Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 23 - SPEECH PATHOLOGY AND AUDIOLOGY SERVICES
Section 471-23-004 - SERVICE REQUIREMENTS
Universal Citation: 471 NE Admin Rules and Regs ch 23 ยง 004
Current through September 17, 2024
004.01 GENERAL SERVICE REQUIREMENTS.
004.01(A)
MEDICAL
NECESSITY. Medicaid incorporates the definition of medical
necessity inform 471 NAC 1 as if fully rewritten herein. Services and supplies
that do not meet the 471 NAC 1 definition of medical necessity are not
covered.
004.01(B)
SERVICE CRITERIA. Medicaid covers speech pathology and
audiology services when the following criteria are met. The service must be:
(i) An evaluation:
(ii) Restorative therapy with a medically
appropriate expectation that the recipient's condition will improve
significantly within a reasonable period of time; or
(iii) For physical therapy services only,
recommended in a Department- approved Individual Program Plan (IPP) and the
recipient is receiving services through one of the following waiver programs:
(1) Comprehensive Developmental Disabilities
Services Waiver;
(2) Developmental
Disabilities Adult Residential Services Waiver;
(3) Adult Comprehensive Waiver; or
(4) Home and Community Based Services Waiver
for Aged Adults and Children with Disabilities.
004.01(C)
SERVICES PROVIDED FOR
RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM.
See 471 NAC 1.
004.01(D)
EARLY PERIODIC, DIAGNOSTIC AND TREATMENT TREATMENT (EPSDT)
SERVICES. See 471 NAC 33.
004.02 COVERED SERVICES. Nebraska Medicaid covers speech pathology and audiology services when the following criteria are met:
(1) The services are ordered by a licensed
physician or nurse practitioner:
(2) The services are medically
necessary;
(3) The services are
such that only a licensed speech pathologist or audiologist can safely and
effectively perform the service; and
(4) The speech pathology or audiology service
meets at least one of the service criteria.
004.02(A)
MAINTENANCE
PROGRAM. The speech pathologist or audiologist must:
(i) Evaluate the recipient's needs;
(ii) Design a maintenance program:
and
(iii) Instruct the recipients,
family members, or nursing facility staff in carrying out the program.
004.02(B)
SERVICES FOR INDIVIDUALS AGE 21 AND OLDER. For
recpients age 21 and older, Nebraska Medicaid limits coverage to a combined
total of 60 therapy sessions per fiscal year. The combined total of 60 therapy
sessions per fiscal year includes all occupational therapy, physical therapy,
speech pathology, and audiology sessions provided to the
recipient.
004.03 NON-COVERED SPEECH PATHOLOGY AND AUDIOLOGY SERVICES. Nebraska Medicaid does not cover the following speech pathology or audiology services:
(A) Maintenance therapy provided by
a speech pathologist:
(B) Therapy
for vocational and prevocational assessment and training;
(C) Therapy for functional capacity
evaluations, educational testing, drivers training, or training in
non-essential self-help or recreational activities, visual perception training,
or treatment of psychological conditions:
(D) Therapy for dysfunctions that are
self-correcting, such as language therapy for young children with natural
dysfluency or developmental articulation errors that are
self-correcting;
(E) Therapy for
delays in speech development that is not due to a specific medical condition or
brain injury; or
(F) Therapy for
the following conditions or diagnosis categories:
(i) Psychosocial speech delay;
(i) Behavior problems;
(ii) Attention disorders;
(iv) Conceptual handicap; or
(v) Learning disability.
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