1. (a) Medicaid covered services shall be provided to children as part of the residential component of a residential treatment program or foster care program and shall not be billed to the Medicaid to schools program pursuant to He-M 1301.

2. (b) Covered services shall be approved by the prescribing practitioner to be medically necessary, using the following criteria:

   1. (1) The services are designed to provide maximum reduction of physical, intellectual, or behavioral disability and restore a child to his or her best possible functional level; and
   2. (2) There is no other equally effective course of treatment available on a fee-for-service basis that is more conservative, less restrictive, or substantially less costly than the per diem rate for residential treatment program or foster care program services.

3. (c) Covered services shall:

   1. (1) Be provided in accordance with a child’s treatment plan; and
   2. (2) Be designed to meet the health and rehabilitative needs of a child to address his or her physical, intellectual, or behavioral disability.

4. (d) Covered services shall include:

   1. (1) Nursing services;
   2. (2) Occupational therapy, including evaluations, treatments or consultations necessary to implement a program of activities to develop or maintain skills necessary to achieve adequate and appropriate physical and mental functioning of a child;
   3. (3) Physical therapy, when provided by or under the supervision of a physical therapist, and for which there shall be a physician’s written authorization for individual or group treatment, supplies, and equipment related to physical therapy;
   4. (4) Psychiatric services when necessary for the evaluation, diagnosis, and treatment of psychiatric problems;
   5. (5) Psychological services when necessary for the evaluation, diagnosis, and treatment of emotional or behavioral problems or disturbances;
   6. (6) Speech, language and hearing services when necessary for the evaluation, diagnosis, and treatment of speech, language, and hearing disorders;
   7. (7) Rehabilitative services, which shall be included in the treatment plan and based on a physician’s written referral or a recommendation from a prescribing practitioner;
   8. (8) Behavioral health, other than psychiatric and psychological services referenced in (4) and (5) above; and
   9. (9) Any other remedial services as are necessary for the maximum reduction of a child’s physical, intellectual, or behavioral disabilities, excluding classroom instruction and academic tutoring.

5. (e) Nursing services referenced in (d)(1) above shall be performed by an RN, LPN or ARNP, and shall include:

   1. (1) Any evaluations, treatments, staff training, or consultations that are necessary for the child to be safely cared for;
   2. (2) Administration of medication;
   3. (3) Observation of children with chronic or acute illnesses in order to assure that medical needs are being appropriately identified, addressed and monitored; and
   4. (4) Other services allowed under their individual identified scope of practice for nursing services.

6. (f) Physical therapy services referenced in (d)(3) above shall include:

   1. (1) Evaluations;
   2. (2) Treatment; and
   3. (3) Consultation that might prevent, restore or alleviate a loss of or impairment of a physical function.

7. (g) Rehabilitative services referenced in (d)(7) above shall include:

   1. (1) Assistance with communication;
   2. (2) Behavior management;
   3. (3) Nutrition counseling;
   4. (4) Medication management and training;
   5. (5) Hygiene and personal care training;
   6. (6) Coordination of medical care; and
   7. (7) Development and implementation of individual treatment plans.

8. (h) Behavioral health services referenced in (d)(8) above shall include, at a minimum:

   1. (1) Behavior management;
   2. (2) Individual, group, and/or family counseling;
   3. (3) Substance use disorder counseling; and
   4. (4) Crisis intervention and stabilization.

Source. #5804, eff 3-28-94, EXPIRED: 3-28-00 New. #9028, eff 11-17-07; ss by #10986, eff 11-26-15