Current through Register No. 40, October 3, 2024
(a) All enrolled
school providers shall:
(1) Be enrolled with
NH medicaid for the purposes of administration and billing;
(2) Verify the qualifications, licensure, and
certifications, as applicable, of performing-only providers upon hire and at
time of any licensure or certification renewal and maintain proof of
verification;
(3) Screen all
performing-only providers for medicaid services for exclusions against the
Office of Inspector General (OIG) exclusion and sanction database pursuant to
section 1866(j)(2) of the Social Security Act, section 1903(i) of the Social
Security Act, and
42 CFR
1001.1901. The OIG exclusion and sanction
database may be found at
https://exclusions.oig.hhs.gov;
(4) Screen all performing-only providers upon
hire, prior to executing a contract, and on a monthly basis thereafter as long
as the performing-only provider is providing medicaid services for which the
school is seeking federal FFP; and
(5) Ensure all providers have knowledge in
the following areas:
a. Medicaid recipient
rights, and the reporting of abuse and neglect; and
b. Record keeping and documentation
requirements pursuant to this part, including the penalties associated with
improper recordkeeping and documentation.
(b) All covered services shall be:
(1) Provided through a student's LEA or SAU;
(2) Medically necessary;
(3) Included and documented in the
student's care plan in accordance with this part;
(4) Provided in a variety of locations and
settings as specified in a student's care plan and may occur outside the hours
of the usual school day;
(5)
Provided by qualified clinicians pursuant to this part and who comply with the
scope of his or her board licensure for his or her clinical practice including
supervision and ordering requirements; and
(6) Prior authorized if required by the NH
medicaid state plan, federal or state law, or the rules adopted thereunder.
(c) Covered services
may be provided by staff employed or subcontracted by the enrolled school
provider and who are:
(1) Either licensed by
the applicable clinical healthcare boards to provide the services provided or
otherwise under the direction of the appropriate licensed clinician to provide
the services as permitted by applicable licensure law; or
(2) Board Certified Behavior Analysts (BCBA)
appropriately certified by the national Behavior Analyst Certification Board,
and if supervising others, have a supervisory certification issued by the
national board and be acting within the scope of that certification.
(d) Covered supplies and equipment
described under He-W 589.04 shall:
(1) Be
acquired for the use of a specific student;
(2) When purchased, be the property of the
student and his or her family; and
(3) When rented or acquired through a used
equipment exchange program, be the property of the student and his or her
family during the period used.
(e) DME shall be provided by a qualified DME
provider, and in accordance with the requirements pursuant to He-W
571.
(f) AAC devices and aids shall
be provided by a qualified DME provider, and in accordance with the
requirements of He-W 575.
(g)
Medical evaluation shall include the following:
(1) Those services rendered by a physician,
APRN, or physician assistant whose opinion or advice is requested regarding the
evaluation or treatment of a student's condition; and
(2) An initial evaluation shall be covered,
however, if the physician, APRN, or physician assistant assumes the continuing
care of the student, any service(s) provided subsequent to the initial
evaluation by such physician, APRN, or physician assistant shall not be
considered an evaluation but might be coverable as another service pursuant to
this part.
(h) The
following medical evaluation services performed by the providers in (g) above
shall be billable under the category of medical evaluation:
(1) Examination of a single organ system,
including:
a. Documentation of
complaint(s);
b. Physical
examination and diagnosis of current illness; and
c. Establishment of a plan of management
relating to a specific problem; and
(2) In-depth evaluation with development and
documentation of medical data, including:
a.
Chief complaint;
b. Present
illness;
c. Family
history;
d. Medical
history;
e. Personal
history;
f. System review;
and
g. Physical examination.
(i) Nursing services shall be
medically necessary to meet the health needs of a student and include:
(1) Any assessments or treatments performed
by a licensed registered nurse, licensed practical nurse (LPN), or APRN for a
student that are medically necessary; and
(2) Supplies and equipment necessary for the
provision of the covered nursing services as determined by the licensed
registered nurse, LPN, or APRN.
(j) Nursing services shall be performed by
the following:
(1) An APRN licensed to
practice in NH by the NH board of nursing in accordance with
RSA
326-B:18 or the state in which he or she
practices as a registered nurse in an advance practice role;
(2) A registered nurse who is:
a. Licensed to practice in NH or the state in
which he or she practices in accordance with RSA 326-B; and
b. Acting under the direction of a physician,
APRN, or physician assistant for those activities that require an order;
or
(3) A LPN who is:
a. Licensed to practice in NH under RSA 326-B
or the state in which he or she practices; and
b. Acting under the direction of a physician,
APRN, registered nurse, or physician assistant.
(k) Nursing services shall include the
following:
(1) Administration of
medication(s);
(2) Positioning or
repositioning;
(3) Assistance with
specialized feeding programs;
(4)
Management and care of specialized medical equipment such as:
a. Colostomy bags:
b. Nasogastric tubes;
c. Tracheostomy tubes; and
d. Related medical devices;
(5) Observation of students with
chronic medical illnesses in order to assure that medical needs are being
appropriately identified, addressed, and monitored; and
(6) Other services determined by a registered
nurse, LPN, or APRN to be medically necessary and appropriate.
(l) Billable categories of nursing
services shall include the following:
(1)
Nursing assessment;
(2) Nursing
treatment; and
(3) Supplies and
equipment necessary to provide covered nursing services.
(m) Private duty nursing services shall be:
(1) Covered services when they are part of
the student's medical regimen and rendered under the order and under the
direction of the student's physician; and
(2) Covered and delivered in accordance with
the requirements of He-W 540.
(n) Occupational therapy services shall be
covered if the services are medically necessary to implement a program of
activities to develop or maintain adaptive skills necessary to achieve adequate
and appropriate physical and mental functioning of a student including:
(1) Any evaluations, treatment, or
assessments performed by an occupational therapist of students whose abilities
to carry out age appropriate tasks are threatened or impaired by physical
illness or injury, mental illness, emotional disorder, or congenital or
developmental disability;
(2)
Supplies and equipment necessary to provide the covered occupational therapy
services as recommended by an occupational therapist; and
(3) Occupational therapy services performed
by an occupational therapy assistant carrying out a therapy plan developed by
the occupational therapist.
(o) Occupational therapy services shall be
provided by:
(1) An occupational therapist who
is licensed to practice in NH or the state in which he or she practices, and is
either:
a. Registered by the National Board
for Certification in Occupational Therapy Inc.; or
b. A graduate of a program in occupational
therapy approved by the Committee on Allied Health Education and Accreditation
of the American Medical Association and engaged in the supplemental clinical
experience required before registration by the National Board for Certification
in Occupational Therapy, Inc.; or
(2) An occupational therapy assistant as
defined in
RSA 326-C:1,
IV working under the direction of a licensed
occupational therapist.
(p) Occupational therapy services, other than
an evaluation, shall require an order.
(q) Occupational therapy services shall
include:
(1) Task-oriented activities to
correct physical or emotional deficits or to minimize the disabling effect of
these deficits in the life of the student;
(2) Evaluations of:
a. Sensorimotor abilities;
b. Self-care activities;
c. Capacity for independence;
d. Physical capacity for prevocational and
work tasks; and
e. Play and leisure
performance;
(3)
Specific occupational therapy techniques involving:
a. Improving skills for ADLs;
b. The fabrication and application of
splinting devices;
c. Sensorimotor
activities;
d. The use of
specifically designed manual and creative activities;
e. Guidance in the selection and use of
adaptive equipment; and
f. Specific
exercises to enhance functional performance and physical capabilities needed
for work activities; and
(4) Other services determined by an
occupational therapist to be medically necessary and appropriate.
(r) Billable categories of
occupational therapy services shall include the following:
(1) Occupational therapy
evaluation;
(2) Occupational
therapy, individual;
(3)
Occupational therapy, group; and
(4) Supplies and equipment necessary for the
provision of covered occupational therapy services.
(s) Physical therapy services shall include:
(1) Any evaluations to determine a student's
level of physical functioning, including performance tests to measure
strengths, balance, endurance, and range of motion;
(2) Any treatment services, evaluations, or
assessments which might utilize therapeutic exercises or the modalities of
heat, cold, water, and electricity, for the purpose of preventing, restoring,
or alleviating a lost or impaired physical function;
(3) Other services, including supplies and
equipment, determined by a physical therapist to be medically necessary and
appropriate for a student's physical therapy; and
(4) Physical therapy services performed by a
physical therapy assistant carrying out a therapy plan developed by the
physical therapist.
(t)
Physical therapy services shall be provided by:
(1) A physical therapist who is a graduate of
a program of physical therapy approved by the Committee on Allied Health
Education and Accreditation of the American Medical Association and the
American Physical Therapy Association or its equivalent and licensed to
practice in the state of NH or the state in which he or she practices;
or
(2) A physical therapy assistant
as defined in
RSA 328-A:2,
VIII who is under the direction of a licensed
physical therapist pursuant to (1) above.
(u) Physical therapy services shall be
medically necessary.
(v) Billable
categories of physical therapy services shall include the following:
(1) Physical therapy, evaluation;
(2) Physical therapy, individual;
(3) Physical therapy, group; and
(4) Supplies and equipment necessary for the
provision of covered physical therapy services.
(w) Psychiatric services shall be medically
necessary for the evaluation, assessment, diagnosis, and treatment of mental or
emotional conditions.
(x)
Psychiatric services shall be provided by:
(1)
A psychiatrist who is a physician licensed to practice in NH as defined in RSA
135-C:2II, XI, or the state in which he or she practices and either board
certified or board eligible according to the most recent regulations of the
American Board of Psychiatry and Neurology, Inc. or its successor organization;
or
(2) An APRN with a psychiatric
specialty pursuant to
RSA
326-B:18.
(y) Billable categories of psychiatric
services shall include the following:
(1)
Psychiatric evaluation and diagnosis; and
(2) Psychiatric treatment.
(z) Psychological services shall
require an order and be medically necessary for the evaluation, diagnosis,
treatment, and counseling of mental or emotional illnesses, symptoms, or
conditions.
(aa) Psychological
services shall be provided by:
(1) A
psychologist who is a school psychologist or associate school psychologist
certified by the state board of education in NH or in the state in which he or
she practices and licensed by the NH board of psychologists or another state's
board of psychology;
(2) A
psychologist or associate psychologist licensed by the NH board of
psychologists or licensed by another state's board of psychology;
(3) A physician;
(4) APRNs with a psychiatric specialty
pursuant to
RSA
326-B:18;
(5) Psychotherapists acting within the scope
of his or her licensure; or
(6) A
master licensed alcohol and drug counselor (MLADC) for co-occurring mental
health and substance use disorders.
(ab) Billable categories of psychological
services shall include the following:
(1)
Psychological testing and evaluation;
(2) Psychodiagnostic testing;
(3) Psychological counseling, individual
treatment;
(4) Psychological
counseling, group treatment; and
(5) Family counseling, during which the
student shall be present at 51% of the counseling session.
(ac) Mental health services, other than
psychiatric and psychological services, shall:
(1) Be covered if they are medically
necessary and ordered; and
(2)
Include, but not be limited to:
a Behavior
management;
b. Individual
counseling;
c. Group counseling;
d. Family counseling, during which
the student shall be present at 51% of the counseling session; and
e. Crisis intervention.
(ad) Persons providing mental
health services shall be:
(1) A psychologist
who is a school psychologist or associate school psychologist certified by the
state board of education in NH or in the state in which he or she practices and
licensed by the NH board of psychologists or another state's board of
psychologist;
(2) A psychotherapist
or mental health practitioner as defined in
RSA 330-A:2, VII and
VIII, respectively;
(3) A psychologist licensed by the board of
psychologists pursuant to RSA 329-B; or
(4) An APRN with a psychiatric specialty
pursuant to
RSA
326-B:18.
(ae) Substance use disorder (SUD) treatment
and recovery support services shall be provided by the licensed qualified
providers described in He-W 513, and in accordance with the requirements in
He-W 513.
(af) Rehabilitative
assistance services shall include the following:
(1) Mobility assistance such as positioning,
transfers, correct application of ankle-foot orthosis, bracing or orthotic
devices, range of motion, fall prevention, safety risk precautions, and
physical therapy carry-over tasks as directed by the licensed physical
therapist;
(2) Communication
assistance such as assistance with sign language, prompting to facilitate
expressive and receptive language, assistance with AAC devices and other such
devices that ameliorate communication limitations, and speech language
carry-over tasks as directed by the licensed speech language
pathologist;
(3) Assistance with
the implementation of behavioral management plans to increase adaptive
behavioral functioning and carry-over tasks as directed by the mental health
practitioner or BCBA;
(4) Nutrition
such as assistance with eating, cutting food, food preparation, and safe eating
plan carry-over tasks as directed by the speech language pathologist or
occupational therapist;
(5) Cueing,
prompting, and guiding, when provided as part of the assistance with ADLs,
communication, or behavior management;
(6) Assistance with adaptive or assistive
devices when linked to the student's medical condition;
(7) Assistance with the use of DME when
linked to the student's medical condition;
(8) Medication administration to the extent
allowable under RSA 326-B and pursuant to
Nur
404.07 when the rehabilitative assistant has been
trained by a nurse in medication administration, and the nurse has delegated
the task of medication administration to the rehabilitative
assistant;
(9) Personal care
services such assistance with ADL and IADL and assistance with occupational
therapy, physical therapy, or speech language carry-over tasks;
(10) Carry-over of therapy skills training as
delegated by a speech language pathologist, physical therapist, and
occupational therapist;
(11)
Observation and reporting of signs of distress in the student's medical
condition as trained by a registered nurse;
(12) Implementation of safe eating plans and
g-tube feedings as delegated by a registered nurse with applicable
training;
(13) Maintaining a safe
environment to assure the student's safety concerns are met for the student,
other students and staff; and
(14)
Any other remedial services, that are included in the student's care plan as
medically necessary for the maximum reduction of a student's physical or mental
disabilities excluding educational and social activities such as classroom
instruction and academic tutoring.
(ag) Rehabilitative assistants shall:
(1) Either:
a. Be certified pursuant to
Ed
504.05 or
Ed
504.06, requirements and certification for
paraeducators;
b. Have
qualifications determined by the department to be equivalent to the
requirements for certification under
Ed
504.05 or 504.06; or
c. Be other licensed clinicians;
and
(2) If applicable
for the tasks delegated to the rehabilitative assistant or if required by law
have knowledge in the following areas:
a.
Personal care and nutrition;
b.
Infection control and universal precautions designed to prevent the
transmission of infectious diseases;
c. Safety and emergency procedures, including
basic first aid and 911 protocols; and
d. Proper lifting techniques.
(ah) Rehabilitative
assistants shall provide rehabilitation assistance services in accordance with
Ed
1113.12.
(ai) Rehabilitative assistance services shall
be medically necessary and require an order.
(aj) Provision of rehabilitative assistance
services shall be reviewed by a licensed clinician designated by the enrolled
school provider's care plan team every 30 days. Such review shall include
review of the activities performed by the rehabilitative assistant and the
effectiveness of the activities as observed by the rehabilitative assistant. As
part of the review, the care plan team designated licensed clinician shall sign
the documentation of the service transaction logs to attest that the service
was actually provided and shall provide review and signature that the
activities have been conducted in accordance with the care plan;
(ak) Speech, language, and hearing services
shall be covered services if they are services, supplies, or equipment ordered
by a licensed audiologist or licensed speech-language pathologist to be
medically necessary for the evaluation, diagnosis, or treatment of speech,
language, and hearing disorders which result in communication
disabilities.
(al) Speech language
services shall include services performed by speech language assistants listed
in (am) below carrying out a therapy plan developed by the speech language
pathologist.
(am) Speech, language,
and hearing services shall be provided by:
(1) An audiologist who is licensed to
practice in NH by the board of hearing care providers or the state in which he
or she practices;
(2) A
speech-language pathologist who is either:
a.
Licensed pursuant to RSA 326-F to practice in NH, which shall be considered
equivalent to having met the requirements for the American
Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence
in Speech-Language Pathology; or
b.
Licensed in the state in which he or she practices and have one of the
following:
1 A Certificate of Clinical Competence from the American
Speech and Hearing Association;
2 Completed the equivalent educational requirements and
work experience necessary for the certificate; or
3 Completed the academic program and is acquiring
supervised work experience to qualify for the certificate; or
(3) A speech-language assistant as
defined in
RSA 326-F:1,
II-a working under the direction of a
licensed speech-language pathologist pursuant to (2) above.
(an) Billable categories of
speech, language, and hearing services shall include the following:
(1) Individual speech, language, or hearing
evaluation;
(2) Speech, language,
or hearing therapy, individual treatment;
(3) Speech, language, or hearing therapy,
group treatment; and
(4) Supplies
and equipment necessary for the provision of covered speech language and
hearing services.
(ao)
Vision services shall be medically necessary for the prevention or
rehabilitation of visual impairment or restoration of a student with a visual
impairment to his or her best possible functional level and be provided by an
optometrist, ophthalmologist, or optician.
(ap) EPSDT comprehensive and age-appropriate
medical assessments and screenings of a student's physical and mental status,
including vision and hearing screenings in accordance with the requirements
pursuant to
He-W
546.05.
(aq) Services that are not covered or have
coverage limits under the NH medicaid state plan shall be covered through the
EPSDT benefit when medically necessary, coverable under Section 1905(a) of the
Social Security Act, and requested in accordance with the requirements of He-W
546.
(ar) Except as indicated in
(at) below, the following shall be examples of services subject to the
requirements of He-W 546:
(1) Rehabilitative
assistance services;
(2) Applied
behavior analysis;
(3) Personal
care services for individuals under the age of 21;
(4) Wrap around services;
(5) Case management services; and
(6) Other optional services listed in 1905(a)
of the Social Security Act and not included in the NH medicaid state plan or
included as a covered service under this part.
(as) The following services shall not be
subject to the prior authorization requirements of He-W 546:
(1) Rehabilitative assistance
services;
(2) Applied behavior
analysis; and
(3) Personal care
services for individuals under the age of 21.
(at) Any services not listed as covered under
the NH medicaid state plan or services with coverage limits shall be given
independent review by the department for coverage based on medical necessity in
accordance with the EPSDT benefit pursuant to He-W 546.
(au) Specialized transportation shall be a
billable service as follows:
(1)
Transportation shall be listed in the student's IEP as a required service and
the student shall be physically in the vehicle for the transportation to be
billable to medicaid;
(2)
Transportation shall be considered a required service if:
a. The student requires transportation in a
vehicle specially adapted to serve the needs of the disabled student, including
a specially adapted school bus; or
b The student resides in an area that does
not have school bus transportation, such as those areas in close proximity to a
school, but has a medical need for transportation that is noted in the
IEP;
(3) The following
transportation may be billed as a medicaid service:
a. Transportation to and from school only on
a day when the student receives a medicaid coverable service at school during
the school day; and
b.
Transportation to and from a medicaid coverable service in the community during
the school day;
(4) The
medicaid coverable service in (3)a. and (3)b. above shall be listed in the
student's IEP as a required service; and
(5) In addition to the documentation required
by He-W 589.06, transportation providers shall maintain a daily transportation
log to include:
a. Student's name;
b. Date of service;
c. Clear indication that the student is being
transported either one-way or round-trip;
d. The total number of students on the bus,
both in the morning and the afternoon;
e. The total miles the bus traveled, both in
the morning and the afternoon;
f.
Driver's name; and
g. Driver's
signature.
