Rule 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 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.
(a) 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).
(i) 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:
(i) 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 orrepair.
(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.
Last updated January 1, 2026 at 12:00 AM
Supplemental Information