This subpart establishes Medicaid coverage under a 1915(b)(3) waiver for personal care services (PCS) and individual placement and support (IPS) services delivered in home and community-based settings to adults (age 21+) with qualifying mental health diagnoses who have transitioned from or been diverted from nursing facility level of care. Services must be medically necessary, prior authorized, and delivered by providers contracted with managed care organizations. The regulation governs provider responsibilities, recipient eligibility criteria, covered services, and reimbursement methodology for this targeted population.
View official sourceSubpart 8. Services for Targeted Populations Chapter 71.General Provisions §7101.Introduction A.The Medicaid program hereby adopts provisions to provide coverage under the 1915(b)(3) waiver for services rendered to the targeted population of adults with mental health disorders who have transitioned from a nursing facility or been diverted from nursing facility level of care. These services shall be administered under the authority of the Department of Health, in collaboration with the managed care organizations (MCOs), which shall be responsible for the necessary operational and administrative functions to ensure adequate service coordination and delivery. B.Personal care services (PCS) rendered to adults shall be necessary to assist and provide supervision with activities of daily living or to restore the individual to his/her best possible functioning level in the community. C.Individual placement and support (IPS) services rendered to adults shall be necessary to reduce the disability resulting from mental illness and to restore the individual to his/her best possible functioning level in the community. 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 47:1874 (December 2021). §7103.Recipient Qualifications A.The targeted population for the 1915(b)(3) services shall be Medicaid recipients who: 1.are at least 21 years of age; 2.have a qualifying mental health diagnosis; 3.meet medical necessity in accordance with LAC 50:I.1101; and 4.have transitioned from a nursing facility or been diverted from nursing facility level of care. B.Recipients of personal care services (PCS) must meet the following additional recipient eligibility criteria: 1.recipients must be medically stable; 2.recipients shall not be enrolled in a Medicaid-funded program which offers a personal care service or related benefit; and 3.recipients’ care needs do not exceed that which can be provided under the scope and/or service limitations of PCS. C.An adult with a diagnosis of a substance use disorder or intellectual and developmental disability without an additional co-occurring qualifying mental health diagnosis shall not meet the criteria for mental 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, Bureau of Health Services Financing and the Office of Behavioral Health, LR 47:1874 (December 2021). Chapter 73.Services §7301.General Provisions A.All services must be medically necessary, in accordance with the provisions of LAC 50:I.1101. The medical necessity for services shall be determined by a licensed mental health practitioner or physician who is acting within the scope of his/her professional license and applicable state law. B.All services must be prior authorized. Services which exceed the initial authorization must be approved for re-authorization prior to service delivery. C.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. 3.Services shall be appropriate for: a.age; b.development; and c.education. D.Anyone providing services must operate within their scope of practice license. E.Evidence-based practices require prior approval and fidelity reviews on an ongoing basis as determined necessary by department. F.Services must be delivered in home and community-based settings. 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 47:1874 (December 2021). §7303.Covered Services A.The following services for the targeted populations shall be reimbursed under the Medicaid Program: 1.personal care services (PCS); and 2.individual placement and support (IPS) services. B.Service 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; and 2.services provided at a work site which are not directly related to the treatment of the recipient’s needs. 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 47:1874 (December 2021). Chapter 75.Provider Participation §7501.Provider Responsibilities A.Each provider of services for the target populations shall enter into a contract with one or more of the managed care organizations (MCOs) in order to receive reimbursement for Medicaid covered services. B.Providers shall deliver all services in accordance with their license and scope of practice, federal and state laws and regulations, the provisions of this Rule, and other directives issued by the department. The provider shall create and maintain documents to substantiate that all requirements are met. 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 47:1875 (December 2021). Chapter 77.Reimbursement §7701.Reimbursement Methodology A.The department, or its fiscal intermediary, shall make monthly capitation payments to the MCOs. The capitation rates paid to the MCOs shall be actuarially sound rates and the MCOs will determine the rates paid to its contracted providers. 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, Bureau of Health Services Financing and the Office of Behavioral Health, LR 47:1875 (December 2021).