CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Behavioral Support Services

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Establishes Medicaid eligibility, covered activities, provider participation conditions, documentation, authorization requirements, annual service limits, and reimbursement rates for behavioral support services provided to participants in the District of Columbia HCBS Waiver for Individuals with Intellectual and Developmental Disabilities.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyBehavioral Support Services

Policy CodePolicy N/A

Change TypeFinal rule amendment

Effective DateSeptember 4, 2015

Next Review DateN/A

Key ActionObtain DDS prior authorization before behavioral support services begin.

SourceLink

POLICY UPDATE CHANGES

The final rule establishes Medicaid reimbursement standards and provider participation conditions for behavioral support services under the HCBS Waiver.

One-to-one behavioral support eligibility was expanded or clarified to include serious-risk self-injurious behavior and medical conditions requiring one-to-one services.

Medicaid-reimbursable training was added for day service staff as members of the participant's support team.

Functional assessments and diagnostic assessment activities must address settings where target behaviors occur, including residential and community settings when applicable.

The rule modifies the responsibilities of Direct Support Professionals providing one-to-one behavioral supports.

Definitions were added for Mental Health Habilitation Services and other behavioral support roles and concepts.

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CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Behavioral Support Services

Customize your policy alerts

Sign up for all District of Columbia Department of Health Care Finance policy alerts

Know when District of Columbia Department of Health Care Finance releases new policies or updates existing guidance.

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Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyBehavioral Support Services

Policy CodePolicy N/A

Change TypeFinal rule amendment

Effective DateSeptember 4, 2015

Next Review DateN/A

Key ActionObtain DDS prior authorization before behavioral support services begin.

SourceLink

POLICY UPDATE CHANGES

The final rule establishes Medicaid reimbursement standards and provider participation conditions for behavioral support services under the HCBS Waiver.

One-to-one behavioral support eligibility was expanded or clarified to include serious-risk self-injurious behavior and medical conditions requiring one-to-one services.

Medicaid-reimbursable training was added for day service staff as members of the participant's support team.

Functional assessments and diagnostic assessment activities must address settings where target behaviors occur, including residential and community settings when applicable.

The rule modifies the responsibilities of Direct Support Professionals providing one-to-one behavioral supports.

Definitions were added for Mental Health Habilitation Services and other behavioral support roles and concepts.

90 daysAssessment and planning deadline

3 yearsDiagnostic assessment validity

1 yearBehavior Support Plan validity

10 hoursNew BSP annual limit

$240Diagnostic assessment rate

$23.88/hourDSP one-to-one rate

Behavioral Support Coverage Criteria

General behavioral support eligibility

Covered when ALL of the following are met:

General eligibility and authorization

Behavioral support need: The participant is enrolled in the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities and has specific behavioral support needs that jeopardize health, safety, or well-being and/or interfere with independence and acquisition of community living skills.
Support team and plan inclusion: The service is recommended by the participant's support team and identified in the participant's ISP and Plan of Care.
Prior authorization: DDS prior authorizes the service before services begin.Before services begin
Medical-condition recommendation: When the service is one-to-one behavioral support related to a medical condition, the service is recommended by a physician or APRN.
Medical-condition cases also require a written order meeting DDS requirements.

One-to-one behavioral support

One-to-one behavioral supports are covered when AT LEAST ONE of the following qualifying characteristics is present:

Qualifying one-to-one characteristic

The participant exhibits elopement resulting in serious risk to the safety of self or others.
The participant exhibits behavior that is life-threatening to self or others.
The participant exhibits destructive behavior causing serious property damage.
The participant exhibits sexually predatory behavior.
The participant exhibits self-injurious behavior that poses a serious risk to the person's safety.

Annual utilization limits

Covered hours must remain within ALL applicable annual service-specific limits:

Development of a new Behavior Support Plan is limited to 10 hours annually.10 hours per year
Reviewing and updating an existing Behavior Support Plan is limited to 6 hours annually.6 hours per year
Training the participant, family, support team, residential staff, and day staff is limited to 12 hours annually.12 hours per year
On-site counseling, consultation, and observations are limited to 26 hours annually.26 hours per year

DSP-provided one-to-one behavioral supports that are Medicaid reimbursable may not be provided concurrently with day habilitation one-to-one services.

Services provided beyond the applicable annual limits are not reimbursed. Additional hours may be reimbursed only when DDS approves the request after the provider submits a diagnostic update that amends the DAR and accompanying worksheet.

Service and Billing Parameters

Diagnostic assessment duration

RequirementAt least 3 hours

Applies toEach diagnostic assessment

Included documentationDevelopment of the Diagnostic Assessment Report and accompanying worksheet

Professional and paraprofessional billing increment

Billing increment15 minutes

Minimum continuous timeAt least 8 continuous minutes

Applies toProfessional and paraprofessional behavioral support services

Provider Requirements and Denial Risks

Prior Authorization

DDS Prior Authorization Required

Obtain DDS prior authorization before behavioral support services begin. Services must also be recommended by the person’s support team and identified in the person’s ISP and Plan of Care.

Prior authorization is required before the commencement of services.
Confirm the service is included in both the ISP and Plan of Care.

Documentation Required

Medical One-to-One Order

For one-to-one behavioral supports related to a medical condition, obtain a physician or APRN recommendation and a compliant written order. The order must satisfy DDS policies and procedures and document the service duration, medical risk, staff responsibilities, and clinical justification.

Specify the time period or duration of services.
Describe the medical condition creating a health or safety risk.

Policy Background and Scope

Behavioral support services are intended for HCBS Waiver participants whose extremely challenging behaviors are complicated by medical or mental health factors. Services use diagnostic assessment, functional behavioral analysis, positive and proactive strategies, individualized behavior support planning, training, monitoring and consultation to improve safety, independence and community living skills. When restrictive procedures are included, the plan must document the rationale and include a plan to fade them out.

Key Behavioral Support Definitions

Functional Behavioral Analysis

ProcessA comprehensive and individualized process

Assessment focusIdentifies events that precede and follow a target behavior

PurposeDevelops hypotheses about the purpose of the target behavior and identifies positive changes to be made

Fade-out plan

DefinitionA plan used by providers

SubjectRestrictive techniques or processes used in the person’s plan of care

Required outcomeThe restrictive techniques or processes are gradually and ultimately eliminated

Annual Service-Specific Hour Limits

Development of a new Behavior Support Plan

ServiceDevelopment of a new Behavior Support Plan

PeriodAnnual

Limit10 hours

Reviewing and updating an existing Behavior Support Plan

ServiceReviewing and updating an existing Behavior Support Plan

PeriodAnnual

Limit6 hours

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyBehavioral Support Services

Policy CodePolicy N/A

Change TypeFinal rule amendment

Effective DateSeptember 4, 2015

Next Review DateN/A

Key ActionObtain DDS prior authorization before behavioral support services begin.

SourceLink

On This Page

The participant has a medical condition that requires one-to-one services.

Medical-condition cases require a physician or APRN recommendation and a written order specifying the service duration, medical risk, staff responsibilities, and justification for one-to-one support.

Participation in behavioral review or treatment team meetings, emergency case conferences, hospital discharge meetings, interagency meetings, pre-ISP and ISP meetings, and human rights meetings is limited to 12 hours annually.12 hours per year

Monitoring of quarterly medication reviews, reports, and monthly data monitoring is limited to 8 hours annually.8 hours per year

Participation in psychotropic medication review meetings to deliver notes is limited to 3 hours annually.3 hours per year

Requests for additional hours beyond these annual limits may be approved by DDS only after submission of a diagnostic update amending the DAR and accompanying worksheet.

Services exceeding the annual limits are not reimbursed unless the additional hours are approved through this process.

Define each staff person’s responsibilities.

Justify the need for one-to-one behavioral supports.

Prior Authorization

Additional Hours and Counseling Approval

Submit requests for hours beyond the annual limits to DDS with a diagnostic update amending the DAR and accompanying worksheet. Counseling requires approval from a DDS-designated staff member and is reimbursable only when it is not available under the District’s State Plan.

Support additional-hour requests with a diagnostic update.
Obtain DDS-designated staff approval for counseling.
Document that requested counseling is outside State Plan-covered services.

Unsupported block type: denial_risk

Documentation Required

Required Audit Records

Maintain complete records supporting service delivery, clinical recommendations, implementation, and reimbursement for monitoring and audit reviews.

Copies of DARs and accompanying worksheets.
Copies of BSPs.
Current behavioral support clinician professional license.
Documentation and data collected during BSP implementation.
Records showing that appropriate staff reviewed the data.
Records required under 29 DCMR § 1909.

Documentation Required

Hours and Reauthorization Justification

Use the DAR worksheet to state the hours requested for professional and paraprofessional services. Update the DAR and worksheet when psychological or clinical functioning changes, annually for one-to-one services, or when otherwise recommended by the support team; include written clinical justification for reauthorization.

The DAR generally remains effective for three years.
Update the DAR annually for persons receiving one-to-one supports.
Submit diagnostic updates to the DDS Service Coordinator.
Have the person and support team review the update with behavioral support staff.

Documentation Required

Diagnostic Assessment Content

Base the diagnostic assessment on direct and indirect assessment methods and provide a written evaluation linking environmental, psychological, and medical influences to behavioral problems.

Observe the person in the setting where target behaviors occur.
Document behavior frequency, duration, and intensity.
Interview family members and the support team.
Review written records and questionnaires.
Evaluate correlations among environmental, psychological, and medical factors.

Documentation Required

DAR Content

The DAR must provide a complete clinical and behavioral picture and support recommendations to initiate, continue, or discontinue services.

Crisis-contact names.
Cognitive and adaptive functioning status.
Full behavior description, including background and environmental contributors.
Counseling and problem-solving strategies used and their effectiveness.
Less restrictive interventions, results, and reasons for failure.
Proposed goals for changing target behaviors.
Recommendations regarding behavioral support services.

Documentation Required

BSP Content and Individualized Planning

Develop the BSP from interviews, observations, and record review, and individualize it to the person’s behavioral and clinical needs. The plan must support coordinated implementation across residential and day settings.

Interview the person and support team.
Observe the person at home and in the community when applicable.
Review medical and psychiatric history, laboratory and diagnostic studies, and behavioral data.
Describe target behaviors consistently with the diagnosis and include frequency data.
Include a functional analysis, data-collection methods, proactive strategies, and measurable goals.
If restrictive procedures are used, document the rationale and a fade-out plan.
Specify staff and caregiver training requirements.

Documentation Required

Consent and Coordination

Coordinate behavioral support delivery in residential and day activity settings and obtain all required approvals before implementation. The provider must secure written informed consent and any required substitute decision-maker, support team, human rights committee, and DDS approvals.

Coordinate services across applicable settings.
Obtain the person’s written informed consent.
Obtain substitute decision-maker approval when applicable.
Obtain support team, provider human rights committee, and DDS approvals when required by DDS policy.

Denial Risk

Missing Eligibility, Plan, or DDS Authorization

Services are not eligible for Medicaid reimbursement unless they are recommended by the support team, identified in the ISP and Plan of Care, and prior authorized by DDS before services begin. One-to-one supports related to a medical condition also require a physician or APRN recommendation.

Missing eligibility, plan documentation, or DDS authorization can result in denial or non-reimbursement.
Confirm all pre-service requirements before delivery or billing.

Denial Risk

One-to-One Criteria Must Be Met

One-to-one behavioral supports require at least one qualifying characteristic or a medical condition requiring one-to-one services. Services may be denied when the record does not establish the required safety, health, or behavioral threshold.

Elopement posing serious risk to self or others.
Life-threatening behavior toward self or others.
Destructive behavior causing serious property damage.
Sexually predatory behavior.
Self-injury posing serious safety risk.
A medical condition requiring one-to-one services.

Denial Risk

Incomplete Medical One-to-One Order

A medical one-to-one order is incomplete if it lacks the physician or APRN recommendation, a defined service period, a description of the medical risk, staff responsibilities, a clinical justification, or compliance with DDS policies and procedures.

Use a written physician or APRN order.
Include all required clinical and operational elements.
Ensure the order conforms to DDS policies and procedures.

Denial Risk

Incomplete Assessment or Plan Record

Complete the diagnostic assessment, DAR, accompanying worksheet, and any recommended BSP within 90 days of authorization, and retain them for monitoring and audit. Missing, incomplete, or unsupported records may result in denial or non-reimbursement.

The worksheet must accompany the DAR.
The BSP is required when recommended by the DAR.
Maintain implementation data and evidence of data review.

Denial Risk

Annual Hour Limits and Additional Hours

Annual service-hour limits apply unless DDS approves additional hours after receiving a diagnostic update amending the DAR and worksheet. Services exceeding the limits without that approval are not reimbursable.

New BSP development: up to 10 hours.
Existing BSP review and update: up to 6 hours.
Training: up to 12 hours.
On-site counseling, consultation, and observations: up to 26 hours.
Behavioral review and treatment-team meetings and specified meetings: up to 12 hours.
Quarterly medication reviews, reports, and monthly data monitoring: up to 8 hours.
Psychotropic medication review meeting notes: up to 3 hours.

Denial Risk

Counseling Approval and Covered-Service Rationale

Counseling is reimbursable only when approved by a DDS-designated staff member and when the service is not available under the District’s State Plan for Medical Assistance. Missing approval or a covered-service rationale creates a reimbursement risk.

Obtain approval before billing counseling as a behavioral support service.
Document why the counseling is not available under the State Plan.

Denial Risk

No Concurrent One-to-One Services

A DSP’s Medicaid-reimbursable one-to-one behavioral supports may not be provided concurrently with day habilitation one-to-one services. Schedule and bill the services so the two one-to-one services do not overlap.

Do not provide concurrent DSP one-to-one behavioral supports and day habilitation one-to-one services.

Positive behavioral support strategies

ApproachAn alternative to traditional or punitive approaches for managing challenging behaviors

Environmental focusChanges the physical and interpersonal environment

Skill-building purposeIncreases skills so the person can get their needs met without resorting to challenging behavior

Proactive strategies

DefinitionSpecific interventions intended to prevent target behaviors

Staff actionsStaff interventions that prevent the occurrence of target behaviors

Environmental modificationsChanges to the environment that prevent the occurrence of target behaviors

Target behavior

DefinitionThe challenging behaviors addressed by staff

SubjectChallenging behaviors

Responsible partiesStaff addressing those behaviors

Mental Health Habilitation Services

ProviderA Department of Behavioral Health-certified community mental health provider

Service typeMental health services provided to consumers

PurposeAssists consumers in partially or fully acquiring or improving skills and functioning

Behavior Management Specialist

QualificationAn individual with training and experience in the theory and technique of changing behavior

RoleEnhances learning of life skills and adaptive behaviors and decreases maladaptive behaviors

SupervisionWorks under the supervision of a licensed practitioner

Training the participant, family, support team, residential staff and day staff

ServiceTraining the participant, family, support team, residential staff and day staff

PeriodAnnual

Limit12 hours

On-site counseling, consultation and observations

ServiceOn-site counseling, consultation and observations

PeriodAnnual

Limit26 hours

Behavioral reviews and treatment-team meetings

ServiceBehavioral review or treatment team meetings, emergency case conferences, hospital discharge meetings, interagency meetings, pre-ISP and ISP meetings, and human rights meetings

PeriodAnnual

Limit12 hours

Quarterly medication review monitoring, reports and monthly data monitoring

ServiceQuarterly medication review monitoring, reports and monthly data monitoring

PeriodAnnual

Limit8 hours

Participation in psychotropic medication review meetings to deliver notes

ServiceParticipation in psychotropic medication review meetings to deliver notes

PeriodAnnual

Limit3 hours