School Based Medicaid Related Services

Presenters: Shannon Dunstan, Department of EducationFrede’ Trenkle, Department of Health and Welfare

What will be presented: Implementation of School Based Medicaid Related Services

Who needs this information: Special Education Directors, SLPs, OTs, PTs, Teachers, Medicaid Billing Staff

IDAPA

16.03.09 – School Based Medicaid24.23.01 - SLP24.06.01 – OT24.13.01 – PT

Who Qualifies to Provide

Related Services

IDAPA 24.23.01 - SLPIDAPA 24.06.01 – OTIDAPA 24.13.01 – PT

Related Service providers are IEP Team Members

• Related service providers collaborate with a student’s IEP and healthcare team members to help promote each child’s potential.

• It is important for collaboration between school teachers, staff members and school related service providers to achieve positive outcomes for our students. Timely physician orders, updates to goals, plans and daily implementation of a student’s plan will enhance each child’s success.

Definitions

SLP – Speech Language PathologistOT – Occupational TherapistPT – Physical Therapist

IDAPA 16.03.09.11.14

• It is a reasonable calculated service to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functional significant condition, deformity or malfunction; and

• There is no other equally effective course of treatment available or suitable for the participant requesting the service which is more conservative or substantially less costly.

• Medicaid services must be of a quality that meets professionally-recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality. Those records must be made available to the Department upon request.

Must Be Medically Necessary

Physician Orders

IDAPA 16.03.09.733:• All therapy must be ordered by a physician, nurse practitioner, or

physician assistant. Such orders must include at a minimum, the service to be provided, the frequency, and, where applicable, the duration of each therapeutic session.

• In the event that services are required for extended periods, these services must be reordered as necessary, but at least every ninety (90) days for all participants with the following exception: • Therapy for individuals with chronic medical conditions, as

documented by physician, nurse practitioner, or physician assistant, must be reordered at least every six (6) months.

Speech Language Pathology

(SLP) Services - Schools

IDAPA 24.23.01

SLP services are therapy services that are…• Provided within the scope of practice of licensed

speech-language pathologists; and

• Necessary for the evaluation and treatment of speech and language disorders which result in communication disabilities; or

• Necessary for the evaluation and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability.

IDAPA 16.03.09.730.05

Billing Medicaid forSpeech & Language Services

According to Idaho law, schools can bill Medicaid for SLP services that are provided by a qualified SLP and a supervised SLP paraprofessional. Qualifications for both are identified in IDAPA.

IDAPA 16.03.09.855.11 and 16.03.09.855.14

The SLP Medicaid Provider

Idaho Medicaid requires services to be provided by or under the direction of a speech pathologist or audiologist who possesses a certificate of clinical competence from the American Speech, Language and Hearing Association (ASHA); or who will be eligible for certification within one (1) year of employment.

IDAPA 16.03.09.855.11

Occupational Therapy

IDAPA 24.06.01

Defined

AOTA, 2008

OT Services IncludeEvaluation and Treatment of…

IDAPA 24.06.01

• Sensory Perceptual Skills

• Motor and Praxis Skills• Emotional Regulation Skills

• Cognitive Skills• Communication and Social Skills

» (AOTA, 2008)

AOTA Ethic Principles• Principle 1. Occupational therapy personnel shall demonstrate a concern for the well-being

and safety of the recipients of their services.

• Principle 2. Occupational therapy personnel shall intentionally refrain from actions that cause harm.

• Principle 3. Occupational therapy personnel shall respect the right of the individual to self-determination.

• Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner.

• Principle 5. Occupational therapy personnel shall comply with institutional rules, local, state, federal, and international laws and AOTA documents applicable to the profession of occupational therapy.

• Principle 6. Occupational therapy personnel shall provide comprehensive, accurate, and objective information when representing the profession.

• Principle 7. Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity.

Billing Medicaid forOccupational Services

According to Idaho law, schools can bill Medicaid for OT services that are provided by a qualified OT and a supervised OT assistant or OT Aide as defined in Idaho statute.

IDAPA 24.06.01

The OT Medicaid Provider

IDAPA 24.06.0116.03.09.732.01. f

Occupational Therapist – OTR/LOccupational Therapist Assistant – COTA/LOccupational Therapy Aide (paraprofessional)

Occupational TherapyIdaho Practice Act

• To practice Occupational Therapy in Idaho, you must be certified nationally and licensed by the State of Idaho as an Occupational Therapist (OT) or Occupational Therapy Assistant (OTA).

• Licenses are renewed annually and require continuing education and professional development

– (Idaho Occupational Therapy Practice Act)

Supervision of a COTA by an OT

IDAPA 16.03.09.730.06.b

General supervision requires direct, on-premises contact between the therapist, the therapy assistant, and the participant at least every five (5) visits or once every week if seen on a daily basis. Between direct contacts, the therapist is required to maintain indirect, off-premises contact with the therapy assistant. These indirect, off-premises contacts may be by telephone, written reports, or group conferences.

Supervision Requirements for the OT Aide

• Aides do not provide skilled occupational therapy services.• An aide is trained by an occupational therapist or an occupational therapy

assistant to perform specifically delegated tasks. • The occupational therapist is responsible for the overall use and actions of

the aide. • An aide first must demonstrate competency to be able to perform the

assigned, delegated client and non-client tasks. • The occupational therapist must oversee the development, documentation,

and implementation of a plan to supervise and routinely assess the ability of the occupational therapy aide to carry out non-client and client-related tasks.

• The occupational therapy assistant may contribute to the development and documentation of this plan.

• An aide shall function only under the direct line of sight supervision of an occupational therapist or occupational therapy assistant.

IDAPA 24.06.01

Physical Therapy

IDAPA 24.13.01

APTA Description of Physical Therapy

PT Services IncludeEvaluation and Treatment of…

• Gross Motor Skills• Visual Motor Impairments• Spasticity Management• Orthopedic Impairments• Neuromuscular Impairments• Adaptive equipment• Gait abnormalities • Wheelchair mobility• Balance Impairments • Postural Impairments• Coordination Impairments

IDAPA 24.13.01

Billing Medicaid forPhysical Therapy Services

According to Idaho law, schools can bill Medicaid for PT services that are provided by a qualified licensed PT as defined in Idaho statute.

IDAPA 24.13.01

PT Providers Must be Licensed

Physical Therapy Supervision

• General supervision requires direct, on-premises contact between the therapist, the therapy assistant, and the participant at least every five (5) visits or once every week if seen on a daily basis. Between direct contacts, the therapist is required to maintain indirect, off-premises contact with the therapy assistant. These indirect, off-premises contacts may be by telephone, written reports, or group conferences.

16.03.09.730.06.b

Related Services Steps

Evaluation and Assessment

IEP Goals Service Page

IEP Implementation

Eligibility Report/Written Notice

Evaluation and

Assessment

• Team determines eligibility for special education at initial evaluation or 3 year re-evaluation, or more frequently as warranted.

• Obtain consent to assess per IDEA and one time parent consent to bill Medicaid• Obtain Physician’s Order if going to billing Medicaid for the Evaluations and

Assessments

EligibilityOr Written

Notice

• IEP Team documents results of evaluations/assessments on initial or 3 year reevaluation.

• If student is demonstrating a need that was not addressed on an initial or 3 yr. evalution, team may need to complete additional assessment(s) during interim period. Results of the evaluation or assessment must be summarized on a Written Notice.

IEP Goal(s)

• Goal(s) are developed to address the needs that were identified during the evaluation process, including the students current present level of performance, in parent friendly language, with clear and measureable goals.

• One goal per present level of performance that includes a baseline that addresses the student’s needs, how the disability impacts the student’s ability to access general education, and relation to typical peer development.

Service Page

• Team documents needed services per district policy/procedure.• Teams should consider use of “Optional Statement of Service Delivery” as a mechanism to

specify when an aide (if applicable) will deliver the services.

IEP Implementation

• Implement IEP• Collect progress monitoring data

• In order to bill Medicaid the service provider must ensure progress monitoring data and service provision is documented according to Medicaid Rules.

• Obtain a physician order for services, every 3 months, or every 6 months if it is documented by a physician that the child has a chronic medical condition.

New Consent Requirement

Evaluation and

Assessment

• Team determines eligibility for special education at initial evaluation or 3 year re-evaluation, or more frequently as warranted.

• Obtain consent to assess per IDEA and one time parent consent to bill Medicaid• Obtain Physician’s Order if going to billing Medicaid for the Evaluations and

Assessments

Obtains Consent for permission to Bill Medicaid

Obtain Physician Order

Complete Assessments

Evaluation and

Assessment

EligibilityOr Written

Notice

• IEP Team documents results of evaluations/assessments on initial or 3 year reevaluation.

• If student is demonstrating a need that was not addressed on an initial or 3 yr., team may need to complete additional assessment(s) during interim period. Results of the evaluation or assessment must be summarized on a Written Notice.

IEP Goal(s)

• Goal(s) are developed to address the needs that were identified during the evaluation process, including the students current present level of performance, in parent friendly language, with clear and measureable goals.

• One goal per present level of performance that includes a baseline that addresses the student’s needs, how the disability impacts the student’s ability to access general education, and relation to typical peer development.

Service Page

• Team documents needed services per district policy/procedure.• Teams should consider use of “Optional Statement of Service Delivery” as a

mechanism to specify when an aide (if applicable) will deliver the services OR use the new Medicaid IEP Form.

Documentation Prior to Billing• Current IEP – indicates the

need for service(s).• Physician’s Orders – makes

recommendation or referral for Medicaid services.

IDAPA 16.03.09

Service Detail Report Must Include:• Student’s name• Name and title of person

providing the service• Date, time, duration for

service• Place of service • Category of service• Brief description of the

specific areas addressed• Students response to the

intervention

IDAPA 16.03.09.853

• Providers must check both the Idaho Medicaid Exclusion List and the HHS‐OIG Exclusion List to determine whether a provider, individual, or entity is excluded and, if so, the dates of such exclusion. 

• The HHS‐OIG Exclusion List is accessed at http://exclusions.oig.hhs.gov and Idaho Medicaid Exclusion list is accessed at http://www.healthandwelfare.idaho.gov/Providers/MedicaidProviders/tabid/214/Default.aspx 

• Providers are responsible for screening all employees and contractors to identify excluded individuals and are responsible for searching the HHS‐OIG website and the Idaho Medicaid Exclusion List monthly to capture exclusions and reinstatements. Providers, individuals and entities are not automatically reinstated at the end of the state or federal exclusion period. If providers, individuals or entities on the state or federal exclusion list do not have a reinstatement date listed, they are not eligible to provide services.  

Exclusion List

Don’t forget…• Districts must be enrolled as a Medicaid

provider to be reimbursed for school based Medicaid services.

• Each service must be specifically identified on the IEP.

• Services cannot be educational.• Services must be medically necessary for

the student to access their educational program.

IDAPA 16.03.09

www.idahotc.com

•Training Calendar•Online Registration•Webinars•Learning Communities•Medicaid Advisory Committee meeting minutes

www.sbs.dhw.idaho.gov

Contact Information:

Shannon DunstanEarly Childhood & Interagency Coordinator

Idaho State Department of Education Division of Student Achievement and School Improvement

Division of Special Education(208) 332-6908

sdunstan@sde.idaho.gov

Contact Information

Frede’ TrenkleAlternative Care Coordination

Bureau of Developmental Disabilities Services

Division of Medicaid(208) 287-1169

TrenkleF@dhw.idaho.gov