Or. Admin. Code § 410-133-0080

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-133-0080 - Coverage

(1) A School-Based Health Service (SBHS) is covered when it meets the following criteria:

(a) The health service must be a medically necessary and medically appropriate non-residential health service;

(b) The health service is recommended by a health care practitioner and is documented in the child or young adult's Individual Plan of Care (IPOC);

(c) The health service is provided or supervised by an Authority-enrolled medically-qualified individual providing and documenting the service within their respective scope of practice and in compliance with their respective board rules and requirements and OAR 410-120-1360;

(d) The health service is billed to the Authority by an enrolled school district or education service district in accordance with SBHS rules; and

(e) The health service is not excluded under OAR 410-133-0200.

(2) Evaluation and assessment:

(a) An evaluation and assessment or re-evaluation is covered for the part of the evaluation, re-evaluation, or assessment regarding a child or young adult's medically necessary and medically appropriate school-based health service needs for the purpose of establishing, re-establishing, or terminating a school-based health service on the child or young adult's IPOC or to develop, review, or revise components of a covered school-based health service currently provided to a child or young adult for continuation of those covered services; and

(b) Reimbursement time may include:

(A) The time that is for the part of the supervisory-level medically-qualified individual's evaluation, re-evaluation, or assessment of a child or young adult's necessary and appropriate school-based health service needs (cannot be delegated).

(B) The time for the supervisory-level medically-qualified individual to prepare the written evaluation or assessment report, including obtaining and interpreting medical information to establish necessary and appropriate referrals and care coordination or to determine whether the necessary and appropriate services shall continue to be specified on the child or young adult's IPOC (cannot be delegated).

(3) Care coordination, consultation, and referrals:

(a) Care coordination, consultation, and referrals are covered when provided as directly related to the SBHS specified on the child or young adult's IPOC; and

(b) Reimbursement time may include:

(A) Care coordination, consultation, or referral performed by a licensed health care practitioner within their scope of practice to manage integration of services relative to the child or young adult as specified on the child or young adult's IPOC:

(i) With the child or young adult's physician, community practitioner(s), community organization(s), parent/guardian, the Authority, or the child or young adult's coordinated care organization (CCO) for community health treatment and integration of services provided through the child or young adult's Medicaid coverage;

(ii) To provide technical assistance to or confer with education agency staff, medically-qualified individuals, healthcare practitioners, or families to assist them in providing covered health services related to specific health services and the goals and objectives in the child or young adult's IPOC.

(iii) To provide training for non-supervisory level medically-qualified individuals performing health care activities.

(B) The portion of a conference between interested parties and a medically-qualified individual for developing, reviewing, or revising a Medicaid-covered health service or therapy treatment plan for services provided pursuant to a child or young adult's IPOC or to establish, re-establish, or terminate a covered health service.

(4) Assistive technology services:

(a) Assistive technology services are covered when directly assisting in the selection, acquisition, or use of an assistive technology device as specified on the child or young adult's IPOC; and

(b) Reimbursement time may include the following when performed by a medically-qualified individual within their respective scope of practice:

(A) An assistive technology assessment with one-to-one child or young adult contact time;

(B) Preparing the required written report of the need, suitability, and benefits of the use of an assistive technology device or adaptive equipment that shall help restore, augment, or compensate for existing functional ability or that shall optimize functional tasks for the child or young adult's environmental accessibility;

(C) Care coordination and consultation with the child or young adult's healthcare practitioner, parent/guardian, and the Authority for the acquisition of a personal assistive technology device for the child or young adult through the child or young adult's Medicaid plan; and

(D) Training or technical assistance provided to, or demonstrated with, the child or young adult which may include instructing on the use of an assistive technology device or adaptive equipment in the educational setting with professionals (including individuals providing education and rehabilitation services) or the child or young adult's family members, guardians, advocates, or authorized representative.

(5) Direct services must be provided and documented by medically-qualified individuals within their scope of practice and in compliance with their respective Oregon board rules and OAR 410-120-1360; and Direct services are covered when the service is supported by:

(a) A current written recommendation, completed within twelve (12) months of the date-of-service, from a health care practitioner;

(b) The direct service is medically necessary and medically appropriate; and

(c) The child or young adult's IPOC includes the health service category, the nature, extent, or units of service and therapeutic value for each service.

(6) Specialized transportation:

(a) Specialized transportation services are covered when:

(A) The child or young adult requires specialized transportation provided in a specially adapted vehicle that has been physically adjusted or designed to meet the needs of the child or young adult to serve their individual health-related needs, specialized transportation is specified as a related service in the child or young adult's Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), and there is documentation to support specialized transportation is necessary and appropriate; and

(B) A separate school-based health service, other than transportation, is specified on the child or young adult's IEP or IFSP and provided and reimbursed on that day.

(b) Specialized transportation must be supported by a transportation vehicle trip log.

Or. Admin. Code § 410-133-0080

HR 39-1991, f. & cert. ef. 9-16-91; HR 21-1995, f. & cert. ef. 12-1-95; OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 31-2003, f. & cert ef. 4-1-03; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 33-2016, f. 6-29-16, cert. ef. 7/1/2016; DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020; DMAP 56-2020, amend filed 10/02/2020, effective 10/5/2020; DMAP 121-2024, amend filed 09/06/2024, effective 9/6/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: 414.065