This Louisiana Medicaid regulation establishes coverage, provider participation requirements, and reimbursement methodology for Psychiatric Residential Treatment Facility (PRTF) services under the state Medicaid program. Providers must be certified by the department, accredited by an approved accrediting body, and contract with managed care organizations (MCOs) or the Coordinated System of Care (CSoC) contractor to receive reimbursement. All services must be medically necessary, prior authorized, and delivered in accordance with federal and state laws; covered services include physician, pharmacy, therapy, and ancillary services included on the active treatment plan. Reimbursement is based on per diem rates differentiated by facility type (free-standing vs. hospital-based) and specialty program, with annual cost report filing required.
View official sourceSubpart 11. Psychiatric Residential Treatment Facility Services Chapter 101.General Provisions §10101.Introduction A.The Medicaid Program hereby adopts provisions to provide coverage under the Medicaid State Plan for behavioral health services rendered to children and youth in an inpatient psychiatric residential treatment facility (PRTF). These services shall be administered under the authority of the Department of Health and Hospitals, in collaboration with managed care organizations 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 behavioral health services rendered to children with emotional or behavioral disorders are those services necessary to reduce the disability resulting from the 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 and Hospitals, Bureau of Health Services Financing, LR 38:369 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2369 (November 2015). §10103.Recipient Qualifications A.Individuals under the age of 21 with an identified mental health or substance use diagnosis, who meet Medicaid eligibility and clinical criteria, shall qualify to receive inpatient psychiatric residential treatment facility 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 38:369 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2369 (November 2015). Chapter 103.Services §10301.General Provisions A.All behavioral health services must be medically necessary. The medical necessity for services shall be determined by a licensed mental health practitioner (LMHP) or physician who is acting within the scope of his/her professional license and applicable state law. B.All services shall be prior authorized. Services which exceed the initial authorization must be approved for re-authorization prior to service delivery. C.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 should occur as needed to achieve the treatment goals. All coordination must be documented in the child’s medical record. 1.The agency or individual who has the decision making authority for a child or adolescent in state custody must request and approve the provision of services to the recipient. 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. 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 38:369 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2369 (November 2015). §10303.Covered Services A.The Medicaid Program may reimburse a psychiatric residential treatment facility for the following services: 1.physician (psychiatric) services; 2.pharmacy services; 3.diagnostic and radiology services; 4.laboratory services; 5.dental services; 6.vision services; 7.occupational therapy; 8.physical therapy; 9.speech-language therapy; and 10.transportation services. B.Service Exclusions. The following services shall be excluded from Medicaid reimbursement: 1.services on the inpatient psychiatric active treatment plan that are not related to the provision of inpatient psychiatric care; 2.group education, including elementary and secondary education; and 3.activities not on the inpatient psychiatric active 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 38:369 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2369 (November 2015). Chapter 105.Provider Participation §10501.Provider Responsibilities A.Each provider of PRTF services shall enter into a contract with one or more of the MCOs and the CSoC contractor in order to receive reimbursement for Medicaid covered services. B.All services shall be delivered in accordance with federal and state laws and regulations, licensing regulations, the provisions of this Rule, the provider manual, and other notices or directives issued by the department. C.Providers of PRTF 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. D.Anyone providing PRTF services must be certified by the department, or its designee, in addition to operating within their scope of practice license. To be certified or recertified, providers shall meet the provisions of this Rule, the provider manual and the appropriate statutes. The provider shall create and maintain documents to substantiate that all requirements are met. E.PRTF 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 its contracted MCOs and the CSoC contractor in writing within the time limit established 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 38:369 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2369 (November 2015). Chapter 107.Reimbursement §10701.General Provisions A.For recipients enrolled with the CSoC contractor, reimbursement for services shall be based upon the established Medicaid fee schedule for behavioral health services. For recipients enrolled in one of the MCOs, 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. Covered inpatient, physician-directed PRTF services rendered to children and youth shall be reimbursed according to the following criteria: 1.Free-Standing PRTF Facilities. The per diem rate shall include reimbursement for the following services when included on the active treatment plan: a.occupational therapy; b.physical therapy; c.speech therapy; d.laboratory services; and e.transportation services. 2.A free-standing PRTF shall arrange through contract(s) with outside providers to furnish dental, vision, and diagnostic/radiology treatment activities as listed on the treatment plan. The treating provider will be directly reimbursed by the MCO or the CSoC contractor. 3.Hospital-Based PRTF Facilities. A hospital-based PRTF facility shall be reimbursed a per diem rate for covered services. The per diem rate shall also include reimbursement for the following services when included on the active treatment plan: a.dental services; b.vision services; c.diagnostic testing; and d.radiology services. 4.Pharmacy and physician services shall be reimbursed when included on the recipient’s active plan of care and are components of the Medicaid covered PRTF services. The MCO or the CSoC contractor shall make payments directly to the treating physician. The MCO shall also make payments directly to the pharmacy. These payments shall be excluded from the PRTF’s contracted per diem rate for the facility. B.All in-state Medicaid participating PRTF providers are required to file an annual Medicaid cost report in accordance with Medicare/Medicaid allowable and non-allowable costs. C.Cost reports must be submitted annually. The due date for filing annual cost reports is the last day of the fifth month following the facility’s fiscal year end. Separate cost reports must be filed for the facility’s central/home office when costs of that entity are reported on the facility’s cost report. If the facility experiences unavoidable difficulties in preparing the cost report by the prescribed due date, a filing extension may be requested. A filing extension must be submitted to Medicaid prior to the cost report due date. 1.Facilities filing a reasonable extension request will be granted an additional 30 days to file their cost report. 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 38:370 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2370 (November 2015). §10703.Reimbursement Methodology (Reserved) §10705.In-State Psychiatric Residential Treatment Facilities A.In-state publicly and privately owned and operated PRTFs shall be reimbursed for covered PRTF services according to the following provisions. The rate paid by the MCO or the CSoC contractor shall take into consideration the following ownership and service criteria: 1.free-standing PRTFs specializing in sexually-based treatment programs; 2.free-standing PRTFs specializing in substance use treatment programs; 3.free-standing PRTFs specializing in behavioral health treatment programs; 4.hospital-based PRTFs specializing in sexually-based treatment programs; 5.hospital-based PRTFs specializing in substance use treatment programs; and 6.hospital-based PRTFs specializing in behavioral health treatment programs. B.Except as otherwise noted in these provisions, the Medicaid fee schedule is the same for governmental and private individual practitioners. C.Risk Sharing. In-state privately owned and operated PRTF covered services provided during the time period from January 1, 2012 through June 30, 2013 shall also receive risk- sharing payments. These payments shall be made as part of a transitional plan to include these services within the Medicaid Program. D.Beginning July 1, 2013, no risk-sharing payments will be paid and all covered PRTF services rendered by private facilities will be reimbursed using the established Medicaid fee schedule rates. 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 38:370 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2370 (November 2015). §10707.Out-of-State Psychiatric Residential Treatment Facilities A.Out-of-state PRTFs shall be reimbursed in accordance with the MCO or CSoC contractor’s established 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 38:370 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health LR 41:2370 (November 2015).