La. Admin. Code tit. 50 § XXI-16325

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXI-16325 - Professional Services

A. Professional services are direct services to beneficiaries based on the beneficiary's need, which assist the beneficiary, unpaid caregivers, and/or paid caregivers in carrying out the beneficiary's approved plan and which are necessary to improve the beneficiary's independence and inclusion in his/her community. The beneficiary must be present in order for the professional to bill for services. Professional services include nutritional services, speech therapy, occupational therapy, physical therapy, social work, and psychological services. All services are to be included in the beneficiary's plan of care. The specific service provided to a beneficiary must be within the professional's area of specialty and licensing.

B. Professional services include services provided by the following licensed professionals:

1. occupational therapists;

2. physical therapists;

3. speech therapists;

4. registered dieticians;

5. social workers; and

6. psychologists.

C. Professional services can include:

1. assessments and/or re-assessments specific to the area of specialty with the goal of identifying status and developing recommendations, treatment, and follow-up;

2. providing training to the beneficiary, family, and caregivers with the goal of increased skill acquisition and proficiency;

3. intervening in a crisis situation with the goal of stabilizing and addressing issues related to the cause(s) of the crisis. Activities may include development of support plan(s), training, documentation strategies, counseling, on-call supports; back-up crisis supports, on-going monitoring, and intervention;

4. provide consultative services and recommendations as the need arises;

5. providing information to the beneficiary, family, and caregivers, along with other support team members, to assist in planning, developing, and implementing a beneficiary's plan of care;

6. providing training and counseling services for natural supports and caregivers in a home setting with the goal of developing and maintaining healthy, stable relationships;

a. emphasis is placed on the acquisition of coping skills by building upon family strengths; and

b. services are intended to maximize the emotional and social adjustment and well-being of the individual, family, and caregiver;

7. providing nutritional services, including dietary evaluation and consultation with individuals or their care provider;

a. services are intended to maximize the individual's nutritional health;

8. providing therapy to the beneficiary necessary to the development of critical skills; and

9. assistance in increasing independence, participation, and productivity in the participant's home, work, and/or community environments.

NOTE: Psychologists and social workers will provide supports and services consistent with person-centered practices and Guidelines for Support Planning.

D. Service Exclusions

1. Private insurance must be billed and exhausted prior to accessing waiver funds. Professional services may only be furnished and reimbursed through ROW when the services are medically necessary, or have habilitative or remedial benefit to the beneficiary.

2. Children must access and exhaust services through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program prior to accessing waiver funds.

E. Provider Qualifications. The provider of professional services must be a Medicaid-enrolled provider. Each professional must possess a current valid Louisiana license to practice in his/her field and have at least one year of experience post licensure in his/her area of expertise.

1. Enrollment of individual practitioners. Individual practitioners who enroll as providers of professional services must:

a. have a current, valid license from the appropriate governing board of Louisiana for that profession; and

b. have a minimum of one year experience delivering services to persons with developmental disabilities.

c. In addition, the specific service delivered must be consistent with the scope of the license held by the professional.

2. Provider agency enrollment of professional services.

a. The following provider agencies may enroll to provide professional services:

i. a Medicare certified free-standing rehabilitation center;

ii. a licensed home health agency;

iii. a supervised independent living agency licensed by the department to provide shared living services;

iv. a substitute family care agency licensed by the department to provide host home services; or

v. a federally qualified health center (U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) grant recipient or Clinical Laboratory Improvement Amendments (CLIA) certificate holder).

b. Enrolled provider agencies may provide professional services by one of the following methods:

i. employing the professionals; or

ii. contracting with the professionals.

c. Provider agencies are required to verify that all professionals employed by or contracted with their agency meet the same qualifications required for individual practitioners as stated in §16325. E.1 a-c.

3. All professionals delivering professional services must meet the required one year of service delivery experience as defined by the following:

a. full-time experience gained in advanced and accredited training programs (i.e. master's or residency level training programs), which includes treatment services for persons with a developmental disability;

b. paid, full-time professional experience in specialized service/treatment settings for persons with a developmental disability (i.e., intermediate care facilities for persons with a developmental disability);

c. paid, full-time professional experience in multidisciplinary programs for persons with a developmental disability (i.e., mental health treatment programs for persons with dual diagnosis - mental illness and a developmental disability); or

d. paid, full-time professional experience in specialized educational, vocational, and therapeutic programs or settings for persons with a developmental disability (i.e., school special education program).

NOTE: Two years of part-time experience (minimum of 20 hours per week) may be substituted for one year of full-time experience.

e. Repealed.

4. The following activities do not qualify for the required experience:

a. volunteer professional experience; or

b. experience gained in caring for a relative or friend with a developmental disability.

La. Admin. Code tit. 50, § XXI-16325

Promulgated by the Department of Health and Hospitals, Office for Citizens with Developmental Disabilities, LR 33:2450 (November 2007), Amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office for Citizens with Developmental Disabilities, LR 422163 (10/1/2015), Amended by the Department of Health, Bureau of Health Services Financing and the Office for Citizens with Developmental Disabilities, LR 471518 (10/1/2021), Amended LR 481566 (6/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.