12VAC30-50-130. Skilled nursing facility services, EPSDT, [ school health services ] and family planning.

A. Skilled nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

Service must be ordered or prescribed and directed or performed within the scope of a license of the practitioner of the healing arts.

B. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on behalf of individuals under 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities, and the accompanying attendant physician care, in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination.

2. Routine physicals and immunizations (except as provided through EPSDT) are not covered except that well-child examinations in a private physician's office are covered for foster children of the local social services departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically necessary to correct a visual defect identified by an EPSDT examination or evaluation. The department shall place appropriate utilization controls upon this service.

4. Consistent with the Omnibus Budget Reconciliation Act of 1989 § 6403, early and periodic screening, diagnostic, and treatment services means the following services: screening services, vision services, dental services, hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in Social Security Act § 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services and which are medically necessary, whether or not such services are covered under the State Plan and notwithstanding the limitations, applicable to recipients ages 21 and over, provided for by the Act § 1905(a).

5. Community mental health services.

a. Intensive in-home services to children and adolescents under age 21 shall be time-limited interventions provided typically but not solely in the residence of a child who is at risk of being moved into an out-of-home placement or who is being transitioned to home from out-of-home placement due to a documented medical need of the child. These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child and his parents to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); case management activities and coordination with other required services; and 24-hour emergency response. These services shall be limited annually to 26 weeks.

b. Therapeutic day treatment shall be provided two or more hours per day in order to provide therapeutic interventions. Day treatment programs, limited annually to 780 units, provide evaluation; medication; education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills (e.g., problem solving, anger management, community responsibility, increased impulse control, and appropriate peer relations, etc.); and individual, group and family psychotherapy.

c. Community-Based Services for Children and Adolescents under 21 (Level A).

(1) Such services shall be a combination of therapeutic services rendered in a residential setting. The residential services will provide structure for daily activities, psychoeducation, therapeutic supervision and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. DMAS will reimburse only for services provided in facilities or programs with no more than 16 beds.

(2) In addition to the residential services, the child must receive, at least weekly, individual psychotherapy that is provided by a licensed mental health professional.

(3) Individuals must be discharged from this service when other less intensive services may achieve stabilization.

(4) Authorization is required for Medicaid reimbursement.

(5) Room and board costs are not reimbursed. Facilities that only provide independent living services are not reimbursed.

(6) Providers must be licensed by the Department of Social Services, Department of Juvenile Justice, or Department of Education under the Standards for Interdepartmental Regulation of Children's Residential Facilities (22VAC42-10).

(7) Psychoeducational programming must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, and stress management.

(8) The facility/group home must coordinate services with other providers.

d. Therapeutic Behavioral Services (Level B).

(1) Such services must be therapeutic services rendered in a residential setting that provides structure for daily activities, psychoeducation, therapeutic supervision and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. DMAS will reimburse only for services provided in facilities or programs with no more than 16 beds.

(2) Authorization is required for Medicaid reimbursement.

(3) Room and board costs are not reimbursed. Facilities that only provide independent living services are not reimbursed.

(4) Providers must be licensed by the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) under the Standards for Interdepartmental Regulation of Children's Residential Facilities (22VAC42-10).

(5) Psychoeducational programming must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, and stress management. This service may be provided in a program setting or a community-based group home.

(6) The child must receive, at least weekly, individual psychotherapy and, at least weekly, group psychotherapy that is provided as part of the program.

(7) Individuals must be discharged from this service when other less intensive services may achieve stabilization.

6. Inpatient psychiatric services shall be covered for individuals younger than age 21 for medically necessary stays for the purpose of diagnosis and treatment of mental health and behavioral disorders identified under EPSDT when such services are rendered by:

a. A psychiatric hospital or an inpatient psychiatric program in a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations; or a psychiatric facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation Facilities, the Council on Accreditation of Services for Families and Children or the Council on Quality and Leadership.

b. Inpatient psychiatric hospital admissions at general acute care hospitals and freestanding psychiatric hospitals shall also be subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25. Inpatient psychiatric admissions to residential treatment facilities shall also be subject to the requirements of Part XIV (12VAC30-130-850 et seq.) of this chapter.

c. Inpatient psychiatric services are reimbursable only when the treatment program is fully in compliance with 42 CFR Part 441 Subpart D, as contained in 42 CFR 441.151 (a) and (b) and 441.152 through 441.156. Each admission must be preauthorized and the treatment must meet DMAS requirements for clinical necessity.

7. Hearing aids shall be reimbursed for individuals younger than 21 years of age according to medical necessity when provided by practitioners licensed to engage in the practice of fitting or dealing in hearing aids under the Code of Virginia.

C. School health [ assistant ] services.

1. School health assistant services are defined as those services that assist the child with disabilities in self-sufficiency, communications, and mobility skills. Services provided by the assistant are related to the child's physical and behavioral health requirements, including assistance with eating, dressing, hygiene, activities of daily living, bladder and bowel needs, use of adaptive equipment, ambulation and exercise, minor behavioral issues and other remedial services to promote reduction of a child's disabilities. The registered nurse or other DMAS-recognized school health professional supervising the assistant shall provide a written plan describing the assistance needed for the child [ repealed effective July 1, 2006 ].

[ 2. School health assistant services are available only to students who are qualified to receive special education services under, and consistent with, Part B of the federal Individuals with Disabilities Education Act, as amended (20 USC § 1400 et seq.).

3. No additional prior authorization is required if the school health assistant services are authorized by the current Individualized Education Program (IEP). The IEP team that authorizes these services must include a physician or other licensed practitioner of the healing arts acting within the scope of his practice under state law, to include a speech-language pathologist, occupational therapist, physical therapist, registered nurse, psychiatrist, clinical psychologist, school psychologist-limited, school social worker, or audiologist. The child shall have a current order from a physician, physician assistant or nurse practitioner for specialized nursing procedures such as tube feedings, where the assistant may be involved in attending to the child.

4. The school health assistant shall perform services consistent with the training received. The school health assistant shall not perform services restricted to, or that cannot be delegated by, a licensed registered nurse or other health professional authorized by DMAS to provide school health services. The school health assistant shall not perform any service for which training was not received.

5. The assistant shall have met standards for school health assistant services as required by the Department of Education and received training for assisting with meeting the health needs of the child. The assistant is to be supervised by a Virginia-licensed physician, physician assistant, nurse practitioner, registered nurse, or other DMAS-recognized school health professional acting within the scope of his license under state law.

6. School health assistant services shall only be billed by school divisions enrolled with DMAS. Services shall be rendered by employees of school divisions or persons under contract to school divisions. Services billed by the school division shall not be duplicative of services the child receives at the school otherwise covered by DMAS.

7. School health assistant services shall be billed in units, with one unit equaling 15 minutes. The number of units billed is not to exceed the number of units in a day that the child is in the care of the school. While more than one assistant may attend to a child over the course of a school day, the unit for a particular period of the day for the child shall not be billed for the services of more than one assistant.

8. The school health assistant shall document on a weekly basis the assistance provided to the child, with the dates and times noted, with initials of the assistant and date of entry. Out-of-the-ordinary needs of the child or assistance provided shall be noted. The documentation shall be reviewed by the supervising registered nurse, or other school health professional recognized in these school services regulations, at least every 30 school days, in addition to any other requirements under state law, with the supervising professional noting approval of the services in the documentation with initials and date.

9. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided. Health professionals authorized by DMAS to deliver school health services shall not provide any service that exceeds the scope of their practice as set forth by the appropriate health professions board or their endorsement by the Board of Education. ]

[ 2. School divisions may provide routine well-child screening services under the State Plan. Diagnostic and treatment services that are otherwise covered under early and periodic screening, diagnosis and treatment services, shall not be covered for school divisions. School divisions to receive reimbursement for the screenings shall be enrolled with DMAS as clinic providers.

a. Children enrolled in managed care organizations shall receive screenings from those organizations. School divisions shall not receive reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's Individualized Education Program (IEP) and covered under one or more of the service categories described in § 1905(a) of the Social Security Act. These services are necessary to correct or ameliorate defects of physical or mental illnesses or conditions.

3. Service providers shall be licensed under the applicable state practice act or comparable licensing criteria by the Virginia Department of Education, and shall meet applicable qualifications under 42 CFR Part 440. Identification of defects, illnesses or conditions and services necessary to correct or ameliorate them shall be performed by practitioners qualified to make those determinations within their licensed scope of practice, either as a member of the IEP team or by a qualified practitioner outside the IEP team.

a. Service providers shall be employed by the school division or under contract to the school division.

b. Supervision of services by providers recognized in subdivision 4 of this subsection shall occur as allowed under federal regulations and consistent with Virginia law, regulations, and DMAS provider manuals.

c. The services described in subdivision 4 of this subsection shall be delivered by school providers, but may also be available in the community from other providers.

d. Services in this subsection are subject to utilization control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services described in subdivision 4 of this subsection are medically necessary and that the treatment prescribed is in accordance with standards of medical practice. Medical necessity is defined as services ordered by IEP providers. The IEP providers are qualified Medicaid providers to make the medical necessity determination in accordance with their scope of practice. The services must be described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for individuals with speech, hearing, and language disorders, performed by, or under the direction of, providers who meet the qualifications set forth at 42 CFR 440.110. This coverage includes audiology services;

b. Skilled nursing services are covered under 42 CFR 440.60. These services are to be rendered in accordance to the licensing standards and criteria of the Virginia Board of Nursing. Nursing services are to be provided by licensed registered nurses or licensed practical nurses but may be delegated by licensed registered nurses in accordance with the regulations of the Virginia Board of Nursing, especially the section on delegation of nursing tasks and procedures. the licensed practical nurse is under the supervision of a registered nurse.

(1) The coverage of skilled nursing services shall be of a level of complexity and sophistication (based on assessment, planning, implementation and evaluation) that is consistent with skilled nursing services when performed by a licensed registered nurse or a licensed practical nurse. These skilled nursing services shall include, but not necessarily be limited to dressing changes, maintaining patent airways, medication administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and specifically related to an active, written plan of care developed by a registered nurse that is based on a written order from a physician, physician assistant or nurse practitioner for skilled nursing services. This order shall be recertified on an annual basis.

c. Psychiatric and psychological services performed by licensed practitioners within the scope of practice are defined under state law or regulations and covered as physicians' services under 42 CFR 440.50 or medical or other remedial care under 42 CFR 440.60. These outpatient services include individual medical psychotherapy, group medical psychotherapy coverage, and family medical psychotherapy. Psychological and neuropsychological testing are allowed when done for purposes other than educational diagnosis, school admission, evaluation of an individual with mental retardation prior to admission to a nursing facility, or any placement issue. These services are covered in the nonschool settings also. School providers who may render these services when licensed by the state include psychiatrists, licensed clinical psychologists, school psychologists, licensed clinical social workers, professional counselors, psychiatric clinical nurse specialist, marriage and family therapists, and school social workers.

d. Personal care services are covered under 42 CFR 440.167 and performed by persons qualified under this subsection. The personal care assistant is supervised by a DMAS recognized school-based health professional who is acting within the scope of licensure. This practitioner develops a written plan for meeting the needs of the child, which is implemented by the assistant. The assistant must have qualifications comparable to those for other personal care aides recognized by the Virginia Department of Medical Assistance Services. The assistant performs services such as assisting with toileting, ambulation, and eating. The assistant may serve as an aide on a specially adapted school vehicle that enables transportation to or from the school or school contracted provider on days when the student is receiving a Medicaid-covered service under the IEP. Children requiring an aide during transportation on a specially adapted vehicle shall have this stated in the IEP.

e. Medical evaluation services are covered as physicians' services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR 440.60. Persons performing these services shall be licensed physicians, physician assistants, or nurse practitioners. These practitioners shall identify the nature or extent of a child's medical or other health related condition.

f. Transportation is covered as allowed under 42 CFR 431.53 and described at State Plan Attachment 3.1-D. Transportation shall be rendered only by school division personnel or contractors. Transportation is covered for a child who requires transportation on a specially adapted school vehicle that enables transportation to or from the school or school contracted provider on days when the student is receiving a Medicaid-covered service under the IEP. Transportation shall be listed in the child's IEP. Children requiring an aide during transportation on a specially adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess the need for medical services in a child's IEP and shall be performed by any of the above licensed practitioners within the scope of practice. Assessments and reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that duplication of services will be monitored.  School divisions have a responsibility to ensure that if a child is receiving additional therapy outside of the school, that there will be coordination of services to avoid duplication of service. ]

C. D. Family planning services and supplies for individuals of child-bearing age.

1. Service must be ordered or prescribed and directed or performed within the scope of the license of a practitioner of the healing arts.

2. Family planning services shall be defined as those services that delay or prevent pregnancy. Coverage of such services shall not include services to treat infertility nor services to promote fertility.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-03-3.1100 § 4, eff. April 1, 1993; amended, eff. June 30, 1993; Virginia Register Volume 10, Issue 22, eff. September 1, 1994; Volume 14, Issue 7, eff. January 22, 1998; Volume 17, Issue 5, eff. January 1, 2001; Volume 20, Issue 7, eff. February 1, 2004; Volume 22, Issue 8, eff. January 25, 2006; Volume 23, Issue 21, eff. January 1, 2008; Volume 25, Issue 5, eff. December 10, 2008.

12VAC30-50-229.1. [ School health services. ] (Repealed.) 

[ A. School health services shall require parental consent and shall be defined as those therapy: Special education services, occupational therapy, physical therapy and speech-language pathology services; nursing services,; psychiatric and psychological screenings, and well-child screenings rendered by employees of school divisions that are enrolled with DMAS to serve children who: services; audiology services; and medical evaluation services.

1. Qualify to receive special education services as described under and consistent with all of the requirements of Part B of the federal Individuals with Disabilities Education Act, as amended (20 USC § 1400 et seq.). Children qualifying

1. Only children who qualify for special education services pursuant to Part B of the federal Individuals with Disabilities Education Act, as amended, are eligible to receive school health services; such children shall not be restricted in their choice of enrolled providers of medical care services as described in the State Plan for Medical Assistance; or. Services billed to DMAS must be stated in the child's Individualized Education Program.

2. Qualify to receive routine screening services under the State Plan. Diagnostic and treatment services, that are otherwise covered under early and periodic screening, diagnosis and treatment services, shall not be covered for participating school divisions. Participating school divisions must receive parental consent before conducting screening services.

2. School health services shall only be billed by school divisions enrolled with DMAS. Services shall be rendered by employees of school divisions or persons under contract to school divisions. Services billed by the school division shall not be duplicative of services the child receives at the school otherwise covered by DMAS.

B. Occupational therapy, physical therapy and related speech-language pathology services.

1. The services covered under this subsection shall include occupational therapy, physical therapy, occupational therapy, and speech-language pathology services. All of the requirements, with the exception of the 24-visit limit, prior authorization and physician order requirements of 12VAC30-50-200, 12VAC30-130-10 through 12VAC30-130-40, and 42 CFR 440.110 are applicable to these services shall continue to apply with regard to, but not necessarily limited to, necessary authorizations, documentation requirements, and provider qualifications. Consistent with the child's Individualized Education Program (IEP), 35 therapy visits will be covered per year per discipline without DMAS prior authorization. The service provider shall be either employed by the school division or under contract to the school division. No additional prior authorization is required if the services are authorized by the current Individualized Education Program (IEP). The IEP team that authorizes these services must include a physician or other licensed practitioner of the healing arts acting within the scope of his license under state law. Other licensed practitioners may include an occupational therapist, physical therapist, or speech-language pathologist.

2. Consistent with § 32.1-326.3 of the Code of Virginia, speech-language pathology services must shall be rendered either by:

a. A speech-language pathologist who meets the qualifications under 42 CFR 440.110(c): (i) has a certificate of clinical competence from the American Speech and Language-Hearing Association; (ii) has completed the equivalent educational requirements and work experience necessary for the certificate; or (iii) has completed the academic program and is acquiring supervised work experience to qualify for the certificate;

b. A speech-language pathologist with a current license in speech language pathology issued by the Board of Audiology and Speech-Language Pathology;

c. A speech-language pathologist licensed by the Board of Education with an endorsement in speech-language disorders preK-12 and a master's degree in speech-language pathology. These persons also have a license without examination from the Board of Audiology and Speech-Language Pathology; or

d. A speech-language pathologist who does not meet the criteria for subdivisions a, b, or c above and is directly supervised by a speech-language pathologist who meets the criteria of clause a (i) or a (ii) or subdivision b or c above. The speech-language pathologist must be licensed by the Board of Education with an endorsement in speech-language disorders preK-12 but does not hold a master's degree in speech-language pathology. Direct supervision must take place on site at least every 30 calendar days for a minimum of two hours and must be documented accordingly. The speech-language pathologist who meets the criteria for clause a (i) or a (ii) or subdivision b or c above is readily available to offer needed supervision when speech-language services are provided.

3. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided. Health professionals authorized by DMAS to deliver school health services shall not provide any service that exceeds the scope of their practice as set forth by the appropriate health professions board or their endorsement by the Board of Education.

C. Skilled nursing services.

1. These services must be medically necessary skilled nursing services that are required by a child in order to benefit from an educational program, as described under Part B of the federal Individuals with Disabilities Education Act, as amended (20 USC § 1400 et seq.). These services shall be limited to a maximum of 26 units a day of medically necessary services and pursuant to 42 CFR 440.60. Services not deemed to be medically necessary, upon utilization review, shall not be covered. A unit, for the purposes of this school-based health service, shall be defined as 15 minutes of skilled nursing care.

2. No additional prior authorization is required if the services are authorized by the current Individualized Education Program (IEP). The IEP team that authorizes these services must include a physician or other licensed practitioner of the healing arts acting within the scope of his license under state law, including a registered nurse. The child shall have a current order from a physician, physician assistant, or nurse practitioner for specialized nursing procedures such as tube feedings.

2. 3. These services must be performed by a Virginia-licensed registered nurse (RN), or licensed practical nurse (LPN) under the supervision of a licensed RN. The service provider shall be either employed by the school division or under contract to the school division. The skilled nursing services shall be rendered in accordance with the licensing standards and criteria of the Virginia Board of Nursing. Supervision of LPNs shall be provided consistent with the regulatory standards of the Board of Nursing at 18VAC90-20-270.

3. 4. The coverage of skilled nursing services shall be of a level of complexity and sophistication (based on assessment, planning, implementation and evaluation) that is consistent with skilled nursing services when performed by a registered nurse or a licensed practical nurse. These skilled nursing services shall include, but not necessarily be limited to, dressing changes, maintaining patent airways, medication administration/monitoring and urinary catheterizations. Skilled nursing services shall be consistent with the medical necessity criteria in the school services manual.

4. 5. Skilled nursing services shall be directly and specifically related to an active, written plan of care that is. The plan shall be based on a physician's, physician assistant's or nurse practitioner's written order for skilled nursing services when specialized nursing procedures are involved. The registered nurse shall establish, sign, and date the plan of care. The plan of care shall be periodically reviewed by a physician or nurse practitioner after any needed consultation with skilled nursing staff. The services shall be specific and provide effective treatment for the child's condition in accordance with accepted standards of skilled nursing practice. The plan of care is further described in subdivision 5 of this subsection. Skilled nursing services rendered that exceed the physician's or nurse practitioner's written order for skilled nursing services or plan of care shall not be reimbursed by DMAS. A copy of the plan of care shall be given to the child's Medicaid primary care provider.

5. 6. Documentation of services shall include a written plan of care that identifies the medical condition or conditions to be addressed by skilled nursing services, goals for skilled nursing services, time tables for accomplishing such stated goals, actual skilled nursing services to be delivered and whether the services will be delivered by an RN or LPN. Services that have been delivered and for which reimbursement from Medicaid is to be claimed must be supported with like documentation. Documentation of school-based skilled nursing services shall include the dates and times of services entered by the responsible licensed nurse; the actual nursing services rendered; the identification of the child on each page of the medical record; the current diagnosis and elements of the history and exam that form the basis of the diagnosis; any prescribed drugs that are part of the treatment including the quantities, dosage, and frequency; and notes to indicate progress made by the child, changes to the diagnosis, or treatment and response to treatment. The plan of care is to be part of the child's medical record. Actions related to the skilled nursing services such as notifying parents, calling the physician, or notifying emergency medical services shall also be documented. All documentation shall be signed and dated by the person performing the service. Lengthier skilled nursing services shall have more extensive documentation. The documentation shall be written immediately, or as soon thereafter as possible, after the procedure or treatment was implemented with the date and time specified, unless otherwise instructed in writing by Medicaid. Documentation is further described in the Medicaid school services manual. Skilled nursing services documentation shall otherwise be in accordance with the Virginia Board of Nursing, Department Board of Medicine, Board of Health, and Department Board of Education statutes, regulations, and standards relating to school health. Documentation shall also be in accordance with school division standards.

6. 7. Service limitations. The following general conditions shall apply to reimbursable skilled nursing services in school divisions:

a. Patient must be under the care of a physician, physician assistant, or nurse practitioner who is legally authorized to practice and who is acting within the scope of his license.

b. A recertification by a physician, physician assistant, or nurse practitioner acting within the scope of his license of the skilled specialized nursing services procedures shall be conducted at least once each school year. The recertification statement must be signed and dated by the physician, physician assistant, or nurse practitioner who reviews the plan of care, and may be obtained when the plan of care is reviewed. The physician or nurse practitioner recertification statement must indicate the continuing need for services and should estimate how long rehabilitative skilled or specialized nursing services will be needed.

c. Physician or nurse practitioner orders for nursing services shall be required The plan of care is to be reviewed by a registered nurse at least annually and modified as necessary, with the RN's initials and date of review entered.

d. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided.

e. d. Skilled nursing services are to be terminated when further progress toward the treatment goals are unlikely or when they are not benefiting the child or when the services can be provided by someone other than the skilled nursing professional.

8. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided. Health professionals authorized by DMAS to deliver school health services shall not provide any service that exceeds the scope of their practice as set forth by the appropriate health professions board or their endorsement by the Board of Education.

D. Psychiatric and psychological services.

1. Evaluations and therapy services shall be covered when rendered by individuals who are licensed by the Board of Medicine and practice as psychiatrists or by psychologists licensed by the Board of Psychology as clinical psychologists or by school psychologists-limited licensed by the Board of Psychology. Evaluation and therapy services shall also be covered when rendered by individuals who are endorsed by the Board of Education as school social workers. Services by these practitioners shall be subject to coverage at 12VAC30-50-140 D and 42 CFR 440.60, with the exception of the service limits and provider qualifications. The service provider shall be either employed by the school division or under contract to the school division. No additional prior authorization is required if the services are authorized by the current Individualized Education Program (IEP). The IEP team that authorizes these services must include a physician or other licensed practitioner of the healing arts acting within the scope of his license under state law, to include a psychiatrist, clinical psychologist, school psychologist-limited, or school social worker.

2. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided. Health professionals authorized by DMAS to deliver school health services shall not provide any service that exceeds the scope of their practice as set forth by the appropriate health professions board or their endorsement by the Board of Education.

E. Audiology services.

1. Audiology services shall be rendered by an audiologist with a current license in audiology issued by the Board of Audiology and Speech-Language Pathology and who meets the requirements of 42 CFR 440.110(c).

2. The service provider shall be either employed by the school division or under contract to the school division. Audiology services shall be authorized by the current Individualized Education Program (IEP). No additional prior authorization is necessary. The IEP team that authorizes these services must include a physician or other licensed practitioner of the healing arts acting within the scope of his license under state law to include a licensed audiologist.

3. The audiological assessment shall include testing and/or observation as appropriate for chronological or mental age for one or more of the following areas of functioning:

a. Auditory, acuity (including pure tone air and bone conduction), speech detection, and speech reception threshold;

b. Auditory discrimination in quiet and noise;

c. Impedience audiometry including tympanometry and acoustic reflex;

d. Hearing amplification evaluation; and

e. Central auditory function.

4. Audiological treatment shall include one or more of the following as appropriate:

a. Auditory training;

b. Speech reading; and

c. Aural rehabilitation, including for cochlear implants.

5. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided. Health professionals authorized by DMAS to deliver school health services shall not provide any service that exceeds the scope of their practice as set forth by the appropriate health professions board or their endorsement by the Board of Education.

F. Medical evaluation services.

1. These evaluation services shall be rendered by a physician, physician assistant or nurse practitioner as part of the development and/or review of a child's Individualized Education Program, to identify or determine the nature and extent of a child's medical or other health-related condition.

2. Physicians and physician assistants shall be licensed by the Virginia Board of Medicine and nurse practitioners shall be licensed by the Virginia Board of Medicine and the Virginia Board of Nursing. The service provider shall be either employed by the school division or under contract to the school division.

3. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the child's school medical record as having been rendered shall be deemed not to have been rendered and no payment shall be provided. Health professionals authorized by DMAS to deliver school health services shall not provide any service that exceeds the scope of their practice as set forth by the appropriate health professions board or their endorsement by the Board of Education.

E. Early and periodic screening, diagnosis, and treatment (EPSDT) services. Routine screening services shall be covered for school divisions when rendered by either physicians or nurse practitioners. Diagnostic and treatment services also covered under EPSDT shall not be covered for school divisions. School divisions shall be required to refer children who are identified through health assessment screenings as having potential abnormalities to their primary care physician for further diagnostic and treatment procedures.

F. G. Specific exclusions from school health services. All services encompassing and related to family planning, pregnancy, and abortion services shall be specifically excluded from Medicaid reimbursement if rendered in the school district setting. ]

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 14, Issue 18, eff. July 1, 1998; amended, Virginia Register Volume 15, Issue 17, eff. June 9, 1999; Errata, 15:18 VA.R. 2411 May 24, 1999; amended, Virginia Register Volume 17, Issue 5, eff. January 1, 2001; Volume 18, Issue 7, eff. January 16, 2002; Volume 25, Issue 5, eff. December 10, 2008.

Part VII
Transportation

12VAC30-50-530. Methods of providing transportation.

A. DMAS will ensure necessary transportation for recipients to and from providers of covered medical services. DMAS shall cover transportation to covered medical services under the following circumstances:

1. Emergency air, ambulance transportation, and all other modes of transportation [ except for transportation services provided by school divisions, ] shall be covered as medical services under 42 CFR 431.53 and any other applicable federal Medicaid regulations. These modes include, but shall not be limited to, nonemergency air travel, nonemergency ground ambulance, stretcher vans, wheelchair vans, common user bus (intra-city and inter-city), volunteer/registered drivers, and taxicabs. DMAS may contract directly with providers of transportation or with brokers of transportation services, or both. DMAS may require that brokers not have a financial interest in transportation providers with whom they contract.

2. Medicaid provided transportation shall only be available when recipients have no other means of transportation available.

3. Recipients shall be furnished transportation services that are the most economical to adequately meet the recipients' medical needs.

4. Ambulances, wheelchair vans, taxicabs, and other modes of transportation must be licensed to provide services in the Commonwealth by the appropriate state or local licensing agency, or both. Volunteer/registered drivers must be licensed to operate a motor vehicle in the Commonwealth and must maintain automobile insurance.

[ 6. Transportation services provided by school divisions.

a. School transportation services are available only to students who are qualified to receive special education health services under Part B of the federal Individuals with Disabilities Education Act, as amended (20 USC § 1400 et seq.).

b. No additional prior authorization is required if the school transportation services are authorized by the current Individualized Education Program (IEP). The IEP team that authorizes these services must meet all the requirements for IEP team composition set forth in 12VAC30-50-229.1.

c. School division provided transportation shall be covered for children in special education on days when the child receives a medical service billed to DMAS, such as physical therapy. The transportation is to enable the child to receive the covered medical service. Transportation shall involve a trip from home to school and the return trip, or from school (or home) to a DMAS medical provider in the community for a service, such as physical therapy, and the return trip.

d. Transportation on a "regular" school bus is not billable to DMAS, unless an aide is necessary for the child to ride the bus. If a child requires transportation on a vehicle adapted to serve the needs of the disabled, such as a specially adapted school bus, that transportation may be billed to DMAS. A school division car or other type of vehicle also qualifies which meets the needs of the child when the child cannot ride a school bus. If an aide is necessary for the child to ride the vehicle and this is noted in the child's IEP, then reimbursement shall include the services of the aide assigned to a child. An aide assigned to ride in a vehicle which transports children, where transportation and an aide are noted in the IEP, can also be billed. The services of a single aide can be billed for up to six children.

e. Vehicles and drivers providing the transportation shall be in compliance with applicable laws and regulations. 

5. DMAS-covered school transportation is described at 12VAC30-50-130 C. Vehicles and drivers providing the transportation shall be in compliance with applicable laws and regulations. ]

B. DMAS will ensure necessary nonemergency transportation for full-benefit, dual eligible recipients to obtain medically necessary, noncovered Medicare Part D prescription drugs.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-02-3.1400, eff. January 1, 1993; amended, Virginia Register Volume 17, Issue 12, eff. July 2, 2001; Volume 20, Issue 1, eff. October 22, 2003; Volume 21, Issue 22, eff. August 10, 2005; Volume 23, Issue 11, eff. March 7, 2007; Volume 25, Issue 5, eff. December 10, 2008.