La. Admin. Code tit. 50 § XXXIII-6103

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

Section XXXIII-6103 - Recipient Qualifications

A. Individuals 21 years of age and older who meet Medicaid eligibility shall qualify to receive adult mental health services referenced in LAC 50:XXXIII.6307 if medically necessary in accordance with LAC 50:I.1101, if the recipient presents with mental health symptoms that are consistent with a diagnosable mental disorder, and the services are therapeutically appropriate and most beneficial to the recipient.

B. Additional Recipient Eligibility Criteria for Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR)

1. Members must meet the Substance Abuse and Mental Health Services Administration (SAMHSA) definition of, serious mental illness (SMI). In addition to having a diagnosable mental disorder, the condition must substantially interfere with, or limit, one or more major life activities, such as:

a. basic daily living (for example, eating or dressing);

b. instrumental living (for example, taking prescribed medications or getting around the community); or

c. participating in a family, school, or workplace.

2. A member must have a rating of three or greater on the functional status domain on the level of care utilization system (LOCUS).

3. Recipients receiving CPST and/or PSR shall have at least a level of care score of three on the LOCUS.

4. An adult with longstanding deficits who does not experience any acute changes in their status and has previously met the criteria stated in LAC 50:XXXIII.6103.B.2.-3, but who now meets a level of care score of two or lower, and needs subsequent medically necessary services for stabilization and maintenance at a lower intensity, may continue to receive CPST services and/or PSR, if deemed medically necessary.

C. An adult with a diagnosis of a substance use disorder or intellectual and developmental disability without an additional co-occurring qualifying mental health diagnosis shall not meet the criteria for adult mental health rehabilitation services.

La. Admin. Code tit. 50, § XXXIII-6103

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:358 (February 2012), Amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 4260 (1/1/2016), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 441014 (6/1/2018), Amended LR 46794 (6/1/2020), Repromulgated LR 46951 (7/1/2020), Amended LR 50983 (7/1/2024).

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