Or. Admin. Code § 410-133-0080 - Coverage
(1) A School-Based
Health Service (SBHS) is covered when it meets the following criteria:
(a) The health service must be a medically
necessary and medically appropriate non-residential health service;
(b) The health service is recommended by a
health care practitioner and is documented in the child or young adult's
Individual Plan of Care (IPOC);
(c)
The health service is provided or supervised by an Authority-enrolled
medically-qualified individual providing and documenting the service within
their respective scope of practice and in compliance with their respective
board rules and requirements and OAR
410-120-1360;
(d) The health service is billed to the
Authority by an enrolled school district or education service district in
accordance with SBHS rules; and
(e)
The health service is not excluded under OAR
410-133-0200.
(2) Evaluation and assessment:
(a) An evaluation and assessment or
re-evaluation is covered for the part of the evaluation, re-evaluation, or
assessment regarding a child or young adult's medically necessary and medically
appropriate school-based health service needs for the purpose of establishing,
re-establishing, or terminating a school-based health service on the child or
young adult's IPOC or to develop, review, or revise components of a covered
school-based health service currently provided to a child or young adult for
continuation of those covered services; and
(b) Reimbursement time may include:
(A) The time that is for the part of the
supervisory-level medically-qualified individual's evaluation, re-evaluation,
or assessment of a child or young adult's necessary and appropriate
school-based health service needs (cannot be delegated).
(B) The time for the supervisory-level
medically-qualified individual to prepare the written evaluation or assessment
report, including obtaining and interpreting medical information to establish
necessary and appropriate referrals and care coordination or to determine
whether the necessary and appropriate services shall continue to be specified
on the child or young adult's IPOC (cannot be delegated).
(3) Care coordination,
consultation, and referrals:
(a) Care
coordination, consultation, and referrals are covered when provided as directly
related to the SBHS specified on the child or young adult's IPOC; and
(b) Reimbursement time may include:
(A) Care coordination, consultation, or
referral performed by a licensed health care practitioner within their scope of
practice to manage integration of services relative to the child or young adult
as specified on the child or young adult's IPOC:
(i) With the child or young adult's
physician, community practitioner(s), community organization(s),
parent/guardian, the Authority, or the child or young adult's coordinated care
organization (CCO) for community health treatment and integration of services
provided through the child or young adult's Medicaid coverage;
(ii) To provide technical assistance to or
confer with education agency staff, medically-qualified individuals, healthcare
practitioners, or families to assist them in providing covered health services
related to specific health services and the goals and objectives in the child
or young adult's IPOC.
(iii) To
provide training for non-supervisory level medically-qualified individuals
performing health care activities.
(B) The portion of a conference between
interested parties and a medically-qualified individual for developing,
reviewing, or revising a Medicaid-covered health service or therapy treatment
plan for services provided pursuant to a child or young adult's IPOC or to
establish, re-establish, or terminate a covered health service.
(4) Assistive
technology services:
(a) Assistive technology
services are covered when directly assisting in the selection, acquisition, or
use of an assistive technology device as specified on the child or young
adult's IPOC; and
(b) Reimbursement
time may include the following when performed by a medically-qualified
individual within their respective scope of practice:
(A) An assistive technology assessment with
one-to-one child or young adult contact time;
(B) Preparing the required written report of
the need, suitability, and benefits of the use of an assistive technology
device or adaptive equipment that shall help restore, augment, or compensate
for existing functional ability or that shall optimize functional tasks for the
child or young adult's environmental accessibility;
(C) Care coordination and consultation with
the child or young adult's healthcare practitioner, parent/guardian, and the
Authority for the acquisition of a personal assistive technology device for the
child or young adult through the child or young adult's Medicaid plan;
and
(D) Training or technical
assistance provided to, or demonstrated with, the child or young adult which
may include instructing on the use of an assistive technology device or
adaptive equipment in the educational setting with professionals (including
individuals providing education and rehabilitation services) or the child or
young adult's family members, guardians, advocates, or authorized
representative.
(5) Direct services must be provided and
documented by medically-qualified individuals within their scope of practice
and in compliance with their respective Oregon board rules and OAR
410-120-1360; and Direct
services are covered when the service is supported by:
(a) A current written recommendation,
completed within twelve (12) months of the date-of-service, from a health care
practitioner;
(b) The direct
service is medically necessary and medically appropriate; and
(c) The child or young adult's IPOC includes
the health service category, the nature, extent, or units of service and
therapeutic value for each service.
(6) Specialized transportation:
(a) Specialized transportation services are
covered when:
(A) The child or young adult
requires specialized transportation provided in a specially adapted vehicle
that has been physically adjusted or designed to meet the needs of the child or
young adult to serve their individual health-related needs, specialized
transportation is specified as a related service in the child or young adult's
Individualized Education Program (IEP) or Individualized Family Service Plan
(IFSP), and there is documentation to support specialized transportation is
necessary and appropriate; and
(B)
A separate school-based health service, other than transportation, is specified
on the child or young adult's IEP or IFSP and provided and reimbursed on that
day.
(b) Specialized
transportation must be supported by a transportation vehicle trip
log.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.065
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