Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-35 - Medicaid School Program
Section 5160-35-06 - Other services, medical supplies and equipment authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers
Universal Citation: OH Admin Code 5160-35-06
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, beyond those indicated in rule 5160-35-05 of the Administrative Code, that a MSP provider can provide, and to set forth the conditions for providing the services.
(B) In addition to the services indicated in rule 5160-35-05 of the Administrative Code, a MSP provider may render and receive payment for the following services:
(1) Transportation:
(a) For purposes of Chapter 5160-35 of the
Administrative Code, "transportation" is specialized conveyance that
accommodates the specific needs of an eligible child (for example,
transportation by wheelchair-accessible vehicle or adapted school bus) for the
purpose of traveling to or from the MSP provider to receive medically necessary
services allowable under rule
5160-35-05 of the Administrative
Code.
(b) Claims for transportation
mileage are paid in accordance with rates as found
in the "Healthcare Common Procedure Coding System (HCPS)," with the 'Current
Procedural Terminology (CPT)" codes, and in rule
5160-1-60 of the Administrative
Code.
(c) Unallowable
services include transportation that is otherwise available to all students,
transportation that is provided in a vehicle that is not used specifically to
accommodate an eligible child, transportation accommodations that are not
indicated in an eligible child's individualized education program (IEP), and
transportation provided from home to school or from school to home if no
medicaid-covered service allowable under rule
5160-35-05 of the Administrative
Code was received at school on that day.
(2) Targeted case management services (TCM):
(a) Description: assessment, care planning,
referral and linkage, monitoring and follow-up activities specified in an
eligible child's IEP that will assist the eligible child in gaining access to
medical, social, educational and other needed services. The amount, frequency,
and duration of the case management services, as well as the case manager
responsible for providing the case management service,
are to
be indicated in the eligible child's IEP.
(b) Qualified practitioners who may deliver
the services:
(i) A licensed registered nurse
who holds a current, valid license issued under section
4723.09 of the Revised Code, and
who is employed or contracted with the MSP provider.
(ii) An individual with a baccalaureate
degree with a major in education or social work, and who is employed or
contracted with the MSP provider.
(iii) An individual who has earned credit in
course work equivalent to that as needed for a major in a specific special education
area, and who is employed or contracted with the MSP provider.
(iv) A person who is employed or contracted
with the MSP provider, and who has a minimum of three years personal experience
in the direct care of an individual with special needs.
(c) The service unit will be fifteen
minutes.
(d) Targeted case
management is
to be billed on a separate claim from all other services. If it is billed
on a claim with other services, the targeted case management claim will be
denied. This is strictly a billing issue and does not
impact
the provision of services.
(e)
Activities under targeted case management are:
(i) Assessment: for an eligible child with an
IEP, ensuring the prescription, by a medicaid authorized prescriber for
services for which medicaid reimbursement is to be sought,
is in the eligible child's case file; gathering of comprehensive information
concerning the eligible child's preferences, personal goals, needs, abilities,
health status and other available supports; determining the eligible child's
need for case management; obtaining agreement from the eligible child and/or
parent/legal guardian, whichever is appropriate, to allow the provision of case
management; making arrangements to obtain from therapists and appropriately
qualified persons the initial and on-going evaluation of the eligible child's
need for any medical, educational, social, and other services.
(ii) Care planning: for an eligible child
with an IEP, ensuring the active participation of the eligible child and the
eligible child's parent/ legal guardian and family; working with the eligible
child's IEP team to develop the IEP goals and course of action to respond to
the assessed needs of the eligible child; coordinating with the eligible
child's medical home.
(iii)
Referral and linkage: connecting an eligible child with an IEP to individuals
capable of providing needed medical, social, educational and other needed
services.
(iv) Monitoring and
follow-up: ensuring that the IEP is effectively implemented and adequately
addresses the needs of the eligible child; conducting quality assurance reviews
on behalf of the eligible child and incorporating the results of quality
assurance reviews into amendments of the IEP; reviewing the progress toward
goals in the IEP and making recommendation for assessment as appropriate based
upon progress reviews; ensuring that services are provided in accordance with
the IEP and that IEP services are effectively coordinated through communication
with service providers, including the medical home.
(f) Although the following list is not
all-inclusive, the following activities are not allowable as targeted case
management through an MSP provider:
(i)
Providing medical, educational, vocational, transportation, or social services
to which the eligible individual has been referred.
(ii) Providing the direct delivery of foster
care services.
(iii) Providing
services, other than assessment services, to an eligible child who has not been
determined to have a developmental disability according to section
5123.01 of the Revised
Code.
(iv) Providing services to an
eligible child who is on a waiver program receiving targeted case management
from county boards of development disabilities (CBDD).
(v) Conducting quality assurance systems
reviews.
(vi) Conducting activities
related to the development, monitoring or implementation of an individual
service plan (ISP) for an eligible child on a waiver.
(vii) Performing activities for or providing
services to groups of individuals.
(viii) Activities performed and services
provided by someone who is not an employee of or contracted with an MSP
provider to provide targeted case management.
(ix) Activities performed and services
provided by someone who is not the case manager specified in the eligible
child's IEP.
(x) Providing services
for which claims are submitted through or should have been submitted through
another program.
(3) Medical supplies and equipment:
(a) Supplies and equipment that are medically
necessary as described in rule
5160-1-01 of the Administrative
Code for the care and treatment of a medicaid eligible child with an IEP while
attending school and that are necessary for the qualified practitioner, as
described in rule
5160-35-05 of the Administrative
Code, to perform his or her function for an eligible child.
(b) Claim for the cost of medical supplies
and equipment are reimbursed through the cost reporting process in accordance
with paragraph (K)(2) of rule
5160-35-04 of the Administrative
Code.
(c) Unallowable: supplies and
equipment furnished to a medicaid eligible child for use outside the school. In
order to be reimbursed for supplies and equipment furnished to an eligible
child for use outside the school, the school will be approved
under the medicaid program as a medical supplies provider. See Chapter 5160-10
of the Administrative Code for coverage, limitation, billing, and reimbursement
provisions relative to medical supplies providers.
(d) Claims cannot be submitted for medical
supplies and equipment for which a claim was submitted or should have been
submitted through another program.
(C) The service provided is to be necessary to enable the recipient to access medically necessary services of the type, frequency, scope and duration that fall within the normal range of services considered under acceptable standards of medical and healing arts professional practice, as appropriate, in accordance with rule 5160-1-01 of the Administrative Code.
(D) The eligible child's IEP is 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 multi-factored evaluation 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 provided, and the amount, duration and
frequency of each service.
(4)
Include specific goals to be achieved for each service.
(5) Specify timelines for
re-assessment/re-evaluation of the eligible child and updates to the plan of
care.
(E) The documentation for the provision of each service will be maintained for purposes of an audit trail. Documentation will include:
(1) The date (i.e., day, month, and
year) that the services, medical supplies and/or equipment were
provided.
(2) The full legal name
of the child for whom the services, medical supplies and/or equipment was
provided.
(3) A description of the
services, medical supplies and/or equipment provided and location where the
services, medical supplies and/or equipment are delivered (may be in case notes
or a coded system with a corresponding key).
(4) The duration in minutes or time in/time
out of the transportation and/or targeted case management service provided.
Duration in minutes is acceptable if the schedule of the person delivering the
service is maintained on file.
(5)
A description of actual progress the eligible child is making/has made toward
the stated goals in the plan of care for each continuous three-month reporting
period.
(6) The signature or
initials of the person delivering the services, medical supplies and/or
equipment on each entry of services, medical supplies and/or equipment
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 services, medical
supplies and/or equipment to correspond with each entry's identifying signature
or initials.
(7) A description of
efforts made to coordinate services with the eligible child's medical home in
accordance with the medicaid provider agreement.
(F) The claims for reimbursement for services will be submitted in accordance with rule 5160-35-04 of the Administrative Code.
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.
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