20505 Covered Services

A. Children covered in phase five of the LaCHIP expansion shall receive health care benefits through an array of covered services offered by health plans participating in the Healthy Louisiana Program, and behavioral health services administered by the statewide management organization under the LBHP. The following services shall be included:

1. inpatient hospital services:

a. pre-certification is required for hospital admissions. Emergency services are covered if, upon review, presentation is determined to be life-threatening, resulting in admission to inpatient, partial hospital or intensive outpatient level of care;

2. outpatient hospital services:

a. the relative therapies require pre-certification;

3. physician services;

4. surgical procedures;

5. clinic services and other ambulatory health care services;

6. prescription drugs;

7. laboratory and radiological services;

8. pre-natal care and pre-pregnancy family services and supplies;

9. inpatient and outpatient behavioral health services other than those listed in any other provisions of §20503:

a. these services include those furnished in a state-operated mental hospital, residential facility or other 24 hour therapeutically-planned structural services. Pre-certification is required for these services. Emergency services are covered if, upon review, presentation is determined to be life-threatening, resulting in admission to inpatient, partial hospital or intensive outpatient level of care;

b. inpatient and outpatient visits are limited to medically necessary services not to exceed a combined 52 visits per plan year for mental health and substance abuse services;

10. durable medical equipment;

11. nursing care services;

12. dental services;

13. inpatient substance abuse treatment services, including residential substance abuse treatment services:

a. inpatient admissions must be pre-certified. Emergency services are covered if, upon review, presentation is determined to be life-threatening, resulting in admission to inpatient, partial hospital or intensive outpatient level of care;

b. inpatient days are limited to medically necessary services not to exceed a combined 45 visits per plan year for mental health and substance abuse services;

14. outpatient substance abuse treatment services:

a. all services must be pre-certified;

b. outpatient visits are limited to medically necessary services not to exceed a combined 52 visits per plan year for mental health and substance abuse services;

15. case management services:

16. physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders:

a. physical and occupational therapy is limited to 50 visits per year and speech therapy is limited to 26 visits per year;

17. hospice care:

18. medical transportation; and

19. any other medically necessary medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative services.

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

HISTORICAL NOTE: Repromulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:660 (April 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:1292 (July 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 52:1189 (July 2026).