Idaho Admin. Code r. 16.03.09.853

Current through September 2, 2024

Section 16.03.09.853 - SCHOOL-BASED SERVICE: COVERAGE AND LIMITATIONS

The Department will pay school districts and charter schools for covered rehabilitative and health-related services. Services include medical or remedial services provided by school districts or other cooperative service agencies, as defined in Section 33-317, Idaho Code.

01.Excluded Services. The following services are excluded from Medicaid payments to school-based programs:

a. Vocational Services.

b. Educational Services. Educational services (other than health-related services) or education-based costs normally incurred to operate a school and provide an education. Evaluations completed for educational services only cannot be billed.

c. Recreational Services.

d. Payment for school-related services will not be provided to students who are inpatients in nursing homes or hospitals.

02.Evaluation and Diagnostic Services. Evaluations to determine eligibility or the need for health-related services may be reimbursed even if the student is not found eligible for health-related services. Evaluations completed for educational services only cannot be billed. Evaluations completed must:

a. Be recommended or referred by a physician or other licensed practitioner of the healing arts. A school district or charter school may not seek reimbursement for services provided more than thirty (30) days prior to the signed and dated recommendation or referral;

b. Be conducted by qualified professionals for the respective discipline as defined in Section 855 of these rules;

c. Be directed toward a diagnosis;

d. Include recommended interventions to address each need; and

e. Include name, title, and signature of the person conducting the evaluation.

03.Reimbursable Services. School districts and charter schools can bill for the following health-related services provided to eligible students when the services are provided under the recommendation of a physician or other practitioner of the healing arts for the Medicaid services for which the school district or charter school is seeking reimbursement. A school district or charter school may not seek reimbursement for services provided more than thirty (30) days prior to the signed and dated recommendation or referral. The recommendations or referrals are valid up to three hundred sixty-five (365) days.

a. Behavioral Intervention. Behavioral Intervention is a direct intervention used to promote positive, meaningful changes in behavior that incorporate functional replacement behaviors and reinforcement-based strategies, while also addressing any identified habilitative skill building needs and the student's ability to participate in educational services, as defined in Section 850 of these rules, through a consistent, assertive, and continuous intervention process to address behavior goals identified on the IEP. Behavioral intervention includes conducting a functional behavior assessment and developing a behavior implementation plan with the purpose of preventing or treating behavioral conditions. This service is provided to students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.

i. Group services must be provided by one (1) qualified staff providing direct services for two (2) or three (3) students.

ii. As the number and severity of the students with behavioral issues increases, the student ratio in the group must be adjusted from three (3) to two (2).

iii. Group services should only be delivered when the student's goals relate to benefiting from group interaction.

b. Behavioral Consultation. Behavioral consultation assists other service professionals by consulting with the IEP team during the assessment process, performing advanced assessment, coordinating the implementation of the behavior implementation plan and providing ongoing training to the behavioral interventionist and other team members.

i. Behavioral consultation cannot be provided as a direct intervention service.

ii. Behavioral consultation must be limited to thirty-six (36) hours per student per year.

c. Crisis Intervention. Crisis intervention services may include providing training to staff directly involved with the student, delivering intervention directly with the eligible student, and developing a crisis plan that directly addresses the behavior occurring and the necessary intervention strategies to minimize the behavior and future occurrences. This service is provided on a short-term basis, typically not exceeding thirty (30) school days and is available for students who have an unanticipated event, circumstance, or life situation that places a student at risk of at least one (1) of the following:

i. Hospitalization;

ii. Out-of-home placement;

iii. Incarceration; or

iv. Physical harm to self or others, including a family altercation or psychiatric relapse.

d. Habilitative Skill Building. Habilitative skill building is a direct intervention service that includes techniques used to develop, improve and maintain, to the maximum extent possible, the developmentally appropriate functional abilities and daily living skills needed by a student. This service may include teaching and coordinating methods of training with family members or others who regularly participate in caring for the eligible student. Services include individual or group interventions.

i. Group services must be provided by one (1) qualified staff providing direct services for two (2) or three (3) students.

ii. As the number and needs of the students increase, the student ratio in the group must be adjusted accordingly.

iii. Group services should only be delivered when the student's goals relate to benefiting from group interaction.

e. Interdisciplinary Training. Interdisciplinary training is a companion service to behavioral intervention and habilitative skill building and is used to assist with implementing a student's health and medication monitoring, positioning and physical transferring, use of assistive equipment, and intervention techniques in a manner that meets the student's needs. This service is to be utilized for collaboration, with the student present, during the provision of services between the intervention specialist or professional and a Speech Language and Hearing Professional (SLP), Physical Therapist (PT), Occupational Therapist (OT), medical professional, or behavioral or mental health professional.

f. Medical Equipment and Supplies. Medical equipment and supplies that are covered by Medicaid must be medically necessary, ordered by a physician or non-physician practitioner, and prior authorized. Authorized items must be for use at the school where the service is provided. Equipment that is too large or unsanitary to transport from home to school and back may be covered, if prior authorized. The equipment and supplies must be for the student's exclusive use and must be transferred with the student if the student changes schools. All equipment purchased by Medicaid belongs to the student.

g. Nursing Services. Skilled nursing services must be provided by a licensed nurse, within the scope of their practice. Emergency, first aid, or non-routine medications not identified on the plan as a health-related service are not reimbursed.

h. Occupational Therapy and Evaluation. These services for vocational assessment, training or vocational rehabilitation are not reimbursed.

i. Personal Care Services (PCS). School-based PCS include medically oriented tasks having to do with the student's physical or functional requirements. PCS do not require a goal on the plan of service. The provider must deliver at least one (1) of the following services:

i. Basic personal care and grooming to include bathing, hair care, assistance with clothing, and basic skin care;

ii. Assistance with bladder or bowel requirements that may include helping the student to and from the bathroom or assisting the student with bathroom routines;

iii. Assistance with food, nutrition, and diet activities including preparation of meals if incidental to medical need;

iv. Assisting the student with physician-ordered medications that are ordinarily self-administered, under IDAPA 24.34.01, "Rules of the Idaho Board of Nursing," Subsection 490.05;

v. Non-nasogastric gastrostomy tube feedings, if the task is not complex and can be safely performed in the given student care situation, and meet the requirements under IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits," Subsection 303.01.

j. Physical Therapy and Evaluation.

k. Psychological Evaluation.

l. Psychotherapy.

m. Skills Building/Community-Based Rehabilitation Services (CBRS). Skills Building/CBRS are interventions to reduce the student's disability by assisting in gaining and utilizing skills necessary to participate in school. They are designed to build competency and confidence while increasing mental health and/or decreasing behavioral symptoms. Skills Building/CBRS provides training in behavior control, social skills, communication skills, appropriate interpersonal behavior, symptom management, activities of daily living, and coping skills. These services are intended to prevent placement of the student into a more restrictive educational situation.

n. Speech/Audiological Therapy and Evaluation.

o. Social History and Evaluation.

p. Transportation Services. School districts and charter schools can receive reimbursement for mileage for transporting a student to and from home and school when:

i. The student requires special transportation assistance, a wheelchair lift, an attendant, or both, when medically necessary for the health and safety of the student;

ii. The transportation occurs in a vehicle specifically adapted to meet the needs of a student with a disability;

iii. The student requires and receives another Medicaid-reimbursable service billed by the school-based services provider, other than transportation, on the day that transportation is being provided;

iv. Both the Medicaid-covered service and the need for the special transportation are included on the student's plan; and

v. The mileage, as well as the services performed by the attendant, are documented. See Section 855 of these rules for documentation requirements.

q. Interpretive Services. Interpretive services needed by a student who is deaf or does not adequately speak or understand English and requires an interpreter to communicate with the professional or paraprofessional providing the student with a health-related service may be billed with the following limitations:

i. Payment for interpretive services is limited to the specific time that the student is receiving the health-related service; documentation for interpretive service must include the Medicaid-reimbursable health-related service being provided while the interpretive service is provided.

ii. Both the Medicaid-covered service and the need for interpretive services must be included on the student's plan; and

iii. Interpretive services are not covered if the professional or paraprofessional providing services is able to communicate in the student's primary language.

Idaho Admin. Code r. 16.03.09.853

Effective July 1, 2024