(A) The purpose of this rule is to set forth the services
authorized for medicaid coverage that an MSP provider can provide, and to set
forth the conditions for providing the services.
(B) The MSP provider will only submit
claims for services which it has statutory authority to provide, including
medically necessary services to eligible children in accordance with this rule
and rules 5160-35-06 and 5160-35-07 of the Administrative Code that are
appropriately documented in the following:
(1) The individualized
education program (IEP) as defined in section 3323.011 of the Revised
Code;
(2) 504 plan as defined
in rule 3301-13-01 of the Administrative Code;
(3) A school services
plan of care as defined in rule 5160-35-01 of the Administrative Code.
(C) 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 an
occupational therapist as defined in Chapter 4755. of the Revised Code.
(b) Qualified practitioners who can deliver the
services:
(i) Occupational therapist as defined in Chapter 4755. of the
Revised Code and in accordance with rule 5160-35-02 of the Administrative
Code.
(ii) Occupational therapy assistant as defined in Chapter 4755. of
the Revised Code and in accordance with rule 5160-35-02 of the Administrative
Code and the occupational therapy assistant will be practicing under the
supervision of an occupational therapist who is employed or contracted by the
MSP provider.
(iii) A student
occupational therapist or a student occupational therapy assistant as defined
by rule 4755:1-2-02 of the Administrative Code.
(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 (C)(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
physical therapist as defined in Chapter 4755. of the Revised
Code.
(b) Qualified practitioners who can deliver the
services:
(i) Physical therapist as defined in Chapter 4755. of the Revised
Code and in accordance with rule 5160-35-02 of the Administrative
Code.
(ii) Physical therapist assistant as defined in Chapter 4755. of
the Revised Code, in accordance with rule 5160-35-02 of the Administrative
Code, and who is practicing under the supervision of a physical therapist as
defined in Chapter 4755. of the Revised Code who is employed or contracted by
the MSP provider.
(iii) A student physical
therapist or a student physical therapist assistant as defined by rule
4755:2-2-02 of the Administrative Code.
(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 (C)(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 speech-language
pathologist as defined in Chapter 4753. of the Revised Code.
(b) Qualified practitioners who can deliver the
services:
(i) Speech-language pathologist as defined in Chapter 4753. of
the Revised Code and in accordance with rule 5160-35-02 of the Administrative
Code.
(ii) Speech-language pathology aide as defined in Chapter 4753. of
the Revised Code in accordance with rule 5160-35-02 of the Administrative Code,
and who is practicing under the supervision of the speech-language pathologist
as defined in Chapter 4753. of the Revised Code who meets the criteria in rule
4753-7-01 of the Administrative Code.
(iii) A person who meets conditional criteria to practice
speech-language pathology as defined 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 an audiologist as defined in Chapter 4753. of the Revised Code.
(b) Qualified practitioners who can deliver the
services:
(i) Audiologist as defined in Chapter 4753. of the Revised Code
and in accordance with rule 5160-35-02 of the Administrative Code.
(ii) Audiology aide as defined in Chapter 4753. of the Revised
Code, in accordance with rule 5160-35-02 of the Administrative Code, and who is
practicing under the supervision of an audiologist as defined in Chapter 4753.
of the Revised Code who meets criteria defined in rule 4753-7-01 of the
Administrative Code.
(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) Physical health
services.
(a) Description: services from a registered nurse that provides
care to individuals and groups as defined in Chapter 4723. of the Revised Code.
Additionally, services from a licensed practical nurse that provides care 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) Registered nurse as defined in Chapter 4723. of the Revised
Code and in accordance with rule 5160-35-02 of the Administrative
Code.
(ii) Licensed practical nurse as defined in Chapter 4723. of the
Revised Code and in accordance with rule 5160-35-02 of the Administrative
Code.
(iii) Clinical nurse
specialist as defined in Chapter 4723. of the Revised Code and in accordance
with rule 5160-35-02 of the Administrative Code.
(iv) Nurse practitioner
as defined in Chapter 4723. of the Revised Code and in accordance with rule
5160-35-02 of the Administrative Code.
(v) Physician assistant
as defined in Chapter 4730. of the Revised Code and in accordance with rule
5160-35-02 of the Administrative Code.
(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) The implementation of medical/nursing
procedures/treatments in accordance with paragraph (A)(11) of rule 5160-35-01
of the Administrative Code for the medicaid eligible child, which may include
tube feeds, bowel and bladder care, colostomy care, catheterizations,
respiratory treatment, wound care, chronic disease management, and behavioral
health services as described in paragraph (C)(6)(c)(iii)(c)(i) of this rule and
any other services that are prescribed in accordance with paragraph (A)(11) of
rule 5160-35-01 of the Administrative Code.
(6) Behavioral health services as defined
by each profession's scope of practice and licensing
criteria.
(a) Description: Behavioral health services are services or
procedures that are performed for the diagnosis and treatment of mental,
behavioral, substance use, or emotional disorders by an allowable professional
as defined in paragraph (C)(6)(b) of this rule or by an allowable professional
as defined in paragraph (C)(6)(b) of this rule who is under appropriate
supervision according to the criteria of their respective boards and who is
acting within their appropriate scope of practice under Ohio law.
(b) Qualified practitioners who can deliver the
services:
(i) A professional counselor, professional clinical counselor,
professional clinical counselor - supervisor, counselor trainee, independent
social worker, independent social worker - supervisor, social worker, social
worker trainee, independent marriage and family therapist, marriage and family
therapist, or marriage and family therapist trainee as defined in Chapter 4757.
of the Revised Code and in accordance with rule 5160-35-02 of the
Administrative Code.
(ii) Psychologist or a school psychologist as defined in
Chapter 4732. of the Revised Code, or to practice school psychology as defined
in Chapter 4732. of the Revised Code or under rule 3301-24-05 of the
Administrative Code in accordance with rule 5160-35-02 of the Administrative
Code.
(iii) Psychology or
school psychology trainee or intern who is completing an internship or
externship in accordance with clinical criteria as defined in section 4732.22
of the Revised Code and in accordance with rule 5160-35-02 of the
Administrative Code.
(iv) Independent chemical
dependency counselor or chemical dependency counselor II or III as defined in
Chapter 4758. of the Revised Code and in accordance with rule 5160-35-02 of the
Administrative Code.
(v) Registered nurse or a
licensed practical nurse as defined in Chapter 4723. of the Revised Code
providing behavioral health services as described in paragraph
(C)(6)(c)(iii)(c)(i) of this rule and in accordance with rule 5160-35-02 of the
Administrative Code.
(c) Allowable services include:
(i) Screening activities.
Behavioral health screenings that identify potential need for
services related to a mental health or substance use disorder.
(ii) Assessment activities.
(a) An assessment is a
clinical evaluation of a person which is individualized as well as age, gender,
and culturally appropriate.
(b) An assessment
determines diagnosis and treatment needs, and establishes a treatment plan to
address the eligible child's mental illness or substance use
disorder.
(iii) Treatment activities.
(a) Counseling and
therapy services provided by an allowable MSP provider acting within their
scope of practice where there is an interaction with an eligible child or
eligible children and the focus is on achieving treatment objectives related to
alcohol and other substance use; or the eligible child's mental illness
or emotional disturbance.
(i) Counseling and
therapy involves an encounter between an eligible child, group of eligible
children, an eligible child and family members, or family members and a
behavioral health professional.
(ii) Group counseling and
therapy encounters will not exceed a one-to-twelve behavioral health
professional to patient ratio.
(b) Therapeutic
behavioral services (TBS).
Provided by an allowable MSP provider listed in paragraphs
(C)(1)(b)(i) to (C)(1)(b)(iii) of this rule acting within their scope of
practice who is rendering activities described in rules 5160-27-08 and
5122-29-18 of the Administrative Code.
(c) Behavioral health
nursing:
Behavioral health nursing services are mental health and
substance use disorder (SUD) nursing services performed by registered nurses or
licensed practical nurses. They include those activities that are performed
within professional scope of practice and in authorized settings by a
registered nurse or licensed practical nurse as defined in section 4723.01 of
the Revised Code and are intended to address the behavioral and other physical
health needs of eligible children receiving treatment for psychiatric symptoms
or substance use disorders.
(d) Allowable practitioners providing behavioral health services
to eligible children are subject to all clinical supervision and documentation
criteria outlined by each profession's scope of practice and licensing
criteria and as described in rule 5160-8-05 of the Administrative Code and will
document appropriate supervision where applicable and in accordance with
respective boards.
(7) Assessments/evaluations for
IEPs.
(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 eligible child unless prior
authorization is obtained) conducted for an eligible child without an IEP or
conducted for a two year old eligible 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 eligible 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 (C)(1) to (C)(6) of this rule
who is employed or contracted with the MSP provider, and who is acting within
the scope of his or her practice under Ohio law.
(D) An MSP provider may provide telehealth services.
Telehealth services are to be delivered in accordance with an eligible
child's IEP, 504 plan, or school services plan of care 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.
(E) In accordance with an eligible child's IEP, 504
plan, or school services plan of care and section 5162.366 of the Revised Code,
a physical therapist, occupational therapist, speech-language pathologist, and
audiologist can make a referral for the eligible child when the referral is
within the practitioner's specific discipline. In accordance with an
eligible child's IEP, 504 plan, or school services plan of care and
section 5162.366 of the Revised Code, a clinical nurse specialist, certified
nurse practitioner, and physician assistant can be an ordering and referring
provider for the eligible child if it is within the practitioner's
specific discipline.
The physical therapist, occupational therapist,
speech-language pathologist, audiologist, clinical nurse specialist, certified
nurse practitioner, and physician assistant will meet criteria in rule
5160-1-17.2 of the Administrative Code.
(F) Although the following list is not all-inclusive, the
following are not allowable for reimbursement through the medicaid school
program:
(1) 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.
(2) Counseling parents and teachers
regarding hearing loss.
(3) In-house training.
(4) Fittings for amplification devices,
and equipment troubleshooting or repair.
(5) Nursing services provided as a part
of immunizations process.
(6) Instruction on self-care that does
not need the expertise of the licensed practitioner.
(7) Services not indicated in an eligible
child's IEP, 504 plan, or school services plan of care documenting medical
necessity as described in paragraph (B) of this rule prior to the provision of
the service with the exception of the initial assessment/evaluation as
described in paragraph (C)(7) of this rule and with the exception of services
described in rule 5160-35-07 of the Administrative Code.
(8) Services provided on days or at times
when the eligible child is not in attendance in the designated school setting
as defined by the child's IEP, 504 plan or school services plan of care as
described in paragraph (B) of this rule with the exception of the initial
assessment/evaluation as described in paragraph (C)(7) of this
rule.
(9) Services that are not provided under
the appropriate supervision or at the appropriate direction of a licensed
practitioner of the healing arts.
(10) Services provided by a non-licensed
person.
(11) Services for which an eligible child
fails to show progress toward identified goals in the IEP, 504 plan or school
services plan of care over two consecutive three-month periods and there is no
documentation that the methods or techniques applied have been modified to
improve progress.
(12) 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.
(13) Services and activities that are not
a direct benefit to the eligible child.
(14) Sensitivity training.
(15) Sexual competency
training.
(16) Educational activities (including
testing and diagnosis - this does not include initial assessments nor
re-assessment as indicated in paragraph (C)(7) of this rule).
(17) Monitoring activities of daily
living.
(18) Recreational therapies.
(19) Teaching grooming skills.
(20) Sensory stimulation.
(21) Teaching social interaction/diversion
skills.
(22) Family therapy that is not a direct
benefit to the eligible child.
(G) 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.
(H) 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.
(I) The eligible child's IEP is to contain the
following components. These IEP components do not supplant any practitioner
plan of care, and will:
(1) Be based on the initial
assessment/evaluation conducted during the ETR as defined in rule 3301-51-01 of
the Administrative Code 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. For medications,
reference and identify the location of the prescription of a physician,
physician assistant, or an advanced practice nurse in accordance with Ohio
law.
(6) Specify timelines for re-assessment,
which should be no more than twelve-months from the date of the initial
evaluation or re-assessment, of the eligible child and updates to the
IEP.
(J) The eligible child's school
services plan of care will contain the following components. These components
do not supplant any practitioner plan of care. The school services plan of care
does not supplant any state or federal processes or timelines related to
identifying and serving children with disabilities.
(1) Be based on an
assessment of need conducted by an authorized school district provider or
community provider.
(2) Be signed by the
authorized school district provider in accordance with rule 5160-35-02 of the
Administrative Code who recommends the service as a result of the assessment of
need.
(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 the 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. For
medications, reference and identify the location of the prescription of a
physician, a physician assistant, or an advanced practice nurse in accordance
with Ohio law.
(6) Specify timelines for
re-assessment, which should be no more than twelve-months from the date of the
initial evaluation or most recent re-assessment, of the eligible child and
updates to the school services plan of care.
(7) Include specific
criteria regarding referrals to community providers, when
appropriate.
(K) 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 eligible
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
practitioner plan of care or the school services 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 eligible
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 provider in
accordance with the medicaid provider agreement.
(L) The claims for reimbursement for services will be
submitted in accordance with rule 5160-35-04 of the Administrative
Code.
(M) 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.
