This subpart establishes Louisiana Medicaid coverage and reimbursement rules for school-based behavioral health services delivered by local education agencies (LEAs) to children and youth ages 3–20 with behavioral health disorders. Covered services include therapeutic mental health and substance use treatment that are medically necessary and reflected in an IEP, section 504 plan, or individualized health care plan. LEAs must ensure practitioners meet Medicaid and state certification requirements, maintain required case records, and submit annual cost reports for reconciliation and audit. Reimbursement is based on actual certified costs using a CMS-approved methodology.
View official sourceSubpart 5. School-Based Behavioral Health Services Chapter 41.General Provisions §4101.Introduction A.The Medicaid Program hereby adopts provisions to provide coverage under the Medicaid state plan for school-based behavioral health services rendered to children and youth with behavioral health disorders. These services shall be administered under the authority of the Department of Health. B.The school-based behavioral health services rendered to children with emotional or behavioral disorders are medically necessary behavioral health services provided to Medicaid recipients in accordance with an individualized education plan (IEP), a section 504 accommodation plan pursuant to 34 CFR §104.36, an individualized health care plan or are otherwise medically necessary. 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 38:400 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2171 (October 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:568 (April 2019), LR 46:185 (February 2020). §4103.Recipient Qualifications A.Individuals at least 3 years of age and under the age of 21, who meet Medicaid eligibility and clinical criteria, shall qualify to receive behavioral health services in a setting determined by the IEP. B.Qualifying children and adolescents must have been determined eligible for Medicaid and behavioral health services covered under Part B of the Individuals with Disabilities Education Act (IDEA), with a written service plan [an IEP, section 504 plan or individualized health care plan (IHP)] which contains medically necessary services recommended by a physician or other licensed practitioner, within the scope of his or practice under state law. 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 38:400 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2172 (October 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:568 (April 2019), LR 46:185 (February 2020). Chapter 43.Services §4301.General Provisions A.The Medicaid Program shall provide coverage for behavioral health services pursuant to §1905(a) of the Social Security Act which are addressed in the IEP, section 504 plan, IHP or otherwise medically necessary, and that correct or ameliorate a child's health condition. B.Services must be performed by qualified providers who provide school-based behavioral health services as part of their respective area of practice (e.g. psychologist providing a behavioral health evaluation and/or services). Services rendered by certified school psychologists must be supervised consistent with R.S. 17:7.1. C.Services shall be provided in accordance with the established service limitations. D.Children who are in need of behavioral health services shall be served within the context of the family and not as an isolated unit. 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 children and youth of diverse racial, ethnic, religious, sexual, and gender identities and other cultural and linguistic groups. 3.Services shall also be appropriate for: a.age; b.development; and c.education. E.Evidence-based practices require prior approval and fidelity reviews on an ongoing basis as determined necessary by 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 38:400 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2172 (October 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:568 (April 2019), LR 46:186 (February 2020). §4303.Covered Services A.School-based behavioral health services shall include Medicaid-covered services, including treatment and other services to correct or ameliorate an identified mental health or substance use diagnosis. Services are provided by or through a local education agency (LEA) to children with, or suspected of having, a disability and who attend public school in Louisiana. B.The following school based behavioral health services shall be reimbursed under the Medicaid Program: 1.therapeutic services, including diagnosis and treatment; and 2.substance use. 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 38:400 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:384 (February 2015), LR 41:2172 (October 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:569 (April 2019), LR 46:186 (February 2020). §4305.Service Limitations and Exclusions A.The Medicaid Program shall not cover school based behavioral health services performed solely for educational purposes (e.g. academic testing). Only services that are reflected in the IEP, section 504 plan, IHP (as determined by the assessment and evaluation) or otherwise medically necessary shall be covered. B.Social needs, educational needs, or habilitative services are not covered school based behavioral health 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 38:401 (February 2012), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:569 (April 2019), LR 46:186 (February 2020). Chapter 45.Provider Participation §4501.Local Education Agency Responsibilities A.The LEA shall ensure that its licensed and unlicensed behavioral health practitioners are employed according to the requirements specified under IDEA. B.An LEA shall ensure that individual practitioners are in compliance with Medicaid qualifications, Department of Education Bulletin 746, and Louisiana Standards for State Certification of School Personnel prior to billing the Medicaid Program for any school based behavioral health services rendered by clinicians. C.All services shall be delivered in accordance with federal and state laws and regulations, the provisions of this Rule, the provider manual, and other notices or directives issued by the department. D.Providers of behavioral health services shall ensure that all services are authorized and any services that exceed established limitations beyond the initial authorization are approved for re-authorization prior to service delivery. E.Anyone providing behavioral health services must be operating within the scope of practice of their applicable license. The provider shall create and maintain documents to substantiate that all requirements are met. F.Providers shall maintain case records that include, at a minimum: 1.a copy of the treatment plan; 2.a copy of the IEP, IHP, etc.; 3.the name of the child or youth receiving services; 4.the dates of service; 5.the nature, content and units of services provided; 6.the progress made toward functional improvement; and 7.the goals of the treatment plan. 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 38:401 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:385 (February 2015), LR 41:2172 (October 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:569 (April 2019), LR 46:186 (February 2020). Chapter 47.Payments §4701.Reimbursement Methodology A.Payments for school based behavioral health services shall be based on the most recent school year’s actual cost as determined by desk review and/or audit for each LEA provider. 1.Each LEA shall determine cost annually by using LDH’s cost report for behavioral health service cost form based on the direct services cost report. 2.Direct cost shall be limited to the amount of total compensation (salaries, vendor payments and fringe benefits) of current behavioral health service providers as allocated to medical services for Medicaid recipients. The direct cost related to the electronic health record shall be added to the compensation costs to arrive at the total direct costs for behavioral health services. There are no additional direct costs included in the rate. 3.Indirect cost shall be derived by multiplying the cognizant agency indirect cost unrestricted rate assigned by the Department of Education to each LEA. There are no additional indirect costs included. 4.To determine the amount of behavioral health services cost that may be attributed to Medicaid; the ratio of total Medicaid students in the LEA to all students in the LEA is multiplied by total direct cost. Cost data is subject to certification by each LEA. This serves as the basis for obtaining federal Medicaid funding. B.For the medical services, the participating LEAs’ actual cost of providing the services shall be claimed for federal financial participation (FFP) based on the following methodology. 1.The state shall gather actual expenditure information for each LEA through its payroll/benefits and accounts payable system. 2.Develop Direct Cost-The Payroll Cost Base. Total annual salaries and benefits paid, as well as contracted (vendor) payments, shall be obtained initially from each LEA’s payroll/benefits and accounts payable system. This data shall be reported on LDH’s behavioral health services cost report form for all behavioral health service personnel (i.e. all personnel providing LEA behavioral health treatment services covered under the state plan). 3.Adjust the Payroll Cost Base. The payroll cost base shall be reduced for amounts reimbursed by other funding sources (e.g., federal grants). The payroll cost base shall not include any amounts for staff whose compensation is 100 percent reimbursed by a funding source other than state/local funds. This application results in total adjusted salary cost. 4.Determine the Percentage of Time to Provide All behavioral health Services. A time study which incorporates the CMS-approved Medicaid administrative claiming (MAC) methodology for nursing service personnel shall be used to determine the percentage of time nursing service personnel spend on behavioral health services and general and administrative (G and A) time. This time study will assure that there is no duplicate claiming. The G and A percentage shall be reallocated in a manner consistent with the CMS-approved Medicaid administrative claiming methodology. Total G and A time shall be allocated to all other activity codes based on the percentage of time spent on each respective activity. To reallocate G and A time to behavioral health services, the percentage of time spent on behavioral health services shall be divided by 100 percent minus the percentage of G and A time. This shall result in a percentage that represents the behavioral health services with appropriate allocation of G and A. This percentage shall be multiplied by total adjusted salary cost as determined under Paragraph B.4 above to allocate cost to school based services. The product represents total direct cost. a.A sufficient number of behavioral health service personnel’s time shall be sampled to ensure results that will have a confidence level of at least 95 percent with a precision of plus or minus 5 percent overall. 5.Determine Indirect Cost. Indirect cost shall be determined by multiplying each LEA’s indirect unrestricted rate assigned by the cognizant agency (the Department of Education) by total adjusted direct cost as determined under Paragraph B.3 above. No additional indirect cost shall be recognized outside of the cognizant agency indirect rate. The sum of direct cost and indirect cost shall be the total direct service cost for all students receiving behavioral health services. 6.Allocate Direct Service Cost to Medicaid. To determine the amount of cost that may be attributed to Medicaid, total cost as determined under Paragraph B.5 above shall be multiplied by the ratio of Medicaid students in the LEA to all students in the LEA. This results in total cost that may be certified as Medicaid’s portion of school-based behavioral health services cost. C.Reconciliation of LEA Certified Costs and Medicaid Management Information System (MMIS) Paid Claims. Each LEA shall complete the behavioral health services cost report and submit the cost report(s) no later than five months after the fiscal year period ends (June 30), and reconciliation shall be completed within 12 months from the fiscal year end. All filed behavioral health services cost reports shall be subject to desk review by the department’s audit contractor. The department shall reconcile the total expenditures (both state and federal share) for each LEA’s nursing services. The Medicaid certified cost expenditures from the behavioral health services cost report(s) will be reconciled against the MMIS paid claims data and the department shall issue a notice of final settlement pending audit that denotes the amount due to or from the LEA. This reconciliation is inclusive of all behavioral health services provided by the LEA. D.Cost Settlement Process. As part of its financial oversight responsibilities, the department shall develop audit and review procedures to audit and process final settlements for certain LEAs. The audit plan shall include a risk assessment of the LEAs using available paid claims data to determine the appropriate level of oversight. 1.The financial oversight of all LEAs shall include reviewing the costs reported on the behavioral health services cost reports against the allowable costs, performing desk reviews and conducting limited reviews. 2.The department will make every effort to audit each LEA at least every four years. These activities shall be performed to ensure that audit and final settlement occurs no later than two years from the LEA’s fiscal year end for the cost reporting period audited. LEAs may appeal audit findings in accordance with LDH appeal procedures. 3.The department shall adjust the affected LEA’s payments no less than annually, when any reconciliation or final settlement results in significant underpayments or overpayments to any LEA. By performing the reconciliation and final settlement process, there shall be no instances where total Medicaid payments for services exceed 100 percent of actual, certified expenditures for providing LEA services for each LEA. 4.If the interim payments exceed the actual, certified costs of an LEA’s Medicaid services, the department shall recoup the overpayment in one of the following methods: a.offset all future claim payments from the affected LEA until the amount of the overpayment is recovered; b.recoup an agreed upon percentage from future claims payments to the LEA to ensure recovery of the overpayment within one year; or c.recoup an agreed upon dollar amount from future claims payments to the LEA to ensure recovery of the overpayment within one year. 5.If the actual certified costs of an LEA’s Medicaid services exceed interim Medicaid payments, the department will pay this difference to the LEA in accordance with the final actual certification agreement. 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 38:401 (February 2012), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 45:569 (April 2019).