BEHAVIORAL HEALTH SERVICES PROVIDER MANUAL

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:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

BEHAVIORAL HEALTH SERVICES

TABLE OF CONTENTS

SUBJECT

OVERVIEW

PROVIDER REQUIREMENTS

BED BASED SERVICES

Crisis Stabilization for Adults Components Eligibility Criteria Service Utilization Service Delivery Allowed Mode(s) of Delivery Provider Responsibilities Supervision of Non-licensed Staff Reporting Requirements Provider Qualifications Allowed Provider Types and Specialties Limitations/Exclusions

Crisis Stabilization for Youth Components Provider Qualifications Allowed Provider Types and Specialties Limitations/Exclusions Allowed Mode(s) of Delivery

Therapeutic Group Homes Components Provider Qualifications Additional Organizational Requirements Agency Staffing Qualifications Allowed Provider Types and Specialties Eligibility Criteria Service Utilization Service Exclusions

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SECTION SECTION 2.0 SECTION 2.1 SECTION 2.2

Table of Contents

LOUISIANA MEDICAID PROGRAM

ISSUED:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

Allowed Mode(s) 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

OUTPATIENT SERVICES

SECTION 2.3

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) of Delivery Additional Service Criteria Telehealth

Peer Support Services

Evaluation and Evidence Based Practices Components Eligibility Criteria Allowed Modes of Delivery Service Utilization

Page 2 of 9

Table of Contents

LOUISIANA MEDICAID PROGRAM

ISSUED:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

Service Delivery Staff Ratios Provider Responsibilities Supervisions Provider Qualifications

Agency Staff CPSS Training and Certification Allowed Partner Types and Specialties Limitations/Exclusions

Rehabilitation Services for Children, Adolescents, and Adults Children and Adolescents Adults Service Delivery Assessment and Treatment Planning Provider Responsibilities Core Services The BHSP Crisis Mitigation Plan Core Staffing Staff Supervision for Non-Licensed Staff Eligibility Criteria Additional Adult Eligibility Criteria for Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Adults receiving CPST and/or PSR must have at least Service Utilization Additional Service Utilization Criteria Member Choice Form and Process Limitations/Exclusions Community Psychiatric Support and Treatment Components CPST Provider Qualifications Agency Staff CPST Allowed Provider Types and Specialties CPST Allowed Mode(s) of Delivery CPST Additional Service Criteria CPST Staff Ratio(s) Psychosocial Rehabilitation Components PSR Provider Qualifications Agency Staff

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Table of Contents

LOUISIANA MEDICAID PROGRAM

ISSUED:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

PSR Allowed Provider Types and Specialties PSR Allowed Mode(s) of Delivery PSR Staff Ratio(s) Crisis Intervention Components Provider Qualifications Agency Staff CI Allowed Provider Types and Specialties CI Eligibility Criteria CI Service Utilization CI Allowed Mode(s) of Delivery CI Additional Service Criteria Crisis Stabilization Components CS Provider Qualifications Agency Staff CS Allowed Provider Types and Specialties CS Limitations/Exclusions CS Allowed Mode(s) of Delivery

ADDICTION SERVICES

SECTION 2.4

ASAM Levels Covered

Provider Qualifications

Agency

Staff

Allowed Provider Types and Specialties

Eligibility Criteria

Allowed Mode(s) 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

Staffing Requirements

Additional Staffing and Service Components

ASAM Level 2.1 Intensive Outpatient Treatment

Admission Guidelines for ASAM Level 2.1 Intensive Outpatient Treatment

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Table of Contents

LOUISIANA MEDICAID PROGRAM

ISSUED:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

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) of Delivery Additional Service Criteria ASAM Level 3.1: Clinically managed low-intensity residential treatment- Adolescent Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.1: Clinically managed low-intensity residential treatment- Adults Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.2-WM: Clinically managed residential social withdrawal management ? Adolescent Admission Guidelines Emergency Admissions Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice ASAM Level 3.-2WM: Clinically managed residential social withdrawal management ? Adults Admission Guidelines Emergency Admissions Screening, Assessment, and Treatment Plan Review

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Table of Contents

LOUISIANA MEDICAID PROGRAM

ISSUED:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice ASAM Level 3.3: Clinically managed population specific high intensity residential treatment- Adult Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice Women with Dependent Children Program ASAM Level 3.5: Clinically managed medium intensity residential treatment ? Adolescent Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.5: Clinically managed high intensity residential treatment- Adult Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.7: Medically monitored high intensity inpatient treatment- Adult Admission Guidelines Emergency Admission Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.7: Medically monitored intensive inpatient treatment ? Adolescent Admission Guidelines Emergency Admission Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.7-WM: Medically monitored inpatient withdrawal management- Adult Admission Guidelines Emergency Admissions

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Table of Contents

LOUISIANA MEDICAID PROGRAM

ISSUED:

01/01/23

REPLACED: 08/17/22

CHAPTER 2: BEHAVIORAL HEALTH SERVICES

SECTION: TABLE OF CONTENTS

PAGE(S) 9

Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice ASAM Level 4-WM: Medically managed intensive inpatient withdrawal management Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice Settings

Opioid Treatment Programs (OTPs)

Components Screening Physician Examination Alcohol and Drug Assessment and Referrals Treatment Planning Process Treatment Services

Eligibility Criteria Client Records Additional Provider Responsibilities Provider Qualifications

Agency Staff Staffing Requirements Medical Director Pharmacist or Dispensing Physician Clinical Supervisor Physician or APRN Nursing Staff Licensed Mental Health Professional (LMHP) Unlicensed professionals (UPs) Staff Ratios Allowed Provider Types and Specialties Allowed Modes of Delivery

COORDINATED SYSTEM OF CARE

Services Service Limitations

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SECTION 2.5

Table of Contents

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