CHAPTER 52

 

School-Based Services

Section 1. Authority.

 

The Wyoming Department of Health (Department) promulgates this Chapter pursuant to the Medical Assistance and Services Act at Wyoming Statutes §§ 42-4-101 through 124.

 

Section 2. Purpose of Applicability.

 

(a)                The Department adopts this Chapter to govern the School-Based Services (SBS) Program covered by Medicaid, the enrollment and participation of local education agencies and providers of covered school based services, and the methods and standards for reimbursement of such services.

 

(b)               This Chapter shall apply to all SBS provided on or after its effective date.

 

(c)                The Department may issue manuals or bulletins to interpret this Chapter. Such manuals and bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in manuals or bulletins shall be subordinate to this Chapter.

 

Section 3. Definitions.

 

(a)                Except as otherwise specified in Wyoming Medicaid Rules Chapter 1 or as defined in this Section, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, healthcare, Medicaid, and Medicare.

 

(b)               "Free care services" means services provided to Medicaid enrolled students at no charge, and/or provided to the community at large free of charge.

 

(c)                "Individualized Education Plan (IEP)" means a document developed pursuant to the Individuals with Disabilities Education Act (IDEA). The IEP guides the delivery of special education supports and services for a student with a disability.

 

(d)               "Individualized Family Services Plan (IFSP)" means a document developed pursuant to the IDEA. The IFSP guides the delivery of early intervention services provided to infants and toddlers (birth to age 3) who have disabilities, including developmental delays. The IFSP also includes family supports services, nutrition services, and case management.

 

(e)                "Local Education Agency (LEA)" means a public authority legally constituted by the State as an administrative agency to provide control of, and direction for, kindergarten through twelfth grade public education institutions.

 

(f)                "Parental Consent Form" means a form executed by a student's parent or guardian authorizing an LEA to share information with and to bill Medicaid for the student's school health services.

(g)               "Participating District" means a school district that is enrolled to provide and receive Medicaid reimbursement for SBS.

 

(h)               "School Counselor" means a professional who meets the qualification

requirements of 42 C.F.R. § 485.904(b)(5). The school counselor must obtain a Professional Services Endorsement for School Counselor through the Professional Teaching Standards Board. A school counselor must practice under the supervision of a qualified clinical supervisor licensed in the State of Wyoming pursuant to W.S. § 33-38-102(a)(xiii).

 

(i)                 "School Health Service" means medical or health-related assistance provided to a student by a qualified provider required for the diagnosis, treatment, or care of a physical or mental disorder, which service is recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under Wyoming law.

 

(j)                 "School Psychologist" means a professional who qualifies as a Specialist in School Psychology pursuant to W.S. § 33-27-113(a)(ix). The school psychologist must obtain a Professional Services Endorsement for School Psychologist by the Wyoming Professional

Teaching Standards Board. A school psychologist must practice school psychology pursuant to the requirements of the Psychology Practice Act, W.S. §§ 33-27-113(a)(iv) and 114.

 

(k) "School Social Worker" means a professional who meets the qualification

requirements of 42 C.F.R. § 410.73. The school social worker must obtain the Professional Services Endorsement for School Social Worker from the Professional Teaching Standards Board. A school social worker must practice under the supervision of a qualified clinical supervisor licensed in the state of Wyoming pursuant to W.S. § 33-38-102(a)(xiii).

 

Section 4. School District and Provider Participation.

 

(a)                To participate in the SBS Program, both the participating district and the providers shall enroll with Medicaid pursuant to Wyoming Medicaid Rules Chapter 3.

 

(b)               Participating districts will act as the billing agent for affiliated providers. Providers may not provide SBS except under the participating districts. Providers may enroll under more than one participating district.

 

Section 5. Provider Qualifications

 

(a)                To qualify for enrollment as a provider of SBS, an individual shall at a minimum, satisfy the following criteria:

 

(i)                 Meet applicable licensing and certification standards found in Wyoming statutes and rules, or in the statutes and regulations of the state in which the provider is located.

 

(ii)               Not be excluded from participation in federally funded health care programs by the U.S. Department of Health and Human Services, Office of Inspector General; and,

(iii)            Be assigned a National Provider Identifier (NPI) number by the National Plan and Provider Enumeration System, as applicable.

 

Section 6. Covered Services.

 

(a)                School health services will be covered for Medicaid enrolled clients under the age of 21. Services shall be medically necessary as defined by Wyoming Medicaid Rules Chapter 1, and rendered as part of the student client's IEP or IFSP.

 

(b)               School health services shall be provided in accordance with the client's individual needs and shall not be subject to limitations as to scope, amount, or duration.

 

(c)                School health services may be performed in the school, at the client's home, or at another appropriate site in the community.

 

(d)               The following service categories and providers are covered services under the SBS Program as further defined in the Department's School-Based Services Program Manual:

 

(i)                 Speech and audiology services

 

(A)             Speech-Language Pathologist; and

 

(B)              Speech-Language Pathology Aide/Assistant.

 

(ii)               Psychological, counseling, and social work services

 

(A)             School Psychologist;

 

(B)              School Social Worker;

 

(C)              School Counselor;

 

(D)             Psychologist;

 

(E)              Marriage and Family Therapist; and

 

(F)               Certified Mental Health Worker (CMHC).

 

(iii)            Nursing and health services

 

(A)             Registered Nurse (RN);

 

(B)              Advanced Practice Registered Nurse (APRN);

 

(C)              Licensed Practical Nurse (LPN); and

 

(D)             Certified Nurse Assistant (CNA).

 

(iv)             Occupational therapy services

 

(A)             Occupational Therapist; and

 

(B)              Occupational Therapy Assistant.

 

(v)               Physical therapy services

 

(A)             Physical Therapist; and

 

(B)              Physical Therapy Aide/Assistant.

 

(e)                Evaluations and reevaluations are reimbursable only when they result in an IEP or IFSP in the specific service(s) being evaluated.

 

Section 7. Excluded Services.

 

(a)    Services billed under the SBS program are subject to the limitations and coverage

restrictions that exist for other Wyoming Medicaid services pursuant to Wyoming Medicaid Rules Chapter 26 and the applicable Medicaid Provider Manuals. Wyoming Medicaid shall not cover the following services:

 

(i)                 Services classified as educational, such as services or activities involving academic assessment, student instruction or curriculum, and supervision of students;

 

(ii)               Services billed by a practitioner outside his or her area of expertise;

 

(iii)            Vocational training that is related solely to specific employment opportunities, work skills, or work settings;

 

(iv)             Services not identified in the client's IEP or IFSP;

 

(v)               Evaluations that do not result in an IEP or IFSP;

 

(vi)             Transportation services;

 

(vii)           Communication and consultation with parents, other providers, and educators.

(A)             Attendance at meetings;

 

(B)              Instructional assistant contact;

 

(C)              Parental contact;

 

(D)             Parental consultation;

 

(E)              Preparation and distribution of correspondence to parents or other professionals;

 

(F)               Professional consultation; and

 

(G)             Teacher contact.

 

(viii)        Free care services.

 

Section 8. Requirements for Obtaining Reimbursement.

 

(a)                LEAs must adhere to SBS Program requirements that may exceed educational requirements.

 

(i)                 The LEA must deliver and document the service provided, based upon the needs of the client.

 

(ii)               LEAs must authorize each client's related service needs by including the nature and extent of required services in the student's IEP or IFSP.

 

(iii)            Schools may only provide medically necessary services and must ensure that all services meet Wyoming requirements for demonstrating medical necessity, as documented in Medicaid Rule Chapter 26.

 

(iv)             LEAs must obtain and document consent from the client's parent or guardian to bill covered services to Medicaid.

 

(b)               The Department shall reimburse only participating districts and not any individual enrolled providers. Medicaid reimbursement for services is limited to those furnished to enrolled clients within participating districts.

 

Section 9. Documentation Requirements.

 

(a)                A provider must maintain all records necessary to fully disclose the nature, quality, amount, and medical necessity of services billed to a client currently receiving Medicaid services. Payment for services billed to Wyoming Medicaid that are not substantiated in the client's records are subject to recoupment. Documentation must be retained for at least six years from the date of payment or until ongoing audit issues are resolved, whichever is longer, as detailed in Wyoming Medicaid Rules Chapter 3.

 

(b)               For services covered under this Chapter, complete copies of the client's IEP or

IFSP must be maintained as part of the participating district's records. The records must clearly indicate that the school-based services are required by the client's IEP or IFSP.

 

(c)                As part of the participating district's required records, the client's file must include:

 

(i)                 The IEP or the IFSP;

 

(ii)               An evaluation performed by the provider, or the annual and current present level of performance;

 

(iii)            Treatment notes describing the IEP or IFSP goals and objectives specific to each client met by their school-based services;

 

(iv)             Billing information recorded in units of time, as specified in Wyoming Medicaid Rules Chapter 3; and,

 

(v)               A copy of the signed consent form from a parent or legal guardian.

 

Section 10. Medicaid Allowable Payment. The Medicaid allowable payment for SBS shall be pursuant to the Medicaid fee schedule.

 

   Section 11. Submission and Payment of Claims.  Submission and payment of claims shall be consistent with the provisions of Wyoming Medicaid Rules Chapter 3.

 

Section 12. Audits.  Audits will be conducted consistent with the provisions of Wyoming Medicaid Rules Chapter 16.

 

Section 13. Recovery of Overpayments. The Department shall recover overpayments pursuant to Wyoming Medicaid Rules Chapter 16. In addition to using its own internal processes for recovery of overpayments, the Department may refer a matter involving suspected overpayments to the Medicaid Fraud Control Unit at any time.