Ohio Administrative Code|Rule 5160-35-06 | Other services, medical supplies and equipment authorized for medicaid coverage that can be provided by medicaid school program (MSP) providers.

                                                
(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.