SERVICE POLICY GUIDELINES
PHYSICAL AND OCCUPATIONAL THERAPY SERVICES
Tri-Counties Regional Center enhances the quality of life for persons with developmental disabilities by working with individuals and their families to secure assessment and treatment supports and services that maximize their opportunities and choices for living, learning, working, and pursuing recreational activities in their community.
Tri-Counties Regional Center will coordinate, support and advocate for individuals to obtain appropriate therapy services in their community. Tri-Counties Regional Center works with and advocates within the communities it serves to develop and identify appropriate physical and occupational therapy services provided by professionals experienced with and sensitive to the needs of individuals with developmental disabilities. Such services maximize the potential for persons served to develop and/or prevent deterioration in areas of their development.
Physical and/or occupational therapy services are prescribed assessments or treatments provided directly by, or under the supervision of, an accredited physical or occupational therapist. These services are provided to individuals who have problems in the areas of fine and/or gross motor skills or the skills related to activities of daily living that can be ameliorated using physical and/or occupational therapies. These treatment modalities encompass multiple activities including, but not limited to: range of motion; home evaluations to assess equipment needs; and, activities to improve overall coordination and to develop self-help, daily living, and motor skills. The services are often provided as part of an overall program with multiple components.
Access to specialized physical and occupational therapy services directly related to the developmental disability of the individual may be necessary for the health and functional ability of some individuals. Tri-Counties Regional Center may authorize funding for physical and/or occupational therapy services when those services are prescribed by a physician; when significant deficits exist in gross and/or fine motor skills or in self help skills; and, when the therapy is both necessary and is likely to make a significant improvement in the individual’s capabilities or to prevent deterioration of function or of health.
When the need is directly related to, or is the direct result of, a developmental disability and all generic and private resources, including private medical insurance, deny necessary specialized therapy services, Tri-Counties Regional Center may authorize funding for specialized physical and occupational therapy services.
For children under the age of three (3), Tri-Counties Regional Center will request the use of private insurance as a generic service in accordance with Section 95004 of the Government Code for Early Start services.
For individuals receiving early intervention services, children in public school programs, and individuals who reside in health care facilities, physical and/or occupational therapy services are expected to be provided as part of the individual’s program, rather than as a separately funded service. Tri-Counties Regional Center service coordinators will actively advocate with early intervention service providers, California Children’s Services, local education agencies, health care facility providers, and health care agencies to ensure the delivery of required and mandated physical and/or occupational therapy services.
Tri-Counties Regional Center recognizes that there are recognized therapies not covered in this policy. Tri-Counties Regional Center will consider authorization of funding for therapy services on the list of recognized therapies developed and maintained by Medi-Cal and California Children’s Services. Therapies on these lists have been reviewed by panels comprised of experts in the specified therapy who have determined that the listed therapies are effective for specific clinical indications. Such therapies are prescriptive in nature and will be considered upon review of a Tri-Counties Regional Center physician or psychologist within the Planning Team process.
Tri-Counties Regional Center may authorize funding for such therapies only when it has been determined by the Planning Team that the therapies are required as a direct consequence of the developmental disability and that provision of the therapy services are necessary.
Tri-Counties Regional Center will advocate for and work with individuals and their family members to ensure that generic and private therapy service providers discharge their obligations to meet the needs of persons with developmental disabilities. It is the financial responsibility of individuals or their families to pay premiums and, for any non-IPP/IFSP services, meet any required deductible amount, co-insurance, or co-payment liabilities as determined by generic resources and/or private insurance carriers. Tri-Counties Regional Center may pay co-insurance, co-payments, or deductibles when the family’s annual gross income does not exceed 400% of the Federal Poverty Level or the family meets criteria for an exception permitted in the Lanterman Act, section 4659.1, when their income exceeds 400% of the Federal Poverty Level. Except as legally prohibited by the terms of a Special Needs Trust, trust funds established for the care or benefit of a person served are considered a private resource and, therefore, it is expected that this source of funds be used prior to regional center funds.
If a generic or private resource initially denies a required therapy service that Tri-Counties Regional Center has determined to be their responsibility, that denial will be appealed. Tri-Counties Regional Center may authorize funding for a therapy service while an individual or family member appeals a denial of service by a generic or private resource under the following circumstances:
The Planning Team will make the determination that the service is required to protect an individual’s health and safety, or that a prolonged wait for the service will have an irreversible impact on the individual’s health and safety; and,
The Planning Team will consider the person’s risk for regression and the capacity of the person to regain any loss of function or ability if the service is not provided in a timely manner.
Tri-Counties Regional Center will not authorize funding of any therapy service that is considered experimental, optional, or elective in nature. The expected result from the provision of a therapy service must meet measurable outcomes as stated on the person’s Individual Program Plan. The provision of the therapy service must be both clinically and fiscally an effective use of public funds.
Exception Policy:
Tri-Counties Regional Center recognizes that some individual needs are so unique that they may not be addressed in this Service Policy and may require an exception. Such requests for an exception to a Service Policy will be made through the Planning Team process.
Approvals:
