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~ PUIN tmER TITLE XIX OF 'mE SOCIAL SEOlRlT'i Acr MIDlCAL ASSISTANCE ~

ATrAalMENI' 3.1-A Item 13. d., Page 1

~ OF IOOISIANA

NP.Nl', OORAT.ICtI, AND SCOPE OF MIDlCAL lIND REMEDIAL CARE AND smvICES PRJIJIDm

LlHITATICtI OF 'IHE AM:X.NI', WRAnCtl lIND SCOPE OF CERrAlN ITEMS OF PRJIJIDm MIDlCAL lIND REMEDIAL CARE lIND SERVICES ARE DESCUBED 105 J'QU.(MS:

c:::ITATlOO 42 CFR .... 0.130

'INI

'INI

MIDlCAL lIND REMEDIAL CARE lIND SERVICES ltan 13.d •

~

DATE RE

other piagnostic. 59'"!fflUm. Preyentive. N!d Behabilitative Seryirr. i.e .. ather than them FroyidEP Elsewhere in this Plan

I . Behabilitation Clinic 5enQres

A. Upon PRIOR N'f'P!:NN... l:7j the Prior AIIthorizatiCrl uut, B.lreau of Health SeJ:vices Financin;J, payment for rehabilitatiCrl services provided l:7j Title XVIII certified plblic or private rehabilitatiCrl centers, or hospital Oltpatient rehabilitatiCrl units will be made in aoocrdan::le with an established payment schedule. llehabilitatiCrl SeJ:vices include oco1p"tional therapy, physical therapy N!d speech, ~ge N!d hearin;J therapy. llehabilitatiCrl SeJ:vices covered under Medicaid do not include the followin;J:

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(1) VocatiCrlal or developDental. evaluatic::ns, or

(2) Voice evaluatic::ns or therapy. '!his includes instructiCrlS in use N!d hygiene of the voice as treatment for vocal CXlrd nodules or hoarseness N!d related corxiitic::ns, unless it is serious enough to interfere with narmal speech.

Effective De 9

DATE APPV'O ~CJ A OAlE EFFJl ~ HerA 119 "

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STATE PlAN UNDER TITLE XIX OF 'mE sx::IAL smJRIT'i ACT ATl7\CiMENI' 3.1-A MEDICAL ASSISTANCE PR'.XiRAM Item 13.~" Page 2

STATE: OF LCmSWiZl

AMXlNI', IXlRAl'IW, AND SCDPE OF MEDICAL lIND REMEDIAL CARE AND SERVIc;£S PRJ\IIDID

LlMITAl'IW OF 'DiE NO.m, IXlRAl'IW lIND SCDPE OF cmrAIN ITEMS OF PklVIDm MEDICAL AND REMEDIAL CARE lIND SERVICES ARE DESaUBED AS fOIlCWS:

CITA:I'Igi 42 CFR 440.130

MEDICAL AND REMEDIAL CARE AND SERVICES Item 13.d. (COn't)

B. ~l will be based m specific criteria and cxn:iiticns related to the lIIBdical recuilleild­dations far rehabilitation services vices and the plan of service pte 'fc&ed ~ the rehabilitatim services provider. Plans far meetin;J the cost, if any, of transpcrtation and ~ ~ far the individual to secure the services IlLISt be part to the plan.

'Dle Priar Autharizatim th'lit shall hC ..... IIIen::l appt'CMll. of rehabili­tatim plans far individuals 1ootlo are likely to realize sutstantial. gains in self-are, self- help ar rehabilitatim. Self-are and self-help are defined as the ability of the in:tividual to take care of perscnal needs, e.g., eatin;J, dressin;J, ability to walk, talk, ar use devices unassisted. Rehabilitatim is defined as a pttqL am to prevent further iIpaizment of ~ical deformity and malfI.Inctim, and enable the individual. to significantly increase his ability to require less care ~ others. Less care ~ others is defined as the ability of the client to use a mininum of ass.istan:::e to take care of persmal needs. q,tim..Im utilizatim of the device will be an acktitimal. criteria Wen prosthesis ~ is involved. miSF does not have a pttqLam far len; terlI1 therapy ar IDI1intenanoe therapy.

~ ~tt'JEC - 21990 Effective ~te JUL -11989

STAT. .......

OA 1£ REC'''0-E:T'-'''..w...~J,.L,"",""_

DATE NPV'O ()~ -;' 40 DATE EFF JlJi .. 1 __ HeFA 119 '?.

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACf MEDICAL ASSISTANCE PROGRAM

Attachment 3.1-A Item t3 .d. Page 3

STATE OF LOUISIANA

AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT. DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:

CITATION 41CFR 440.130

Medical aDd Remedial Can ud Serviees Item 13.d

Other resources such as Handicapped Children's Services, school therapy programs, and community resources should be considered.

C. The following conditions shall be met:

1) Referral for services has been made by a licensed physician and the Prior Authorization Unit, Bureau of Health Services Financing (BHSF) has a copy of his recommendations to the provider. The recommendation must include the diagnosis; date of accident or onset of illness, the address of the referring physician his specialty, if known, and the date of the referral.

2) The rehabilitation services provider has evaluated the client and a copy of the proposed plan of services includes Form RC-1 and the physician's statement of referral has been sent to State Office. BHSF will not pay for vocational or development evaluations or voice evaluations or voice therapy as specified in Item 13.d., I., A., above.

3) The Bureau of Health Services Financing, with the advice of the Prior Authorization Unit bas approved the Plan.

4) The rehabilitation services provider has agreed to provide progress reports to State Office as recommended by the Prior Authorization Unit when the plan is approved.

[Exclusions]:

Effective for dates of service on or after February 1, 2013, The Department terminates the coverage of all rehabilitation clinic services to recipients 21 years of age and older.

TN# /3 -ct Approval Date __ "'1.:-- 7~-/:....;6;;..._ __ Effective Date i) - 1- 1&

Supersedes TN# ~9-fflf SUPER'3EDES: TN-__ CZtt'_-D1._~--

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 4

STATE OF LOUISIANA

AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:

CITATION 42 CFR 440.130

Medical and Remedial Care and Services Item 13.d (cont'd.)

RESERVED

TN# _____________Approval Date ____ Effective Date ______________ Supersedes TN# ____________________

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 5 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:  

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) Substance Use Disorders Services The Medicaid program provides coverage under the Medicaid State Plan for substance use disorders (SUD) services rendered to children and adults. SUD services rendered shall be those services which are medically necessary to reduce the disability resulting from the illness and to restore the individual to his/her best possible functioning level in the community. Children and adults who meet Medicaid eligibility and clinical criteria shall qualify to receive medically necessary SUD services. Qualifying children and adults with an identified SUD diagnosis shall be eligible to receive SUD services. American Society of Addiction Medicine (ASAM) levels of care require reviews on an ongoing basis, as deemed necessary by the Department, to document compliance with national standards. Services provided to children and youth must include communication and coordination with the family and/or legal guardian and custodial agency for children in state custody. Coordination with other child-serving systems shall occur as needed to achieve the treatment goals. All coordination must be documented in the child’s medical record. The agency or individual who has the decision making authority for a child or adolescent in state custody must approve the provision of services to the recipient, provided that written consent is obtained from the minor. These services include a continuum of individually centered outpatient, intensive outpatient and residential services consistent with the individual’s assessed treatment needs. The rehabilitation and recovery focus is designed to promote skills for coping with and managing substance use symptoms and behaviors. Services should address an individual’s major lifestyle, attitudinal and behavioral problems that have the potential to undermine the goals of treatment.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 5a STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:  

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

Children who are in need of SUD services shall be served within the context of the family and not as an isolated unit. Services shall be: a. delivered in a culturally and linguistically competent manner; b. respectful of the individual receiving services; c. appropriate to individuals of diverse racial, ethnic, religious, sexual, gender identities,

and other cultural and linguistic groups; and d. appropriate for age, development, and education.

Evidence-based practices require prior approval and fidelity reviews on an ongoing basis as determined necessary by the Department.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 6 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:  

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) The following ASAM levels are covered for outpatient treatment: Level I: Outpatient Outpatient level 1 services are professionally directed assessment, diagnosis, treatment and recovery services provided in a non-residential treatment setting. Outpatient services are organized activities which may be delivered in any appropriate community setting that meets State licensure. Level II.1 Intensive Outpatient Treatment Intensive outpatient treatment is professionally directed assessment, diagnosis, treatment and recovery services provided in non-residential treatment setting. Intensive outpatient services are organized activities which may be delivered in any appropriate community setting that meets State licensure. These services include, but are not limited to, individual, group, family counseling and psycho-education on recovery, as well as monitoring of drug use, medication management, medical and psychiatric examinations, crisis intervention coverage and orientation to community-based support groups. Intensive outpatient program services should include evidence-informed practices, such as cognitive behavioral therapy (CBT), motivational interviewing and multidimensional family therapy. Level II-D Ambulatory Detoxification with Extended On-site Monitoring This level of care is an organized outpatient service, which may be delivered in an office setting, health care or addiction treatment facility by trained clinicians, who provide medically supervised evaluation, detoxification and referral services. These services are designed to achieve safe withdrawal from mood-altering chemicals and to effectively facilitate the individual’s entry into ongoing treatment and recovery. Counseling services may be available through the detoxification program or may be accessed through affiliation with entities providing outpatient services. Ambulatory detoxification is provided in conjunction with intensive outpatient treatment services (Level II.1).

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 7 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:  

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) The following ASAM levels are covered for residential treatment: Level III.1 Clinically Managed Low Intensity Residential Treatment – Adolescent and Adult Residential programs offer at least five hours per week of a combination of low-intensity clinical and recovery-focused services. All facilities are licensed by LDH. Treatment is directed toward applying recovery skills, preventing relapse, improving emotional functioning, promoting personal responsibility and reintegrating the individual into the worlds of work, education and family life. Services provided may include individual, group and family therapy, medication management and medication education. Mutual/self-help meetings usually are available on site. Does not include sober houses, boarding houses or group homes where treatment services are not provided (ex: halfway house). Level III.2D Clinically Managed Residential Social Detoxification – Adolescent and Adult Residential programs provided in an organized, residential, non-medical setting delivered by an appropriately trained staff that provides safe, 24-hour medication monitoring, observation and support in a supervised environment for a person served, to achieve initial recovery from the effects of alcohol and/or other drugs. All facilities are licensed by LDH.

Social detoxification is appropriate for individuals who are able to participate in the daily residential activities and is often used as a less restrictive, non-medical alternative to inpatient detoxification. Level III.3 Clinically Managed Medium Intensity Residential Treatment - Adult Residential programs offer at least 20 hours per week of a combination of medium-intensity clinical and recovery-focused services. All facilities are licensed by LDH. Frequently referred to as extended or long-term care, Level III.3 programs provide a structured recovery environment in combination with medium-intensity clinical services to support recovery from substance-related disorders.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 8 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:  

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) Level III.5 Clinically Managed High Intensity Residential Treatment – Adolescent and Adult Designed to treat persons who have significant social and psychological problems. All facilities are licensed by LDH. Programs are characterized by their reliance on the treatment community as a therapeutic agent. Treatment goals are to promote abstinence from substance use and antisocial behavior and to effect a global change in participants’ lifestyles, attitudes and values. Individuals typically have multiple deficits, which may include substance-related disorders, criminal activity, psychological problems, impaired functioning and disaffiliation from mainstream values. (Example: therapeutic community or residential treatment center.) The program must include an in-house education/vocational component if serving adolescents. Level III.7 Medically Monitored Intensive Residential Treatment – Adult The Co-occurring Disorder (COD) residential treatment facility provides 24 hours of structured treatment activities per week including, but not limited to, psychiatric and substance use assessments, diagnosis treatment, habilitative and rehabilitation services to individuals with co-occurring psychiatric and substance disorders (ICOPSD), whose disorders are of sufficient severity to require a residential level of care. All facilities are licensed by LDH. It also provides a planned regiment of 24-hour professionally directed evaluation, observation and medical monitoring of addiction and mental health treatment in a residential setting. They feature permanent facilities, including residential beds, and function under a defined set of policies, procedures and clinical protocols. Appropriate for patients whose subacute biomedical and emotional, behavior or cognitive problems are so severe that they require co-occurring capable or enhanced residential treatment, but who do not need the full resources of an acute care general hospital. In addition to meeting integrated service criteria, COD treatment providers must have experience and preferably licensure and/or certification in both addictive disorders and mental health. Level III.7D Medically Monitored Residential Detoxification – Adult Medically monitored residential detoxification is an organized service delivered by medical and nursing professionals, which provide for 24-hour medically supervised evaluation under a defined set of physician-approved policies and physician-monitored procedures or clinical protocols. All facilities are licensed by LDH.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 9 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) This level provides care to patients whose withdrawal signs and symptoms are sufficiently severe to require 24-hour inpatient care. It may overlap with Level IV-D services (as a “step-down” service) in a specialty unit of an acute care general or psychiatric hospital. Twenty-four hour observation, monitoring and treatment are available. Limitations: These SUD services are provided as part of a comprehensive specialized psychiatric program available to all Medicaid eligible individuals with significant functional impairments resulting from an identified addiction diagnosis. Services must be medically necessary and must be recommended by a licensed mental health practitioner or physician, who is acting within the scope of his/her professional license and applicable state law, to promote the maximum reduction of symptoms and/or restoration of an individual to his/her best age-appropriate functional level 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, family and providers and be based on the individual’s condition and the standards of practice for the provision of rehabilitative services. The treatment plan should identify 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 physician responsible for developing the plan with the participant (or authorized representative) also signing to note concurrence with the treatment plan. The plan will specify a timeline for re-evaluation of the plan that is at least an annual redetermination. The reevaluation should involve the individual, family and 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 different rehabilitation strategies with revised goals and services. Providers must maintain medical records that include a copy of the treatment plan, the name 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 treatment plan.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 10 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:  

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) Exclusions The following services shall be excluded:

1. Components that are not provided to, or directed exclusively toward the treatment of, the Medicaid eligible individual;

2. Services provided at a work site which are not directly related to treatment of the recipient’s needs;

3. Any services or components of services of which the basic nature is to supplant housekeeping, homemaking, or basic services for the convenience of a person receiving covered services (including housekeeping, shopping, child care, and laundry services); and

4. Services provided in an institution for mental disease (IMD), unless provided through the Code of Federal Regulations “allowed in lieu of”, or a U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) approved waiver.

5. Room and board is excluded from any rates provided in a residential setting. Unless otherwise specified, a unit of service is defined according to the Healthcare Common Procedure Coding System (HCPCS) approved code set. Provider Qualifications All services shall be delivered in accordance with federal and state laws and regulations, the provider manual, and other notices or directives issued by the Department. Anyone providing SUD services must be licensed in accordance with state laws and regulations, in addition to operating within their scope of practice license. Providers shall meet the provisions of the provider manual and the appropriate statutes. Services are provided by licensed and unlicensed professional staff, who are at least 18 years of age with a high school or equivalent diploma, according to their areas of competence as determined by degree, required levels of experience as defined by state law and regulations and departmentally approved guidelines. Anyone who is unlicensed providing addiction services must be registered with the Addictive Disorders Regulatory Authority and demonstrate competency as defined by LDH, state law (ACT 803 of the Regular Legislative Session 2004) and regulations. State regulations require supervision of unlicensed professionals by a qualified professional supervisor (QPS).

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 11 STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:   

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

CITATION Rehabilitation Services 42 CFR 440.130(d) A QPS includes the following professionals who are currently registered with their respective Louisiana board:

1. licensed psychologists; 2. licensed clinical social workers; 3. licensed professional counselors; 4. licensed addiction counselors; 5. licensed physicians; and 6. advanced practice registered nurses.

The following professionals may obtain QPS credentials:

1. a masters-prepared individual who is registered with the appropriate state board and under the supervision of a licensed psychologist;

2. licensed professional counselor (LPC); and 3. licensed clinical social worker (LCSW).

The QPS can provide clinical/administrative oversight and supervision of staff.

Residential addiction treatment facilities shall be accredited by an approved accrediting body and maintain such accreditation. Denial, loss of or any negative change in accreditation status must be reported to the MCO, in writing, within the time limit established by the Department. Addiction Services include an array of individual-centered outpatient, intensive outpatient, residential, and inpatient services consistent with the individual’s assessed treatment needs, with a rehabilitation and recovery focus designed to promote skills for coping with and managing substance use symptoms and behaviors. Master’s Prepared Behavioral Health Professional:

1. A master’s-prepared behavioral health professional that has not obtained full licensure privileges and is participating in ongoing professional supervision.

2. When working in addiction treatment settings, the master’s-prepared unlicensed professional (UP) must be supervised by a Licensed Mental Health Professional (LMHP).

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1 -A MEDICAL ASSISTANCE PROGRAM Item 13.d, Page 11a STATE OF LOUISIANA AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED BELOW:   

TN _________ Approval Date ______________ Effective Date _____________ Supersedes TN

Services 1. Alcohol and/or drug assessment; 2. Alcohol and/or drug services – Individual Session; 3. Alcohol and/or drug services - Group Session; and 4. Alcohol and/or drug services - Family Counseling.

Certified Addiction Counselor (CAC)

1. Possesses a bachelor's degree from an accredited institution of higher education. The degree shall be in a human services or behavioral science discipline, or such other discipline or disciplines as the department may deem appropriate;

2. Has met all of requirements of Louisiana Addictive Disorders Regulatory Authority (ADRA); and

3. Has demonstrated professional competence by passing a written and oral exam and conducting a case presentation.

CAC Service Provision

1. Alcohol and/or drug assessment; 2. Alcohol and/or drug services – Individual Session; 3. Alcohol and/or drug services - Group Session; and 4. Alcohol and/or drug services - Family Counseling

Registered Addiction Counselor (RAC)

1. Has met all of requirements of Louisiana Addictive Disorders Regulatory Authority (ADRA); and

2. Has demonstrated professional competence by passing a written and oral exam and conducting a case presentation.

RAC Service Provision

1. Alcohol and/or drug Assessment; 2. Alcohol and/or drug services – Individual Session; 3. Alcohol and/or drug services - Group Session; and 4. Alcohol and/or drug services - Family Counseling.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 12

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

CITATION Rehabilitation Health Services

42 CFR 440.130 (d)

Adult Mental Health Services

The Medicaid program provides coverage under the Medicaid State Plan for mental

health services rendered to adults with mental health disorders. The mental health

services rendered to adults shall be necessary to reduce the disability resulting from

mental illness and to restore the individual to their best possible functioning level in the

community.

Qualifying individuals, 21 years of age and older who are enrolled in Healthy

Louisiana, shall be eligible to receive the following medically necessary adult mental

health services:

1. Therapeutic services; and

2. Mental health rehabilitation services, including community psychiatric support and

treatment (CPST), psychosocial rehabilitation (PSR) crisis intervention (CI)

services and assertive community treatment (ACT).

Licensed Mental Health Professionals

Licensed mental health professionals (LMHPs) are individuals licensed in the State of

Louisiana to diagnose and treat mental illness or substance use disorders. LMHPs

include the following individuals who are licensed to practice independently:

1. Medical Psychologists;

2. Licensed Psychologists;

3. Licensed Clinical Social Workers (LCSWs);

4. Licensed Professional Counselors (LPCs);

5. Licensed Marriage and Family Therapists (LMFTs);

6. Licensed Addiction Counselors (LACs); and

7. Advanced Practice Registered Nurses (APRN) (must be a nurse practitioner

specialist in Adult Psychiatric & Mental Health, and Family Psychiatric & Mental

Health or a Certified Nurse Specialist 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).

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 13

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Exclusions

The following shall be excluded from Medicaid reimbursement:

1. Components that are not provided to, or directed exclusively toward the treatment

of, the Medicaid eligible individual;

2. Services provided at a work site which are job tasks oriented and not directly

related to the treatment of the recipient’s needs; and

3. Any services, or components in which the basic nature of the service(s) are to

supplant housekeeping, homemaking, or basic services for the convenience of an

individual receiving services.

Service Descriptions

1. Therapeutic Services: Individualized therapeutic interventions including assessment,

medication management, individual, family, and group therapy, and psychological testing.

Provider Qualifications

A licensed mental health professional as defined above, must provide therapeutic services.

2. Community Psychiatric Support and Treatment: A comprehensive service which

focuses on reducing the disability resulting from mental illness, restoring functional skills

of daily living, building natural supports and solution-oriented interventions intended to

achieve identified goals or objectives as set forth in the individualized treatment plan,

including supportive intervention. Supportive intervention includes problem behavior

analysis, as well as, emotional and behavioral management with a focus on developing

skills and improving daily functional living skills in order to restore stability, support

functional gains and adapt to community living. CPST is a face-to-face intervention;

however, it may include family or other collaterals. Most contacts occur in community

locations where the person lives, works, attends school, and/or socializes.

Provider Qualifications

Prior to January 1, 2019, agencies providing CPST services must have or have applied for

accreditation by an accrediting organization approved by the Department. Agencies are

allowed to render CPST services prior to obtaining full accreditation; however, agencies

are required to attain a full accreditation status within 18 months of the initial

accreditation application date.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 14

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Effective January 1, 2019, agencies providing CPST services must be fully accredited, or

obtained preliminary accreditation prior to rendering CPST services. Agencies must

maintain continuous, uninterrupted full or preliminary accreditation. Agencies providing

CPST services must obtain a full accreditation status within 18 months of the agency’s

initial accreditation application date.

Individuals rendering CPST services must operate under an agency licensed to provide

mental health services. Prior to January 1, 2019, individuals with a master’s degree from

an accredited university or college in social work, counseling, psychology, sociology or a

human services related field are qualified to provide all aspects of CPST, including the

individual supportive intervention.

Effective January 1, 2019, individuals must have a minimum of a master’s degree from an

accredited university or college in social work, counseling, psychology, or sociology to

provide all aspects of CPST, including the individual supportive intervention. Any

individual rendering the individual supportive intervention component of CPST for a

licensed and accredited agency, who does not possess the minimum master's degree in one

of the four listed educational fields, but who has a minimum of a bachelor’s degree in

social work, counseling, psychology or sociology and who met all master’s degree

provider qualifications in effect prior to January 1, 2019, may continue to provide all

components of CPST including the individual supportive intervention component of

CPST for the same licensed provider agency.

Prior to the individual rendering the master’s level aspects of CPST, including the

individual supportive intervention component of CPST, for a different provider agency,

the individual must comply with the minimum master’s degree provisions of this section.

Effective January 1, 2019, other aspects of CPST, except for the individual supportive

intervention component, may otherwise be performed by an individual with a bachelor’s

degree in social work, counseling, psychology or sociology. Credentialed peer support

specialists who meet the qualifications above may also provide this service.

3. Psychosocial Rehabilitation Services: Services that are designed to assist the

individual with compensating for, or eliminating functional deficits, and

interpersonal and/or environmental barriers associated with their mental illness.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 15

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Activities included must be intended to achieve the identified goals or objectives as

set forth in the individualized treatment plan. The intent of psychosocial

rehabilitation is to restore the fullest possible integration of the individual as an

active and productive member of his or her family, community, and/or culture with

the least amount of ongoing professional intervention. PSR is a face-to-face

intervention provided individually or in a group setting. Most contacts occur in

community locations where the person lives, works, attends school, and/or

socializes.

Provider Qualifications

Prior to January 1, 2019, agencies providing PSR services must have or have

applied for accreditation by an accrediting organization approved by the

Department. Agencies are allowed to render PSR services prior to attaining full

accreditation; however, agencies are required to attain a full accreditation status

within 18 months of the initial accreditation application date.

Effective January 1, 2019, agencies providing PSR services must be fully

accredited, or obtain a preliminary accreditation prior to rendering PSR services.

Agencies must maintain continuous, uninterrupted full or preliminary accreditation.

Agencies providing PSR services must obtain a full accreditation status within 18

months of the agency’s initial accreditation application date.

PSR services may be provided by an agency licensed to provide mental health

services. Individuals rendering PSR services must operate under an agency license.

Any individual rendering PSR services for a licensed provider agency shall hold a

minimum of a bachelor's degree from an accredited university or college in the field

of counseling, social work, psychology, or sociology. Any individual rendering

PSR services who does not possess the minimum bachelor's degree as described

here, but who met all provider qualifications in effect prior to January 1, 2019, may

continue to provide PSR services for the same licensed provider agency. Prior to

the individual rendering PSR services for a different provider agency, the

individual must comply with the provisions of this section. Credentialed peer

support specialists who meet the qualifications above may also provide PSR

services.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 16

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

4. Crisis Intervention Services: Services that are provided to a person who is

experiencing a psychiatric crisis, designed to interrupt and/or ameliorate a crisis

experience including a preliminary assessment, immediate crisis resolution and de-

escalation, and referral and linkage to appropriate community services to avoid

more restrictive levels of treatment. The goal of crisis intervention is symptom

reduction, stabilization, and restoration to a previous level of functioning. All

activities must occur within the context of a potential or actual psychiatric crisis.

Crisis Intervention is a face-to-face intervention and can occur in a variety of

locations where the person lives, works, attends school, and/or socializes.

Provider Qualifications

CI services may be provided by an agency licensed to provide behavioral health

services. Agencies providing CI services must be fully accredited or have applied

for accreditation by an accrediting organization approved by the Department prior

to providing CI services. Agencies are allowed to render CI services prior to

attaining full accreditation; however, agencies must have applied for full

accreditation by an accrediting organization approved by the Department, and must

attain full accreditation status within 18 months of the initial accreditation

application date. Agencies must maintain continuous, uninterrupted accreditation.

Individuals rendering CI services must operate under an agency licensed to provide

mental health services. At minimum, individuals rendering CI services must be at

least 20 years old and have an associate’s degree in social work, counseling,

psychology or a related human services field, or two years of equivalent education

and/or experience working in the human services field. The provider must be at

least three years older than an individual under the age of 18.

Credentialed peer support specialists with the above qualifications may provide CI

services.

5. Assertive Community Treatment Services (ACT):

ACT is a community-based rehabilitative service for individuals with severe mental

illness to support recovery through the restoration of functional daily living skills,

to build strengths, to increase independence, develop social connections and leisure

opportunities, and reduce the symptoms of their illness.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 17

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Services are coordinated by a team to connect individuals with other community-

based supports. The team is comprised of a team leader, a board certified or board-

eligible psychiatrist, two nurses (at least one RN), one other licensed mental health

professional, one substance use service provider and one peer specialist. Other

levels of staffing may be approved by the Department as long as they operate under

licensure and supervision appropriate to their role.

Services include, but are not limited to:

a. Needs assessment, crisis assessment and intervention, and individualized care

plan development;

b. Symptom management;

c. Individual counseling;

d. Medication administration, monitoring, education;

e. Skills restoration to enable self-care, daily life management, e.g. household

maintenance, food preparation, nutrition and health; to function in appropriate

social and interpersonal relationships and to participate in community based

activities, including but not limited to, leisure and employment as indicated in the

individualized plan of care; f. Peer support providing expertise about symptom management and the recovery

process, peer counseling to ACT recipients with their families, as well as other

rehabilitation and support functions based on their own life experience with

mental illness and/or substance use disorders, as coordinated within the context

of a comprehensive, individualized plan of care;

g. Ongoing evaluation for relapse prevention, harm reduction, anger and stress

management;

h. Referral and linkage to other agency supports, if needed for services including

substance use disorders treatment; and

i. Monitoring and following-up to determine if psychiatric, substance use, mental

health support and health related services are being delivered, as set forth in the

care plan, adequacy of services in the plan and changes, needs or status of the

individual.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 18

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Provider Qualifications

ACT services may be provided by an agency licensed to provide behavioral health

services. Agencies providing ACT services must be accredited or have applied for

accreditation by an accrediting organization approved by the Department prior to

providing ACT services. Agencies are allowed to render ACT services prior to attaining

full accreditation; however, agencies must have applied for full accreditation prior to

rendering ACT services and must attain a full accreditation status within 18 months of the

initial accreditation application date. Agencies must maintain continuous, uninterrupted

accreditation.

ACT Team Leader: A full time licensed mental health professional who must have

administrative and clinical skills.

Licensed Psychiatrist: Must be board certified or board eligible.

Psychiatric Nurses (one of which must be a registered nurse (RN): Nurses who have

experience in carrying out medical functioning activities such as basic health and medical

assessment, education, coordination of health care, psychiatric medical assessment and

treatment, and administration of psychotropic medication administration.

Licensed Mental Health Professional: A fully licensed practitioner able to practice

independent of supervision, i.e., medical psychologist, licensed psychologist, licensed

clinical social worker, licensed professional counselor, licensed marriage and family

therapist, or licensed addiction counselor.

Substance Use Specialist: Must have a minimum of one year specialized substance use

training or supervised experience.

Peer Specialist: A person who self-identified as being in recovery from mental illness

and/or substance use disorders who has successfully completed required training and

credentialing requirements through the Office of Behavioral Health as a peer

specialist. This includes ongoing completion of continuing education requirements

consistent with Louisiana requirements for Peer Support. The peer specialist functions as

a fully integrated team member providing expertise about symptom management and the

recovery process, promotes a team culture that maximizes recipient choice and self-

determination, provides peer counseling to ACT recipients and families and carries out

other rehabilitation and support functions.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 19

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Service Delivery

A. All mental health services must be medically necessary. The medical necessity for services

shall be determined by an LMHP or physician who is acting within the scope of their

professional license and applicable state law.

B. All services shall be delivered in accordance with federal and state laws and regulations, the

provider manual, and other notices or directives issued by the Department. The provider

shall create and maintain documents to substantiate that all requirements are met. C. Services rendered by the Peer Specialist will be coordinated within the context of a

comprehensive, individualized plan of care that includes specific individualized goals, with

supervision provided to the Peer Specialist by a Licensed Mental Health Professional.

D. Each provider of adult mental health services shall enter into a contract with one or more of

the managed care organizations in order to receive reimbursement for Medicaid covered

services.

E. There shall be recipient involvement throughout the planning and delivery of services.

1. Services shall be:

a. delivered in a culturally and linguistically competent manner; and

b. respectful of the individual receiving services;

2. Services shall be appropriate to individuals of diverse racial, ethnic, religious,

sexual, and gender identities and other cultural and linguistic groups; and

3. Services shall be appropriate for:

a. age;

b. development; and

c. education.

F. Anyone providing adult mental health services must operate within their scope of practice

license. G. Fidelity reviews must be conducted for evidenced based practices on an ongoing

basis as determined necessary by the Department.

H. Services may be provided in the community or in the individual’s place of

residence as outlined in the treatment plan. Services shall not be provided at an

intuition for mental disease (IMD).

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A

MEDICAL ASSISTANCE PROGRAM Item 13.d., Page 20

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED

MEDICAL AND REMEDICAL CARE AND SERVICES DESCRIBED AS FOLLOWS:

TN Approval Date Effective Date

Supersedes

TN

Assessments

For mental health rehabilitation, each enrollee shall be assessed, at least annually, by a

LMHP and shall have a treatment plan developed for CPST, PSR and ACT based on

that assessment.

Treatment Plan

Treatment plans shall:

1. be based on the assessed needs of the member;

2. be developed by a LMHP or physician in collaboration with direct care staff, the

member, family and natural supports; and

3. contain goals and interventions targeting areas of risk and need identified in the

assessment.

The individualized treatment plan shall be developed and reviewed in accordance with

the criteria and frequency established by the Department, and in accordance with the

provider manual and other notices or directives issued by the Department.