaid Participants for Total Number 1915(i) category 1915(i} only of Projected

category Participants

Year 1 ::\/lnihl ' oN:'·' I?,,< , 32,000 .. , ,,23i llQO· :;;,'," 55~OOO . ::\/112012 " "13 ,,33;600', ,

"

'24h50 :?s.:, ' '57,750 Year 2 '"

Year 3 ::\/11201 :'! n": 1.<1. 35286 20,358 60,638

Year 4 ::\/1/2014 n [:Ii 37044 26,62.6 63,669'

I YearS ~i1l?01i; 212&12016 3889S 27.957 00;853 2. Ii1I Annual Reporting. (By checking this box the State agrees to): annually report !he actual number of

unduplicated individuals served and the estimated number of individuals fur !he following Year,

SUPERSEDES: NONE - NEW PAGE

TN# _1l-13 ___ --'Approval Date 12. - I q:: t \ Ef'l'WtiveDate_31l12012c.......... ___ _ Supersedes TN# _None'--__

11-13-2008

!

, State: Louisiana §1915(i) HCBS State plan Services State Pian Attachment 3.1 -&

Financial Eligibility

1. X Income Limits. (By checking this box the State assures that): Individuals receiving State plan HCBS are in eligIbility group covered under the State's Medicaid State plan, and who have income that does not exceed 150% of the Federal Poverty Level (FPL). Individuals with incomes up to 150% of the FPL who are only eligIble for Medicaid because they are receiving 1915(c) waiver services may be eligIble to receive services under 1915(i) provided they meet all other requirements of the 1915(i) State plan option. The State has a process in place that identifies individuals who have income that does not exceed l50"A of the FPL.

2. Medically Needy. (Select one):

0 The State does not provide State plan HCBS to the medically needy .

• The State provides State plan HCBS to the medically needy (select one):

• The State elects to disregard the requirements at section 1902(a)(10)(C)(i)(III) of the ,Social Security Act relating to community income and resource rules for the medically needy. Once the individual has been detennined to be eligible as medically needy using institutional rules, and has been determined to meet the 150% FPL limit, the individual would only be eligible for State plan HCBS under section 1915(i) of the Act. However, individuals who are eligible for Medicaid as medically needy under income and resource rules applicable in the community, and whose income does not exceed the 150% limit, would be eligible for State plan BCBS, as well as, all Medicaid State pian services.

0 The State does not elect to disregard the requirements at section 1902(a)(10)(C)ll)l111).

3. Presumptive Eligibility. The State, at its option, elects to provide for a period of presumptive eligibility (not to exceed a period of60 days) only for those individuals that the State has reason to believe may be eligIble for home and community-based services. Such presumptive eligIbility shall be limited to medical assistance for carrying out the independent evaluation and assessment to determine an individual's eligIbility for such services and ifthe individual is so eligIble, the specific home and community-based services that the individual will receive.

Needs-Based Evaluation/Reevaluation

1. Responsibility for Performing Evaluations I Reevaluations. Eligibility for the State plan HCBS benefit must be determined through an independent evaluation of each individual). Independent

. ,evaluations/reevaluations to determine whe.tner applicants are eligible for the State plan HCBS benefit are perfofmecl (select one)' ,', . , !,,;

, 0 : Directly by the Medicaid agency; i . . . "

, f. By.Other (specify State agency or. entity with contract with the State Medicaid agency): ,

' ,' . " . . ~ , .. ' " " .... . ,

" • Effective Date_3/112012'---____ _ TN# _11-13 Approval Date (J/I'h- II SuP.ers, .. ed, es, ,', '.,-:", .. -. .- ' . ... .. .. .. .. - , :, , . ',-, '; '1 : . .. .. _ '," ... , _ .. . _ ......... . .. . 0' .. ' ., .«'

W#_None. __ _ 11-13-2008

, State: Louisiana §1915(i) HCBS State plan Services State Pian Attachment 3.1 -& Page 9

Financial Eligibility

1. X Income Limits. (By checking this box the State assures that): Individuals receiving State plan HCBS are in eligIbility group covered under the State's Medicaid State plan, and who have income that does not exceed 150% of the Federal Poverty Level (FPL). Individuals with incomes up to 150% of the FPL who are only eligIble for Medicaid because they are receiving 1915(c) waiver services may be eligIble to receive services under 1915(i) provided they meet all other requirements of the 1915(i) State plan option. The State has a process in place that identifies individuals who have income that does not exceed l50"A of the FPL.

2. Medically Needy. (Select one):

0 The State does not provide State plan HCBS to the medically needy .

• The State provides State plan HCBS to the medically needy (select one):

• The State elects to disregard the requirements at section 1902(a)(10)(C)(i)(III) of the ,Social Security Act relating to community income and resource rules for the medically needy. Once the individual has been detennined to be eligible as medically needy using institutional rules, and has been determined to meet the 150% FPL limit, the individual would only be eligible for State plan HCBS under section 1915(i) of the Act. However, individuals who are eligible for Medicaid as medically needy under income and resource rules applicable in the community, and whose income does not exceed the 150% limit, would be eligible for State plan BCBS, as well as, all Medicaid State pian services.

0 The State does not elect to disregard the requirements at section 1902(a)(10)(C)ll)l111).

3. Presumptive Eligibility. The State, at its option, elects to provide for a period of presumptive eligibility (not to exceed a period of60 days) only for those individuals that the State has reason to believe may be eligIble for home and community-based services. Such presumptive eligIbility shall be limited to medical assistance for carrying out the independent evaluation and assessment to determine an individual's eligIbility for such services and ifthe individual is so eligIble, the specific home and community-based services that the individual will receive.

Needs-Based Evaluation/Reevaluation

1. Responsibility for Performing Evaluations I Reevaluations. Eligibility for the State plan HCBS benefit must be determined through an independent evaluation of each individual). Independent

. ,evaluations/reevaluations to determine whe.tner applicants are eligible for the State plan HCBS benefit are perfofmecl (select one)' ,', . , !,,;

, 0 : Directly by the Medicaid agency; i . . . "

, f. By.Other (specify State agency or. entity with contract with the State Medicaid agency): ,

' ,' . " . . ~ , .. ' " " .... . ,

" • Effective Date_3/112012'---____ _ TN# _11-13 Approval Date (J/I'h- II SuP.ers, .. ed, es, ,', '.,-:", .. -. .- ' . ... .. .. .. .. - , :, , . ',-, '; '1 : . .. .. _ '," ... , _ .. . _ ......... . .. . 0' .. ' ., .«'

W#_None. __ _ 11-13-2008

Slate: Louisiana §1915(i) HCBS Slate plan Services Slate Plan Attachment 3.1 •

2. Qualifications of Individuals Performing EvaluationlReevaluation. The independent evaluation is performed by an agent that is independent and qualified. There are qualifications (that are reasonably related to performing evaluations) for the individual responsible for evaluation/reevaluation of needsbased eligibility for Slate plan HCBS. (SpecifY qualificatIons):

.• ' , -, '

.', ." ~ . ·Lic6iJ.'!e4GIfui~·~Pcilll W<>'*)!:Ill'S(LCSW:s) . " .. , ... ,:" .:' . .' .. . : ' .. : ..•....... ~ ........• :-.,;.;. :.' . .. Lid:insedP~ofii$iiiOriilrCou:ns~loti;Q',PCsy. :, ...• , • Licensed~ieiui¥):1a:&iJ)'Therap.!S~;(LMFTS) " .... . . "'{: " , : • LicensedAddiction.COlinsdors(LACs): ·· ...... :. ' " . '. ',' .' • '~van'c¥ J>t:actice R~gistere<J"Ni.lis!!S (,*l)'st ·be ,/l..n,~epiac~~Q~<isped~]i~t~J\.duJt ." ."

Psychmtric & . ¥~Health,imdFaD:riJ.YPSychiaiiic 8iM!ittlll ~c;alth ota Certified NUrse speCialiSts in Psy,,4~~qcia4Getontologlcal Psychiatriq: Meiit/l.t~ci!ii~ Adult PsyChiatric and Menial Heal~andCiilld-AdoleSCent Mental Heiilth aiidmaypra\itice to.the extent that services are withiIi the APRN's soo e'of ractice . '

3. Process for Performing EvaluationIReevaluation. Describe the process for evaluating whether individuals meet the needs-based Slate plan HCBS eligibility criteria and any instrument(s) used to make this determination. If the reevaluation process differs from the evaluation process, descn'be the differences:

The evaluation and reevaluation must use the targeting and needs-based assessment criteria outlined in the 19l5(i) SPA and LOCUS assessment tool and qualified personnel This is the same process used to both evaluate and reevaluate whether an individual is eligIble for the 1915(i) services.


TN#_II-13 ___ --'ApprovaIDate 12-- '<i.h Supersedes TN# None. __ _

---STATE t.. OtA.\ 'i) I 0.. t..Q

DATE REC'D_ 0 - 10 - It DATE APPV'D 11, - (tt -II I)ATE EFF 9. - ( - l:e

II - 13 ...l HC'''A 179 / - ,t.~~' "I _._-.-.~.~ L---~--

Effective Date _3/112012. _____ _

11-13-2008

Slate: Louisiana §1915(i) HCBS Slate plan Services Slate Plan Attachment 3.1 • Page 10

2. Qualifications of Individuals Performing EvaluationlReevaluation. The independent evaluation is performed by an agent that is independent and qualified. There are qualifications (that are reasonably related to performing evaluations) for the individual responsible for evaluation/reevaluation of needsbased eligibility for Slate plan HCBS. (SpecifY qualificatIons):

.• ' , -, '

.', ." ~ . ·Lic6iJ.'!e4GIfui~·~Pcilll W<>'*)!:Ill'S(LCSW:s) . " .. , ... ,:" .:' . .' .. . : ' .. : ..•....... ~ ........• :-.,;.;. :.' . .. Lid:insedP~ofii$iiiOriilrCou:ns~loti;Q',PCsy. :, ...• , • Licensed~ieiui¥):1a:&iJ)'Therap.!S~;(LMFTS) " .... . . "'{: " , : • LicensedAddiction.COlinsdors(LACs): ·· ...... :. ' " . '. ',' .' • '~van'c¥ J>t:actice R~gistere<J"Ni.lis!!S (,*l)'st ·be ,/l..n,~epiac~~Q~<isped~]i~t~J\.duJt ." ."

Psychmtric & . ¥~Health,imdFaD:riJ.YPSychiaiiic 8iM!ittlll ~c;alth ota Certified NUrse speCialiSts in Psy,,4~~qcia4Getontologlcal Psychiatriq: Meiit/l.t~ci!ii~ Adult PsyChiatric and Menial Heal~andCiilld-AdoleSCent Mental Heiilth aiidmaypra\itice to.the extent that services are withiIi the APRN's soo e'of ractice . '

3. Process for Performing EvaluationIReevaluation. Describe the process for evaluating whether individuals meet the needs-based Slate plan HCBS eligibility criteria and any instrument(s) used to make this determination. If the reevaluation process differs from the evaluation process, descn'be the differences:

The evaluation and reevaluation must use the targeting and needs-based assessment criteria outlined in the 19l5(i) SPA and LOCUS assessment tool and qualified personnel This is the same process used to both evaluate and reevaluate whether an individual is eligIble for the 1915(i) services.


TN#_II-13 ___ --'ApprovaIDate 12-- '<i.h Supersedes TN# None. __ _

---STATE t.. OtA.\ 'i) I 0.. t..Q

DATE REC'D_ 0 - 10 - It DATE APPV'D 11, - (tt -II I)ATE EFF 9. - ( - l:e

II - 13 ...l HC'''A 179 / - ,t.~~' "I _._-.-.~.~ L---~--

Effective Date _3/112012. _____ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -&

4. 0' Needs-based HCBS Eligibility Criteria. (By checking this box the State assures that): Needs.based criteria are used to evaluate and reevaluate whether an individual is eligtble for State plan HCBS.

The criteria take into account the individual's support needs. and may include other risk factors : (SpecifY the needs-based criteria):

Needs-based Criteria /Must meet one or more ofthe foUowing criteria or has previously met the above criteria and needs

subsequent medically necessary services for stabilization and maintenance)

*The needs based criteria is measured objectively (described more fully below) through the use of the LOCUS.

I. The person is experiencing at least "moderate" levels of risk to self or others as evidenced by at least a score of 3 and no more than a score of 4 on the LOCUS Risk of Harm subscale and/or serious or severe levels of functional impairment as evidenced by at least a score of 4 on the LOCUS Functional Status subscale. This rating is made based on current manifestation and not past history. 2. The person experiences at least "moderate" levels of need as indicated by AT LEAST a composite LOCUS total score of 14 to 16. indicative of a Level of Care of 2 (aka. Low Intensity Community Based Services). 3. The person is experiencing "moderate" levels of need as indicated by AT LEAST a composite LOCUS total score of 17 to 19. indicative of at least a Level of Need of 3 (aka. High Intensity Community Based Service).


5. 0' Needs-based Institutional and Waiver Criteria. (By checking this box the State assures that): There are needs-based criteria for receipt of institutional services and participation in certain waivers that are more stringent than the criteria above for receipt of State plan HCBS. If the State bas revised institutional level of care to reflect more stringent needs-based criteria. individuals receiving institutional services and participating in certain waivers on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer require that level of care. (Complete chart below Ie summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions):

In practice, the hospital institutional criteria are approximately equivalent to a LOCUS score of 6 on the risk of harm subscale (compared to a 3 or 4 for the 1915(i) The hospital cannot admit an individual for chronic needs (Le., cannot admit for "Moderate" levels of need).

Needs-BasedlLevel of Care (LOC) Criteria

State plan HCBS needs-bared NF (& NF WC wal ..... ) ICFfMR (& ICFfMR WC AppU.able Hospital> WC (& eliglbDlty criteria walven) Hospital WC waivers) To receive 1915(1) SOIVice5. the For iriltialllld annual level of lIbe level of care criteria is T~ be admitted to on i;'l'!I~ent individual may either meet a risk care· assessl,lleuts. Louisiana ~ upon the following: psychialric bospita\, the in.dividual ofbarm subscale of3 or 4 for the ub1izes tbe Level of Care must meet a risk "ofbann subseale 1915(i) or experience a Eligibility Tool (LOCET) and/or ~ R.S. 28:451.2. Definiti""s: of 6" (this corresponds to a "moderate" level of need as the Minimum Data Set-Home composite WCUS score blgher indicated by at I .... t a composite Care (MDS-HC) to determine if • ... (12) Developmental than.iiI4) A1lmdividuals eliglDle LOCUS score of14. an individual meets nursing . loiSability means either: for inpatient hospital admission

TN# _1l-13 ___ ---'Approval Date 1"2-- I i>t -\ \ Effective Dale_31112012'--____ _ Supersedes TN# __ None, __ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -& Page 11

4. Ii:1 Needs-based RCBS Eligibility Criteria. (By checking this box the State assures that): Needs-based criteria are used to evaluate and reevaluate whether au individual is eligible for State plan HCBS.

The criteria tak:e into account the individual's support needs, and may include other risk: factors: (SpecifY the needs-based criteria).'

Needs-based Criteria (Must meet one or more of the fuRowing criteria or has previously met the above criteria lind needs

subsequent medically necessary services fur stabilization lind mainteUllnee )

"The needs based criteria is measured objectively (described more fully below) through the use of the LOCUS.

I. The person is experiencing at least "moderate" levels of risk to self or others as evidenced by at least 1I score of 3 and no more than a score of 4 on the LOCUS Risk of Harm subscale and/or serious or severe levels of functional impairment as evidenced by at least a score of 4 on the LOCUS Functional Status subscale. This rating is made based on current manifestation and not past history. 2. The person experiences at least "moderate" levels of need as indicated by AT LEAST a composite LOCUS total score of 14 to 16, indicative of a Level of Care of2 (aka, Low Intensity Community Based Services). 3. The person is experienciog "moderate" levels of need as iodicaled by AT LEAST a composite LOCUS total score of 17 to 19. indicative of alleast a Level of Need of 3 (aka, High Intensity Community Based Service). GE

SUPERSEDES: NONE - NEW PA

5. 1;;1 Needs-based Institutional and Waiver Criteria. (By checking this hox the State assures that): There are needs-based critcris fOr receipt of institutionel services and participation in certain waivers that are more stringent than the criteria above for receipt of State plan HCBS. If the State bas revised institutional level of care to reflect more stringent needs-based criteria, iodividnaIs receiving institutional services and participating in certain waivers on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer reqnire that level of care. (Complete chart below to summarize the needs-hosed criteria for State Plan HCBS and corresponding more--stringent criteria for each of the following institutions):

In pramce, the bospitel institutional criteria are approximately equivalent to a LOCUS score of 6 on the r1skofbarm subscale (compared to a 3 or 4 fur the 1915(i) The hospital cannot admit an individual for ehronic needs (I.e., cannot admit fur "Moderate" levels of need).

Needs-Based/Level of Care (LOG) Criteria

Stat. plan HCBS need ... &ased NI' (& NI' LOC WllI", ... ) ICFfMR (& ICFfMR LOC Applicable "oopilAl" LOC (& eligibility criteria waivers) """"itsl LOe waiv .... ) To receive 1915(i) services, the For milia! and lIIlIluall_l of lb. level or care criteria is To b. admitted 10 011 inP!'dent individual may either meet a risk care' assesst;nents. Louisiana based upon the following: pSyChiatric hospitaJ, thein!lividual ofharm subscsl. of3 or4 for the utmzes the Lew! of Care must meet a risk 'ofliarm subseal. 1915(1) or experience a Bligibility Tool (LOCBT) and/or La. 1l8. 28::451.2. Deliniti",!s: of 6 (this corresponds to. "modernte" level ofoee<! as the Minimum Data Set-Home composite LOCUS score bigber indicated by at least a composite Care (MDS·HC) 10 determine if ' ... (12) Developmenfal thau.id4} Allfudividuals ellgtu!e LOCUS sooreofl4. an individual meets nlll"Sing . plSability means either: for inpii6eht hospital admission

TNfI_lI-I3, ___ --'Approval Date 1'1-- I ~J~Effective Date_31112012, _____ _ Supersedes TN# __ None. __ _

11·13·2008

State: Louisiana §1915(i) HCBS State plan Services State PIan Attachment 3.1 -tIT'

•

,,'I' • Th. person' experfences at'least '

"modeiate~~ levels ofneecras ii1dic:at~ byAT LEAsT a; , ' compciS!!e !..Oemi'tcita(sixire of('4 10 16"indiaitive of a: ~I cifCareof2 (alm,1.ow Intensity Conimunlty Based Service.), '

• ,The person is e..perienciug t'modcrate" levels'ofneed as indicated by AT LBASl'a, - , composite LOCUS lo!aI 'score ofl? to 19, indic:atlveofat ' least a,LeveI ofl-ieed:of3 (alm, High Intensity QlJnmuniry BasedSOrv!ce), --

- ,

SlJP~RSEDES: NONE - NEW PAGE

_~=~" -l 1- J\."~\f> \ "". c.. STATE I\.V,", 1M'

DAlE REC'1ll .a -10 - , I Ii DATEAPPV'D L;).- 11 . II ' A I)ATE EFF Z ~I ~I!t , ' HCFA 179 11- '.2 _ ' , ! 1.--_ _ __ .. __ ._~._J......:....",_

W# _1l-13, ____ ApprovaIDate Il.--Iq - U Supersedes W# __ None'-__ _

. ~!.;:.:-.:

behavior ,: .. ~ "

', - " ' .. ". ';

Etrective Date_3/112012, _____ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State PIan Attachment 3.1 -tIT' Page 12

•

,,'I' • Th. person' experfences at'least '

"modeiate~~ levels ofneecras ii1dic:at~ byAT LEAsT a; , ' compciS!!e !..Oemi'tcita(sixire of('4 10 16"indiaitive of a: ~I cifCareof2 (alm,1.ow Intensity Conimunlty Based Service.), '

• ,The person is e..perienciug t'modcrate" levels'ofneed as indicated by AT LBASl'a, - , composite LOCUS lo!aI 'score ofl? to 19, indic:atlveofat ' least a,LeveI ofl-ieed:of3 (alm, High Intensity QlJnmuniry BasedSOrv!ce), --

- ,

SlJP~RSEDES: NONE - NEW PAGE

_~=~" -l 1- J\."~\f> \ "". c.. STATE I\.V,", 1M'

DAlE REC'1ll .a -10 - , I Ii DATEAPPV'D L;).- 11 . II ' A I)ATE EFF Z ~I ~I!t , ' HCFA 179 11- '.2 _ ' , ! 1.--_ _ __ .. __ ._~._J......:....",_

W# _1l-13, ____ ApprovaIDate Il.--Iq - U Supersedes W# __ None'-__ _

. ~!.;:.:-.:

behavior ,: .. ~ "

', - " ' .. ". ';

Etrective Date_3/112012, _____ _

11-13-2008

State: Louisiana §19l5(i) HCBS State plan Services State Plan Attachment 3.1 -ti-Page l3

.. ' .: :. ,,' J ~ . "

' -, ,"

-. ".: . ," ";, ".'-

" . . ". ', ' - :

. : - .' " .. .

.. · 'e·Stat~tnenfo.fA'~;I'··fuwL:: '. "". "'. , . ,',"> ,", ,",

, ' ' . ," ;'~(,:;~:~i ~ ':,} eleriDined by the OCDD"""" i·' .,.. .,.

SUPERSE~ES: N,ON~~ ~WFW]E :~;:=i~W)he:' i~._: ::. . '.' ". .. . . ., ';.. . is8h.i1ityJIi~" @S ~;4SI) ..... .

STATE L alA !'!') C!N\: £!. " I DATE REC'I:) ~ -10 -l( I

t' DATE APPV'D 11- - I 4 -\I A . '=lATE EFF 3 -I -12... . HCrA 179 11 -13 _ I _ _. __ ."" .. . _.&r __ .................. ....J

(By checking thefollowing boxes the State assures that):

r. partidpatjoti:fu' i1rogmns ;, . . .dminisiereci by OcAI:l!';"4 " . . at they~ave ~. !,!,aMoa be Request for· Services: .

. gistry fii.l:.wliiv~.~.ervi!;eS . , ad their da.te of requ~:'The O'L; sbA and pJanofcare ocWDents are sublliitted to tbe eOn.Regional WaIver ffioo fur statfrevlew to surelhat tbe

pplicantlparticlpant eets/continues 10: meel the

. evel of we critena. : .. *Long Term Care/Chronic Care Hospital

6, "" Reevaluation Schedule. Needs-based eligibility reevaluations are conducted at least every twelve months,

7, "" Adjustment Authority. The State will notify eMS and the public at least 60 days before exercising the option to modify needs-based eligibility criteria in accord with 19l5(iXI )(D)(ii).

8. 0 Residence in home or community. The State plan HeBS benefit will be furnished to individuals who reside in their home or in the community, not in an institution. The State attests that each individual receiving State plan HeBS: (i) Resides in a home or apartment not owned, leased or controlled by a provider of any health-related

treatment or support services; or (ii) Resides in a home or apartment that is owned, leased or controlled by a provider of one or more

health-related treatment or support services, if such residence meets standards for community living as defined by the State. (Ifapplicable, specify any residential settings, other than an individual's home or apartmen~ in which residents will be furnished State plan HCBS. Describe the standards for community living that optimize participant independence and community integration, promote initiative and choice in daily living, andfacilitate full access to community services):

TN# _l1-13 ___ ~Approval Date b _ It! -11 Effective Date_3/In.012'---___ _ _ Supersedes TN# __ None. ___ _

11-13-2008

State: Louisiana §19l5(i) HCBS State plan Services State Plan Attachment 3.1 -ti-Page l3

.. ' .: :. ,,' J ~ . "

' -, ,"

-. ".: . ," ";, ".'-

" . . ". ', ' - :

. : - .' " .. .

.. · 'e·Stat~tnenfo.fA'~;I'··fuwL:: '. "". "'. , . ,',"> ,", ,",

, ' ' . ," ;'~(,:;~:~i ~ ':,} eleriDined by the OCDD"""" i·' .,.. .,.

SUPERSE~ES: N,ON~~ ~WFW]E :~;:=i~W)he:' i~._: ::. . '.' ". .. . . ., ';.. . is8h.i1ityJIi~" @S ~;4SI) ..... .

STATE L alA !'!') C!N\: £!. " I DATE REC'I:) ~ -10 -l( I

t' DATE APPV'D 11- - I 4 -\I A . '=lATE EFF 3 -I -12... . HCrA 179 11 -13 _ I _ _. __ ."" .. . _.&r __ .................. ....J

(By checking thefollowing boxes the State assures that):

r. partidpatjoti:fu' i1rogmns ;, . . .dminisiereci by OcAI:l!';"4 " . . at they~ave ~. !,!,aMoa be Request for· Services: .

. gistry fii.l:.wliiv~.~.ervi!;eS . , ad their da.te of requ~:'The O'L; sbA and pJanofcare ocWDents are sublliitted to tbe eOn.Regional WaIver ffioo fur statfrevlew to surelhat tbe

pplicantlparticlpant eets/continues 10: meel the

. evel of we critena. : .. *Long Term Care/Chronic Care Hospital

6, "" Reevaluation Schedule. Needs-based eligibility reevaluations are conducted at least every twelve months,

7, "" Adjustment Authority. The State will notify eMS and the public at least 60 days before exercising the option to modify needs-based eligibility criteria in accord with 19l5(iXI )(D)(ii).

8. 0 Residence in home or community. The State plan HeBS benefit will be furnished to individuals who reside in their home or in the community, not in an institution. The State attests that each individual receiving State plan HeBS: (i) Resides in a home or apartment not owned, leased or controlled by a provider of any health-related

treatment or support services; or (ii) Resides in a home or apartment that is owned, leased or controlled by a provider of one or more

health-related treatment or support services, if such residence meets standards for community living as defined by the State. (Ifapplicable, specify any residential settings, other than an individual's home or apartmen~ in which residents will be furnished State plan HCBS. Describe the standards for community living that optimize participant independence and community integration, promote initiative and choice in daily living, andfacilitate full access to community services):

TN# _l1-13 ___ ~Approval Date b _ It! -11 Effective Date_3/In.012'---___ _ _ Supersedes TN# __ None. ___ _

11-13-2008

State: Louisiana § 1915(i) HCBS State plan Services State Plan Attachment 3.1 -tir

In all settin:gs '~ere Inglvlqualsjl'i~y; recelv~I;j~.B§~~(~>t)I~n:'$ei:Vlc~sfRetso'ilsare ; encoura ed and 'affordedtheo"~ottult ?fo :~xer6is-e'ti1eif6 'tio:sof.Wh'ena · (f·'· .' . g .. ... . . .-- ..... . PP' .. : " .. .. p ."Y ........ '. '"''''.''''' " ... ,'. '.: .......... .R .. · ... ·R .. ·, .............. < ...... 1')." . . where to take. co mmul)ity.putlngsj ha.'{e:ff~~dqm~~o . c:noo~43;roorTjrnat~s; a!1d;~iteJtee to exercise per~nal!?fioice~as '~re 9th~r persoct~ Wtl() :dq:!f8Li:iq~l!fi;t9r sef::q¢Eis under the 19151 SPA;Persons partlclpath"lg through PSH wjll ti/iveJreedom· to

" .' . . . . . . . ... . . I,. ., .

choose their services providers. Indlvl.duals·will. be encouraged to. have control over their meal and . sleep tirne~~VI~'$9f!:l¢~s,. P~~i:lcy; room<:f~C<?rC!tlons; .pnd ability to engage freely In the community; 'All the facilities are community based. with a homelike environment providing access to typicalholT)e facilitlesan,d, liit~g~!~ !nto the community. .. ... . . ... ' .. c.. . '

This particular 1915(1) was written to support Ule.J_ouisiana PElI1nanent$upported Housing (pSH) program~s:goa,s.Tfie P.sHis by' nafure small, !)cattered site housing aimed at peiscin-centeredplannlng for Individuals enjoyfng :allaspe~~ of the . community. The s~ngs thatl)'io~tindivlduals will res,ide'A.'llll:!e, psH .Or·qth~Lslmlrar settings. These settihgs are home and community based, Integrated In the . . community, pr.ovlde meaningful access·tqthe community and community actiVities, and Individuals have fr:eechqic:eof providers, IndividUals wit,hwh'om tb' lnteract, and dally life activities.

No residences are IMDs or Institutional In nature. Residences must not be located in · 'a building that is also a publicly or privately operated facility that provides

Institutional treatment or custodial care; and must not be located In a building on the grounds of, or immediatelv adlacent to, a public institution.

Person-Centered Planning & Service Delivery

(By checking the following boxes the State assures that): 1. 0 There is an independent assessment of individuals determined to be eligible for the State plan HCBS

benefit The assessment is based on: • An objective face-to-face assessment with a person·centered process by an agent that is independent

and qualified; • Consultation with the individual and if applicable, the individual's authorized representative, and

includes the opportunity for the individual to identify other persons to be consulted, such as, but not limited to, the individual's spouse, family, guardian, and treating and consulting health and support professionals caring fur the individual;

• An examination of the individual's relevant history, including findinlg8j'~B>8I1tBlll4litl!lee.HiR~d.ej;u:n.r.lenL. ___ .....,.-_ evaluation of eligibility, medical records, an objective evaluation offu ~~bility, and any other LA-records or information needed to develop the plan of care; DATE REC'[;) 3 _ '0 -II .

DATE APPV'D 1,*-/9-/1 ____________ _ .,...--.-_ ___ ~~Jl1JE EFF :3 -, d-~II TN# _1l-13, ____ Approval Date I'}... -) q - I Efrective Date_3/112 ~e;=A 179 • 11-13 Supersedes ~-.~ ... ----:-._:-"-='.,L. __ ... -... TN#_None, __ _

11-13-2008

State: Louisiana § 1915(i) HCBS State plan Services State Plan Attachment 3.1 -. Page 14

In aU sattln:gsVlJ!:lere' in~ivitluals miiy;i'ecelv~.ijCBS~i;lf~,plftn:·serVI~;·r:1~tSohsare; encouraged andaffQ!j:I!;fdthe 0' '~ort:uolt!fOe'ie'reis~iheifo,;J'ons'otwtlefiaHIf; .' . . ,.' , P,P"".,.,., ;.,~ .. ,., .. ,~.".y~ .. ,., " ........• R"' .. -.-.r' ....... '>: .. l,:~_"". __ .-, '

where to take. commul)ityputlngs .. h~\{e~ft.€i~d~m;~o 1itlliQ~~;roprnil:i~(~.· a!ld;l;ir~f\'ee to exercisepe~nalclipic6$as1:ire 9tMf peF~il~ Wt)(j'dq n8tqq~I'fi;;fQr sei)lj~es under the 1915! SPA;.Persons participating through P$H wjll fii:lveJreedomfo

",_' , . _ . • • • _~ _ _ J, _ ,- " _

choose their services providers. Individuals will ",e encouraged to have control over their meal and sieeptlrnes.vi~!~orac~s, plivl3cy; room.deC{)ni!tlons,and abllity to engage freely in thecommunlty;,AII the facllitles areco.mmunlty .ba!3ed,with a homelike environment providing access to typical home facmtlesand.lJ1tegra~1ild Into the community. . . '.' . > ..'

This particular 1915(1) Was writte~to sUPPort th9.j."oliisianaPermanent$upported Housing (P$H) program~s:goals. The P$His by natUre small, saatteredsite housing aimed at person-celiteredplannlng forilidivlduals enjoying all aspecl.l?of the . community. The settings thatmo~t:lndivlduals will r~ideliVllI~ ,pSHOf,olhe.rsimlfar settings. These settlhgs are home' and community based, Integrated In the . . community. provide meaningful access·tothe community and comm4nify actiVities, and individuals have fr.ee choice of provldeis, lndivldlli:tls with whom to !riteracl, and dally life activities.

No residences are IMDs or Institutional in nature. Res!dences must not be located in · 'a building that is also a publicly or privately operated Jacility that provides

institutional treatment or custodial care; and must not be located in a building on the grounds of, or immediate! adjacent to, a public institution.

. Person-Centered Planning lSi Service Delivery

(By checking the /o{{owing boxes the State assures that): 1. (;'1 There is an independent assessment of individuals determined to be eligible for the State plan HCBS

benefit. The assessment is based on: • An objective face-to-face assessment with a person.centered process by an agent that is independent

and qualified; • Consultation with the individual and if applicable, the individual's authorized representative, and

includes the opportunity for the individual to identify other persOIlS to be consulted, such liS, but not limited to, the individual's spouse, family, guardian. and treating and consulting health and support professionals caring lOr the individual;

• An eu.millStion of the individual's relevant history. including findings~~_,",·~'··liI!kp'.emI·Jlmt ____ --t' __

evaluation of eligibility, medical records, an objective evaluation of til ~~billty, and any other LA records or inforlDlltion needed to develop the plan of care; DKfE REC'[,) a _ 10 -II

DATE APPV'D IJ.-I'I-/I A --------__ .......... ----::-:::--":"T"'-=::::-:':'-= ...... ~:t:-: n\~.A·rEEFF a -I ;:).. ~Il TN# _ll-13, ___ --'Approval Date I'l- -I q -I , Bftective Date_3/112 'tlSfA 179 • II v 1:3 Supersedes ~- .. ~-----l"'>-.-;;..~&~ .... -.. TN# __ ",'uv ___ _

11-13-2008

State: Louisiana § 1915(1) HCBS State plan Services State Plan Attachment 3.1 -D-

• An examination of the individual's physical, addiction, and mental health care and support needs, strengths and preferences, available service and housing options, and when unpaid caregivers will be relied upon to implement the plan of care, a caregiver assessment;

• If the State offers individuals the option to self-direct State plan HCBS, an evaluation of the ability of the individual (with and without supports), or the individual's representative, to exercise budget and/or employer authority; and

• A determination of need for (and, if applicable, determination that service-specific additional needsbased criteria are met for), at least one State plan home and community-based service before an individual is enrolled into the State plan HCBS benefit.

2. [;"/ Based on the independent assessment, the individualized plan of care: • Is developed with a person-centered process in consultation with the individual, and others at the

option of the individual such as the individual's spouse, family, guardian, and treating and consulting health care and support professionals. The person-centered planning process must identify the individual's physical and mental health support needs, strengths and preferences, and desired outcomes;

• Takes into account the extent of, and need for, any tinnily or other supports fur the individual, and neither duplicates, nor compels, natural supports;

• Prevents the provision of unnecessary or inappropriate care; • Identifies the State plan HCBS that the individual is assessed to need; • Includes any State plan HCBS in which the individual has the option to self-direct the purchase or

control; • Is guided by best practices and research on effective strategies fur improved health and quality of life

outcomes; and • Is reviewed at least every 12 months and as needed when there is significant change in the individual's

circumstances.

3. Responsibility fur Face-to-Face Assessment of an Individual's Support Needs and Capabilities. There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with physical and mental needs for HCBS. (SpecifY qualifications):

Educational/professional qualifications of individuals conducting assessments are a case manager who is a physician or an LMHP with a psychiatrist who must comolete oortions of the assessment

LMHPs include: STATE liY-l"J <S (Ctf\tt • Medical Psychologists 3 ,~_/ ( • Licensed Psychologists DATE REC'6_-'L':'-~Il.L-.!...!...--+ • Licensed Clinical Social Workers (LCSWs) DATEAPPV'O I:J.. -/ 'I. -/ \ A • Licensed Professional Counselors (LPCs) I)ATE EFF ~ - I - I !:l-• Licensed Marriage and Family Therapists (LMFTs) HccA 179 \ 1- I 3 • Licensed Addiction Counselors (LACs) L..;...;:: ____ ~ __ ._.;:'~_:;;r-.t. __ ~...l

Advanced Practice Registered Nurses (must be a nurse practitioner specialist in Adult Psychiatric & Mental Health, and Family Psychiatric & Mental Health or a Certified Nurse Specialists in Psychosocial, Gerontological Psychiatric Mental Health, Adult Psychiatric and Mental Health, and Child-Adolescent Mental Health and may practice to the extent that services are within the APRN's scope of practice)

4. Responsibility for Plan of Care Development There are qualifications (that are reasonably related to developing plans of care) for persons responsible for the development of the individualized, personcentered plan of care. (SpecifY qualifications);

TN# _1l-13 ____ .Approval Date (-;).. -\ 9. -II Ef!ective Date _31112012'--____ _ Supersedes TN# __ None. ___ _

SUPERSEDES; NONE - NEW PAGE 11-13-2008

Slate: Louisiana § 1915(1) HCBS Slate plan Services State Plan Attachment 3.1 -Er Page 15

• An examination of the individual's physical, addiction, and menial health care and support needs. strengths and preferences, available service and housing options, and when unpaid caregivers will be relied upon to implement the plan of care, a caregiver assessment;

• If the State offers individuals the option to self-direct State plan HeBS, an evaluation of the ability of the individual (with and without supports), Of the individual's representative, to exercise budget and/or employer authority; and

• A determination of need for (and, if applicable, determination that service-specific additional needsbased criteria are met for), at least one State plan home and community-based service before an individual is enrolled into the State plan HCBS benefit.

2. li'! Based on the independent assessment, the individualized plan of care: • Is developed with a person-centered process in consultation with the individual, and others at the

option of the individual such as the individnsl's sPOUse, family, guardisn, and !reatiog and consulting health care and support profussionals. The person-centered planning process must identifY the individual's physical and mental health support needs, strengths and preferences, and desired outcomes;

• Takes into account the extent of, and need for. any filmily or other supports for the individual, and neither dUplicates, nor compels. natural supports;

• Preventa the provision of unnecessary or inappropriate care; • Identifies the State plan HeSS that the individual is assessed to need; • Includes any State plan HCBS in which the individual bas the option to self-direct the purchase or

control; • Is guided by best practices and research on effective strategies for improved health and quality afIife

outcomes; and • Is reviewed at least every 12 months and as needed when there is significant change in the individual's

circumstances.

3. Responsibility fur Faee-to-FaeeAssessment of an Individual's Support Needs and Capabilities. Thefe are educationsllprofessional qualifications (that are reasonably related to performing assessmeats) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with physical and mental needs fOf HCBS. (Specify qualifications):

Educationallprofussional qualifications of individuals conducting assessments are a case manager who is a physician or an LMHP with a psychiatrist who must comDlete Domons of the assessment. LMHPs include;

STATE 1,..".l6'et.r\4, • Medical Psychologists 3-10-11 • Licensed Psychologists DATEREC'!:J

• Licensed Clinical Social Workers (LCSW s) DATE APPV'D 1:1. -14 ~fI • Licensed Professional Counselors (LPCs) I)ATEEFF ?l-l-I!l-• Licensed Marriage and Family Therspists (LMFTs) HCfA179 11- J:;3 _ • Licensed Addiction Counselors (LACs)

L....:..:.._"' ____ ~,-&;;.."':

Advanced Practice Registered Nurses (must be a nurse practitioner specialist in Adult Psychiatric & Mental Health, and Family Psychiatric & Mental Health or a Certified Nurse Specialists in Psychosocial, Gerontological Psychiatric Mental Health, Adult Psychiatric and Mental Health, and Child-Adolescent Mental Health and may practice to the extent that services are within the APRN's scope of practice)

4. Responsibility for Plan of Care Development. There are qualifications (tbat are reasonably related to developing plans of care) for persons responsible for the development of the individualized, personcentered plan of care. (Specify quafijicatio/Vi):

ThIll _1I-13 ___ --'Approval Date ! ~ -\ It - \ \ Supersedes ThI# __ None, __ _


A

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -~

~~:~tl~~\i~~~e~~tft~~;~!-~~1~~r·,:~~7~~5~~f$~:r~~¥fg, 5. Supporting the Participant in Plan of Care Development. Supports and information are made available

to the participant (and/or the additional parties specified, as appropriate) to direct and be actively engaged in the plan of care development process. (SpecifY: (a) the supports and infonnation made available, and (b) the participant s authority to detennlne who is included in the process):

(a) The treatment plan is developed by the participant and his or her interdiscipIinary team based on information from the needS-based assessment, and taking into account the participant's social history, and treatment and service history. The case manager acts as an advocate for the participant in this process and is a source of information for the participant and the team. The participant and the team identify the participant's strengths, needs, prererences, desired outcomes, and his or her desires in order to determine the scope of services needed. The case manager infurms the participant of all avai1able Medicaid and non-Medicaid services. The participant is encouraged to choose goals based on his or her own desires while recognizing the need for supports to attain those goals.

(b )The interdiscipIinary team includes the participant; his or her legal representative if applicable; the case !pIIlllIger; and any other persons the participant chooses, which may include service

I providers. Individuals that are not Medicaid providers are not reimbursed for their participation

6. Informed Choice of Providers. (Describe how participants are assisted in obtaining infonnation about and selectingfrom among qualified providers of the 1915(i) services in the plan of care}:

The case manager informs the participant and his or her interdiscipIinary team of all available , qualified providers. This is part of the interdiscipIinary team process when the treatment plan is developed, and again whenever it is renewed or revised. Participants are encoumged to meet with the available providers before choosing a provider.

7. Process for Making Plan of Care Subject to the Approval of the Medicaid Agency. (Describe the process by which the plan of care is made subject to the approval of the Medicaid agency):

Louisiana will contract with a Statewide Management Organization (a Prepaid Inpatient Health Plan- PIHP) to support certain Medicaid programs. The case manager requests authorization through the SMO, and SMO staff responsible for managing enrollment will respond. Case managers complete the assessment of the need for services and submit it to the SMO unit for evaluation of progmm eligibility. The case manager is also responsible for entering treatment plan information such as the services to be received, the effective dates, the amount of each service, and the selected provider into the online electronic medical record and care plan authorization forms maintained by the SMO. OBH, as the operating agency, will monitor SMO review and approval of the Plans of Care through the SMO subject to Medicaid agency oversight.

8. Maintenance of Plan of Care Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §74.53. Service plans are maintained by the following (check each that applies):

D Medicaid agency D 1 Opemtingae:ency 10 1 Casemanager

0 Other (specifY): SMO will retain electronic copies of service plan

STATE J...o.u' <-_Ie; raAt-dl." DATEREC'~ g -lO~H DATE APPV'D 1).-1 q,.. lJ

W#_ll-13 Approval Date Ikl~ ~II Effective Date_3/112012_ I)ATE EFF '0 ~ i~ I?-

--

--

Supersedes HC\:A 179 " \J 13 1.--_______ .--,.,.... •• u-W# __ None. ___ _ --:---11-13-2008

'I ...... •

· ,. ! t • r

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 - E:f Page 16

~:=:ift:~~~~~~f~*!HW~~1~fx!~~~~~~mfr~~~'fg 5. Supportiug the Participant in Plan of Care Development. Supports and information are made available

to the participant (andlor the additional parties specified, as appropriate) to direct and be actively engaged in the plan of care development process. (SpecifY: (a) the supports and information made available, and (b) the participants authority to determine who is included in the process):

(a) The treatment plan is developed by the participant and his or her interdisciplinary team based on information from the needS-based assessment, and taking into account the participant's social history, and treatment and service history. The case manager acts as an advocate fur the participant in this process and is a source of information for the participant and the team. The participant and the team identifY the participant's strengths, needs, prererences, desired outeomes, and his or her desires in order to determine the scope of services needed. The case manager infurms the participant of all ava\lable Medicaid and non-Medicaid services. The participant is encoorsged to choose goals based on his or her own desires while recognizing the need fur supports to attain those goals.

(b )The interdisciplinary team includes the participant; his or her legai representative if applicable; the case J1.lS.ll8ger; and any other persons the participant chooses, whieh may include service roviders. Individuals that are not Medicaid roviders are not reimbursed for their artiei tion

6. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about and selectingfrom among qualified providers of the 1915(i) services in the plan of care):

The case manager infurms the participant and his or her interdisciplinary team of ail ava\lable " qualified providers. This is part of the interdisciplinary team process when the l«:atment plan is developed, and again whenever it is renewed or revised. Participants are enccumged to meet with the available providers before choosiuj:( II provider.

7. Process for Making Plan of Care Subject to the Approval ofthe Medicaid Agency. (Describe the process by which the plan of earn is made subject to the approval afthe Medicaid agency):

Louisiana will contract with a Statewide Management Organization (8 Prepaid Inpatient Hcaith PIan- PIHP) to support certain Medicaid programs. The case manager requests authorization through the SMO, and SMO staff' responsible for managing enrollment will respond. Case managers complete the assessment of the need for services and submit it to the SMO unit fur evaluation of program eligibility. The case manager is also responsible fur entering treetmen! plan information such as the services to be received, the effective dates, the amount of each service, and the selected provider into the online electronic medical record and care plan authorization forms maintained by the SMO. OBH, as the operating agency, will monitor SMO review and approval of the Plans of Care through the SMO subiect to Medicaid agency oversight.

8. Maintenance of Plan of Care Forms. Written copies or electronic facsimiles of service pians are maintained for II minimum period of 3 yeers as required by 45 CPR §74.53. Service plans are maintained by the following (check each that applies):

0 Medicaid agency o I Operatiru!: agency I Ii:! I Case manager

Ii:! 0lller (specifY): SMO will retain electronic ccpies of service plan ---- ._.

STATE L.o-u < " _!I!II~~,"

DA'(E REC'" (I -lO-H DATE APPV'D 1;).-1 '1" tl

.---

1:z,-I~HI Effective Date_3/112012_ OATE EFF 2l-i~ I~ TNti 11-13 Approval Date SnpetSooes HC:'='A 179 Ii \~ 13 ._ TNti None '---* *"--....-.. ~"""--.•

11-13-2008

- \

, '" - , , I i

State: Louisiana § 19l5(i) HCBS State plan Services State Plan Attachment 3.1 -~

Services

1. State plan HCBS. (Complete thejol/owing tableforeach setvf~~~~~~~~G~~]--'l

SUPEB.SEDES: NONE - NEW PAGE

DA-{E REC'B'_-"!.-L'>L.:J.l.,...,..._ DATE APPV'D..,J..~.J.:I.':"":'':-'''_

'=lATE EFF_---'02-...L:,~_HCFA179

Service Specifications (Specify a service title from the optwnsfor HeBS State plan services in Attachment 4.

Service Rehabilitation Services

utilizing •

• • •

practitioner.s. The psychosocial rehabilitation treatmeot the fullowing: by a licensed mental health practitioner (IMHP) who is an individualliccnsed in the State of

Louisiana to diagnose and treat mental illness or substance abuse disorder acting within the scope of all applicable state laws and their profussionalliccnse. Community Psychiatric Support and Treatment (CPST) Psychosocial Rehabilitation (PR) Crisis Intervention (Cl)

These psychosocial rehabilitation services are provided as part of a compreheosive specialized psychiatric program available to all Medicaid eligible adults with sigoificant functional impairments meeting the need levels in the 1915(i) resulting from an ideotified mental health or substance abuse disorder diagnosis. The medical necessity for these rehabilitative services must be determined by a licensed mental health practitioner or physician who is acting within the scope ofhislher profussionallicensed and applicable state law and furnished by or UDder the direction of a licenaed practitioner, to promote the maximum reduction of symptoms and/or restoration of a individual to hislher best ageappropriate functional level conducting an assessment consistent with state law, regulation and policy. A unit of service is defined according to the HCPCS approved code set unless otherwise specified. .

Definitions: The services are defined as fullows: I. Treatment by a licensed mental health practitioner (IMHP) who is an individual licensed in the State of

Louisiana to diagnose and treat mental illness or substance abuse disorder acting within the scope of all applicable state laws and their professional license.

2. Community Psychiatric Support and Treatment (CPST) are goal directed supports and solution-fucused interventions intended to achieve identified goal or objectives as set furth in the individual's individualized treatment plan. CPST is a filce-to-filce intervention with the individual present; however, fumilyor other collaterals may also be involved. A minimum of5l% ofCPST contacts must occur in community locations where the person lives, works, attends school, and/or sociaUzes. This service may include the fullowing components: A. Assist the individual and fumily meml>ez-s or other collaterals to ideotify strategies or treatment options

associated with the individual's mental illness, with the goal of minimizing the negative effucts of menial illness symptoms or emotional disturbances or associated environmental stressors which interfere with the individual's daily living, financial management, housing, academic and/or employment progress, personal recovery or resilience, fumilyand/or interpersonal relationships, and community integration.

B. Individual supportive counseling, solution fucused interventions, emotional and behavioral management,

A

and behavior with the ~~W1~'th~~~~~ TN# _\1- 13 ___ ----' Date_3/1120l2 _____ _

Supersedes TN# __ None, __ _

11-13-2008

Slate: Louisiana § 1915(i) HeBS Slate plan Services Slate Plan Attachment 3.1 -~ Page 17

Services

1. State plan RCBS. (Complete the following table for each lief"f~~~~~~~~~~:=]---l

SUPERSEDES: NONE - NEW PAGE OATE EFF_--'>2.........J...:,F-HCFA179

Service Specifications (Specify a service title/rom the optwns/or BeBS State plan services in Attachment

Service Rehabilitation Services

•

• • •

practitioner.B. The psychosocial rehabilitation treatment proVided !he fuUowing: Treatm.ent by a licensed mental heal!h practitioner (LMHP) who is an iadividoallicensed m !he State of Louisiana to diagnose and treat mentallliness or substance abuse disorder actiog wilhio !he scope of all applicable state laws and !heir profbssionllillcense. Community Psych.iatric SUpport and Treatment (CPST) Psychosocial Rehabilitation (PR) Crisis Intervootion (Cl)

These psychosocial rehabilitation services are provided as part of a comprehensive speciallzed psyctriatric program available to all Medicaid eligible adults with significant functional impainnents meeting !he need levels m!he 1915(;) resulting from an identified mental heal!h or substance abuse disorder diagnosis. The medical necessity for !hese rehabilitative services must be determiaed by a licensed mental heal!h practitioner or physician who i. acting within !he seope ofhislher professional licensed and applicable state law md furnished by or under the direction of a licensed practitioner, to promote the maximum reduction of symptoms and/or restoration of a iadividual to bislher best ageappropriate functional level conducting ao assessment consistent with slate law, regnistion and policy. A unit of service is defined according to the HCPCS approved code set uniess o!heme specified ..

Definitions: The services are defined .s milaws: I. Treatment by a licensed mental health prnctitiooer (LMHP) who is an iadividuallicensed m !he State of

Louisiana to diagnose aod treat mental ilmes. or subatance abuse diaorder actiog withiD the seope of all applicable slate laws and their professional license.

2. Community Psych.ialric Support and Treatment (CPST) are goa! dirooted supports and solution-fucose<! mterventi011ll intanded to achleve identified goal or objectives as set furIh m the individoal's mdividuaJilred treatment plan. CPST is a mce-Io-lil<le intervootion with the mdividual present; however. fitmily or other coUaterals may also be involved. A miDimum of 51 % ofCPST contacts must occur m community locations where the person lives, works, attends school, and/or sociali2es. This service may include the fullowing components: A. Assist !he mdlvidual and linnlIy members or other collaterals to identify strategies or treatment options

associated with the mdividual's mentsi illness, with the goal ofmiDimizing the negative effuclS of mental ilIoess symptoms or emotiooal disturbances or associated environmental slressora which mterfi:re with the mdividual's dally IiviDg, fioancial management, houamg, academic and/or emploJ'll1ent progress, persolllli recovery or resilience, linnlIyand/or interpersonal relationships, and community mtegralion.

A

B. Individoal supportive counseliDg. solution fucused iDterventions. emotional sad bebaviorallllllUllgement. and behavior with the ~Wl~·~th~~~~)

TN# _11-13 ___ --' Supersedes TN# __ Nooe'--__

11-13-2008

State: Louisiana §19l5(i) HCBS State plan Services Slate Plan Attachment 3.1 -&

3.

'and'im ltimelitiil :.iioc·l;liif" · - .. <> !IIi.'seJ(Cifr "daiITYiii ·· '!!;liid ' end ' i.liYiil ' SkiIls:w'J'esiOre!,··,· stilbW~, '~:~P~:i,t'~t#d~~'ani!tp~~~~J~:~~~;ti.~:i'::« <.:;:~·;~ ;':·;'.:·;::~:i,:,·:.;,~\ ".

C. Pamci ' tio :iiiaruhiii1iZ8tiiili'iif.tt&lgil!Sbii~ ~ ijj'nf,iD ~andiiMirii'i2tts:wliicli·iii.i:iUde ·sSiSliittij. : .

~~tJI5~,~!~~~~*i~~:r~r~~l~~rt~~\o D. AsSist the iiidiVidilal\\itil!iffiicnveiY.tcspondliiglo oia~ol<iiligid~tilied pr~ui'sor~br triggers that\wwd ..

risk their reinlilDfu iD.'a n8~cOminuDi" 16catio lncliJd!iiassiStiD th~ fudivi'd';ar~d filini(m~iiiik ' . • '.. ... ,.0< . . g .. ... , .. ';' '.' .... ..... ... ~ty .... .. n, .... '. g . .... . g ..... . ' '-' ... y ,. .. . S or other collateraIfWjj#j4~iifYlii:iia p'!ten'tial.p~clli8tric ori?~r!~~!'risis, d~~16piii~ a crisis " . • management pl.ah:ailC!lorasappi'opiiil!e, iie~)<:iii.g, other supportflc:i,testore' slB,biUlY, !ri\clfunctionliig.

E. Restoration; 'iebabil,liatfdri iind 'suPport-io develop sIiills to .Ibcate;:t¢hl 'ii,nd keeP . Ii h!ime, landlordfWnant . negotiations; s~lect41.g ,~i:Q9iiimate slid ren!er'sriii!!is 8ii~(esp~i1iW#es. .!,' ". . .' '\

F. ' Assistiilg the ii!dividiiafi~d~velop <W1y IiVirij:skilCli Speciticto.'J!iagagmg th~frciwnhomeii).clii&ig managliig iheh:moiley,m¢iCatioPs, and ~gi;9mijiimitiresOUi'~;~(foihei;self«itrer~wr~en!s.

Psychosocial ~habiUtation:&S~~ceS are designed!6 assiSt fI[~ lii~~diiai\';ith.cP~pek';;tiligfuror eliminating fimctioDal deficl~ ·and ·lri~sonal and/or enwcinmelii81bairi.~assdGl~ted With Hiett mental illness. Activities.liicluded inUS! ~ jIlt,?,ded to achieVe the iden~ed ge>a.!~O~ ~bJ~.t.iveS~ set..f0rth Iii the individual 'sindividualize4· l:piAAo,~!plaii. J1>,e iI?-~t ofpsY:C!t~S9C~. ~eh!<bi!.itat!0Ii!B tifres!Oretlie.fiillcst possible iiitegriitioo of the. ii'idividli8l U an IIC~VeaIidpriXluCtivemeq;,11.et"ofli1s'Or her'DiriiiIy, eomfu.unity, and/or culture with the least ain:ount ofongoliig proressiona/.liiterventiiin. PRis a·.mce-to-filce in'ierventioo with. the individual present. Semcejl may be provided liic!iYidually of Iii.a gr9UP settiiig. A minimuin of51%ofPR contacts must occur Iii commWJ,ity.locations·where iheperSOIi lives, works, attends school, and/or sociiilizcs. A. Restoration, rehabiUfation and slipporl with the development of sooial.and·liiterpersonal Skills to increase

community tenure, enhance personal relationShips, establiSh.support networks, increase community awareness, deVelop copil;lg strategiClS, ~d effective functionliigp\tli~ iI!!iividaal'sso~ial environment liicludliig home, .workaIid school. . . '. ' .' '. ,': '. ." .. . '. .

B. Restoration, rehabilitation and support with the development ~f dailyli~g skills to improve self management of the negative effects of psychiatric or emotional symptOms that interfure with a person's daily living. Supporting the individual with development and implementation of datly living skills and daily routiiles critical to ,.imaining Iii home, school, work, and.commuriil:y. .

C. Implementiilg leamed SkiIls·so the person can r~ in a natwW. community loea.tion. D. Assistiilg the liidividool with etfuctive1Y respondliig to or avoiding identified precursors or triggers that

result in functioaal impairments. .

4. Crisis Intervention (CI) services are provi'ded to a person who is cxPeriencing a psychiairlc crisis, designed to liitemlpt and/or ameliorate a cpsis experi!='lce liicluding 8I1 preliminary assessment, iD!mediate ~is resolution and de-escalation, and refurral and!inkage.to appropriate community services to avoid more restrictive levels of treatment. The goals of Crisis Interventions ate symptom reduction, stabilization, and restoration to a previous leveloffunctionliig. All activities must occur withlii the context of a potential ex: actual. psychiatric crisis. Crisis Intervention is a fuce-to-fuce liiterventio/1 and can o.ccur Iii a variety of.locations, liicludliig.an emergency room or clinic setting, Iii addition to other community locations where the person lives, works; attends scliool, and/or socia1izes. . A. A preliminary assessment of risk, mental statos, and medical stabilitY; and .the need fur fUrther

evaluation or other meniru health services. Includes contact with the clieO.t, fiitilily members or other collateral sources (e.g. caregiver, school personnel) with pertinent infurmation for the porpose ofa preliminary assessment and/or rcfenal to other alternative mental health services at an .appr.opriate level.

B. Short-term crisis interventions including crisis resolution lII1d de>,hriefing witht!J,~ identified MediCaid eligible liidividuat , . . , . '. .

." " ,~, Follow-up with the liidividuJll"and as necessary, with the liidividuals' caretaker and/or fumilymembers. b. Consultation with a physiqil,lll .or (Nith other qualified providers to assist-with the individuals"specific

~ .. '. CMS " .' ~ I .\. : .

Additional needs-baSed criteria fur'feteiving the service, if apillicable (specify): ,"0

fJ.'N# 11-13 ' .. Approval naii: · 1'.l..1~ ' I 9 ~ 1 ( Effective Date_3/In.OI2, _ ____ _ :SuPef$~~" - .-... - --""_ .:.. -.---.--- '. :,. , ". :';' i :

," ~ ' - .. "~ .. ........ ,. "- ...... .... ... .. ;. TN# __ None. __ _

11-13-2008

State: Louisiana §19l5(i) HCBS State plan Services Slate Plan Attachment 3.1 -& Page 18

3.

'and'im ltimelitiil :.iioc·l;liif" · - .. <> !IIi.'seJ(Cifr "daiITYiii ·· '!!;liid ' end ' i.liYiil ' SkiIls:w'J'esiOre!,··,· stilbW~, '~:~P~:i,t'~t#d~~'ani!tp~~~~J~:~~~;ti.~:i'::« <.:;:~·;~ ;':·;'.:·;::~:i,:,·:.;,~\ ".

C. Pamci ' tio :iiiaruhiii1iZ8tiiili'iif.tt&lgil!Sbii~ ~ ijj'nf,iD ~andiiMirii'i2tts:wliicli·iii.i:iUde ·sSiSliittij. : .

~~tJI5~,~!~~~~*i~~:r~r~~l~~rt~~\o D. AsSist the iiidiVidilal\\itil!iffiicnveiY.tcspondliiglo oia~ol<iiligid~tilied pr~ui'sor~br triggers that\wwd ..

risk their reinlilDfu iD.'a n8~cOminuDi" 16catio lncliJd!iiassiStiD th~ fudivi'd';ar~d filini(m~iiiik ' . • '.. ... ,.0< . . g .. ... , .. ';' '.' .... ..... ... ~ty .... .. n, .... '. g . .... . g ..... . ' '-' ... y ,. .. . S or other collateraIfWjj#j4~iifYlii:iia p'!ten'tial.p~clli8tric ori?~r!~~!'risis, d~~16piii~ a crisis " . • management pl.ah:ailC!lorasappi'opiiil!e, iie~)<:iii.g, other supportflc:i,testore' slB,biUlY, !ri\clfunctionliig.

E. Restoration; 'iebabil,liatfdri iind 'suPport-io develop sIiills to .Ibcate;:t¢hl 'ii,nd keeP . Ii h!ime, landlordfWnant . negotiations; s~lect41.g ,~i:Q9iiimate slid ren!er'sriii!!is 8ii~(esp~i1iW#es. .!,' ". . .' '\

F. ' Assistiilg the ii!dividiiafi~d~velop <W1y IiVirij:skilCli Speciticto.'J!iagagmg th~frciwnhomeii).clii&ig managliig iheh:moiley,m¢iCatioPs, and ~gi;9mijiimitiresOUi'~;~(foihei;self«itrer~wr~en!s.

Psychosocial ~habiUtation:&S~~ceS are designed!6 assiSt fI[~ lii~~diiai\';ith.cP~pek';;tiligfuror eliminating fimctioDal deficl~ ·and ·lri~sonal and/or enwcinmelii81bairi.~assdGl~ted With Hiett mental illness. Activities.liicluded inUS! ~ jIlt,?,ded to achieVe the iden~ed ge>a.!~O~ ~bJ~.t.iveS~ set..f0rth Iii the individual 'sindividualize4· l:piAAo,~!plaii. J1>,e iI?-~t ofpsY:C!t~S9C~. ~eh!<bi!.itat!0Ii!B tifres!Oretlie.fiillcst possible iiitegriitioo of the. ii'idividli8l U an IIC~VeaIidpriXluCtivemeq;,11.et"ofli1s'Or her'DiriiiIy, eomfu.unity, and/or culture with the least ain:ount ofongoliig proressiona/.liiterventiiin. PRis a·.mce-to-filce in'ierventioo with. the individual present. Semcejl may be provided liic!iYidually of Iii.a gr9UP settiiig. A minimuin of51%ofPR contacts must occur Iii commWJ,ity.locations·where iheperSOIi lives, works, attends school, and/or sociiilizcs. A. Restoration, rehabiUfation and slipporl with the development of sooial.and·liiterpersonal Skills to increase

community tenure, enhance personal relationShips, establiSh.support networks, increase community awareness, deVelop copil;lg strategiClS, ~d effective functionliigp\tli~ iI!!iividaal'sso~ial environment liicludliig home, .workaIid school. . . '. ' .' '. ,': '. ." .. . '. .

B. Restoration, rehabilitation and support with the development ~f dailyli~g skills to improve self management of the negative effects of psychiatric or emotional symptOms that interfure with a person's daily living. Supporting the individual with development and implementation of datly living skills and daily routiiles critical to ,.imaining Iii home, school, work, and.commuriil:y. .

C. Implementiilg leamed SkiIls·so the person can r~ in a natwW. community loea.tion. D. Assistiilg the liidividool with etfuctive1Y respondliig to or avoiding identified precursors or triggers that

result in functioaal impairments. .

4. Crisis Intervention (CI) services are provi'ded to a person who is cxPeriencing a psychiairlc crisis, designed to liitemlpt and/or ameliorate a cpsis experi!='lce liicluding 8I1 preliminary assessment, iD!mediate ~is resolution and de-escalation, and refurral and!inkage.to appropriate community services to avoid more restrictive levels of treatment. The goals of Crisis Interventions ate symptom reduction, stabilization, and restoration to a previous leveloffunctionliig. All activities must occur withlii the context of a potential ex: actual. psychiatric crisis. Crisis Intervention is a fuce-to-fuce liiterventio/1 and can o.ccur Iii a variety of.locations, liicludliig.an emergency room or clinic setting, Iii addition to other community locations where the person lives, works; attends scliool, and/or socia1izes. . A. A preliminary assessment of risk, mental statos, and medical stabilitY; and .the need fur fUrther

evaluation or other meniru health services. Includes contact with the clieO.t, fiitilily members or other collateral sources (e.g. caregiver, school personnel) with pertinent infurmation for the porpose ofa preliminary assessment and/or rcfenal to other alternative mental health services at an .appr.opriate level.

B. Short-term crisis interventions including crisis resolution lII1d de>,hriefing witht!J,~ identified MediCaid eligible liidividuat , . . , . '. .

." " ,~, Follow-up with the liidividuJll"and as necessary, with the liidividuals' caretaker and/or fumilymembers. b. Consultation with a physiqil,lll .or (Nith other qualified providers to assist-with the individuals"specific

~ .. '. CMS " .' ~ I .\. : .

Additional needs-baSed criteria fur'feteiving the service, if apillicable (specify): ,"0

fJ.'N# 11-13 ' .. Approval naii: · 1'.l..1~ ' I 9 ~ 1 ( Effective Date_3/In.OI2, _ ____ _ :SuPef$~~" - .-... - --""_ .:.. -.---.--- '. :,. , ". :';' i :

," ~ ' - .. "~ .. ........ ,. "- ...... .... ... .. ;. TN# __ None. __ _

11-13-2008

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -,..

Specify limits (if any) on the amount, duration, or scope of this service fur (chose each that applies):

18) Categorically needy (specify limits):

LMHP limitations: .~ovi~¢r~ c8wiotw.qXlc.¥ ,.Oi:ii~ 'or~pti~llion)'!l~Ci'~s :s""tjoji jii§;~~ilie a ~vider who is excluded from partiCIpation m' Pederallieal~ care programsund.er either section 1128 or seCtion 1128A of the Social Security AcL In adilitioil, they piiiynot be debarred,sUsp~ded, or ;;th~se' eXcludiid from partiCipating in procurement activities under the State and Federal laws, regulations, and policies ini:luiliilg the Federal'AcqUisiti<m Regulation, Executive Oi:der N",.12549,.and Executive Order No. 125~9. Ip.ad&timi, pI9viders who are an affiliate, as defined in the Federal Acquisition ReguJation, of a pers911 exclude<!; debBiTed; suspended or otherwise """Iuded under State and Federal U;ws,r~gulationS, and poliCies ~y not participate. All sClvici:s iri~tbe authorized. Services which exceed the limitation of the i!ljtial 'authorization l!Iust be approved for i'e-autii()riza~OnpriQr'to serviCjl . delivery. In addition to liceusure, soMC. providerS tl\atoffur addictiqn services lIIust'demimsb;1l!c ;,o",pet,"!cyas defined by the Department of Health and Hospitals, siaie law (ACT 803 ofthe,ReguJar LegislativeSe.ijon 2004) and regulations. Anyone providing addiction or behavioral health·services must be certified by ORR, in addition to their scope of practice license. lMFTs and LACs are not permitted to diagnose under their scope of practice under state law. LPCs are limited to rendering or offering prevention, assessment; diagnosis and treatment of mental, emotional, behavioral, and addiction disorders requiring mental health counseling in aCcordance with scope of practice under state law. Inpatient·hospitahisit .... re limited to, those ordered by the individual's physician. VlSits,to nursing filcility are allowed for psychologists if a P ASRR (preadruission Sereenllig ""d ReSident Review indicates it is medically necessary treatmenLSociai worker visits are inCluded in the NursingViSiland may not be billed separately. Visits to ICF-MR filcilities are rion-covered . . AIl LMHP services provided while a person is a resident of an IMD such as a free standing psyphiatrichospital or psychiatric residential treatmelit filcility ate content of the institutional service and not otherwise reimbursable by Medicald. Evidenco-bssed Practices require prior approval and fidelity reviews on an ongoing basis as determined necessary by ORR.

CPST, PR, and cr Limitations: Services are subject to prior approval, must iii: medically necessary and must be recommended by a licensed mental health practitioner or physician according to an individualized treatment plan. The activities included in the service must be intended to achieve identified treatment plan goals or objectives. The treatment plan should be developed in a perSon-centered manner with the active participation of.the individual, filruily and providers and be based 1m the individual's condition and the standards of practiCe for the provision of these specific rehabilitative serviCes. The treatment plan should identUy the medical or remedial services intended to reduce the identified condition as well as the anticipated outcomes of the individual. The treatment plan must specifY the frequency, amount and duration of services. The treatment plan must be signed by the licensed mental health practitioner or physioian responsible fur developing the plan. The plan will specify a timeline fur reevaluation of the plan that is at least an annual redetermination. Thereevaluation should involve the individual, fiImilyand providers and include a reevaluation of plan to determine whether services .have contributed to meeting the stated goals. A new treatment plan should be developed if there is no measureable reduction of disability or restoration of functional level. The new plan should identifY diffurent rehabilitation strategy with revised goals and services. Anyone providing addiction or mental health services must be certified by OHH., in addition to any required scope of practice license required fur the filci1ity or agency to practice in the State of Louisiana. Providers must maintain case records that include a copy of the treatment plan, the name of the individual, dates of services provided, Dature, content and units of rehabilitation services provided, and progress made toward functional improvement and goals in the treatment plan. Services provided at a work site must not be job tasks oriented. Any services or components of services the basic nature of which are to supplant housekeeping, homemaking, or basic services for the convenience of a person receiving covered services (including housekeeping, shopping, child care, and laundry services) are noncoyere"' .... Services cannot be provided in an institute for mental disease (IMD). Room.and bo!u'd is excluded from any rateS proVided' Iii aiesidelitial setting."Evidenc;e-based Practices require prior approval lind fidelity reviews <m an ongoing basis as determin¢ necessaryby',OIllL Services may be provided at a site-based filcility, in the

I commwiity or in the individual's p\!ice, cif~dence as outlined in the Plan of Care. Components that are not , prdVideil to, or dir~ed exclusiVeli towilnJithe trejltment o~ the Medicaid eligible individual are not eligible fur Medicaid reimbursement. ' ',i' .. : , ,-:'f;','; :

: • . .:... : - . "'" - ' --0 f. - :. •

cPST LiIlIilations: Caseload siZe m~ iie' bli~ bn the needs of the clientslfilmilies with an emphasis on successful outComes' and iIiiUVidiiiil iiitiSfilction:,!Ii}~ mlls~lneet the needs identified in the individual treatment plan. The CPST

TN# _ ll-13, ____ ,Approval Oate (1. .... ,'\ ..... 1{ Etrective Oate_3/112012. _____ _

Supersedes TN# __ None, ___ _

11-13-2008

Slate: Louisiana §1915(i) HeBS State plan Services Stale Plan Attachment 3.1 -(iPage 19

SpecifY limits (if any) on the amount, duration, or scope of this service fur (chose each that applies):

lEI Categorically needy (specify limits):

LMHP limitations: .~ovl~~ crumot~~~iI~~'oiinlperv,ilJi"n\l'!l'lerWs;8C<)t\oji ~iI¥.~'~ a P!'lvider who is excluded from partiCIJIllfion m Eedeml ~ea!1\1 care programsu.n4t>r eillla sectiQll 1128 Or iIliCIion II28A ofllle Social Security Act. In adiiition, lIley may not be debarred,.uspended, or iitherwise eicluaiid from parj,icipoting in procurement activities under the State eud Fed<;rallaws, regulations, and policies including the Federal Acquisition IWgulation, Executive O¢er N",.12S49,.lII1d Executive Order No. 125,,9. lit addltimi, pr;>viders who are an affiliate, as defined in the Federal Acqui~ition RJiguJati()lI, of a pars\'lll exclude(!; detmiTi!d; ~liPend~ or otherwise """IUded under State and Federal laws, regulationS, and poliCies may not participate. All services mill!tbe authorized. Services which exceed the limitation of the iJlitialauthorization ~ust be approved for re-authori:mjiohpriorto serviCjl delivery. In addition to licensure, servi.., provi<:iers t11at6ffur addictiQ11 services tnust deti;lOOsb;'a!e i:o!l1perency as defined by the Department of Health and Hospital.,llIate law (ACT 803 oftheRilguIar LegislatiVe Sesijon 2004) and regulations. Aoyoneprovidiog addiction or behavioral health·services Iliust be 9erjified by DIm, in addition to their scope of practice Iioonse. LMFTs III1d IACs are not permitted to diagnose under·the;. scope of practice under IlIate law. LPCs are limited to ren.deringor offuring preventiOll, lIllsessmenl; diagucais and treatment of menta!, emotiOllal, behavioral, and addiction disorders requiring menta! health COIIIlSeling in aeoordance with scope of practice wder slate law. Inpatienthcsplta! :visits..re limited to those oidered by the individual's physician. VlSitsto nursing fucllity are allowed fur psycll(~logists if a P ASRR (PreadmissiOll. Si:rceoing III).d ReSident IWview indicates It is medically necessary trealment. sociai worker visits are included in the NursingVii!itlll1d may not be billed separately. Visits to ICF-MR liIcilities ate non-covered. All LMHP services provided '!'I'hlle'il person is • residaot of an lMD such.s Ii free slandiog pswhiatrichospita! or psychiatric rcaidtintial Irealment fucility are content of!he institotional service and not otherwise reimbursable by Medicaid. Evidao_based Practices require prior approval and fidelity reviews on an ongoing basis as determined necessary by mm.

CPST, PR, and CI Limitations: Services are subject to prior approval, must ha medically necessary and must be recommended by II licensed menta! health practitioner or physician accordiog to an individualized trealment pian. The activities included in the service must be intended to achieve identified trealment pian goals or objectives. The trealment plan should be developed in a perilon-centered manner with the active participation of the individual, fJImlly and providers and be based on the individual's condition and the standards of practiCe fur the provision of these specific rehabilitative sei'vil:es. The treatment plan should identilY the! medical or remedial services intended to reduce the identified condition as well as the anticipated ou!comes of the individual. The trealment pllll1 must specllY the frequency, amOlllll and duration of services. The trealment pian must be signed by the lioonsed mental health practitioner or physician responsible fur developing the plan. The plan will speci(y II limeline fur reevaluation of the pian that is at least 1111 annual redetermination. The r-'uation should involve the individual, fllmlly end providers and Include a reevaluation of plan to detennine 'Whether services have OO1llributed to meeting the slated goals. A new fnlalment plan should be developed if lIlere is 11() measurcable reduction of disability or restomtioo of functionalle.vel. The new plan should identilY diffmlnt rehabilitation stmlegy with revised goals III1d ~. Aoyone providiog addiction or menial health services m1lllt be certified by DHH, inaddilion to any required scope of practice license required fur the fuci!ity or agency to practice in the Slate of Louisiana. Providers must maintain case records that include a copy of the trealment plaD, the ntlllle of the individual, dates of services provided, nature, content and units of rehabilitation services provided, and progress made toward functional improvement and goals in the Irealment plan. Services provided at a work site must not be job tasks orientecl Any services or oompOll.ents of services the basic nature of which are to supplant holl8ekeeping, homemaking, or basic services fur the convenience of a person receiving covered services (includiog housekeeping, shopping, child care, and laundry services) are nOllcOYel'ed •. Services cannot be provided in an institute fur menial disease (lMD). Room.and bo!ud is excluded from any rat; proVIde<! iii a!'esldential setting." Eviden"",besed Practices require prior approval aild fidelity reviews on an ongoing basis as determine.<! necessaryby'.DIUL Services may be provided at a site-besed fucility, in the

I community or in Ih;e individual's P.l!ioo cif~dence as outlined in the Plan ofCare. Componeols that are net : prdvideil to, or directed exclUsillel~ Iowardithe ~lment of; the Medicaid elig..'ble individual are not eligible Ibr Medicaid reimbursement.· v" "'1/, :

CPST LilDi1ations: Caseload S~ m~ lie ~ in the nee&! of the clienlsl1limi!ies with an emphasis on successful ! QutOOilii:s and ii1dfVidiiiil :satrstilctioJl)iJ.!i mllStlfueet the nee&! idaotified in lIle individual treatu:lt:!ltplan. The CPST

TN# _U-13, ___ -'Approval Date 1:1".lq,--!( Effil<ltive Date _3fI12012. _____ _

Supersedes TN# __ " .. ".¥ ___ _

11-13-2008


provider must receive regularly ~qheduled clilil.cal sui>~ion f!:J>ina per~'iJi""ii!tg',~~,qUlilification~"'f a IMHP or PIlIP-designated -LMBPwitli experienc~ regardlDgibis specitiliZed mci!tiilie\litl1seivi~::!n iUiaiYsi." of problem behaviors must be perfurmed under the supervlsion ofalicensOd psycliolomStlOi~&Ii p~fiologist. -" .

. .' :.' .'. ." ." ~-. ", ~ .... , '!":'>":" .:.~. >'(:;.:: -.. :.~ <" - .: ," ........ ,-PR Limilations: Liniit of750 h!l~sof grt,uPP;Y9hoSP9-iai;e)I~b@aiion pi; ca\~d¥Y~; ijus liinit'¥'oo exceeded when medicallyneceSliary through prior aiJthOrization. ThePRpr9Videi must recil.i~ regularlyscheduled clinical superVision from a person 'meeting the qualifications ora· LMHP orPIHP-aesi/WatOO lMHP· with experience regarding this ~ecialized mental health serVice.

CI Limilations: All indiViduals who self identify as experiencing a.seriously acute p~chologicallemotipna\ change which results in a marke4 increase in perspna\ distress and which exc!l6ds the abilities and the resources of those involved to effuctively resolve it are eligible .. An individual in Crisis lIIay be represen~ by a lilniiIy mC;IllOOr!Jr other Collateral contact who has knowledge of the indiVidual's capabilities-and.fimctioning .. IndiVidualiiin crisis who require this serVice may be uSing sUbst8iices dtu'iOgtlie cnsi .. SI!1>Stimce.ilse sboiUd oorecogQ;zediind addressed in an integratedfilshion -as it may add. to t)le risk increasing the need fur engagement in care. The assessment of risk, mental status, and medical s!;lbility inust be completed by a LMHP or !,iIBP-desiguated IMHP with experience regarding tliis ~ecialized menlalliealth serVice, practicingwit11in tlie scope o{their pr~filsSional license. The crisis plan developed from ibis assessment and all services delivered during a crisis must be provided under the superVision of a LMBP or.PIHP-desiguated LMBPwith experience regarding this specialized menial health service, and such must be avaiiliblealall timestoproVide back tip, supp<lrt, and/or conSuIlation. Crisis services cannot be denied based upon subatance use. The Crisis Intervention ~ecialist must receive regularly scheduled clinical superVision from a person meeting the qualifications of a IMBl'or PIHP-deSiguated IMHP with experience regarding this ~ecializ<;d mental health service. CriSis InterVentiori --Emergent is limited to 6 hours per episode. Crisis Intervention - Ongoing is limited to 66 hours per episode. An epism\e is defined as the initisl mce to mce conlact with the indiVidual until the ourrent crisis is resolved, not to exceed 14 days. The individUal's chart must reflect resolution of the Crisis which marks the end of the. current episode. Ifthe·individual has another crisis within 7 calendar days of a preVious episode, it shall be considered part of the previous episode and a new episode Will not be allowed.

IRl Medically needy (specify limits): LMBP limitations: ProViders cannot provide serVices or superVision under this section if they are a provider who is excluded from participatinn in Federal health care programs under either section 1128 or section ll28A of the Social Security Act. In addition, they may not be debarred, ~ended, Or otherwise excluaed froin participating in procurement actiVities under the Slate and Federal laws, regulations, and policies including the Federal AcquiSition Regulation, Executive Order No. 12549, and Executive Order No. 12549. In addition, proViders who are an affiliate, as defined in the Federal Acquisition Regulation, of a person excluded, debarred, suspended or otherwise excluded under Slate and Federal laws, regulations, and policies may not participate. All services must be authorized. SerVices which exceed the limitation of the initial authorization must be approved fur re-authorization prior to serVice delivery. In addition to licensure, service providers that offer addiction serVices must demonstrate competency as defined by the Oepartment of Health and Hospitals, state law (Act 803 of the Regular Legislative Session 2004) and regulations. Anyone providing addic.tion or behavioral health services must be certified by OHH, in addition to their scope of practice license. LMFTs and lACs are not pemiiiied to diagnose under their scope of practice under slate law. LPCs are limited by scope of practice under state law to diagnoSirig conditions or <lisorders requiring mental health counseling and may not use appraisal instruments, devices or procedures for the purpose of treabnent planning, diagnosis, classification or description of menial and emotional disorders and disabilities, or of disorders of personality or behavior, which are outside the scope of personal problems, social concerns, educational progress and ocoupations and careers. Inpatient ho~ilal visits are limited to those ordered by the indiVidual's physician. ViSits to nurSing filcility are allowed fur psychologists if a PASRR (preadmission Screening and Resident Review indicates it is medically necessary treatment. Social worker visits are included in the Nursing Visit and may not be billed separately. ViSits to ICF~~.mcilities are non-covered. .All LMBP serVices provided while a person is a r"llident ofan IMD iiuch as's"free stan4ing p_sychiatric ho~ital or psychiatric residentisl treabnent mcility are content of the instittitional serVice and not otherwise reimbursable by Medicaid. Evidence-based Practices require prior ~pProvai and fidelity ievi~y.>s on· aII'ongohjg basis as determined necessary by OHH.

~ •. ' _. . ... _" I ',' .,. _,', :~~F .... j I

-' '. 1 .. _ _

1N# _11-13 Approval Date J:J '/\O\''; 'II! Effective Oate_3/112012, _____ _ Supersedes ---~---' ____ . '. " rI'"H"I •

.. -1 ... , ••• ~::~, .", "- .". •• ' ••• '

1N# __ None .. ,~ ~- ,-' 11-13-2008

Stale: Louisiana §1915(i) HCBS StalepJan Services Stale Plan Attachment 3.1 -& Page 20

provider must receive regul""ly ~qheduled clfulcaiwpe1;Yillionf!:J>!lla per~'m!l6ii!tlr,tI1!l,qtiiill1icati9ll~"'fa LMHP or PIHP-designaled LMHPwitli experienc~ regtirdlIigthis~ililiZed mentiilie\iltllsefvi~:$:1l ;maiYsi,~ of problem behaviors must be perfurmed under tile supervIsion bfalicensOd psychoioil!StiDi~&Ii p!iY<liio!oi!ist.' '" '

. .' :.' .'. ," ." ~-.. ". . ... ..',.:.\:: .. :.~. >.;~?: -.':<: ':-;" - .: .......... ,-

PR Limitations: Limit of150 h()~sof grt,upp~9hoS9"iah~~bil,iiation pi; cai~dWy~; ijus liinit'~be exceeded when medicallyneceStiary tlmJUgb prior authOrization. ThePRpr"Vidii must recci~ regul""lyscheduled clinical superVision from a person meeting the qualifications ofRr..M:HP orPlHP-desigp:"tiid LMHPwith experience regarding thia ~ecialized mental health serVice.

CI Limilations: AU indiViduals who self identify as experiencing a.seriously acute psychological/emotional change which results in a marke4 increase in personal distress and which exc~ the abilities and the resources ofthose involved to etrectively resolve it are eligible. , An individual in Crisis 1I\ay be representiid by a filniiIy m¢nlber pr other Collateral contact who has knowledge of the indiVidnal's capabilities' and: fimcj:!oning. ,indiVidnals in crisis who require this serVice may be uSing sUbstiiitCiJs dwglhe cnsis, SIl~ce.~se shotIJd oorecog.iiZi:dimd addressed in an integratedfushlon 'as it may add. to t)le risk incressing the iieed fur engagement in care. The assessment of risk, mental status, and medical s!;lbility inust be completed by a r..M:HP or l?IBP-designated LMHP with experience regarding this ~ecialized mental health serVice, practicing within the scope ofiheir pr~resSional license. The crisis plan developed from this assessment and all services delivered during a crisis must be provided under the superVision of a LMHP or.PIIlP-designated IMBPwith experience regarding thlsspeciallzed mental health service, and wch must be avaihibleafall timestoproVide bsck tip, support, and/or conSultation. Crisis serVices cannot be denied bssed llpollsubstance use. The Crisis Intervention ~eciallst mUI!! receive regularly scheduled cllnicalsuperVision from a person meeting the qualifications of a LMHPor PlHP-deSignaled LMHP with experience regarding this specializ<;d mental health serVice. CriSis Intetire.ntiOIi -'Emergent is limited to 6 hours per episode. Crisis Intervention - Ongoing is limited to 66 hours per episode. An episo<\e is defined as the initial fuceto mce conlact with the individnal until the ourrent crisis is resolved, not to exceed 14 days. The individual's chart must reflect resolution of the Crisis which marks the end of the, current episode. Ifthe·individual has another crisis within 1 calendar days of a preVious episode, it shall be considered pm of the previous episode and a new episode Will not be allowed.

IE Medically needy (specify limits): IMBP limitations: ProViders cannot provide serVices or superVisiou under this section lfthey are a provider who is excluded from participatinn in Federal healJh care programs under either sectimi 1128 or section 1128A of the Social Security Act. In addition, they may not be debarred, ~ended, or otherwise excluded frain participsting in procurement actiVities under the State and Federal laws, regulations, and policies including the Federal AcquiSition Regulation. Executive Order No. 12549, and Executive Order No. 12549. In addition, proViders who are an affiliate, as defined in the Federal Acquisition Regulation, of a person excluded, debarred, suspended or otherwise excluded onder State and Federal laws, regulations. and policies may no! participate. AU services must be authorized. SerVices which exceed the limitation of the initial authorization mus! be approved fur re-authorlzation prior to serVice delivery. In addition to licensure, serVice providers that offer addiction serVices must demonstrate compelency as defined by the Department of Health and Hospitals, state law(ACf g03 of the Regular Legislative Session 2004) and regulations. Anyone providing addic.tion or behsvioral health services must be certified by DHH, in addition to their scope of practice license. LMFfs and LACs are not pemillt.id to diagnose under their scope of practice under state law. !.PCs ""e limited by scope of practice under state law to diagnosing conditions or ,disorders requiring mental health counseling and may not use appraisal instruments, devices or procedures for the purpose of treatment planning, diagnosis, classification or description of mental and emotional disorders and disabilities, or of disorders of personality or behavior, which are outside the scope of personal problems, social concerns, educational progress and occupations and careers. Inpatient ho~ital visits are limited to those ordered by the indiVidual's physician. Visits to nursing fucility are allowed fur psychologists if a PASRR (preadmisSion Screening and Resident Review indicates it is medically necessary treatment. Social worker visits ""e included in the Nursing Visit and may not be billed separateiy. Visits to ICF~Ml},fucilities are non-covered. ,AU IMBP serVices provided while a person is a resident ofan lMD Such iIliidree standing p,sychiatric ho~ital or psychiatric residential treatment mcility are content of the instittitioool serVice and not oth~se reimbursable by Medicaid. Evidence-based Practices rcquire prior ~pProvai and fidelity ievi~ws on· all '6hgoh\g basis as determined necessary by DHH,

~ •. ' _. " .. _" I ",' ,\. _,", :~~ ;:'."-.L I

.' ~', ). - -

11-13-2008

State: Louisiana §19l5(i) HeBS State plan Services State Plan Attachment 3.1 -&

CPST, PR; .imd CI I:.imibitiims: · 'Sej'yices:are 'subjCl)t t"l1 , ot.·iipjiro'vaFilillSt ...... IiiMicidl :n" ...... ·• .. , ' ,1" ·ust.lic' '-'" . recomni~dtd bya li~lieameJ;t81h:e&!ih .-;. ctiIi8iici'/6rii~cJik:ici6iciifi:"'"~":"j;( .. ~~~~~(jn~T:ian':; .. ' The activities fuCludedlii~ih6~erii~muStt£ ilitendedto~Cili~wd(j~tifi&t.:kif~t~~i&it6~'6b'~~ The ifeaanentian:' sJioUldilo:d' ?' i · ~-fi{~·'· ~61i~(;;ibdfui.rid~: · ' ;lii~Ui'ci'iiawe"';;;H~~~ ~i;1il'i>tfih<6:iJd!:;,id~'·' . fiimilanlroyjc/ . saild~ii~ bn:fu:kdiv.idiiaJii&;h\lii:iciii ·ltibi1~dlirls:of-., 1'"Cticnb,>.iii;.' 'i6ViSibir'of _ ... y. p .... cr .......... ,..... .. .. .... ,"" ... .. " .. . -...... . ...... . •. ' ...... " , .. PfJ' .. , . ~ " ~.R , .... . . these speciJic reliabilililtiveseCvi~;: Th¢fi'~fui~t.pJ!l!I'ShoiM{ae;;~:Weii:i'tdic8I,ii(reiii&!iAi'~MceS liif&!dedto. reduce the identifiei!'ooiiililiona~\~lias!he""ticip~f.e<!'.~~ii:Om: .. ofi!1'e iIi(ijViiluali ·'ih~).r~!iIi.~t.i>I~.;iust ·, ....

iCy the fte nenc ·amoiiiit-iiriddUtauon·(ifSci"iiice!i: Theiieatment " lililliiust besl . ·.'i'b "'U\c'liCiiis<id mcnt8I spec q Y' ., . " , " . .' '. .. _. ''' . . .' - .. P... ..' .. ~ . . y........ ..... '.' helllth praeritio~erorpliysic~tesg~~sj~\~1i?,r;d~elopWg the'i'lan:Thepl~ .~:'spCp!..fY,~ ~~lliie for reevalUation of the jllan that IS aHeast ~.'annuaJ ~et\illIlWlli.Qn; .Th~reelilU8\i!'D:~Shoul~'!.nv9Iy" themdivi~~ fiu)tilyand providers and include a reevaJ1l!'t\o.n of plan to deterinin'lwlie(her servi~hji~ cOiitPbut~ 'fl)!il~.ti!lgtl)." _.fated goals. A new treatment p!i!nSl\o~!doo deveI9Peq .ifi!ier~ isn!t!li~~~leredj.Ic!ioil of ~SiM#t<ir~stol'a,tion of. functiona1le~l. The~e~J?!F.,~q\ll!1.:iden~,~~tj-~~ili~~6!l :STt:ii!~gy¥!Jl:~Y.t~}~~jiJ!~d~~~;·· '.' Anyone prOVl4ll\g addiction or'mental heat:th ·~erytcesJ:llu.~~ ~.Cei@04 bYJil~ m'a~'fitio,t\t9'~y',r~u~ sc:op.e ' of practice license ~~for i)1ll1i!~ty:9.r;agency'.to pracIiC{l.\!!. th~ .Sfiit,c:';fI-oU¥iiDl\' Ptoyi~e~ ,nuSt'tna!ri&';in ease records that incilii!ie iI copy of the tr~tmeut pl!U'i,;' ilieiiillri.liof the liidiYid1l)lW~(e(of seivii:~fpi'6'Viae<l; 'lI4fure, content and uilits ofrehaliititatioxi sefyi~eS;proVidedi\iii:d pfOgressri1a~e'towaid'fuiiliiiiilllii'1ii1provem~nti!D.d goals in the treabnent plan . .M~caln~ty ofthe~ces'iS:¥~ed bY.ali~ ir!eiltal hcalthP<;lctittii.Ifei·or physician C<?Ilductiiig;an~s~Sijieiit ~sistent v4ili ~!i!i;"liiw, :iegulation:M!lp,olicy . . Servj¢es JiiOviaCi! at a 'Mlrk site must not be'job tal!kB Orientell. Any ServlCjls or..c<imp~nCiiiS ofservi~ll'e b8SlcPature.of,*h,iCh.iu-e.'tO supplant housekeeping, homemaking, or basic services fur. the ¢<itiveru~nce ofa person reCeiVing cOvered services (lnclQding housekeeping, Shopping, ~.bildClare, an~ lawl<ltyser;Viees) are non-cOvered. serVices #<!tbepr,oVidediO an institute fur mental diSease (IMIJ).Room and liOardls ex~luded frdm any rates provi~ in'l\' residcn&.' setting. Evidence-based 'Practices requ.ire prior app~val and fidelity:rilv!ews on .an ongoihibasis as .detenhliiedli~cessary· by Dmt Services may be provided at a site-based mciliiy, in the commUnity or i1i1heindividu8I's place of residence as ouUined in the Plan of Care. Components th~t are not provide4·to, or directed exclusively toward the ~bnent o~ the Medicaideligihle.individual are not eligible fur Medicaid reimbursement ' '. . .

cPST Limitations: Caseload Size-must.be based on' the needs of the clientslfiunilies with'an emphasis on successful outcomes and individual satismerion and must -meet thimeeds identified in the individ\Jal tre;abnent plan. The'CPST provider must receive regularly sch!',diJIed clinical supcrVisi.onfrom a PCrson m~ .the qWili1ications .of a LMHP or PIHP-designated u.mP with experience'regaromg:t!iis Sjiecializedni~iafhe8It1i· servi~, All analysis of'proolem behaviors must be perfurmed under the suPc:rvision: of a licensedpSYChologiStl~~1 p,*)IolOj:ist

PSR Limitation: Limit of 750 hours ofgioup psych~ci8I rehabilitatioo per'c8Iencl8r ye;u-. This limit can be exceeded when medically necessary through prior authorization. The PRproviciCr must receive regulafly &clieduled clinic8I supervision from a person meeting the. qualifications ofa LMHP or PIHP-designated !MHP' with experience regarding this specialized ment8I he8Ith service.

CI Limitations: All individuals who Se!fidentify as ei'l;erienciD.g" seriously acute psychologicaVemotional change which results in amacked increase in persolial diStress a:ndy.-hich exceeds the abilities and t!te r~ources of those . involved to effectively resolve it are eligible. An individual in crisis may be represented by'li 1imWy member or other coUatera! contact VJho has knowledge of the in!\ividual's capabilities and functioning .. l!!dividuals in crisis who require this service may be using substances dwing the crisis. SubStance'lI8e Should be recognizeil. and addressed fu an integrated mshion as it'may add to the risk increasing the. need fur engageinerii iIi eare. The assessment ofrisk, ment8I slatus, and medical stability must be completed by a IMHP or PIHP.,designated LMHP with experience regar4,ing'this -speci8ii7.ed IIll'l1ta! lle8Ithservi~ practiciD.g~,!1iin the scop~of.*~_ir :Jl!:Ofi:ssiona1 license. The erig~ plalideveloped from this-~t and all ~~deli~dwing a Il.risiSlllust.be provided Ul\der the supe;...;sion of a LMHP .Clf..PIHP~eSignai'e4 LMHP with experience regarding this specialized ment8I h<iaIth service;"aiid such miiSi be avail".b!~ .~t,aINj~~ to provi~e back up, .support,,~d1or consul~tion. Crisis services cannot be denied'baaec!-upon substance u1'.l'. The CriSIS latervention specialist must recetve regularly scheduled ~linica.1_ supervision from a pef~ tiicUifug:;the qualifications of a LMHP or PIHP-designated LMHP with experience re&aromg this specialized m!'1lliilheilili'!;e;vjce. Crisis latervention - Emergent is liiniled to 6 hours per

I episode.Cris~ ':rnteiVCiitiOii''::::6il'~6in~ iii liiDitei! to 66 hours per episode. An episode is defined as 1I1e initial fuce to

TN#_11-13 ____ Approv8IDate '!:l.-IQ .1( Effective Date_3/1120IZ'--_ ___ _ Supersedes TN# _ _ None __ _

11-13·2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -.

these reduce the specifY the ' health orthe

goals. A ftmctionallevel. Anyone pro,ri4it,g ofpmctice case records

Page 21

OO11tent and un;'" gOals in the treatment plan._ physician With - a work site must not be job housekeeping, housekeeping, shopping,

insti!1lte fur mental diSease ::an~:y~~~:~~~~S~::t~r:~y Evidence-baSedPri!Ciices reqUire prior apIJ1:OVlll and on by DHH. Services maybe provided at aslte-based fucilii¥, in the , residence as outlined in the Pian of Care. Components that are not provide!! to, or directed exclusively towani the tr!l'lltment 01; the Medicaideligibleindividua! are not eligIble fur MediCaid reimbursement. - -

cPST Limitations: Caseload Size must ,be bru;ed on the !leeds of the clientslmmilies with-an emphasis on truccessful outcomes and individual satisfilction and must meet thlmeeds identified in the individual tre,alment plan. TheCPST provider must receive regularlyoohedwed clinical supervision from " person m~ting ,the qualifications of a LMHP or PIHP-designated LMHP with experienreieg8rding tbls SjJeeializedni~talhea!tliService, AI! analysis of problem behaviors must be perfurmed under the sup~ion: of a IicensedpsyohillogiiillinediCsl psyi::)1ologisl'.

PSR Limitation: Limit of150 hourn ofgrilup psychosocial rehahilitatioo per'calender~. Tms liiirlt can be exceeded: when medically necessary through prior authorization. The PR provider must '-ive regulaIly scheduled clinical supervision from a person meeting theqllllllficatinns oia LMHP or PIHP-designated IMHIi with experience regarding this specialized mental health service.

eI Limitations: Ali individuals who Selfiden\ifY as ekPerlencWg" seriously "cute PSYChological/emotional change which results in a marked increal;e in personal dj8lr_ IInd1l'hich exyeeds the abiliti~ and Ill" reSOurces of Ihose ' involved to effi:"tive!y resolve it are eligibLe. An individual in crisis may' bereJiresOOled by-a WniIy member or other collateral contact \'\!ho has knowledge of the in!lividual's capabilities and functioning •. li)dividuals in crisis who require this service may be ,using subetarJ.ces during the crisis. SubStanceliSC should be recognized and addr_ed in an integrated mshlon as ifmay add to the risk increeslng the need fur engagement m Care. The assessment ofrisk, mental status, ~9 }I\eru.cal. stabililY must be completed by a LMHP or PlHP-desiguated LMHP with experience regard,il:lglhls ipoou.llzed ~ta! /leaIthservice, pmcticing:wi,.1hin the seop~of.th"irIR:Otessiooa1 license. The mgs plaii developed fh~m this·~t and ali l!eIVi~deli~ during a I1[lsis)1luSt,be provided uqder the SlJpemslon of a LMHP ,CJr; .PIHP~ignaie4 LMHP withexperieriee regarding this specialized Illental health servic';-arld such must beava1labj~,~t,a~jtA>t!ll\to provide back up, support, and/or consuli:;ltion. Crisis services cannot be denied-baset:\)Jpon sul:!sPlnca, IlI'h ''!he Crisis lntarvention specialist must receive regntarly scheduled .lJiIdca.t SlJPervision from a persOO m:eeting';tbe qcallfimtions of II. I.MHP or PIHP-designated LMHP with exPerience regarding this . heiilili service. Crisis intervention - is liinited to 6 hours per

. , to 66 hours An

1N1I _lI-13 ____ .ApprovaI Date I'J. -& (LLI_-,Effi>ctive DauL3/1120 12, ____ _ Supersedes 1N1I

11-13-2008

State: Louisiana § 1915(1) HCBS State plan Services State Plan Attachment3.1 -~

SpecifY whether the service may be provided by a

(check each that applies):

o ,0

o

Relative

Legal Guardian

Legally Responsible Person

Provider QuaUfications (For each type of provider. Copy rOll(\" as needed .

Provider Type License (Specify): Certification (Specify): Other Standard (Specify): (Specify):

Agency

Clinic

LMHP

Mental Health Clinic RS 28:567

A LMHP includes,individuals licensed to practice independently:

• ' Medical PsYchologists • licenB~ Psychologists • lice~~ Clini,cal Social

Wm:kers (LCSWs) • licensed Proressional

Counselots (des) • licensed Manjage and

Family Therapists (LMFfs)

• licensed Addiction Co~seiors (LACS)

• Advanoed Practice Registered Nurses (must be a nurse practitioner specialist in Adult Psychiatric & Mental Health, and Family

TN# _11·13 ___ ~ApproV81 Date 11--"" J\\ Supersedes TN# __ None'--__

. Mental H.,;dth ' Rehabilitation Certification '

, certifii:!1 ~giiricl~'iii~y' proVide anycOl11j>Oiient of the Rehabilitlitioo services lisied and ';l\ist ~Ioy and ,uti1ize,the qualified providers ,as ~tedbelow(U.lliPs, CP,ST specialiSts, PR

, ,specialistS, aild CI specialists) , '

, Clinics inay proVide any" ~riiponeD.t of the ' ,

, RehabilitatiOn services listed and'must emploYilnd utilize ,the qualified'proViders as ' lis\l:4 bCiI6<y(l'j.ffips,CPST speciij,is!B, PR specialistS, and C(speCialistS)

Practitioners must operate under the scope of Plllctice as outlined,in state law.

SOPERSEDES: 'NONE - NEW PAGE

STATE 1 m.!.!:'2 \ etl\. it 1 DATE REC'S '3 - 10-1 II f

DATEAPPV'D 1l..'1l1-11 A I)ATE EFF '3 -1 - I?-HCfA 179 \1-1$._ '"-- ___ ... _. ___ ........ _L-.-. ... ·...J.

,.

Effective nate_3/112012, _____ _

11-13·2008

Stale: Louisiana § 191 S(i) HeBS Stale plan Services State Plan Attachment 3.1 -~ Page 22

Specify whether the service may be provided by a

(check each that applies): ,0

o

,,":.

Relative

Legal Guardi8ll

Legally Responsible Person

Provider Qualificatiolls (For each type of provider. Copy rollif as needed:

Provider Type License (SpecifY): Certification (SpecifY): Other Standard (SpecifY): (SpecifY):

Agency

Clinic

LMHP

Mental Health Clinic RS 28:567

A LMHP includcsindividuals licensed to practice independently.

• Medica! PsYChologists • UcenSlid Psychologists • UceDsed Clinical Social

Worirers (LCsWs) • Ucensed Pro1lissional

Cotmselots (Iiics) • UcenSlid Mmjage and

Family Therapists (LMFTs)

• UcenSlid Addiction Co~seiors (LACs)

• Advanc¢ (>ractice Registered Nurses (must be a nurse practitioner specialist in Adult Psychiatric &, Mental Healih, IlIld Family

Menial Health . .Rehabilitation CertifiClltion

· ceitifieJ ;'iende:;"i,j~y .,' provide anycnqiponent of thll Reh~billta!iQn .~ervices listed IlIld must employ sud utilize.the qualified providers as l.i;lte4be1ow(U.mPs, CPST specialists, PR

, specialists, aild CI specialists) . . .

· Clinics inay provide any ~mponent of the . .

· RehabilitatiOn services listed andmllllt employiind utilize ,the ql,lalifiedproviders as 'lis~ bii16'iy .(i;MHPS;CPST speciill.i$, PR speclalistS, and c(speClalistS)

Practitioners mllllt operate und\lf the scope of Pl1Ictice as OIltlined.in slale law.

SOPERSEDES: 'NONE -NEW PAGE

STATE lm4i5\1i1>{t 1 DATE REC'El~ -10 ,~ I \1 I DATEAPPV'D 1:L1q v II A QATEEfF a-I ~ I!). HCfA 179 ti- \!. ._ L---_... _ ... _-._ ..... ,,...._J... ....... """"""'....l

.. TN# _1I-13 ___ ---CApproWll Date _J1c::lt\L"'J.I.l..\ __ E,!reclive Date _31112012. _____ _ Supersedes TN# __ None, __ _

11-13-2008

State: Louisiana

CPST specialists

Psychosocial Rehabilitation specialist

Crisis Intervention Specialist

§ 1915(i) HCBS State plan Services

. . , ...... , .... ..

State Plan Attachment 3.1 -C}-'

- ' - 'j ,"

~ .. '

;~ ~ . ," ..... -.-.~ . . '" ' .. ~" '~ '" -=.:.:::-," .:, ..... ~ '; ;:-' .

5U"PERSEDES: NONE - NEW PAGE

---'--'-'---''''-1 STATE lou"m'()It!\t\. ! DATE REC'!:) 2. - 10 -II DATE APPV'D I;)", -lq - ( I A I)ATEEFF 2 -I-I~ HCfA 179 11-19> __ •

'--- --~ .. ----.-.-.. -~ ........... ~.-

. ...•. ' ¥~~~ve '.' ~-<¥Iiree to proVl'!ti all ~ts:of

" .. : ~J!~~~~~t . cOUnselliC-" Other ii ~ts_of . '. ". '.' .. ' .. ,g --' "_,"'.' .SP.. .. . .'., CPST exce' t furciiuilsclin .' .. ... , .. , , ;.,_ .. P ..... - .. , ..... ', '- .- g.

: ~ay.~th~se~.p~ed QY ail .indiVidual Viitl.t-BAJaS

.~ffouryears o(~~V1IIent ed~catlOn, aild!or experience

... W91'king ip..the.h\iliian . . . services field. CertificatiOIi in

lheStiite QfLouisi.iha iO · p~oVi\l~ t1!~ ~etvic~, wliich incluClesp:j.m.jn~ . pi'o(~sio~~ ba:Cikground · ch~Ii:S. m,~completion of a · stale apjiroved starid8rdized .. bilsio triWiinit·peciiiram. MUst havc'meetPRS n;qiuteinkiti t6 prPvid~ ail aspectS ofpR$:.· . S1!lx:omponents of RehabilitJtion. M:ust be at least 18 years' old; and bave a high schoof diploma or equivalent Additionally, the PI9vid,er:must !le at lesst thriiC years older than .individWiI Under the age of 18. Certification. in the State ofLoUisljii1i1-tO provide the service, which includes 'cri!)1ina1, professional bilckSrollilil che«ks, ~ · completion ora sta~ approved standar<!jzed basic train)Ug prograJjl. Must lIavemeet CI requirements to provide all aspects of CI subcomponents

TNII _11-13, ___ ---'Approval Date 1':)..-\ q -\ \ Effuctive Date_3/112012 ____ _ _

Supersedes TNII __ None. ___ _

11-13-2008

State: Louisiana

CPST specialists

Psychosocial Rehabilitation specialist

Crisis Intervention Specialist

§ 1915(i) HCBS State plan Services

. . , ...... , .... ..

State Plan Attachment 3.1 -C}-' Page 23

- ' - 'j ,"

~ .. '

;~ ~ . ," ..... -.-.~ . . '" ' .. ~" '~ '" -=.:.:::-," .:, ..... ~ '; ;:-' .

5U"PERSEDES: NONE - NEW PAGE

---'--'-'---''''-1 STATE lou"m'()It!\t\. ! DATE REC'!:) 2. - 10 -II DATE APPV'D I;)", -lq - ( I A I)ATEEFF 2 -I-I~ HCfA 179 11-19> __ •

'--- --~ .. ----.-.-.. -~ ........... ~.-

. ...•. ' ¥~~~ve '.' ~-<¥Iiree to proVl'!ti all ~ts:of

" .. : ~J!~~~~~t . cOUnselliC-" Other ii ~ts_of . '. ". '.' .. ' .. ,g --' "_,"'.' .SP.. .. . .'., CPST exce' t furciiuilsclin .' .. ... , .. , , ;.,_ .. P ..... - .. , ..... ', '- .- g.

: ~ay.~th~se~.p~ed QY ail .indiVidual Viitl.t-BAJaS

.~ffouryears o(~~V1IIent ed~catlOn, aild!or experience

... W91'king ip..the.h\iliian . . . services field. CertificatiOIi in

lheStiite QfLouisi.iha iO · p~oVi\l~ t1!~ ~etvic~, wliich incluClesp:j.m.jn~ . pi'o(~sio~~ ba:Cikground · ch~Ii:S. m,~completion of a · stale apjiroved starid8rdized .. bilsio triWiinit·peciiiram. MUst havc'meetPRS n;qiuteinkiti t6 prPvid~ ail aspectS ofpR$:.· . S1!lx:omponents of RehabilitJtion. M:ust be at least 18 years' old; and bave a high schoof diploma or equivalent Additionally, the PI9vid,er:must !le at lesst thriiC years older than .individWiI Under the age of 18. Certification. in the State ofLoUisljii1i1-tO provide the service, which includes 'cri!)1ina1, professional bilckSrollilil che«ks, ~ · completion ora sta~ approved standar<!jzed basic train)Ug prograJjl. Must lIavemeet CI requirements to provide all aspects of CI subcomponents

TNII _11-13, ___ ---'Approval Date 1':)..-\ q -\ \ Effuctive Date_3/112012 ____ _ _

Supersedes TNII __ None. ___ _

11-13-2008


.- ,

... :-

' .. :

: .. '" ..

... :'

'. :-

"

State Plan Attachment 3.1 - .....

" inUl£be'~t1e8st ihree s · " .... , . . . , ....... ~ . . older ihaii iI iii~Vi"~\Illder the· ... ge 'of 18i Ccrtification ,in '!Iie SIIi!eofloiiisiana to

... ili.oxi~~iIi.~'~~~~hich . inchidescriniin'aJ :':r'.' , 'pr~~~ii(i5i;¥kg;;ound cliciccks. 81lirCQiriplCtiori of a ·sliir.,...pp,rQV;,d stiiildaidized baslc"tniitiing prdg'J:foi!:

,. ".- : ., ' -: '; . .'.:

:~ " , '

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed):

Provider Type (Specify):

Agency

Clinic

Entity Responsib Ie fur Verification

(Specify):

Statewide Management Organiza~on ·


Statewide Management Organization

DA'"fE REC'I:) P -10 viI .\' DATEAPPV'D I'Jdl-11 A I)ATE EFF :3 - I-II).. HCfA 179 k \- L2-_ ,

~"""'---I$----.-"'---~."-~~"-

Frequency of Verification (Specify):

· Upon Contracting and

at:i~t anillm»y th~r~after the Statewide Management oriaIrization wjll conduct and on-site audit to ensure that all providers are appropriately

· credentiaIed

Upon .Contracting and at lCiastannually , thereafter the Statewide MaIiagement Orgaol?:ation. will conduct an on-site aud it to ensure that all pro:viders are appropriately credentialed

TN# _ll-13 ____ ,Approval Date t';)~ - \ q ~ 1\ Effective Da!e_311f2012. _____ _ Supersedes TN# __ None'--__

11-13-2008


.- ,

... :-

' .. :

: .. '" ..

... :'

'. :-

"

State Plan Attachment 3.1 - ..... Page 24

" inUl£be'~t1e8st ihree s · " .... , . . . , ....... ~ . . older ihaii iI iii~Vi"~\Illder the· ... ge 'of 18i Ccrtification ,in '!Iie SIIi!eofloiiisiana to

... ili.oxi~~iIi.~'~~~~hich . inchidescriniin'aJ :':r'.' , 'pr~~~ii(i5i;¥kg;;ound cliciccks. 81lirCQiriplCtiori of a ·sliir.,...pp,rQV;,d stiiildaidized baslc"tniitiing prdg'J:foi!:

,. ".- : ., ' -: '; . .'.:

:~ " , '


Provider Type (Specify):

Agency

Clinic

Entity Responsib Ie fur Verification

(Specify):

Statewide Management Organiza~on ·


Statewide Management Organization

DA'"fE REC'I:) P -10 viI .\' DATEAPPV'D I'Jdl-11 A I)ATE EFF :3 - I-II).. HCfA 179 k \- L2-_ ,

~"""'---I$----.-"'---~."-~~"-

Frequency of Verification (Specify):

· Upon Contracting and

at:i~t anillm»y th~r~after the Statewide Management oriaIrization wjll conduct and on-site audit to ensure that all providers are appropriately

· credentiaIed

Upon .Contracting and at lCiastannually , thereafter the Statewide MaIiagement Orgaol?:ation. will conduct an on-site aud it to ensure that all pro:viders are appropriately credentialed

TN# _ll-13 ____ ,Approval Date t';)~ - \ q ~ 1\ Effective Da!e_311f2012. _____ _ Supersedes TN# __ None'--__

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 - &

Service Delivery Method. (Check each that applies):

oJ Participant-directed n~ I Provider managed

Service Specifications (Specify a service title for the HC8S listed In Attachment 4. 19-8 that the State plans to cover):

Service Psychlatristserviees" ..... .. , ... , .

Title: .' . ' .. Service Definition (Scope):

As apprpved in the rv,edicaid'State Plan under Attachment 3:1A, Item·12.a~ Physician (for· Psychiatrist Specialty only) i' . .

Additional needs-based criteria for receiving the service, if ~pllcable (specify):

Specify limits If any) on the amount, duration, or scope of this service for (chose each that applies):

00 Categorically needy (specify limits):

Individuals must access under 1905(a) of the State Plan. [&] Medically needy (specify limits:

Available to individuals unable to access under 1905(a) of the State Plan.

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type license Certification Other Standard (Specify): (Specify): (Specify): (Sneeifvl:

As approved STATE 1,.ou.i etru-. ~ n Physician, OATEREC'B · a -/O-li Psychiatrist OATEAPPV'O I :l.--I ~-I/ A specialty, I)ATEEFF 2 ~ 1 - ["-

-

Attachment 3.1 A, HC;=A179 11-12._ . item 5 ~ ___ "._--._. __ -...~ ... _ • .i.-_


Provider Type Entity Responsible for Verification Frequency of Verification (Specify): (Specify): (Specify):

As approved Statewide Management Organization Upon enrollment and every 5

in Physician, years thereafter. Psychiatrist, r

Attachment 3.1A, item 5.

Service Delivery. Method. (Check each that applies):

o participant-directed I 00 I Provider manaQed

TN# _ll-\3 ____ .Approval Date 1;).-\,\ -I \ Effective Date _31112012. _____ _

Supersedes TN#_None'--__

SUPERSEDES: NONE - NEW PAGE 11-13-2008

l

State: Louisiana §1915(i) HCBS Stale plan Services Stale Plan Attachment 3.1 - • Page 25

Service Delivery Method. (Check each that applies): o J Participant-directed r Itl I Provider managed

Service Specifications (Specify B service title for the HCSS listed In Attachment 4.19-8 that the State plans to rover):

Service Psychlatrist'seIVlres ' ," '"

Tille: ,

SelVice Definition (Scope):

As apprpved in the Medicaid 'State Plan under Attachment 3jA.ltem'12.a~ Physician (for ' Psychiatrist Specialty only) /' , "

Additional needs-based criteria for receivina the selVics, if appUcable (specify):

Specify limits (if any) on the amount, duration, or scope of this sSlVice for (chose each that applfes):

r&l Categorically needy (specify limits):

Individuals must access under 1906(a 1 of the State Plan. r&l Medically needy (specify limits):

Available to Individuals unable to access under 1905(a) ofthl? State Plan.

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard (Specify); (Specify): (Specify): (Snecifvl:

As approved STATE- I...or.&r '0 r lU\ ~ n PhYSician, DATE REC'I:) . a -Ie) -it Psychiatrist DATE APPV'D 10...-1 !i-II A speCialty, OATEEFF S ~ 1- f:;L. Attachment 3.1 A, HC;::A179 1\-1 a._ itemS ~-.-..... -""""" ....... ---......... .. < .... - .. ~""""""'" •


Provider Type Entity Responsible for Verification Frequency of Verification (Specify): (Specify): (Specify):

As approved Statewide Management Organization Upon enrollment and every S in Physician, years thereafter. Psychiatrist, , Attachment 3.1A, item 5.

Service Delivery Method. (Check each thai applies):

o participant-directed I 00 I Provider manaaed .

IN# _1l-13 ____ ,ApprovallJare--=I~l.~-~' '\:L.·.t:I\L....._,Effi:cttve Date _3/112012. _____ _ Supersedes IN# __ .,,'u-___ _

SUPERSEDES; NONE - NEW PAGE 11-13·2008

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -C§,

2. 0" Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the State assures that): There are policies pertaining to payment the State makes to qualified persons furnishing State plan HeBS, who are relatives of the individual. There are additional policies and controls if the State makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (SpecifY (a) who may be paid to provide State plan HCBS; (b) how the State ensures that the provision of services by such persons is in the best interest of the individual; (c) the State s strategies for ongoing monitoring of services provided by such persons; (d) the controls to ensure that payments are made only for services rendered; and (e) if legally responsible individuals may provide personal care or similar services, the palicies to determine and ensure that the services are extraordinary (over and above that which would ordinarily be provided by a legally responsible individual):

The State does not make (and will not permit the SMO to make) payment to legally responsible individuals, other relatives, or legal guardians for furnishing state pian Home and Community Based Services (HCBS).

Participant-Direction of Services

Definition: Participant-direction means self-direction of services per §J9J5(i)(1)(G)(i/iJ.

1. Election of Participant-Direction. (Select one):

• •• The State does not offer opportunity for participant-direction of State plan HeBS .

0 Every participant in State plan HCBS (or the participant's representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available fur particip~ts who decide not to direct their services.

0 Participants in State pian HCBS (or the participant's representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the State. (SpecifY criteria):

2. Description of Participant-Direction. (Provide an . overview of the opportunities for participantdirection under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction):

3. Limited Implementation of Participant-Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to statewideness requirements. Select one):

'0 Participant direction is avail~ble in all geographic areas in which State plan HeBS are , . . . ~ ' -.

available. . ' " . 0 Particiiiant~direCtiqiJ.. is a~\ia~i~ only to individuals who reside in the following geographic

: '. . . ·areas or politicalsu1idivisld~Jof the State. Individuals who reside in these areas may elect . _self. directed service 'd~fiV6'Y'(jp!ions offered by the State, or may choose instead to receive

, compar)\ble. ~qvices . thr'ough ·the·.beneJit's standard service delivery methods that are in effect .

m# _ll-13, ___ --'ApprovaIDate 13- -Itt ~I ( Effective Date_3/1120 12, _ _ ___ _ Supersedes m# __ None. ___ _

11-13-2008

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -C§, Page 26

2. 0" Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the State assures that): There are policies pertaining to payment the State makes to qualified persons furnishing State plan HeBS, who are relatives of the individual. There are additional policies and controls if the State makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (SpecifY (a) who may be paid to provide State plan HCBS; (b) how the State ensures that the provision of services by such persons is in the best interest of the individual; (c) the State s strategies for ongoing monitoring of services provided by such persons; (d) the controls to ensure that payments are made only for services rendered; and (e) if legally responsible individuals may provide personal care or similar services, the palicies to determine and ensure that the services are extraordinary (over and above that which would ordinarily be provided by a legally responsible individual):

The State does not make (and will not permit the SMO to make) payment to legally responsible individuals, other relatives, or legal guardians for furnishing state pian Home and Community Based Services (HCBS).

Participant-Direction of Services

Definition: Participant-direction means self-direction of services per §J9J5(i)(1)(G)(i/iJ.

1. Election of Participant-Direction. (Select one):

• •• The State does not offer opportunity for participant-direction of State plan HeBS .

0 Every participant in State plan HCBS (or the participant's representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available fur particip~ts who decide not to direct their services.

0 Participants in State pian HCBS (or the participant's representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the State. (SpecifY criteria):

2. Description of Participant-Direction. (Provide an . overview of the opportunities for participantdirection under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction):

3. Limited Implementation of Participant-Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to statewideness requirements. Select one):

'0 Participant direction is avail~ble in all geographic areas in which State plan HeBS are , . . . ~ ' -.

available. . ' " . 0 Particiiiant~direCtiqiJ.. is a~\ia~i~ only to individuals who reside in the following geographic

: '. . . ·areas or politicalsu1idivisld~Jof the State. Individuals who reside in these areas may elect . _self. directed service 'd~fiV6'Y'(jp!ions offered by the State, or may choose instead to receive

, compar)\ble. ~qvices . thr'ough ·the·.beneJit's standard service delivery methods that are in effect .

m# _ll-13, ___ --'ApprovaIDate 13- -Itt ~I ( Effective Date_3/1120 12, _ _ ___ _ Supersedes m# __ None. ___ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Aitachment 3.1 -&

in all geographic areas in which State plan HCBS are available. (SpecifY the areas of the State afficted by this option):

4. Participant-Directed Services. (Indicate the State plan HeBS that may be participant-directed and the authorityofferedforeach. Add lines as required):

Participant-Directed Service Employer Budget Authority Authori~

0 0 0 0

s. Financial Management. (Select one):

0 Financial Management is not furnished. Standard Medicaid payment mechanisms are used.

0 Financial Management is furnished as a Medicaid administrative activity necessary for administration of the Medicaid State plan.

6. 0 Participant-Directed Plan of Care. (By checking this box the State assures that): Based on the independeIjt assessment, a person-centered process produces an individualized plan of care for participant-directed services that:

• Be developed through a person-centered process that is directed by the individual participant, builds upon the individual's ability (with and without support) to engage in activities that promote community life, respects individual preferences, choices, strengths, and involves families, friends, and professionals as desired or required by the individual;

• Specifies the services to be participant-directed, and the role of family members or others whose participation is sought by the individual participant;

• For employer authority, specifies the methods to be used to select, manage, and dismiss providers; • For budget authority, specifies the method for determining and adjusting the budget amount, and a

procedure to evaluate expenditures; and • Includes appropriate risk management techniques, including contingency plans, that recognize the

roles and sharing of responsibilities in obtaining services in a self-directed manner and assure the appropriateness of this plan based upon the resources and support needs of the individual.


STATE 'WIO i CU\. a DATEREC'B a-IO -1 ..... 1_ DATEAPPV'D l?--I'I -I( I)ATE EFF ~ - r -I Q"

A

HeFA 179 I I - 11. ~~ _____ • __ ._." .... _ .. ),(.... ____ ..... ...J

W# _11-\3 ___ ---'Approval Datel:l- ~ I~ -II Effuctive Date_3/112012c....-___ _ Supersedes W# __ None ___ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -&Page 27

in all geographic areas in which State plan HCBS are available. (SpecifY the areas of the State a ected by this 0 tion. :

4. Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed IIlId the authority offered for each. Add lines as required):

Participant-Directed Service Employer Budget

! Authority Autliority

0 D

0 0

S. Financial Management. (Select one):

0 Financial Manal1:ement is not furnished. Standard Medicaid payment mechanisms are used.

0 Financial Management is furnished as a Medicaid administrative activity necessary for administration of the Medicaid State plan.

6. 0 Participant-Directed Plan of Care. (By checking this box the State assures that): Based on the independellt assessment, II pmon..;::entered process produces an individualized plan of care for participant-directed services that:

• Be developed through a person-centered process that is directed by the individual participant, builds upon the individual's ability (with and without support) to engage in activities that promote community life, respects individual preferences, choices, stronp, and involves fillnilies, friends, and professiOlJals as desired or required by the individual;

• ' Specifies the services to be participant-directed, and the role of family members or others whose participation is sought by the individual participant;

• For employer authority, specifies the methods to be used to select, manage, and dismiss providers; • For budget authority, specifies the method for determ.ining and adjusting the budget amount, and a

procedure to evaluate expenditures; and • Includes appropriate risk management techniques, including contingency plans, that recognize the

roles and sharing of responsibilities in obtaining services in a self-directed maener and assure the appropriateness of this plan based upon the resources and support needs of the individual.

STATE Lau'o~cvn.q -1

SUPERSEDES: NONE - NEVI} PAGE

DATE REC'!:) a -10 -/I tl DATEAPPV'D l'l--Iti -I( A OATE EFF $ - r -I:l.. HCFA179 II-I~ ._ L.,.;"... ..................... ___ • __ ,_"" .. """._"'.k,.~ .... ....J

1N# _1l-13 ___ --'Approval Date t ~ ~ I~ -n El.ll:clive Dllte_3/1f2012'--___ _ Supersedes 1N# __ None __ _

11-13-2008

State: Louisiana §1915(i) HeBS State plan Services State Plan Attachment 3.1 - (j/

6. Voluntary and IDvoluntary Termination of Participant-Direction. (Describe how the State Jacilitates an individual's transition from participant-direction, and specify any circumstances when transition is involuntary);

I 7. Opportunities for Participant-Direction

a. Participant-Employer Authority (individual can hire and supervise staff). (Select one);

• The State does not offer opportunity for participant-employer authority .

0 Participants may elect participant-emp\oyer Authority (Check each that applies);

0 Participant/Co-Employer. The participant (or the participant's representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and perfurms necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions.

0 Participant/Common Law Employer. The participant (or the participant's representative) is the common law employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the participant's agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions.

b. Participant-Budget Authority (individual directs a budget). (Select one);

• 0

The State does not offer opportunity for participants to direct a budget.

Participants may elect Participant-Budget Authority.

Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the amount oj the budget over which the participant has authority. including how the method makes use of reliable cost estimating information, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information about these method(s) must be made publicly available and included in the plan of care);

Expenditure Safeguards. (Describe the safeguards that have been establishedJor the timely prevention of the premature deple(ion of the participant-directed budget or to address patential service delivery problems that may be associated with budget underutilization and the entity (or entities) respansible for implementing these saJeguards);

STATE Lou;tl 113 n4. DATE REC'I:) 3 - ,() ~ II DATEAPPV'D I ~ -/1) - I {

IJATE EFF :; - I - II A

Sl.jPERSEDES: NONE - NEW PAGE HCFA 179 r I - I '3 _ ~ L....,;"....-.-...-.... __ ..... ---....... "'._._.t...-.x:... ..... ...,J

TN# _ll-13 ____ ...:Approval Date Supersedes TN# __ None. __ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -6/ Page 28

6. Voluntary and Involuntary Termination of Participant-Direction. (Describe how the Slate facilitates an individualS transition from participant-direction, and circumstances when transition is

7. Opportunities fur Participant-Direction a. Participant-Employer Authority (individual can hire and supervise staff). (Select one): .. The State does not offer opportunity for participant-employer authority .

0 Participants may elect participant-employer Authority (Check each that app[{es):

0 Participant/Co-Employer. The participant (or the participant's representative) functions as the co-employer (managing employer) of workers who provide waiver services. Au agency is the common law employer of psrticipant-selectedlrecruited staff and perfurms necessary psyroll and human resources Ihnctions. Supports are available to assist the participant in conducting employer-reinted IhnCtiOIlS.

0 Participant/Common Law Employer. The participant (or the participant's representative) is the common law employer of workers who provide waiver services. Au IRS-approved FiscallEmployer Agent Ihnctions as the participant's agent in perfurming payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions.

h. Participant-Budget Anthority (individual directs II budget). (Select one): .. 0

The State does not offer opportunity for participants to direct a budget .

Participants may elect Participant-Budget Authority. Participant-Directed Budget. (Describe in detail the methodes) that are used to establish the amount of the budget over which the participant has authority. including how the method makes use of reliable cost estimating information, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information aboullhese methodes) must be made publicly available and included in the plan of care}:

..

Expenditure Safeguards. (Describe thesajeguards that have been established for the timely prevention of the premature deple~ion of the participant-tiirected budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) respanlliblefor implementing these safeguards):

STATE Lo-u i 't:! Ill( n4, DATE REC'I.:) ..3. I(J ~ I , DATE APPV'D I tl- -/11 - II 'JATE EFF ?> • I - I!

SupERSEDES: NONE - NEW PAGE HCFA 179 f I - I '3 _ ~"'-~n. ___ " ___ '_"''''_.tt~

TN# _1l-13 ____ -:Approval Dale Supersedes TN# __ None, __ _

11-13-2008


Quality Improvement Strategy

(Describe the State's quality improvement strategy in the tables below): Discovery Evidence: Performance Measures Discovery Activity: Source of Data and sample size Monitoring Responsibilities: agency or entity that conducts discovery activities Remediation responsibilities: who corrects, analyzes. and aggregates remediation activities; required

timeframes for remediation Frequency of analysis and aggregation

Discovery Activities Remediation quirement Discovery Evidence Discovery Monitoring Remediation

Activity Responsibilities Frequency Responsibilities Frequency ~processes 1. The number 1. Prior 1. SMO collects 1.,2., 3" 4., OBH Continuously I andlor percent of Authoriz and Continuously and and on-going truments

adults that were ation generates; ongoing

""bedin Reports OBHaild 5. Semi-anIiually approved determined to to the SMO

l5(i) SPA meet LON OBH; aggregate applied requirements 100% and analyze

.capriately prior to receiving Review 2.,3.,4., S., laccording 1915(i) services. 2 .. 3.,4.,5., SMO he Record collects and ICOVed 2. The number review, generates; cription to andlor percent of onsile; less OBHand ermine adults who than a 100% SMO ticipant if receive their sample with aggregate needs- annual LON a 95% and analyze ed criteria evaluation within confidence ; met.

twelve months of level

the previous

LON evaluation. 3. The number

andlor percent of adults' initial

LON SUPERSEDES: NONE - N!:W PAGE determination formsfmstrument

"" s that were

STATE~ Icvyy4. '-I completed, as

required in the DATE REC'B_3 - 10 - I ( approved SPA. DATE APPV'D l'l- -I q ~(C A

4. The number 'JATE EFF 3-1-''-andlor percent of

~c:.::A 179 ll-l.:3 __ LON ---..... - ..... ~._J.,._ ......... determinations

madebya Qualified

TN# _1l-13 ___ ----'Approval Datel:t.. ' 19 -\ ( Effective Date_3/112012 _____ _

Supersedes TN# __ None. __ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -GPage 29

(Describe the State's quality improvement strategy in the tables below): Discovery Evidence: PeifOrmance Measures Discovery Activity: Source of Data and sample size Monitoring Responsibilities: agency or entity thai conducts discovery activilies Remediation responsibilities; who corrects, analyzes. and aggregates remediation activities; required

timeframes for remediation Frequency of analysis and aggregation

Discovery Activities Remediation qllirement Discovery Evidence Discovery MoDitoring Remediation

Activity RespollSibilities Frequency Responsibilities Frequency ~ processes 1. The number 1. Prior I. SMO collects 1.,2.,3 .• 4., OSH Continuomly I andlor percent of Authoriz and Continuously and and on-going truments

adults that were atioo generates; ongoing

:cribedin RAlports OBHaild 5. Semi-amiually approved determined to to the SMO l5(i}SPA meelLON OBB; aggregate applied requirements 100% and analyze .ropriately prior to receiving RIilview 2~'1 3 . ., 4", 5~, laccording 1915(1) services. 2..3.,4 .• 5., SMO he Record collects and >roved 2. The number review; generales; cription 10 andlor percent of onsile; less OBH!ll1d ermine adults who th!ll1 a 100"11> SMO ticipant if receive their sample with aggregate needs- annual LON a 95% and analyze ed criteria evaluation within confideoce ~ met.

twelve months of level

the previous LON evuluanon.

3. The number

andlor percent of adults'ioitiul LON SUPERSEDES: NONE - 'N0N PAGE determination fu!'l1lS!'m.strument .; .

a that were .... -_. . ,

I~! "'-. < ~ completed, as STATE O]AIOIl?W'y/t

required in the DATE REC'EI_i1 - I 0 - J I approved SPA. DATEAPPV'D_ll::1 q-(( A

4. The number 'JATE EFF 3-1-1.9-. andlor percent of He:=A 179 [1-13 __ LON -~.' _-.-."_ ... _-, ... ,-;",_J,.,._".,,,

determinations madebya Qualified

TN#_1I-13 ___ ---'ApprovaIDate 1::1.-,19-11 EffilctiveDale_3111201Z'--____ _ Supersedes TN# __ None'---__

11-13-2008

State: Louisiana

~tment

illS address :essed :<Isof IS(i) :ticipants, ,updated lually, and ,ument lice of vices and .viders.

Discovery

5. The)lumber:- ·' .. and/qc 'pei¢nt ~f adults' annual detenilinations, Wh~~ I';el ~f ' care criteria Was applied

1. percent of pllrticipants reviewed who

. had plaqs of care that were ade<juate'and appropriate,to their needs and goals' (including health care needs) as indicated in the assessment(s).

2. Number aDd/or percent of participants reviewed whose plans,of care had adequate 'and appropriate strategies to address their health and sarety risks as indicated in the . asscssinent(s).

3. Number and/or percent of plans ofcare that address participants' goals as indicated in the assessment(s)

4. Number and/or percent of participants' plans of care that include the

§1915(i) HCBS State pian Services State Plan Attachment 3.1 -&-'

, 5.

Recru:d reviews,.

>~~~ ;,: iO:O"A.' sample ' OfCSS6 MaDager s with a 95% confiden ee level

6.SMO repcrts on Irealinent piOn perfurma nee measures ;.iOOOIo sample

7. SMO database; 100% sample

8. Record reviews; . 100"10 sample

9. SMO Reports to the Operatin gAgcncy from the SMO; less titan a 100"10

..... . , ••.. J: .. '

I., OBJiland SMO collect, .generate, awegate' ' and·inal ' . ........... ,yze

6. 0PH~d §¥Q 'collect, , gep,erate, aggregate and' analyze

7.,8. SMO collects and generates; OBHand SMO aggregate andaniuyze

9.,10. SMO iiollects, ' generates, aggregates and I\D8lyzes

II.OBHand sMO collect, generate, aggregate and analyze

12: SMO collects.and generates; OBHand SMO aggregate and analyze

13 OBHand SMO collect, generate, aggregate and analyze

DATE: RE(:'e_~;t:.!Q.:lL~

DATE APPV'D-'-'-'''''--J=:..!.1.-'---~

1. . and ,ongiiliill

QiUIrIerly-' J 4., ·5.; - _

Contil)u.OUsIY 6. , ~~~~r~ ,<~"" .y

COrr~tire ,action plan monitoring; seini-annually reportitig on measures by SlvIO

7. Ongong 8. QWu:terly data .

collection/genera tion; annual data aggre&atiop. and analysis

9. QuarterlY data collection/genera tion; contjnllous and <in,going data aggregation: and analysis

10. Quarterlyd;sta collection/genera tion; semiannual data aggregation and analysis

II. Continuously and ongoing

12. Quarterly (\ata collection/genera lion; annual data aggregation and analysis

13. Continuous and ongoing

. ' ..

A·

. .

TN# lI-13, ____ Approval Date_3/112012--_ __ _

Supersedes TN# __ None, _ __ _

$Ul?EBSEDES: NONE - NEW PAGE 11-13-2008

State: Louisiana

illS address :essed lds of 15(1) :ticipanls, ,updated lually, and lumen! lice of vices and ,viders.

Discovery Evidence

s. The:number: '< and/or'peroent of adults' aairuaI detCrti.inatinn .. Vm~ ItWe! of ' care eriteria WaS appijed

1. Number percent of pl)rticipan~ reviewed who

, had plans of care that were ade<jllllte and appr>;lPriateto their needs and goals·(including health care needs) as indicated in the assessment(s).

2. Number aildlor percent of participants reviewed whose plans of care had adeqllllteand apprnprlate strategies 10 address their health and sarety risks as indicated in the assessment(s).

3. Number andlor percent of plans ofcarethat address participants' goslsas indicated in the assessment(s)

4. Number and/or percent of participanls' plans of care that include the

§ 1915(i) HeBS State plan Services State Plan Attachment 3.1 -Sr Page 30

", ;:

Recot:d ~~s,' ,generate,

:m1~\k aggregat", ~'~alyz6

',,' Ii iOo%' 6·~~~,:~ect, sample' or Case genei:ate, Manager. aggregate " with a and analyze 95% 7.,S.SMO confiden collects and ce level generates;

6.SMO OBHand reports SMO on aggregate trealinen! and Bruilyze plan 9., to.SMO perfurma 'coliects, ' nee generates, measures aggregates ;.i00% and analyzes sample 11.OBHand

7. SMO SMO collect, database; generate, 100% aggregate sample and analyze

8. Rooord 12.SMO nMe\VS; collects,and 100"Ai generates; sample OBHand

9. SMO SMO Reports aggregate Iolhe and analyze Operatin 130BHand gAgency SMO collect, limn the geuerate, SMO; aggregate less !\Ian and llIllllyze

100%

DAT~~(;'B_~~~!L~ DATE APPV'D-"-''''-J=~''--_

aildongbmg QiJjlrterly "

4.,5.;· '" ,Continl!,oosly , d' ,', ' • an,ong"mg

6. ' Quarterly for eorreciii-e action pllin mOiiJiOring; I!eini-annually rilPortirig on measures by SlvIO

7. Ongong 8. QWu:terly data

collection/genera lion; annual data aggreg'atiOJl and analysis

9. ,Qwtrterly data collection/genera lion; contjnljous an4 ongoing data aggregation and analysis

10. Quarterly data collection/genera tion; semi-annualdala a8gregation and analysis

11. Continuoosly and ongoing

12. Qwtrterly ilata collection/genera tion; annual data aggregation and analysis

13. Continuous and ongoing

TNII 11-13 Approval Dllte_3/112012 Supersedes TNII __ None

Sifl?EBSEDES: NONE - NEJN PAGE 11-13-2008

State: Louisiana § 19I5(i) HCBS State plan Services State Plan Attachment 3.1 -6r'

Discovery Activities Remediation equirement Discovery Evidence Discovery Monitoring

Activity' Responsibilities Frequency Remediation

Responsibilities Frequency

;:,e:,~.;;;.~~v~ :rf= t': ;;S~~t~~:';:" ;\ ' ,,', ::;: "': ;i,'" r's signl!ture a. ~ , . ~i!i.pl,i!!g;, ' " ,' specifie'd in the , m~thOilol approved.w8,iv","; , . :oilY:: ,':' .

:' ':~,;":,,,; );: ":,;~ ":>:' ;'; .. ":'~ .. ' ." .: r . '. ;;- '~. 1

'. ','

5, !!ru:n~o~d(oi , , ~~~e . ,,; ' pamcipant$' .OJG , plai1s of care ~t 10; PerSOn were developed' c~ter:cii by an PI'!D interdiscip1inary RecOrd team. ~eWs,

6. The Slste " ''Fmancw-requires the ~c~;:ds; SM:O to report less than ' results of . . , . . '8-:100% performailce . ~ple ' messures rel8ted With a to ,the lreatD!,ent .,'. 95% plai1 to OBli: and ~fiden the Inter- ce level Departmeolsl II.Record Monitoring Team reviews, (lMT) and onsite; requires (ess than corrective action a 1000/0 as appropriate. sample CorrectiVe action ofCase is monitored at Maoager minimum s with a quarterly by 95% OBH and the confiden IMT. BHSF (the ce level Medicaid 12., 13. agency) is a Record member oflMT reviews, . and monitors the onsite; OBH through less than this process. a 100%

7. Number aod/or sample percent of of Case participants Manager whose plaos of s with a care~ 95% updated within oonfiden 90 days of the ce level last evaluation.

8. Number and/or percent of participants

: . , . ,: ....

,~.

'" .. ~ :

SLJ1'ERSEDES: NONE> NEiIY rAGE

------,.--j STATE LOtA,i 61 ~I\-ll I . DATE REO'!:) 3 -10 - \I I

DATEAPPV'D (:l.--Ill -II I)ATE EFF 3 - 1 - \ ~

I' r\

He:=A 179 ( l- I 3 ( L...:...:.._ .... -......_-..._._ _._....::.:;;;;..,%.._._.. .... -!

I

"IN# _11-13, ___ --'Approva! Date 1').- - \ 11 v \I Effective Date_3/1f1012. _____ _ Supersedes "IN# __ None, ___ _

11-13-2008

State: Louisiana § 19I5(i) HCBS State plan Services State Plan Attachment 3.1 -6r' Page 31

Discovery Activities Remediation equirement Discovery Evidence Discovery Monitoring

Activity' Responsibilities Frequency Remediation

Responsibilities Frequency

;:,e:,~.;;;.~~v~ :rf= t': ;;S~~t~~:';:" ;\ ' ,,', ::;: "': ;i,'" r's signl!ture a. ~ , . ~i!i.pl,i!!g;, ' " ,' specifie'd in the , m~thOilol approved.w8,iv","; , . :oilY:: ,':' .

:' ':~,;":,,,; );: ":,;~ ":>:' ;'; .. ":'~ .. ' ." .: r . '. ;;- '~. 1

'. ','

5, !!ru:n~o~d(oi , , ~~~e . ,,; ' pamcipant$' .OJG , plai1s of care ~t 10; PerSOn were developed' c~ter:cii by an PI'!D interdiscip1inary RecOrd team. ~eWs,

6. The Slste " ''Fmancw-requires the ~c~;:ds; SM:O to report less than ' results of . . , . . '8-:100% performailce . ~ple ' messures rel8ted With a to ,the lreatD!,ent .,'. 95% plai1 to OBli: and ~fiden the Inter- ce level Departmeolsl II.Record Monitoring Team reviews, (lMT) and onsite; requires (ess than corrective action a 1000/0 as appropriate. sample CorrectiVe action ofCase is monitored at Maoager minimum s with a quarterly by 95% OBH and the confiden IMT. BHSF (the ce level Medicaid 12., 13. agency) is a Record member oflMT reviews, . and monitors the onsite; OBH through less than this process. a 100%

7. Number aod/or sample percent of of Case participants Manager whose plaos of s with a care~ 95% updated within oonfiden 90 days of the ce level last evaluation.

8. Number and/or percent of participants

: . , . ,: ....

,~.

'" .. ~ :

SLJ1'ERSEDES: NONE> NEiIY rAGE

------,.--j STATE LOtA,i 61 ~I\-ll I . DATE REO'!:) 3 -10 - \I I

DATEAPPV'D (:l.--Ill -II I)ATE EFF 3 - 1 - \ ~

I' r\

He:=A 179 ( l- I 3 ( L...:...:.._ .... -......_-..._._ _._....::.:;;;;..,%.._._.. .... -!

I

"IN# _11-13, ___ --'Approva! Date 1').- - \ 11 v \I Effective Date_3/1f1012. _____ _ Supersedes "IN# __ None, ___ _

11-13-2008

Slate: Louisiana § 1915(i) HeBS Slate plan Services

Discovery Activities

State Plan Attachment 3.1 -.

Remediation 'quirement Discovery Evidence Discovery Mouitoring Remediation

Activity~ Responsibilities Frequency Responsibilities Frequency whose'PI"ll8, of catewefe ,' ,

, updated 'wh:.n ' wmrantedby changes in the particip!lilts' " needs "

9. Number ,1IIid/or participants ,who received ~c;t:s in the type, amount, duration, and 'frequency specified in the plan of care.

10. Proportiop. of new participants who are receiving services according to their poe within 45 days of poe approval

ll. Number and/or Percent of participant records reviewed, completed and signed freedom of choice form' that specifies choice was offered between institutional and' waiver services.

12. Proportion of participants reporting their care coordinator helps them to know what waiver services are available

13. Number and/or Percent of participant records reviewed, completed and

".' ,.;"

• ". : "f " ;"' ."

1N# _1l-13 ___ ---'Approval Date \;!.. -\1.\ -\ \ Supersedes 1N# __ None. ___ _

..•.

. ' ". :"."

SUPERSEDES: NON~ - NEW PAGE , ' , '. !

Effuctlve Date_31112012. _____ _

11-13-2008

Slate: Louisiana § 1915(i) HeBS Slate plan Services

Discovery Activities

State Plan Attachment 3.1 -.Page 32

Remediation 'quirement Discovery Evidence Discovery Mouitoring Remediation

Activity~ Responsibilities Frequency Responsibilities Frequency whose'PI"ll8, of catewefe ,' ,

, updated 'wh:.n ' wmrantedby changes in the particip!lilts' " needs "

9. Number ,1IIid/or participants ,who received ~c;t:s in the type, amount, duration, and 'frequency specified in the plan of care.

10. Proportiop. of new participants who are receiving services according to their poe within 45 days of poe approval

ll. Number and/or Percent of participant records reviewed, completed and signed freedom of choice form' that specifies choice was offered between institutional and' waiver services.

12. Proportion of participants reporting their care coordinator helps them to know what waiver services are available

13. Number and/or Percent of participant records reviewed, completed and

".' ,.;"

• ". : "f " ;"' ."

1N# _1l-13 ___ ---'Approval Date \;!.. -\1.\ -\ \ Supersedes 1N# __ None. ___ _

..•.

. ' ". :"."

SUPERSEDES: NON~ - NEW PAGE , ' , '. !

Effuctlve Date_31112012. _____ _

11-13-2008


~quirement

oviders let required alifications.

Discovery Activities Discovery Evidence Discovery Monitoring

signed freedom of choice funn tbat speafies cboiCeWas.

Activity Responsibilities

-,' "

otimed. afuong I'. waiver)s~~· ::.? .: and providerii~ . ..

... ... ) ...

I. Number and/or percent of Waiver providers providing waiver services initially · meeting licensure and certification r~uirement8.

prior to fUrnishing waiv~r services.

2. Number and/or percent of Waiver providers providing waiver services continuously meeting licensure and certification requirements while fumishing waiver services.

3. Number and/or percent of Waiver providers providing waiver services that have an active agreement with thoSMO.

4. Number and/or percent of nonlicensed/noncertified providers of waiver services that meet training requirements.

5. Number and/or percent of

1.,2.0BH; 100%

1.,.2.0BH. CQlleC~

siunple generate, 3. 9BH aggregate

Cotin:act· . and analyze s .with a~. SMO ·SMOto ~oll quaMe d provider sand pay claims; 100% sample

4., 5.,6. Tra

ining verificat ion records; 100% sample

. collects, generates, aggregates and analyzes and sends to OBH

4., 5. Training contractor collects and gMerates, OBH aggregates and analyzes

6. SMO collects, generates and aggregates; OBH analyzes

TN# _ll-i3. ___ --"Approval Date I 'J,.-\ q -\1 Supersedes TN# __ None. ___ _

Frequency

..... : .'." ' '; :

..

.; . ': .,

Remediation Remediation

Responsibilities Frequency :~:' ~ '.;~ ~ <~:t?~. :/~:: :~:~ : ";:\":' ;;:',::0...

;-: " .• ' r.",· ":': , '<::.:" ..

. 1.,2.,.3. OBH • ..... ua1l ,""I' Y

CO,!tlnuously.an,d. ongoing .

4. Monthly 5. Quarter).y

: . .-;' 6. AnOua1ly

.. "';


STATE Uru.1;llC!N\lt DATE REC'~_ 2. -10 -\( DATEAPPV'O \;)--\q -I r I)ATE EFF 3 - \ -\:J.. . HC?A 179 l \ -13 _-": I.oo.-_.....-... _~ .... _ ._._ ........ _ ._ ..... ...!

Effective Date_311120 I 2. _ _ ___ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -&Page 33

~quirement

oviders let required alifications.

Discovery Activities Discovery Evidence Discovery Monitoring

signed freedom of choice funn tbat speafies cboiCeWas.

Activity Responsibilities

-,' "

otimed. afuong I'. waiver)s~~· ::.? .: and providerii~ . ..

... ... ) ...

I. Number and/or percent of Waiver providers providing waiver services initially · meeting licensure and certification r~uirement8.

prior to fUrnishing waiv~r services.

2. Number and/or percent of Waiver providers providing waiver services continuously meeting licensure and certification requirements while fumishing waiver services.

3. Number and/or percent of Waiver providers providing waiver services that have an active agreement with thoSMO.

4. Number and/or percent of nonlicensed/noncertified providers of waiver services that meet training requirements.

5. Number and/or percent of

1.,2.0BH; 100%

1.,.2.0BH. CQlleC~

siunple generate, 3. 9BH aggregate

Cotin:act· . and analyze s .with a~. SMO ·SMOto ~oll quaMe d provider sand pay claims; 100% sample

4., 5.,6. Tra

ining verificat ion records; 100% sample

. collects, generates, aggregates and analyzes and sends to OBH

4., 5. Training contractor collects and gMerates, OBH aggregates and analyzes

6. SMO collects, generates and aggregates; OBH analyzes

TN# _ll-i3. ___ --"Approval Date I 'J,.-\ q -\1 Supersedes TN# __ None. ___ _

Frequency

..... : .'." ' '; :

..

.; . ': .,


Responsibilities Frequency :~:' ~ '.;~ ~ <~:t?~. :/~:: :~:~ : ";:\":' ;;:',::0...

;-: " .• ' r.",· ":': , '<::.:" ..

. 1.,2.,.3. OBH • ..... ua1l ,""I' Y

CO,!tlnuously.an,d. ongoing .

4. Monthly 5. Quarter).y

: . .-;' 6. AnOua1ly

.. "';


STATE Uru.1;llC!N\lt DATE REC'~_ 2. -10 -\( DATEAPPV'O \;)--\q -I r I)ATE EFF 3 - \ -\:J.. . HC?A 179 l \ -13 _-": I.oo.-_.....-... _~ .... _ ._._ ........ _ ._ ..... ...!

Effective Date_311120 I 2. _ _ ___ _

11-13-2008

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -.. Page34

equirement

leSMA tains Ithority and sponsibility rprogram lerations Id oversight

Discovery Activities Discovery Evidence Discovery MOnitoring

ptovider ' , trainings

erated·o "P .... " y .. SMO. ··

6. Number iiid/or

Activity RespollSibilities , ~. '" ~. ":: :--"':.'.'

', . '~. -. '" . ',. " .~ . .. : . . . '

peicex;t~f .. ~tive ',' p~:Yiders:M:'· ·.c ·! .·:.· •. :,..,:·.',:., ., ..... ,. proVide: tYPe) . . ' ... '

. mecitiiig ongoing tritiDln8' .. requirements.

I. NllDlber and/or peroentof aggregaied perfumiance meas(n'e rep,arts generated by the Operating Agency and reviewed by the Slate Medicaid . Agency that contain discovery, remediation, and system improvement fur ongoing compliance of the asSUl1l)l~.

2. NllDlber and/or percent of waiver amendments, renewals, and financial reports approved by the Slate Medicaid Agency (BHSF) prior to implementation by the Operating Agency (OBH) ..

3. NllDlber and/or percent or' '.

waiver concepts and policies requiring MMIS programming approved by the Slate Medicaid

1,,2. &:,~ . '. Reports to Siiit~ . MediCaid ;' Aie.;i~i :--

, (BID.lF)on delegated . . Administrati ve fuD.Ctions; 100% sJl1I1ple size

I '.


Frequency Responsibilities Frequency

····J.':\:'1ti ,~·~·:;·~·T; :·· •. ":,;~'-, ..: "";. .~.:":.; :. :. :.' .-~. ~ ~~.

~ . '. '. , :; ....

. . , " . :.::.' ~-:;:

. : .

,-, : .. . :-;. . ... ::,. -. .... ... ,.

L, 2. &3" ¥<l.~thly Ol,lH,.SMO . .. -: .. , ",- ' . Monthly

... ;.~.'" . "'."'

". :.., ... : ..• .--.. ::", ....... :; ;:".

..: '."'. ':: .. .. \, .....

,.. __ ,_ ' ....... 1

STATE Lcru l~ r c!'nt(, · DATE REC'Cl~-=-Jb -L I

. DATE APPV'O.J ~ ~,ot - II IJATE EFF 3 -) -I !)... HC;=A 179 ' .. l \- 12 _

--.-"---=--,-.. ~-.-.-.~~

--I ,

A


I I

TN# 11-13 ___ ---'Approval DateL:l.- -\ I') - II Effective Date_3I1flOI2 _____ _ Supersedes TN# __ None. __ _

11-13-2008

State: Louisiana § 1915(i) HeBS State plan Services State Plan Attachment 3.1 -.. Page34

equirement

leSMA tains Ithority and sponsibility rprogram lerations Id oversight

Discovery Activities Discovery Evidence Discovery MOnitoring

ptovider ' , trainings

erated·o "P .... " y .. SMO. ··

6. Number iiid/or

Activity RespollSibilities , ~. '" ~. ":: :--"':.'.'

', . '~. -. '" . ',. " .~ . .. : . . . '

peicex;t~f .. ~tive ',' p~:Yiders:M:'· ·.c ·! .·:.· •. :,..,:·.',:., ., ..... ,. proVide: tYPe) . . ' ... '

. mecitiiig ongoing tritiDln8' .. requirements.

I. NllDlber and/or peroentof aggregaied perfumiance meas(n'e rep,arts generated by the Operating Agency and reviewed by the Slate Medicaid . Agency that contain discovery, remediation, and system improvement fur ongoing compliance of the asSUl1l)l~.

2. NllDlber and/or percent of waiver amendments, renewals, and financial reports approved by the Slate Medicaid Agency (BHSF) prior to implementation by the Operating Agency (OBH) ..

3. NllDlber and/or percent or' '.

waiver concepts and policies requiring MMIS programming approved by the Slate Medicaid

1,,2. &:,~ . '. Reports to Siiit~ . MediCaid ;' Aie.;i~i :--

, (BID.lF)on delegated . . Administrati ve fuD.Ctions; 100% sJl1I1ple size

I '.


Frequency Responsibilities Frequency

····J.':\:'1ti ,~·~·:;·~·T; :·· •. ":,;~'-, ..: "";. .~.:":.; :. :. :.' .-~. ~ ~~.

~ . '. '. , :; ....

. . , " . :.::.' ~-:;:

. : .

,-, : .. . :-;. . ... ::,. -. .... ... ,.

L, 2. &3" ¥<l.~thly Ol,lH,.SMO . .. -: .. , ",- ' . Monthly

... ;.~.'" . "'."'

". :.., ... : ..• .--.. ::", ....... :; ;:".

..: '."'. ':: .. .. \, .....

,.. __ ,_ ' ....... 1

STATE Lcru l~ r c!'nt(, · DATE REC'Cl~-=-Jb -L I

. DATE APPV'O.J ~ ~,ot - II IJATE EFF 3 -) -I !)... HC;=A 179 ' .. l \- 12 _

--.-"---=--,-.. ~-.-.-.~~

--I ,

A


I I

TN# 11-13 ___ ---'Approval DateL:l.- -\ I') - II Effective Date_3I1flOI2 _____ _ Supersedes TN# __ None. __ _

11-13-2008

Stale: Louisiana § 1915(i) HCBS State plan Services State Plan Attachment 3.1 -~

Discoverv Activities 'q.urement

leSMA lintains IlII1cial countability .ough ymentof limS for .vices that , authorized d furnished 1915(i) rticipants qualified )viders.

Discovery Evidence Discovery Activity

Agency prior'to . the develOpment ofa fotiDal . implementation plan bY: ih"

~e:~g....... .. / ... :> 1. NUiribCii' and/or!. 'Rouooe

percc:nt of.: . . MCdiC8id providers that ' . cl8lDiS . have payment verlficati recouped for waiver.services without supportiog documentation.

2. Ntimbet and/or percent of claims verified through theSMO's compliance alidit to have paid in accordance with the participant's waiver treatment plan.

on audits; Rqjresen talive

. . ..' 1 S8I1lpe of Case mailagers with a 95% confiden ce interval

2. SMO's complian ce report; less than a 10(>% sample with the RAND sampling methodol ogy recomme nded by theOiG

Monitoring Responsibilities

:.: :',

,.,.

L SMO " ,~l!~,.

gc:nc:rates. aggregates and analyzes

2 . . ~O caUcels and generates; ·OBHand SMO. aggregate and analyze

SU?ERSEDES: NONE - NEW PAGE

TN#_11-13 ____ .ApprovaiDate I:t.-Il\ vII Supersedes TN#_None, __ _

Remediation

Frequency

" .. - .. ":.f·~ · ' .. ,;~.~, ",

'";;:: .. .... .. .'. ....

Remediation Responsibilities

".

LContinilouslyand . . SMO. .ong()iiig}. ,,', ' . " · 2: Q\!artet:1y.!lata .. coUectioO: and

· g~neration; cciniiiiuOus and ongoiiigdsta aggregation and

· analysis

' .. ,' .

Frequency

..

• • Con!in\lously lindoiigoing

STATE LOJA~16 r~ I DATE REC'l) 1> - 16 ~ II I' DATEAPPV'D L ~ -(.l. t I A OATE EFF '6 ~ I - IJ..

HCFA179 l\ -(~ __ • ~ ...... __ ~ __ • ___ -=o.."_.9_'" ,.._ .... _ , .

Effective Date_3/lI2012 _____ _

11-13-2008

Stale: Louisiana § 1915(i) HCBS State plan Services State Plan Attachment 3.1 -~ Page 35

Discoverv Activities 'q.urement

leSMA lintains IlII1cial countability .ough ymentof limS for .vices that , authorized d furnished 1915(i) rticipants qualified )viders.

Discovery Evidence Discovery Activity

Agency prior'to . the develOpment ofa fotiDal . implementation plan bY: ih"

~e:~g....... .. / ... :> 1. NUiribCii' and/or!. 'Rouooe

percc:nt of.: . . MCdiC8id providers that ' . cl8lDiS . have payment verlficati recouped for waiver.services without supportiog documentation.

2. Ntimbet and/or percent of claims verified through theSMO's compliance alidit to have paid in accordance with the participant's waiver treatment plan.

on audits; Rqjresen talive

. . ..' 1 S8I1lpe of Case mailagers with a 95% confiden ce interval

2. SMO's complian ce report; less than a 10(>% sample with the RAND sampling methodol ogy recomme nded by theOiG

Monitoring Responsibilities

:.: :',

,.,.

L SMO " ,~l!~,.

gc:nc:rates. aggregates and analyzes

2 . . ~O caUcels and generates; ·OBHand SMO. aggregate and analyze

SU?ERSEDES: NONE - NEW PAGE

TN#_11-13 ____ .ApprovaiDate I:t.-Il\ vII Supersedes TN#_None, __ _

Remediation

Frequency

" .. - .. ":.f·~ · ' .. ,;~.~, ",

'";;:: .. .... .. .'. ....

Remediation Responsibilities

".

LContinilouslyand . . SMO. .ong()iiig}. ,,', ' . " · 2: Q\!artet:1y.!lata .. coUectioO: and

· g~neration; cciniiiiuOus and ongoiiigdsta aggregation and

· analysis

' .. ,' .

Frequency

..

• • Con!in\lously lindoiigoing

STATE LOJA~16 r~ I DATE REC'l) 1> - 16 ~ II I' DATEAPPV'D L ~ -(.l. t I A OATE EFF '6 ~ I - IJ..

HCFA179 l\ -(~ __ • ~ ...... __ ~ __ • ___ -=o.."_.9_'" ,.._ .... _ , .

Effective Date_3/lI2012 _____ _

11-13-2008

State: Louisiana § 1915(i) HCBS State plan Services State Phm Attachment 3.1 -&

.e :ntifies, dresses and ,ks to ,vent :idents of <ISC, ~ect, and ,Ioitation, :Iuding the , of .1raints.

Discovery Evidence

perCent of reports related to· the abuse, neglect, or ."q,lo'itation of participantS · .. ng-:"" .• where llQ .. . .. .3.' A ~ple . investigation was orcas., Inl• ·(j·a·t··ed· .WI·· "thin. . . ..... , .• •..

Miina~ · established time s willi . frames. 95%

2. Number and/or conJiden percent of . i:e; ansite participants who reCord received .. teVlews infurmation on 4. IOOOIa how to report the review, suspected abuse, Provider neglect, or perfurma exploitation of nee adults. monitori

3. Number and/or ng percent of 5. IOOOIa participants who review, received OBH infurmation abuse, regarding their negl!"'t, . rights toa State or Fair Hearing via exploitati the Notice of on Action furm. database

4. Number and/or percent of grievances filed by participants that were resolved within 14 calendar days according to approved waiver guide1ines.

5. Number and/or percent of allegations of abuse, neglect, or exploitation investigated that were later

... ~~.

. . collect, gen.~te, aggiegate • and analyze

4. SMO · collecitsand generates; OBH aggregates and analyzes

5.0BH collects generates, aggregates and.analyzes

1N# _11-13. ____ -Approval Date IJ.. ~I?/vll Supersedes 1N# __ None. ___ _

. : ,'-

"." , -"' :" r .'

. -.

SUPERSEDES: NONE -NE\IJ PAGE

STATE Lou. I ~ {OVI1~ DATEREc'e_~IO -II OATEAPPV'O_1 ~ -\9 - If I)ATE EFF a -/ -I:J.. HC?A 179 1I -/2 _ ---~-...... ---.~ .. -

Effective 00Ie_3/112012 _____ _

.-u-- .... ....!

11-13-2008

Slate: Louisial1ll

Discovery Evidence

.f!

mtifies. ptircimiof dresses and reports related to oks to the abuse, went neglect, or :idents of eiplQltation of use, pai:1iclpantS . glee!. and ~!Ill ,loilalion, investigation WlIS ,Iudingthe initiii~ Within , of established time trafuts. frames.

2. Number andlor percent of pllrtieipants who received infurmation 011 how' to report the suspected abuse, neglect, or exploitation of adults.

3. Number audlor percent of partleipauts who received infurm.tion regarding their rights loa Stale Fair Hearing via the Notice of Action ibrm.

4. Number audiO! percent of grievances filed by partlcipants that were resolved within 14 calendar days according to approved waiver guidelines.

5. Number andlor percent of a1!egauOlIS of abuse, neglect, or exploitation investigated that were later

§1915(i) HCBS Slate plan Services Slate Pkm Attachment 3.1 .SPage 36

<.nee':. . rii<m.tton,

.3. ~~r;~· ofC8Se .. M~i<i 5 with 95% cO!ljldm

. 00; ooslte r~rtI hiviews

4. 100% reviewt

Prov!-der performa nee moo1tori ng

5. lOO"A review, OBH abuse, neglllCt, , or exploitati on database

. collect, gen"",te, , aggre!lllte ,and analyze

4. SMO' ' colleCts and generates; OBH aggte!llltes audanalyms

S.OBH collects gonemtes, aggregates aud,analyms

st lPERSEDES: NONE -NE\IJ PAGE

.

STATE k.ott Ie> tov\lli2 DATE REC'6_z:IO ~ II DATE APPV'D_' ~ -19 -II I)ATE EFF a -I -(:;L. HerA 179 II -/;J ~ ................. - _ .. _--_ .............. -

TNii _1I-13. ____ -Approval Date Jl,:.,·14:L..v .ull'---_E,ffeetive Date_3/1120 12 ____ _ Supersedes TNiI __ None. __ _

11-13-2008

State: Louisiana § 1915(i) HCBS State plan Services

System Improvement:

State Plan Attachment 3.1 - €r Page ~7

mescribe orocess fOr Sjlstems improvement as a result of aggregated discovery and remediation activities.) Methods for Analyzing Roles and Frequency Data and Prioritizing Responsibilities Need for System Improvement

STATE t-..~i~t~~ DATEREC'D'·· '3 -I.l>~ II

DATEAPpitD~ 1;J...-19-11 I)ATltEFF . :3 -\ ~ 1:1

HC;=A179 .'. ll-I~ _ ,~.It_.. . ===;--:- ........ ___ '"':""!'_ ........ '!"_ . .-..

, ~ .

Method for Evaluating Effectiveness of System Changes

- Onsite reviews of SMO operations

lncludes documentation

OBHooordinates :\- . Annuallbiannual -Review of lidirilii!siiiitN.i . :: ~~tr:;'(fi'h~ii~ihl ::" .~, ~ . \!OS ,.. .. . .'

review and on-site interviews May include review of M;HlDD/SAS care management records

reView . management, iiifi}mmoon ~~iUi.ii'Ogy, ~ilrimsfand '. cliniciU opci-atiODS (care . . IWinagiiiii~t; , utjlli;ation _ileJ)lent; network managei'ri.e~t; quality : .• ~JlllgemCnt)

• Any compli!mce issues round on the reView will reauire the

TN#_1l-13, ____ Approva1Date_.\-I'~r-.!.:,,/L_\~.1.\4_\-EffectiveDate_3/112012. ____ _ Supersedes ~ TN# __ None __ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services

System Improvement

State Plan Attachment 3.1 -Ir Page ~7

(lJescribe nrocess for SlIslems improvement as a result of ailf!regated discovery and remediation activitiesJ Methods fur Analyzing Roles and Frequenoy Data and Prioritizing Respoosibilities Need for System Improvement QuiiliJ.y -'.' . t .. n

c, QAFr '1.,/<' 'QUi.lrter1 .

r··., .:~2:.I,'l:';· impl=.,entatiop of the '''JldTandOBH

. ·.··~ir:···· ...• :.;[~~~::I;·., < ' care, ~1u,diti8 . -,' J. , .'

reporting requirements" ' , , refining of reports and ., ,'.

implementation of , _,!

EQR aotivities

• Onsiie reviews of SMO operatiollll

J;noludes documentation review and onsite interviews May include review of M;HIDD/SAS care management records

Supersedes TN# __ None __ _

OBH.ooordfuates Annua1lbiannual


-RevieW of tidinuiiStiifhii ". ~'~a:~(flh~Ti~W:" .~, :;'ma~~ iiifOrinatioil ~i:ilOgy, chtims)"and' . clinicill ernnoriS (care ' nilinag~~t;, utiliZation -ge;:n~t; netwm:k management; quality • ~gemimt)

• Ariy compliance issues fuund 00 the review will i:'eQuire the ,

11-13-2008

State: Louisiana §1915(i) HCBS State pIan Services State Plan Attachment 3.1 -(i.

System Improvement: (Describe process for systems improvement as a result of aggregated discovery and remediation activities.l

Methods for Analyzing Roles and Frequency Method fur Evaluating Data and Prioritizing Responsibilities Effectiveness of System Changes Need for System Im~ovement

• Meetings to review n!lD1erical data and narrative reports descnoing clinical and related information on health services and outcomes

• QI reporting minimally includes statistical , analysis. root cause analysis. analysis of barriers and improvement interventions

• Areas of non'compliance or opportunities for improvement are monitored for progress made in implementing corrective actions or improvement in·the quality of service or care provided to Enrollees

Corrective action plans (CAPs)

, Inli'adepartlhental . ' Monitoring Team ' (IMT). which is cOmprised cif represenl1.ltives from OBI!, OHH, BHSJ.? orr. OCFS,DOE, ," 'Waiver Participants and the SMO

Quarterly (meetings)

" ' subiIlission of a ,correctiVe , acticlIlpIan to the lMT for approval andon-gofug monitoring

• IMT activitiCiS will fOCUson'a -. . / . . ,' ., '

quality 1JIIpi:ovemep.t,'as 'well as iinplemenilitiori, ~~ foc~.in , boib: clinibai'ahd noii..c!iiilcaI '

· " . ':;!.:I ;'';''

~. ,,' '"

• MCliitoe "y;illability of ser:viceS, deiiv~ofnetWork q~cy, tinielyaccess tq care" cultural considecation, prirpiiryeare and

, coordination/continuity of , services, special healthcare 'needs"cOverage and authorization of services, emerg~~y andpost- , stabi,lization services, enrollinent and disenrollment, grievm;cesyste~s, hearth information systems, " compliance with ~ntract;and

, State and F~ Medicaid re(iU.irements. ,

q j"'l=.DSFDE"· NONE - NEW PAGl ; • Quartedyreportr~l!ltsare , .., . r. d h - v . documented inlMT meeting

nlin.u!es and co~uni~ted to stakeholders andthe'QAPI Committee:

'-S-r.-AT-E-l.'-· cm-'-, ~.,..' ~-I CV1\-&-~--r

DATE REC'D_tJ_:::JD.<:--...1.I .L.\ _

DATE APPV'D_I 6.--1 ~- \ \ t' A. • Quality res,u1ts are reported to

providers through pIan mailings.

• Members an!i fiunilies receive , I)ATE EFF __ .:x9_-..... '_v ..,,~1,-. _

HC:=A 179 \ \ - \ 3 _ t....:...:.. ...... .......... _ ..... __ • ____ ~ ...... - ...... ,-.- ~~'_ QAPI activity information

• Developed by the SMOatthe request ofOBH

Areas for improvement will be prioritized and monitored on a day-

, through member newsletters. • Analysis of perfurmance

measure reporting, findings from IMT and external reviews.

TN# _ll-13, ____ .Approval Date I ~~ \ '\ ~ II Effi:ctive Date_311fl012. _____ _ Supersedes TN# __ None, _ _ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 • fi. Page 38

System Improvement: (Describe process for systems improvement as a result of aggregated discovery and remediation activities,)

Methods for Analyzing Roles and Frequency Method fur Evaluating Data and Prioritizing Responsibilities Effi>ctiveness of System Changes Need for System Improvement

• Meetings to review . Intradepartmental •. nJllllCrical data and MonitoringTcam' narrative reporta (IMT), which is . describing clinical and comprised of related information on represen\!ltives from hcaith services and OBll, DHH, BllSF, outeornes orr; DCFS,DOE,

'WaiverPamcipants • Qlreportingminimally and !lie SMO

includes statistical. ., analysis, root cause analysis, analysis of barriers and imProvement interventions

• Areas of non· 'compliance or opportunities for improvement are monitored for progress made in imPlementing

QlUIl"terly (meetings)

" . submission ofa ¢orrecl.tlfe actioliplan to the IMT fur approval and on-going monitoring

• IM:r activitilJs will focw; on' a Cruanty ~p'rovemeri~.aswen as UnRlemen~tio~ ~lhfoous)n. . bothclinicafahd non-cliiiicaI

· '" "t;[; , ~ '::.";-. areas. '" • M:oziitQr ~yailability of set;vicm, · dellyeryof network ~gequacy,

ilirielyacceSs to care, cultural consideration, prirr!iiryeare and coordination/continnity of

. services, special hea1thcare 'needs, coverage and authorization of services, emerg~~y and-post- . stabilization services, enrollment and disenrollment, grie~e Syaten:is, hearth information systems, compliance wi~ c9n!raCt,and Stato and Federal Medicaid ~ents. corrective actions or

improvement intire quality of service or care provided to Enrollees

C:UPB.DSFDE'" NONE - NEW PAGl~ • QWJrterlyreportr~nilsare "" , ,~,t ~ y, documented in;IM:T m¢ing

Corrective action plans (CAPs)

minutes and communicated to • .--.-.~. ""'-~--'--' - s~ldeiS andtheQAPI

STATE lo-u.-I':> I (\.1\ IL _ Committee:

DATE REC'D_O.:::J.b. - ! I • Qu.aliIY results are reported to OATEAPPV'D_' '6- ..... t~~ \\ A providers through plan

. IJATE EFF 'b ~ \ v ~1. mailings. \ I (1 • Members and fiunilies receive Ji~~! 1E_m_.~~': .... ,~_~~;:;;;:;=. _~_ QAPI activitY infurmation

• Developed by the SMOatfue request ofOBll

Areas for improvement will be prioritized aed monitored on a day-

. through member newsletters. • Analysis of perfurmance

mcasore reporting, findings from IMT and external reviews,

TN# _1l-13, ___ ---'Apprcwl Date \ ~; \ '\ ~ II Etreclive Date_3/1120 12, _____ _ Supersedes TN#_Nonec........ __

11-13-2008


System Improvement:

State Plan Attachment 3.1 - &-

(Describe Drocess for systems imDrovement as a result of aI!I!reIlated discovery and remediation activities.) Methods for Analyzing Roles and Frequency Method for Evaluating nata and Prioritizing Responsibilities Effectiveness of System Changes Need for System Improvement

~ .,.

. .

Ongoing monitoring activities using perfonilance measures specific to the 1915(i) SPA

"

~: .: .

: .. :'

STATE l.~ \ C<A\ tt. DATE REC'D __ Q -10 -\ \

DATE APPV'D_I ~ -.\1-1, I IJATEEFF .'b - \ ~ I d-HC:=A 179 \ \ ~ I ?> _ ~--..~-~ ..... ...., ........... -,~ .............. -.-

I

1 I

A

__ ... ....J p~es; and as afina1 example. inconsistencies identified'in level"ofneed determinationS could result in

TN# _l1-13, ___ ~Approva1 Date I).. ~ \ q ~ '\ Effective Date.)/I12012. _____ _ Supersedes TN# _ _ None'---_ _

11-13-2008


System Improvement:

State Plan Attachment 3.1 - &-Page 39

(Describe Drocess for systems imDrovement as a result of aI!I!reIlated discovery and remediation activities.) Methods for Analyzing Roles and Frequency Method for Evaluating nata and Prioritizing Responsibilities Effectiveness of System Changes Need for System Improvement

~ .,.

. .

Ongoing monitoring activities using perfonilance measures specific to the 1915(i) SPA

"

~: .: .

: .. :'

STATE l.~ \ C<A\ tt. DATE REC'D __ Q -10 -\ \

DATE APPV'D_I ~ -.\1-1, I IJATEEFF .'b - \ ~ I d-HC:=A 179 \ \ ~ I ?> _ ~--..~-~ ..... ...., ........... -,~ .............. -.-

I

1 I

A

__ ... ....J p~es; and as afina1 example. inconsistencies identified'in level"ofneed determinationS could result in

TN# _l1-13, ___ ~Approva1 Date I).. ~ \ q ~ '\ Effective Date.)/I12012. _____ _ Supersedes TN# _ _ None'---_ _

11-13-2008


System Improvement: (Describe process for systems improvement as a result of aggregated discovery and remediation activities.)

Methods for Analyzing Roles and Frequency Method fur Evaluating Data and Prioritizing Responsibilities Effectiveness of System Changes Need for System Improvement

Review of quality . strategy and development of a new quality strategy . fur the next year

External Quality Review (EQR) to evaluate the SMO'

Performance Improvement Projects (PIT's)

.. ~ . , . . . ,.'

" ,' :.

," "

. :',',,' ',·t ••

• QBHquality,~quz;

>~~~;~~,ri.ri i- -S~tidlderS '.,

' .. "'iliCitia~ g6~~en:tar ' agencies;

, ptOvi4ers, conSl4ners and advocates

• ,EXteillalvendor perfon:ns.EQR EQR contracted • byOBH

• Monitoredby IMT~ which uses EQR information to update the ' QMSandto initiate and develop quality impr9v:ement projects ,.

• Results (validation of • PIT's) analyzed and compared to expected • outcomes

SMO peIfurms PIT'sahd collects and presents data Contracted EQR validates PIT's lMT monitors PIT's

Annually

, Ongoing, . reporting

• Consumer survey developed' to measure adult and child cons,umer exjJerienc;e and satiSfactiQl) with

• 'SMO adiDinisters Annually survey

• OBH approves . survey·and . , ..

methodology ". I ••

• Provides detailcid:iilformation Qn:ther~i$torY.¢;'~P~ce of.

.the.SMOaS .welfas resilltsol .' . ,', Pci:f.~;P;~~~~P~~~~IA~t .. ,. , projects ~IP,s?~~!~s: ,"

. • TheE.QRrep()rtp~Y1-~~ '. mroi1liii:~on about die'quality, ~ejiliessari.ii ~cc'eSsfuilitY of care funii¥~~y the SMO, assesSiiSiis strengtlis Wid ' weabl~s~,; ~'~.i4~t~~ , opportimitj~ Iodmprovement . " ...

annual • Mo#.tors3i~~ ~ .' , ' Perfcin:iiliilceiiDptovement pro~8Pi.·· "

• fOcus on clinical and noncliniCal 'areas.

• The survey60ntahis.queStions , designed tomea,sure at least

the following !limensions of client satisfiiction with SMO Providers, serviCes, deliverY,

TN# IPl3 ApprovaiDate I ~ vi£! ~Il ; Effective Date_31112012. ____ _ _ SupmooeS .... '.:;-'" .... • : _-:.' ... ' - c· .. TN# _ _ ·None, __ _

11-13-2008

State: Louisiana §1915(i) HeSS State plllll Services

System Improvement:

State PIlIll Attachment 3.1 -~ Page 40

(Describe process far systems improvement as a result af aggregated discovery and remediation activities.) Methods for Analyzing Roles lIlld Frequency Method fur Evaluating Data and Prioritizing Responsibilities Effectiveness of System Changes Need for System Improvement

Review of quality . strategy lIlld develOpment of a new quality Stnlregy , for the next year

External Quality Review (EQR) to evaluate the SMO

'.' ! ., , . . '

• QBHquality(~tldt ':'SM(j,'t' , .... ',"

iiliikdioldeiS IMT .. '8t,~iidided ' .. ·;iii:6itfij~ gmi~eiiial' agi:ncieil, pio'lid,ers, conSWners lIlld advocates

.. . Eli.teina1"andbr plriorms.EQR

.. EQR contracted byOSH

.. M.onitoredby IMT, which uses EQR informstion to update the . QMSandto initiate and develop quality impJ:l)",ement proj~ ,

rp;:;-erfl-;;-o-rm-an-ce-----r .. ~ SMO peIfurms

Improvement Projects PIPs and collects (PIPs) lIlld presents data • Resu1!s (validation of • Contracted EQR

PIPs) analyzed'and validates PIPs compared to expected • outcomes

IMT monitors PIPs

. Ongoing, 'reporting

• Consumer survey developed'to measure adult and child cons,umer ex\Jerienc.e and satiMilcti(llJ with

.. 'SMO adniinisters Annually survey

.. OBH approves survey.and . . ',-:

methodology ,

annual ... ~:}~ta~~~ent pro~Iiill.,' .'

.. focus on clinicallllld ooncliniCalarcas.

.. The surveyriontalriB,quootions designed !Omel\S\!1'Il at least the following 4\mensiOJisof client satisiiiotion with SMO Providers, serviCes, delivetY.

~:els:!!3 .'. ;,:;~ .. ,:<\~~ J)ale~1 ",~~vLI q:±, ",;:' :,l,I1..';_Effective Dale_3/112012. _____ _

TN# __ ,None. __ _ 11-13-2008

Slate: Louisiana §19l5(i) HCBS Slate plan Services State Plan Attachment 3.1 -Ii


Methods for Analyzing Roles and Dala and Prioritizing Responsibilities Need for System ImJlrovement

the SMO. _ " '\'"' ',. . OBH:8hil IMT. ... • ResUIis iooorpbi=a~ :; A "mc:ihitor· ' . ."

into the 'overall ' c· .... ' .:; . '.'.: quality management slIategy (QMS)

:; ,' "

Frequency Method for Evaluating Effectiveness of System Changes

" ;l' { 'S'lt!fty~6i~cl~F' .~ .

. -: ' Co~Jliner lQlo'wl~ge. of .

.. .... ... : ;:J~'t:~~;:~~~(: . . -COnSWil&mowloo" pf

';': . ': I,: "

, " ,:"".If! • A.l'rovider .SMO develops , . .

satisfuction survey is survey included in the annual • OBH and IMT statistical reporting to monitor the State - The purpose is to

solicit input from Providers regarding levels of satisfuction with program areas such as claims submission and payment, assistance from theSMO,and communication

• Behavioral health Grievance and Appeals review - Dataand

information used

SMO reports address type or'grievance, source of grievance, type of Provider (MIl, DO, SA), 2rievance resolution,

TN# _1l-13 ___ -'Approval Date I ;).. ~\" ~ II Supersedes TN# _ _ None,-__

.",

- . Cul~,s~~ty ·: ... , .-CODsWner~i:tcepti~n of

. ' acCessibilitY iri' ~CrviCes, . i,ncli,lding acCess' to

. . Eri>:riders Annually • ProVidet'satisfill;tionsUlVey"is

_.w. ._

." : l '~ . .

State-'apprqved • The" survey is developed by

- theSM,0 !Iild'aI'pr~vedfor~.e by theSliitti:iigency'

• MonitOrs aVi(ijabi!itY of servi~;tiIDcly~tocare, . coor~ti~~c9ntiliuity of . services, and.coverage·and ..

. ··autliOriZatiOi{6f seT\;j~ .. . .

STATE_ lOlA IO\O,A\'b ..•

DATE REC'G~ 2> -ID .; Ii "

DATE APPV'D_' ~ -11:\ -I f A

I ••

I)ATE EFF $ - ( "" (.9-He:=A 179 . II ~ (~ .' . ~,. ... ~~- .. --... --::,,- ...... ;;-:-~ .. - .. ~-'-!

Quarterly • The SMo'will revise its reporting Qn grievances and appeaisto identity those made specifiCiilly by or on behalf of LA 19,15(i)HCBS

EffuctiveDate_3/112012 _____ _

~V1'E..RSEDES: NONE - NEW PAGE 11-13-2008

Stale: Louisiana § 1915(i) HCBS Stale plan Services

System Improvement;

Stale Plan Attaclunent 3.1 -IiiPage 41

(Describe process for systems improvement all a result of aggregated discovery and remediation activities.) Methods fur Analyzing Roles and Data and Prioritizing Responsibilities Need for System Improvement

the l'MO ••..... ,'/ l'." .~9 .. ~;iiiftl IMT .. • Results incorp0i8(cili. r'i 'mQmtor .

into the 'overall' <. .... :"', . quality mamigement strategy (QMS)

.. A. Provider

",:

~: ,

..SMO~evelops satisfuction survey is survey included in the annual .. OBH and IMT statistical reporting to monitor the State - The purpose is to

solicit input from Providers regarding levels of satisfuction with program areas such as claims submission and payment, assistance from the SMO, and communication

.. Behavioral health Grievance and Appeals review - Dataand

infurmation used

SMO n:Ports address type of grievance, source of grievance, type of Provider (MH, DO, SA), llrievance resolution,

Frequency

.

, .

Annually

Quarterly


., .';. '·and'quliljtY;. ,:.' .' ',' )?;> o;.,~~~oo~wi~

:i <i;sMO~'&vices 'dell" " . ai1dqii~iity '; very

- Con&1linerknOwl~g'eof.

..' ~:if~~$~~f. ~. . rl.gh1S;uiiir&p6iiSlIiiliti~: .

··.·····:······~~t~t·~tt4~~~~ ·transferprocess··' .. ' .

- . Cut~s~lljt&i!ty·.· ," . r:-COnsumerpetcepti~n of

"/l(lOOssibility iii· serviCes, . ip.clil~ acCesS' to P~Viders

.. ProVidet's'Itisi'aQtionsurvey'is Stat&:apprqved' . "

.. Thi survey is developed by the sMo ai1d'appr!JVedfor~e by theStiite:ageilcy

.. MonitOrs aViUiabilitY Qf aervi~:·tini~ly a~to~ . ooordimitioD/conlhiuity of· . ., ; ~

services, and.ooverage"and . autliOrizatloih>f serviceS ..

.. The SMowiil revise its reporting Qn grievances and appealt;to identifY those made specificiilly by or on bebaIf of LA 19,15(i)HCBS

.

~l)PE.RSEDES: NONE - NEW PAGE 11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -t;v


Methods for Analyzing Data and Prioritizing Need for System Improvement

Roles and Responsibilities

to assess qUality as well asthe:i oCr' mid utiliZation. of ., :i!iJrnl?!f,%,~~ilAd. ' , d' ' , ' . ' c;lispositi," 9,-n,' of'~p" ·,p·' ea,- ,Is, care an servIces., Results from Stateriiviews ' ongoing analysis lMTmonitors; ,; are applied to process

evaluation of grievances with quality expectations.

SU':?E.BSEDES: NONE - NEW PAGE

TN# _1l-13 ___ --'Approval Date la.- \t\ ~\\ Supersedes TN# __ None. __ _

Frequency

.. :"


' " " ':;,.~:~r~~~;ij:~t~~ '." .~, '", C , '" "."siirVicell ddiveryofri'etwork

". : .

,."

.autoo:nzat!O:ii: o'f.serVi~, . , . _. em,ergeJjcy·ah4 post"' :, ' '- .. s!ljFiitiljionsernces. ,,' ~nfugnt"~',<lliiDroIlment,

• ii;i~()~sy~t~,lIlUi;h~lth "iiifomliition~ysteins. . ' ,

, -. - ~ STATE '-V (A, 1'::).!..Qt Mi\ DATE REC'B ~ - 16 -I (_ DATE APPlrO_' :l.. -I q • II OATE EFF ~ .3 ~ \ - ! IJ.

A

He:=A 179 I \ -l~ l...:....:.. __ .--.......-... ~. __ ..... . "-.... -..::::=.. ,.._ .... ...!

Effective Date_3/1120 1 2. _____ _

11-13-2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 .Jiiv Page.rz


Methods fur Analyzing Data and Prioritizing Need fur System Improvement

Roles and Responsibilities

to assess qUality as weir as tlilr':' .r<: ~ utilii.atfon:of < ~pmq~,iYi?~~II!id.

~1i-oiiiH9:ri. ilfiip<'p«< eaJs =ul~da:,e:ces. S;~riMeWs .' < •

ongoing analysis IMTmonitors;.: are applied to process evaluation of grievances with quality expectations.

SU'?ERSEDES: NONE - NEW PAGE

TN# _1l-13 ___ .....:Approval Dale la..- t/1-t\ Supersedes TN# __ ,,---___ _

Frequency Method fur Evaluating Effectiveness of System Cbmlges

STATE Lou,I"::>.t~ , i DATE REC'[}~~....::J.j_ I

DATE APPlfO_l :i.. -I~ -II A OATE EFF-,..... 3 -l - t ~ Hei'A 179 I \ - 1I~ t.....,:;.,.,:. __ • • ......... """'......"."..., ___ .... ,_ ........ =:;:;:,. _ ... ....!

Effective Dau'-3/l12012, _____ _

11-13-2008

State: Louisiana §1915(i} HCBS State plan Services State Plan Attachment 3.\ -(ijr

Methods and Standards for Establishing Payment Rates

1. Services Provided Under Section 1915(i) ofthe Social Security Act. For each optional service, describe the methods and standards used to set the associated payment rate. (Check each that applies, and describe methods and standards to set rates):

D HCBS Case Management ", . . . . ~ . .

D HCBS Homemaker

D HCBS Home Health Aide

. --0 HCBS Personal Care STATE I. m. ;t5~4.

DATEREC'C 3_:10 -I( ,

D HCBS Adult Day Health DATE APPltD_1 2.- ~11- II - A I)ATEEFF_ 3 - / -12:,

D HCBS Habilitation HerA 179 ~ I - I'D ~_.-"""-I":;'OOID_~ __ • __ ,_,_""",:::::="

D HCBS Respite Care

I&l Other

As descnbed in Attachment 4. 19B, item 5. Reimbursement for Psychiatrists under Physician.

For Individuals witb Chronic Mental nlness, tbe following services:

D HCBS Day Treatment or Otber Partial Hospitalization Services

0 HCBS Psychosocial Rehabilitation The 19I5(i} is being implemented concurrent with a 19I5(b} waiver. Concurrent § 1915(b }/§ 1915(i} authorities will utilize a capita!OO payment arrangement The capitation' will be described in the State'. 19l5(b} waiver and approved contract consistent with 42 CFR 438.6(c}. The description below i. the State Plan FFS reimbui'sement methodology on which capitalionpayments are based.

A State Plan Reimbursement Methodology Reimbursements for services are based upon a Medicaid tee'schedule established by the Stale of Louisiana. 1f a Medicare tee exists for a defined covered procedure code, then Louisiana will pay Psychologists and ARNPs at 80% of the Medicaid physician rates as .outlined under 4.19-B, Item 5. 1f a Medicare fee exists for a defined covered procedure code, than Louisiana will pay LCSWs, LPCs, LMFTs, and LAC's as Well as qualified lII\li~ed jmictition"!,, delivering substance abuse services at 70% of the Medi9llid physician.rat"" as outlined under4.J.9-B, item 5. Where Medicare fees do not exist for a covered code, the fee development methodology will build fees considering each component of provider costs as outlined below. These reimbursement methodologies will produce rates sufficient to enlist enough provider. so that services under the Plan are available to individuals at least to the extent that these services are available to the general DOPulation, as required by 42 CFR 447.204. These rates comply with the requirements of

TN# _11-13 ____ .Approval Date t k11-11 EffuctiveDale_31112012 _____ _ Supersedes TN# __ None'--__

SUPERSEDES: NONE - NEW PAGE 11-13-2008

State: Louisiana §19J5(i) HCBS State plan Services State Plan Attachment 3.1 .(i;Page 43

r!1letnoas aod Stan daras for Estn blisfiing Payment Rates

1. SemceJ; Provided Under Section 1915(1) ofthe Social Security Act. For each optional service, descnoe the methods and standards used to set the associated payment rete. (Check each that applies, and describe methods and standards to set rates):

0 HCBS Csse Management . _-. " •

0 HCBS Homemaker

0 HCBS Home Health Aide

, 0 HCBS PersoDRI Care STATE .1. ~~4.

DATE REC'D~_: I (> -t { _ 0 HCSS Adult Day Health DATEAF'p\rD_I2-~11-11 - A

I)ATEEFF_ (3 -I 1:.4

0 HCBS Hsbilitation HerA 179 - I.!'lI ~ .... ~~~-.~ .. - ..... ,,,,,--........ =.

0 HCSS Respite Care ---~----- ---------~~ ...

rn:J Other

As descnbed in Attachment 4. 19B, item 5. Reimbursement for Psychiatrists under Physician

For individuals with Chronic Mental IDness, the following services:

0 HCSS Day Treatment or Other Partial Hospitslization Services

0 HCBS Psychosocial Rehabilitation The 1915(i) is being implemented OOllcurren~ with a 1915(b) waiver. Concurrent §1915(b}l§1915(i) authorities will utilize a capitated payment ammgement. The capItation will be descnbed in the State's 1915(b) waiver and approved contmct consistent with 42 CPR 438.6{ c). The deserlption below is the Slate Plan FFS reimbursement methodology on which capitation payments are based.

A State Plan ~imbm:sement Methodology ~b=ts fur services are based upon a Medicaid roe schedule estsblished by the Slate of Louisiana. If II Medicare roe exists fur a defined covered proeedure code, thea Louisiana will pay Psychologists Illld ARNPs at 80"" of the Medicaid physician mtes as.outlined under 4.l9-B, item 5. If a Medicare fee exists fur a defined covered procedure oode, then Louisiana will pay LCSWs, [,pes, LMFTs, and LAC' •• s Wen as qualified unU<lefiSed pnictitiOtlfl!'S delivering substml:e abuse services at 70% of the Medicaid physician,mi",! as outlined uruIer4.19-B, item 5. Where Medicare !i:es do not exist fur II covered code, the roe development methodology will build rees considering each component ofprovider costs lIS outlined below. ~ reimbursement methodologies will produce rates sufficient to eu1ist enough providers 110 that services under the Plan are available to individual •• t least to the extent that Ihose services are available to the I!eneral Dooulation, as required by 42 CPR 447.204. These rates comply with the requirements of

TN# _1I-13 ___ -:ApproVilIDate tt-LtjL--,I1,--_,EffectiveDate_3/112012,--_~ __ _ Supersedetl TN# __ Notle, __ ~

Sl)PEI~SEDES: NONE - NEW PAGE 11-13·2008

State: Louisiana §1915(i) HCBS State plan Services State Plan Attachment 3.1 -ti'

adjustments,t6 ilie,1\le'soh"llHlfl arePubJished in (si>ecifY;\!'liere'publisl!edm9@lirig:webSiie," .

·~;:~!~ttr:~·:~~tm~i:t!:;:1:~~~~~~~{~g~;:~~;tt.""·::·· . The.iiie deVer' "i!ientmethoooici .. Will rimarii .1ie,con1 oSed.·ot ·io:\iidei':';"stiii~ ··· ·:' "lhou '. ... . . '. 9P.,. . ., •..... .... gy ... p -. ' .... Y ........ P ., ... , .... .. p ...... , .... .... ... c' ..... . . .. ~g, .. .. 1lI!. .. Louisiana provider.comp~~()n~es, cOSt datiandf~~6;9jn~'sirnila!'StiI#:.¥~9aid '." .' programsmay be coosldered,lIliweIJ. The fullo~g (jSt o.utliijes:.thciioajqr compOnentS of (lie costmodelto lie Use.! in fi'C developmeil.l . .' '.; ' . .. . - . - . .

• St8!ling~tiOhs 8I\d SiaffWageS . - . . . . . , '. • Bm.ploYe<;-~laiedEXPenSes":'Berielits, EinployerTilxes (e.g~,Ji'ICA,tin:employmeiJ.~

, . 8I\d'work~:coinpens;lt,ion) 'c' . ; ... ;<; . . ". . , .. • . Program-Belated &P.n~ (e.g., supplies) · ,. • Provider·OverheadExpenses • Program BillableUnitS·

The tee schedule rates will be developed as the ratio of total annual modeled provider costs to the estimated annual billable units.

B. Standards fur Payment I. ProViders must meet provider participation requirements fucliuling certification and licensure of agencies and clinic, . ., 2~ All services must be prior authorized and provided in accordance With the approved Plan of Care. . . . . '. '. , ,. . . ..

3. Providers must comply With all state'ilnd federal regulations regardiDg subcontracts.

o HCBS Clinic Services (whether or not furnished in a facility for CM!)


1N#_lI-13, ____ ApprovalDate ,a; ~Iq -I \ Supersedes 1N# __ Nooe'--__

ST~~7i ~', Ct-t't,!,;:A:..-_ DATE REC'D._a: /0 -! I DATEAPPV'D.J.L::,,)'l. -II IJATE EFF B ~ 1...::,1 J--HG'!A 179 11-1.2-_._

l---~ .. ...-vn_., .. ~ ....... -:_·J>-·" ... ·n.-

Effective Date_3f In.O 12, _____ _

11-13-2008

State: Louisiana §1915(i) HeBS Stale plan Services

programs miwCii. The fullo:wmg USt .

State Plan Attachment 3.1 -fir Page 44

cost model to be usit! . developtnooi:. .. . . .. • StafJing As,sUiUptlOils an,d Sim;fWages ' , • ilmplo~)lllla~ll><PiiilseS ,c: BOO"fits. Employer Taxes (e.g:.l!ICA,Unemploymeil.~

'md'W!lr~8:00inpensJltjo!lh . ;·i'· ,. ; .. •. Program~ReJatiid BiqJen~ (e.g., supplies) • Provider Overhead Expen.ses • Program BilIable'UnitS

The too schedule rates will be developed as the ratio of total annual modeled provider costs to t!le estimated annual billable unit •.

B. SllIndards fur Payment L ProVideri! must meet provider participation requirements fucluding certificatiooll1ld IicenBure ofagencies and clinic. ., 2. All services must be prior aUlhorized and provided in accordance With the approved pian of Care. ' . ., - "

3. Providers . With all federal suhoontmcts.

o HCBS Clinic Services or not fun:lished in a for

8DPEI{SEDES: NONE· NEW PAGE

TNII 1l-13 ___ -'ApprovalDate J;); ~\4 -\1 Supersooes

Effi:ctive Date _3/112012. _____ _

TNII __ Nonc'--__ 11-13-2008

Adult BehaviOilii'HeiithState: Louisiana 1915(i) Hess State plan Services State Plan Attachment 3.1...

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