9016 BEHAVIORAL SUPPORT SERVICES

9016.1 The purpose of this section is to establish standards governing Medicaid eligibility for behavioral support services for persons enrolled in the Home and Community-Based Services Waiver for Individual and Family Support (IFS Waiver), and to establish conditions of participation for providers of behavioral support services.

9016.2 Behavioral support services are designed to assist people who exhibit behavior that inhibits their ability to live safely in the community or who need support to:

1. (a) Build alternative and more communication skills;
2. (b) Achieve positive personal outcomes including their Individual Support Plan (ISP) goals, based on what is important to and important for people; and
3. (c) Interact more effectively in the community.

9016.3 Medicaid reimbursable behavioral support services shall be:

1. (a) Recommended by the person's support team;
2. (b) Identified in the person's ISP and Plan of Care;
3. (c) Approved by the Department on Disability Services (DDS) Restrictive Controls Review Committee or Health and Wellness Unit for 1:1 behavioral supports;
4. (d) Recommended by a physician or Advanced Practice Registered Nurse (APRN) if the services are 1:1 behavioral supports related to a medical condition; and
5. (e) Prior authorized by DDS before the commencement of services.

9016.4 Medicaid reimbursable behavioral support services may include the following activities, as needed by the person:

1. (a) Development of a Diagnostic Assessment Report (DAR) in accordance with the requirements described under § 9016.22 to 9016.23;
2. (b) Development of a Behavior Support Plan (BSP) in accordance with the requirements described under § 9016.24 to 9016.26;

(c) Implementation of positive behavioral support strategies and principles based on the DAR and BSP;

(d) Training of the person, his or her family, support team, and providers of their residential services and day services, to implement the BSP;

(e) Evaluation of the effectiveness of the BSP by monitoring the plan at least monthly, or more often as necessary, developing a system for collecting BSP-related data, and revising the BSP;

(f) Consultation services for the person, his or her family and/or support team;

(g) Counseling services for the person, if pre-approved by DDS; and

(h) Participating in the person's quarterly psychotropic medication review.

9016.5 Behavioral support services shall be provided in one (1) of three (3) tiers, based upon the assessed needs of the person:

(a) Tier 1, or Low-Intensity Behavioral Support, shall provide up to twelve (12) hours per year of behavioral support consultation and training for a person, their family, and/or support team to provide technical assistance to address behaviors that interfere with a person's ability to achieve their ISP goals, but which are not dangerous to themselves or others, and to support skill building. Tier 1 Behavior Support Services may also be used to support a fade plan or develop a less restrictive option for any allowable modifications of the requirements of the HCBS Setting Rule (specifically Section 441.710, paragraphs (a)(1)(vi)(A) through (D)) that has been supported by a specific assessed need and justified in the person-centered service plan;

(b) Tier 2, or Moderate Behavioral Support, shall provide up to fifty (50) hours per year (plus up to twenty-six (26) hours of counseling services) for a person who exhibits challenging behavior that either impacts a person's ability to retain a baseline level of independence (i.e. loss of job, loss of natural supports, eviction/ loss of residence, or causes a higher level of supervision than would otherwise be necessary); or that interferes with the person's quality of life (i.e. desired outcomes, relationships, exposure to and opportunities for engagement in a range of community activities); and

(c) Tier 3, or Intensive Behavioral Support, shall provide up to one hundred (100) hours per year (plus up to fifty-two (52) hours of counseling services) to assist a person who exhibits behaviors that are extremely challenging and frequently complicated by medical or mental health factors. Tier 3 shall

assist a person who exhibits behaviors that, due to their frequency, severity, or intensity, pose a threat to the person's health or safety or to the health and safety of others. Behavior support services for a person in Tier 3 may incorporate one (1) or more restrictive measures.

9016.6 Medicaid reimbursement for Tier 1 Low Intensity Behavioral Support Services shall provide up to twelve (12) hours of support per year for the services listed below. Services provided that exceed the limitations shall not be reimbursed except as provided in § 9016.10.

- (a) Training of the person, his or her family, the support team, and residential and day staff; and

- (b) On-site consultation and observations.

9016.7 Medicaid reimbursement for Tier 2 Moderate Behavioral Support Services shall provide up to fifty (50) hours of support per year for the services listed below; and Medicaid reimbursement for Tier 3 Intensive Behavioral Support Services shall provide up to one hundred (100) hours of support per year for the services listed below. Services provided that exceed these limitations shall not be reimbursed except as provided in § 9016.10.

- (a) Development of a new BSP;

- (b) Reviewing and updating the existing BSP, which shall be limited to up to three (3) hours for Tier 2 and eight (8) hours for Tier 3;

- (c) Training of the person, his or her family, the support team, and residential and day staff;

- (d) On-site consultation and observations;

- (e) Participation in behavioral review or treatment team meetings, delivering notes including emergency case conferences, hospital discharge meetings, interagency meetings, pre-ISP and ISP meetings, and human rights meetings;

- (f) Completion of quarterly reports, diagnostic updates and monitoring monthly data; and

- (g) Participation in psychotropic medication review meetings to deliver notes.

9016.8 In order to be eligible for Medicaid reimbursement, requests for more than seventy-five (75) hours of behavior support services must be reviewed and approved by a DDS designated staff member.

9016.9 In addition, a person receiving Tier 2 Moderate Behavioral Support Services may receive up to twenty-six (26) hours of counseling per year, if approved by DDS; and a person receiving Tier 3 Intensive Behavioral Support Services may receive up to fifty-two (52) hours of counseling per year, if approved by DDS.9016.10 In order to be eligible for Medicaid reimbursement, requests for additional hours beyond the annual limits may be approved by DDS upon the submission of a diagnostic update to amend the DAR and accompanying worksheet.9016.11 In order to be eligible for Medicaid reimbursement, requests for counseling as a behavioral support service shall be approved by a DDS designated staff member and shall be limited to counseling services that are not available under the District of Columbia State Plan for Medical Assistance.9016.12 To qualify for Medicaid reimbursable one-to-one behavioral supports, a person shall meet at least one (1) of the following criteria:- (a) Exhibit elopement resulting in serious risk to the safety of self or others;

- (b) Exhibit behavior that is life threatening to self and others;

- (c) Exhibit destructive behavior causing serious property damage;

- (d) Exhibit sexually predatory behavior;

- (e) Exhibit self-injurious behavior that poses a serious risk to the person's safety; or

- (f) Have a medical condition that requires one-to-one services.9016.13 Medicaid reimbursable one-to-one behavioral supports related to a medical condition shall be approved by DDS, and shall be based upon a physician or APRN order for one-to-one behavioral supports associated with a medical condition that meets the requirements of DDS's policies and procedures. The order shall include, at a minimum, the following information:- (a) A specific time period or duration for the delivery of services;

- (b) A description of the medical condition that causes the person's health or safety to be at risk;

- (c) The responsibilities of each staff person delivering supports; and

(d) A justification of the need for one-to-one behavioral supports.

9016.14 Medicaid reimbursable one-to-one behavioral support services provided by a DSP shall not be provided concurrently with in-home supports, day habilitation, companion or individualized day supports one-to-one services unless authorized by DDS, required by court order or otherwise necessary to support a person or persons who have complex behaviors or medical needs that involve a risk to the health, safety or well-being of the person based on the intensity of the person's behavioral or medical needs.

9016.15 Within the service authorization period, a provider of Medicaid reimbursable behavioral supports services shall:

(a) Complete the diagnostic assessment;

(b) Complete the DAR and the accompanying behavioral support referral worksheet ("worksheet") based on the results of the diagnostic assessment; and

(c) Complete the BSP when recommended by the DAR.

9016.16 The DAR shall be effective for three (3) years except as indicated in § 9016.17, or for a person receiving one-to-one behavioral supports, which shall be updated annually. Reauthorization of behavioral support services within the three (3) year period shall be requested in a diagnostic update with accompanying referral worksheet submitted to the DDS Service Coordinator.

9016.17 When a person experiences changes in psychological or clinical functioning, the behavioral supports provider shall submit a diagnostic update with an accompanying worksheet to amend the DAR to the DDS Service Coordinator at any time during the three (3) year period, upon the recommendation of the support team.

9016.18 The worksheet accompanying the DAR shall include the number of hours requested for professional services, paraprofessional services, and one-to-one behavioral support services to address recommendations in the DAR.

9016.19 The diagnostic update shall include a written clinical justification supporting the reauthorization of services.

9016.20 The diagnostic update shall be reviewed by the person and his or her support team in consultation with behavioral supports staff.

9016.21 The BSP shall be effective for up to two (2) calendar years, which shall correspond with the person's ISP year unless revised, updated or discontinued

when no longer necessary in accordance with the recommendations of the DAR and accompanying worksheet.

9016.22 To be eligible for Medicaid reimbursement, the diagnostic assessment shall include the following activities:

1. (a) Direct assessment techniques such as observation of the person in the setting in which target behaviors are exhibited, and documentation of the frequency, duration, and intensity of challenging behaviors;
2. (b) Indirect assessment techniques such as interviews with the person's family members and support team, written record reviews, and questionnaires; and
3. (c) An explanation of how existing environmental, psychological, and/or medical influences impact the occurrence of behavioral problems.

9016.23 To be eligible for Medicaid reimbursement, the DAR shall include the following:

1. (a) The names of individuals to contact in the event of a crisis;
2. (b) A summary of the person's cognitive and adaptive functioning status;
3. (c) A full description of the person's behavior including background, and environmental contributors;
4. (d) The counseling and problem-solving strategies used to address behavioral problems and their effectiveness;
5. (e) A list of positive, non-restrictive or less restrictive interventions utilized, the results, and an explanation of why the interventions were unsuccessful;
6. (f) A list of proposed goals for achieving changes in target behaviors; and
7. (g) The recommendations to initiate, continue, or discontinue behavioral support services.

9016.24 In order to be eligible for Medicaid reimbursement, the BSP shall be developed utilizing the following activities:

1. (a) Interviews with the person and their support team;
2. (b) Observations of the person at his or her residence and in the community, if applicable; and

(c) Review of the person's medical and psychiatric history including laboratory and other diagnostic studies, and behavioral data.

9016.25 In order to be eligible for Medicaid reimbursement, the behavioral supports staff that develops the BSP shall be responsible for:

1. (a) The coordination of the delivery of behavioral support services in the person's residential and day activity settings; and
2. (b) Obtaining the person's written informed consent and the approval of the person's substitute decision-maker, the support team, the provider's human rights committee, and DDS, when required by DDS's policies and procedures.

9016.26 In order to be eligible for Medicaid reimbursement, the BSP shall include the following:

1. (a) A clear description of the targeted behavior(s) that is consistent with the person's diagnosis;
2. (b) The data reflecting the frequency of target behaviors;
3. (c) A functional behavioral analysis of each target behavior;
4. (d) A description of techniques for gathering information and collecting data;
5. (e) The proactive strategies utilized to foster the person's positive behavioral support;
6. (f) The measurable behavioral goals to assess the effectiveness of the BSP;
7. (g) If restrictive techniques and procedures are included, the rationale for utilizing the procedures and the development of a fade-out plan; and
8. (h) Training requirements for staff and other caregivers to implement the BSP.

9016.27 Each provider of behavioral support services shall comply with Sections 9010 (Provider Qualifications) and 9009 (Provider Enrollment) of Chapter 90 of Title 29 DCMR and consist of one (1) of the following provider types:

1. (a) A professional service provider in private practice as an independent clinician, as described in Section 9010 (Provider Qualifications) of Chapter 90 of Title 29 DCMR;
2. (b) A Mental Health Rehabilitation Services agency (MHRS) certified in accordance

with the requirements of Chapter 34 of Title 22-A DCMR;

(c) A home health agency as described in Section 9010 (Provider Qualifications), of Chapter 90 of Title 29 DCMR; or

(d) A HCBS Provider, as described under Section 9010 (Provider Qualifications), of Chapter 90 of Title 29 DCMR.

9016.28 In order to be eligible for Medicaid reimbursement, each MHRS agency shall serve as a clinical home by providing a single point of access and accountability for the provision of behavioral support services and access to other needed services.

9016.29 Individuals authorized to provide professional behavioral support services without supervision shall consist of the following professionals:

(a) A psychiatrist;

(b) A psychologist;

(c) An APRN or a Nurse Practitioner (NP); and

(d) A Licensed Independent Clinical Social Worker (LICSW).

9016.30 Individuals authorized to provide paraprofessional behavioral support services under the supervision of qualified professionals described under § 9016.29 shall consist of the following behavior management specialists:

(a) A licensed Professional Counselor;

(b) A licensed Social Worker (LISW);

(c) A licensed Graduate Social Worker (LGSW);

(d) A board Certified Behavior Analyst;

(e) A board Certified Assistant Behavior Analyst; and

(f) A registered Nurse.

9016.31 In order to receive Medicaid reimbursement, the person who drafts the BSP shall be a psychologist with at least a master's level degree working under the supervision of a licensed psychologist or an LICSW.

9016.32 In order to receive Medicaid reimbursement, the minimum qualifications for a person providing consultation are: a master's level degree in psychology, an APRN, an LICSW, an LGSW, or a licensed professional counselor, with at least one (1) year of experience in serving people with developmental disabilities. Knowledge and experience in behavioral analysis shall be preferred.

9016.33 In order to receive Medicaid reimbursement, an LGSW may only provide counseling under the supervision of an LICSW or a LISW in accordance with the requirements set forth in Section 3413 of Chapter 34 of Title 22-A DCMR.

9016.34 In order to receive Medicaid reimbursement, each DSP providing behavioral support services or one-to-one behavioral supports shall meet the following requirements:

(a) Comply with Section 9011 (Requirements for Persons Direct Support Professionals) of Chapter 90 of Title 29 DCMR; and

(b) Possess specialized training in physical management techniques where appropriate, and all other training required for implementing the person's specific BSP.

9016.35 Each provider of Medicaid reimbursable behavioral support services shall meet the requirements established under Section 9013 (Reporting Requirements) and Section 9005 (Individual Rights) of Chapter 90 of Title 29 DCMR.

9016.36 In order to be eligible for Medicaid reimbursement, each provider of Medicaid reimbursable behavioral supports services shall maintain the following documents for monitoring and audit reviews, as applicable:

(a) A copy of the DARs and accompanying worksheets;

(b) A copy of the BSPs;

(c) A current copy of the behavioral support clinician's professional license to provide clinical services;

(d) The documentation and data collection related to the implementation of the BSP;

(e) The records demonstrating that the data was reviewed by appropriate staff; and

(f) The documents required to be maintained under Section 9006 (Records and Confidentiality of Information) of Chapter 90 of Title 29 DCMR.

9016.37 The Medicaid reimbursement rate for each diagnostic assessment shall be a flat fee rate and the assessment shall be at least three (3) hours in duration and include the development of the DAR and accompanying worksheet.9016.38 There shall be a Medicaid reimbursement rate for behavioral support services provided by professionals identified in § 9016.29, which shall be billed at the unit rate of fifteen (15) minutes. A standard unit of fifteen (15) minutes requires a minimum of eight (8) minutes of continuous service to be billed.9016.39 There shall be a Medicaid reimbursement rate for behavioral support services provided by paraprofessionals identified in § 9016.30, which shall be billed at the unit rate of fifteen (15) minutes. A standard unit of fifteen (15) minutes requires a minimum of eight (8) minutes of continuous service to be billed.9016.40 There shall be a Medicaid reimbursement rate for one-to-one behavioral support services provided by DSPs, which shall be billed at the unit rate of fifteen (15) minutes. A standard unit of fifteen (15) minutes requires a minimum of eight (8) minutes of continuous service to be billed.9016.41 Behavioral support services may be delivered through remote supports to the extent the recommended service delivery is through remote supports services, and the person is able to utilize equipment/technology needed for remote supports services as assessed and determined by the support team.9016.42 Each provider of remote behavioral support services shall comply with the requirements under Section 9036 (Remote Supports Services) of Chapter 90 of Title 29 DCMR.9016.43 Behavioral support services delivered through remote supports services shall be issued as a separate service authorization indicating the frequency of usage. A hybrid model may be used for in-person and remote supports services behavioral support hours where two (2) service authorizations are issued to cover the in-person service hours and the remote supports services hours.9016.44 Remote behavioral support services reimbursement rates shall reflect the same rate as professional in-person behavioral support reimbursement rates.9016.45 Behavioral support services provided by HCBS Waiver professionals through remote supports services must meet the criteria specified at § 9036.12.

SOURCE: Final Rulemaking published at 69 DCR 010229 (August 12, 2022); as amended by Final Rulemaking published at 71 DCR 010475 (August 23, 2024).