BEHAVIORAL HEALTH SERVICES PROVIDER MANUAL

1 BEHAVIORAL HEALTH SERVICES PROVIDER MANUAL Chapter Two of the Medicaid SERVICES MANUAL Issued March 14, 2017 State of Louisiana Bureau of HEALTH SERVICES Financing LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 10/12/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION: TABLE OF CONTENTS PAGE(S) 5 Page 1 of 5 Table of Contents BEHAVIORAL HEALTH SERVICES TABLE OF CONTENTS SUBJECT SECTION OVERVIEW SECTION RESIDENTIAL SERVICES SECTION Therapeutic Group Homes Components PROVIDER Qualifications Additional Organizational Requirements Agency Staffing Qualifications Allowed PROVIDER Types and Specialties Eligibility Criteria Service Utilization Service Exclusions Allowed Mode(s)

2 Of Delivery Additional Service Criteria TGH Cost Reporting Requirements Psychiatric Residential Treatment Facilities Plan of Care PROVIDER Qualifications Agency Additional Organizational Requirements Staff Staffing Treatment Model and Service Delivery Allowed PROVIDER Types and Specialties Eligibility Criteria Limitations/Exclusions LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 10/12/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION: TABLE OF CONTENTS PAGE(S) 5 Page 2 of 5 Table of Contents OUTPATIENT SERVICES SECTION BEHAVIORAL HEALTH SERVICES in a Federally Qualified HEALTH Center or Rural HEALTH Center PROVIDER Qualifications Agency or Group Practice Allowed PROVIDER Types and Specialties Eligibility Criteria Allowed Mode(s) of Delivery Outpatient Therapy by Licensed Practitioners PROVIDER Qualifications Agency or Group Practice Allowed PROVIDER Types and Specialties Eligibility Criteria Limitations/Exclusions Allowed Mode(s)

3 Of Delivery Additional Service Criteria Telehealth Rehabilitation SERVICES for Children, Adolescents, and Adults Children and Adolescents Adults Service Delivery Assessment and Treatment Planning PROVIDER Responsibilities Eligibility Criteria Service Utilization Additional Service Criteria Limitations/Exclusions Psychosocial Rehabilitation Components PROVIDER Qualifications Agency Staff Staff Ratio(s) Allowed PROVIDER Types and Specialties Allowed Mode(s) of Delivery Crisis Intervention Components PROVIDER Qualifications Agency Staff LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 10/12/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION: TABLE OF CONTENTS PAGE(S) 5 Page 3 of 5 Table of Contents Allowed PROVIDER Types and Specialties Service Utilization Eligibility Criteria Service Utilization Allowed Mode(s) of Delivery Additional Service Criteria Crisis Stabilization Components PROVIDER Qualifications Agency Staff Allowed PROVIDER Types and Specialties Limitations/Exclusions Service Utilization Allowed Mode(s) of Delivery Community Psychiatric Support and Treatment Components PROVIDER Qualifications Agency Staff Allowed PROVIDER Types and Specialties Limitations/Exclusions Allowed Mode(s) of Delivery Additional Service Criteria Staff Ratio(s) ADDICTION SERVICES SECTION ASAM Levels Covered PROVIDER Qualifications Agency Staff Allowed PROVIDER Types and Specialties Eligibility Criteria Allowed Mode(s)

4 Of Delivery Additional Service Criteria ASAM Level 1 in an Outpatient Setting Admission Guidelines for ASAM Level 1 Additional Admission Guidelines for Outpatient Treatment Screening/Assessment/Treatment Plan Review PROVIDER Qualifications Agency Staff LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 10/12/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION: TABLE OF CONTENTS PAGE(S) 5 Page 4 of 5 Table of Contents Staffing Requirements Additional Staffing and Service Components ASAM Level Intensive Outpatient Treatment Admission Guidelines for ASAM Level Intensive Outpatient Treatment Additional Admission Guidelines for Intensive Outpatient Treatment Screening/Assessment/Treatment Plan Review PROVIDER Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 2-WM Ambulatory Withdrawal Management with Extended On-Site Monitoring Admission Guidelines for ASAM Level 2-WM Ambulatory Withdrawal Management with Extended On-Site Monitoring Screening/Assessment/Treatment Plan Review PROVIDER Qualifications Staffing Requirements Additional Staffing and Service Components Allowed PROVIDER Types and Specialties Eligibility Criteria Allowed Mode(s)

5 Of Delivery Additional Service Criteria COORDINATED SYSTEM OF CARE SECTION SERVICES Service Limitations Eligibility Parent Support and Training Components PROVIDER Qualifications Family Support Organization (FSO) Parent Support Specialist Parent Support Supervisor Allowed PROVIDER Types and Specialties Limitations and Exclusions Allowed Mode(s) of Delivery Additional Service Criteria Youth Support and Training Components PROVIDER Qualifications Family Support Organization (FSO) Youth Support Specialist Youth Support Supervisor Allowed PROVIDER Types and Specialties LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 10/12/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION: TABLE OF CONTENTS PAGE(S) 5 Page 5 of 5 Table of Contents Limitations and Exclusions Allowed Mode(s) of Delivery Additional Service Criteria RECORD KEEPING SECTION Components of Record Keeping Retention of Records Confidentiality and Protection of Records Review by State and Federal Agencies Member Records Organization of Records, Record Entries and Corrections Service/Progress Notes Progress Summaries Discharge Summary for Transfers and Closures FORMS AND LINKS APPENDIX A GLOSSARY AND ACRONYMS APPENDIX B MEDICAID MEDICAL NECESSITY AND EPSDT EXCEPTIONS APPENDIX C CURRICULUM/EQUIVALENCY STANDARDS APPENDIX D EVIDENCE BASED PRACTICES (EBPs) POLICY.

6 ASSERTIVE COMMUNITY TREATMENT APPENDIX E-1 FUNTIONAL FAMILY THERAPY (FFT) AND FUNCTIONAL THERAPY CHILD WELFARE (FFT-CCW) APPENDIX E-2 HOMEBUILDERS APPENDIX E-3 MULTI-SYSTEMIC THERAPY APPENDIX E-4 CSoC WRAPAROUND APPENDIX F LOUISIANA MEDICAID PROGRAM ISSUED: 06/09/17 REPLACED: 03/14/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION : OVERVIEW PAGE(S) 1 Page 1 of 1 Section OVERVIEW Specialized BEHAVIORAL HEALTH SERVICES (SBHS) are mental HEALTH SERVICES and substance use/addiction disorder SERVICES , specifically defined in the Medicaid State Plan and/or applicable waivers. These SERVICES shall be administered under the authority of the Louisiana Department of HEALTH (LDH) in collaboration with the Healthy Louisiana plans, as well as through the Coordinated System of Care (CSoC) program contractor, for members enrolled in CSoC.

7 Specialized BEHAVIORAL HEALTH SERVICES are distinguished from basic BEHAVIORAL HEALTH (BH) SERVICES offered by the Healthy Louisiana plans and the CSoC contractor. Basic BH SERVICES are mental HEALTH and substance use SERVICES which are provided to enrollees with emotional, psychological, substance use, psychiatric symptoms and/or disorders that are provided in the member s primary care physician (PCP) office by the member s PCP as part of primary care service activities. This PROVIDER MANUAL chapter outlines SBHS offered under Medicaid managed care, 1915(c) and 1915(b) waiver SERVICES offered only though the CSoC program contractor, as well as other specialized BEHAVIORAL HEALTH SERVICES offered to CSoC children and Medicaid members enrolled in a Healthy Louisiana plan. Service limitations, utilization, allowed PROVIDER types and specialties, and eligibility criteria are covered for SERVICES within the chapter.

8 LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 08/24/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION : PROVIDER REQUIREMENTS PAGE(S) 1 Page 1 of 1 Section PROVIDER REQUIREMENTS A PROVIDER must be enrolled in the Medicaid Program and meet the PROVIDER qualifications at the time service is rendered to be eligible to receive reimbursement through the Louisiana Medicaid Program. Providers should refer to Chapter 1 General Information and Administration of the Medicaid SERVICES MANUAL for additional information on PROVIDER enrollment and requirements, including general standards for participation. (See Appendix A for information on accessing Chapter 1.) Healthy Louisiana managed care organizations (MCOs) are responsible for ensuring providers with whom they contract to provide specialized BEHAVIORAL HEALTH SERVICES (SBHS), meet the minimum qualification requirements in accordance with the below provisions, all applicable state and federal laws, rules and regulations, and Centers for Medicare and Medicaid SERVICES (CMS) approved waivers and Medicaid State Plan amendments.

9 Licensure and Specific PROVIDER Requirements Providers must meet licensure and/or certification requirements, as well as other additional requirements as outlined in the sections below: Section Subject Topic Residential SERVICES Therapeutic Group Homes Residential SERVICES Psychiatric Residential Treatment Facilities Outpatient SERVICES BEHAVIORAL HEALTH SERVICES in a Federally Qualified HEALTH Center or Rural HEALTH Clinic Outpatient SERVICES Outpatient Therapy by Licensed Practitioners Outpatient SERVICES Rehabilitation SERVICES for Children, Adolescents, and Adults Addiction SERVICES same Coordinated System of Care same LOUISIANA MEDICAID PROGRAM ISSUED: 12/13/17 REPLACED: 06/09/17 CHAPTER 2: BEHAVIORAL HEALTH SERVICES SECTION : RESIDENTIAL SERVICES PAGE(S) 35 Residential SERVICES Page 1 of 35 Section RESIDENTIAL SERVICES Therapeutic Group Homes Therapeutic group homes (TGHs) provide a community-based residential service in a home-like setting of no greater than ten beds, under the supervision and program oversight of a psychiatrist or psychologist.

10 TGHs are located in residential communities in order to facilitate community integration through public education, recreation and maintenance of family connections. TGHs deliver an array of clinical and related SERVICES within the home, including psychiatric supports, integration with community resources and skill-building taught within the context of the home-like setting. The treatment should be targeted to support the restoration of adaptive and functional behaviors that will enable the child or adolescent to return to and remain successfully in his/her home and community, and to regularly attend and participate in work, school or training, at the child s best possible functional level. TGH treatment must target reducing the severity of the BEHAVIORAL HEALTH issue that was identified as the reason for admission. Most often, targeted behaviors will relate directly to the child s or adolescent s ability to function successfully in the home and school environment ( , compliance with reasonable BEHAVIORAL expectations, safe behavior and appropriate responses to social cues and conflicts, ability to communicate and problem-solve within family relationships), with a focus on skills that will generalize to the youth s next living situation (ideally, a permanent family home).