coordinating services covered by medicaid in school and community settings

COORDINATING SERVICES COVERED BY MEDICAID

IN SCHOOL AND COMMUNITY SETTINGS

A Family Voices Presentation to Wisconsin FACETS

September 28, 2006

Family Voices of Wisconsin 2006 2

WHAT IS THE SCHOOL BASED SERVICES BENEFIT?

The school-based services (SBS) benefit has been established according to Wisconsin Statute 49.45(39). This benefit is designed to increase federal funding to Wisconsin schools to help pay for medically related special education and related services. The SBS benefit defines the services that can be reimbursed by Wisconsin Medicaid for medically necessary services provided to Medicaid-eligible children.


MEDICAL NECESSITY

All Medicaid-covered services must be medically necessary, as defined in HFS 101.93(96m), Wisconsin Administrative Code. A school-based service is considered medically necessary when the service:


MEDICAL NECESSITY, cont

Identifies, treats, manages or addresses a medical problem, or a mental, emotional or physical disability.

Is identified in the child’s IEP. Is necessary for a child to benefit from

special education. Is prescribed by a physician when required.

(The Medicaid School Based Services Handbook list prescription requirements.)


COVERED SCHOOL-BASED SERVICES

School-Based services must be identified in the child’s IEP and certain requirements must be met. Covered services include the following: Developmental testing and assessments

when resulting in a created or revised IEP;

Durable medical equipment (DME);


COVERED SCHOOL-BASED SERVICES, continued

Nursing; Occupational Therapy (OT); Physical Therapy (PT); Psychological services, counseling and

social work; Speech and language pathology (SLP),

audiology, and hearing; and Transportation.


AVOIDING DUPLICATION OF SERVICES

Medicaid will not pay for duplicative services

Educational necessity vs medical necessity

Importance of the IEP to include service delivery


COORDINATION OF SERVICES

Collaboration between school and community therapists is essential to coordinate a child’s therapy and prevent duplication of services which results in denial of payment of community-based therapy.

A child benefits most when therapy providers work together with a family to determine what therapies are needed and where a child’s needs can be met most effectively.


COORDINATION OF SERVICES, continued

Understanding the framework in which services are delivered will help families and providers access and coordinate services for children. School based therapy is provided to assist a

child to benefit from special ed. The goal of community based services is to

optimize the child’s functional performance in relation to needs in home and community settings.


SCHOOL-BASED SERVICES

Therapy is provided only if the child need therapy to function in the educational settting.

Need for therapy is determined by IEP. Therapy can be delivered across

educational settings. Discontinuation decided by IEP team.


COMMUNITY BASED SERVICES

Provided in clinics, hospitals, homes and across community settings.

Physician, therapist and family decide on amount, frequency and duration.

Discontinuation can occur for a variety of reasons, including: functional skills are achieved; there is a plateau; discharge is requested.


MEDICAID RESOURCE

The Medicaid School Based Services Handbook provides much information for families, providers and advocates. It can be found online at: http://dhfs.wisconsin.gov/medicaid2/handbooks/sbs/sbs.pdf


ACKNOWLEDGEMENTS

Information for slides 2 -6 was taken directly from the Medicaid School Based Services handbook.

Information for slides 8 -11 was taken from the brochure, School and Community Based Therapy Services (distributed by the Wisconsin Occupational Therapy Association)

coordinating services covered by medicaid in school and community settings

Documents