Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-35 - Medicaid School Program
Section 5160-35-05 - Services authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers
Universal Citation: OH Admin Code 5160-35-05
Current through all regulations passed and filed through September 16, 2024
(A) The purpose of this rule is to set forth the services authorized for medicaid coverage that a MSP provider can provide, and to set forth the conditions for providing the services.
(B) 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 a licensed occupational therapist acting within the scope of his
or her practice under Ohio law who holds a current, valid license to practice
occupational therapy issued under Chapter 4755. of the Revised Code. Services
provided by an individual holding a limited permit, as described in section
4755.08 of the Revised Code, are
not allowable.
(b) Qualified
practitioners who can deliver the services:
(i) Licensed occupational therapist who holds
a current, valid license to practice occupational therapy issued under Chapter
4755. of the Revised Code, who is employed or contracted with the MSP provider,
and who is acting within the scope of his or her practice under Ohio
law.
(ii) Licensed occupational
therapy assistant who holds a current, valid license issued under Chapter 4755.
of the Revised Code, who is employed or contracted with the MSP provider, and
who is acting within the scope of his or her practice under Ohio law. Further,
the licensed occupational therapy assistant will be
practicing under the supervision of a licensed occupational therapist who is
employed or contracted by the MSP provider.
(iii)
An occupational
therapy 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 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 (B)(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 licensed physical
therapist acting within the scope of his or her practice under Ohio law who
holds a current, valid license to practice physical therapy issued under
Chapter 4755. of the Revised Code.
(b) Qualified practitioners who can deliver
the services:
(i) Licensed physical therapist
who holds a current, valid license to practice physical therapy issued under
Chapter 4755. of the Revised Code, who is employed or contracted with the MSP
provider, and who is acting within the scope of his or her practice under Ohio
law.
(ii) Licensed physical
therapist assistant who holds a current, valid license issued under Chapter
4755. of the Revised Code, who is employed or contracted with the MSP provider,
who is acting within the scope of his or her practice under Ohio law, and who
is practicing under the supervision of a licensed physical therapist employed
or contracted by the MSP provider.
(iii)
A physical
therapy 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 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 (B)(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 licensed speech-language
pathologist acting within the scope of his or her practice under Ohio law who
holds a current, valid license to practice speech-language pathology issued
under Chapter 4753. of the Revised Code.
(b) Qualified practitioners who can deliver
the services:
(i) Licensed speech-language
pathologist who holds a current, valid license to practice speech-language
pathology issued under Chapter 4753. of the Revised Code, who is employed or
contracted with the MSP provider, and who is acting within the scope of his or
her practice under Ohio law.
(ii)
Licensed speech-language pathology aide who holds a current, valid license
issued under Chapter 4753. of the Revised Code, who is employed or contracted
with the MSP provider, who is acting within the scope of his or her practice
under Ohio law, and who is practicing under the supervision of the licensed
speech-language pathologist who completed, signed and submitted to the Ohio
board of speech-language pathology and audiology the speech-language pathology
aide plan. The supervising speech-language pathologist
will be
employed or contracted by the MSP provider.
(iii) A person holding a conditional license
to practice speech-language pathology, if the eligible provider supervising the
professional experience keeps on file a copy of the conditionally-licensed
speech-language pathologist's plan of supervised professional experience,
mandated
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 a licensed audiologist acting
within the scope of his or her practice under Ohio law who holds a current,
valid license to practice audiology issued under Chapter 4753. of the Revised
Code.
(b) Qualified practitioners
who can deliver the services:
(i) Licensed
audiologist who holds a current, valid license to practice audiology issued
under Chapter 4753. of the Revised Code, who is employed or contracted with the
MSP provider, and who is acting within the scope of his or her practice under
Ohio law.
(ii) Licensed audiology
aide holds a current, valid license issued under Chapter 4753. of the Revised
Code, who is employed or contracted with the MSP provider, who is acting within
the scope of his or her practice under Ohio law, and who is practicing under
the supervision of the licensed audiologist who completed, signed and submitted
to the Ohio board of speech-language pathology and audiology the audiology aide
plan. The supervising audiologist
will be employed or contracted by the MSP
provider.
(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)
Nursing services
(a) Description: services
from a registered nurse that provides to individuals and groups nursing care as
defined in Chapter 4723. of the Revised Code. And, services from a licensed
practical nurse that provides 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) Licensed registered nurse
who holds a current, valid license issued under Chapter 4723. of the Revised
Code, who is employed or contracted with the MSP provider, and who is acting
within the scope of his or her practice under Ohio law.
(ii) Licensed practical nurse who holds a
current, valid license issued under Chapter 4723. of the Revised Code, who is
employed or contracted with the MSP provider, who is practicing at the
direction of a medicaid authorized prescriber, and who is acting within the
scope of his or her practice under Ohio law.
(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)
Administering medications prescribed by a medicaid authorized
prescriber.
(iii) The
implementation of medical/nursing procedures/treatments prescribed by a
medicaid authorized prescriber for the medicaid eligible child, which may
include tube feeds, bowel and bladder care, colostomy care, catheterizations,
respiratory treatment, wound care, and any other services that are prescribed
by a medicaid authorized prescriber.
(6) Mental health services
(a) Description:
(i) Counseling services rendered to an
individual or group and involves the application of clinical counseling
principles, methods, or procedures to assist individuals in achieving more
effective personal or social development and adjustment, including the
diagnosis and treatment of mental and emotional disorders;
(ii) Social work services that involve the
application of specialized knowledge of human development and behavior and
social, economic, and cultural systems in directly assisting individuals,
families, and groups in a clinical setting to improve or restore their capacity
for social functioning, including counseling, the use of psychosocial
interventions, and the use of social psychotherapy, which includes the
diagnosis and treatment of mental and emotional disorders; and
(iii) Psychology services that are the
application of psychological procedures to assess, diagnose, prevent, treat, or
ameliorate psychological problems or emotional or mental disorders of
individuals or groups; or to assess or improve psychological adjustment or
functioning of individuals or groups, whether or not there is a diagnosable
pre-existing psychological problem.
(b) Qualified practitioners who can deliver
the services:
(i) Licensed clinical
counselor, licensed counselor who holds a current, valid license to practice
professional counseling issued under Chapter 4757. of the Revised Code, who is
employed by or contracted with the MSP provider, and who is acting within the
scope of his or her practice under Ohio law;
(ii) Licensed independent social worker, or
licensed social worker who holds a current, valid license to practice social
work issued under Chapter 4757. of the Revised Code, who is employed by or
contracted with the MSP provider, and who is acting within the scope of his or
her practice under Ohio law;
(iii)
Licensed psychologist or a licensed school psychologist who holds a current,
valid license to practice psychology issued under Chapter 4732. of the Revised
Code, or to practice school psychology issued under Chapter 4732. of the
Revised Code or under rule
3301-24-05 of the Administrative
Code who is employed or contracted with the MSP provider, and who is acting
within the scope of his or her practice under Ohio law.
(c) Allowable activities include:
(i) Diagnosis and rehabilitative treatment of
mental and emotional disorders performed by a licensed independent social
worker, licensed social worker, professional counselor, or professional
clinical counselor acting within his or her scope of practice under Ohio
law.
(ii) Assessment and diagnostic
services performed by a licensed psychologist or a licensed school psychologist
acting within his or her scope of practice under Ohio law to determine the
current psychological condition of the eligible child and to identify
appropriate psychological treatment and/or therapy for the eligible child to
address the findings of the assessment/diagnosis.
(iii) Psychological and neuropsychological
testing when performed to assist in determining the possible presence of a
psychological or neuropsychological disorder.
(iv) Rehabilitative treatment using
psychological procedures for the purpose of treating, correcting or alleviating
the mental and emotional impairment of the eligible child.
(d) Unallowable activities include
sensitivity training, sexual competency training, educational activities
(including testing and diagnosis - this does not include initial assessments
nor re-assessment as indicated in paragraph (B)(7) of this rule), monitoring
activities of daily living, recreational therapies, teaching grooming skills,
sensory stimulation, teaching social interaction/diversion skills, crisis
intervention not included in an eligible child's individualized educational
program (IEP), and family therapy that is not as a direct benefit to the
eligible child.
(7)
Assessments/evaluations
(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
child unless prior authorization is obtained) conducted for an eligible child
without an IEP or conducted for a two year old 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 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 (B)(1) to (B)(6) of this rule who holds a current,
valid license, who is employed or contracted with the MSP provider, and who is
acting within the scope of his or her practice under Ohio law.
(C) An MSP provider may provide telehealth services. Telehealth services are to be delivered in accordance with an eligible child's IEP, 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.
(D) In accordance with an eligible child's IEP and section 5162.366 of the Revised Code, a physical therapist, occupational therapist, speech-language pathologist, and audiologist can make a referral for the child when the referral is within the practitioner's specific discipline.
The licensed physical therapist, occupational therapist, speech-language pathologist, and audiologist is obligated to have an active medicaid provider agreement in place.
(E) Although the following list is not all-inclusive, the following are not allowable for reimbursement through the medicaid school program:
(1) Attending IEP and ETR meetings, and
development of the IEP.
(2) 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.
(3) Health/medical screens, including mass screens
provided to an eligible child with an IEP.
(4) Counseling parents
and teachers regarding hearing loss.
(5) In-house
training.
(6) Fittings for amplification devices, and equipment
troubleshooting and/or repair.
(7) Nursing services
provided as a part of immunizations process.
(8) Instruction on
self-care that does not need the expertise of the licensed
practitioner.
(9) Services provided to a child who does not have an
IEP with the exception of the initial assessment/evaluation as described in
paragraph (B)(7) of this rule.
(10) Services not
indicated in an eligible child's IEP prior to the provision of the service with
the exception of the initial assessment/evaluation as described in paragraph
(B)(7) of this rule.
(11) Services
provided to a child who does not have a disability and a need for special
education and related services with the exception of the initial
assessment/evaluation as described in paragraph (B)(7) of this rule.
(12)
Services provided on days or at times when the eligible child is not in
attendance in the IEP designated school setting with the exception of the
initial assessment/evaluation as described in paragraph (B)(7) of this
rule.
(13) Services that are not provided under the
appropriate supervision and/or at the appropriate direction of a licensed
practitioner of the healing arts.
(14) Services
provided by a non-licensed person.
(15) Services for
which an eligible child fails to show progress toward IEP identified goals over
two consecutive three-month periods and there is no documentation that the
methods and/or techniques applied have been modified to improve
progress.
(16) 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.
(17) Services and
activities that are not a direct benefit to the eligible child.
(F) 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.
(G) 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.
(H) The eligible child's IEP are to contain the following components that, taken together and for the purposes of Chapter 5160-35 of the Administrative Code, are called the plan of care. This plan of care does not supplant any practitioner plan of care, and will:
(1) Be based
on the initial assessment/evaluation conducted during the ETR 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, and for medications, reference and identify the location of the
prescription of a physician or an advanced practice nurse with certification to
prescribe in accordance with Ohio law.
(6) Specify timelines for
re-assessment/re-evaluation, which should be no more than twelve-months from
the date of the initial assessment/evaluation, of the eligible child and
updates to the plan of care/IEP.
(I) 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 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 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 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 home in accordance with
the medicaid provider agreement.
(J) The claims for reimbursement for services will be submitted in accordance with rule 5160-35-04 of the Administrative Code.
(K) 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.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
