This Louisiana Medicaid subpart establishes coverage, recipient qualifications, provider requirements, and reimbursement methodology for substance use disorder (SUD) services for both children and adults. Covered services include outpatient treatment, residential treatment, and inpatient treatment, all of which must be medically necessary and consistent with ASAM criteria. Residential treatment providers must be licensed, accredited, and offer or facilitate access to medication-assisted treatment (MAT). Reimbursement is administered through managed care organizations (MCOs) and the Coordinated System of Care (CSoC) contractor.
View official sourceSubpart 15. Substance Use Disorders Services Chapter 141.General Provisions §14101.Introduction A.The Medicaid Program hereby adopts provisions to provide coverage under the Medicaid State Plan for substance use disorders (SUD) services rendered to children and adults. These services shall be administered 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. The CSoC contractor shall only manage specialized behavioral health services for children and youth enrolled in the CSoC program. B.The 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 level of functioning 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 38:426 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2357 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 44:1890 (October 2018), LR 45:270 (February 2019). §14103.Recipient Qualifications A.Children and adults who meet Medicaid eligibility and clinical criteria shall qualify to receive medically necessary SUD services. B.Qualifying children and adults with an identified SUD diagnosis shall be eligible to receive SUD services covered under the Medicaid state 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 38:426 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2357 (November 2015). Chapter 143.Services §14301.General Provisions A.All SUD 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.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. C.Children who are in need of SUD services should be served within the context of the family and not as an isolated unit. Services provided to children and youth shall include communication and coordination with the family and/or legal guardian and custodial agency for children in state custody provided that written consent is obtained from minor. Coordination with other child-serving systems should occur as needed to achieve the treatment goals subject to the minor’s consent and applicable privacy laws. All coordination and consent must be documented in the child’s medical record. 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 also be appropriate for: a.age; b.development; and c.education. D.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 38:426 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2357 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 44:1890 (October 2018), LR 45:270 (February 2019). §14303.Covered Services A.The following SUD services shall be reimbursed under the Medicaid Program: 1.assessment; 2.outpatient treatment; 3.residential treatment; and 4.inpatient treatment. B.Service Exclusions. The following services/components 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; 3.any services or components in which the basic nature of which are to supplant housekeeping, homemaking, or basic services for the convenience of an individual receiving services; and 4.room and board for any rates provided in a residential setting. 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 38:426 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2357 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 44:1891 (October 2018), LR 45:270 (February 2019). Chapter 145.Provider Participation §14501.Provider Responsibilities A.Each provider of SUD services shall enter into a contract with one or more of the managed care organizations (MCOs) and with the Coordinated System of Care (CSoC) contractor for youth enrolled in the Coordinated System of Care program in order to receive reimbursement for Medicaid covered services. B.Providers shall deliver all services in accordance with their license, scope of practice, federal and state laws and regulations, the provisions of this Rule, the provider manual, and other notices or directives issued by the department. The provider shall create and maintain documentation to substantiate that all requirements are met. F.Residential treatment facilities shall meet the following additional requirements: 1.Be a licensed organization, pursuant to the residential service provider qualifications described in the Louisiana Administrative Code and the Louisiana Medicaid provider manual. 2.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. 3.Provide full disclosure of ownership and control, including but not limited to any relative contractual agreements, partnerships, etc. 4.Follow all residential treatment provider qualifications and program standards in licensure, Medicaid provider manual, managed care contracts or credentialing. 5.Must deliver care consistent with the specifications in the ASAM Criteria or other OBH approved, nationally recognized SUD program standards, hours of clinical care, and credentials of staff for residential treatment settings. 6.Effective April 1, 2019, must offer medication-assisted treatment (MAT) on-site or facilitate access to MAT off-site, and appropriately document MAT options, education and facilitation efforts in accordance with requirements outlined in the Medicaid provider manual. 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 38:427 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2357 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 44:1891 (October 2018), LR 45:270 (February 2019), LR 46:1563 (November 2020). Chapter 147.Reimbursement §14701.General Provisions A.For recipients enrolled with the CSoC contractor, the department or its fiscal intermediary shall make monthly capitation payments to the CSoC contractor, exclusive of coverage for residential substance use treatment services. 1.The capitation rates paid to the CSoC contractor shall be actuarially sound rates. 2.The CSoC contractor will determine the rates paid to its contracted providers. a.No payments shall be less than the minimum Medicaid rate. B.For recipients enrolled in one of the MCOs, the department or its fiscal intermediary shall make monthly capitation payments to the MCOs inclusive of coverage for the provision of residential substance use services for recipients enrolled in CSoC. 1.The capitation rates paid to the MCOs shall be actuarially sound rates. 2.The MCOs 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 38:427 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 39:3301 (December 2013), LR 41:2358 (November 2015). §14703.Reimbursement Methodology A.Effective for dates of service on or after July 1, 2012, the reimbursement rates for outpatient SUD services provided to children/adolescents shall be reduced by 1.44 percent of the rates in effect on June 30, 2012. 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 and the Office of Behavioral Health, LR 41:2358 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 44:1891 (October 2018).