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DEPARTMENT OF HEALTH CARE FINANCE
NOTICE OF PROPOSED RULEMAKING
The Director of the Department of Health Care Finance, pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2006 Repl. & 2012 Supp.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2008 Repl.)) hereby gives notice of the intent to adopt a new Chapter 71 (Medicaid Reimbursement for Early Intervention Services) to Title 29 (Public Welfare) of the District of Columbia Municipal Regulations (DCMR). These proposed rules set forth standards governing Medicaid reimbursement for Early Intervention services under the Strong Start initiative, administered by the Office of the State Superintendent of Education (OSSE). In accordance with the Individuals with Disabilities Education Act (IDEA), approved April 13, 1970 (84 Stat. 175; 20 U.S.C. § 1400 et seq.), these rules set forth the conditions of Medicaid reimbursement for Early Intervention services provided to eligible beneficiaries by OSSE.
A Medicaid beneficiary aged zero (0) through three (3) with an Individualized Family Service Plan is eligible for Early Intervention services. Beginning July 1, 2013, Medicaid reimbursement for Early Intervention services shall be available for Medicaid beneficiaries who have been assessed and found to have a twenty-five percent (25%) developmental delay in two (2) or more of the following areas: cognitive development; physical development; communication development; social or emotional development; and/or adaptive development. Beginning on July 1, 2014, Medicaid reimbursement for the continuation of Early Intervention services shall be available for beneficiaries ages three (3) through the first year for which the child enters or is eligible under District of Columbia law to enter kindergarten or elementary school. Medicaid reimbursement for the continuation of Early Intervention services shall not be provided beyond the age at which the child actually enters or is eligible under District of Columbia law to enter kindergarten or elementary school.
The Director also gives notice of the intent to take final rulemaking action to adopt these rules not less than thirty (30) days from the date of publication of this notice in the D.C. Register.
Title 29 (Public Welfare) of the DCMR is amended as follows:
Add a new Chapter 71, MEDICAID REIMBURSEMENT FOR EARLY INTERVENTION SERVICES, to read as follows:
7100 EARLY INTERVENTION SERVICES: GENERAL AND SPECIFIC STANDARDS
7100.1 Early Intervention (EI) services are specialized habilitative and rehabilitative services designed to promote the optimal development of infants and toddlers, aged birth to three, who have a delay in one or more areas of development. EI services are required under Part C of the Individuals with Disabilities Education Act (IDEA) (20 U.S.C. § 1400 et seq.).
7100.2 The Office of the State Superintendent of Education (OSSE) is the Lead Agency responsible for administering EI services to eligible infants and toddlers in the District of Columbia under Part C of the IDEA. The Department of Health Care Finance (DHCF) is the single state agency responsible for administering the Medicaid program under Title XIX of the Social Security Act (42 U.S.C. § 1396).
7100.3 DHCF will reimburse the Lead Agency for EI services provided to Medicaid beneficiaries in accordance with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit and the requirements set forth in these rules.
7100.4 The Lead Agency shall be the qualified Medicaid enrolled provider for EI services and shall ensure the following:
(a) A multidisciplinary evaluation and assessment of the child’s level of functioning as described in 34 C.F.R. § 303.321, in the following developmental areas:
(1) Cognitive development;
(2) Physical development, including vision, and hearing;
(3) Communication development;
(4) Social or emotional development; and
(5) Adaptive development.
(b) Consultation with the child’s family or other service provider;
(c) Evaluation of the family’s capacity to meet the developmental needs of the child;
(d) Development, review and evaluation of the child’s Individualized Family Service Plan (IFSP) as described in 34 C.F.R §§ 303.342-303.344, which shall include initial and subsequent plans of care, assessments for services, IFSP team orders, medical conditions, functional losses, other pertinent documentation of the beneficiary’s progress or lack of progress, and treatment goals and services provided in order to demonstrate that EI Services are reasonable and necessary;
(e) Service coordination as described in 34 C.F.R. § 303.34;
(f) The ability to communicate with the child and their parent or other authorized caregiver;
(g) Completion of screenings pursuant to the Criminal Background Checks for the Protection of Children Act of 2004, effective April 13, 2005 (D.C. Law 15-353; D.C. Official Code § 4-1501.01 et seq.) and, if applicable, shall comply with any background check requirements established by the Department of Health Care Finance (DHCF) and/or the Lead Agency;
(h) On-site inspections to be conducted by the Centers for Medicare and Medicaid Services (CMS) and DHCF to determine provider compliance with all applicable laws; and
(i) Maintenance of documentation for at least ten (10) years from service initiation.
7100.5 DHCF will reimburse the Lead Agency for EI services provided to eligible Medicaid beneficiaries who are enrolled in the fee-for-service program, and have been assessed, pursuant to § 7101.2, and found to meet one (1) or more of the following requirements:
(a) Has a fifty-percent (50%) developmental delay in one (1) or more of the following areas:
(1) Cognitive development;
(2) Physical development, including vision and hearing;
(3) Communication development;
(4) Social or emotional development; or
(5) Adaptive development; and
(b) Has a diagnosed physical or mental condition that has a high probability of resulting in a significant developmental delay.
7100.6 Transportation services for EI services shall be provided in accordance with the contract between DHCF and the District’s Medicaid Non-Emergency Transportation Broker.
7100.7 Beginning on July 1, 2013, Medicaid reimbursement for EI services shall be provided to Medicaid beneficiaries, age three (3) and under, who have been assessed and found to meet one (1) or more of the following requirements in §7101.3 and/or has a twenty-five percent (25%) developmental delay in two (2) or more of the following areas:
(1) Cognitive development;
(2) Physical development, including vision and hearing;
(3) Communication development;
(4) Social or emotional development; or
(5) Adaptive development.
7100.8 Beginning on July 1, 2014, and in accordance with 34 C.F.R. § 303.211, a parent of a child with a disability who is eligible for preschool services under § 619 of Part C of Individuals with Disabilities Education Act (IDEA) and who previously received EI services under Part C of IDEA, may choose the continuation of Medicaid reimbursement for EI services under Part C for his or her child after the child turns three (3) or become eligible pursuant to §§ 7101.3 and 7101.4.
7100.9 The continuation of Medicaid reimbursement for EI services under Part C of IDEA for eligible children with disabilities is available from age three (3) until the first year for which the child enters or is eligible under District of Columbia law to enter pre-kindergarten or elementary school. The continuation of EI services shall not be provided beyond the age at which the child actually enters, or is eligible under District of Columbia law to enter pre-kindergarten or elementary school.
7100.10 Medical and health services shall be reimbursed by DHCF under the authority of the EPSDT services benefit subject to any requirements set forth in the State Plan, implementing rules, and any subsequent amendments thereto.
7100.11 EI Services that are eligible for Medicaid reimbursement shall include the following:
(a) Assistive technology devices and services as described in 34 C.F.R. § 303.13(b)(1);
(b) Audiology services as described in 34 C.F.R. § 303.13(b)(2);
(c) Developmental therapy, also known as Special Instruction as described in 34 C.F.R. § 303.13(b)(14);
(d) Nursing services as described in 34 C.F.R. § 303.13(b)(6);
(e) Nutrition services as described in 34 C.F.R. § 303.13(b)(7);
(f) Occupational therapy as described in 34 C.F.R. § 303.13(b)(8);
(g) Physical therapy as described in 34 C.F.R. § 303.13(b)(9);
(h) Psychological services as described in 34 C.F.R. § 303.13(b)(10);
(i) Social work services as described in 34 C.F.R. § 303.13(b)(13);
(j) Speech-language pathology as described in 34 C.F.R. § 303.13(b)(15); and
(k) Vision services as described in 34 C.F.R. § 303.13(b)(17).
7100.12 In accordance with 20 USC § 1432(4)(G), to the maximum extent appropriate, EI services shall be provided in natural environments, including the home and community settings in which children without disabilities participate.
7101 ASSISTIVE TECHNOLOGY
7101.1 Medicaid reimbursable assistive technology devices shall be:
(a) Authorized through DHCF or its designee;
(b) Deemed medically necessary; and
(c) Included in the child’s IFSP.
7101.2 Medicaid reimbursable assistive technology services shall directly assist the child and shall include the following:
(a) Selecting, designing, fitting, customizing, adapting, applying, maintaining, or replacing assistive technology devices;
(b) Training or technical assistance for a child or, if appropriate, that child’s family; and
(c) Training or technical assistance for professionals or other individuals who are otherwise substantially involved in the major life functions of the child.
7101.3 Medicaid reimbursement for assistive technology devices shall be made according to the District of Columbia Medicaid fee schedule available online at http://www.dc-medicaid.com.
7102 AUDIOLOGY SERVICES
7102.1 In accordance with 42 C.F.R § 440.110(c)(3), Medicaid reimbursable audiology services shall be provided by an audiologist. Each audiologist shall also comply with the requirements set forth in the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code § 3-1201.01 et seq.), implementing rules, and any subsequent amendments thereto.
7102.2 Each audiologist who provides Medicaid reimbursable EI Services shall also be certified by the Lead Agency in accordance with 5-E DCMR § 1663.
7102.3 Each audiologist who provides Medicaid reimbursable EI Services shall:
(a) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis; and
(b) Undergo an annual physical examination by a physician, and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7102.4 Medicaid reimbursable audiology services shall include the following:
(a) Identification of auditory impairment, using at risk criteria and appropriate audiological screening techniques;
(b) Determination of the range, nature, and degree of hearing loss and communication functions, by use of audiological evaluation procedures;
(c) Provision of auditory training, including, but not limited to:
(1) Language habilitation;
(2) Speech reading (lip-reading);
(3) Cued language services; and
(4) Listening device orientation, training, and other services.
(d) Evaluation, selection, fit and dispensation of hearing assistive technology devices, including hearing aids, dispensing appropriate listening and vibrotactile devices, and evaluating the effectiveness of those devices; and
(e) Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with an auditory impairment.
(f) Provision of services for the prevention of hearing loss.
7103 DEVELOPMENTAL THERAPY SERVICES
7103.1 Providers of Medicaid reimbursable developmental therapy services, also known as Special Instruction, shall meet one (1) or more of the following requirements:
(a) Have a Teaching Endorsement in Early Childhood Education (ECE) or Special Education;
(b) Have a bachelor’s degree in Early Childhood Development, Early Childhood Education, Early Childhood Special Education, Special Education, or a related health, human service, or education field with one (1) year of direct experience with children age three (3) and under; or
(c) Be a licensed occupational therapist, physical therapist, or qualified speech pathologist subject to the requirements set forth in §§ 7107.1, 7108, and 7111, with one (1) year of direct experience with children age three (3) and under.
7103.2 Licensed occupational therapists, physical therapists, or qualified speech pathologists providing Medicaid reimbursable developmental therapy services shall comply with the requirements set forth in § 7104.1 and shall have documented completion of at least three (3) semester hours or thirty (30) continuing education units (CEU) in the following EI core knowledge content areas:
(1) The development of young children;
(2) Typical and atypical child development;
(3) Working with families of young children with disabilities; and
(4) Intervention strategies for young children with special needs.
7103.3 Applied Behavioral Analysis (ABA) therapy shall be provided by a provider with the credentialing requirements set forth in §§ 7104.1 and 7104.2 and shall also be certified as a Board Certified Behavior Analyst by the Behavior Analyst Certification Board.
7103.4 Medicaid reimbursable developmental therapy services shall include the following:
(a) Assistance with developing and/or enhancing social and adaptive skills to enable the child to attain maximum functional level;
(b) Assistance with acquisition, retention, and/or improvement of skills related to activities of daily living, such as feeding, dressing communicating with caregivers, and the social and adaptive skills to enable the child to reside in his/her home or non-institutional community setting;
(c) Individual, group, or family therapy with the parents and other family members;
(d) Family training, education, and support provided to assist the family of the child in understanding the special needs of the child as related to enhancing their skill development; and
(e) ABA for children suspected to have Autism Spectrum Disorders (ASD).
7104 NURSING SERVICES
7104.1 In accordance with 42 C.F.R. § 440.60(a), Medicaid reimbursable nursing services shall be provided by a registered nurse (RN). Each RN shall comply with the requirements set forth in the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code §3-1201 et seq.), implementing rules, and any subsequent amendments thereto.
7104.2 Each RN providing Medicaid reimbursable nursing services shall:
(a) Be certified by the Lead Agency in accordance with 5-E DCMR § 1660; and
(b) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis.
(c) Undergo an annual physical examination by a physician, and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7104.3 Medicaid reimbursable nursing services provided within the scope of EI services and as described under the child’s IFSP shall include the following:
(a) The assessment of health status for the purpose of providing nursing care, including the identification of patterns of human response to actual or potential health problems;
(b) The provision of nursing care to prevent health problems, restore or improve functioning, and promote optimal health and development; and
(c) The administration of medications, treatments, and regimens prescribed by a licensed physician.
7105 NUTRITION SERVICES
7105.1 In accordance with 42 C.F.R. § 440.60(a), Medicaid reimbursable nutrition services shall be provided by a dietician or nutritionist. Each dietician or nutritionist shall also comply with the requirements set forth in the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 as amended (D.C. Law 6-99; D.C. Official Code § 3-1201 et seq.), implementing rules, and any subsequent amendments thereto.
7105.2 Each dietician or nutritionist providing Medicaid reimbursable EI services shall:
(a) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis; and
(b) Undergo an annual physical examination by a physician and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7105.3 Medicaid reimbursable nutrition services shall include the following:
(a) Individual assessments, which shall include:
(1) Nutritional history and dietary intake;
(2) Anthropometric, biochemical, and clinical variables;
(3) Feeding skills and feeding problems; and
(4) Food habits and food preferences.
(b) Developing and monitoring appropriate plans to address the nutritional needs of the child, based on the individual assessments;
(c) Making referrals to appropriate community resources to carry out nutrition goals; and
(d) Family training, education, and support to assist the family of the child in understanding the special needs of the child as related to nutritional services.
7106 OCCUPATIONAL THERAPY
7106.1 In accordance with 42 C.F.R. § 440.110(b), Medicaid reimbursable occupational therapy (OT) services shall be provided and delivered by an occupational therapist or OT assistant and shall comply with the requirements set forth in the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code § 3-1201 et seq.), implementing rules, and any subsequent amendments thereto.
7106.2 Each provider of Medicaid reimbursable OT services shall:
(a) Be a licensed occupational therapist or be an OT assistant working under the direct supervision of a licensed occupational therapist; and
(b) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis.
(c) Undergo an annual physical examination by a physician, and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7106.3 Each provider of individual and group Medicaid reimbursable OT services shall:
(a) Prepare reports that measure the child’s strength, range of motion, balance, coordination, posture, muscle performance, respiration, and motor functions;
(b) Develop and describe treatment plans that explain the treatment strategies including direct therapy and monitoring requirements, instruments, instructions, and anticipated outcomes;
(c) Address the functional needs of a child related to adaptive development, adaptive behavior and play, and sensory, motor, and postural development;
(d) Assist with selection, design, fabrication, and adaptation of assistive and orthotic devices to facilitate development and promote the acquisition of functional skills;
(e) Provide individual and group services intended to prevent or minimize the impact of initial or future impairment, delay in development, or loss of functional ability; and
(f) Provide family training, education, and support provided to assist the family of the child in understanding the special needs of the child as related to OT services and the enhancement of the child’s development.
7107 PHYSICAL THERAPY
7107.1 In accordance with 42 C.F.R. § 440.110(a), Medicaid reimbursable physical therapy (PT) services shall be provided by a qualified physical therapist or PT assistant and shall also comply with the requirements set forth in the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code §§ 3-1201 et seq.), implementing rules, and any subsequent amendments thereto.
7107.2 Each provider of Medicaid reimbursable PT services shall:
(a) Be a licensed physical therapist or be a physical therapy assistant working under the direct supervision of a licensed physical therapist, and have a Bachelor’s Masters, and/or Doctorate degree in Physical Therapy; and
(b) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis.
(c) Undergo an annual physical examination by a physician and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7107.3 Each provider of Medicaid reimbursable individual and group PT services shall:
(a) Provide a comprehensive screening, evaluation, and assessment to measure the child’s strength, range of motion, balance and coordination, posture, muscle performance, respiration, and motor functions;
(b) Develop and describe treatment plans that explain the treatment strategies including direct therapy and monitoring requirements, instruments, instructions, and anticipated outcomes;
(c) Address the promotion of sensorimotor function through enhancement of musculoskeletal status, neurobehavioral organization, perceptual and motor development, cardiopulmonary status, and effective environmental adaptation;
(d) Obtain, interpret, and integrate information appropriate to program planning, that is intended to prevent, alleviate, and/or mitigate movement dysfunction and related functional problems;
(e) Provide individual and group services intended to prevent, alleviate, and/or mitigate movement dysfunction and related functional problems; and
(f) Provide family training, education, and support provided to assist the family of the child in understanding the special needs of the child as related to PT services and enhancing the child’s development.
7108 PSYCHOLOGICAL SERVICES
7108.1 In accordance with the 42 C.F.R. § 440.60(a), Medicaid reimbursable psychological services shall be provided by a clinical psychologist. Each clinical psychologist shall also comply with the requirements set forth in the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code § 3-1201.01 et. seq.), implementing rules, and any subsequent amendments thereto.
7108.2 Each clinical psychologist providing Medicaid reimbursable EI services shall:
(a) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis; and
(b) Undergo an annual physical examination by a physician, and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7108.3 Medicaid reimbursable psychological services shall include the following:
(a) Obtaining, integrating, and interpreting information about child behavior and child and family conditions related to learning, mental health, and development;
(b) Administration and interpretation of psychological or other appropriate developmental tests;
(c) Diagnosis and assessment of social or emotional development of the child;
(d) Individual, group, or family counseling with the parents and other family members, including appropriate skill-building activities; and
(e) Family training, education, and support provided to assist the family of the child in understanding the special needs of the child as related to development, behavior or social-emotional functioning, and enhancement of the child’s development.
7109 SOCIAL WORK SERVICES
7109.1 In accordance with 42 C.F.R § 440.60(a), Medicaid reimbursable social work services shall be provided by social workers. Each social worker shall also comply with the requirements set forth in the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code § 3-1201.01 et seq.), implementing rules, and any subsequent amendments thereto.
7109.2 Each social worker providing Medicaid reimbursable social work services shall be certified by the Lead Agency in accordance with 5-E DCMR § 1660.
7109.3 Each social worker providing Medicaid reimbursable EI services shall:
(a) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis; and
(b) Undergo an annual physical examination by a physician and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7109.4 Medicaid reimbursable social work services shall include the following:
(a) Home visits to evaluate a child’s living conditions and patterns of parent-child interaction;
(b) Individual and family group counseling with parents and other family members, and appropriate social skill-building activities with the child and parent;
(c) Working with the child and family to alleviate problems in the living situation that affect the child’s maximum utilization of EI services; and
(d) Identifying, mobilizing, and coordinating community resources and services to enable the child to receive maximum benefit from EI services.
7110 SPEECH-LANGUAGE PATHOLOGY SERVICES
7110.1 In accordance with 42 C.F.R. § 440.110(c)(2), Medicaid reimbursable speech-language pathology services shall be provided by qualified speech pathologists. Each speech pathologist providing EI services shall also comply with the requirements set forth in the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code § 3-1201 et seq.), implementing rules, and any subsequent amendments thereto.
7110.2 Each speech pathologist providing Medicaid reimbursable speech-language pathology services shall:
(a) Be certified by the Lead Agency in accordance with 5 DCMR E § 1658; and
(b) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis.
(c) Undergo an annual physical examination by a physician, and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7110.3 Medicaid reimbursable speech-language pathology services shall include the following:
(a) Comprehensive diagnosis and assessment of communicative or oropharyngeal disorders and delays in the development of communication skills;
(b) The provision of services for the habilitation, rehabilitation, or the prevention of communicative or oropharyngeal disorders and delays in the development of communication skills;
(c) Assessment of need for augmentative and alternative speech devices, methods, strategies, and the use of adaptive equipment;
(d) Family training, education, and support provided to assist the family of the child in understanding the special needs of the child as related to speech-language pathology services and enhancing the child’s development.
7111 VISION SERVICES
7111.1 In accordance with 42 C.F.R. § 440.130(d), Medicaid reimbursable vision services shall be provided by qualified orientation and mobility specialists. Each orientation and mobility specialist shall comply with the requirements set forth in the District of Columbia Health Occupations Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code § 3-1201 et seq.), implementing rules, and any subsequent amendments thereto.
7111.2 Each orientation and mobility specialist providing Medicaid reimbursable EI services shall be certified as an Orientation/Mobility Specialist from the Association for Education and Rehabilitation of the Blind and Visually Impaired (AER) or the Academy for Certification of Vision Rehabilitation and Education.
7111.3 Each orientation and mobility specialist providing Medicaid reimbursable EI services shall:
(a) Undergo an annual purified protein derivative (PPD) skin test to confirm that he or she is free from tuberculosis; and
(b) Undergo an annual physical examination by a physician, and obtain written and signed documentation from the examining physician to confirm that he or she is free from all disease in communicable form.
7111.4 Medicaid reimbursable vision services shall include the following:
(a) Evaluation and assessment of visual functioning, including the diagnosis and appraisal of specific visual disorders, delays, and abilities that affect early childhood development;
(b) Communication skills training, orientation and mobility training for all environments, visual training, and additional training necessary to activate visual motor abilities; and
(c) Referral for medical or other professional services necessary for the habilitation or rehabilitation of visual functioning disorders, or both.
7112 REIMBURSEMENT
7112.1 DHCF and the Lead Agency shall identify policies and procedures for allocating financial responsibility for EI services through a Memorandum of Understanding.
7112.2 The Lead Agency shall take all responsible measures to ascertain the legal liabilities of third-party payers prior to billing Medicaid. Rendering providers shall bill the OSSE Strong Start program for Medicaid covered services.
7112.3 In accordance with 42 U.S.C. § 1396, the Lead Agency shall utilize public insurance, such as Medicaid’s (Title XIX) and the EPSDT benefit, to the maximum extent possible within the limits of the program.
7112.4 The Lead Agency shall agree to accept as payment in full the amount determined by DHCF as Medicaid reimbursement for the authorized services provided to beneficiaries pursuant to § 7115. Rendering providers shall not bill the beneficiary or any member of the beneficiary’s family for EI services.
7112.5 Reimbursement to the Lead Agency for EI services shall be available when:
(a) Described in the IFSP according to the amount, scope, and duration of services required;
(b) Ordered by qualified health care professionals who shall be licensed practitioners of the healing arts, as set forth in 42 C.F.R. §§ 440.60, 440.110, 440.130, and 440.167, the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986, as amended, (D.C. Law 6-99; D.C. Official Code § 3-1201.01 et seq.), implementing rules, and any subsequent amendments thereto; and
(c) The Lead Agency has provided a parent with written notification of IDEA no-cost protections and confidentiality provisions.
7112.6 Medicaid reimbursement for EI services shall not include:
(a) Traveling, training, waiting, or preparation of reports;
(b) Therapeutic services that are not developmentally-based, but required due to, or as part of, a medical procedure, a medical intervention, or an injury, unless the condition has become chronic or sub-acute;
(c) Services other than the initial and periodic assessments that are not documented in the IFSP;
(d) Services rendered in a clinic or provider’s office without justification for the location;
(e) Service coordination; and
(f) Services provided in the absence of the child and a parent or other authorized caregiver identified in the IFSP with the exception of IFSP team meetings, which do not include the child.
7113 PROGRAM OVERSIGHT AND INTEGRITY
7113.1 DHCF and the Lead Agency shall comply with the agreement set forth in the Memorandum of Agreement.
7113.2 All records shall be available for review by DHCF, OSSE, CMS, and the U.S. Department of Health and Human Services.
7114 MEDICAID REIMBURSEMENT RATES
Services
Procedure Codes
Rate
Assistive Technology Services
DME Procedure Codes
Varies depending on code
Assessments for Service Planning
T1023 R1 (RC1)
T1023 R2 (RC2)
$37.50/15 min
$28.50/ 15 min
Audiology
G0153 GP (group)
$25.13/15 min
G0153 R1 (individual RC1)
G0153 R2 (individual RC2)
$37.50/15 min
$28.50/15 min
Developmental Therapy
T1027 R2 (individual RC2)
$27.50/15 min
Developmental Therapy– Applied Behavioral Analysis Method
T1027 R1 (individual RC1)
T1027 R2 (individual RC2)
T1027 GP (group)
$31.25/15 min
$27.50/15 min
$18.43/15 min
Group Therapy (two (2) or more children)
T1027 GP (group)
$18.43/15 min
Nursing Services
G0154 U1 (individual)
$37.50/15 min
G0154 GP (group)
$25.13/15 min
Nutrition Services
97802 R2 (initial)
$30.41/15 min
97803 R2 (subsequent)
$26.49/15 min
97804 R2 (group)
$13.32/15 min
Occupational Therapy
G0152 U1 (individual)
$37.50/15 min
G0152 GP (group)
$25.13/15 min
Social Work Services
90806
$70.94/50 min
90846
$71.06/50 min
Psychological Services
90802
$146.76/dx interview
90804
$54.06/30 min
90806
$70.94/50 min
90808
$103.32/80 min
90810
$55.23/30 min
96111
$108.71
Physical Therapy
G0151 U1 (individual RC1)
G0151 U1 (individual RC2)
$37.50/15 min
$28.50/15 min
G0151 GP (group)
$25.13/15 min
Speech-Language Pathology
G0153 U1 (individual RC1)
G0153 U1 (individual RC2)
$37.50/15 min
$28.50/15 min
G0153 GP (group)
$25.13/15 min
Team Treatment Activities (more than one professional providing services during same session for an individual child/family)
T1024 R1 (individual RC1)
$37.50/15 min
7199 DEFINITIONS
For the purposes of this chapter, the following terms shall have the meanings
ascribed as follows:
Applied Behavioral Analysis (ABA) - The science of applying interventions based on principles of learning and motivation to promote socially significant behavior changes by teaching new skills, promoting generalization of these skills, and reducing challenging behaviors with systematic reinforcement.
Assessment – Assessment refers to the process of determining the beneficiary’s need, nature, amount, scope, and duration of treatment; determining the level of coordination between varying forms of treatment; and the detailed documentation of the assessment findings.
Autism Spectrum Disorder (ASD) – Refers to any of a group of developmental disorders marked by impairments in the ability to communicate and interact socially and by the presence of repetitive behaviors or restricted interests.
Department of Health Care Finance (DHCF) – Single State Agency for the administration of medical assistance programs.
Early and Periodic Screening, Diagnostic and Treatment (EPDST) services benefit – Services designed for Medicaid-eligible beneficiaries through the age of twenty (20) that include periodic and inter-periodic screenings to identify physical and mental conditions, vision, hearing, and dental, as well as diagnostic and medically necessary treatment services to correct conditions identified during screenings.
Office of the State Superintendent of Education (OSSE) – The Lead Agency for IDEA Part C for the District of Columbia responsible for establishing District-wide policies, providing resources and support, and exercising accountability to ensure a statewide, comprehensive, coordinated, multidisciplinary, interagency system to provide early intervention services for infants and toddlers with disabilities and their families.
Individualized Family Service Plan (IFSP) – A written plan for providing early intervention services to an infant or toddler who is eligible for EI services based on an evaluation and assessment, including outcome measurements, as required under Section 636 of the IDEA (20 U.S.C. § 1436).
Individuals with Disabilities Education Act (IDEA) – 20 U.S.C. §§ 1432 et. seq.
IFSP Team– Each initial and annual IFSP is required to have: the parent or parents of the child; other family members, as requested by the parent; an advocate ore person outside the family, if parent requests that person to participate; the service coordinator; a person or persons directly involved in conducting the evaluations or assessments, and; as appropriate, persons who will be providing early intervention services to the child or family. The team determines the frequency, intensity, method, duration, and location of EI services required in order to carry out the beneficiaries care plan.
Pre-Kindergarten – the year immediately preceding kindergarten.
Comments on these rules should be submitted in writing to Linda Elam, Ph.D., Medicaid Director, Department of Health Care Finance, Government of the District of Columbia, 899 North Capitol Street, NE, 6th Floor, Washington DC 20002, via telephone at (202) 442-9115, via email at DHCFPubliccomments@dc.gov, or online at www.dcregs.dc.gov, within thirty (30) days of the date of publication of this notice in the D.C. Register. Additional copies of these rules are available from the above address.
