N.H. Admin. Code § He-W 589.04

Current through Register No. 45, November 7, 2024

Section He-W 589.04 - Covered Services and Provider Qualifications

(a) All enrolled school providers shall:

(1) Be enrolled with NH medicaid for the purposes of administration and billing;

(2) Verify the qualifications, licensure, and certifications, as applicable, of performing-only providers upon hire and at time of any licensure or certification renewal and maintain proof of verification;

(3) Screen all performing-only providers for medicaid services for exclusions against the Office of Inspector General (OIG) exclusion and sanction database pursuant to section 1866(j)(2) of the Social Security Act, section 1903(i) of the Social Security Act, and 42 CFR 1001.1901. The OIG exclusion and sanction database may be found at https://exclusions.oig.hhs.gov;

(4) Screen all performing-only providers upon hire, prior to executing a contract, and on a monthly basis thereafter as long as the performing-only provider is providing medicaid services for which the school is seeking federal FFP; and

(5) Ensure all providers have knowledge in the following areas:

a. Medicaid recipient rights, and the reporting of abuse and neglect; and

b. Record keeping and documentation requirements pursuant to this part, including the penalties associated with improper recordkeeping and documentation.

(b) All covered services shall be:

(1) Provided through a student's LEA or SAU;

(2) Medically necessary;

(3) Included and documented in the student's care plan in accordance with this part;

(4) Provided in a variety of locations and settings as specified in a student's care plan and may occur outside the hours of the usual school day;

(5) Provided by qualified clinicians pursuant to this part and who comply with the scope of his or her board licensure for his or her clinical practice including supervision and ordering requirements; and

(6) Prior authorized if required by the NH medicaid state plan, federal or state law, or the rules adopted thereunder.

(c) Covered services may be provided by staff employed or subcontracted by the enrolled school provider and who are:

(1) Either licensed by the applicable clinical healthcare boards to provide the services provided or otherwise under the direction of the appropriate licensed clinician to provide the services as permitted by applicable licensure law; or

(2) Board Certified Behavior Analysts (BCBA) appropriately certified by the national Behavior Analyst Certification Board, and if supervising others, have a supervisory certification issued by the national board and be acting within the scope of that certification.

(d) Covered supplies and equipment described under He-W 589.04 shall:

(1) Be acquired for the use of a specific student;

(2) When purchased, be the property of the student and his or her family; and

(3) When rented or acquired through a used equipment exchange program, be the property of the student and his or her family during the period used.

(e) DME shall be provided by a qualified DME provider, and in accordance with the requirements pursuant to He-W 571.

(f) AAC devices and aids shall be provided by a qualified DME provider, and in accordance with the requirements of He-W 575.

(g) Medical evaluation shall include the following:

(1) Those services rendered by a physician, APRN, or physician assistant whose opinion or advice is requested regarding the evaluation or treatment of a student's condition; and

(2) An initial evaluation shall be covered, however, if the physician, APRN, or physician assistant assumes the continuing care of the student, any service(s) provided subsequent to the initial evaluation by such physician, APRN, or physician assistant shall not be considered an evaluation but might be coverable as another service pursuant to this part.

(h) The following medical evaluation services performed by the providers in (g) above shall be billable under the category of medical evaluation:

(1) Examination of a single organ system, including:

a. Documentation of complaint(s);

b. Physical examination and diagnosis of current illness; and

c. Establishment of a plan of management relating to a specific problem; and

(2) In-depth evaluation with development and documentation of medical data, including:

a. Chief complaint;

b. Present illness;

c. Family history;

d. Medical history;

e. Personal history;

f. System review; and

g. Physical examination.

(i) Nursing services shall be medically necessary to meet the health needs of a student and include:

(1) Any assessments or treatments performed by a licensed registered nurse, licensed practical nurse (LPN), or APRN for a student that are medically necessary; and

(2) Supplies and equipment necessary for the provision of the covered nursing services as determined by the licensed registered nurse, LPN, or APRN.

(j) Nursing services shall be performed by the following:

(1) An APRN licensed to practice in NH by the NH board of nursing in accordance with RSA 326-B:18 or the state in which he or she practices as a registered nurse in an advance practice role;

(2) A registered nurse who is:

a. Licensed to practice in NH or the state in which he or she practices in accordance with RSA 326-B; and

b. Acting under the direction of a physician, APRN, or physician assistant for those activities that require an order; or

(3) A LPN who is:

a. Licensed to practice in NH under RSA 326-B or the state in which he or she practices; and

b. Acting under the direction of a physician, APRN, registered nurse, or physician assistant.

(k) Nursing services shall include the following:

(1) Administration of medication(s);

(2) Positioning or repositioning;

(3) Assistance with specialized feeding programs;

(4) Management and care of specialized medical equipment such as:

a. Colostomy bags:

b. Nasogastric tubes;

c. Tracheostomy tubes; and

d. Related medical devices;

(5) Observation of students with chronic medical illnesses in order to assure that medical needs are being appropriately identified, addressed, and monitored; and

(6) Other services determined by a registered nurse, LPN, or APRN to be medically necessary and appropriate.

(l) Billable categories of nursing services shall include the following:

(1) Nursing assessment;

(2) Nursing treatment; and

(3) Supplies and equipment necessary to provide covered nursing services.

(m) Private duty nursing services shall be:

(1) Covered services when they are part of the student's medical regimen and rendered under the order and under the direction of the student's physician; and

(2) Covered and delivered in accordance with the requirements of He-W 540.

(n) Occupational therapy services shall be covered if the services are medically necessary to implement a program of activities to develop or maintain adaptive skills necessary to achieve adequate and appropriate physical and mental functioning of a student including:

(1) Any evaluations, treatment, or assessments performed by an occupational therapist of students whose abilities to carry out age appropriate tasks are threatened or impaired by physical illness or injury, mental illness, emotional disorder, or congenital or developmental disability;

(2) Supplies and equipment necessary to provide the covered occupational therapy services as recommended by an occupational therapist; and

(3) Occupational therapy services performed by an occupational therapy assistant carrying out a therapy plan developed by the occupational therapist.

(o) Occupational therapy services shall be provided by:

(1) An occupational therapist who is licensed to practice in NH or the state in which he or she practices, and is either:

a. Registered by the National Board for Certification in Occupational Therapy Inc.; or

b. A graduate of a program in occupational therapy approved by the Committee on Allied Health Education and Accreditation of the American Medical Association and engaged in the supplemental clinical experience required before registration by the National Board for Certification in Occupational Therapy, Inc.; or

(2) An occupational therapy assistant as defined in RSA 326-C:1, IV working under the direction of a licensed occupational therapist.

(p) Occupational therapy services, other than an evaluation, shall require an order.

(q) Occupational therapy services shall include:

(1) Task-oriented activities to correct physical or emotional deficits or to minimize the disabling effect of these deficits in the life of the student;

(2) Evaluations of:

a. Sensorimotor abilities;

b. Self-care activities;

c. Capacity for independence;

d. Physical capacity for prevocational and work tasks; and

e. Play and leisure performance;

(3) Specific occupational therapy techniques involving:

a. Improving skills for ADLs;

b. The fabrication and application of splinting devices;

c. Sensorimotor activities;

d. The use of specifically designed manual and creative activities;

e. Guidance in the selection and use of adaptive equipment; and

f. Specific exercises to enhance functional performance and physical capabilities needed for work activities; and

(4) Other services determined by an occupational therapist to be medically necessary and appropriate.

(r) Billable categories of occupational therapy services shall include the following:

(1) Occupational therapy evaluation;

(2) Occupational therapy, individual;

(3) Occupational therapy, group; and

(4) Supplies and equipment necessary for the provision of covered occupational therapy services.

(s) Physical therapy services shall include:

(1) Any evaluations to determine a student's level of physical functioning, including performance tests to measure strengths, balance, endurance, and range of motion;

(2) Any treatment services, evaluations, or assessments which might utilize therapeutic exercises or the modalities of heat, cold, water, and electricity, for the purpose of preventing, restoring, or alleviating a lost or impaired physical function;

(3) Other services, including supplies and equipment, determined by a physical therapist to be medically necessary and appropriate for a student's physical therapy; and

(4) Physical therapy services performed by a physical therapy assistant carrying out a therapy plan developed by the physical therapist.

(t) Physical therapy services shall be provided by:

(1) A physical therapist who is a graduate of a program of physical therapy approved by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Physical Therapy Association or its equivalent and licensed to practice in the state of NH or the state in which he or she practices; or

(2) A physical therapy assistant as defined in RSA 328-A:2, VIII who is under the direction of a licensed physical therapist pursuant to (1) above.

(u) Physical therapy services shall be medically necessary.

(v) Billable categories of physical therapy services shall include the following:

(1) Physical therapy, evaluation;

(2) Physical therapy, individual;

(3) Physical therapy, group; and

(4) Supplies and equipment necessary for the provision of covered physical therapy services.

(w) Psychiatric services shall be medically necessary for the evaluation, assessment, diagnosis, and treatment of mental or emotional conditions.

(x) Psychiatric services shall be provided by:

(1) A psychiatrist who is a physician licensed to practice in NH as defined in RSA 135-C:2II, XI, or the state in which he or she practices and either board certified or board eligible according to the most recent regulations of the American Board of Psychiatry and Neurology, Inc. or its successor organization; or

(2) An APRN with a psychiatric specialty pursuant to RSA 326-B:18.

(y) Billable categories of psychiatric services shall include the following:

(1) Psychiatric evaluation and diagnosis; and

(2) Psychiatric treatment.

(z) Psychological services shall require an order and be medically necessary for the evaluation, diagnosis, treatment, and counseling of mental or emotional illnesses, symptoms, or conditions.

(aa) Psychological services shall be provided by:

(1) A psychologist who is a school psychologist or associate school psychologist certified by the state board of education in NH or in the state in which he or she practices and licensed by the NH board of psychologists or another state's board of psychology;

(2) A psychologist or associate psychologist licensed by the NH board of psychologists or licensed by another state's board of psychology;

(3) A physician;

(4) APRNs with a psychiatric specialty pursuant to RSA 326-B:18;

(5) Psychotherapists acting within the scope of his or her licensure; or

(6) A master licensed alcohol and drug counselor (MLADC) for co-occurring mental health and substance use disorders.

(ab) Billable categories of psychological services shall include the following:

(1) Psychological testing and evaluation;

(2) Psychodiagnostic testing;

(3) Psychological counseling, individual treatment;

(4) Psychological counseling, group treatment; and

(5) Family counseling, during which the student shall be present at 51% of the counseling session.

(ac) Mental health services, other than psychiatric and psychological services, shall:

(1) Be covered if they are medically necessary and ordered; and

(2) Include, but not be limited to:

a Behavior management;

b. Individual counseling;

c. Group counseling;

d. Family counseling, during which the student shall be present at 51% of the counseling session; and

e. Crisis intervention.

(ad) Persons providing mental health services shall be:

(1) A psychologist who is a school psychologist or associate school psychologist certified by the state board of education in NH or in the state in which he or she practices and licensed by the NH board of psychologists or another state's board of psychologist;

(2) A psychotherapist or mental health practitioner as defined in RSA 330-A:2, VII and VIII, respectively;

(3) A psychologist licensed by the board of psychologists pursuant to RSA 329-B; or

(4) An APRN with a psychiatric specialty pursuant to RSA 326-B:18.

(ae) Substance use disorder (SUD) treatment and recovery support services shall be provided by the licensed qualified providers described in He-W 513, and in accordance with the requirements in He-W 513.

(af) Rehabilitative assistance services shall include the following:

(1) Mobility assistance such as positioning, transfers, correct application of ankle-foot orthosis, bracing or orthotic devices, range of motion, fall prevention, safety risk precautions, and physical therapy carry-over tasks as directed by the licensed physical therapist;

(2) Communication assistance such as assistance with sign language, prompting to facilitate expressive and receptive language, assistance with AAC devices and other such devices that ameliorate communication limitations, and speech language carry-over tasks as directed by the licensed speech language pathologist;

(3) Assistance with the implementation of behavioral management plans to increase adaptive behavioral functioning and carry-over tasks as directed by the mental health practitioner or BCBA;

(4) Nutrition such as assistance with eating, cutting food, food preparation, and safe eating plan carry-over tasks as directed by the speech language pathologist or occupational therapist;

(5) Cueing, prompting, and guiding, when provided as part of the assistance with ADLs, communication, or behavior management;

(6) Assistance with adaptive or assistive devices when linked to the student's medical condition;

(7) Assistance with the use of DME when linked to the student's medical condition;

(8) Medication administration to the extent allowable under RSA 326-B and pursuant to Nur 404.07 when the rehabilitative assistant has been trained by a nurse in medication administration, and the nurse has delegated the task of medication administration to the rehabilitative assistant;

(9) Personal care services such assistance with ADL and IADL and assistance with occupational therapy, physical therapy, or speech language carry-over tasks;

(10) Carry-over of therapy skills training as delegated by a speech language pathologist, physical therapist, and occupational therapist;

(11) Observation and reporting of signs of distress in the student's medical condition as trained by a registered nurse;

(12) Implementation of safe eating plans and g-tube feedings as delegated by a registered nurse with applicable training;

(13) Maintaining a safe environment to assure the student's safety concerns are met for the student, other students and staff; and

(14) Any other remedial services, that are included in the student's care plan as medically necessary for the maximum reduction of a student's physical or mental disabilities excluding educational and social activities such as classroom instruction and academic tutoring.

(ag) Rehabilitative assistants shall:

(1) Either:

a. Be certified pursuant to Ed 504.05 or Ed 504.06, requirements and certification for paraeducators;

b. Have qualifications determined by the department to be equivalent to the requirements for certification under Ed 504.05 or 504.06; or

c. Be other licensed clinicians; and

(2) If applicable for the tasks delegated to the rehabilitative assistant or if required by law have knowledge in the following areas:

a. Personal care and nutrition;

b. Infection control and universal precautions designed to prevent the transmission of infectious diseases;

c. Safety and emergency procedures, including basic first aid and 911 protocols; and

d. Proper lifting techniques.

(ah) Rehabilitative assistants shall provide rehabilitation assistance services in accordance with Ed 1113.12.

(ai) Rehabilitative assistance services shall be medically necessary and require an order.

(aj) Provision of rehabilitative assistance services shall be reviewed by a licensed clinician designated by the enrolled school provider's care plan team every 30 days. Such review shall include review of the activities performed by the rehabilitative assistant and the effectiveness of the activities as observed by the rehabilitative assistant. As part of the review, the care plan team designated licensed clinician shall sign the documentation of the service transaction logs to attest that the service was actually provided and shall provide review and signature that the activities have been conducted in accordance with the care plan;

(ak) Speech, language, and hearing services shall be covered services if they are services, supplies, or equipment ordered by a licensed audiologist or licensed speech-language pathologist to be medically necessary for the evaluation, diagnosis, or treatment of speech, language, and hearing disorders which result in communication disabilities.

(al) Speech language services shall include services performed by speech language assistants listed in (am) below carrying out a therapy plan developed by the speech language pathologist.

(am) Speech, language, and hearing services shall be provided by:

(1) An audiologist who is licensed to practice in NH by the board of hearing care providers or the state in which he or she practices;

(2) A speech-language pathologist who is either:

a. Licensed pursuant to RSA 326-F to practice in NH, which shall be considered equivalent to having met the requirements for the American Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence in Speech-Language Pathology; or

b. Licensed in the state in which he or she practices and have one of the following:

1 A Certificate of Clinical Competence from the American Speech and Hearing Association;

2 Completed the equivalent educational requirements and work experience necessary for the certificate; or

3 Completed the academic program and is acquiring supervised work experience to qualify for the certificate; or

(3) A speech-language assistant as defined in RSA 326-F:1, II-a working under the direction of a licensed speech-language pathologist pursuant to (2) above.

(an) Billable categories of speech, language, and hearing services shall include the following:

(1) Individual speech, language, or hearing evaluation;

(2) Speech, language, or hearing therapy, individual treatment;

(3) Speech, language, or hearing therapy, group treatment; and

(4) Supplies and equipment necessary for the provision of covered speech language and hearing services.

(ao) Vision services shall be medically necessary for the prevention or rehabilitation of visual impairment or restoration of a student with a visual impairment to his or her best possible functional level and be provided by an optometrist, ophthalmologist, or optician.

(ap) EPSDT comprehensive and age-appropriate medical assessments and screenings of a student's physical and mental status, including vision and hearing screenings in accordance with the requirements pursuant to He-W 546.05.

(aq) Services that are not covered or have coverage limits under the NH medicaid state plan shall be covered through the EPSDT benefit when medically necessary, coverable under Section 1905(a) of the Social Security Act, and requested in accordance with the requirements of He-W 546.

(ar) Except as indicated in (at) below, the following shall be examples of services subject to the requirements of He-W 546:

(1) Rehabilitative assistance services;

(2) Applied behavior analysis;

(3) Personal care services for individuals under the age of 21;

(4) Wrap around services;

(5) Case management services; and

(6) Other optional services listed in 1905(a) of the Social Security Act and not included in the NH medicaid state plan or included as a covered service under this part.

(as) The following services shall not be subject to the prior authorization requirements of He-W 546:

(1) Rehabilitative assistance services;

(2) Applied behavior analysis; and

(3) Personal care services for individuals under the age of 21.

(at) Any services not listed as covered under the NH medicaid state plan or services with coverage limits shall be given independent review by the department for coverage based on medical necessity in accordance with the EPSDT benefit pursuant to He-W 546.

(au) Specialized transportation shall be a billable service as follows:

(1) Transportation shall be listed in the student's IEP as a required service and the student shall be physically in the vehicle for the transportation to be billable to medicaid;

(2) Transportation shall be considered a required service if:

a. The student requires transportation in a vehicle specially adapted to serve the needs of the disabled student, including a specially adapted school bus; or

b The student resides in an area that does not have school bus transportation, such as those areas in close proximity to a school, but has a medical need for transportation that is noted in the IEP;

(3) The following transportation may be billed as a medicaid service:

a. Transportation to and from school only on a day when the student receives a medicaid coverable service at school during the school day; and

b. Transportation to and from a medicaid coverable service in the community during the school day;

(4) The medicaid coverable service in (3)a. and (3)b. above shall be listed in the student's IEP as a required service; and

(5) In addition to the documentation required by He-W 589.06, transportation providers shall maintain a daily transportation log to include:

a. Student's name;

b. Date of service;

c. Clear indication that the student is being transported either one-way or round-trip;

d. The total number of students on the bus, both in the morning and the afternoon;

e. The total miles the bus traveled, both in the morning and the afternoon;

f. Driver's name; and

g. Driver's signature.

N.H. Admin. Code § He-W 589.04

Derived from Volume XL Number 11, Filed March 12, 2020, Proposed by #12994, Effective 2/21/2020, Expires 2/21/2030.