D.C. Mun. Regs. tit. 29, § 1918
1918.1 Professional services shall be reimbursed by the District of Columbia Medicaid Program for each participant in the Home and Community-based Services Waiver for Persons with Mental Retardation and Developmental Disabilities (Waiver) subject to the requirements set forth in this section.
1918.2 To be eligible for reimbursement, professional services shall be:
1918.3 The professional services eligible for reimbursement shall be:
1918.4 The specific professional service delivered shall be consistent with the scope of the license or certification held by the professional. Service intensity, frequency, and duration shall be determined by individual need. The professional services may be short-term, intermittent, or long-term, depending on the need. The interdisciplinary team developing the plan of support shall determine service utilization.
1918.5 Sexuality Education shall be delivered by:
1918.6 The following professional services shall be delivered by credentialed professionals as set forth in the definition section of this rule:
1918.7 Each professional, within the first two (2) hours of services, shall conduct an assessment and develop an individualized plan for the person that is in keeping with his or her choices, goals and prioritized needs. The individualized plan shall identify specific outcomes for the person. The completed plan shall be delivered to the person, family, guardian, other caretaker, or Department on Disability Services (DDS) Case Manager.
1918.8 Professional services may be utilized to:
1918.9 Services shall be provided by an agency or professional in private practice. Each professional and agency shall meet the requirements set forth in Chapter 19 of Title 29 DCMR.
1918.10 The agency or professional in private practice shall have a current Medicaid Provider Agreement that authorizes the service provider to bill for Professional Services.
1918.11 Each person providing professional services shall be acceptable to the person.
1918.12 Each professional shall provide DDS and the Department of Health, Medical Assistance Administration a brochure listing his or her academic background, licensure information, experience and the nature of his or her practice to assist those who will receive services in making their provider selection.
1918.13 Professionals, without regard to their employer of record, shall be selected by the person receiving services or his or her guardian or legal representative and shall be answerable to the person receiving services. Any provider substituting professionals for more than a two (2) week period or four (4) visits due to emergency or availability events shall request a case conference with the DDS Case Manager to evaluate continuation of services.
1918.14 Each professional shall be responsible for providing written documentation in the form of reports, visit notes, progress notes, and other pertinent documentation of the person's progress or lack of progress. The documentation shall include evidence that services did not exceed the authorized frequency and duration as authorized in the individualized plan required pursuant to section 1918.7. The agency or professional in private practice shall maintain a copy of the documentation for at least six (6) years after the person's date of service.
1918.15 The reimbursement rate for professional services shall be:
(a) Sixty dollars ($60.00) per hour for Massage Therapy;
(b) Seventy five dollars ($75.00) per hour for Sexuality Education;
(c) Forty five dollars ($45.00) per hour for Art Therapy;
(d) Forty five dollars ($45.00) per hour for Dance Therapy;
(e) Forty five dollars ($45.00) per hour for Drama Therapy;
(f) Seventy five dollars ($75.00) per hour for Fitness Trainer;
(g) Seventy dollars ($70.00) per hour for Acupuncture; and
(h) Forty five dollars ($45.00) per hour for Music Therapy.
1918.16 The billable unit of service for professional services shall be fifteen (15) minutes. A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to bill a unit of service.
1918.17 Professional services shall be limited to a maximum of two thousand, two hundred and fifty dollars ($2,250.00) per participant per year and in accordance with the person's IHP or ISP and Plan of Care. Additional services may be prior authorized if the participant reaches the limitation before the expiration of the IHP or ISP and Plan of Care year and the participant's health and safety are at risk. The need for ongoing services shall be approved by a physician and DDS.
1918.99 DEFINITIONS
When used in this section, the following terms and phrases shall have the meanings ascribed:
Acupuncture - A professional service under this section which shall be provided by a person who is authorized to practice acupuncture pursuant to Chapter 47 of Title 17 of the District of Columbia Municipal Regulations (DCMR).
Art Therapy - A professional service under this section which shall be provided by a person who is certified to practice art therapy pursuant to certification by the American Art Therapy Association, Inc. and/or credentialing of the Art Therapy Credentialing Board.
Clinical Record - A comprehensive compilation of medical and other data that identifies the person and justifies and describes the diagnosis and treatment of the person.
Dance Therapy - A professional service under this section which shall be provided by a person who is authorized to practice dance therapy pursuant to Chapter 71 (Dance Therapy) of Title 17 DCMR.
Drama Therapy - A professional service under this section which shall be provided by a person who is certified to practice drama therapy pursuant to the National Association for Drama Therapy.
Fitness Trainer - A person who is certified to practice fitness training pursuant to Fitness Standards Council (FSC) Personal Trainer Accreditation.
Individual Habilitation Plan (IHP) - That plan as set forth in section 403 of the Mentally Retarded Citizens Constitutional Rights and Dignity Act of 1978, effective March 3, 1979 (D.C. Law 2-137; D.C. Official Code § 7-1304.03).
Individual Support Plan (ISP) - The successor to the individual habilitation plan (IHP) as defined in the 2001 Plan for Compliance and Conclusion of Evans v. Williams.
Interdisciplinary Team - A group of persons with special training and experience in the diagnosis and habilitation of mentally retarded persons who have the responsibility of performing a comprehensive person evaluation while participating in the development, implementation, and monitoring of the person's IHP or ISP and Plan of Care.
Licensed Clinical Social Worker - A person who is licensed as an independent clinical social worker pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code § 3-1202 et seq.) or licensed as an independent clinical social worker in the jurisdiction where the services are being provided.
Licensed Professional Counselor - A person who is licensed to practice professional counseling pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code § 3-1202 et seq.) or licensed as a professional counselor in the jurisdiction where the services are being provided.
Massage Therapy - A professional service under this section provided by a person who is authorized to practice massage therapy pursuant Chapter 75 of Title 17 DCMR.
Music Therapy - A professional service under this section provided by a person who is certified by the Certification Board for Music Therapists, which is managed by the American Music Therapy Association.
Person - An individual with intellectual and developmental disabilities who has been determined eligible to receive services under the Home and Community-based Waiver for Persons with Mental Retardation and Developmental Disabilities (Waiver).
Physician - A person who is authorized to practice medicine pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 D.C. Law 6-99; D.C. Official Code § 3-1201 et seq.) or licensed as a physician in the jurisdiction where services are provided.
Plan of Care - A written service plan that meets the requirements set forth in section 1904.4 of Title 29 DCMR, is signed by the person receiving services, and is used to prior authorize Waiver services.
Progress Note - A dated, written notation by a member of the health care team that summarizes facts about a person's care and response to treatment during a given period of time.
Psychiatrist - A person who is licensed to practice psychiatry pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code § 3-1202 et seq.) or licensed as a psychiatrist in the jurisdiction where the services are being provided.
Psychologist - A person who is licensed to practice psychology pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code § 3-1202 et seq.) or licensed as a psychologist in the jurisdiction where the services are being provided.
Sexuality Education Specialist - A person who is certified to practice sexuality education pursuant to certification by the American Association of Sexuality Educators, Counselors and Therapists (AASECT) Credentialing Board.
Waiver - The Home and Community-based Services Waiver for Persons with Mental Retardation and Developmental Disabilities as approved by the Council of the District of Columbia (Council) and the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), as may be further amended and approved by the Council and CMS.
SOURCE: Final Rulemaking published at 55 DCR 2906 (March 21, 2008).