Sbs: Coverage And Limitations

The Department will pay for services including medical or remedial services provided by school districts or other cooperative service agencies, as defined in Section 33-317, Idaho Code. (7-1-26) 01. Excluded Services. (7-1-26) a. Payment for school-related services will not be provided to students who are inpatients in nursing homes or hospitals. (7-1-26) b. Services provided more than thirty (30) days prior to the signed and dated recommendation or referral. (7-1-26) 02. Evaluation and Diagnostic Services. Evaluations to determine eligibility or the need for health- related services may be reimbursed even if the student is not found eligible for health-related services. Evaluations completed for educational services only cannot be billed. Evaluations completed must: (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 323 Page 84 a. Be conducted by providers for the respective SBS discipline; (7-1-26) b. Be directed toward a diagnosis; (7-1-26) c. Include recommended interventions to address each need; and (7-1-26) d. Include name, title, and signature of the person conducting the evaluation. (7-1-26) 03. Reimbursable Services. Providers can bill for the following health-related services provided under the recommendation of a provider for reimbursement. The recommendations or referrals are valid up to three hundred sixty-five (365) days. (7-1-26) a. Behavioral Intervention is a direct intervention used to promote positive, meaningful changes in behavior that incorporate functional replacement behaviors and reinforcement-based strategies, while also addressing any identified habilitative skill building needs and the student’s ability to participate in educational services through a consistent, assertive, and continuous intervention process to address behavior goals identified on the IEP. Behavioral intervention includes conducting a functional behavior assessment and developing a behavior implementation plan for preventing or treating behavioral conditions. This service is provided to students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions. (7-1-26) i. Group services provided by one (1) qualified staff providing direct services for two (2) or three (3) students. (7-1-26) ii. As the severity of the students with behavioral issues increases, the student ratio in the group must be adjusted from three (3) to two (2). (7-1-26) iii. Group services should only be delivered when the student’s goals relate to benefiting from group interaction. (7-1-26) b. Behavioral consultation assists other service professionals by consulting with the IEP team during the assessment process, performing advanced assessment, coordinating the implementation of the behavior implementation plan and providing ongoing training to the behavioral interventionist and other team members. (7-1-26) i. Behavioral consultation cannot be provided as a direct intervention service. (7-1-26) ii. Behavioral consultation must be limited to thirty-six (36) hours per year. (7-1-26) c. Crisis intervention as defined for CHIS services. This service is provided on a short-term basis, typically not exceeding thirty (30) school days. (7-1-26) d. Habilitative skill building as defined for CHIS services. (7-1-26) e. Interdisciplinary training as defined for CHIS services. (7-1-26) f. Durable Medical Equipment and Supplies for use at the school where the service is provided. The equipment and supplies must be for the student's exclusive use. All equipment purchased by Medicaid belongs to the student. (7-1-26) g. Nursing services including emergency, first aid, or non-routine medications not identified on the plan as a health-related service are not reimbursed. (7-1-26) h. Occupational Therapy. (7-1-26) i. PCS include medically oriented tasks having to do with the student's physical or functional requirements. PCS do not require a goal on the plan of service. The provider must deliver at least one (1) of the IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 323 Page 85 following services: (7-1-26) i. Basic personal care and grooming to include bathing, hair care, assistance with clothing, and basic skin care; (7-1-26) ii. Assistance with bladder or bowel requirements that may include helping the student to and from the bathroom or assisting the student with bathroom routines; (7-1-26) iii. Assistance with food, nutrition, and diet activities including preparation of meals if incidental to medical need; (7-1-26) iv. Assisting the student with provider-ordered medications that are ordinarily self-administered, under IDAPA 24.34.01; (7-1-26) v. Non-nasogastric gastrostomy tube feedings meeting the requirements under personal care services. (7-1-26) j. Physical Therapy. (7-1-26) k. Psychological Evaluation. (7-1-26) l. Psychotherapy. (7-1-26) m. Skills Building/Community-Based Rehabilitation Services (CBRS) are interventions to reduce the student’s disability by assisting in gaining and utilizing skills necessary to participate in school. They are designed to build competency and confidence while increasing mental health and/or decreasing behavioral symptoms. Skills Building/CBRS provides training in behavior control, social skills, communication skills, appropriate interpersonal behavior, symptom management, activities of daily living, and coping skills to prevent placement in a more restrictive situation. (7-1-26) n. Speech/Audiological Therapy and Evaluation. (7-1-26) o. Social History and Evaluation. (7-1-26) p. Transportation Services. Providers can receive reimbursement for mileage for transporting a student between home and school when: (7-1-26) i. The student requires special transportation assistance, a wheelchair lift or an attendant, when medically necessary; (7-1-26) ii. The vehicle is specifically adapted to meet the needs of a disability; (7-1-26) iii. The student receives Medicaid-reimbursable services billed by the provider, other than transportation, on the day transportation is provided; (7-1-26) iv. The transportation is included on the student's plan; and (7-1-26) v. The mileage, as well as the services performed by the attendant, are documented. (7-1-26) q. Interpretive services for a student requiring an interpreter to communicate with the professional or paraprofessional providing a health-related service may be billed when services are: (7-1-26) i. Limited to the specific time the health-related service is received. Documentation must include the service provided. (7-1-26) ii. Included on the student's plan; and (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 324 Page 86 iii. Provided by a professional or paraprofessional unable to communicate in the student's primary language. (7-1-26)