Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXXIII - Behavioral Health Services › Subpart 1 - Healthy Louisiana and Coordinated System of Care Waiver › Chapter 5 - Reimbursement › Section XXXIII-503 - Directed Payments

Current through Register Vol. 50, No. 6, June 20, 2024
A. Provider
				  Directed Payments
1. Subject to written
				  approval by the U.S. Department of Health and Human Services, Centers for
				  Medicare and Medicaid Services (CMS), the Department of Health (hereafter
				  referred to as "the department" and/or "LDH") shall provide directed payments
				  to qualifying providers that participate in the Healthy Louisiana Medicaid
				  managed care program or Coordinated System of Care (CSoC) waiver, in accordance
				  with the applicable section 438.6(c) preprint(s) approved by CMS, federal
				  regulations, and departmental requirements. Each CMS approved directed payment
				  arrangement is effective for one Healthy Louisiana Medicaid managed care or
				  CSoC contract rating period, unless otherwise approved by CMS.
2. Qualifying Provider
a. High fidelity wraparound agencies (WAA)
				  and wraparound facilitators (WF), WF supervisors, WAA coaches, and WAA
				  administrators that meet the criteria specified in the applicable section
				  438.6(c) preprint approved by CMS and departmental requirements; or
b. Peer support specialists, supervisors,
				  trainers, and administrators employed by the family support organization (FSO)
				  that meet the criteria specified in the applicable section 438.6(c) preprint
				  approved by CMS and departmental requirements; or
c. Licensed mental health practitioners
				  (LMHPs) and psychiatrists that provide behavioral health outpatient services
				  and that meet the criteria specified in the applicable section 438.6(c)
				  preprint approved by CMS and departmental requirements.
3. The Healthy Louisiana Medicaid managed
				  care organization (MCO) and CSoC contractor shall assign qualifying providers
				  to provider classes based upon criteria specified in the applicable section
				  438.6(c) preprint(s) approved by CMS, in accordance with departmental
				  requirements.
a. Qualifying providers shall
				  have no right to an administrative appeal regarding the qualifying provider
				  criteria or determination of which providers meet the qualifying provider
				  criteria.
4. The MCO and
				  CSoC contractor shall utilize a payment process, whereby directed payments will
				  be calculated and paid out based on the data and methodology specified in the
				  applicable section 438.6(c) preprint(s) approved by CMS, in accordance with
				  departmental requirements.
a. Qualifying
				  providers shall have no right to an administrative appeal regarding calculation
				  of directed payments or measurement rates.
5. Based upon the methodology specified in
				  the applicable section 438.6(c) preprint(s) approved by CMS, in accordance with
				  departmental requirements, the department shall cause directed payments to be
				  paid in a single upfront lump sum payment to the MCOs; and payments shall be
				  paid to the CSoC contractor within 30 days of receipt of invoice(s), on a
				  retrospective basis.
a. Funding for the
				  directed payments is only available during the time period in the applicable
				  section 438.6(c) preprint(s) approved by CMS or until payments are exhausted,
				  whichever comes first.
6.
				  In accordance with the applicable section 438.6(c) preprint(s) approved by CMS
				  and departmental requirements, directed payments must be based on actual
				  utilization and delivery of services during the applicable contract period.
a. Within six months of the end of the rating
				  period, the MCOs and CSoC contractor shall perform a reconciliation as
				  specified in the applicable section 438.6(c) preprint approved by CMS or as
				  otherwise dictated in accordance with departmental requirements.
i. Qualifying providers shall have no right
				  to an administrative appeal regarding any issue related to reconciliation,
				  including, but not limited to, the timing, amount of the reconciliation, and
				  process.
7. If
				  a qualifying provider is subject to a reconciliation, the qualified provider
				  shall pay all amounts owed to the MCO or CSoC contractor, in accordance with
				  departmental requirements.
a. In addition to
				  all other available remedies, the MCO and the CSoC contractor has the authority
				  to offset all amounts owed by a qualifying provider due to a reconciliation
				  against any payment owed to the qualifying provider, including, but not limited
				  to, any payment owed by the MCOs or CSoC
				  contractor.