5123:2-9-41 Home and community-based services waivers - clinical/therapeutic intervention under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define clinical/therapeutic intervention and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "Clinical/therapeutic intervention" means services that are necessary to reduce an individual's intensive behaviors and to improve the individual's independence and inclusion in his or her community and that are not otherwise available under the state medicaid program. Clinical/therapeutic intervention includes consultation activities that are provided by professionals in psychology, counseling, special education, and behavior management. The service includes the development of a treatment/support plan, training and technical assistance to assist unpaid caregivers and/or paid support staff in carrying out the plan, delivery of the services described in the plan, and monitoring of the individual and the provider in the implementation of the plan. Clinical/therapeutic intervention may be delivered in the individual's home or in the community as described in the individual service plan. Clinical/therapeutic intervention must be determined necessary to reduce an individual's intensive behaviors by a functional behavioral assessment conducted by one of the following: licensed psychologist, licensed professional clinical counselor, licensed professional counselor, licensed independent social worker, or licensed social worker working under the supervision of a licensed independent social worker. Experimental treatments are prohibited.

(3) "County board" means a county board of developmental disabilities.

(4) "Department" means the Ohio department of developmental disabilities.

(5) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(6) "Functional behavioral assessment" means an assessment not otherwise available under the state medicaid program to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. Functional behavioral assessments describe the relationship between a skill or performance problem and the variables that contribute to its occurrence. Functional behavioral assessments can provide information to develop a hypothesis as to why the individual engages in the behavior, when the individual is most likely to demonstrate the behavior, and situations in which the behavior is least likely to occur.

(7) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(8) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either.

(9) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(10) "Medicaid program" has the same meaning as in section 5111.01 of the Revised Code.

(11) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(14) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Clinical/therapeutic intervention shall be provided by an independent provider or an agency provider that:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Has completed and submitted an application and adheres to the requirements of rule 5123:2-2-01 of the Administrative Code, except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of that rule do not apply to providers of clinical/therapeutic intervention.

(2) Clinical/therapeutic intervention shall be provided by senior level specialized clinical/therapeutic interventionists, specialized clinical/therapeutic interventionists, and clinical/therapeutic interventionists.

(a) A senior level specialized clinical/therapeutic interventionist shall have a doctoral degree in psychology, special education, medicine, or a related discipline; be licensed under the laws of the state to practice in his or her field; and have at least three months of experience and/or training in the implementation and oversight of comprehensive interventions for individuals with developmental disabilities who need significant behaviorally-focused interventions.

(b) A specialized clinical/therapeutic interventionist shall:

(i) Have a master's degree in psychology, special education, or a related discipline and be licensed under the laws of the state to practice in his or her field or be registered with the state board of psychology as an aide or a psychology aide working under psychological work supervision in accordance with rule 4732-13-03 of the Administrative Code; and

(ii) Have at least three months of experience and/or training in the implementation and oversight of comprehensive interventions for individuals with developmental disabilities who need significant behaviorally-focused interventions.

(c) A clinical/therapeutic interventionist shall work under the supervision of a senior level specialized clinical/therapeutic interventionist or a specialized clinical/therapeutic interventionist and shall either:

(i) Have experience providing one-to-one care for an individual with developmental disabilities who needs significant behaviorally-focused interventions; or

(ii) Have undergone two monitored sessions with an individual with developmental disabilities who needs significant behaviorally-focused interventions.

(3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide clinical/therapeutic intervention by senior level specialized clinical/therapeutic interventionists only when no other certified provider is willing and able. Neither a county board nor a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards shall provide clinical/therapeutic intervention by specialized clinical/therapeutic interventionists or clinical/therapeutic interventionists.

(4) Clinical/therapeutic intervention shall not be provided to an individual by his or her family member.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

Clinical/therapeutic intervention shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(E) Documentation of services

Service documentation for clinical/therapeutic intervention shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided and details of the individual's response to the services, including progress toward achieving outcomes specified in the individual service plan.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Times the delivered service started and stopped.

(F) Payment standards

(1) The billing units, service codes, and payment rates for clinical/therapeutic intervention are contained in the appendix to this rule.

(2) The payment rates for clinical/therapeutic intervention provided by independent providers shall be negotiated by the individual and the provider subject to the minimum and maximum payment rates contained in the appendix to this rule and shall be identified in the individual service plan.

(3) The payment rates for clinical/therapeutic intervention provided by agency providers shall be the lesser of the provider's usual and customary charge or the statewide payment rates contained in the appendix to this rule.

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Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16