471 Neb. Admin. Code, ch. 23, § 004

Current through June 17, 2024

Section 471-23-004 - SERVICE REQUIREMENTS

004.01GENERAL SERVICE REQUIREMENTS.

004.01(A)MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity inform 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

004.01(B)SERVICE CRITERIA. Medicaid covers speech pathology and audiology services when the following criteria are met. The service must be:

(i) An evaluation:

(ii) Restorative therapy with a medically appropriate expectation that the recipient's condition will improve significantly within a reasonable period of time; or

(iii) For physical therapy services only, recommended in a Department- approved Individual Program Plan (IPP) and the recipient is receiving services through one of the following waiver programs:

(1) Comprehensive Developmental Disabilities Services Waiver;

(2) Developmental Disabilities Adult Residential Services Waiver;

(3) Adult Comprehensive Waiver; or

(4) Home and Community Based Services Waiver for Aged Adults and Children with Disabilities.

004.01(C)SERVICES PROVIDED FOR RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM. See 471 NAC 1.

004.01(D)EARLY PERIODIC, DIAGNOSTIC AND TREATMENT TREATMENT (EPSDT) SERVICES. See 471 NAC 33.

004.02COVERED SERVICES. Nebraska Medicaid covers speech pathology and audiology services when the following criteria are met:

(1) The services are ordered by a licensed physician or nurse practitioner:

(2) The services are medically necessary;

(3) The services are such that only a licensed speech pathologist or audiologist can safely and effectively perform the service; and

(4) The speech pathology or audiology service meets at least one of the service criteria.

004.02(A)MAINTENANCE PROGRAM. The speech pathologist or audiologist must:

(i) Evaluate the recipient's needs;

(ii) Design a maintenance program: and

(iii) Instruct the recipients, family members, or nursing facility staff in carrying out the program.

004.02(B)SERVICES FOR INDIVIDUALS AGE 21 AND OLDER. For recpients age 21 and older, Nebraska Medicaid limits coverage to a combined total of 60 therapy sessions per fiscal year. The combined total of 60 therapy sessions per fiscal year includes all occupational therapy, physical therapy, speech pathology, and audiology sessions provided to the recipient.

004.03NON-COVERED SPEECH PATHOLOGY AND AUDIOLOGY SERVICES. Nebraska Medicaid does not cover the following speech pathology or audiology services:

(A) Maintenance therapy provided by a speech pathologist:

(B) Therapy for vocational and prevocational assessment and training;

(C) Therapy for functional capacity evaluations, educational testing, drivers training, or training in non-essential self-help or recreational activities, visual perception training, or treatment of psychological conditions:

(D) Therapy for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting;

(E) Therapy for delays in speech development that is not due to a specific medical condition or brain injury; or

(F) Therapy for the following conditions or diagnosis categories:

(i) Psychosocial speech delay;

(i) Behavior problems;

(ii) Attention disorders;

(iv) Conceptual handicap; or

(v) Learning disability.

471 Neb. Admin. Code, ch. 23, § 004

Amended effective 12/26/2021