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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-35. Medicaid School Program |
5160-35-05. Services authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers
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(A) The purpose of this rule is to set forth the services authorized for medicaid coverage that a MSP provider can provide, and to set forth the conditions for providing the services.
(B) A MSP provider may provide skilled services. Following are the skilled services an MSP provider may provide:
(1) Occupational therapy services:
(a) Description: services that evaluate and treat, as well as services to analyze, select, and adapt activities for an eligible child whose functioning is impaired by developmental deficiencies, physical injury or illness. The occupational therapy service will be recommended by a licensed occupational therapist acting within the scope of his or her practice under Ohio law who holds a current, valid license to practice occupational therapy issued under Chapter 4755. of the Revised Code. Services provided by an individual holding a limited permit, as described in section 4755.08 of the Revised Code, are not allowable.
(b) Qualified practitioners who can deliver the services:
(i) Licensed occupational therapist who holds a current, valid license to practice occupational therapy issued under Chapter 4755. of the Revised Code, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(ii) Licensed occupational therapy assistant who holds a current, valid license issued under Chapter 4755. of the Revised Code, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law. Further, the licensed occupational therapy assistant will be practicing under the supervision of a licensed occupational therapist who is employed or contracted by the MSP provider.
(iii) An occupational therapy student who is completing an internship or externship in accordance with the clinical requirements as established by the credentialing board.
(c) Allowable activities include:
(i) Evaluation and re-evaluation to determine the current sensory and motor functional level of the eligible child and identifying appropriate therapeutic interventions to address the findings of the evaluation/re-evaluation.
(ii) Therapy to improve the sensory and motor functioning of the eligible child, to teach skills and behaviors crucial to the eligible child's independent and productive level of functioning.
(iii) Application and instruction in the use of orthotic and prosthetic devices, and other equipment to accomplish the goal of therapy in accordance with paragraph (B)(1)(c)(ii) of this rule.
(iv) May make referrals for occupational therapy services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.
(2) Physical therapy services
(a) Description: services that evaluate and treat an eligible child by physical measures and the use of therapeutic exercises and procedures, with or without assistive devices, for the purpose of correcting, or alleviating a disability. The physical therapy service will be recommended by a licensed physical therapist acting within the scope of his or her practice under Ohio law who holds a current, valid license to practice physical therapy issued under Chapter 4755. of the Revised Code.
(b) Qualified practitioners who can deliver the services:
(i) Licensed physical therapist who holds a current, valid license to practice physical therapy issued under Chapter 4755. of the Revised Code, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(ii) Licensed physical therapist assistant who holds a current, valid license issued under Chapter 4755. of the Revised Code, who is employed or contracted with the MSP provider, who is acting within the scope of his or her practice under Ohio law, and who is practicing under the supervision of a licensed physical therapist employed or contracted by the MSP provider.
(iii) A physical therapy student who is completing an internship or externship in accordance with the clinical requirements as established by the credentialing board.
(c) Allowable activities include:
(i) Evaluation and re-evaluation to determine the current level of physical functioning of the eligible child and to identify appropriate therapeutic interventions to address the findings of the evaluation/ re-evaluation.
(ii) Therapy, with or without assistive devices, for the purpose of preventing, correcting or alleviating the impairment of the eligible child.
(iii) Application and instruction in the use of orthotic and prosthetic devices, and other equipment to accomplish the goal of therapy in accordance with paragraph (B)(2)(c)(ii) of this rule.
(iv) May make referrals for physical therapy services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.
(3) Speech-language pathology services
(a) Description: services that are planned, directed, supervised and conducted for individuals or groups of individuals who have or are suspected of having disorders of communication. The application of principles, methods, or procedures related to the development and disorders of human communication can include identification, evaluation, and treatment. The speech-language pathology service will be recommended by a licensed speech-language pathologist acting within the scope of his or her practice under Ohio law who holds a current, valid license to practice speech-language pathology issued under Chapter 4753. of the Revised Code.
(b) Qualified practitioners who can deliver the services:
(i) Licensed speech-language pathologist who holds a current, valid license to practice speech-language pathology issued under Chapter 4753. of the Revised Code, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(ii) Licensed speech-language pathology aide who holds a current, valid license issued under Chapter 4753. of the Revised Code, who is employed or contracted with the MSP provider, who is acting within the scope of his or her practice under Ohio law, and who is practicing under the supervision of the licensed speech-language pathologist who completed, signed and submitted to the Ohio board of speech-language pathology and audiology the speech-language pathology aide plan. The supervising speech-language pathologist will be employed or contracted by the MSP provider.
(iii) A person holding a conditional license to practice speech-language pathology, if the eligible provider supervising the professional experience keeps on file a copy of the conditionally-licensed speech-language pathologist's plan of supervised professional experience, mandated in section 4753.071 of the Revised Code.
(iv) A speech-language pathology student who is completing an internship or externship in accordance with the clinical requirements as established by the credentialing board.
(c) Allowable activities include:
(i) Evaluation and re-evaluation to determine the current level of speech-language of the eligible child and to identify the appropriate speech-language treatment to address the findings of the evaluation/re-evaluation.
(ii) Therapy, with or without assistive devices, for the purpose of preventing, correcting or alleviating the impairment of the eligible child.
(iii) Application and instruction in the use of assistive devices.
(iv) May make referrals for speech-language pathology services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.
(4) Audiology services
(a) Description: hearing exams, diagnostic tests, and services requiring the application of principles, methods, or procedures related to hearing and the disorders of hearing. The audiology service will be recommended by a licensed audiologist acting within the scope of his or her practice under Ohio law who holds a current, valid license to practice audiology issued under Chapter 4753. of the Revised Code.
(b) Qualified practitioners who can deliver the services:
(i) Licensed audiologist who holds a current, valid license to practice audiology issued under Chapter 4753. of the Revised Code, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(ii) Licensed audiology aide holds a current, valid license issued under Chapter 4753. of the Revised Code, who is employed or contracted with the MSP provider, who is acting within the scope of his or her practice under Ohio law, and who is practicing under the supervision of the licensed audiologist who completed, signed and submitted to the Ohio board of speech-language pathology and audiology the audiology aide plan. The supervising audiologist will be employed or contracted by the MSP provider.
(iii) An audiology student who is completing an internship or externship in accordance with clinical requirements as established by the credentialing board.
(c) Allowable activities include:
(i) Evaluation and re-evaluation to determine the current level of hearing of the eligible child and to identify the appropriate audiology treatment, as well as treatment to address the findings of the evaluation/re-evaluation.
(ii) May make referrals for audiology services under the MSP component of the medicaid program as authorized in section 5162.366 of the Revised Code.
(5) Nursing services
(a) Description: services from a registered nurse that provides to individuals and groups nursing care as defined in Chapter 4723. of the Revised Code. And, services from a licensed practical nurse that provides to individuals and groups nursing care as defined in Chapter 4723. of the Revised Code. The nursing service, with the exception of evaluations and assessments, will be prescribed by a medicaid authorized prescriber acting within the scope of his or her practice under Ohio law who holds a current, valid license.
(b) Qualified practitioners who may deliver the services:
(i) Licensed registered nurse who holds a current, valid license issued under Chapter 4723. of the Revised Code, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(ii) Licensed practical nurse who holds a current, valid license issued under Chapter 4723. of the Revised Code, who is employed or contracted with the MSP provider, who is practicing at the direction of a medicaid authorized prescriber, and who is acting within the scope of his or her practice under Ohio law.
(c) Allowable activities include:
(i) Assessment/evaluation and re-assessment/re-evaluation to determine the current health status of the eligible child in order to identify and facilitate provision of appropriate nursing treatment to address the findings of the assessment/evaluation or re-assessment/re-evaluation.
(ii) Administering medications prescribed by a medicaid authorized prescriber.
(iii) The implementation of medical/nursing procedures/treatments prescribed by a medicaid authorized prescriber for the medicaid eligible child, which may include tube feeds, bowel and bladder care, colostomy care, catheterizations, respiratory treatment, wound care, and any other services that are prescribed by a medicaid authorized prescriber.
(6) Mental health services
(a) Description:
(i) Counseling services rendered to an individual or group and involves the application of clinical counseling principles, methods, or procedures to assist individuals in achieving more effective personal or social development and adjustment, including the diagnosis and treatment of mental and emotional disorders;
(ii) Social work services that involve the application of specialized knowledge of human development and behavior and social, economic, and cultural systems in directly assisting individuals, families, and groups in a clinical setting to improve or restore their capacity for social functioning, including counseling, the use of psychosocial interventions, and the use of social psychotherapy, which includes the diagnosis and treatment of mental and emotional disorders; and
(iii) Psychology services that are the application of psychological procedures to assess, diagnose, prevent, treat, or ameliorate psychological problems or emotional or mental disorders of individuals or groups; or to assess or improve psychological adjustment or functioning of individuals or groups, whether or not there is a diagnosable pre-existing psychological problem.
(b) Qualified practitioners who can deliver the services:
(i) Licensed clinical counselor, licensed counselor who holds a current, valid license to practice professional counseling issued under Chapter 4757. of the Revised Code, who is employed by or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law;
(ii) Licensed independent social worker, or licensed social worker who holds a current, valid license to practice social work issued under Chapter 4757. of the Revised Code, who is employed by or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law;
(iii) Licensed psychologist or a licensed school psychologist who holds a current, valid license to practice psychology issued under Chapter 4732. of the Revised Code, or to practice school psychology issued under Chapter 4732. of the Revised Code or under rule 3301-24-05 of the Administrative Code who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(c) Allowable activities include:
(i) Diagnosis and rehabilitative treatment of mental and emotional disorders performed by a licensed independent social worker, licensed social worker, professional counselor, or professional clinical counselor acting within his or her scope of practice under Ohio law.
(ii) Assessment and diagnostic services performed by a licensed psychologist or a licensed school psychologist acting within his or her scope of practice under Ohio law to determine the current psychological condition of the eligible child and to identify appropriate psychological treatment and/or therapy for the eligible child to address the findings of the assessment/diagnosis.
(iii) Psychological and neuropsychological testing when performed to assist in determining the possible presence of a psychological or neuropsychological disorder.
(iv) Rehabilitative treatment using psychological procedures for the purpose of treating, correcting or alleviating the mental and emotional impairment of the eligible child.
(d) Unallowable activities include sensitivity training, sexual competency training, educational activities (including testing and diagnosis - this does not include initial assessments nor re-assessment as indicated in paragraph (B)(7) of this rule), monitoring activities of daily living, recreational therapies, teaching grooming skills, sensory stimulation, teaching social interaction/diversion skills, crisis intervention not included in an eligible child's individualized educational program (IEP), and family therapy that is not as a direct benefit to the eligible child.
(7) Assessments/evaluations
(a) Description: the initial assessment/evaluation that is part of the evaluation team report (ETR) process (reimbursement is limited to one per continuous twelve month period per child unless prior authorization is obtained) conducted for an eligible child without an IEP or conducted for a two year old child with a disability to determine whether or not an IEP is appropriate. The assessment/evaluation will include a description of the services and supports which are needed to address the findings from the assessment/evaluation and will be signed by the qualified practitioner who conducted the assessment/ evaluation. Reimbursement is not available for the development of the IEP.
(b) Description: the re-assessment/re-evaluation conducted thereafter and identified in the eligible child's IEP (reimbursement is limited to one per continuous six month period per child unless prior authorization is obtained). The re-assessment/re-evaluation will include a recommendation that describes the services and supports which are needed to address the findings from the re-assessment/re-evaluation and be signed by the qualified practitioner who conducted the re-assessment/re-evaluation. Reimbursement is not available for the development of the IEP.
(c) Qualified practitioners who may deliver the initial assessment/evaluation, or re-assessment/re-evaluation services: one of the qualified practitioners identified in paragraphs (B)(1) to (B)(6) of this rule who holds a current, valid license, who is employed or contracted with the MSP provider, and who is acting within the scope of his or her practice under Ohio law.
(C) An MSP provider may provide telehealth services. Telehealth services are to be delivered in accordance with an eligible child's IEP, and in accordance with the telehealth service delivery methods as identified in rule 5160-1-18 of the Administrative Code or as provided in written guidance, as set forth by ODM or the appointing authority, when not clarified in rule 5160-1-18 of the Administrative Code.
(D) In accordance with an eligible child's IEP and section 5162.366 of the Revised Code, a physical therapist, occupational therapist, speech-language pathologist, and audiologist can make a referral for the child when the referral is within the practitioner's specific discipline.
The licensed physical therapist, occupational therapist, speech-language pathologist, and audiologist is obligated to have an active medicaid provider agreement in place.
(E) Although the following list is not all-inclusive, the following are not allowable for reimbursement through the medicaid school program:
(1) Attending IEP and ETR meetings, and development of the IEP.
(2) Services and activities that go beyond the recommendation of the qualified practitioner conducting the assessment/evaluation, re-assessment/re-evaluation and therefore are provided solely for the purpose of education, special education or special instruction.
(3) Health/medical screens, including mass screens provided to an eligible child with an IEP.
(4) Counseling parents and teachers regarding hearing loss.
(5) In-house training.
(6) Fittings for amplification devices, and equipment troubleshooting and/or repair.
(7) Nursing services provided as a part of immunizations process.
(8) Instruction on self-care that does not need the expertise of the licensed practitioner.
(9) Services provided to a child who does not have an IEP with the exception of the initial assessment/evaluation as described in paragraph (B)(7) of this rule.
(10) Services not indicated in an eligible child's IEP prior to the provision of the service with the exception of the initial assessment/evaluation as described in paragraph (B)(7) of this rule.
(11) Services provided to a child who does not have a disability and a need for special education and related services with the exception of the initial assessment/evaluation as described in paragraph (B)(7) of this rule.
(12) Services provided on days or at times when the eligible child is not in attendance in the IEP designated school setting with the exception of the initial assessment/evaluation as described in paragraph (B)(7) of this rule.
(13) Services that are not provided under the appropriate supervision and/or at the appropriate direction of a licensed practitioner of the healing arts.
(14) Services provided by a non-licensed person.
(15) Services for which an eligible child fails to show progress toward IEP identified goals over two consecutive three-month periods and there is no documentation that the methods and/or techniques applied have been modified to improve progress.
(16) Services provided as a part of the eligible child's waiver services, or as a part of services through an intermediate care facility or of a nursing facility.
(17) Services and activities that are not a direct benefit to the eligible child.
(F) In accordance with rule 5160-1-01 of the Administrative Code, the services provided will be medically necessary and the type, frequency, scope and duration of the services will fall within the normal range of services considered under acceptable standards of medical and healing arts professional practice, as appropriate.
(G) The services provided are of such level of complexity and sophistication, or the condition of the patient is such that the service can be safely and effectively performed only by or under the supervision of a licensed practitioner as indicated in this rule.
(H) The eligible child's IEP are to contain the following components that, taken together and for the purposes of Chapter 5160-35 of the Administrative Code, are called the plan of care. This plan of care does not supplant any practitioner plan of care, and will:
(1) Be based on the initial assessment/evaluation conducted during the ETR or the subsequent assessments/evaluations and re-assessments/re-evaluations.
(2) Be signed by the qualified practitioner who recommends the service as a result of the assessment/evaluation, re-assessment/re-evaluation.
(3) Include specific services to be used, and the amount, duration and frequency of each service.
(4) Include specific goals to be achieved as a result of service provided, including the level or degree of improvement expected.
(5) For nursing services, reference and identify the location of the prescription of a physician, and for medications, reference and identify the location of the prescription of a physician or an advanced practice nurse with certification to prescribe in accordance with Ohio law.
(6) Specify timelines for re-assessment/re-evaluation, which should be no more than twelve-months from the date of the initial assessment/evaluation, of the eligible child and updates to the plan of care/IEP.
(I) The documentation for the provision of service will be maintained for purposes of supporting the delivery of the service and to provide an audit trail. Documentation will include:
(1) The date (i.e., day, month, and year) that the activity was provided.
(2) The full legal name of the child for whom the activity was provided.
(3) A description of the service, procedure, and method provided, as well as the location where the service is delivered (may be in case notes or a coded system with a corresponding key).
(4) Group size if the service was provided to more than one individual during the service delivery time.
(5) The duration in minutes or time in/time out of the activity provided. Duration in minutes is acceptable if the schedule of the person delivering the service is maintained on file.
(6) A description of the actual progress demonstrated by the eligible child toward the stated goals outlined in the plan of care for each continuous three-month reporting period.
(7) The signature or initials of the person delivering the service on each entry of service delivery. Each documentation recording sheet will contain a legend that indicates the name (electronic, typed or printed), title, signature, and initials of the person delivering the service to correspond with each entry's identifying signature or initials.
(8) Evidence in either the child's case file or a separate supervision log that the appropriate supervision was provided in accordance with appropriate licensing standards.
(9) A description of efforts made to coordinate services with the eligible child's medical home in accordance with the medicaid provider agreement.
(J) The claims for reimbursement for services will be submitted in accordance with rule 5160-35-04 of the Administrative Code.
(K) Guidance in this rule is specific to services performed by qualified practitioners in a school-based setting. Qualified practitioners will exercise reasonable professional judgement consistent with standards as set by his or her professional board. This guidance does not alter any practitioner's scope of practice, nor does it negate the necessity to meet other mandates as obligated when services are furnished outside of the medicaid school program.