Or. Admin. R. 410-133-0080 - Coverage
Current through Register Vol. 60, No. 12, December 1, 2021
The Authority may reimburse school medical (SM) providers for covered health services that meet all the following criteria:
(1) The health service must be "necessary and
appropriate," considered as a covered service under the Oregon Health Plan
(OHP) Prioritized List of health services, and the health service may not be
excluded under OAR 410-133-0200 Not Covered Services.
(2) The health service must be required by a
Medicaid-eligible student's physical or mental condition that adversely affects
the child/student's educational performance and that helps the child/student
keep, learn, or improve skills and functioning as specified on the
Individualized Education Program (IEP) or Individualized Family Service Plan
(IFSP) and further described in the treatment plan and the evaluation of the
student.
(3) The health service,
individual, or group may include corrective health services treatments and
Medicaid-covered related services as described in a student's IEP or IFSP:
(a) The payment rate for health services
includes case management and necessary supplies for these services. Additional
reimbursement for such services is not paid separately from the health
service;
(b) These services must be
provided by medically qualified staff that meet the standards of licensing or
certification for the health service being provided as described in OAR
410-133-0120 and comply with the respective medical provider's governing
definitions, scope of practice, documentation requirements, and licensure or
certification.
(4)
Evaluation and assessment for SBHS are reimbursed for the part of the
evaluation or assessment regarding a Medicaid-eligible student's "necessary and
appropriate" SBHS needs for the purpose of establishing, re-establishing, or
terminating a Medicaid-covered service on a Medicaid-eligible student's IEP or
IFSP or to develop, review, or revise components of a covered health service
currently provided to a Medicaid-eligible student for continuation of those
covered services pursuant to an IEP or IFSP under the Individuals with
Disabilities Education Act (IDEA):
(a)
Evaluation services are procedures used to determine an SBHS covered
health-related need, diagnosis, or eligibility under IDEA;
(b) Re-evaluation services are procedures
used to measure a Medicaid-eligible student's health status compared to an
initial or previous evaluation and is focused on evaluation of progress toward
current goals, modifying goals or treatment, or making a professional judgment
to determine whether or not a Medicaid-eligible student will continue to
receive continued care for a SBHS covered service pursuant to the IEP or IFSP
under IDEA. Continuous assessment of the student's progress as a component of
ongoing therapy services is not billable as a re-evaluation.
(5) Assistive technology services
directly assist a Medicaid-eligible student with a disability eligible under
IDEA to receive assistive technology-covered SBHS as specified on the IEP or
IFSP in the selection, acquisition, or use of an assistive technology device,
including:
(a) The assistive technology
assessment with one-to-one student contact time by medically-qualified staff
within the scope of practice performing the assessment of the need,
suitability, and benefits of the use of an assistive technology device or
adaptive equipment that will help restore, augment, or compensate for existing
functional ability in the Medicaid-eligible student or that will optimize
functional tasks for the Medicaid-eligible student's environmental
accessibility. This requires and includes the preparation of a written
report;
(b) Care coordination with
the Medicaid-eligible student's physician, parent/guardian, and the Division)
for the parent/guardian's acquisition of a personal assistive technology device
for their Medicaid-eligible student through the student's Medicaid plan for the
benefit of the Medicaid-eligible student to maximize her functional ability and
environmental accessibility; and
(c) Training or technical assistance provided
to or demonstrated with the Medicaid-eligible student by medically-qualified
staff, instructing the use of an assistive technology device or adaptive
equipment in the educational setting with professionals (including individuals
providing education and rehabilitation services) or where appropriate the
family members, guardians, advocates, or authorized representative of the
Medicaid-eligible student. In order to bill Medicaid for this service, the
student must be present.
(6) The Authority may reimburse physical
therapy services provided by:
(a) A physical
therapist authorized to administer physical therapy to an individual when the
individual is a Medicaid-eligible student eligible for special education, as
defined by state or federal law, and is being seen pursuant to the
Medicaid-eligible student's individual education plan or individual family
service plan (see Oregon administrative rules chapter 848, division 10,
Licensed Physical therapist and Licensed Physical Therapist Assistants;
Division 15 Physical Therapist Assistants; and Division 40 Minimum Standards
For Physical Therapy Practice and Records);
(b) A physical therapist assistant providing
treatment under the supervision of a physical therapist that is available and
readily accessible for consultation with the assistant at all times either in
person or by means of telecommunications (see OAR chapter 848, division 15,
Physical Therapist Assistants). Physical therapy services must be provided by
medically qualified staff that meet the standards of licensing or certification
for the health service being provided as described in OAR
410-133-0120;
(c) Reimbursement
time may include:
(A) Preparation of the
written initial evaluation or initial assessment report to establish necessary
and appropriate physical therapy services on a Medicaid-eligible student's IEP
or IFSP;
(B) Obtaining and
interpreting medical information for the part of an evaluation or assessment
performed by the physical therapist to establish necessary and appropriate
physical therapy services on a Medicaid-eligible student's IEP or IFSP or to
determine whether or not necessary and appropriate physical therapy services
will continue to be specified on the Medicaid-eligible student's IEP or IFSP
under IDEA (cannot be delegated);
(C) Care coordination and integrating
services within the scope of practice for providing necessary and appropriate
physical therapy services relative to the Medicaid-eligible student pursuant to
an IEP or IFSP;
(D) Direct
treatment and supervision of services provided to a Medicaid-eligible student
by the physical therapist and defined in the individual plan; when
(E) Documentation by the supervising physical
therapist supporting the appropriate supervision of the assistant is maintained
and kept by the School Medical Provider for a period of seven years (see OAR
chapter 848, division 40, Minimum Standards for Physical Therapy Practice and
Records);
(F) Individual or group
physical therapy services provided to a Medicaid-eligible student by or under
the supervision and direction of a licensed physical therapist pursuant to the
Medicaid-eligible student's IEP or IFSP; when the documentation describing
physical therapy services provided are signed by the therapist providing the
service in accordance with their board licensing requirements, and
documentation for supervision of services performed by or under the supervision
and direction of the supervising physical therapist supporting the services
provided is maintained and kept by the school medical provider for seven years
(see Minimum Standards for Physical Therapy Practice and Records OARs
848-040-0100 through 848-040-0170);
(G) Other covered physical therapy services
within the scope of practice and sections (1) and (2) of this rule.
(7) The Authority may
reimburse occupational therapy services provided by:
(a) A licensed Occupational Therapist (OT)
authorized to administer occupational therapy to an individual when the
individual is a Medicaid-eligible student eligible for special education, as
defined by state or federal law, and is being seen pursuant to the
Medicaid-eligible student's individual education plan or individual family
service plan; and
(b) A licensed
occupational therapy assistant assisting in the practice of occupational
therapy under the general supervision of a licensed occupational therapist.
General supervision requires the supervisor to have at least monthly direct
contact in person with the supervisee at the work site with supervision
available as needed by other methods; and
(c) Before an occupational therapy assistant
assists in the practice of occupational therapy, he must file with the Board a
signed, current statement of supervision of the licensed occupational therapist
that will supervise the occupational therapy assistant (see OAR 339-010-0035
Statement of Supervision for Occupational Therapy Assistant). Occupational
therapy services must be provided by medically qualified staff that meet the
standards of licensing or certification for the health service being provided
as described in OAR 410-133-0120;
(d) Reimbursement time may include:
(A) Preparation of the written initial
evaluation or initial assessment reports that establish necessary and
appropriate occupational therapy services on a Medicaid-eligible student's IEP
or IFSP;
(B) Obtaining and
interpreting medical information for the part of the evaluation or assessment
performed by the occupational therapist to establish necessary and appropriate
occupational therapy services on a Medicaid-eligible student's IEP or IFSP or
to determine whether or not necessary and appropriate occupational therapy
services will continue to be specified on the Medicaid eligible student's IEP
or IFSP under IDEA (cannot be delegated);
(C) Development of the initial occupational
therapy treatment plan by the OT (cannot be delegated);
(D) Coordinating care and integrating
services within the scope of practice relative to the Medicaid-eligible student
receiving necessary and appropriate occupational therapy services as specified
on the IEP or IFSP;
(E) Individual
or group occupational therapy services provided to a Medicaid-eligible student
by or under the supervision and direction of a licensed occupational therapist
as specified on Medicaid-eligible student's IEP or IFSP;
(F) Direct treatment and supervision of
services provided to a Medicaid-eligible student by the occupational therapist
and defined in the individual plan when documentation supporting the
appropriate supervision of the assistant is kept and maintained by the school
medical provider for a period of seven years;
(G) The occupational therapy services
provided are consistent with OAR 339-010-0050 Occupational Therapy Services for
Children and Youth in Education and Early Childhood Programs Regulated by
Federal Laws; and
(H) Documentation
describing occupational therapy treatment provided must be signed including
credentials by the occupational therapist providing the service. Where
appropriate, services provided by an occupational therapist assistant shall be
reviewed and co-signed by the supervising occupational therapist. All
documentation describing treatment provided by an occupational therapy
assistant must name the assistant therapist and the supervising therapist
including credentials as reflected on the current statement of supervision
filed with the Occupational Therapist Licensing Board. Supervision and
documentation of supervision by the supervising therapist for therapy provided
by the occupational therapy assistant must meet general supervision
requirements or closer supervision where professionally appropriate. See OAR
339-010-0005, 339-010-0035, and 339-010-0050. Also, see 410-133-0320
Documentation and Record Keeping Requirements in these rules;
(I) Other covered occupational therapy
services within the scope of practice and sections (1) and (2) of this
rule.
(8) The
Authority may reimburse speech therapy services provided by:
(a) A licensed speech pathologist licensed by
the Oregon Board of Examiners for Speech-Language Pathology and Audiology or
holds a license issued by the Teacher Standards and Practice Commission (TSPC)
prior to July 1, 2016, exemption in ORS
681.230(4)
pursuant to SB287, and holds a Certificate of Clinical Competency (CCC) from
the American Speech and Hearing Association (ASHA), or has completed the
equivalent educational requirements and work experience necessary for the
certificate, or has completed the academic program and is acquiring supervised
work experience to qualify for the certificate, or is authorized to administer
speech therapy to an individual when the individual is a Medicaid-eligible
student eligible for special education, as defined by state or federal law,
receiving speech therapy services pursuant to an individual education plan or
individual family service plan; or
(b) A graduate speech pathologist in their
Clinical Fellowship Year (CFY) practicing under the supervision of al licensed
speech pathologist with CCC meeting the standards of licensing or certification
for the health service provided as described in OAR 410-133-0120 medically
qualified staff; and when:
(A) A standardized
system for reviewing the clinical work of the clinical fellow is performed at
regularly scheduled intervals, using the Skills Inventory Rating (CFSI) form
addressing the fellow's attainment of skills for independent
practice;
(B) The clinical fellow
supervisor maintains and documents the supervision of the clinical fellow to be
kept by the school medical provider for a period of seven years;
(C) Documentation describing the treatment
provided is signed and initialed by the clinical fellow for review and
co-signed by the supervising clinical fellow.
(c) Speech-language pathology assistants
(SLPA), licensed by the Oregon State Board of Examiners for Speech-Language
Pathology and Audiology, under the supervision of a supervising speech-language
pathologist and who meet the standards of licensing or certification for the
health service provided as described in OAR 410-133-0120 Medically Qualified
Staff, when the following conditions are met:
(A) The supervising speech-language
pathologist must have at least two years of full-time professional
speech-language pathology experience (see OAR 335-095-0040 and 335-095-0050,
Requirements for Supervising Licensed Speech-Language Pathology
Assistants);
(B) The supervising
speech therapist does not supervise more than the equivalent of two full-time
speech-language pathology assistants;
(C) The supervising speech-language
pathologist maintains documentation supporting the appropriate supervision of
the assistant to be kept by the school medical provider for a period of seven
years;
(D) The caseload of the
supervising clinician allows for administration, including assistant
supervision, evaluation of students and meeting times. All students assigned to
an assistant are considered part of the caseload of the supervising
clinician;
(E) The supervising
speech-language pathologist must be able to be reached at all times. A
temporary supervisor may be designated as necessary;
(F) The services provided by the assistants
are consistent with the Scope of Duties for the Speech-Language Pathology
Assistant (SLPA) pursuant to OAR 335-095-0060;
(G) Documentation describing the treatment
provided is signed and initialed by the SLPA for review and co-signature by the
supervising speech-language pathologist to be kept by the school medical
provider for a period of seven years from date of payment.
(d) Reimbursement time may include:
(A) Preparation of the written initial
evaluation or initial assessment report, including obtaining and interpreting
medical information for the part of the evaluation or assessment performed by
the speech pathologist to establish necessary and appropriate speech therapy
services on a Medicaid-eligible student's IEP or IFSP or determine whether or
not necessary and appropriate speech therapy services will continue to be
specified on the Medicaid-eligible student's IEP or IFSP under IDEA (cannot be
delegated);
(B) Development of the
initial speech therapy treatment plan by the speech pathologist (cannot be
delegated);
(C) Care coordination
and integrating services within the scope of practice relative to the
Medicaid-eligible student receiving necessary and appropriate speech therapy
services specified on the IEP or IFSP;
(D) Direct individual or group speech therapy
services provided to a Medicaid-eligible student for speech services specified
on the IEP or IFSP delivered by or under the supervision and direction of a
speech pathologist who is medically qualified to deliver the service, see
410-133-0120 Medically Qualified Staff;
(E) Direct training and supervision of
services provided to a Medicaid-eligible student by the medically qualified
supervising speech pathologist to be kept by the school medical provider for a
period of seven years; and
(F)
Other covered speech therapy services within the scope of practice and sections
(1) and (2) of this rule.
(9) The Authority may reimburse audiology
services provided by:
(a) A licensed
audiologist within the scope of practice as defined by state or federal law who
meet the standards of licensing or certification for the health service
provided as described in OAR 410-133-0120, Medically Qualified Staff;
(b) Reimbursement time may include:
(A) Preparation of the written initial
evaluation or initial assessment report, including obtaining and interpreting
medical information for the part of the evaluation or assessment performed by
the audiologist within the scope of practice to establish necessary and
appropriate hearing services on a Medicaid-eligible student's IEP or IFSP or
determine whether or not necessary and appropriate hearing impairment services
will continue to be specified on the Medicaid-eligible student's IEP or IFSP
under IDEA;
(B) Periodic hearing
evaluations and assessments of a Medicaid-eligible student with hearing loss
found eligible under IDEA pursuant to services as specified on the IEP or IFSP
for determination of the range, nature, and degree of hearing loss;
(C) Care coordination and integration of
services for medical or other professional attention relative to a
Medicaid-eligible student receiving services for restoration or rehabilitation
due to hearing and communication disorders as specified on the IEP or
IFSP;
(D) Provision of
rehabilitative activities such as language restoration or rehabilitation,
auditory training, hearing evaluation and speech conversation, and
determination of the Medicaid-eligible-student's need for individual
amplification in accordance with the student's IEP or IFSP.
(10) The Authority may
reimburse nurse services provided by:
(a) A
nurse practitioner (NP), registered nurse (RN), licensed practical nurse (LPN),
or delegated health care aid under the supervision of an RN or NP who meet the
standards of licensing or certification for the health service provided as
described in OAR 410-133-0120 Medically Qualified Staff;
(b) Nursing services under this program are
not intended to reimburse nursing activities of a private duty RN or LPN that
is otherwise billing Medicaid directly for those services;
(c) Reimbursement time may include:
(A) Preparation of the written initial
evaluation or initial assessment report to establish nursing services including
obtaining and interpreting medical information for the part of the evaluation
or assessment performed to establish necessary and appropriate nursing services
on the Medicaid-eligible student's IEP or IFSP or determine whether or not
necessary and appropriate nursing services will continue to be specified on the
Medicaid-eligible students IEP or IFSP under IDEA;
(B) Coordinated care for other specified care
management for a chronic medical condition that is not addressed on the current
IEP or IFSP that will result in amending nursing services specified in the IEP
or IFSP and requires an updated nursing plan of care. This may result in an
increase in supervision, monitoring, and training of DHC staff to provide new
nursing tasks related to the change in condition, i.e., a child with seizure
disorder that develops diabetes;
(C) Care coordination and integration of
necessary and appropriate nursing services relative to the Medicaid-eligible
student's covered health service specified on the IEP or IFSP;
(D) Nurse to student interactive services
that are covered health services provided to a Medicaid-eligible student with a
chronic medical condition receiving nursing services pursuant to an IEP or
IFSP;
(E) Oversight of delegated
health care aides performing delegated nursing services directly with the
student as specified on the IEP or IFSP;
(F) Student observation by medically
qualified staff for medical reasons of a Medicaid-eligible student with a
chronic medical condition as part of an evaluation, assessment, or care
coordination. An observation by itself is not a billable activity;
(G) Other covered nursing care services
within the scope of practice and sections (1) and (2) of this rule.
(11) The Authority may
reimburse mental health services provided by:
(a) A psychiatrist who meets the standards of
licensing or certification for the health service being provided as described
in OAR 410-133-0120(2)(f)(A), or a psychologist who meets the standards of
licensing or certification for the health service being provided as described
in OAR 410-133-0120(2)(f)(B), or a mental health nurse practitioner who meets
the standards of licensing or certification for the health service being
provided as described in OAR 410-133-0120(2)(e)(A); or
(b) A psychologist associate with authority
to function without immediate supervision, performing functions that may
include but are not restricted to administering tests of mental abilities,
conducting personality assessments and counseling (see OAR 858-010-0039
Application for Independent Status). These services must be provided by
medically qualified staff who meet the standards of licensing or certification
for the health service being provided as described in OAR
410-133-0120(2)(f)(C); or
(c) A
psychologist associate under the supervision of a psychologist as specified by
the Board of Psychologist Examiners, OAR chapter 858, division 010. These
services must be provided by medically qualified staff who meet the standards
of licensing or certification for the health service being provided as
described in OAR 410-133-0120(2)(f)(D); or
(d) A technician under the supervision of a
psychologist as specified by the Board of Psychologist Examiners, chapter 858,
division 10, OAR 858-010-0002, Guidelines for Supervising Technicians, and who
meet the standards of licensing or certification for the health service being
provided as described in OAR 410-133-0120(f)(E); or
(e) An LCSW qualified and licensed to deliver
the service, or a Clinical Social Work Associate (CSWA) under the supervision
of an LCSW specified by the Board of Licensed Social Workers, chapter 877
division 20 and who meet the standards of licensing or certification for the
health service being provided as described in OAR 410-133-0120(f)(F);
(f) Reimbursable time may include:
(A) Preparation of the written initial
evaluation or initial assessment report for a suspected disability per the
referral process for determining IDEA eligibility, including obtaining and
interpreting medical information for the part of the evaluation or assessment
performed by the mental health care practitioner within the scope of practice
to establish necessary and appropriate mental health services on the
Medicaid-eligible student's IEP or IFSP or to determine whether or not
necessary and appropriate mental health services will continue to be specified
on the Medicaid-eligible student's IEP or IFSP under IDEA;
(B) Care coordination and integrating
services within the scope of practice relative to the Medicaid-eligible student
receiving mental health services as specified on the IEP or IFSP;
(C) Direct individual therapy services
provided within the scope of practice under state law and covered under
sections (1) and (2) of this rule to a Medicaid-eligible student by or under
the supervision and direction of a psychologist, a psychiatrist, or mental
health nurse practitioner, or a Licensed Clinical Social Worker qualified and
licensed to deliver the service pursuant to the Medicaid-eligible student's IEP
or IFSP.
(12)
The Authority may reimburse telehealth, tele-electronic/telephonic School-Based
Health Services (SBHS) provided to the same extent the services would be
covered if they were provided in person and billed to Medicaid using
appropriate SBHS procedure codes and modifiers. All SBHS telehealth services
billed to Medicaid shall:
(a) Be provided by a
licensed practitioner/clinician employed by or contracted by an Oregon public
school district or Education Service District, enrolled with Oregon Health
Authority (OHA) as a "school medical (SM)" provider with authority to provide
SBHS to Oregon Medicaid beneficiaries;
(b) Be performed by or under a supervising
licensed practitioner/clinician within the scope of practice governed by their
licensing board, who meet the federal requirements as described in medically
qualified staff in OAR 410-133-0120, and who hold a current and valid license
without restriction from a state licensing board where the provider is
located;
(c) Use synchronous audio
and visual interactive technologies, including interactive audio/telephonic
services provided to a child/student in a geographical area where synchronous
audio and video is not available or consent for audio/video is refused for
services provided to a child/student;
(d) Include, when applicable, electronic or
telephonic communications such as telephone conversation, video conference, or
an internet relay chat session for care coordination defined in OAR
410-133-0040(16);
(e) Assist the
licensed practitioner/clinician with care coordination and oversight of a
Medicaid eligible child/student's covered health related services provided in
support of a child/student's education program required by the Individuals with
Disabilities Education Act (IDEA);
(f) Be compliant with applicable privacy
rules and security protections for the child/student in connection with the
telehealth communication and confidentiality related to records required by
HIPAA and FERPA;
(g) Ensure the
telehealth communication obtained, used and maintained is compliant with
privacy and security standards in HIPAA and the Authority's Privacy and
Confidentiality Rules set forth in OAR 943 division 14;
(h) Ensure policies and procedures are in
place to prevent a breach in privacy or exposure of protected health
information or records (whether oral or recorded in any form or medium) to
unauthorized individuals.
(13) Providers billing Medicaid for SBHS
health related services via telehealth must:
(a) Align services provided within a licensed
practitioner/clinician scope of practice governed by their licensing board;
(b) Obtain the child's/student's
parent or guardian's written or verbal consent to receive the services via
telehealth technologies, prior to the delivery of health-related services to an
eligible child/student with disabilities using a telehealth modality. Verbal
consent must be documented/noted in the child's plan of care by the
practitioner. Consent must be obtained and documented annually or with change
in services on the child/students plan of care;
(c) Model SOAP charting or equivalent for
covered health related services required by the Individuals with Disabilities
Education Act (IDEA) in compliance with Documentation and Recordkeeping
Requirements OAR 410-133-0320;
(d)
Describe services provided as telehealth synchronous audio/visual interactive
equivalent to face to face; or electronic/telephonic interactive communication
described as telephone conversation, video conference, or internet relay chat
requiring decision making for coordinating care;
(e) Bill Medicaid using the most appropriate
Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding
System (HCPCS) codes and modifiers for SBHS considered as an OHP covered
service. A two-digit modifier assigned to telehealth is required for billing
SBHS telehealth services using audio and video interactive technologies;
(f) For services covered using
synchronous audio and video with modifiers GT, the Division will cover the same
services provided by synchronous audio (e.g. telephone), when billed with the
same codes but without modifier GT when provision of the same service via
synchronous audio and video is not available or feasible, when the patient
declines to enable video, or necessary consents cannot reasonably be obtained
with appropriate documentation in the child/student's plan of care;
(g) Maintain clinical documentation and
financial records related to telehealth services as required in OAR
410-120-1360 and these SBHS Rules.
(14) In the event a National or declared
state of emergency, crisis, pandemic or other disaster occurs that results in
prolonged school closure, the Authority may adopt flexibilities to remove
barriers in support of medically necessary service delivery:
(a) The state recognizes that exceptional
circumstances may affect how all educational and related services and supports
are provided during a declared state of emergency and will follow guidance from
the US Department of Health and Human Services (HHS), Office for Civil Rights
(OCR), Office of Special Education Programs (OSEP) in the Department of
Education, and Office of Special Education and Rehabilitative Services (OSERS)
for flexibility where possible and may allow enforcement discretion related to
encryption requirements;
(b)
Oregon's school program must ensure that, to the greatest extent possible,
students with a disability are provided the special education and related
services identified in a student's IEP/IFSP required by IDEA, or a plan
developed under Section 504 of the Rehabilitation Act of 1973;
(c) Federal disability law guaranteed by the
Rehabilitation Act of 1973 and the Individuals with Disabilities Education Act
(IDEA) allow for flexibility in the determination of how a Free Appropriate
Public Education (FAPE) is to be provided during a public health emergency or
any declared state of emergency consistent with the need to protect the health
and safety of students with disabilities and those individuals providing
special education and related services to students;
(d) During an emergency declaration, the
Authority may reimburse any necessary and appropriate physical, mental,
behavioral and oral health service delivered using a telehealth platform when
the telehealth delivery reasonably approximates in person services to maximize
access to services and reduce barriers in the delivery of these services
provided to eligible children included in a child's Individualized Education
Program (IEP) or Individualized family Service Plan (IFSP) required by the
Individuals with Disabilities Education Act (IDEA), a Section 504 plan pursuant
to Section 504 of the Rehabilitation Act, or other school services plan. Other
types of telecommunications are not covered, without necessary and appropriate
decision making for an eligible child's /student's plan of care.
(15) Medicaid reimbursed
transportation:
(a) Transportation to a
covered health service as documented in the child's IEP/IFSP and defined in
these rules (see 410-133-0245, Cost Determination and Payment);
(b) Ongoing transportation specified as a
related service on the Medicaid-eligible student's IEP or IFSP may be claimed
as a Medicaid service on the days a Medicaid-eligible student receives a
covered health service that is also specified on the IEP or IFSP and the
transportation is supported by a transportation vehicle trip log;
(c) The Authority may only reimburse for
transportation as a related service to and from a Medicaid-covered service for
a Medicaid-eligible student when the transportation is supported by a
transportation vehicle trip log; and the student receives a Medicaid-covered
health service other than transportation on that day when either of the
following situations exist:
(A) The
Medicaid-eligible student requires specialized transportation adapted to serve
the needs of the disabled student; there is documentation to support
specialized transportation is "necessary and appropriate;" and transportation
is listed as a related service on the student's IEP or IFSP; or
(B) The Medicaid-eligible student has a
medical need for transportation that is documented in the IEP or IFSP and
resides in an area that does not have regular school bus transportation such as
those areas in close proximity to a school.
(d) If a Medicaid-eligible student is able to
ride on a regular school bus, but requires the assistance of a delegated health
care aide trained by an RN to provide a delegated nursing task specific to the
student and cannot be transported safely without the delegated health care
aide, the service provided by the delegated healthcare aide is reimbursed under
the delegated healthcare code. See the Standards for Community-Based Care
Registered Nurse Delegation of a nursing care task as outlined in the Nurse
Practice Act, OAR chapter 851 division 47;
(e) If a Medicaid-eligible student requires
the assistance of a delegated health care aide and transportation adapted to
serve the needs of the disabled student, both the necessary and appropriate
transportation and the service provided by the delegated healthcare aide may be
reimbursed when both are specified on the Medicaid-eligible student's current
IEP or IFSP;
(f) If an education
agency provides special transportation to a Medicaid-eligible student to a
covered service outside the district or the Medicaid-eligible student's
resident school and the student cannot be transported safely without a
transportation aide as specified on the IEP or IFSP, the transportation is
billable. However, a transportation aide who is not a delegated healthcare aide
trained by an RN cannot be billed as a separate cost because the cost of the
transportation aide is included in the cost of the transportation;
(g) Transportation is not reimbursable by the
Division when provided by the parent or relative of the child;
(h) Transportation to an "evaluation" service
is covered if:
(A) Medically necessary
transportation is listed and included in the Medicaid-eligible student's
current IEP or IFSP and the evaluation is to establish, re-establish, or
terminate a SBHS covered service under IDEA;
(B) The evaluation is a SBHS covered health
service;
(C) The medical provider
conducting the evaluation, if not employed or contracted by the school medical
provider, is an enrolled provider with the Division and meets applicable
medical licensing standards necessary to conduct the evaluation.
(16) Medicaid may
reimburse for contracted consultation health services for furnishing
consultations regarding a Medicaid-eligible student's covered health service
specified on the IEP or IFSP for an evaluation or assessment to establish,
re-establish, or terminate a covered SBHS on an IEP or IFSP. Contracted
consultation services must be provided by a licensed medical professional other
than school medical provider staff:
(a) This
service may be on a contracted basis for a number of students;
(b) Allowable services must be furnished
through a personal service contract between the school medical provider and the
licensed health care practitioner;
(c) This service would only be an SBHS
covered health service by the school medical provider when the licensed health
care practitioner did not bill Medicaid directly under other programs for the
same services.
(17)
Reimbursed coordinated care performed by medically qualified staff as described
in OAR 410-133-0120 directly related to health services required by a
Medicaid-eligible student's physical or mental condition as described in the
IEP or IFSP must be one of the following:
(a)
Managing integration of those Medicaid covered health services for treatment
provided in the education setting;
(b) The portion of a conference between
interested parties and medically-qualified staff for developing, reviewing, or
revising a Medicaid-covered health service or therapy treatment plan for
services provided pursuant to a Medicaid-eligible student's IEP or IFSP or to
establish, re-establish, or terminate a covered health service under IDEA for
eligibility purposes;
(c)
Consultation from medically qualified staff providing technical assistance to
or conferring with special education providers, physicians, or families to
assist them in providing covered health services to Medicaid-eligible students
for treatment provided in the educational setting related to specific health
services and the goals and objectives in the student's IEP or IFSP.
Consultation services must be completed by a licensed health care practitioner
within the scope of practice under their licensure.
Notes
Statutory/Other Authority:ORS 413.042
Statutes/Other Implemented:ORS 413.042 & 414.065
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