Ohio Administrative Code
Title 5123:2 - Community Services
Chapter 5123:2-9 - Home and Community-Based Services Waivers
Section 5123:2-9-41 - Home and community-based services waivers - clinical/therapeutic intervention under the self-empowered life funding waiver
Universal Citation: OH Admin Code 5123:2-9-41
Current through all regulations passed and filed through September 16, 2024
(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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