Current through Register Vol. 50, No. 9, September 20, 2024
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.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
