Ohio Admin. Code 5160-35-06 - Other services, medical supplies and equipment authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers
Current through all regulations passed and filed through March 11, 2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5162.20, 5164.02, 5164.70
Prior Effective Dates: 11/26/2008 (Emer.), 03/02/2009, 10/15/2009, 04/01/2015
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§ 5160-35-06. Other services, medical supplies and equipment authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers
(A) The purpose of this rule is to set forth the services authorized for medicaid coverage, beyond those indicated in rule 5160-35-05 of the Administrative Code, that a MSP provider can provide, and to set forth the conditions for providing the services.
(B) In addition to the services indicated in rule 5160-35-05 of the Administrative Code, a MSP provider may render and receive payment for the following services:
(a) For purposes of Chapter 5160-35 of the Administrative Code, "transportation" is specialized conveyance that accommodates the specific needs of an eligible child (for example, transportation by wheelchair-accessible vehicle or adapted school bus) for the purpose of traveling to or from the MSP provider to receive medically necessary services allowable under rule 5160-35-05 of the Administrative Code.
(b) Claims for transportation mileage are paid in accordance with rates as found in the "Healthcare Common Procedure Coding System (HCPS)," with the 'Current Procedural Terminology (CPT)" codes, and in rule 5160-1-60 of the Administrative Code.
(c) Unallowable services include transportation that is otherwise available to all students, transportation that is provided in a vehicle that is not used specifically to accommodate an eligible child, transportation accommodations that are not indicated in an eligible child's individualized education program (IEP), and transportation provided from home to school or from school to home if no medicaid-covered service allowable under rule 5160-35-05 of the Administrative Code was received at school on that day.
(2) Targeted case management services (TCM):
(a) Description: assessment, care planning, referral and linkage, monitoring and follow-up activities specified in an eligible child's IEP that will assist the eligible child in gaining access to medical, social, educational and other needed services. The amount, frequency, and duration of the case management services, as well as the case manager responsible for providing the case management service, are to be indicated in the eligible child's IEP.
(b) Qualified practitioners who may deliver the services:
(i) A licensed registered nurse who holds a current, valid license issued under section 4723.09 of the Revised Code, and who is employed or contracted with the MSP provider.
(ii) An individual with a baccalaureate degree with a major in education or social work, and who is employed or contracted with the MSP provider.
(iii) An individual who has earned credit in course work equivalent to that as needed for a major in a specific special education area, and who is employed or contracted with the MSP provider.
(iv) A person who is employed or contracted with the MSP provider, and who has a minimum of three years personal experience in the direct care of an individual with special needs.
(c) The service unit will be fifteen minutes.
(d) Targeted case management is to be billed on a separate claim from all other services. If it is billed on a claim with other services, the targeted case management claim will be denied. This is strictly a billing issue and does not impact the provision of services.
(e) Activities under targeted case management are:
(i) Assessment: for an eligible child with an IEP, ensuring the prescription, by a medicaid authorized prescriber for services for which medicaid reimbursement is to be sought, is in the eligible child's case file; gathering of comprehensive information concerning the eligible child's preferences, personal goals, needs, abilities, health status and other available supports; determining the eligible child's need for case management; obtaining agreement from the eligible child and/or parent/legal guardian, whichever is appropriate, to allow the provision of case management; making arrangements to obtain from therapists and appropriately qualified persons the initial and on-going evaluation of the eligible child's need for any medical, educational, social, and other services.
(ii) Care planning: for an eligible child with an IEP, ensuring the active participation of the eligible child and the eligible child's parent/ legal guardian and family; working with the eligible child's IEP team to develop the IEP goals and course of action to respond to the assessed needs of the eligible child; coordinating with the eligible child's medical home.
(iii) Referral and linkage: connecting an eligible child with an IEP to individuals capable of providing needed medical, social, educational and other needed services.
(iv) Monitoring and follow-up: ensuring that the IEP is effectively implemented and adequately addresses the needs of the eligible child; conducting quality assurance reviews on behalf of the eligible child and incorporating the results of quality assurance reviews into amendments of the IEP; reviewing the progress toward goals in the IEP and making recommendation for assessment as appropriate based upon progress reviews; ensuring that services are provided in accordance with the IEP and that IEP services are effectively coordinated through communication with service providers, including the medical home.
(f) Although the following list is not all-inclusive, the following activities are not allowable as targeted case management through an MSP provider:
(i) Providing medical, educational, vocational, transportation, or social services to which the eligible individual has been referred.
(ii) Providing the direct delivery of foster care services.
(iii) Providing services, other than assessment services, to an eligible child who has not been determined to have a developmental disability according to section 5123.01 of the Revised Code.
(iv) Providing services to an eligible child who is on a waiver program receiving targeted case management from county boards of development disabilities (CBDD).
(v) Conducting quality assurance systems reviews.
(vi) Conducting activities related to the development, monitoring or implementation of an individual service plan (ISP) for an eligible child on a waiver.
(vii) Performing activities for or providing services to groups of individuals.
(viii) Activities performed and services provided by someone who is not an employee of or contracted with an MSP provider to provide targeted case management.
(ix) Activities performed and services provided by someone who is not the case manager specified in the eligible child's IEP.
(x) Providing services for which claims are submitted through or should have been submitted through another program.
(3) Medical supplies and equipment:
(a) Supplies and equipment that are medically necessary as described in rule 5160-1-01 of the Administrative Code for the care and treatment of a medicaid eligible child with an IEP while attending school and that are necessary for the qualified practitioner, as described in rule 5160-35-05 of the Administrative Code, to perform his or her function for an eligible child.
(b) Claim for the cost of medical supplies and equipment are reimbursed through the cost reporting process in accordance with paragraph (K)(2) of rule 5160-35-04 of the Administrative Code.
(c) Unallowable: supplies and equipment furnished to a medicaid eligible child for use outside the school. In order to be reimbursed for supplies and equipment furnished to an eligible child for use outside the school, the school will be approved under the medicaid program as a medical supplies provider. See Chapter 5160-10 of the Administrative Code for coverage, limitation, billing, and reimbursement provisions relative to medical supplies providers.
(d) Claims cannot be submitted for medical supplies and equipment for which a claim was submitted or should have been submitted through another program.
(C) The service provided is to be necessary to enable the recipient to access medically necessary services of the type, frequency, scope and duration that fall within the normal range of services considered under acceptable standards of medical and healing arts professional practice, as appropriate, in accordance with rule 5160-1-01 of the Administrative Code.
(D) The eligible child's IEP is 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 multi-factored evaluation 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 provided, and the amount, duration and frequency of each service.
(4) Include specific goals to be achieved for each service.
(5) Specify timelines for re-assessment/re-evaluation of the eligible child and updates to the plan of care.
(E) The documentation for the provision of each service will be maintained for purposes of an audit trail. Documentation will include:
(1) The date (i.e., day, month, and year) that the services, medical supplies and/or equipment were provided.
(2) The full legal name of the child for whom the services, medical supplies and/or equipment was provided.
(3) A description of the services, medical supplies and/or equipment provided and location where the services, medical supplies and/or equipment are delivered (may be in case notes or a coded system with a corresponding key).
(4) The duration in minutes or time in/time out of the transportation and/or targeted case management service provided. Duration in minutes is acceptable if the schedule of the person delivering the service is maintained on file.
(5) A description of actual progress the eligible child is making/has made toward the stated goals in the plan of care for each continuous three-month reporting period.
(6) The signature or initials of the person delivering the services, medical supplies and/or equipment on each entry of services, medical supplies and/or equipment 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 services, medical supplies and/or equipment to correspond with each entry's identifying signature or initials.
(7) A description of efforts made to coordinate services with the eligible child's medical home in accordance with the medicaid provider agreement.
(F) The claims for reimbursement for services will be submitted in accordance with rule 5160-35-04 of the Administrative Code.(Effective: 7/1/2020 Five Year Review (FYR) Dates: 4/14/2020 and 07/01/2025 Promulgated Under: 119.03 Statutory Authority: 5164.02 Rule Amplifies: 5162.03, 5162.20, 5164.02, 5164.70 Prior Effective Dates: 11/26/2008 (Emer.), 03/02/2009, 10/15/2009, 04/01/2015)