1936.1The purpose of this section is to establish standards governing Medicaid eligibility for wellness services for persons enrolled in the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver), and to establish conditions of participation for providers of wellness services in order to receive reimbursement.
1936.2Wellness services are designed to promote and maintain good health, The provision of these services shall be based upon what is important to and for the person as reflected in his or her Person-Centered Thinking tools and the goals in his or her Individual Service Plan (ISP). Wellness services assist in increasing the person's independence, participation, prevent further disability, maintain health and increase emotional well-being, and productivity in their home, work, and community.
1936.3The wellness services eligible for Medicaid reimbursement are:
(a) Bereavement Counseling;(d) Nutrition Evaluation/Consultation; and1936.4Fitness training is available as either an individual service, or in small group 1:2 setting, based upon the recommendation of the person's support team. When a person is enrolled in small group fitness, efforts should be made to match the person with another beneficiary of his or her choosing, or, if not available, with a person who has similar skills and interests.
1936.5To be eligible for Medicaid reimbursement of bereavement counseling:
(a) The person must have experienced a loss through death, relocation, change in family structure, or loss of employment;(b) The service must be recommended by the person's support team; and(c) The service shall be identified as a need in the person's ISP and Plan of Care.1936.6To be eligible for Medicaid reimbursement of sexuality education, the services shall be:
(a) Recommended by the person's support team; and(b) Identified as a need in the person's ISP and Plan of Care.1936.7To be eligible for Medicaid reimbursement of fitness training and massage therapy, the services shall be:
(a) Recommended by the person's support team;(b) Identified as a need in the person's ISP and Plan of Care; and(c) Ordered by a physician.1936.8To be eligible for Medicaid reimbursement of nutritional evaluation/consultation services, each person shall meet one or more of the following criteria:
(a) Have a history of being significantly above or below body weight;(b) Have a history of gastrointestinal disorders;(c) Have received a diagnosis of diabetes;(d) Have a swallowing disorder; or(e) Have a medical condition that can be a threat to health if nutrition is poorly managed.1936.9In addition to the requirements set forth in § 1936.8, nutritional evaluation/ consultative services shall be:
(a) Recommended by the person's support team;(b) Identified as a need in the person's ISP and Plan of Care based upon the Stage of Change the person is in;(c) Ordered by a physician; and(d) Targeted to the identified Stage of Change.1936.10The specific wellness 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 the person's individual needs and documented in the person's ISP and Plan of Care.
1936.11In order to be eligible for Medicaid reimbursement, each professional providing wellness services shall:
(a) Conduct an initial assessment within the first four (4) hours of service delivery with long term and short term goals;(b) Develop and implement a person-centered plan consistent with the person's choices, goals and prioritized needs that describes wellness strategies and the anticipated and measurable, functional outcomes, based upon what is important to and for the person as reflected in his or her Person-Centered Thinking tools and the goals in his or her ISP. The plan shall include treatment strategies including direct therapy, caregiver training, monitoring requirements and instructions, and specific outcomes;(c) Deliver the completed plan to the person, family, guardian, residential provider, or other caregiver, and the DDS Service Coordinator prior to the Support Team meeting;(d) Participate in the ISP and Support Team meetings, when invited by the person, to provide consultative services and recommendations specific to the wellness professional's area of expertise with the focus on how the person is doing in achieving the functional goals that are important to him or her;(e) Provide necessary information to the person, family, guardian, residential provider, or other caregivers and assist in planning and implementing the approved ISP and Plan of Care;(f) Record progress notes on each visit which contain the following:(1) The person's progress in meeting each goal in the ISP;(2) Any unusual health or behavioral events or change in status;(3) The start and end time of any services received by the person; and(4) Any matter requiring follow-up on the part of the service provider or DDS.(g) Submit quarterly reports in accordance with the requirements in Section 1909 (Records and Confidentiality of Information) of Chapter 19 of Title 29 DCMR; and(h) Conduct periodic examinations and modify treatments for the person receiving services, as necessary.1936.12In order to be eligible for Medicaid reimbursement, each professional providing nutrition evaluation/consultation services shall comply with the following additional requirements, as needed:
(a) Conduct a comprehensive nutritional assessment within the first four (4) hours of delivering the service;(b) Conduct a partial nutritional evaluation to include an anthropometric assessment;(c) Perform a biochemical or clinical dietary appraisal;(d) Analyze food-drug interaction potential, including allergies;(e) Perform a health and safety environmental review of food preparation and storage areas;(f) Assess the need for a therapeutic diet that includes an altered/textured diet due to oral-motor problems;(g) Conduct a needs assessment for adaptive eating equipment and dysphagia management;(h) Conduct a nutrition evaluation and provide consulting services on a variety of subjects, including recommendations for the use of adaptive equipment, to promote improved health and increase the person's ability to manage his or her own diet or that of his or her child(ren) in an effective manner; and(i) Provide education to include menu development, shopping, food preparation, food storage, and food preparation procedures consistent with the physician's orders.1936.13Each professional providing wellness services shall be employed by a Home and Community-Based Services Waiver provider agency or by a professional service provider who is in private practice as an independent clinician as described in Subsection 1904.2 of Title 29 DCMR.
1936.14Each provider shall comply with the requirements set forth under Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR.
1936.15In order to be eligible for Medicaid reimbursement, professionals delivering wellness services shall meet the following licensure and certification requirements:
(a) Bereavement counseling services shall be performed by a professional counselor licensed pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code§§ 3-1201 et seq. (2012 Repl. & 2014 Supp.)) and certified by the American Academy of Grief Counseling as a grief counselor;(b) Fitness services shall be performed by professional fitness trainers who have been certified by the American Fitness Professionals and Associates, or who have a bachelor's degree in physical education, health education, exercise, science or kinesiology, or recreational therapists;(c) Dietetic and nutrition counselors shall be licensed pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code§§ 3-1201 et seq. (2012 Repl. & 2014 Supp.)); and (d ) Massage Therapists shall be licensed pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code§§ 3-1201 et seq. (2012 Repl. & 2014 Supp.)) and certified by the National Verification Board for Therapeutic Massage and Bodywork. 1936.16In order to be eligible for Medicaid reimbursement, sexuality education services shall be delivered by:
(a) A Sexuality Education Specialist who is certified to practice sexuality education by the American Association of Sexuality Educators, Counselors and Therapists Credentialing Board; or(b) Any of the following professionals with specialized training in Sexuality Education: (3) Licensed Clinical Social Worker; or(4) Licensed Professional Counselor.1936.17Each Wellness service provider, and professional, without regard to their employer of record, shall be selected by the person receiving services or his or her authorized representative, and shall be answerable to the person receiving services.
1936.18Any provider substituting treating 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 Service Coordinator to evaluate the continuation of services.
1936.19 In order to be eligible for Medicaid reimbursement, services shall be authorized in accordance with the following requirements:
(a) DDS shall provide a written service authorization before the commencement of services;(b) The provider shall conduct an initial assessment and develop a personcentered plan within the first four (4) hours of service delivery which:(1) Describes wellness strategies and the anticipated and measurable, functional outcomes, based upon what is important to and for the person as reflected in his or her Person-Centered Thinking tools; and(2) Includes training goals and techniques in the ISP that will assist the caregivers;(c) The service name and provider entity delivering services shall be identified in the ISP and Plan of Care; and(d) The ISP, Plan of Care, and Summary of Supports and Services shall document the amount and frequency of services to be received.1936.20Each Provider shall comply with the requirements described under Section 1908 (Reporting Requirement), Section 1909 (Records and Confidentiality of Information), and Section 1911 (Individual Rights) of Chapter 19 of Title 29 DCMR.
1936.21Wellness services shall be limited as follows:
(a) Massage Therapy shall be limited to fifty-two (52) hours per ISP year. Additional hours up to one hundred (100) hours per year may be authorized before the expiration of the ISP year with approval by DDS Deputy Director for DDA based upon assessed medical or clinical need;(b) Sexuality Education shall be limited to fifty-two (52) hours per ISP year. Additional hours up to one hundred (100) hours per year may be authorized before the expiration of the ISP year with approval by DDS Deputy Director for DDA based upon assessed medical or clinical need;(c) Fitness Training and Small Group Fitness Training shall be limited to fifty-two (52) hours per ISP year for people receiving host home, supported living, residential habilitation or in-home supports services, or who otherwise have natural supports available that can assist the person practice the fitness skills they need to achieve their fitness goals. Additional hours up to one hundred four (104) hours per year may be authorized before the expiration of the ISP year, and when the person's health and safety are at risk, for people who live in natural homes without in-home supports services and do not have such natural supports available that can assist the person practice the fitness skills they need to achieve their fitness goals. Requests for additional hours may be approved when accompanied by a physician's order or if the request passes a clinical review by staff designated by DDS;(d) Nutrition Counseling shall be limited to twenty-six (26) hours per ISP year and to people who have natural or paid supports to help them implement the learning and nutrition goals outside of the time with the dietician or nutritionist. Additional hours up to one hundred four (104) may be authorized before the expiration of the ISP year with approval by DDS Deputy Director for DDA based upon assessed medical or clinical need; and(e) Bereavement Counseling shall be limited to one hundred (100) hours per ISP year. Additional hours may be authorized before the expiration of the ISP year and when the person's health and safety are at risk and the person is demonstrating progress towards achieving established outcome and/or maintenance of goals.1936.22The person may utilize one (1) or more wellness services in the same day, but not at the same time.
1936.23The Medicaid reimbursement rate for wellness services shall be:
(a) Fifteen dollars and twenty-five cents ($15.25) per billable unit or sixty-one dollars ($61.00) per hour for Massage Therapy;(b) Nineteen dollars and five cents ($19.05) per billable unit or seventy-six dollars and twenty cents ($76.20) per hour for Sexuality Education;(c) Eighteen dollars and eighty-one cents ($18.81) per billable unit or seventy-five dollars and twenty-four cents ($75.24) per hour for Fitness Training;(d) Eleven dollars and twenty-eight cents ($11.28) per billable unit or forty-five dollars and twelve cents ($45.12) per hour for Small Group Fitness Training;(e) Sixteen dollars and thirty cents ($16.30) per billable unit or sixty-five dollars and twenty cents ($$65.20) per hour for Nutrition Counseling; and(f) Sixteen dollars and thirty cents ($16.30) per billable unit or sixty-five dollars and twenty cents ($65.20) per hour for Bereavement Counseling.1936.24The billable unit of service for wellness 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.
D.C. Mun. Regs. Tit. 29, § 1936
Final Rulemaking published at 60 DCR 16834 (December 13, 2013); amended by Final Rulemaking published at 63 DCR 289 (1/8/2016); amended by Final Rulemaking published at 63 DCR 9388 (7/8/2016); amended by Final Rulemaking published at 69 DCR 10218 (8/12/2022) Authority: 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. 774; D.C. Official Code § 1-307.02 (2012 Repl.)) 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) (2012 Repl.)).