OAR 410-133-0200
Not Covered Services
(1)
Education-based costs normally incurred to operate a school and provide an education are not covered for payment by the Authority.(2)
Health services and treatment not documented on the Medicaid-eligible student’s IEP or IFSP is not covered for payment by the Authority under the School-Based Health Services (SBHS) rules.(3)
Reviewing records (exception: reviewing records as part of an evaluation to establish, re-establish, or terminate a SBHS covered health service on a Medicaid-eligible student’s IEP or IFSP).(4)
Meeting preparation.(5)
Health services preparation including materials preparation.(6)
Report writing (exception: report writing as part of preparation of initial evaluation and initial treatment plan to establish a covered health service on a Medicaid-eligible student’s IEP or IFSP).(7)
Correspondence.(8)
Treatment and care coordination for an acute medical condition.(9)
Medication management not specific to mental health related services listed in the IEP/IFSP.(10)
Purchase of an assistive technology device is not covered through SBHS.(11)
Activities related to researching student names, determining Medical Assistance Program eligibility status, administrative activities such as data entry of billing claim forms, and travel time by service providers.(12)
Family therapy where the focus of treatment is the family.(13)
Routine health nursing services provided to all students by school nurses and nursing intervention for acute medical issues in the school setting, e.g., students who become ill or are injured.(14)
Educational workshops, training classes, and parent training workshops.(15)
Regular transportation services to and from school.(16)
Vocational services.(17)
Screening services.(18)
Evaluation services that are not performed by medically qualified staff within the scope of practice to establish, re-establish, or terminate a covered SBHS under IDEA.(19)
Service provided to non-Medicaid students in a group, class, or school free of charge. If only Medicaid-eligible students are charged for the service, the care is free, and Medicaid will not reimburse for the service. The free care limitation does not apply to health services provided as a result of an educational agency’s obligation to provide FAPE services, and the health service is identified on the Medicaid-eligible student’s IEP/IFSP. This means that school medical providers may bill for covered health services provided to Medicaid-eligible students under IDEA even though they may be provided to non-Medicaid-eligible students for free as a part of FAPE.(20)
Any non-medical unit of time spent on evaluations.(21)
Recreational services.(22)
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) comprehensive examinations described in OAR 410-130-0245 (Early and Periodic Screening, Diagnostic and Treatment Program) are not authorized to be provided by school medical providers.(23)
Services provided by an entity that employs an excluded provider. It is the obligation of the education agency to utilize the excluded provider web site to check for providers who have been excluded from receiving any monies affiliated with Medicaid and Medicare service reimbursements.(24)
Covered health services listed on an IEP or IFSP for those dates of service when the IEP/IFSP has lapsed.(25)
Covered health services that do not have a current recommendation by medically qualified staff within the scope of practice for the treatment provided as specified on the IEP or IFSP.(26)
Orientation and Mobility Training. Services provided to blind or visually impaired students by qualified personnel to enable those students to attain systematic orientation to and safe movement within their environments in school, home, and community.(27)
Using a rubber stamp to authenticate any entry for documentation of therapy provided to a student and billed to Medicaid for reimbursement for SBHS.(28)
Services provided by staff in an education setting licensed solely by the Teacher Standards and Practices Commission (TSPC). It is not sufficient for a state to use Department of Education provider qualifications for reimbursement of Medicaid-covered health services provided in an education setting.(29)
Services provided by speech-language pathology assistants in schools under the supervision of a speech-language pathologist who do not meet the requirements for a speech pathologist described in 410-133-0120 (Medically Qualified Staff) Medically Qualified Staff but instead holds either a basic, initial, standard, or continuing license in speech impaired issued by the Teacher Standards and Practices Commission and has obtained a permit from the Oregon Board of Examiners for Speech-Language Pathology and Audiology to supervise SLPA’s in education settings under OAR 335-095-0055.
Source:
Rule 410-133-0200 — Not Covered Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-133-0200.