Chapter 5160-35 Medicaid School Program

5160-35-01 Definitions.

(A) For the purposes of Chapter 5160-35 of the Administrative Code, the following terms are defined as:

(1) At the direction of: communication of a plan of care to a licensed practical nurse by a licensed physician or registered nurse who is acting within the scope of his or her practice under Ohio law for the provision of nursing services by the licensed practical nurse.

(2) Clinical setting: for the purpose of counseling and social work roles, a location in the school, or a location for which the medicaid school program provider has contracted for the delivery of services, where the child's confidentiality can be maintained when a service is being rendered.

(3) Community school: a public school, independent of any school district, established in accordance with Chapter 3314. of the Revised Code that is part of the state's program of education.

(4) Common procedural terminology (CPT): a list of descriptive terms and identifying codes for reporting medical services and procedures performed.

(5) Direct service costs: costs associated with salaries, benefits, and contract compensation for individuals and entities delivering services to an eligible child, services as defined in rule 5160-35-05 of the Administrative Code and as defined in paragraph (B)(2) of rule 5160-35-06 of the Administrative Code.

(6) Eligible child: a student for whom medicaid reimbursement may be sought through the medicaid school program who is enrolled in an entity defined in paragraph (B)(1) of rule 5160-35-02 of the Administrative Code, who is between the age of three to twenty-one, and has an individualized education program in which is indicated services that are allowable under medicaid.

(7) Healthcare common procedure coding system (HCPCS): is a uniform method for health care providers and medical suppliers to report professional services, procedures and supplies.

(8) The individualized education program (IEP) is as defined in section 3323.011 of the Revised Code.

(9) Licensed practitioner of the healing arts: for purposes of these rules, includes the following qualified practitioners delineated in rule 5160-35-05 of the Administrative Code - occupational therapist; physical therapist; speech-language pathologist; and audiologist.

(10) Local education agency: city school district, local school district, exempted village school district, as defined in sections 3311.01 to 3311.04 of the Revised Code.

(11) Medicaid authorized prescriber: a physician (M.D. or D.O.), podiatrist, dentist, or advanced practice nurse working within his or her scope of practice as defined by state law.

(12) Medical home: a physician, physician group practice, or an advanced practice nurse with a current medicaid provider agreement, or a provider with a contract with an Ohio medicaid managed care plan. This provider serves as an ongoing source of primary and preventive care and provides assistance with care coordination for the patient.

(13) Medically necessary: skilled services recommended by a qualified licensed practitioner in accordance with rules 5160-35-05 and 5160-35-06 of the Administrative Code who is acting within the scope of his or her licensure that meet the requirements in rule 5160-1-01 of the Administrative Code and meet general principles regarding reimbursement for medicaid covered services found in rule 5160-1-02 of the Administrative Code.

(14) Medicaid school program (MSP): is as set forth in Chapter 5160-35 of the Administrative Code.

(15) MSP provider: entity that meets the qualifications delineated in rule 5160-35-02 of the Administrative Code.

(16) Other costs: costs for service-related activities for which there is no CPT or HCPCS code and for which claiming is not possible by the MSP provider due to medicaid rule restrictions; administrative claiming, equipment, supplies, indirect costs, and billing fees.

(17) Skilled services: services of such complexity and sophistication that the service can be safely and effectively performed only by or under the supervision of a licensed practitioner of the healing arts practicing within the scope of their licensure. Skilled services do not include services provided by persons not licensed in accordance with the Ohio Revised Code.

(18) State school: school under the control and supervision of the state board of education established for students who are deaf or blind as defined by section 3325.01 of the Revised Code.

(19) Supervision: is as defined in rules 4753-7-02, 4755-27-01, 4755-27-04, and 4755-7-04 of the Administrative Code.

Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/08/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 11/26/08 (Emer.), 3/2/09, 10/15/09

5160-35-02 Qualifications to be a medicaid school program (MSP) provider.

(A) The purpose of this rule is to set forth the qualifications to become a medicaid school program provider (MSP) and requirements for a MSP provider must follow.

(B) An MSP provider shall:

(1) Be one of the following:

(a) Local education agency (LEA) city school district, local school district, exempted village school district as defined in sections 3311.01 to 3311.04 of the Revised Code;

(b) State school for the deaf as defined by section 3325.01 of the Revised Code;

(c) State school for the blind as defined by section 3325.01 of the Revised Code;

(d) Community school as defined by Chapter 3314. of the Revised Code.

(2) Obtain and maintain a current valid medicaid provider agreement in accordance with rule 5160-1- 17.2 of the Administrative Code.

(3) Employ or contract for at least one of the following:

(a) Occupational therapist who holds a current, valid license to practice occupational therapy issued under Chapter 4755. of the Revised Code.

(b) Physical therapist who holds a current, valid license to practice physical therapy issued under Chapter 4755. of the Revised Code.

(c) Speech-language pathologist who holds a current, valid license to practice speech-language pathology issued under Chapter 4753. of the Revised Code.

(d) Audiologist who holds a current, valid license to practice audiology issued under Chapter 4753. of the Revised Code.

(e) Licensed clinical counselor or licensed counselor who holds a current, valid license to practice professional counseling issued under Chapter 4757. of the Revised Code.

(f) Licensed psychologist or licensed school psychologist who holds a current, valid license to practice psychology or school psychology issued under Chapter 4732. of the Revised Code or under rule 3301-24-05 of the Administrative Code.

(g) Licensed independent social worker or social worker who holds a current, valid license to practice social work issued under Chapter 4757. of the Revised Code.

(h) Licensed registered nurse who holds a current, valid license to practice nursing issued under Chapter 4723. of the Revised Code.

(C) An MSP provider shall ensure all employees and contractors who have in-person contact with consumers for the provision of services undergo and successfully complete criminal records checks pursuant to rules adopted under section 5164.34 of the Revised Code.

(D) An MSP provider shall provide services in accordance with rules 5160-35-05 and 5160-35-06 of the Administrative Code.

(E) An MSP provider shall submit claims in accordance with rule 5160-35-04 of the Administrative Code to receive reimbursement for the provision of services.

(F) An MSP provider shall comply with the following for cost reporting and cost reconciliation purposes:

(1) Participate in all random moment time studies(RMTS) RMTS are designed to document the level of effort of MSP providers on a state-wide basis in compliance with the applicable RMTS guide provided by the Ohio department of education (ODE).

(2) Submit the federal child count of special education students included as a part of the total student count defined in section 3301.011 of the Revised Code.

(3) Prepare a cost report in accordance with paragraph (K)(2) of rule 5160-35-04 of the Administrative Code.

(4) Contract with an independent certified public accountant or firm to perform an agreed upon procedures review of the cost report and to document adjustments to the cost report, in accordance with paragraph (K)(2) of rule 5160-35-04 of the Administrative Code.

(5) Adhere to all applicable rules, including, but not limited to 45 C.F.R. 92, dated December 24, 2013, Revised Code, Administrative Code, "CMS Publication 15-1" (found at www.cms.gov/manuals), and provisions outlined in the cost report instructions.

Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/08/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 11/26/08 (Emer.), 3/02/09, 10/15/09

5160-35-04 Reimbursement for services provided by medicaid school program (MSP) providers.

(A) The purpose of this rule is to set forth the provisions for claiming to receive medicaid reimbursement for the provision of services by medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.

(B) The CPT (common procedural terminology) and HCPCS (healthcare common procedure coding system) covered services provided through MSP providers that are allowable for medicaid reimbursement are listed in the appendix to this rule and are provided in accordance with Chapter 5160-35 of the Administrative Code. The following limits apply:

(1) Assessment/evaluation services cannot be billed more than once per continuous twelve month period.

(2) Re-assessment/re-evaluation services cannot be billed more than once per continuous six-month period.

(3) Skilled services cannot be billed for dates of service beyond twelve months of the initial assessment/evaluation or re-assessment/re-evaluation.

(C) Medically necessary services for individuals under age twenty-one that go beyond the coverage and limitations established in this rule shall be:

(1) Prior authorized by the Ohio department of medicaid (ODM) in accordance with rule 5160-1-31 of the Administrative Code; and

(2) Services defined as medical assistance in accordance with section 1905(a) of the Social Security Act, 42 U.S.C. 1396d (January 1, 2013).

(D) The following conditions shall be met in order to receive medicaid reimbursement for services provided through the medicaid school program:

(1) The school district shall be a qualified MSP provider in accordance with rule 5160-35-02 of the Administrative Code.

(2) The MSP provider shall submit claims for reimbursement for all direct service costs provided in accordance with rule 5160-35-05 of the Administrative Code and paragraph (B)(3) of rule 5160-35-06 of the Administrative Code for which the MSP provider will submit a cost report seeking cost reconciliation.Costs for direct services for which a provider has not submitted an interim claim will not be paid to the provider in any final cost report settlement.

(3) The MSP provider shall submit claims for only those services for which it has statutory responsibility to provide to either an eligible child with an IEP or for assessment/evaluation for a medicaid eligible child for whom they are trying to determine the appropriateness of developing an individualized education program (IEP).

(4) The executive officer of the MSP provider or his/her designee shall attest to the validity of the non-federal share of expenditures in accordance with paragraph (G) of this rule.

(5) The service provided through the MSP provider shall be in accordance with rules 5160-35-05 and 5160-35-06 of the Administrative Code.

(6) The service for which reimbursement is sought shall be one clearly identified in the IEP of an eligible child, with the exception of the initial assessment/evaluation as described in paragraph (B)(7) of rule 5160-35-05 of the Administrative Code.

(E) The MSP provider is required to enroll and submit claims as an ODM electronic data interchange (EDI) trading partner or contract with an ODM EDI trading partner for the submission of claims to ODM.

(F) Claims shall be submitted in accordance with rule 5160-1-02 of the Administrative Code.

(G) When a medicaid claim is submitted through an EDI trading partner, the claim shall include a ten character code that is the first item listed in the NTE02 field, and that is an attestation of whether or not the claim is certified by the executive officer of the MSP provider or his/her designee as follows:

(1) Attest yes: used if the claim is certified by the executive officer of the MSP provider or his/her designee to only include expenditures under the medicaid program under Title XIX of the Social Security Act (the Act), and as applicable, under the state children's health insurance program (SCHIP), under Title XXI of the Act, that are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, and policies, and the state plan approved by the secretary of health and human services and in effect at the time of the submission of this claim; and the expenditures included in the claim are based on the MSP provider's accounting of actual recorded expenditures; and the required amount of local public funds were available and used to match the MSP provider's (local public school district's) allowable expenditures included in this claim, and such local public funds were in accordance with all applicable federal requirements for the non-federal share match of expenditures; and federal matching funds are not being claimed in this claim submission to match any expenditure under any medicaid and/or SCHIP state plan amendment that has not been approved by the secretary of health and human services effective for the period of this claim.

(2) Attest nay: used if the claim is not certified by the executive officer of the MSP provider or his/her designee to only include expenditures under the medicaid program under Title XIX of the Social Security Act (the Act), and as applicable, under the state children's health insurance program (SCHIP), under Title XXI of the Act, that are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, and policies, and the state plan approved by the secretary of health and human services and in effect at the time of the submission of this claim; and the expenditures included in the claim are based on the MSP provider's accounting of actual recorded expenditures; and the required amount of local public funds were available and used to match the MSP provider's (local public school district's) allowable expenditures included in this claim, and such local public funds were in accordance with all applicable federal requirements for the non-federal share match of expenditures; and federal matching funds are not being claimed in this claim submission to match any expenditure under any medicaid and/or SCHIP state plan amendment that has not been approved by the secretary of health and human services effective for the period of this claim. If attest nay is used, the claim will be denied for payment.

(H) Claim submissions must be received by ODM within three-hundred sixty-five days of the actual date the service was provided.

(I) References to cartridge tape, paper claim and pharmacy-point-of-sale in rule 5160-1-20 of the Administrative Code are not applicable to the claim and shall not be allowed.

(J) A billing unit for a service code reported in minutes is as indicated in the appendix to this rule, and claims shall be for minutes of actual service delivery time as follows:

(1) If service is provided in a group of two or more, the total number of minutes of each type of service, as distinguished by service codes, provided during the school or calendar day to the group of children is divided by the number of children in the group. This resulting number is then divided by the number of minutes identified for the service code to determine the number of units of service to an eligible child.

(2) The number of units is equivalent to the total number of minutes of each type of service, as distinguished by service codes, provided during the school or calendar day to the eligible child, divided by the number of minutes (a per hour unit is sixty minutes), or minimum minutes of the range identified for the service code.

(3) For service codes with a fifteen minute billing unit, one additional unit of service may be added to this quotient if the remainder equals eight or more minutes.

(4) For service codes with a per hour billing unit, one additional unit of service may be added to this quotient if the remainder equals fifty-two or more minutes.

(5) For service codes with a billing unit range, one additional unit of service may be added to this quotient if the remainder equals at least the minimum minutes of the range.

(K) The following applies to medicaid reimbursement:

(1) Interim payments. ODM shall reimburse the MSP provider interim payments. The interim payments shall be the federal financial participation (FFP) portion of the lesser of the billed charge (not to exceed the usual and customary charge) or the medicaid maximum according to the department's procedure code reference files for the particular services performed.

(2) Cost reports. Each MSP provider shall complete the Ohio department of education (ODE) developed medicaid school based cost report. The cost report is to be completed by the MSP provider in compliance with all state and federal provisions the cost report instructions also developed by ODE. The MSP provider shall contract with an independent certified public accountant (CPA) firm, the state auditor, or other entity authorized to conduct audits in the state of Ohio to perform an agreed upon procedures review of the cost report and document adjustments to the cost report. Once the agreed upon procedures review is completed, the reviewed cost report shall be submitted to ODE no later than eighteen months after the end of the cost reporting period as identified in the cost report instructions. The submitted cost report will be used by ODE and ODM in the cost reconciliation and final settlement process. ODM or ODE may conduct a desk or field audit up to three years after the fiscal year end based on risk assessment criteria developed by ODM. All cost reports for each fiscal year prior to the effective date of this rule but not starting earlier than July 1, 2005 shall be submitted in accordance with the schedule developed by ODM in cooperation with ODE and approved by CMS.

(3) Cost report extension. For good cause and upon written request from the MSP provider, ODE may grant an extension of the cost report filing deadline. The written request must be submitted to the grants management unit at ODE thirty calendar days before the cost report submission deadline specified in paragraph (K)(2) of this rule. The request must include information explaining the facts and circumstances giving rise to the need for a cost report extension, projected time line for filing the cost report, and any other information which the MSP provider would like to have considered. Upon reviewing the written request, ODE may, at its sole discretion, request additional information, approve or deny the extension.

(4) Final cost settlement and reconciliation. The ODM and /or its designee shall review the cost reports identify adjustments needed, compare the federal financial participation (FFP) identified in the cost report against the interim payments made by ODM to the MSP provider, identify the number of students for which claims for services were received and paid and determine the proportionate costs for those students using the costs from the cost report for the total population of medicaid eligible IEP students, and issue a notice of intended action pursuant to rule 5160-70-03 of the Administrative Code that denotes the amount due to or from the MSP provider as a result of the reconciliation. The MSP provider will have thirty-days from the date of the notice during which it may request a hearing. If no hearing request is received, ODM will process the reconciled amount. An overpayment determined as a result of this annual reconciliation to actual cost shall be collected from the MSP provider by ODM. An underpayment determined as a result of this annual reconciliation to actual cost shall be paid to the MSP provider by ODM. Failure by a MSP provider to submit an acceptable cost report in accordance with paragraphs (K)(2) and (K)(3) of this rule, will result in full repayment by the MSP provider of the total interim payment received by the MSP provider for the cost reporting period. In addition, failure to submit an acceptable cost report will result in possible revocation of the MSP provider agreement and number.

(5) The provider shall accept reimbursement for all covered services as payment in full with limitations as set forth in accordance with rule 5160-1-60 of the Administrative Code.

(6) The MSP providers shall comply with all applicable federal and state rules, including but not limited to 45 C.F.R. Part 92 (December 24, 2013), 45 C.F.R. Part 74 (December 24, 2013), Chapters 5160-1 and 5160-35 of the Administrative Code, CMS Publication 15-1 (found at www.cms.gov/manuals), and the terms and conditions set forth within the provider agreement.

(L) Records shall be maintained and disclosed by providers in accordance with rule 5160-1-27 of the Administrative Code. Records necessary to fully disclose the extent of services provided and costs associated with these services shall be maintained for a period of six years from the end of the cost reporting period based upon those records or until any initiated audit, review, investigation or other activities are completed and appropriately resolved, whichever is longer. Records shall be made available upon request to ODM, ODE or the U.S. department of health and human services. Failure to supply requested records, documentation or information as required in this rule may result in no payment for outstanding services, recoupment of any reimbursements provided for services that cannot be validated, termination from the medicaid program and/or any sanctions available pursuant to section 5162.10 of the Revised Code.

(M) State monitoring: ODM or its designee may conduct audits, reviews, investigations, or any other activities necessary to assure a medicaid school program provider, its subgrantee(s) or subcontractor(s) are compliant with federal and state requirements. Based on the results of an audit, review, investigation or other activities, ODM may seek recoupment of funding related to overpayments, misuse, fraud waste or abuse or noncompliance with federal or state requirements from the MSP provider.

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Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/08/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5162.20, 5164.02, 5164.70
Prior Effective Dates: 11/26/08 (Emer.), 3/2/09, 10/15/09, 3/28/13, 12/18/13 (Emer), 3/27/14

5160-35-05 Services 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 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 shall 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 shall be practicing under the supervision of a licensed occupational therapist who is employed or contracted by the MSP provider.

(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.

(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 shall 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.

(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.

(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 shall 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 shall 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, required by section 4753.071 of the Revised Code.

(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.

(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 shall 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 shall be employed or contracted by the MSP provider.

(c) Allowable activities include:

Evaluation and re-evaluation to determine the current level of hearing of the eligible child and to identify the appropriate audiology treatment, and treatment to address the findings of the evaluation/re-evaluation.

(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. Revised Code. The nursing service, with the exception of evaluations and assessments, shall 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 shall include a recommendation that describes the services and supports which are needed to address the findings from the assessment/evaluation and shall 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 shall 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) 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 provided for the purpose of habilitation (in accordance with rule 5160-1-02 of the Administrative Code).

(3) 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.

(4) Health/medical screens, including mass screens provided to an eligible child with an IEP.

(5) Counseling parents and teachers regarding hearing loss.

(6) In-house training.

(7) Fittings for amplification devices, and equipment troubleshooting and/or repair.

(8) Nursing services provided as a part of immunizations process.

(9) Instruction on self-care that does not require the expertise of the licensed practitioner.

(10) 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.

(11) 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.

(12) 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.

(13) 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.

(14) Services that are not provided under the appropriate supervision and/or at the appropriate direction of a licensed practitioner of the healing arts.

(15) Services provided by a non-licensed person.

(16) 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.

(17) 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.

(18) Services and activities that are not a direct benefit to the eligible child.

(D) In accordance with rule 5160-1-01 of the Administrative Code, the services provided shall be medically necessary and the type, frequency, scope and duration of the services shall fall within the normal range of services considered under acceptable standards of medical and healing arts professional practice, as appropriate.

(E) 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.

(F) The eligible child's IEP shall 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 shall:

(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.

(G) The documentation for the provision of service shall be maintained for purposes of supporting the delivery of the service and to provide an audit trail. Documentation shall 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 shall contain a legend that indicates the name (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 when required 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.

(H) The claims for reimbursement for services shall be submitted in accordance with rule 5160-35-04 of the Administrative Code.

Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/08/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5162.20, 5164.02, 5164.70
Prior Effective Dates: 11/26/08 (Emer.), 3/2/09, 10/15/09

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:

(1) Transportation:

(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 the rate established in appendix A to rule 5160-35-04 of the Administrative Code; the service unit is a one-way trip.

(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, shall 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 required 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 shall 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 effect 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 shall 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 (J)(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 shall 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 shall 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 shall 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 shall:

(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 shall be maintained for purposes of an audit trail. Documentation shall 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 shall contain a legend that indicates the name (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 shall be submitted in accordance with rule 5160-35-04 of the Administrative Code.

Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/08/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5162.20, 5164.02, 5164.70
Prior Effective Dates: 11/26/08 (Emer.), 3/02/09, 10/15/09