HEALTH CARE AUTHORITY

(Washington Apple Health)

The medicaid agency pays school districts for school-based health care services provided to medicaid-eligible children ((in)) who require special education services consistent with Sections ((1905(c))) 1903(c) and 1905(a) of the Social Security Act. Covered services must:

(1) Identify, treat, and manage the education-related disabilities (i.e., mental, emotional, and physical) of a child ((in)) who requires special education services;

(2) Be prescribed or recommended by licensed physicians or other licensed health care providers within their scope of practice under state law;

(3) Be medically necessary;

(4) Be diagnostic, evaluative, habilitative, or rehabilitative in nature; ((and))

(5) Be included in the child's current individualized education program (IEP) or individualized family service plan (IFSP); and

(6) Be provided in a school setting.

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Agency" - See WAC 182-500-0010.

"Assessment" - For purposes of this chapter an assessment is made-up of medically necessary tests given to an individual child by a licensed professional to evaluate whether a child is determined to be a child with a disability, and in need of special education and related services. Assessments are a part of the evaluation and re-evaluation processes and must accompany the individualized education program (IEP) or individualized family service plan (IFSP).

"Child with a disability" - For purposes of this chapter, a child with a disability is a child evaluated and determined to need special education and related services because of a disability in one or more of the following eligibility categories:

• Autism;

• ((Deaf/blindness)) Deaf-blindness;

• Developmental delay for children ages three through nine, with an adverse educational impact, the results of which require special education and related direct services;

• Hearing loss (including deafness);

• Intellectual disability;

• Multiple disabilities;

• Orthopedic impairment;

• Other health impairment;

• Serious emotional disturbance (emotional behavioral disturbance);

• Specific learning disability;

• Speech or language impairment;

• Traumatic brain injury; and

• Visual impairment (including blindness).

"Direct health care related services" - Services provided directly to a child either one-on-one or in a group setting. This does not include special education.)) "Early intervention services" - Services designed to meet the developmental needs of an infant or toddler with a disability and the needs of the family to assist appropriately in the infant's or toddler's development, as identified in the infant or toddler's individualized family service plan (IFSP), in any one or more of the following areas, including:

"Evaluation" - Procedures used to determine whether a child has a disability, and the nature and extent of the special education and related services ((are)) needed. (See WAC ((392-172A-03005 through 392-172A-03080)) 392-172A-01070.)

(("Face-to-face supervision" or "direct supervision" - Supervision that is conducted on-site, in-view, by an experienced licensed health care professional to assist the supervisee to develop the knowledge and skills to practice effectively, including administering the treatment plan.)) "Evaluation report" - See WAC 392-172A-03035.

"Fee-for-service" - See WAC 182-500-0035.

"Health care-related services" - Developmental, corrective, and other supportive services required to assist an eligible child to benefit from special education. For the purposes of the school-based health care services program, related services include:

• Audiology;

• Counseling;

• Nursing;

• Occupational therapy;

• Physical therapy;

• Psychological assessments; and

• Speech-language therapy.

"Individualized education program (IEP)" - A written ((statement of an)) educational program for a child who is age three through twenty and eligible for special education. (((See)) An IEP is developed, reviewed and revised under WAC 392-172A-03090 through 392-172A-03135.(()))

"Medically necessary" - See WAC 182-500-0070.

"National provider identifier (NPI)" - See WAC 182-500-0075.

"Qualified health care provider" - See WAC 182-537-0350.

"Reevaluation" - Procedures used to determine whether a child continues to be in need of special education and related services. (See WAC 392-172A-03015.)

"School-based health care services program" or "((SBS)) SBHS" - School-based health care services for infants and toddlers receiving early intervention services and children ((in)) who require special education ((that)) services, which are diagnostic, evaluative, habilitative, and rehabilitative in nature; are based on the child's medical needs; and are included in the child's ((individualized education plan ())IEP(())) or IFSP. The agency pays school districts for school-based health care services delivered to medicaid-eligible children ((in)) who require special education services under Section 1903(c) of the Social Security Act, and to ((individuals)) people under the Individuals with Disabilities Education Act (IDEA) Part B and Part C.

(("School-based health care services program specialist" or "SBHS specialist" - An individual identified in the interagency agreement school district reimbursement contract.)) "Signature log" - A typed list that verifies a licensed provider's identity by associating each provider's signature with their name, handwritten initials, credentials, license and national provider identification (NPI) numbers.

"Special education" - Specially designed instruction, at no cost to the parents, to meet the unique needs of a student eligible for special education, including instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings, and instruction in physical education. Refer to WAC 392-172A-01175.

(("Washington Administrative Code (WAC)" - Codified rules of the state of Washington.)) "Supervision" - Supervision that is provided by a licensed health care provider either directly or indirectly in order to assist the supervisee in the administration of health care-related services outlined in the IEP or IFSP.

Children ((in)) who require special education services must be receiving Title XIX Medicaid under a Washington apple health (WAH) categorically needy program (CNP) or WAH medically needy program (MNP) to be eligible for school-based health care services. Eligible children enrolled in a managed care organization (MCO) receive school-based health care services on a fee-for-service basis.

((The medicaid agency pays school districts to provide certain health care-related services (see WAC 182-537-0400). These)) (1) School-based health care services (SBHS) must be delivered by qualified health care providers who are enrolled with the medicaid agency and ((hold a current professional license:

(8))) who meet state licensure and certification requirements. The following people may provide SBHS:

(2) For services provided under the supervision of a ((physical therapist, occupational therapist or speech-language pathologist, nurse, or counselor/social worker, the following requirements apply:

(a) The nature, frequency, and length of the supervision must be provided in accordance with professional practice standards, and be sufficient to ensure a)) PT, OT, SLP, nurse, counselor, or social worker, the supervising provider must:

(a) Ensure the child receives quality therapy services by providing supervision in accordance with professional practice standards;

(b) ((The supervising therapist must)) See the child face-to-face ((at the beginning of)) when services begin and at least once more during the school year;

(c) ((At a minimum, supervision must be face-to-face communication between the supervisor and the supervisee once per month. Supervisors are responsible for approving and cosigning)) Approve and cosign all treatment notes written by the supervisee before submitting claims for payment; and

(d) ((Documentation of)) Record supervisory activities ((must be recorded)) and ((available)) provide the documents to the agency or its designee upon request.

(((9))) (3) The school district must ((assure)) ensure providers meet the professional licensing and certification requirements.

(((10))) (4) The licensing exemptions found in the following regulations do not apply to federal medicaid reimbursement ((for the services indicated below)):

(a) Counseling ((as found in)) under RCW 18.225.030;

(b) Psychology ((as found in)) under RCW 18.83.200;

(c) Social work ((as found in)) under RCW 18.320.010; and

(d) Speech therapy ((as found in)) under RCW 18.35.195.

All services covered under this section may be provided through telemedicine as described in WAC 182-531-1730. Covered services include:

(1) Evaluations when the child is determined to have a disability, and is in need of special education and health care-related services that result in an IEP or IFSP;

(2) ((Direct health care)) Health care-related services including:

(a) Audiology;

(b) Counseling;

(c) Nursing;

(d) Occupational therapy;

(e) Physical therapy;

(f) Psychological assessments; and

(g) Speech-language therapy.

(3) Reevaluations, to determine whether a child continues to need special education and health care-related services.

Noncovered services include, but are not limited to the following:

(1) Applied behavior analysis (ABA);

(2) Attending meetings;

(3) Charting;

(4) Equipment preparation;

(5) Evaluations that do not result in an IEP or IFSP;

(6) Instructional assistant contact;

(((6))) (7) Observation;

(8) Parent consultation;

(((7))) (9) Parent contact;

(((8))) (10) Planning;

(((9))) (11) Preparing and sending correspondence to parents or other professionals;

(((10))) (12) Professional consultation;

(((11))) (13) Report writing;

(((12))) (14) Review of records;

(((13))) (15) School district staff accompanying a child ((in)) who requires special education services to and from school on the bus;

(15))) (16) Teacher contact;

(17) Test interpretation; and

(18) Travel and transporting((; and

(19) Continuous observation of a child when direct school-based health care services are not actively provided. The agency pays for the act of watching carefully and attentively only if it involves actual interventions)).

To receive payment from the medicaid agency for providing school-based health care services (SBHS) to eligible children, a school district must:

(1) Have a current, signed core provider agreement (CPA) with the agency. ((A copy of the CPA must be on-site within the school district.))

(2) Have a current, signed, and executed interagency agreement with the agency. ((A copy of the agreement must be on-site within the school district for review as requested.))

(3) Meet the applicable requirements in chapter 182-502 WAC.

(4) Comply with the agency's current, published ProviderOne billing and resource guide.

(5) Bill according to the agency's current((, published)) school-based health care services ((for children in special education medicaid)) provider guide, the school-based health care services fee schedule, and the intergovernmental transfer (IGT) process. After a school district((s)) receives ((their)) its invoice from the agency, ((they)) the district must provide ((their)) its local match to the agency within one hundred twenty days.

(6) ((Meet the applicable requirements in chapter 182-537 WAC.

(7))) Provide only health care-related services identified through a current ((individualized education program ())IEP(())) or IFSP.

(((8))) (7) Use only ((licensed)) health care professionals((, as described in)) qualified under WAC 182-537-0350 ((and the school-based care services for children in special education medicaid provider guide)).

(9) Meet documentation requirements in WAC 182-537-0700.

(1) Providers must document ((in writing)) all school-based health care ((related)) services ((in the manner set out)) (SBHS) as required in this section, WAC 182-502-0020, and the medicaid agency's ((program-specific)) school-based health care services provider guide.

(2) All required documentation must include the provider's printed name, handwritten or electronic signature, and title. Assistants practicing under WAC 182-537-0350 must have a licensed supervisor cosign all documents as required by this subsection.

(3) The following documentation must be maintained for each client for a minimum of six years:

(a) Professional assessment reports;

(b) Evaluation and reevaluation reports;

(c) ((Individualized education program ())IEP(())) or IFSP; and

(d) Treatment notes ((for each date of service that give a clear, comprehensive picture of the care being provided, the response to each intervention, and that include the:

(a) Child's name;

(((ii))) (b) Child's ProviderOne client ID;

(((iii))) (c) Child's date of birth;

(v))) (d) Date of service((;

(i) Time-in;

(((vii))) (ii) Time-out;

(((viii))) (iii) A procedure code for and description of each service provided;

(v) Number of units billed for the service; and

(((ix))) (vi) Whether the treatment described in the note was individual or group therapy.

(b) Assistants practicing under WAC 182-537-0350 must have a supervisor cosign all documents in the manner required by subsection (3) of this section.)) (5) The agency accepts electronic records and signatures. Maintaining the records in an electronic format is acceptable only if the original records are available to the agency for program integrity activities for up to six years after the date of service. Each school district is responsible for determining what standards are consistent with state and federal electronic record and signature requirements.

(1) To ensure compliance with program rules, the medicaid agency conducts program integrity activities under chapter 182-502A WAC.

(2) School districts must participate in all ((monitoring and auditing)) program integrity activities.

(((2))) (3) School districts are responsible for the accuracy, compliance, ((truthfulness,)) and completeness of all claims submitted for medicaid reimbursement.