La. Admin. Code tit. 50 § XXXIII-301

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

Section XXXIII-301 - Participation Requirements and Responsibilities

A. In order to participate in the Medicaid Program, an MCO and the CSoC contractor shall execute a contract with the department, and shall comply with all of the terms and conditions set forth in the contract.

B. MCOs and the CSoC contractor shall:

1. manage contracted services;

2. establish credentialing and re-credentialing policies consistent with federal and state regulations;

3. ensure that provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment;

a. Repealed.

4. maintain a written contract with subcontractors that specifies the activities and reporting responsibilities delegated to the subcontractor, and such contract shall also provide for the MCOs or CSOC contractors right to revoke said delegation, terminate the contract, or impose other sanctions if the subcontractors performance is inadequate;

5. contract only with providers of services who are licensed and/or certified according to state laws, regulations, rules, the provider manual and other notices or directives issued by the department, meet the state of Louisiana credentialing criteria and enrolled with the Bureau of Health Services Financing, or its designated contractor, after this requirement is implemented;

6. ensure that contracted rehabilitation providers are employed by a rehabilitation agency or clinic licensed and authorized under state law to provide these services;

7. sub-contract with a sufficient number of providers to render necessary services to Medicaid recipients/enrollees;

8. require each provider to implement mechanisms to assess each Medicaid enrollee identified as having special health care needs in order to identify special conditions of the enrollee that require a course of treatment or regular care monitoring;

9. ensure that treatment plans or plans of care meet the following requirements:

a. are developed by the enrollees primary care provider (PCP) or behavioral health provider with the enrollees participation and in consultation with any specialists providing care to the enrollee, with the exception of treatment plans or plans of care developed for recipients in the Home and Community Based Services (HCBS) Waiver. The wraparound agency shall develop plans of care according to wraparound best practice standards for recipients who receive behavioral health services through the HCBS Waiver;

b. are approved by the MCO or CSoC contractor in a timely manner, if required;

c. are in accordance with any applicable state and federal quality assurance and utilization review standards; and

d. allow for direct access to any specialist for the enrollees condition and identified needs, in accordance with the contract; and

10. ensure that Medicaid recipients/enrollees receive information:

a. in accordance with federal regulations and as described in the contract and departmental guidelines;

b. on available treatment options and alternatives in a manner appropriate to the enrollees condition and ability to understand; and

c. about available experimental treatments and clinical trials along with information on how such research can be accessed even though the Medicaid Program will not pay for the experimental treatment.

La. Admin. Code tit. 50, § XXXIII-301

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:362 (February 2012), Amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 412355 (11/1/2015), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43322(2/1/2017, Amended LR 441889 (10/1/2018).

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