WSR 09-07-004

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed March 4, 2009, 4:00 p.m. , effective April 4, 2009 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: In response to an audit conducted by the Centers for Medicare and Medicaid Services, the amendment and new sections bring this chapter into compliance with federal medicaid regulations, and delineates essential requirements for the delivery of school-based healthcare services. The department is changing the name of this chapter to school-based healthcare services for children in special education, amending WAC 388-537-0100 and adding new sections to chapter 388-537 WAC. The new sections solidify requirements for (1) provider qualifications; (2) healthcare services covered under this program; (3) the appropriate documentation for program audits and monitoring, and (4) requirements for billing and payment. The changes make it easier for the school districts to comply with program rule, thus providing qualified service to the children in special education.

Citation of Existing Rules Affected by this Order: Amending WAC 388-537-0100.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.

Other Authority: RCW 74.09.500, 42 C.F.R. 440.110.

Adopted under notice filed as WSR 08-19-100 (supplemental notice to WSR 08-15-129) on September 17, 2008.

Changes Other than Editing from Proposed to Adopted Version: The following text changes have no material impact on the rule:

WAC 388-537-0200 School-based healthcare services for children in special education - Definitions, added the following text to the definition of "Child with a disability": Visual impairment (including blindness);

WAC 388-537-0500 School-based healthcare services for children in special education - Noncovered services, added the following text:

(17) RN/LPN continuously monitoring a child during the school day.

A final cost-benefit analysis is available by contacting Jonell O. Blatt, Rules, P.O. Box 45504, Olympia, WA 98504-5504, phone (360) 725-1571, fax (360) 586-9727, e-mail blattj@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 8, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 8, Amended 1, Repealed 0.

Date Adopted: March 4, 2009.

Stan Marshburn

Interim Secretary

4004.5
AMENDATORY SECTION(Amending WSR 01-02-076, filed 12/29/00, effective 1/29/01)

WAC 388-537-0100   ((School medical services for students in special education programs)) School-based healthcare services for children in special education - Purpose.   (1) ((The medical assistance administration (MAA) pays school districts or educational service districts (ESD) for qualifying medical services provided to an eligible student. To be covered under this section, the student must be eligible for Title XIX (i.e., either the categorically needy or medically needy programs).

(2) To qualify for payment under this section, the medical services must be provided:

(a) By the school district or the ESD; and

(b) To the eligible special education student as part of the student's individualized education program (IEP) or individualized family service plan (IFSP).

(3) To qualify for payment under this section, the medical services must be provided by one of the following service providers:

(a) A qualified Medicaid provider as described under WAC 388-502-0010;

(b) A psychologist, licensed by the state of Washington or granted an educational staff associate (ESA) certificate by the state board of education;

(c) A school guidance counselor, or a school social worker, who has been granted an ESA certificate by the state board of education; or

(d) A person trained and supervised by any of the following:

(i) A licensed registered nurse;

(ii) A licensed physical therapist or physiatrist;

(iii) A licensed occupational therapist; or

(iv) A speech pathologist or audiologist who:

(A) Has been granted a certificate of clinical competence by the American speech, hearing, and language association;

(B) Is a person who completed the equivalent educational and work experience necessary for such a certificate; or

(C) Is a person who has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(4) Student service recommendations and referrals must be updated at least annually.

(5) The student does not need a provider prescription to receive services described under this section.

(6) MAA pays for school-based medical services according to the department-established rate or the billed amount, whichever is lower.

(7) MAA does not pay individual school practitioners who provide school-based medical services.

(8) For medical services billed to Medicaid, school districts or ESD, must pursue third-party resources)) The department of social and health services (DSHS) pays school districts for school-based healthcare services provided to children in special education in accordance with the individuals with disabilities education act (IDEA). The services must:

(a) Address the physical and/or mental disabilities of a child;

(b) Be prescribed or recommended by a physician or other qualified healthcare provider within his or her scope of practice under state law; and

(c) Be included in the child's individualized education program (IEP).

[Statutory Authority: RCW 74.08.090. 01-02-076, 388-537-0100, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, 388-537-0100, filed 12/14/99, effective 1/14/00.]


NEW SECTION
WAC 388-537-0200   School-based healthcare services for children in special education - Definitions.   The following definitions and those found in WAC 388-500-0005 apply to this chapter:

"Assessment" - For purposes of this chapter an assessment is made-up of tests given to an individual child by qualified professionals 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.

"Child with a disability" - For purposes of this chapter, a child with a disability means 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:

Mental retardation;

Hearing impairment (including deafness);

Speech or language impairment;

Serious emotional disturbance (emotional behavioral disability);

Orthopedic impairment;

Autism;

Visual impairment (including blindness);

Traumatic brain injury;

Other health impairment;

Specific learning disability;

Deaf/blindness;

Multiple disabilities; or

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

"Direct healthcare services" - Services provided directly to a child either one-on-one or in a group setting.

"Educational staff associate (ESA) certification" - The ESA certificate is an official document that attests to minimum prerequisites of age, moral character/fitness, education, experience, competence, and preparation program, depending on the certificate types. The ESA certification is required to serve in a Washington public school.

"Evaluation" - Procedures used according to WAC 392-172A-03005 through 392-172A-03080 to determine whether a student has a disability, and the nature and extent of the special education and related services needed.

"Fee-for-service" - For the purpose of this section, the general payment method the department uses to reimburse providers for covered medical services provided to medical assistance clients when those services are not covered under the department's managed care plans or state children's health insurance program (SCHIP).

"Individuals with disabilities education act (IDEA)" - The IDEA is a United States federal law that governs how states and public agencies provide early intervention, special education, and related services to children with disabilities. It addresses the educational needs of children with disabilities from birth to age of twenty-one.

"Individualized education program (IEP)" - A written statement of an educational program for a student eligible for special education. (See WAC 392-172A-03090 through 392-172A-03135.)

"Qualified healthcare provider" - See WAC 388-537-0350.

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

"Related services" - Developmental, corrective, and other supportive services as may be required to assist a child with a disability to benefit from specially designed instruction. For purposes of this program, related services include: physical therapy, occupational therapy, speech-language therapy, audiology services, psychological assessments, counseling, and nursing services.

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NEW SECTION
WAC 388-537-0300   School-based healthcare services for children in special education - Client eligibility.   Children in special education must be receiving Title XIX Medicaid under a categorically needy program (CNP) or medically needy program (MNP) to be eligible for school-based healthcare services. Eligible children enrolled in a managed care organization (MCO) receive school-based healthcare services on a fee-for-service basis.

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NEW SECTION
WAC 388-537-0350   School-based healthcare services for children in special education - Provider qualifications.   The department pays school districts to provide certain healthcare services (see WAC 388-537-0400) to eligible children (see WAC 388-567-0300). These services must be provided by qualified healthcare providers who meet Washington state and federal requirements and operate within the scope of their practitioner's license:

(1) Audiology services delivered by:

(a) A licensed audiologist; or

(b) A school-based audiologist who:

(i) Meets the education and work experience necessary for a state professional license;

(ii) Holds a valid school audiologist educational staff associate certificate; and

(iii) Limits their audiology services to the school setting.

(2) Counseling services delivered by:

(a) A licensed independent social worker;

(b) A licensed advanced social worker;

(c) A licensed mental health counselor; or

(d) A school-based social worker or mental health counselor who:

(i) Meets the education and work experience necessary for a state professional license;

(ii) Holds a valid school social worker or school counselor educational staff associate certificate; and

(iii) Limits their counseling services to the school setting.

(3) Nursing services delivered by:

(a) A licensed registered nurse;

(b) A licensed practical nurse; or

(c) A noncredentialed school employee who is delegated certain limited healthcare tasks by a registered nurse and, trained and supervised according to professional practice standards.

(4) Occupational therapy services delivered by:

(a) A licensed occupational therapist; or

(b) A certified occupational therapy assistant supervised by a licensed occupational therapist in accordance with professional practice standards.

(5) Physical therapy services delivered by:

(a) A licensed physical therapist; or

(b) A licensed physical therapist assistant supervised by a licensed physical therapist in accordance with professional practice standards.

(6) Psychological services delivered by:

(a) A licensed psychologist; or

(b) A school-based psychologist who:

(i) Holds a masters degree in school psychology;

(ii) Holds a valid school psychologist educational staff associate certificate; and

(iii) Limits their psychological services to the school setting.

(c) A school-based psychologist who:

(i) Holds a doctoral degree in psychology;

(ii) Holds a valid school psychologist educational staff associate certificate; and

(iii) Limits their psychological services to the school setting.

(7) Speech therapy services delivered by:

(a) A licensed speech-language pathologist;

(b) A speech-language pathology assistant, who has graduated from a speech-language pathology assistant program, and is supervised by a speech-language pathologist with a certificate of clinical competence (CCC) in accordance with professional practice standards; or

(c) A school-based speech-language pathologist who:

(i) Meets the education and work experience necessary for a state professional license;

(ii) Holds a valid school speech-language pathologist educational staff associate certificate; and

(iii) Limits their speech therapy services to the school setting.

(8) For services provided under the supervision of a physical therapist, occupational therapist or speech-language pathologist the following requirements apply:

(a) The nature, frequency and length of the supervision must be provided in accordance with professional practice standards and adequate to assure the child receives quality therapy services.

(b) At a minimum, supervision must be one-on-one communication between the supervisor and the supervised professional.

(c) Documentation of supervisory activities must be on record and available to the department upon request.

(9) It is the responsibility of the school district to assure providers meet the professional requirements necessary for reimbursement.

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NEW SECTION
WAC 388-537-0400   School-based healthcare services for children in special education - Covered services.   Covered services include:

(1) Evaluations, when the child is determined to be a child with a disability and in need of special education and related services;

(2) Direct healthcare services including:

(a) Audiology;

(b) Counseling;

(c) Nursing;

(d) Occupational therapy;

(e) Physical therapy;

(f) Psychological assessments;

(g) Speech-language therapy.

(3) Re-evaluations, to determine whether the child continues to need special education and related services.

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NEW SECTION
WAC 388-537-0500   School-based healthcare services for children in special education - Noncovered services.   Noncovered services include, but are not limited to the following:

(1) Attending meetings;

(2) Charting;

(3) Equipment preparation;

(4) Instructional assistant contact;

(5) Parent consultation;

(6) Parent contact;

(7) Planning;

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

(9) Professional consultation;

(10) Report writing;

(11) Review of records;

(12) Set-up;

(13) Teacher contact;

(14) Test interpretation;

(15) Travel;

(16) Observation; and

(17) For the purposes of this chapter, the department does not reimburse school districts for a RN or LPN to monitor a child continuously throughout the school day.

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NEW SECTION
WAC 388-537-0600   School-based healthcare services for children in special education - School district requirements for billing and payment.   To receive payment from the department for school-based healthcare services, a school district must:

(1) Have a current, signed core provider agreement with the department;

(2) Meet the applicable requirements in chapter 388-502 WAC; and

(3) Bill according to the department's published school-based healthcare services billing instructions.

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NEW SECTION
WAC 388-537-0700   School-based healthcare services for children in special education - School district documentation requirements.   (1) The school districts must maintain sufficient documentation to support and justify the paid claims, to include, at a minimum:

(a) Professional assessment reports;

(b) Evaluation and re-evaluation reports;

(c) Individualized education program (IEP); and

(d) Treatment notes for each date of service the provider billed to the department.

(2) All provider licenses and other credentials must be current and on file with the school district and available for review upon request.

(3) All records must be easily and readily available to the department upon request.

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NEW SECTION
WAC 388-537-0800   School-based healthcare services for children in special education - Program monitoring/audits.   (1) School districts must participate in the monitoring process.

(2) The department monitors school-based healthcare services as established by the school-based healthcare services program manager and in compliance with the department's monitoring policy and plan.

(3) The department conducts audits of school-based healthcare services in accordance with chapter 388-502A WAC.

(4) The department authority to conduct audits and recover overpayments is found in RCW 74.09.200, 74.09.220 and 74.09.290.

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Washington State Code Reviser's Office