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