health care transmittal 2 state for health care … · 2017. 6. 15. · complete blocks 6 thru 10...

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO 0938 0193

TRANSMITTAL AND NOTICE OF APPROVAL OF 1 TRANSMITTAL NUMBER 2 STATE STATE PLAN MATERIAL

09 New York FOR HEALTH CARE FINANCING ADMINISTRATION

TO REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5 TYPE OF PLAN MATERIAL Check One

3 PROGRAM IDENTIFICATION TITLE XIX OF THE

SOCIAL SECURITY ACT MEDICAID

4 PROPOSED EFFECTIVE DATE

September 1 2009

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Separate Transmittalfor each amendment 6 FEDERAL STATUTEREGULATION CITATION

42 CFR Part 447205 Social Services Law Section 368d 368e

8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment4 1 Attachment 31A Supplement Pages2Axii through 2

19B Pages 17e through 17

xiiP Attachment 31B Supplement Pages2Athroughx112xiiP SEE REMARKS

10 SUBJECT OF AMENDMENT

School Supportive Health Services

11 GOVERNOR REVIEW Check OneSGOVERNOR OFFICE REPORTED NO COMMENTS

COMMENTS OF GOVERNORSOFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

112 SIGNA STATE AGENC OFF IAL

13 TYPED NAME Deborah Bachrach

14 TITLE Deputy Commissioner

Department of Health 15 DATE SUBMITTED

September 30 2009

7 FEDERAL BUDGET IMPACT

a FFY 01 0909 2M0909 30 15b FFY 1009 0910 3M01 30 182

9 PAGE NUMBER OF THE SUPERSEDED PLAN

SECTION OR ATTACHMENT IfApplicable

OTHER AS SPECIFIED

16 RETURN TO

New York State Department of Health Corning Tower Empire State Plaza Albany New York 12237

FOR REGIONAL OFFICE USE ONLY 17 DATE RECEIVED 18 DATE APPROVED

X262 PLAN APPROVED ONE COPY ATTACHED

19 EFFECTIVE DATE OF 20 S GI at F ICIALAPPROVVAIERIS

21 TYPED NAME 22 L1 soc ate egiona dministratorActing ndpz ivieion of M rMir a4 j ele 1 kaid snd SOO

23 REMARKS

Originally submitted pages have been replaced by revised pages submitted via Stateemail of March 19 2010 April 12 2010 and April 14 2010

FORM HCFA179 0792

y81 Fk

New York 4 g gialit 17e

Attachment419B

1009

Type of Service

Early and Periodic Screening Diagnostic and Treatment services

Early and Periodic Screening Diagnostic and Treatment services for individuals under 21 years of age and treatment of conditions found

Reimbursement Methodologies for Early and Periodic Screening Diagnostic and Treatment Services provided as the School Supportive Health Services CSSHS and Pre School Supportive Health Services PSSHS Programs

School Supportive Health Services SSHS and Pre School uoaortive Health Services PSSHS are delivered by or through a school district a Section 4201 school a county in the State or the City of New York and include the following Medicaid services as described in Appendix 1 to Attachment 31A and B of the Medicaid State Plan under item 4b EPSDT

1 Physical Therapy Services

2 Occupational Therapy Services

3 Speech Therapy Services

4 Psychological Counseling

8 Skilled Nursing Services

1 Psychological Evaluations

7 Medical Evaluations

8 Medical Specialist Evaluations

9 Audiological Evaluations

10 Special Transportation

Effective for dates of service on or after September 1 2009 payments to a school district a Section 4201 school a county in the State or the City of New York for School Supportive Health Services and Pre School Supportive Health Services shall be based on fees established by the Department of Health

i

TN 0961 Approval Date APR 2 5 2010 Effective DateSupersedes TN New SEP 0 1 2009

New York

17f

Attachment419B

1009

Fees will be established for each service or procedure and except for Special Transportation such fees shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region

Fees shall be published on the Department of Health website on the State EducationsDepartment website on the eMedNY website and shall be issued in policy and billing guidancesdistributed to school districts Section 4201 schools and counties in the state and the City of New York

L Physical Therapy Service

Fees for physical therapy services and procedures shall be set at 75 percent of the 2010 Medicare fee schedule for the Mid Hudson Region

Fees shall be published on the Department of Health website on the State EducationsDepartment website on the eMedNY website and shall be issued in policy and billingsguidance for school districts Section 4201 schools counties in the State and the City of New York

2 Occupational Therapy

Fees for occupational therapy services and procedures shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region

Fees shall be published on the Department of Health website on the State EducationsDepartment website on the eMedNY website and shall be issued in policy and billingsguidance distributed to school districts Section 4201 schools counties in the State and the

City of New York

61 kill 26a TN 09 Approval Date

New Effective Date SEP 0 1 204Supersedes TN

fI

New York

17g

Attachment419B 1009


Fees for speech therapy services and procedures shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson region

Such fees shall be published on the Department of Health website on the State Education sDepartmentswebsite on the eMedNY website and shall be issued in policy and billingguidance distributed to school districts Section 4201 schools counties in the State and the City of New York


Fees for psychological counseling services shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region

Such fees shall be published on the Department of Healthswebsite on the State Education Departmentswebsite on the eMedNY website and shall be issued in policy and billingguidance distributed to school districts Section 4201 schools counties in the State and the City of New York

Skilled Nursing Services

Fees for skilled nursing services shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region


APR 2 6 20 TN 0961 Approval Date SEP 0 1 2009

Effective DateSupersedes TN New

New York

17h

Attachment419B

1009

q4 rival Psychological Evaluations

Fees for psychological evaluations shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region

Such fees shall be published on the Department of Health website on the State EducationsDepartmentswebsite on the eMedNY website and shall be issued in policy and billingguidance distributed to school districts Section 4201 schools counties in the State and the City of New York

1 Medical Evaluations

Fees for medical evaluations shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region


1 Medical Specialist Evaluations

Fees for medical specialist evaluations shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region


APR 2 6 2010 TN 0961 Approval Date

Effective Date SEP 0 1 2009Supersedes TN New

New York

17i

Attachment419B

1009

FRCAudiological Evaluations

Fees for audiological evaluations shall be set at 75 of the 2010 Medicare fee schedule for the Mid Hudson Region

Such fees shall be published on the Department of Health website on the State EducationsDepartment website on the eMedNY website and shall be issued in policy and billingsguidance distributed to school districts Section 4201 schools counties in the State and the City of New York

iQ Special Transportation

One way rates of payment for special transportation services have been set based on a statistically valid cost study that was conducted in 1999 to establish round trip transportation rates Such rates have been trended forward based on changes in the Consumer Price Index from 7 09 and converted to one way rates99 through 8

Such rates shall be published on the Department of Health website on the StatesEducation Department website on the eMedNY website and shall be issued in policy andsbilling guidance distributed to school districts Section 4201 schools counties in the State and the City of New York

TN 0961 Approval Date pPR 2 6 2018 Supersedes TN New Effective Date SFP Q 1 2009

New York

Page2xiiA

Attachment 31A

t SupplementycriA4b Early and Periodic Screening Diagnostic and Treatment services EPSDT

School Supportive Health Services and Pre School Supportive Health Services

School Supportive Health Services SSHS and Pre School Supportive Health Services PSSHS are services provided by or through a school district a Section 4201 school a county in the State or New York City to children with disabilities who attend public or State Education Department approved schools orpreschools The services must be

medically necessary and included in a Medicaid covered category in accordance with 1905a19055cof the Social Security Actr1903ordered or prescribed by a physician or other licensed practitioner acting within his or her scope of practice under New York State Law included in the child Individualized Education Program IEPsprovided by qualified professionals under contract with or employed by a school district a Section 4201 school a county in the State or the City of New York furnished in accordance with all requirements of the Stage Medicaid Program and other pertinent state and federal laws and regulations including those for providerqualifications comparability of services and the amount duration and scope provisions and

included in the state plan or available under Early Periodic Screening Diagnostic andsTreatment EPSDT services

Effective September 1 2009 the services covered by the SSHS and PSSHS Program for Medicaid eligible children under the age of 21 who are eligible for Early and Periodic ScreeningDiagnostic and Treatment services EPSDT include medically necessary physical therapyservices occupational therapy services speeh therapy services psychological counselingskilled nursing services psychological evaluations medical evaluations medical specialistevaluations audiological evaluations and special transportation within the limits of EPSDT services A school district Section 4201 school a county in the State and New York City must be enrolled as a Medicaid provider in order to bill Medicaid

1 Physical Therapy Services

Definition Physical therapy services outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

TN 0961 Approval Date 201Rs2 0w Effective DateSupersedes TN Ne

New York xuPage2Bclr Attachment 318

Supplement

Services Physical therapy services provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order or prescriptionfrom a physician physician assistant or nurse practitioner who is acting within the scope of his or her practice under NYS law and must be provided to a child by or under the direction of a qualified physical therapist Physical therapy services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE These services include any necessary supplies and equipment utilized during the therapy session

Medically necessary EPSDT services are health care diagnostic services treatments and other measures necessary to correct or ameliorate physical defects mental illnesses and other disabilities

Physical therapy services include but are not limited to

Identification of children with physical therapy needs Evaluation for the purpose of determining the nature extent and degree of the need for physical therapy services Provision of physical therapy services for the purpose of preventing or alleviating movement dysfunction and related functional problemsObtaining interpreting and integrating information appropriate to program planningDiagnosis and treatment of physical disability injury or disease using physical and mechanical means including but not limited to heat cold light air water sound electricity massage mobilization and therapeutic exercise with or without assistive devices and The performance and interpretation of tests and measurements to assist pathopsychological pathomechanical and developmental deficits of human systems to determine treatment and assist in diagnosis and prognosis

Physical therapy services may be provided in an individual or group setting

Providers Services must be provided by

a New York State licensed and registered physical therapist qualified in accordance with 42 CFR 4401100 and with applicable state and federal laws and regulations actingwithin his or her scope of practice under New York State Law or a certified physical therapy assistant under the direction of such a qualified licensed and registered physical therapist acting within his or her scope of practice under New York State Law

TN 0961

Supersedes TN New

Approval Date

Effective Date

Am 2 6 20 s s 0 1 7003

OrripNew York

Page2xiiC

Attachment 318

Supplement

Under the direction of means that with respect to each Medicaid beneficiary the qualified therapist

sees the participant at the beginning of and periodically during the course of treatment is familiar with the treatment plan as recommended by the referring physician or other licensed practitioner of the healing arts practicing under State law has continued involvement in the care provided and reviews the need for continued services throughout treatment assumes professional responsibility for the services provided under his or her direction and monitors the need for continued services spends as much time as necessary directly supervising services to ensure beneficiaries are receivi g services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps Iocumentation supporting the supervision of services and ongoing involvement in the treatment

Services may be rendered in the setting in which the childs IEP will be implemented includingbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCESI programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitionersoffices at home andor in community based settings

L Occupational Therapy Services

Definition Occupational therapy services as outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Occupational therapy services provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order or prescription from a physician physician assistant or nurse practitioner who is acting within the

APR 5 201 TN 0961 Approval Date

01 2009New Effective Date SEPSupersedes TN

Ipprrvei

New York

Page2xiiD

Attachment 31B

Supplement

scope of his or her practice under New York State Law and must be provided to a child by or under the direction of a qualified occupational therapist Occupational therapy services must be included in the TEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE These services include any necessary supplies and equipment utilized during the therapy session


Occupational therapy services include but are not limited to

Identification of children with occupational therapy needs Evaluation for the purpose of determining the nature extent and degree of the need for occupational therapy services Improving developing or restoring functions impaired or lost through illness injury or deprivationPreventing through early intervention initial or further impairment or loss of function and

Planning and utilization of a program of activities to develop or maintain adaptive skills designed to achieve maximal physical and mental functioning of the student in daily life tasks

Occupational therapy services may be provided in an individual or group setting


a New York State licensed and registered occupational therapist qualified in accordance with 42CFR 440110band applicable state and federal laws and regulations acting within his or her scope of practice under New York State Law or

a certified occupational therapy assistant COTA under the direction of such a qualified licensed and registered occupational therapist within his or her scope of practice under New York State Law


sees the participant at the beginning of and periodically during the course of treatment

nt 61

APR 2 6 TN 09 Approval Date

New firsEffective Date SEP 0 1Supersedes TN

uia

New York

Page2xiiE

Attachment 31B

Supplement

is familiar with the treatment plan as recommended by the referring physician or other licensed practitioner of the healing arts practicing under State law has continued involvement in the care provided and reviews the need for continued services throughout treatment assumes professional responsibility for the services provided under his or her direction and monitors the need for continued services spends as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supporting the supervision of services and ongoing involvement in the treatment

Services may be rendered in the settings in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools 4201 schools state operated schools in private practitioner offices at home andor in communitysbased settings


Definition Speech therapy services as outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Speech therapy services provided by or through a school district a Section 4201 school a county in the Stag or the City of New York must have a written order or prescriptionfrom a physician physician assistant nurse practitioner or a speech language pathologist who is acting within his or her scope of practice under New York State law and must be provided to a child by or under the direction of a ualified speechlanguage pathologist Speech therapyservices must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE

Medically necessary EPSDT services are health care diagnostic services treatments and other measures to correct or ameliorate physical defects mental illnesses and other disabilities

2 6 2010TN 0961 Approval Date

New 0 l 2009Effective Date SEPSupersedes TN

New York

Page2xiiF

Attachment 318

Supplement R

Speech therapy services include but are not limited to i

Identification of children with speech disorders Diagnosis and appraisal of specific speech disorders Referral for medical or other professional attention necessary for the habilitation of speech disorders

Provision of speech or language services for the habilitation or prevention of communicative disorders

Evaluation and application of principles methods and procedures of measurement prediction diagnosis testing counseling consultation rehabilitation and instruction related to the development of disorders of speech voice andor language and Preventing ameliorating or modifying speech disorder conditions in children andor groups of children

Speech therapy services may be provided in an individual or group setting


a licensed and registered speech language pathologist qualified in accordance with 42CFR Section 440cand applicable state and federal laws and regulations acting110within his or her scope of practice under New York State law or a teacher certified to provide speech and language services under the documented direction of such a qualified licensed and registered speech language pathologist ASHA Certified or equivalent acting within his or her scope of practice under New York State Law



is familiar with the treatment plan as recommended by the referring physician or other licensed practitioner of the healing arts practicing under State law has continued involvement in the care provided and reviews the need for continued services throughout treatment assumes professional responsibility for the services provided under his or her direction and monitors the need for continued services

61 APR 2 6 2010TN 09 Approval Date

Effective DateSupersedes TN New SEP n 1 2009

1

New York

Page2xiiG

Attachment 31B

Supplement

spends as much time as necessary directly supervising services to ensure benefidaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supporting the supervision of services and ongoing involvement in the treatment

Services may be rendered in the setting s IEP will be implemented includingInwhich the childbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools Section4201 schools state operated schools in private practitionersoffices at home andor in community based settings


Definition Psychological counseling services outlined in this section of the State Plan areavailable to Medicaid eliaible beneficiaries under 21 nears of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Psychological counseling provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a referral from a physicianphysician assistant or a nurse practitioner who is acting within the scope of his or her practiceunder NYS law or an appropriate school official or other voluntary health or social agency and must be provided to a child by or under the direction of a qualified practitioner Psychologicalcounseling services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE


Psychological counseling services include

treatment services using a variety of techniques to assist the child in amelioratino behavioral and emotional problems that are severe enough to require treatment

Psychological counseling services may be provided in an individual or group setting

TN 0961 Approval Date ApR 2 6 71110 Effective Date SEP 0 1 2009

Supersedes TN New

14New York

Page2xiiH

Attachment 31B

Supplement

P i viiders Psychological counseling services must be provided by a qualified practitionerwithin his or her scope of practice in accordance with New York State Law and with the qualification requirements of 42 CFR Section 440 502and with other 60 aaand 440applicable state and federal laws or regulations Psychological counseling services may only beprovided by a professional whose credentials are comparable to those of providers who areable to provide psychological counseling services in the community

Services may be provided by

a New York State licensed and registered psychiatrist qualified in accordance with 42CFR Section 44050aand other applicable state and federal law or regulations actingwithin his or her scope of practice under New York State Law a New York State licensed and registered psychologist qualified in accordance with 42CFR Section 44060aand other applicable state and federal law or regulations actingwithin his or her scope of practice under New York State Law in accordance 42 CFR a New York State licensed clinical social worker LCSW qualifiedSection 44060aand other applicable state and federal law or regulations actingwithin his or her scope of practice under NYS law or a licensed master social worker LMSW qualified in accordance with 42 CFR Section44060aand other applicable state and federal law or regulations acting within his orher scope of practice under New York State Law under the supervision of such aqualified licensed clinical social worker a qualified licensed and registered psychologistor a qualified licensed and registered psychiatrist as described above

Supervision of the clinical social work services provided by the licensed master social worker withrespect to each Medicaid beneficiary shall consist of contact between the licensed master social worker and supervisor during which

the licensed master social worker apprises the supervisor of the diagnosis and treatment of each client the licensed master social workerscases are discussedthe supervisor provides the licensed master social worker with oversight and guidance in diagnosing and treating clientsthe supervisor regularly reviews and evaluates the professional work of the licensed master social worker andthe supervisor provides at least one hour per week or two hours every other week ofinperson individual or group clinical supervision provided that at least two hours per month shall be individual clinical supervision

2 6 2010 Approval Date

TN 0961 SE 0New Effective Date LA

Supersedes TN

New York

Page2xiiI

Attachment 310

Supplement

Services may be rendered in the setting in which the child IEP will be implemented includingsArticle 28 facilities Board of Cooperative Educational rvices CBOCESbut not limited to

programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitionersoffices at home andor in community based settings

5 Skilled Nursing

Definition Skilled nursing services outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Skilled nursing services provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order or prescriptionfrom a physician physician assistant or nurse practitioner acting within his or her scope of practice under New York State law and must be provided to a child by a registered nurse actingwithin his or her scope of practice under New York State law or by a NYS licensed practical nurse acting within his or her scope of practice under New York State law under the directionof a NYS licensed and registered nurse or licensed physician dentist or other licensed health care provider authorized under the Nurse Practice Act Skilled nursing services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE when there is a specific need based on a medical condition of the child

Medically necessary EPSDT services are health care diagnostic services treatments and other measures necessary to correct and ameliorate physical defects mental illnesses and other disabilities

Skilled nursing services include the promotion of health prevention of illness care of the ill and disabled people through the provision of services essential to the maintenance and restoration of health Skilled nursing services may include

health assessments and evaluations medical treatments and proceduresadministering andor monitoring medication needed by the student during school hours and

consultation with licensed physicians parents and staff regarding the effects of medication

APR 262010 TN 0961 Approval Date

New SEP 0 1 2009Effective DateSupersedes TN

fGl

New York S Page 2xii3

Attachment 31B

Supplement

Providers Skilled nursing services must be provided by

a New York State licensed registered nurse qualified in accordance with the requirements at 42 CFR 440aand other applicable state and federal law and 60regulations acting within his or her scope of practice or a New York State licensed practical nurse qualified in accordance with 42 CFR 44060a and other applicable state and federal law or regulations acting within his or her scopeof practice under the direction of a licensed registered nurse a physician dentist or other licensed health care provider authorized under the Nurse Practice Act

Under the direction of means that the licensed registered nurse physician or other licensed health care provider authorized under the Nurse Practice Act

sees the participant at the beginning of and periodically during the course of treatment is familiar with the treatment plan as recommended by the referring physician or other licensed practitioner of the healing arts practicing under State law has continued involvement in the care provided and reviews the need for continued services throughout treatment assumes professional responsibility for the services provided under his or her direction and monitors the need for continued services spends as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supporting the supervision of services and onaoinq involvement in the treatment


a New York State licensed and registered nurse or a New York State licensed practical nurse under the direction of a New York State licensed and registered nurse or licensed physician dentist or other licensed health care practitioner legally authorized under the Nurse Practice Act

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES

RA

TN 0961 Approval Date A SEP


New York Of Page i K

PP Attachment 31B4L41 Supplement1 programs aDDroved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices andor in communitysbased settings

Psychological Evaluations

Definition Psychological evaluations outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Psychological evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a referral from a physician physicianassistant or nurse practitioner acting within his or her scope of practice under New York State law or an appropriate school official or other voluntary health or social agency and must be provided to a child by a aualified practitioner Psychological evaluations must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If a psychological evaluation is used to identify a childs health related needs as part of the IEP process the evaluation is eligible for Medicaid coverage once the evaluation is reflected in the child IEPs

Services Medically necessary EPSDT services are health care diagnostic services treatments and other measures to correct or ameliorate physical defects mental illnesses and other disabilities

Psychological evaluations include but are not limited to

Administering psychological tests and other assessment procedures Interpreting testing and assessment results and Evaluating a Medicaid recipient for the purpose of determining the needs for specific psychological health or related services

Providers Psychological evaluations must be provided by a qualified provider who meets the requirements of 42 CFR Section 440 5060 or 42 CFR Section 440aand other applicable state and federal laws and regulations Psychological evaluation services may only be provided by a professional whose credentials are comparable to those of providers who are able to providepsychological evaluation services in the community

APR262010 TN 0961 Approval Date

New Effective Date 01 2001Supersedes TN SFP

New York

Page2xiiL

Attachment 31B

Supplement et

Services may be provided by 1iliN16 a New York State licensed and registered psychiatrist qualified in accordance with 42CFR Section 440aand other applicable state and federal law or regulations50acting within his or her scope of practice under NYS law or

a New York State licensed and registered psychologist qualified in accordance with 42CFR Section 440aand other applicable state and federal law or regulations60acting within his or her scope of practice under NYS law

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOLES programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices and in communitys orbased settings

Medical Evaluations Z

Definition Medical evaluations outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary


Medical evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must be performed by a physician physician assistant or nurse practitioner acting within the scope of his or her practice under New York State law A medical evaluation must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If a medical evaluation is used to identify a child health related needs as part of the IEP process the sevaluation is eligible for Medicaid coverage once the evaluation is reflected in the child IEPs

A medical evaluation is the recording of

chief complaints present illness

ApR 2 6 UV TN 09 ApprovalPP Date61

New Effective DateSupersedes TN SEP 0 1 200

New York

Page2xiiM

Attachment 31B

Supplement

Orfirast medical historyry

personal history and social history a system review a complete physical evaluation ordering of appropriate diagnostic tests and procedures and recommended plan of treatment

Providers A medical evaluation must be provided by a New York State licensed and registered physician physician assistant or nurse practitioner qualified in accordance with 42 CFR Section 440a440a 166 and other applicable state and federal laws5060 aand 440and regulations acting within his or her scope of practice under NYS law

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitionersoffices andor in community based settings

D Medical Specialist Evaluations

Definition Medical specialist evaluations outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Medically necessary EPSDT services are health care diagnostic services treatments and other measures to correct and ameliorate physical defects mental illnesses and other disabilities

Medical specialist evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must be providqd by a New York State licensed and registered physician physician assistant or nurse practitioner specialist acting within his or her scope of practice and related area of specialization A medical specialist evaluation must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If a medical specialist evaluation is used to identify a child health related needs as part of the IEP process the evaluation is eligible for Medicaidscoverage once the evaluation is reflected in the child IEPs

TN 0961 Approval Date gpp 2 f Mil 01 ZOOS

Ne SEPEffective DateSupersedes TN

New York

Page 2xiiN

Attachment 31B

nrrlp A Ul

Supplement

A medical specialist evaluation is

an examination of the affected bodily area or organ system and other symptomatic or related organ systemsthe ordering of appropriate diagnostic tests and procedures and the reviewing of the results and reporting on the tests and procedures

Providers A medical specialist evaluation must be provided by a qualified New York State licensed and registered physician physician assistant or nurse practitioner specialist practicingin the related area of specialization within his or her scope of practice under NYS law in accordance with 42CFR Section 440a440x 166 and other applicable5060 xand 440state and federal laws and regulations

Services may be rendered in the setting in which the childs IEP will be implemented includingbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved privet schools Section4201 schools state operated schools in private practitionersoffices andor in community based settings


Definition Audiological evaluations as outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Audiological evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order from a physician physician assistant or nurse practitioner who is acting within the scope of his or herpractice under NYS law and provided to a child by a qualified practitioner An audiologicalevaluation must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If an audiologicalevaluation is used to identify a childs health related needs as part of the IEP process theevaluation is eligible for Medicaid coverage once the evaluation is reflected in the childs IEP

Medically necessary EPSDT services are health care diagnostic services treatments and other measures to correct and ameliorate physical defects mental illnesses and other disabilities

2 6 2010 TN 0961 Approval Date

zu090New Effective Date SEP

Supersedes TN

New York gmcilPage2xii0

Attachment 31B

Supplement

Medically necessary audiology services include but are not limited to

Identification of children with hearing loss Determination of the range nature and degree of hearing Toss including the referral for medical or other professional attention for the amelioration of hearing and determination of the child need for grow and individual amplifications

An audiological evaluation is the determination of the range nature and degree of hearing Toss including

measurement of hearing acuity tests relating to air and bone conduction speech reception threshold speech discrimination

conformity evaluations pure tone audiometry

Providers Audiology evaluation services must be provided by a New York State licensed and registered audiologist qualified in accordance with 42 CFR Section 440aand 42CFR60Section 440110c3and other applicable state and federal law or regulations acting within his or her scope of practice under NYS law

Services may be rendered in the setting in which the childs IEP will be implemented includingbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices andor in communitysbased settings

j Special Transportation

Definition Special transportation outlined in this section of the State Plan is available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary


TN 09 Approval Date 2 201061 pp

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Services Special transportation provided by or through a school district a Section 4201 school a county in the State or the City of New York must be included in the IEP as recommended by the Committee on Special Education CSE or the Committee on Preschool Special Education CPSE Special transportation arrangements must be identified in the IEP

Special transportation is provided when a child requires specialized transportation equipment supports or services because of hisher disability as cited in 34 CFR30034c16iii

Special transportation is limited to those situations where the child receives transportation to obtain a Medicaid covered service other than transportation and both the Medicaid covered service and the need for special transportation are included in the child TEP Specialstransportation can only be billed on a day that a Medicaid reimbursable service was delivered and may only be billed at the rate for each one way trip

Providers Special transportation services must be provided by a qualified Medicaid provider Attendance documentation bus Togs is required in order to bill Medicaid In order to receive payment for services provided to a Medicaid recipient a vendor must be lawfully authorized to provide transportation services on the date the services are rendered


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4 Early and Periodic Screening Diagnostic and Treatment services EPSDT

School Supportive Health Services and Pre School Supportive Health Services

School Supportive Health Services SSHS and Pre School Supportive Health Services PSSHS are services provided by or through a school district a Section 4201 school a county in the State or New York City to children with disabilities who attend public or State Education Department approved schools or preschools The services must be

medically necessary and included in a Medicaid covered category in accordance with 1905a19055cr1903 of the Social Security Act ordered or prescribed by a physician or other licensed practitioner acting within his or her scope of practice under New York State Law included in the child Individualized Education Program IEPsprovided by qualified professionals under contract with or employed by a school district a Section 4201 school a county in the State or the City of New York furnished in accordance with all requirements of the State Medicaid Program and other pertinent state and federal laws and regulations including those for providerqualifications comparability of services and the amount duration and scope provisions and

included in the states plan or available under Early Periodic Screening Diagnostic and Treatment EPSDT services

Effective September 1 2009 the services covered by the SSHS and PSSHS Program for Medicaid eligible children under the age of 21 who are eligible for Early and Periodic ScreeningDiagnostic and Treatment services EPSDT include medically necessary physical therapyservices occupational therapy services speech therapy services psychological counselingskilled nursing services psychological evaluations medical evaluations medical specialistevaluations audiological evaluations and special transportation within the limits of EPSDT services A school district Section 4201 school a county in the State and New York City must be enrolled as a Medicaid provider in order to bill Medicaid

L Physical Theraoy Services

Definition Physical therapy services outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

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Services Physical therapy services provided by or through a schoI district a Section 4201 school a county in the State or the City of New York must have a written order or prescription from a physician physician assistant or nurse practitioner who is acting within the scope of his or her practice under NYS law and must be provided to a child by or under the direction of a qualified physical therapist Physical therapy services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE These services include any necessary supplies and equipment utilized during the therapy session


Physical therapy services include but are not limited to

Identification of children with physical therapy needs Evaluation for the purpose of determining the nature extent and degree of the need for physical therapy services Provision of physical therapy services for the purpose of preventing or alleviating movement dysfunction and related functional problems Obtaining interpreting and integrating information appropriate to program planning Diagnosis and treatment of physical disability injury or disease using physical and mechanical means including but not limited to heat cold Tight air water sound electricity massage mobilization and therapeutic exercise with or without assistive devices and

The performance and interpretation of tests and measurements to assist pathopsychological pathomechanical and developmental deficits of human systems to determine treatment and assist in diagnosis and prognosis

Physical therapy services may be provided in an individual or group setting


a New York State licensed and registered physical therapist qualified in accordance with 42 CFR 440aand with applicable state and federal laws and regulations acting110within his or her scope of practice under New York State Law or a certified physical therapy assistant under the direction of such a qualified licensed and registered physical therapist acting within his or her scope of practice under New York State Law

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kk Attachment 31A

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Under the direction or means that with respect to each Medicaid beneficiary the qualified therapist



spends as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supporting the supervision of services and ongoing involvement in the treatment

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices at home andor inscommunity based settings

2 Occupational Therapy Services

Definition Occupational therapy services as outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Occupational therapy services provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order or prescription from a physician physician assistant or nurse practitioner who is acting within the

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Attachm 31A

mentSuppleoFficin scope of his or her practice under New York State Law and must be provided to a child by or under the direction of a qualified occupational therapist Occupational therapy services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE These services include any necessary supplies and equipment utilized during the therapy session


Occupational therapy services include but are not limited to

Identification of children with occupational therapy needs Evaluation for the purpose of determining the nature extent and degree of the need for occupational therapy services Improving developing or restoring functions impaired or lost through illness injury or deprivation Preventing through early intervention initial or further impairment or loss of function an

Planning and utilization of a program of activities to develop or maintain adaptive skills designed to achieve maximal physical and mental functioning of the student in daily life tasks

Occupational therapy services may be provided in an individual or group setting

Providers Services mus be provided by

a New York State licensed and registered occupational therapist qualified in accordance with 42CFR 440110band applicable state and federal laws and regulations acting within his or her scope of practice under New York State Law or

a certified occupational therapy assistant COTA under the direction of such a qualified licensed and registered occupational therapist within his or her scope of practice under New York State Law



f A10TN 0961 Approval Date itejtNew XEffective DateSupersedes TN Qa9

1

eAovfld New York

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Attachment 31A

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spends as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supporting the supervision of services and ongoing involvement in the treatment

Services may be rendered in the settings in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools 4201 schools state operated schools in private practitioner offices at home andor in communitysbased settings


Definition Speech therapy services as outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Speech therapy services provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order or prescription from a physician physician assistant nurse practitioner or a speech language pathologist who is acting within his or her scope of practice under New York State law and must be provided to a child by or under the direction of a qualified speech language pathologist Speech therapy services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CCSE


2 f 2010TN 0961 Approval Date

New 01 2005Effective Date SEPSupersedes TN

New York irVaiNiPage2xiiF s Attachment 31A

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Speech therapy services include but are not limited to

Identification of children with speech disorders Diagnosis and appraisal of specific speech disorders Referral for medical or other professional attention necessary for the habilitation of speech disorders Provision of speech or language services for the habilitation or prevention of communicative disorders

Evaluation and application of principles methods and procedures of measurement prediction diagnosis testing counseling consultation rehabilitation and instruction related to the development of disorders of speech voice andor language and Preventing ameliorating or modifying speech disorder conditions in children andor groups of children

Speech therapy services may be provided in an individual or group setting


a licensed and registered speech language pathologist qualified in accordance with 42CFR Section 440cand applicable state and federal laws and regulations acting110within his or her scope of practice under New York State law or a teacher certified to provide speech and language services under the documented direction of such a qualified licensed and registered speech language pathologist ASHA Certified or equivalent acting within his or her scope of practice under New York State Law



is familiar with the treatment plan as recommended by the referring physician or other licensed practiti of the healing arts practicing under State lawnerhas continued involvement in the care Drovided and reviews the need for continued services throughout treatment assumes professional responsibility for the services provided under his or her direction and monitors the need for continued services

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spends as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supportina the supervision of services and ongoing involvement in the treatment

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES1 programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices at home and ins orcommunity based settings


Definition Psychological counseling services outlined in this section of the State Plan are available to Medicaideiigibl beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Psychological counseling provided by or thro gh a school district a Section 4201 school a county in the State or the City of New York must have a referral from a physician physician assistant or a nurse practitioner who is acting withjn the scope of his or her practiceunder NYS law or an appropriate school official or other voluntary health or social agency and must be provided to a child by or under the direction of a qualified practitioner Psychological counseling services must be included in the IEP as recommended by the Committee on preschool Special Education CPSE or Committee on Special Education CSE


Psychological counseling services include

treatment services using a variety of techniques to assist the child in ameliorating behavioral and emotional problems that are severe enough to require treatment

Psychological counseling services may be provided in an individual or group setting

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Page2xiiH

1 Attachment314110 SupplementtiVt04 Providers Psychological counseling services must be provided by a qualified practitioner within his or her scope of practice in accordance with New York State Law and with the qualification requirements of 42 CFR Section 44060 and 440aa 502and with other applicable state and federal laws or regulations Psychological counseling services may only be provided by a professional whose credentials are comparable to those of providers who are able to provide psychological counseling services in the community


a New York State licensed and registered psychiatrist qualified in accordance with 42 CFR Section 440aand other applicable state and federal law or regulations acting50within his or her scope of practice under New York State Law a New York State licensed and registered psychologist qualified in accordance with 42 CFR Section 440aand other applicable state and federal law or regulations acting60within his or her scope of practice under New York State Law a New York State licensed clinical social worker LCSW qualified in accordance 42 CFR Section 440aand other applicable state and federal law or regulations acting60within his or her scope of practice under NYS law or a licensed master social worker LMSW qualified in accordance with 42 CFR Section 440aand other applicable state and federal law or regulations acting within his or60her scope of practice under New York State Law under the supervision of such a qualified licensed clinical social worker a qualified licensed and registered psychologist or a qualified licensed and registered psychiatrist as described above

Supervision of the clinical social work services provided by the licensed master social worker with respect to each Medicaid beneficiary shall consist of contact between the licensed master social worker and supervisor during which

the licensed master social worker apprises the supervisor of the diagnosis and treatment of each client the licensed master social worker cases are discussedsthe supervisor provides the licensed master social worker with oversight and

uid nce in dia nosin and atin clients

the supervisor regularly reviews and evaluates the professional work of the licensed master social worker and

the supervisor provides at least one hour per week or two hours every other week of inperson individual or group clinical supervision provided that at least two hours per month shall be individual clinical supervision


01 NSP


New York

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Attachment 31A

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Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES ramsr ol r chool roved rivateroaved re o bli a ion

4201 schools state operated schools in private practitioner offices at home andor inscommunity based settings

5 Skilled Nursing

Definition Skilled nursing services outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Skilled nursing services provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a written order or prescription from a physician physician assistant or nurse practitioner acting within his or her scope of practice under New York State law and must be provided to a child by a registered nurse acting within his or her scope of practice under New York State law or by a NYS licensed practical nurse acting within his or her scope of practice under New York State law under the direction of a NYS licensed and registered nurse or licensed physician dentist or other licensed health care provider authorized under the Nurse Practice Act Skilled nursing services must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE when there is a specific need based on a medical condition of the child

Medically necessary EPSDT services are health care diagnostic services treatments and other measures necessary to correct and ameliorate physical defects mental illnesses and other disabilities

Skilled nursing services include the promotion of health prevention of illness care of the ill and disabled people through the provision of services essential to the maintenance and restoration of health Skilled nursing services may include

health assessments and evaluations

medical treatments and procedures administering andor monitoring medication needed by the student during school hours and

consultation with licensed physicians parents and staff regarding the effects of medication

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Providers Skilled nursing services must be provided by

a New York State licensed registered nurse qualified in accordance with the requirements at 42 CFR 440aand other applicable state and federal law and60regulations acting within his or her scope of practice or a New York State licensed practical nurse qualified in accordance with 42 CFR 44060a and other applicable state and federal law or regulations acting within his or her scope of practice under the direction of a licensed registered nurse a physician dentist or other licensed health care provider authorized under the Nurse Practice Act

Under the direction of means that the licensed registered nurse physician or other licensed health care provider authorized under the Nurse Practice Act



spends as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards ofpractice ensures that individuals working under his or her direction have contact information to permit him or her direct contact with the supervising therapist as necessary during the course of treatment and keeps documentation supporting the supervision of services and ongoing involvement in the treatment


a New York State licensed and registered nurse or a New York State licensed practical nurse under the direction of a New York State licensed and registered nurse or licensed physician dentist or other licensed health care practitioner legally authorized under the Nurse Practice Act

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES

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programs approved preschool programs public sbIs approved private schools Section 4201 schools state operated schools in private practitioner offices andor in communitysbased settings

Psychological Evaluations

Definition Psychological evaluations outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Psychological evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must have a referral from a physician physician assistant or nurse practitioner acting within his or her scope of practice under New York State law or an appropriate school official or other voluntary health or social agency and must be provided to a child by a qualified practitioner Psychological evaluations must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If a psychological evaluation is used to identify a childs health related needs as part of the IEP process the evaluation is eligible for Medicaid coverage once the evaluation is reflected in the child IEPs


Psychological evaluations include but are not limited to

Administering psychological tests and other assessment procedures Interpreting testing and assessment results and Evaluating a Medicaid recipient for the purpose of determining the needs for specific psychological health or related services

Providers Psychological evaluations must be provided by a qualified provider who meets the requirements of 42 CFR Section 44060 or 42 CFR Section 440a50 and other applicable state and federal laws and regulations Psychological evaluation services may only be provided by a professional whose credentials are comparable to those of providers who are able to provide psychological evaluation services in the community

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a New York State licensed and registered psychiatrist qualified in accordance with 42CFR Section 440aand other applicable state and federal law or regulations50acting within his or her scope of practice under NYS law or

a New York State licensed and registered psychologist qualified in accordance with 42CFR Section 440aand other applicable state and federal law or regulations60acting within his or her scope of practice under NYS law

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services BOCES programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices andor in communitysbased settings

Medical EvaluationsZ

Definition Medical evaluations outlined in this section of the State Plan are available to Medicaideligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary


Medical evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must be performed by a physician physician assistant or nurse practitioner acting within the scope of his or her practice under New York State law A medical evaluation must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If a medical evaluation is used to identify a child health related needs as part of the IEP process thesevaluation is eligible for Medicaid coverage once the evaluation is reflected in the child IEPs

A medical evaluation is the recording of

chief complaints present illness

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past medical history personal history and social history a system review a complete physical evaluation ordering of appropriate diagnostic tests and procedures and recommended plan of treatment

Providers A medical evaluation must be provided by a New York State licensed and registered physician physician assistant or nurse practitioner qualified in accordance with 42 CFR Section 440a440a 166 and other applicable state and federal laws5060 aand 440and regulations acting within his or her scope of practice under NYS law


Medical Specialist Evaluations

Definition Medical specialist evaluations outlined in this section of the State Plan are available to Medicaideligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Medically necessary EPSDT services are health care diagnostic services treatments and other measures to correct and ameliorate physical defects mental illnesses and other disabilities

Medical specialist evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York must be provided by a New York State licensed and registered physician physician assistant or nurse practitioner specialist acting within his or her scope of practice and related area of specialization A medical specialist evaluation must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If a medical specialist evaluation is used to identify a child health related needs as part of the IEP process the evaluation is eligible for Medicaidscoverage once the evaluation is reflected in the child IEPs

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A medical specialist evaluation is

an examination of the affected bodily area or organ system and other symptomatic or related organ systems the ordering of appropriate diagnostic tests and procedures and the reviewing of the results and reporting on the tests and procedures

Providers A medical specialist evaluation must be provided by a qualified New York State licensed and registered physician physician assistant or nurse practitioner specialist practicing in the related area of specialization within his or her scope of practice under NYS law in accordance with 42CFR Section 440a440a 166 and other applicable5060 aand 440state and federal laws and regulations

Services may be rendered in the setting in which the child IEP will be implemented includingsbut not limited to Article 28 facilities Board of Cooperative Educational Services IBOCES programs approved preschool programs public schools approved private schools Section 4201 schools state operated schools in private practitioner offices andor in communitysbased settings


Definition Audiological evaluations as outlined in this section of the State Plan are available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary

Services Audiological evaluations provided by or through a school district a Section 4201 school a county in the State or the City of New York mustjiave a written order from a physician physician assistant or nurse practitioner who is acting within the scope of his or her practice under NYS law and provided to a child by a qualified practitioner An audiologicalevaluation must be included in the IEP as recommended by the Committee on Preschool Special Education CPSE or Committee on Special Education CSE If an audiologicalevaluation is used to identify a child health related needs as part of the IEP process thesevaluation is eligible for Medicaid coverage once the evaluation is reflected in the child IEPs

Medically necessary EPSDT services are health care diagnostic services treatments and other measures to correct and am liorate physical defects mental illnesses and other disabilities

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Medically necessary audiology services include but are not limited to

Identification of children with hearing loss Determination of the range nature and degree of hearing Toss including the referral for medical or other professional attention for the amelioration of hearing and determination of the child need for group and individual amplifications

An audiological evaluation is the determination of the range nature and degree of hearing loss including

measurement of hearing acuity tests relating to air and bone conduction speech reception threshold speech discrimination conformity evaluations pure tone audiometry

Providers Audiology evaluation services must be provided by a New York State licensed and registered audiologist qualified in accordance with 42 CFR Section 440aand 42CFR60Section 440cand other applicable state and federal law or regulation acting within1103his or her scope of practice under NYS law


I Special Transportation

Definition Special transportation outlined in this section of the State Plan is available to Medicaid eligible beneficiaries under 21 years of age who are eligible for Early and Periodic Screening Diagnostic and Treatment EPSDT services and for whom services are medically necessary


Apil 26201L 61TN 09 Approval Date

New Effective Date SEP 01 AS Supersedes TN

flflrAI New York

Page2xiiP

Attachment 31A

Supplement

Services Special transportation provided by or through a school district a Section 4201 school a county in the State or the City of New York must be included in the IEP as recommended by the Committee on Special Education CSE or the Committee on Preschool Special Education CPSE Special transportation arrangements must be identified in the IEP

Special transportation is provided when a child requires specialized transportation equipment supports or services because of hisher disability as cited in 34 CFR 30034c16iii

Special transportation is limited to those situations where the child receives transportation to obtain a Medicaid covered service other than transportation and both the Medicaid covered service and the need for special transportation are included in the child IEP Specialstransportation can only be billed on a day that a Medicaid reimbursable service was delivered and may only be billed at the rate for each one way trip

Providers Special transportation services must be provided by a qualified Medicaid providerAttendance documentation jbus Togs is required in order to bill Medicaid In order to receive payment for services provided to a Medicaid recipient a vendor must be lawfully authorized to provide transportation services on the date the services are rendered

TN 0961 Approval Date Wiz 2 6 Z41 New Effective DateSupersedes TN SE 0 2009

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