IDAPA 2/18/2015. School Based Medicaid Related Services School Based Medicaid SLP OT PT

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1 School Based Medicaid Related Services Presenters: Shannon Dunstan, Department of Education Frede Trenkle, Department of Health and Welfare What will be presented: Implementation of School Based Medicaid Related Services Who needs this information: Special Education Directors, SLPs, OTs, PTs, Teachers, Medicaid Billing Staff IDAPA School Based Medicaid SLP OT PT 1

2 Who Qualifies to Provide Related Services IDAPA SLP IDAPA OT IDAPA PT Related Service providers are IEP Team Members Related service providers collaborate with a student s IEP and healthcare team members to help promote each child s potential. It is important for collaboration between school teachers, staff members and school related service providers to achieve positive outcomes for our students. Timely physician orders, updates to goals, plans and daily implementation of a student s plan will enhance each child s success. Definitions SLP Speech Language Pathologist OT Occupational Therapist PT Physical Therapist 2

3 Must Be Medically Necessary It is a reasonable calculated service to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functional significant condition, deformity or malfunction; and There is no other equally effective course of treatment available or suitable for the participant requesting the service which is more conservative or substantially less costly. Medicaid services must be of a quality that meets professionally-recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality. Those records must be made available to the Department upon request. IDAPA Physician Orders IDAPA : All therapy must be ordered by a physician, nurse practitioner, or physician assistant. Such orders must include at a minimum, the service to be provided, the frequency, and, where applicable, the duration of each therapeutic session. In the event that services are required for extended periods, these services must be reordered as necessary, but at least every ninety (90) days for all participants with the following exception: Therapy for individuals with chronic medical conditions, as documented by physician, nurse practitioner, or physician assistant, must be reordered at least every six (6) months. Speech Language Pathology (SLP) Services - Schools IDAPA

4 SLP services are therapy services that are Provided within the scope of practice of licensed speech-language pathologists; and Necessary for the evaluation and treatment of speech and language disorders which result in communication disabilities; or Necessary for the evaluation and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. IDAPA Billing Medicaid for Speech & Language Services According to Idaho law, schools can bill Medicaid for SLP services that are provided by a qualified SLP and a supervised SLP paraprofessional. Qualifications for both are identified in IDAPA. IDAPA and The SLP Medicaid Provider Idaho Medicaid requires services to be provided by or under the direction of a speech pathologist or audiologist who possesses a certificate of clinical competence from the American Speech, Language and Hearing Association (ASHA); or who will be eligible for certification within one (1) year of employment. IDAPA

5 Occupational Therapy IDAPA Defined AOTA, 2008 OT Services Include Evaluation and Treatment of Sensory Perceptual Skills Motor and Praxis Skills Emotional Regulation Skills Cognitive Skills Communication and Social Skills» (AOTA, 2008) IDAPA

6 AOTA Ethic Principles Principle 1. Occupational therapy personnel shall demonstrate a concern for the well-being and safety of the recipients of their services. Principle 2. Occupational therapy personnel shall intentionally refrain from actions that cause harm. Principle 3. Occupational therapy personnel shall respect the right of the individual to selfdetermination. Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner. Principle 5. Occupational therapy personnel shall comply with institutional rules, local, state, federal, and international laws and AOTA documents applicable to the profession of occupational therapy. Principle 6. Occupational therapy personnel shall provide comprehensive, accurate, and objective information when representing the profession. Principle 7. Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity. Billing Medicaid for Occupational Services According to Idaho law, schools can bill Medicaid for OT services that are provided by a qualified OT and a supervised OT assistant or OT Aide as defined in Idaho statute. IDAPA The OT Medicaid Provider Occupational Therapist OTR/L Occupational Therapist Assistant COTA/L Occupational Therapy Aide (paraprofessional) IDAPA f 6

7 Occupational Therapy Idaho Practice Act To practice Occupational Therapy in Idaho, you must be certified nationally and licensed by the State of Idaho as an Occupational Therapist (OT) or Occupational Therapy Assistant (OTA). Licenses are renewed annually and require continuing education and professional development (Idaho Occupational Therapy Practice Act) Supervision of a COTA by an OT General supervision requires direct, on-premises contact between the therapist, the therapy assistant, and the participant at least every five (5) visits or once every week if seen on a daily basis. Between direct contacts, the therapist is required to maintain indirect, off-premises contact with the therapy assistant. These indirect, off-premises contacts may be by telephone, written reports, or group conferences. IDAPA b Supervision Requirements for the OT Aide Aides do not provide skilled occupational therapy services. An aide is trained by an occupational therapist or an occupational therapy assistant to perform specifically delegated tasks. The occupational therapist is responsible for the overall use and actions of the aide. An aide first must demonstrate competency to be able to perform the assigned, delegated client and non-client tasks. The occupational therapist must oversee the development, documentation, and implementation of a plan to supervise and routinely assess the ability of the occupational therapy aide to carry out non-client and client-related tasks. The occupational therapy assistant may contribute to the development and documentation of this plan. An aide shall function only under the direct line of sight supervision of an occupational therapist or occupational therapy assistant. IDAPA

8 Physical Therapy IDAPA APTA Description of Physical Therapy PT Services Include Evaluation and Treatment of Gross Motor Skills Visual Motor Impairments Spasticity Management Orthopedic Impairments Neuromuscular Impairments Adaptive equipment Gait abnormalities Wheelchair mobility Balance Impairments Postural Impairments Coordination Impairments IDAPA

9 Billing Medicaid for Physical Therapy Services According to Idaho law, schools can bill Medicaid for PT services that are provided by a qualified licensed PT as defined in Idaho statute. IDAPA PT Providers Must be Licensed Physical Therapy Supervision General supervision requires direct, on-premises contact between the therapist, the therapy assistant, and the participant at least every five (5) visits or once every week if seen on a daily basis. Between direct contacts, the therapist is required to maintain indirect, off-premises contact with the therapy assistant. These indirect, off-premises contacts may be by telephone, written reports, or group conferences b 9

10 Related Services Steps IEP Implementation Service Page IEP Goals Eligibility Report/Written Notice Evaluation and Assessment Team determines eligibility for special education at initial evaluation or 3 year reevaluation, or more frequently as warranted. Evaluation Obtain consent to assess per IDEA and one time parent consent to bill Medicaid and Obtain Physician s Order if going to billing Medicaid for the Evaluations and Assessments Assessment Eligibility Or Written Notice IEP Team documents results of evaluations/assessments on initial or 3 year reevaluation. If student is demonstrating a need that was not addressed on an initial or 3 yr. evalution, team may need to complete additional assessment(s) during interim period. Results of the evaluation or assessment must be summarized on a Written Notice. IEP Goal(s) Goal(s) are developed to address the needs that were identified during the evaluation process, including the students current present level of performance, in parent friendly language, with clear and measureable goals. One goal per present level of performance that includes a baseline that addresses the student s needs, how the disability impacts the student s ability to access general education, and relation to typical peer development. Service Page Team documents needed services per district policy/procedure. Teams should consider use of Optional Statement of Service Delivery as a mechanism to specify when an aide (if applicable) will deliver the services. IEP Implementation Implement IEP Collect progress monitoring data In order to bill Medicaid the service provider must ensure progress monitoring data and service provision is documented according to Medicaid Rules. Obtain a physician order for services, every 3 months, or every 6 months if it is documented by a physician that the child has a chronic medical condition. 10

11 New Consent Requirement Evaluation and Assessment Team determines eligibility for special education at initial evaluation or 3 year reevaluation, or more frequently as warranted. Obtain consent to assess per IDEA and one time parent consent to bill Medicaid Obtain Physician s Order if going to billing Medicaid for the Evaluations and Assessments Evaluation and Assessment Obtains Consent for permission to Bill Medicaid Obtain Physician Order Complete Assessments 11

12 Eligibility Or Written Notice IEP Team documents results of evaluations/assessments on initial or 3 year reevaluation. If student is demonstrating a need that was not addressed on an initial or 3 yr., team may need to complete additional assessment(s) during interim period. Results of the evaluation or assessment must be summarized on a Written Notice. IEP Goal(s) Goal(s) are developed to address the needs that were identified during the evaluation process, including the students current present level of performance, in parent friendly language, with clear and measureable goals. One goal per present level of performance that includes a baseline that addresses the student s needs, how the disability impacts the student s ability to access general education, and relation to typical peer development. Service Page Team documents needed services per district policy/procedure. Teams should consider use of Optional Statement of Service Delivery as a mechanism to specify when an aide (if applicable) will deliver the services OR use the new Medicaid IEP Form. 12

13 Documentation Prior to Billing Current IEP indicates the need for service(s). Physician s Orders makes recommendation or referral for Medicaid services. IDAPA Service Detail Report Must Include: Student s name Name and title of person providing the service Date, time, duration for service Place of service Category of service Brief description of the specific areas addressed Students response to the intervention IDAPA Exclusion List Providers must check both the Idaho Medicaid Exclusion List and the HHS OIG Exclusion List to determine whether a provider, individual, or entity is excluded and, if so, the dates of such exclusion. The HHS OIG Exclusion List is accessed at and Idaho Medicaid Exclusion list is accessed at aspx Providers are responsible for screening all employees and contractors to identify excluded individuals and are responsible for searching the HHS OIG website and the Idaho Medicaid Exclusion List monthly to capture exclusions and reinstatements. Providers, individuals and entities are not automatically reinstated at the end of the state or federal exclusion period. If providers, individuals or entities on the state or federal exclusion list do not have a reinstatement date listed, they are not eligible to provide services. 13

14 Don t forget Districts must be enrolled as a Medicaid provider to be reimbursed for school based Medicaid services. Each service must be specifically identified on the IEP. Services cannot be educational. Services must be medically necessary for the student to access their educational program. IDAPA Training Calendar Online Registration Webinars Learning Communities Medicaid Advisory Committee meeting minutes 14

15 Contact Information: Shannon Dunstan Early Childhood & Interagency Coordinator Idaho State Department of Education Division of Student Achievement and School Improvement Division of Special Education (208) Contact Information Frede Trenkle Alternative Care Coordination Bureau of Developmental Disabilities Services Division of Medicaid (208)

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