Ohio Administrative Code
Title 5123:2 - Community Services
Chapter 5123:2-9 - Home and Community-Based Services Waivers
Section 5123:2-9-43 - Home and community-based services waivers - functional behavioral assessment under the self-empowered life funding waiver
Universal Citation: OH Admin Code 5123:2-9-43
Current through all regulations passed and filed through March 18, 2024
(A) Purpose
The purpose of this rule is to define functional behavioral assessment 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)
"County board"
means a county board of developmental disabilities.
(3)
"Department"
means the Ohio department of developmental disabilities.
(4)
"Family member"
means a person who is related to the individual by blood, marriage, or
adoption.
(5)
"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.
(6)
"Independent
provider" means a person who provides services and does not employ, either
directly or through contract, anyone else to provide the services.
(7)
"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.
(8)
"Individual service plan" means the written
description of services, supports, and activities to be provided to an
individual.
(9)
"Medicaid program" has the same meaning as in section
5111.01 of the Revised
Code.
(10)
"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.
(11)
"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.
(12)
"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.
(13)
"Usual and
customary charge" means the amount charged to other persons for the same
service.
(14)
"Waiver eligibility span" means the twelve-month
period following either an individual's initial enrollment date or a subsequent
eligibility redetermination date.
(C) Provider qualifications
(1)
Functional behavioral assessment 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 paragraph (C)(2) of rule
5123:2-2-01
of the Administrative Code. The remainder of rule
5123:2-2-01
of the Administrative Code does not apply to providers of functional behavioral
assessment.
(2)
Functional behavioral assessment shall be provided by
persons who have the experience necessary to perform psychometric tests that
assess an individual's functional behavioral level and who are one of the
following:
(a)
Psychologist licensed by the state pursuant to Chapter 4732. of the Revised
Code;
(b)
Professional clinical counselor licensed by the state
pursuant to section 4757.22 of the Revised
Code;
(c)
Professional counselor licensed by the state pursuant
to section 4757.23 of the Revised
Code;
(d)
Independent social worker licensed by the state
pursuant to section 4757.27 of the Revised Code;
or
(e)
Social worker licensed by the state pursuant to
section 4757.28 of the Revised Code
working under the supervision of a licensed independent social worker.
(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 functional behavioral assessment only
when no other certified provider is willing and able.
(4)
Functional
behavioral assessment 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, as applicable, may result in denial, suspension, or
revocation of the provider's certification.
(D) Requirements for service delivery
Functional behavioral assessment 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 functional behavioral assessment shall include each of the following to validate payment for medicaid service:
(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.
(F) Payment standards
(1)
The billing unit, service code, and payment rate for functional behavioral
assessment are contained in the appendix to this rule.
(2)
Providers of
functional behavioral assessment shall be paid no more than their usual and
customary charge for the service.
(3)
An individual
may receive only one functional behavioral assessment in a waiver eligibility
span, the cost of which shall not exceed one thousand five hundred
dollars.
(4)
Providers of functional behavioral assessment are
prohibited from submitting claims under both the self-empowered life funding
waiver and the state medicaid program for the same functional behavioral
assessment.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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