Ohio Administrative Code
Title 5123:2 - Community Services
Chapter 5123:2-10 - Early Intervention Services
Section 5123:2-10-01 - Early intervention services - system of payments
Universal Citation: OH Admin Code 5123:2-10-01
Current through all regulations passed and filed through September 16, 2024
(A) Purpose
This rule establishes a structure to pay for activities and expenses that are reasonable and necessary for implementing Ohio's early intervention system for eligible children and their families.
(B) Definitions
(1)
"Assistive technology device" means any item, piece of
equipment, or product, whether acquired commercially off the shelf, modified,
or customized, that is used to increase, maintain, or improve the functional
capabilities of a child. The term does not include a medical device that is
surgically implanted, including a cochlear implant, or the optimization (e.g.,
mapping), maintenance, or replacement of that device.
(2)
"County board"
means a county board of developmental disabilities.
(3)
"Department"
means the Ohio department of developmental disabilities.
(4)
"Early
intervention service coordinator" means a person that assists and enables an
eligible child and the child's family to receive the services and rights,
including procedural safeguards, required under part C.
(5)
"Early
intervention services" means developmental services selected in collaboration
with the parents of a child birth through age two who is eligible for services
under part C, and designed to meet the developmental needs of the child and the
needs of the child's family to assist appropriately in the child's development
as identified in the individualized family service plan.
(6)
"Early
intervention system" means Ohio's statewide, coordinated, comprehensive,
interagency system for which the department is the lead agency, that promotes
transdisciplinary, family-centered services and supports to eligible children
birth through age two and their families.
(7)
"Eligible" means
a child, birth through age two, who has:
(a)
A physical or
mental condition with a high probability of resulting in a developmental delay
listed in the appendix to this rule as documented by a diagnosis signed by a
professional licensed to diagnose and treat physical or mental
conditions;
(b)
A physical or mental condition which is not listed in
the appendix to this rule as documented by a diagnosis signed by a professional
licensed to diagnose and treat physical or mental conditions that includes the
name of the diagnosed physical or mental condition, and a statement of how the
diagnosed condition has a high likelihood of causing a developmental delay;
or
(c)
A developmental delay of at least one and one-half
standard deviations below the mean, or the equivalent determined through
informed clinical opinion, in adaptive, cognitive, communication, physical, or
social-emotional development, as determined and documented by the "Bayley
Infant Scales of Development" or the "Battelle Developmental
Inventory."
(8)
"Extraordinary medical expenses" means non-reimbursable
costs paid during the individualized family service plan year by the family of
the eligible child for medical and related care including, but not limited to,
hospital stays, physician visits, dental care, vision care, prescribed
medications/ supplies/therapies, health insurance
premiums/co-payments/deductibles, and modifications to the child's home to make
the home accessible when such costs constitute:
(a)
At least one per
cent of the family's gross income when the family's gross income is less than
or equal to two hundred ten per cent of the federal poverty
level;
(b)
At least two per cent of the family's gross income when
the family's gross income is greater than two hundred ten per cent of the
federal poverty level and less than or equal to two hundred twenty per cent of
the federal poverty level;
(c)
At least three
per cent of the family's gross income when the family's gross income is greater
than two hundred twenty per cent of the federal poverty level and less than or
equal to two hundred thirty per cent of the federal poverty
level;
(d)
At least four per cent of the family's gross income
when the family's gross income is greater than two hundred thirty per cent of
the federal poverty level and less than or equal to two hundred forty per cent
of the federal poverty level;
(e)
At least five per
cent of the family's gross income when the family's gross income is greater
than two hundred forty per cent of the federal poverty level and less than or
equal to two hundred seventy per cent of the federal poverty
level;
(f)
At least six per cent of the family's gross income when
the family's gross income is greater than two hundred seventy per cent of the
federal poverty level and less than or equal to three hundred per cent of the
federal poverty level;
(g)
At least seven per cent of the family's gross income
when the family's gross income is greater than three hundred per cent of the
federal poverty level and less than or equal to four hundred per cent of the
federal poverty level; or
(h)
At least eight per cent of the family's gross income
when the family's gross income is greater than four hundred per cent of the
federal poverty level.
(9)
"Home and
community-based services medicaid waiver component" has the same meaning as in
section 5166.01 of the Revised
Code.
(10)
"Individualized family service plan" means the written
plan for providing early intervention services to an eligible child and his or
her family. The fifty-five units of early intervention services per
individualized family service plan year provided at no cost to an eligible
child and his or her family in accordance with paragraph (C)(1)(f) of this rule
shall not serve to limit the team's recommendation of needed early intervention
services in the individualized family service plan.
(11)
"Individualized
family service plan year" means the period, not to exceed three hundred
sixty-six calendar days or extend beyond the child's third birthday, beginning
on the day signatures are secured on an initial or annual individualized family
service plan and ending when signatures are secured on a subsequent annual
individualized family service plan.
(12)
"Parent" means a
biological or adoptive parent of a child, a guardian, a person acting in place
of a parent and with whom the child lives, or an appointed surrogate
parent.
(13)
"Part C" means part C of the Individuals with
Disabilities Education Act,
20 U.S.C.
1431 through 1445, as in effect on the
effective date of this rule, and 34 C.F.R. part 303, as in effect on the
effective date of this rule.
(14)
"Payor of last
resort" means the use of federal part C funds to pay for early intervention
services only when all other funding sources have been exhausted. These funds
may be used to prevent a delay in the timely provision of early intervention
services, pending reimbursement from the agency or entity that has ultimate
responsibility for the payment.
(15)
"Qualified
personnel" means persons who:
(a)
Hold, as applicable based on the early intervention
services provided:
(i)
Valid early intervention services certification issued
by the department in accordance with rule
5123:2-5-05
of the Administrative Code;
(ii)
Valid license or
certificate issued under Title XLVII of the Revised Code; or
(iii)
Valid license
or certificate issued under Chapter 3319. of the Revised Code.
(b)
Provide early intervention services in accordance with part
C and rules promulgated by the department.
(c)
Shall be subject
to the department's oversight of the early intervention services
provided.
(16)
"Team" means the group of persons who develop the
individualized family service plan and includes, at a minimum, the parent of
the eligible child, other family members when requested by the parent, an
advocate or other person outside of the family when requested by the parent,
the early intervention service coordinator, and a person who conducted the
evaluation or assessment of the child.
(17)
"Unit" means
either:
(a)
Sixty minutes of early intervention services;
or
(b)
One hundred dollars expended for an assistive
technology device.
(C) Provision of and payment for early intervention services
(1)
The department
shall ensure that the following early intervention services and functions are
funded through local, state, and federal public funds and are provided at no
cost to eligible children and their families:
(a)
Child
find;
(b)
Evaluation and assessment;
(c)
Service
coordination;
(d)
Administrative and coordinating activities related to
the development, review, and evaluation of the individualized family service
plan and interim individualized family service plan;
(e)
Implementation of
procedural safeguards in accordance with paragraph (H) of this rule;
and
(f)
Fifty-five units of early intervention services per
individualized family service plan year identified as needed in the
individualized family service plan.
(2)
Early
intervention services, other than those listed in paragraphs (C)(1)(a) to
(C)(1)(f) of this rule, may be financed through:
(a)
County boards,
based on a county board's strategic plan and written policy regarding early
intervention services in accordance with rule
5123:2-1-02
of the Administrative Code;
(b)
Private insurance
of the child or parent, with the consent of the parent of the eligible
child;
(c)
Public insurance of the child or parent (e.g., medicaid
or children's health insurance program), with the consent of the parent of the
eligible child for disclosure of the child's personally-identifiable
information to the public insurance program for billing
purposes;
(d)
Parent cost participation based on the determination of
the parent's ability to pay; and
(e)
The department
through a combination of state general revenue funds and federal part C funds,
with federal part C funds being payor of last resort.
(3)
When
the first fifty-five units of early intervention services per individualized
family service plan year are not available from or are denied by the funding
sources set forth in paragraphs (C)(2)(a) to (C)(2)(c) of this rule, the
department shall pay qualified personnel for early intervention services
identified as needed in an individualized family service plan, regardless of
the parent's ability to pay as determined in accordance with paragraph (D)(2)
of this rule.
(4)
When more than fifty-five units of early intervention
services per individualized family service plan year are identified as needed
in an individualized family service plan:
(a)
A parent
determined able to pay for early intervention services in accordance with
paragraph (D)(2) of this rule shall be responsible for paying the cost of early
intervention services.
(b)
The child of a parent determined unable to pay for
early intervention services in accordance with paragraph (D)(2) of this rule
shall continue to receive early intervention services at public
expense.
(5)
Providers of early intervention services, other than
county boards, shall enter into a contractual relationship with the department
for provision of the services.
(D) Determination of a parent's ability to pay for early intervention services
(1)
The early
intervention service coordinator shall explain this rule and determine a
parent's ability to pay for early intervention services in accordance with
paragraph (D)(2) of this rule within forty-five calendar days of the parent's
initial contact with the early intervention system and within forty-five
calendar days of each scheduled annual review of the individualized family
service plan.
(2)
A parent shall be determined able to pay for early
intervention services unless:
(a)
The parent is receiving services from the special
supplemental food program for women, infants, and children, authorized by
section 17 of the Child Nutrition Act of 1966,
42
U.S.C. 1786, as in effect on the effective
date of this rule; or
(b)
The parent or the child is receiving medicaid benefits;
or
(c)
The family's income is less than or equal to that
required for Ohio healthy start eligibility for uninsured children
(http://www.medicaid.ohio.gov/ forohioans/programs/childrenfamiliesandwomen.aspx);
or
(d)
The family has extraordinary medical expenses as
determined by the department within thirty calendar days of the department's
receipt of necessary supporting documentation.
(3)
A parent who
chooses not to share financial information needed by the early intervention
service coordinator or the department to determine the parent's ability to pay
shall be responsible for paying the cost of early intervention services other
than the early intervention services listed in paragraphs (C)(1)(a) to
(C)(1)(f) of this rule.
(4)
The early intervention service coordinator shall inform
the parent of the option to submit a request for redetermination of the
parent's ability to pay if, after the initial determination, the parent or
family meets a criterion set forth in paragraphs (D)(2)(a) to (D)(2)(d) of this
rule.
(E) Parent cost participation
(1)
When a parent is
determined unable to pay in accordance with paragraph (D)(2) of this rule, the
eligible child shall be provided all early intervention services identified as
needed in the individualized family service plan, including those early
intervention services that exceed fifty-five units per individualized family
service plan year, at no cost to the child or family.
(2)
When a parent is
determined able to pay in accordance with paragraph (D)(2) of this rule, the
parent shall be responsible for paying the cost of early intervention services,
including private insurance co-payments and deductibles, needed to meet the
outcomes in the individualized family service plan, other than the early
intervention services listed in paragraphs (C)(1)(a) to (C)(1)(f) of this
rule.
(3)
A parent shall not be charged more than the actual cost
of the early intervention services (factoring in any amount received from other
sources for payment for those services).
(4)
A child or parent
with private insurance or public insurance shall not be charged
disproportionately more than a child or parent without private insurance or
public insurance.
(F) Using the private insurance of a child or parent to pay for early intervention services
(1)
The early
intervention system shall not use the private insurance of a child or parent to
pay for early intervention services without written consent of the parent.
Prior to asking a parent if he or she consents to use of private insurance, the
early intervention service coordinator shall:
(a)
Provide the
parent with a description of Ohio's system of payments for early intervention
services;
(b)
Explain this rule;
(c)
Explain that
there are potential costs (e.g., co-payments, deductibles, premiums, or
long-term costs such as the loss of benefits because of annual or lifetime
health insurance coverage caps of the insurance policy) and that there may be
service limits that the parent may incur when private insurance is used to pay
for early intervention services; and
(d)
Suggest the
parent review his or her private insurance coverage and contact the insurer if
he or she has questions about using private insurance to pay for early
intervention services.
(2)
When using the
private insurance of a child or parent to pay for early intervention services,
the early intervention service coordinator shall obtain parental consent prior
to an increase in the amount, duration, or scope of early intervention services
specified in the individualized family service plan.
(3)
When using the
private insurance of a child or parent to pay for early intervention services,
the early intervention system:
(a)
Shall pay the cost of co-payments and deductibles using
payor of last resort funds as necessary for the first fifty-five units of early
intervention services per individualized family service plan year and for
additional units of early intervention services when a parent is determined
unable to pay in accordance with paragraph (D)(2) of this rule;
and
(b)
Shall not pay the cost of private insurance
premiums.
(4)
When a child is covered by both private insurance and
public insurance and the child's parent consents to the use of private
insurance to pay for early intervention services, the use of private insurance
is required prior to the use of public insurance to pay for early intervention
services.
(G) Using the public insurance of a child or parent to pay for early intervention services
(1)
The early intervention system shall not require a child
or parent to enroll in public insurance programs as a condition of receiving
early intervention services, but shall share information about the enrollment
process for such programs.
(2)
The early intervention system shall not enroll a child
or parent in public insurance programs or use the public insurance of a child
or parent to pay for early intervention services if the child or parent is not
already enrolled in a public insurance program.
(3)
When using the
public insurance of a child or parent to pay for early intervention services,
the early intervention system shall:
(a)
Obtain initial,
one-time parental consent for disclosure of the child's personally-identifiable
information to the public insurance program for billing
purposes.
(b)
Make available those early intervention services in the
individualized family service plan for which the parent has provided
consent.
(c)
Provide written notification to the parent prior to
using the public insurance of the child or parent to pay for early intervention
services. The written notification shall include a statement:
(i)
That after
obtaining parental consent, the child's personally-identifiable information
will be disclosed to the public insurance program for billing
purposes.
(ii)
That the parent has the right, at any time, to withdraw
consent of disclosure of the child's personally-identifiable information to the
public insurance program.
(iii)
That the parent
will not be charged co-payments, deductibles, or premiums for using public
insurance.
(iv)
That for children covered by both private insurance and
public insurance, the use of private insurance to pay for early intervention
services is required prior to the use of public insurance to pay for early
intervention services. When the parent does not consent to use of private
insurance, however, neither private insurance nor public insurance will be used
to pay for early intervention services and the early intervention system shall
make available those early intervention services in the individualized family
service plan for which the parent has provided consent.
(v)
That the parent
will not, as a result of using public insurance for early intervention
services:
(a)
Have to pay for services that would otherwise be covered by
the public insurance program;
(b)
Incur any
premiums or discontinuation of public insurance for the child or the
parent;
(c)
Risk loss of eligibility for the child or the parent
for a home and community-based services medicaid waiver component based on
aggregate health-related expenditures; or
(d)
Risk decrease in
available lifetime coverage or any other insured
benefits.
(vi)
Of the procedural safeguards set forth in paragraphs
(G)(1), (G)(2), and (H) of this rule.
(H) Procedural safeguards
(1)
A parent
contesting the determination of the parent's ability to pay or imposition of
parent cost participation shall be afforded the procedural safeguards set forth
in part C, including mediation, state complaint procedures, and due process
hearing procedures. In addition, a parent contesting the determination of the
parent's ability to pay or the imposition of parent cost participation may
request an informal review by the department.
(a)
The parent must
submit a request for review to the department within thirty calendar days from
receipt of notification of the determination of the parent's ability to pay or
imposition of parent cost participation. The request must contain a statement
of the reasons the parent believes the determination or imposition is incorrect
or inappropriate and a proposed resolution.
(b)
The department
shall issue a written decision to the parent within twenty calendar days from
receipt of the request for review.
(2)
Early
intervention services shall not be delayed or denied to an eligible child of a
parent determined unable to pay for early intervention services in accordance
with paragraph (D)(2) of this rule.
(3)
Early
intervention services shall not be delayed or denied to an eligible child due
to lack of:
(a)
Parental consent to use the private insurance of the child or parent to pay for
early intervention services;
(b)
The child's or
parent's enrollment in public insurance programs; or
(c)
Parental consent
to share the child's personally-identifiable information with public insurance
programs.
(4)
Parents shall be notified of the procedural safeguards
set forth in paragraphs (H)(1) to (H)(3) of this rule at the time of the
determination of the parent's ability to pay in accordance with paragraph
(D)(2) of this rule and prior to finalization and securing of signatures on the
individualized family service plan.
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