This subpart establishes the administrative and operational framework for Louisiana's Healthy Louisiana Medicaid managed care program and the Coordinated System of Care (CSoC) Waiver, governing how managed care organizations (MCOs) and the CSoC contractor must administer, coordinate, and deliver specialized behavioral health and physical health services to Medicaid enrollees. It sets requirements for MCO and CSoC contractor participation, enrollment and disenrollment processes, enrollee rights and responsibilities, benefits and services, and service delivery standards. The regulation does not license or set operating standards for any specific behavioral health facility type; rather, it governs the managed care contracting and administrative structure through which services are accessed. Facility operators must ensure they are properly licensed, credentialed, and contracted with MCOs or the CSoC contractor to serve Medicaid enrollees.
View official sourceSubpart 1. Healthy Louisiana and Coordinated System of Care Waiver Chapter 1.Managed Care Organizations and the Coordinated System of Care Contractor §101.General Provisions A.The Medicaid Program hereby adopts provisions to establish a comprehensive system of delivery for specialized behavioral health and physical health services. These services shall be administered through the Healthy Louisiana and Coordinated System of Care (CSoC) Waiver under the authority of the Department of Health (LDH), in collaboration with managed care organizations (MCOs) and the coordinated system of care (CSoC) contractor, which shall be responsible for the necessary operational and administrative functions to ensure adequate service coordination and delivery. B.The provisions of this Rule shall apply only to the services provided to Medicaid recipients/enrollees by or through an MCO or the CSoC contractor. C.Managed care organizations shall operate as such, and the CSoC contractor shall operate as a prepaid inpatient health plan (PIHP). The MCOs and the CSoC contractor were procured through a competitive request for proposal (RFP) process. The MCOs and CSoC contractor shall assist with the state’s system reform goals to support individuals with behavioral health and physical health needs in families’ homes, communities, schools and jobs. D. Through the utilization of MCOs and the CSoC contractor, it is the department’s goal to: 1.increase access to a broad array of evidence-based home and community-based services that promote hope, recovery and resilience; 2.improve quality by establishing and measuring outcomes; 3.manage costs through effective utilization of State, federal, and local resources; and 4.foster reliance on natural supports that sustain individuals and families in homes and communities. E.The CSoC contractor shall be paid on a risk basis for specialized behavioral health services rendered to children/youth enrolled in the Coordinated System of Care Waiver. The MCOs shall be paid on a risk basis for specialized behavioral health and physical health services rendered to adults and children/youth. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:360 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2353 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:321 (February 2017), LR 44:1889 (October 2018). §103.Recipient Participation A.The following Medicaid recipients shall be mandatory participants for integrated specialized behavioral health and physical health services: 1.children who are blind or have a disability and related populations, under age 18; 2.aged and related populations, age 65 and older who are not blind, do not have a disability, and are not members of the §1931 adult population; 3.children who receive foster care or adoption assistance (title IV-E), or who are in foster care or who are otherwise in an out-of-home placement; 4.children with special health care needs as defined in §1932(a); 5.Native Americans; 6.full dual eligibles (for behavioral health services only and non-emergency medical transportation (NEMT); 7.children residing in an intermediate care facility for persons with intellectual disabilities (for behavioral health services only and NEMT); 8.all enrollees of waiver programs administered by the LDH Office for Citizens with Developmental Disabilities (OCDD) or the LDH Office of Aging and Adult Services (OAAS) (mandatory for behavioral health services only and NEMT); 9.all Medicaid children functionally eligible for the CSoC; 10.adults residing in a nursing facility (for behavioral health services only and NEMT); 11.supplemental security income/transfer of resources/long-term care related adults and children (for behavioral health services only and NEMT); and 12.transfer of resources/long-term care adults and children (for behavioral health services only and NEMT). NOTE: Recipients qualifying for retroactive eligibility are enrolled in the waiver. B.Mandatory participants shall be automatically enrolled and disenrolled from the MCOs. C.Notwithstanding the provisions of Subsection A of this Section, the following Medicaid recipients are excluded from enrollment in the MCOs and the CSoC contractor: 1.for adults and children: a.refugee cash assistance; b.refugee medical assistance; c.spend-down medically needy; d.specified low-income beneficiaries (SLMB)-only; e.aliens emergency services; f.qualified individuals (QI) 1; g.long-term care (LTC) co-insurance; h.qualified disabled and working individuals (QDWI); and i.qualified medicare beneficiaries (QMB)-only; and 2.adult-only populations excluded from the 1915(b) waiver: a.residents of an ICF/ID; b.Program of All Inclusive Care for the Elderly (PACE); and c.Take Charge Plus. D.Any Medicaid eligible person is suspended from participation during a period of incarceration. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:361 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:1286 (July 2015), LR 41:2354 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:321 (February 2017), LR 44:1889 (October 2018). §105.Enrollment Process A.The MCOs and the CSoC contractor shall abide by all enrollment and disenrollment policies and procedures as outlined in the contract entered into by department. B.The MCOs and the CSoC contractor shall ensure that mechanisms are implemented to assess each Medicaid enrollee identified as having special health care needs in order to identify any ongoing conditions that require a course of treatment or regular care monitoring. The assessment mechanism shall incorporate appropriate health care professionals. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:361 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2354 (November 2015). §107.Enrollee Rights and Responsibilities A.The enrollee’s rights shall include, but are not limited to the right to: 1.participate in treatment decisions, including the right to: a.refuse treatment; b.seek second opinions; and c.receive assistance with care coordination from the primary care providers (PCP’s) office or the enrollee's behavioral health provider; 2.express a concern about their provider or the care rendered via a grievance process; 3.appeal an MCO and CSoC contractor decision through the MCO’s and CSoC contractor’s internal process and/or the state fair hearing process; 4.receive a response about a grievance or appeal decision within a reasonable period of time determined by the department; 5.receive a copy of his/her medical records; 6.be furnished health care services in accordance with federal regulations, including those governing access standards; 7.choose a participating network health care professional in accordance with federal and state regulations; and 8.be allowed to receive a specialized service outside of the network if a qualified provider is not available through the network. B.The Medicaid recipient/enrollee’s responsibilities shall include, but are not limited to: 1.informing their MCO or CSoC contractor of the loss or theft of their Medicaid identification card; 2.presenting their identification card when accessing behavioral health services; 3.being familiar with their MCO’s or CSoC contractor’s procedures to the best of his/her abilities; 4.contacting their MCO or CSoC contractor, by telephone or in writing (formal letter or electronically, including email), to obtain information and have questions clarified; 5.providing participating network providers, or any other authorized provider, with accurate and complete medical information; 6.following the prescribed treatment of care recommended by the provider or letting the provider know the reasons the treatment cannot be followed, as soon as possible; 7.making every effort to keep any agreed upon appointments and follow-up appointments and contacting the provider in advance if unable to do so; and 8.accessing services only from specified providers contracted with their MCO or CSoC contractor. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:361 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2354 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:322 (February 2017). Chapter 3.Managed Care Organizations and the Coordinated System of Care Contractor Participation §301.Participation Requirements and Responsibilities A.In order to participate in the Medicaid Program, an MCO and the CSoC contractor shall execute a contract with the department, and shall comply with all of the terms and conditions set forth in the contract. B.MCOs and the CSoC contractor shall: 1.manage contracted services; 2.establish credentialing and re-credentialing policies consistent with federal and state regulations; 3.ensure that provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; 4.maintain a written contract with subcontractors that specifies the activities and reporting responsibilities delegated to the subcontractor, and such contract shall also provide for the MCOs’ or CSOC contractor’s right to revoke said delegation, terminate the contract, or impose other sanctions if the subcontractor’s performance is inadequate; 5.contract only with providers of services who are licensed and/or certified according to state laws, regulations, rules, the provider manual and other notices or directives issued by the department, meet the state of Louisiana credentialing criteria and enrolled with the Bureau of Health Services Financing, or its designated contractor, after this requirement is implemented; 6.ensure that contracted rehabilitation providers are employed by a rehabilitation agency or clinic licensed and authorized under state law to provide these services; 7.sub-contract with a sufficient number of providers to render necessary services to Medicaid recipients/enrollees; 8.require each provider to implement mechanisms to assess each Medicaid enrollee identified as having special health care needs in order to identify special conditions of the enrollee that require a course of treatment or regular care monitoring; 9.ensure that treatment plans or plans of care meet the following requirements: a.are developed by the enrollee’s primary care provider (PCP) or behavioral health provider with the enrollee’s participation and in consultation with any specialists’ providing care to the enrollee, with the exception of treatment plans or plans of care developed for recipients in the Home and Community Based Services (HCBS) Waiver. The wraparound agency shall develop plans of care according to wraparound best practice standards for recipients who receive behavioral health services through the HCBS Waiver; b.are approved by the MCO or CSoC contractor in a timely manner, if required; c.are in accordance with any applicable state and federal quality assurance and utilization review standards; and d.allow for direct access to any specialist for the enrollee’s condition and identified needs, in accordance with the contract; and 10.ensure that Medicaid recipients/enrollees receive information: a.in accordance with federal regulations and as described in the contract and departmental guidelines; b.on available treatment options and alternatives in a manner appropriate to the enrollee’s condition and ability to understand; and c.about available experimental treatments and clinical trials along with information on how such research can be accessed even though the Medicaid Program will not pay for the experimental treatment. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:362 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2355 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:322 (February 2017), LR 44:1889 (October 2018). §303.Benefits and Services A.Benefits and services shall be rendered to Medicaid recipients/enrollees as provided under the terms of the contract and department-issued guidelines. B.The MCO and CSoC contractor: 1.shall ensure that medically necessary services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are being furnished and shall not be more restrictive than services provided under the Medicaid State Plan; 2.may not arbitrarily deny or reduce the amount, duration, or scope of a required service because of diagnosis, type of illness, or condition of the member; 3.may place appropriate limits on a service: a.on the basis of medical necessity; and b.for the purpose of utilization control, provided the services furnished can reasonably be expected to achieve their purpose; 4.shall provide benefits and services as outlined and defined in the contract and shall provide medically necessary and appropriate care to enrollees; and C.The benefits and services provided to enrollees shall include, but are not limited to, those services specified in the contract between the MCOs and the CSoC contractor and the department. 1.Policy transmittals, State Plan amendments, Rules and regulations, provider bulletins, provider manuals and fee schedules issued by the department are the final authority regarding services. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:362 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2355 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:322 (February 2017). §305.Service Delivery A.The MCOs and CSoC contractor shall ensure that services rendered to enrollees are medically necessary, are authorized or coordinated, and are provided by professionals according to their scope of practice and licensing in the state of Louisiana. B.Access to emergency services and family-oriented services shall be assured within the network. C.MCOs shall offer a contract to all federally qualified health centers (FQHCs), rural health clinics (RHCs), and tribal clinics. Enrollees shall have a choice of available providers in the plan’s network to select from. The CSoC contractor shall be required to contract with at least one FQHC in each medical practice region of the state (according to the practice patterns within the state) if there is an FQHC which can provide substance use disorder services or specialty mental health services under state law and to the extent that the FQHC meets the required provider qualifications. D.MCOs and the CSoC contractor shall ensure that the recipient is involved 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. 3.Services shall be appropriate for: a.age; b.development; and c.education. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:363 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2356 (November 2015). Chapter 5.Reimbursement §501.General Provisions A.For recipients enrolled in one of the MCOs or with the CSoC contractor, the department or its fiscal intermediary shall make monthly capitation payments to the MCOs or CSoC contractor. 1.The capitation rates paid to the MCOs or CSoC contractor shall be actuarially sound rates. 2.The MCOs or CSoC contractor will determine the rates paid to its contracted providers. a.No payment shall be less than the minimum Medicaid rate. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:363 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 39:317 (February 2013), LR 41:2356 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 44:1890 (October 2018). §503.Directed Payments A.Provider Directed Payments 1.Subject to written approval by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), the Department of Health (hereafter referred to as “the department” and/or “LDH”) shall provide directed payments to qualifying providers that participate in the Healthy Louisiana Medicaid managed care program or Coordinated System of Care (CSoC) waiver, in accordance with the applicable section 438.6(c) preprint(s) approved by CMS, federal regulations, and departmental requirements. Each CMS approved directed payment arrangement is effective for one Healthy Louisiana Medicaid managed care or CSoC contract rating period, unless otherwise approved by CMS. 2.Qualifying Provider a.High fidelity wraparound agencies (WAA) and wraparound facilitators (WF), WF supervisors, WAA coaches, and WAA administrators that meet the criteria specified in the applicable section 438.6(c) preprint approved by CMS and departmental requirements; or b.Peer support specialists, supervisors, trainers, and administrators employed by the family support organization (FSO) that meet the criteria specified in the applicable section 438.6(c) preprint approved by CMS and departmental requirements; or c.Licensed mental health practitioners (LMHPs) and psychiatrists that provide behavioral health outpatient services and that meet the criteria specified in the applicable section 438.6(c) preprint approved by CMS and departmental requirements. 3.The Healthy Louisiana Medicaid managed care organization (MCO) and CSoC contractor shall assign qualifying providers to provider classes based upon criteria specified in the applicable section 438.6(c) preprint(s) approved by CMS, in accordance with departmental requirements. a.Qualifying providers shall have no right to an administrative appeal regarding the qualifying provider criteria or determination of which providers meet the qualifying provider criteria. 4.The MCO and CSoC contractor shall utilize a payment process, whereby directed payments will be calculated and paid out based on the data and methodology specified in the applicable section 438.6(c) preprint(s) approved by CMS, in accordance with departmental requirements. a.Qualifying providers shall have no right to an administrative appeal regarding calculation of directed payments or measurement rates. 5.Based upon the methodology specified in the applicable section 438.6(c) preprint(s) approved by CMS, in accordance with departmental requirements, the department shall cause directed payments to be paid in a single upfront lump sum payment to the MCOs; and payments shall be paid to the CSoC contractor within 30 days of receipt of invoice(s), on a retrospective basis. a.Funding for the directed payments is only available during the time period in the applicable section 438.6(c) preprint(s) approved by CMS or until payments are exhausted, whichever comes first. 6.In accordance with the applicable section 438.6(c) preprint(s) approved by CMS and departmental requirements, directed payments must be based on actual utilization and delivery of services during the applicable contract period. a.Within six months of the end of the rating period, the MCOs and CSoC contractor shall perform a reconciliation as specified in the applicable section 438.6(c) preprint approved by CMS or as otherwise dictated in accordance with departmental requirements. i.Qualifying providers shall have no right to an administrative appeal regarding any issue related to reconciliation, including, but not limited to, the timing, amount of the reconciliation, and process. 7.If a qualifying provider is subject to a reconciliation, the qualified provider shall pay all amounts owed to the MCO or CSoC contractor, in accordance with departmental requirements. a.In addition to all other available remedies, the MCO and the CSoC contractor has the authority to offset all amounts owed by a qualifying provider due to a reconciliation against any payment owed to the qualifying provider, including, but not limited to, any payment owed by the MCOs or CSoC contractor. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act HISTORICAL NOTE:Promulgated by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 49:1218 (July 2023). Chapter 7.Grievance and Appeals Process §701.General Provisions A.The MCOs and the CSoC contractor shall be required to have an internal grievance system and internal appeal process. The appeal process allows a Medicaid recipient/enrollee to challenge a decision made, a denial of coverage, or a denial of payment for services. B.An enrollee, an enrollee’s authorized representative or a provider on behalf of an enrollee, with the enrollee’s prior written consent, has 60 calendar days from the date on the notice of action in which to file an appeal. C.An enrollee, an enrollee’s authorized representative or a provider on behalf of an enrollee, with the enrollee’s prior written consent, may file a grievance at any time after an occurrence or incident which is the basis for the grievance. D.An enrollee must exhaust the MCO or the CSoC contractor grievance and appeal process before requesting a state fair hearing. E.The MCO and CSoC contractor shall provide Medicaid enrollees with information about the state fair hearing process within the timeframes established by the department and in accordance with the state fair hearing policies. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:363 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2356 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:322 (February 2017), LR 44:1890 (October 2018). §703.Provider Grievance and Appeal Process A.If the provider is filing a grievance or appeal on behalf of the member, the provider shall adhere to the provisions outlined in §701 of this Chapter. B.The MCO and CSoC contractor must have a grievance and appeals process for claims, medical necessity, and contract disputes for providers in accordance with the contract and department issued guidance. 1.The MCO and CSoC contractor shall establish and maintain a procedure for the receipt and prompt internal resolution of all provider initiated grievances and appeals as specified in the contract and department issued guidance. 2.The grievance and appeals procedures, and any changes thereto, must be approved in writing by the department prior to their implementation. 3.Notwithstanding any MCO, CSoC contractor, or department grievance and appeal process, nothing contained in any document, including, but not limited to Rule or contract, shall preclude a provider’s right to pursue relief through a court of appropriate jurisdiction. 4.The MCO and CSoC contractor shall report on a monthly basis all grievance and appeals filed and resolutions in accordance with the terms of the contract and department issued guidance. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act HISTORICAL NOTE:Promulgated by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 49:1219 (July 2023). Chapter 9.Monitoring Activities §901.General Provisions A.The contracted MCOs and the CSoC contractor shall be accredited by an accrediting body that is designated in the contract, or agrees to submit an application for accreditation at the earliest possible date as allowed by the accrediting body. Once accreditation is achieved, it shall be maintained through the life of this agreement. B.The MCOs and CSoC contractor shall be required to track grievances and appeals, network adequacy, access to services, service utilization, quality measure and other monitoring and reporting requirements in accordance with the contract with the department. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:363 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2356 (November 2015).