OAR 410-133-0080
Coverage

The Authority may reimburse school medical (SM) providers for covered health services that meet all the following criteria:
(1) The health service must be “necessary and appropriate,” considered as a covered service under the Oregon Health Plan (OHP) Prioritized List of health services, and the health service may not be excluded under OAR 410-133-0200 (Not Covered Services) Not Covered Services.
(2) The health service must be required by a Medicaid-eligible student’s physical or mental condition that adversely affects the child/student’s educational performance and that helps the child/student keep, learn, or improve skills and functioning as specified on the Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) and further described in the treatment plan and the evaluation of the student.
(3) The health service, individual, or group may include corrective health services treatments and Medicaid-covered related services as described in a student’s IEP or IFSP:
(a) The payment rate for health services includes case management and necessary supplies for these services. Additional reimbursement for such services is not paid separately from the health service;
(b) These services must be provided by medically qualified staff that meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff) and comply with the respective medical provider’s governing definitions, scope of practice, documentation requirements, and licensure or certification.
(4) Evaluation and assessment for SBHS are reimbursed for the part of the evaluation or assessment regarding a Medicaid-eligible student’s “necessary and appropriate” SBHS needs for the purpose of establishing, re-establishing, or terminating a Medicaid-covered service on a Medicaid-eligible student’s IEP or IFSP or to develop, review, or revise components of a covered health service currently provided to a Medicaid-eligible student for continuation of those covered services pursuant to an IEP or IFSP under the Individuals with Disabilities Education Act (IDEA):
(a) Evaluation services are procedures used to determine an SBHS covered health-related need, diagnosis, or eligibility under IDEA;
(b) Re-evaluation services are procedures used to measure a Medicaid-eligible student’s health status compared to an initial or previous evaluation and is focused on evaluation of progress toward current goals, modifying goals or treatment, or making a professional judgment to determine whether or not a Medicaid-eligible student will continue to receive continued care for a SBHS covered service pursuant to the IEP or IFSP under IDEA. Continuous assessment of the student’s progress as a component of ongoing therapy services is not billable as a re-evaluation.
(5) Assistive technology services directly assist a Medicaid-eligible student with a disability eligible under IDEA to receive assistive technology-covered SBHS as specified on the IEP or IFSP in the selection, acquisition, or use of an assistive technology device, including:
(a) The assistive technology assessment with one-to-one student contact time by medically-qualified staff within the scope of practice performing the assessment of the need, suitability, and benefits of the use of an assistive technology device or adaptive equipment that will help restore, augment, or compensate for existing functional ability in the Medicaid-eligible student or that will optimize functional tasks for the Medicaid-eligible student’s environmental accessibility. This requires and includes the preparation of a written report;
(b) Care coordination with the Medicaid-eligible student’s physician, parent/guardian, and the Division) for the parent/guardian’s acquisition of a personal assistive technology device for their Medicaid-eligible student through the student’s Medicaid plan for the benefit of the Medicaid-eligible student to maximize her functional ability and environmental accessibility; and
(c) Training or technical assistance provided to or demonstrated with the Medicaid-eligible student by medically-qualified staff, instructing the use of an assistive technology device or adaptive equipment in the educational setting with professionals (including individuals providing education and rehabilitation services) or where appropriate the family members, guardians, advocates, or authorized representative of the Medicaid-eligible student. In order to bill Medicaid for this service, the student must be present.
(6) The Authority may reimburse physical therapy services provided by:
(a) A physical therapist authorized to administer physical therapy to an individual when the individual is a Medicaid-eligible student eligible for special education, as defined by state or federal law, and is being seen pursuant to the Medicaid-eligible student’s individual education plan or individual family service plan (see Oregon administrative rules chapter 848, division 10, Licensed Physical therapist and Licensed Physical Therapist Assistants; Division 15 Physical Therapist Assistants; and Division 40 Minimum Standards For Physical Therapy Practice and Records);
(b) A physical therapist assistant providing treatment under the supervision of a physical therapist that is available and readily accessible for consultation with the assistant at all times either in person or by means of telecommunications (see OAR chapter 848, division 15, Physical Therapist Assistants). Physical therapy services must be provided by medically qualified staff that meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff);
(c) Reimbursement time may include:
(A) Preparation of the written initial evaluation or initial assessment report to establish necessary and appropriate physical therapy services on a Medicaid-eligible student’s IEP or IFSP;
(B) Obtaining and interpreting medical information for the part of an evaluation or assessment performed by the physical therapist to establish necessary and appropriate physical therapy services on a Medicaid-eligible student’s IEP or IFSP or to determine whether or not necessary and appropriate physical therapy services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA (cannot be delegated);
(C) Care coordination and integrating services within the scope of practice for providing necessary and appropriate physical therapy services relative to the Medicaid-eligible student pursuant to an IEP or IFSP;
(D) Direct treatment and supervision of services provided to a Medicaid-eligible student by the physical therapist and defined in the individual plan; when
(E) Documentation by the supervising physical therapist supporting the appropriate supervision of the assistant is maintained and kept by the School Medical Provider for a period of seven years (see OAR chapter 848, division 40, Minimum Standards for Physical Therapy Practice and Records);
(F) Individual or group physical therapy services provided to a Medicaid-eligible student by or under the supervision and direction of a licensed physical therapist pursuant to the Medicaid-eligible student’s IEP or IFSP; when the documentation describing physical therapy services provided are signed by the therapist providing the service in accordance with their board licensing requirements, and documentation for supervision of services performed by or under the supervision and direction of the supervising physical therapist supporting the services provided is maintained and kept by the school medical provider for seven years (see Minimum Standards for Physical Therapy Practice and Records OARs 848-040-0100 (Definitions) through 848-040-0170 (Standards For Discharge Records));
(G) Other covered physical therapy services within the scope of practice and sections (1) and (2) of this rule.
(7) The Authority may reimburse occupational therapy services provided by:
(a) A licensed Occupational Therapist (OT) authorized to administer occupational therapy to an individual when the individual is a Medicaid-eligible student eligible for special education, as defined by state or federal law, and is being seen pursuant to the Medicaid-eligible student’s individual education plan or individual family service plan; and
(b) A licensed occupational therapy assistant assisting in the practice of occupational therapy under the general supervision of a licensed occupational therapist. General supervision requires the supervisor to have at least monthly direct contact in person with the supervisee at the work site with supervision available as needed by other methods; and
(c) Before an occupational therapy assistant assists in the practice of occupational therapy, he must file with the Board a signed, current statement of supervision of the licensed occupational therapist that will supervise the occupational therapy assistant (see OAR 339-010-0035 (Supervision of an Occupational Therapy Assistant) Statement of Supervision for Occupational Therapy Assistant). Occupational therapy services must be provided by medically qualified staff that meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff);
(d) Reimbursement time may include:
(A) Preparation of the written initial evaluation or initial assessment reports that establish necessary and appropriate occupational therapy services on a Medicaid-eligible student’s IEP or IFSP;
(B) Obtaining and interpreting medical information for the part of the evaluation or assessment performed by the occupational therapist to establish necessary and appropriate occupational therapy services on a Medicaid-eligible student’s IEP or IFSP or to determine whether or not necessary and appropriate occupational therapy services will continue to be specified on the Medicaid eligible student’s IEP or IFSP under IDEA (cannot be delegated);
(C) Development of the initial occupational therapy treatment plan by the OT (cannot be delegated);
(D) Coordinating care and integrating services within the scope of practice relative to the Medicaid-eligible student receiving necessary and appropriate occupational therapy services as specified on the IEP or IFSP;
(E) Individual or group occupational therapy services provided to a Medicaid-eligible student by or under the supervision and direction of a licensed occupational therapist as specified on Medicaid-eligible student’s IEP or IFSP;
(F) Direct treatment and supervision of services provided to a Medicaid-eligible student by the occupational therapist and defined in the individual plan when documentation supporting the appropriate supervision of the assistant is kept and maintained by the school medical provider for a period of seven years;
(G) The occupational therapy services provided are consistent with OAR 339-010-0050 (Occupational Therapy Services for Children and Youth in Education and Early Childhood Programs regulated by federal laws) Occupational Therapy Services for Children and Youth in Education and Early Childhood Programs Regulated by Federal Laws; and
(H) Documentation describing occupational therapy treatment provided must be signed including credentials by the occupational therapist providing the service. Where appropriate, services provided by an occupational therapist assistant shall be reviewed and co-signed by the supervising occupational therapist. All documentation describing treatment provided by an occupational therapy assistant must name the assistant therapist and the supervising therapist including credentials as reflected on the current statement of supervision filed with the Occupational Therapist Licensing Board. Supervision and documentation of supervision by the supervising therapist for therapy provided by the occupational therapy assistant must meet general supervision requirements or closer supervision where professionally appropriate. See OAR 339-010-0005 (Definitions), 339-010-0035 (Supervision of an Occupational Therapy Assistant), and 339-010-0050 (Occupational Therapy Services for Children and Youth in Education and Early Childhood Programs regulated by federal laws). Also, see 410-133-0320 (Documentation and Record keeping Requirements) Documentation and Record Keeping Requirements in these rules;
(I) Other covered occupational therapy services within the scope of practice and sections (1) and (2) of this rule.
(8) The Authority may reimburse speech therapy services provided by:
(a) A licensed speech pathologist licensed by the Oregon Board of Examiners for Speech-Language Pathology and Audiology or holds a license issued by the Teacher Standards and Practice Commission (TSPC) prior to July 1, 2016, exemption in ORS 681.230 (Exemptions from licensure requirement)(4) pursuant to SB287, and holds a Certificate of Clinical Competency (CCC) from the American Speech and Hearing Association (ASHA), or has completed the equivalent educational requirements and work experience necessary for the certificate, or has completed the academic program and is acquiring supervised work experience to qualify for the certificate, or is authorized to administer speech therapy to an individual when the individual is a Medicaid-eligible student eligible for special education, as defined by state or federal law, receiving speech therapy services pursuant to an individual education plan or individual family service plan; or
(b) A graduate speech pathologist in their Clinical Fellowship Year (CFY) practicing under the supervision of al licensed speech pathologist with CCC meeting the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 (Medically Qualified Staff) medically qualified staff; and when:
(A) A standardized system for reviewing the clinical work of the clinical fellow is performed at regularly scheduled intervals, using the Skills Inventory Rating (CFSI) form addressing the fellow’s attainment of skills for independent practice;
(B) The clinical fellow supervisor maintains and documents the supervision of the clinical fellow to be kept by the school medical provider for a period of seven years;
(C) Documentation describing the treatment provided is signed and initialed by the clinical fellow for review and co-signed by the supervising clinical fellow.
(c) Speech-language pathology assistants (SLPA), licensed by the Oregon State Board of Examiners for Speech-Language Pathology and Audiology, under the supervision of a supervising speech-language pathologist and who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 (Medically Qualified Staff) Medically Qualified Staff, when the following conditions are met:
(A) The supervising speech-language pathologist must have at least two years of full-time professional speech-language pathology experience (see OAR 335-095-0040 (Qualifications for Supervising Speech-Language Pathology Assistants) and 335-095-0050 (Requirements for Supervising Licensed Speech-Language Pathology Assistants), Requirements for Supervising Licensed Speech-Language Pathology Assistants);
(B) The supervising speech therapist does not supervise more than the equivalent of two full-time speech-language pathology assistants;
(C) The supervising speech-language pathologist maintains documentation supporting the appropriate supervision of the assistant to be kept by the school medical provider for a period of seven years;
(D) The caseload of the supervising clinician allows for administration, including assistant supervision, evaluation of students and meeting times. All students assigned to an assistant are considered part of the caseload of the supervising clinician;
(E) The supervising speech-language pathologist must be able to be reached at all times. A temporary supervisor may be designated as necessary;
(F) The services provided by the assistants are consistent with the Scope of Duties for the Speech-Language Pathology Assistant (SLPA) pursuant to OAR 335-095-0060 (Scope of Duties for the Speech-Language Pathology Assistant);
(G) Documentation describing the treatment provided is signed and initialed by the SLPA for review and co-signature by the supervising speech-language pathologist to be kept by the school medical provider for a period of seven years from date of payment.
(d) Reimbursement time may include:
(A) Preparation of the written initial evaluation or initial assessment report, including obtaining and interpreting medical information for the part of the evaluation or assessment performed by the speech pathologist to establish necessary and appropriate speech therapy services on a Medicaid-eligible student’s IEP or IFSP or determine whether or not necessary and appropriate speech therapy services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA (cannot be delegated);
(B) Development of the initial speech therapy treatment plan by the speech pathologist (cannot be delegated);
(C) Care coordination and integrating services within the scope of practice relative to the Medicaid-eligible student receiving necessary and appropriate speech therapy services specified on the IEP or IFSP;
(D) Direct individual or group speech therapy services provided to a Medicaid-eligible student for speech services specified on the IEP or IFSP delivered by or under the supervision and direction of a speech pathologist who is medically qualified to deliver the service, see 410-133-0120 (Medically Qualified Staff) Medically Qualified Staff;
(E) Direct training and supervision of services provided to a Medicaid-eligible student by the medically qualified supervising speech pathologist to be kept by the school medical provider for a period of seven years; and
(F) Other covered speech therapy services within the scope of practice and sections (1) and (2) of this rule.
(9) The Authority may reimburse audiology services provided by:
(a) A licensed audiologist within the scope of practice as defined by state or federal law who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 (Medically Qualified Staff), Medically Qualified Staff;
(b) Reimbursement time may include:
(A) Preparation of the written initial evaluation or initial assessment report, including obtaining and interpreting medical information for the part of the evaluation or assessment performed by the audiologist within the scope of practice to establish necessary and appropriate hearing services on a Medicaid-eligible student’s IEP or IFSP or determine whether or not necessary and appropriate hearing impairment services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA;
(B) Periodic hearing evaluations and assessments of a Medicaid-eligible student with hearing loss found eligible under IDEA pursuant to services as specified on the IEP or IFSP for determination of the range, nature, and degree of hearing loss;
(C) Care coordination and integration of services for medical or other professional attention relative to a Medicaid-eligible student receiving services for restoration or rehabilitation due to hearing and communication disorders as specified on the IEP or IFSP;
(D) Provision of rehabilitative activities such as language restoration or rehabilitation, auditory training, hearing evaluation and speech conversation, and determination of the Medicaid-eligible-student’s need for individual amplification in accordance with the student’s IEP or IFSP.
(10) The Authority may reimburse nurse services provided by:
(a) A nurse practitioner (NP), registered nurse (RN), licensed practical nurse (LPN), or delegated health care aid under the supervision of an RN or NP who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 (Medically Qualified Staff) Medically Qualified Staff;
(b) Nursing services under this program are not intended to reimburse nursing activities of a private duty RN or LPN that is otherwise billing Medicaid directly for those services;
(c) Reimbursement time may include:
(A) Preparation of the written initial evaluation or initial assessment report to establish nursing services including obtaining and interpreting medical information for the part of the evaluation or assessment performed to establish necessary and appropriate nursing services on the Medicaid-eligible student’s IEP or IFSP or determine whether or not necessary and appropriate nursing services will continue to be specified on the Medicaid-eligible students IEP or IFSP under IDEA;
(B) Coordinated care for other specified care management for a chronic medical condition that is not addressed on the current IEP or IFSP that will result in amending nursing services specified in the IEP or IFSP and requires an updated nursing plan of care. This may result in an increase in supervision, monitoring, and training of DHC staff to provide new nursing tasks related to the change in condition, i.e., a child with seizure disorder that develops diabetes;
(C) Care coordination and integration of necessary and appropriate nursing services relative to the Medicaid–eligible student’s covered health service specified on the IEP or IFSP;
(D) Nurse to student interactive services that are covered health services provided to a Medicaid-eligible student with a chronic medical condition receiving nursing services pursuant to an IEP or IFSP;
(E) Oversight of delegated health care aides performing delegated nursing services directly with the student as specified on the IEP or IFSP;
(F) Student observation by medically qualified staff for medical reasons of a Medicaid-eligible student with a chronic medical condition as part of an evaluation, assessment, or care coordination. An observation by itself is not a billable activity;
(G) Other covered nursing care services within the scope of practice and sections (1) and (2) of this rule.
(11) The Authority may reimburse mental health services provided by:
(a) A psychiatrist who meets the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(2)(f)(A), or a psychologist who meets the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(2)(f)(B), or a mental health nurse practitioner who meets the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(2)(e)(A); or
(b) A psychologist associate with authority to function without immediate supervision, performing functions that may include but are not restricted to administering tests of mental abilities, conducting personality assessments and counseling (see OAR 858-010-0039 (Application for Independent Status — Psychologist Associate) Application for Independent Status). These services must be provided by medically qualified staff who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(2)(f)(C); or
(c) A psychologist associate under the supervision of a psychologist as specified by the Board of Psychologist Examiners, OAR chapter 858, division 010. These services must be provided by medically qualified staff who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(2)(f)(D); or
(d) A technician under the supervision of a psychologist as specified by the Board of Psychologist Examiners, chapter 858, division 10, OAR 858-010-0002 (Guidelines for Supervising Technicians), Guidelines for Supervising Technicians, and who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(f)(E); or
(e) An LCSW qualified and licensed to deliver the service, or a Clinical Social Work Associate (CSWA) under the supervision of an LCSW specified by the Board of Licensed Social Workers, chapter 877 division 20 and who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (Medically Qualified Staff)(f)(F);
(f) Reimbursable time may include:
(A) Preparation of the written initial evaluation or initial assessment report for a suspected disability per the referral process for determining IDEA eligibility, including obtaining and interpreting medical information for the part of the evaluation or assessment performed by the mental health care practitioner within the scope of practice to establish necessary and appropriate mental health services on the Medicaid-eligible student’s IEP or IFSP or to determine whether or not necessary and appropriate mental health services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA;
(B) Care coordination and integrating services within the scope of practice relative to the Medicaid-eligible student receiving mental health services as specified on the IEP or IFSP;
(C) Direct individual therapy services provided within the scope of practice under state law and covered under sections (1) and (2) of this rule to a Medicaid-eligible student by or under the supervision and direction of a psychologist, a psychiatrist, or mental health nurse practitioner, or a Licensed Clinical Social Worker qualified and licensed to deliver the service pursuant to the Medicaid-eligible student’s IEP or IFSP.
(12) The Authority may reimburse telehealth, tele-electronic/telephonic School-Based Health Services (SBHS) provided to the same extent the services would be covered if they were provided in person and billed to Medicaid using appropriate SBHS procedure codes and modifiers. All SBHS telehealth services billed to Medicaid shall:
(a) Be provided by a licensed practitioner/clinician employed by or contracted by an Oregon public school district or Education Service District, enrolled with Oregon Health Authority (OHA) as a “school medical (SM)” provider with authority to provide SBHS to Oregon Medicaid beneficiaries;
(b) Be performed by or under a supervising licensed practitioner/clinician within the scope of practice governed by their licensing board, who meet the federal requirements as described in medically qualified staff in OAR 410-133-0120 (Medically Qualified Staff), and who hold a current and valid license without restriction from a state licensing board where the provider is located;
(c) Use synchronous audio and visual interactive technologies, including interactive audio/telephonic services provided to a child/student in a geographical area where synchronous audio and video is not available or consent for audio/video is refused for services provided to a child/student;
(d) Include, when applicable, electronic or telephonic communications such as telephone conversation, video conference, or an internet relay chat session for care coordination defined in OAR 410-133-0040 (Definitions)(16);
(e) Assist the licensed practitioner/clinician with care coordination and oversight of a Medicaid eligible child/student’s covered health related services provided in support of a child/student’s education program required by the Individuals with Disabilities Education Act (IDEA);
(f) Be compliant with applicable privacy rules and security protections for the child/student in connection with the telehealth communication and confidentiality related to records required by HIPAA and FERPA;
(g) Ensure the telehealth communication obtained, used and maintained is compliant with privacy and security standards in HIPAA and the Authority’s Privacy and Confidentiality Rules set forth in OAR 943 division 14;
(h) Ensure policies and procedures are in place to prevent a breach in privacy or exposure of protected health information or records (whether oral or recorded in any form or medium) to unauthorized individuals.
(13) Providers billing Medicaid for SBHS health related services via telehealth must:
(a) Align services provided within a licensed practitioner/clinician scope of practice governed by their licensing board;
(b) Obtain the child’s/student’s parent or guardian’s written or verbal consent to receive the services via telehealth technologies, prior to the delivery of health-related services to an eligible child/student with disabilities using a telehealth modality. Verbal consent must be documented/noted in the child’s plan of care by the practitioner. Consent must be obtained and documented annually or with change in services on the child/students plan of care;
(c) Model SOAP charting or equivalent for covered health related services required by the Individuals with Disabilities Education Act (IDEA) in compliance with Documentation and Recordkeeping Requirements OAR 410-133-0320 (Documentation and Record keeping Requirements);
(d) Describe services provided as telehealth synchronous audio/visual interactive equivalent to face to face; or electronic/telephonic interactive communication described as telephone conversation, video conference, or internet relay chat requiring decision making for coordinating care;
(e) Bill Medicaid using the most appropriate Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes and modifiers for SBHS considered as an OHP covered service. A two-digit modifier assigned to telehealth is required for billing SBHS telehealth services using audio and video interactive technologies;
(f) For services covered using synchronous audio and video with modifiers GT, the Division will cover the same services provided by synchronous audio (e.g. telephone), when billed with the same codes but without modifier GT when provision of the same service via synchronous audio and video is not available or feasible, when the patient declines to enable video, or necessary consents cannot reasonably be obtained with appropriate documentation in the child/student’s plan of care;
(g) Maintain clinical documentation and financial records related to telehealth services as required in OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records) and these SBHS Rules.
(14) In the event a National or declared state of emergency, crisis, pandemic or other disaster occurs that results in prolonged school closure, the Authority may adopt flexibilities to remove barriers in support of medically necessary service delivery:
(a) The state recognizes that exceptional circumstances may affect how all educational and related services and supports are provided during a declared state of emergency and will follow guidance from the US Department of Health and Human Services (HHS), Office for Civil Rights (OCR), Office of Special Education Programs (OSEP) in the Department of Education, and Office of Special Education and Rehabilitative Services (OSERS) for flexibility where possible and may allow enforcement discretion related to encryption requirements;
(b) Oregon’s school program must ensure that, to the greatest extent possible, students with a disability are provided the special education and related services identified in a student’s IEP/IFSP required by IDEA, or a plan developed under Section 504 of the Rehabilitation Act of 1973;
(c) Federal disability law guaranteed by the Rehabilitation Act of 1973 and the Individuals with Disabilities Education Act (IDEA) allow for flexibility in the determination of how a Free Appropriate Public Education (FAPE) is to be provided during a public health emergency or any declared state of emergency consistent with the need to protect the health and safety of students with disabilities and those individuals providing special education and related services to students;
(d) During an emergency declaration, the Authority may reimburse any necessary and appropriate physical, mental, behavioral and oral health service delivered using a telehealth platform when the telehealth delivery reasonably approximates in person services to maximize access to services and reduce barriers in the delivery of these services provided to eligible children included in a child’s Individualized Education Program (IEP) or Individualized family Service Plan (IFSP) required by the Individuals with Disabilities Education Act (IDEA), a Section 504 plan pursuant to Section 504 of the Rehabilitation Act, or other school services plan. Other types of telecommunications are not covered, without necessary and appropriate decision making for an eligible child’s /student’s plan of care.
(15) Medicaid reimbursed transportation:
(a) Transportation to a covered health service as documented in the child’s IEP/IFSP and defined in these rules (see 410-133-0245 (Cost Determination and Payment), Cost Determination and Payment);
(b) Ongoing transportation specified as a related service on the Medicaid-eligible student’s IEP or IFSP may be claimed as a Medicaid service on the days a Medicaid-eligible student receives a covered health service that is also specified on the IEP or IFSP and the transportation is supported by a transportation vehicle trip log;
(c) The Authority may only reimburse for transportation as a related service to and from a Medicaid-covered service for a Medicaid-eligible student when the transportation is supported by a transportation vehicle trip log; and the student receives a Medicaid-covered health service other than transportation on that day when either of the following situations exist:
(A) The Medicaid-eligible student requires specialized transportation adapted to serve the needs of the disabled student; there is documentation to support specialized transportation is “necessary and appropriate;” and transportation is listed as a related service on the student’s IEP or IFSP; or
(B) The Medicaid-eligible student has a medical need for transportation that is documented in the IEP or IFSP and resides in an area that does not have regular school bus transportation such as those areas in close proximity to a school.
(d) If a Medicaid-eligible student is able to ride on a regular school bus, but requires the assistance of a delegated health care aide trained by an RN to provide a delegated nursing task specific to the student and cannot be transported safely without the delegated health care aide, the service provided by the delegated healthcare aide is reimbursed under the delegated healthcare code. See the Standards for Community-Based Care Registered Nurse Delegation of a nursing care task as outlined in the Nurse Practice Act, OAR chapter 851 division 47;
(e) If a Medicaid-eligible student requires the assistance of a delegated health care aide and transportation adapted to serve the needs of the disabled student, both the necessary and appropriate transportation and the service provided by the delegated healthcare aide may be reimbursed when both are specified on the Medicaid-eligible student’s current IEP or IFSP;
(f) If an education agency provides special transportation to a Medicaid-eligible student to a covered service outside the district or the Medicaid-eligible student’s resident school and the student cannot be transported safely without a transportation aide as specified on the IEP or IFSP, the transportation is billable. However, a transportation aide who is not a delegated healthcare aide trained by an RN cannot be billed as a separate cost because the cost of the transportation aide is included in the cost of the transportation;
(g) Transportation is not reimbursable by the Division when provided by the parent or relative of the child;
(h) Transportation to an “evaluation” service is covered if:
(A) Medically necessary transportation is listed and included in the Medicaid-eligible student’s current IEP or IFSP and the evaluation is to establish, re-establish, or terminate a SBHS covered service under IDEA;
(B) The evaluation is a SBHS covered health service;
(C) The medical provider conducting the evaluation, if not employed or contracted by the school medical provider, is an enrolled provider with the Division and meets applicable medical licensing standards necessary to conduct the evaluation.
(16) Medicaid may reimburse for contracted consultation health services for furnishing consultations regarding a Medicaid-eligible student’s covered health service specified on the IEP or IFSP for an evaluation or assessment to establish, re-establish, or terminate a covered SBHS on an IEP or IFSP. Contracted consultation services must be provided by a licensed medical professional other than school medical provider staff:
(a) This service may be on a contracted basis for a number of students;
(b) Allowable services must be furnished through a personal service contract between the school medical provider and the licensed health care practitioner;
(c) This service would only be an SBHS covered health service by the school medical provider when the licensed health care practitioner did not bill Medicaid directly under other programs for the same services.
(17) Reimbursed coordinated care performed by medically qualified staff as described in OAR 410-133-0120 (Medically Qualified Staff) directly related to health services required by a Medicaid-eligible student’s physical or mental condition as described in the IEP or IFSP must be one of the following:
(a) Managing integration of those Medicaid covered health services for treatment provided in the education setting;
(b) The portion of a conference between interested parties and medically-qualified staff for developing, reviewing, or revising a Medicaid-covered health service or therapy treatment plan for services provided pursuant to a Medicaid-eligible student’s IEP or IFSP or to establish, re-establish, or terminate a covered health service under IDEA for eligibility purposes;
(c) Consultation from medically qualified staff providing technical assistance to or conferring with special education providers, physicians, or families to assist them in providing covered health services to Medicaid-eligible students for treatment provided in the educational setting related to specific health services and the goals and objectives in the student’s IEP or IFSP. Consultation services must be completed by a licensed health care practitioner within the scope of practice under their licensure.

Source: Rule 410-133-0080 — Coverage, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-133-0080.

Last Updated

Jun. 8, 2021

Rule 410-133-0080’s source at or​.us