1. (a) All enrolled school providers shall:

   1. (1) Be enrolled with NH medicaid for the purposes of administration and billing;
   2. (2) Verify the qualifications, licensure, and certifications, as applicable, of performing-only providers upon hire and at the time of any licensure or certification renewal and maintain proof of verification;
   3. (3) Screen all providers, employees, contractors, and school personnel that are involved with administering or delivering medicaid services, upon hire and on a monthly basis thereafter, for exclusions against the Office of Inspector General (OIG) exclusion and sanction database pursuant to section 1866(j)(2) of the Social Security Act, section 1903(i) of the Social Security Act, and 42 CFR 1001.1901. The OIG exclusion and sanction database may be found at https://exclusions.oig.hhs.gov; and

   4. (4) Ensure all providers have knowledge in the following areas:

      1. a. Medicaid recipient rights, and the reporting of abuse and neglect; and
      2. b. Record keeping and documentation requirements pursuant to this part, including the penalties associated with improper recordkeeping and documentation.

2. (b) All covered services shall be:

   1. (1) Provided through a student's LEA or SAU;
   2. (2) Medically necessary;
   3. (3) Included and documented in the student’s care plan in accordance with this part;
   4. (4) Provided in a variety of locations and settings as specified in a student’s care plan and might occur outside the hours of the usual school day;
   5. (5) Provided by qualified clinicians pursuant to this part and who comply with the scope of their board licensure for their clinical practice including supervision and ordering requirements; and
   6. (6) Prior authorized if required by the NH medicaid state plan, federal or state law, or the rules adopted thereunder.

3. (c) Covered services may be provided by staff employed or subcontracted by the enrolled school provider and who shall be:

   1. (1) Either licensed by the applicable clinical boards to provide the services provided or otherwise under the direction of the appropriate licensed clinician to provide the services as permitted by applicable licensure law; or
   2. (2) Board certified behavior analysts (BCBA) appropriately certified by the national Behavior Analyst Certification Board, and if supervising others, have a supervisory certification issued by the national board and be acting within the scope of that certification.

4. (d) Covered supplies and equipment described under He-W 589.04 shall:

   1. (1) Be acquired for the use of a specific student;
   2. (2) When purchased, be the property of the student and their family; and
   3. (3) When rented or acquired through a used equipment exchange program, be the property of the student and their family during the period used.
5. (e) DME shall be provided by a qualified DME provider, and in accordance with the requirements pursuant to He-W 571.
6. (f) AAC devices and aids shall be provided by a qualified DME provider, and in accordance with the requirements of He-W 575.

7. (g) A medical evaluation shall be covered when performed to address a recipient complaint or illness and shall include the following:

   1. (1) An initial evaluation conducted by a physician, APRN, or physician assistant; and
   2. (2) The opinion or advice of a physician, APRN, or physician assistant regarding the evaluation or treatment of the student’s condition including services rendered.
8. (h) If after the initial evaluation in (g) above the physician, APRN, or physician assistant assumes the continuing care of the student, any service(s) provided subsequent to the initial evaluation by such physician, APRN, or physician assistant shall not be considered an evaluation but might be coverable as another service pursuant to this part.

9. (i) The following medical evaluation services performed by the providers in (g) above shall be billable under the category of medical evaluation:

   1. (1) Examination of a single organ system, including:

      1. a. Documentation of complaint(s);
      2. b. Physical examination and diagnosis of current illness; and
      3. c. Establishment of a plan of management relating to a specific problem; and

   2. (2) In-depth evaluation with development and documentation of medical data, including:

      1. a. Chief complaint;
      2. b. Present illness;
      3. c. Family history;
      4. d. Medical history;
      5. e. Personal history;
      6. f. System review; and
      7. g. Physical examination.
10. (j) Any consult service for which the student was present at least 51% of the time shall be a covered consultation service.

11. (k) Nursing services shall be medically necessary to meet the health needs of a student and include:

    1. (1) Any assessments or treatments performed by a licensed registered nurse, licensed practical nurse (LPN), or APRN for a student; and
    2. (2) Supplies and equipment necessary for the provision of the covered nursing services as determined by the licensed registered nurse, LPN, or APRN.

12. (l) Nursing services shall be performed by the following:

    1. (1) An APRN licensed to practice in NH by the NH board of nursing in accordance with RSA 326-B:18 or the state in which they practice as a registered nurse in an advance practice role;

    2. (2) A registered nurse who is:

       1. a. Licensed to practice in NH or the state in which they practice in accordance with RSA 326-B; and
       2. b. Acting under the direction of a physician, APRN, or physician assistant for those activities that require an order; or

    3. (3) A LPN who is:

       1. a. Licensed to practice in NH under RSA 326-B or the state in which they practice; and
       2. b. Acting under the direction of a physician, APRN, registered nurse, or physician assistant.

13. (m) Nursing services shall include the following:

    1. (1) Administration of medication(s);
    2. (2) Positioning or repositioning;
    3. (3) Assistance with specialized feeding programs;

    4. (4) Management and care of specialized medical equipment such as:

       1. a. Colostomy bags:
       2. b. Nasogastric tubes;
       3. c. Tracheostomy tubes; and
       4. d. Related medical devices;
    5. (5) Observation of students with chronic medical illnesses in order to assure that medical needs are being appropriately identified, addressed, and monitored; and
    6. (6) Other services determined by a registered nurse, LPN, or APRN to be medically necessary and appropriate.

14. (n) Billable categories of nursing services shall include the following:

    1. (1) Nursing assessment;
    2. (2) Nursing treatment; and
    3. (3) Supplies and equipment necessary to provide covered nursing services.

15. (o) Private duty nursing services shall be:

    1. (1) Covered services when they are part of the student’s medical regimen and rendered under the order and under the direction of the student’s physician; and
    2. (2) Covered and delivered in accordance with the requirements of He-W 540.

16. (p) Occupational therapy services shall be covered if the services are medically necessary to implement a program of activities to develop or maintain adaptive skills necessary to achieve adequate and appropriate physical and mental functioning of a student including:

    1. (1) Any evaluations, treatment, or assessments performed by an occupational therapist of students whose abilities to carry out age appropriate tasks are threatened or impaired by physical illness, injury, or disease, mental illness, emotional disorder, or congenital or developmental disability;
    2. (2) Supplies and equipment necessary to provide the covered occupational therapy services as recommended by an occupational therapist; and
    3. (3) Occupational therapy services performed by an occupational therapy assistant carrying out a therapy plan developed by the occupational therapist.

17. (q) Occupational therapy services shall be provided by:

    1. (1) An occupational therapist who is licensed to practice in NH or the state in which they practice; or
    2. (2) An occupational therapy assistant as defined in RSA 326-C:1, III working under the direction of a licensed occupational therapist.

18. (r) Occupational therapy services shall include:

    1. (1) Task-oriented activities to correct physical or emotional deficits or to minimize the disabling effect of these deficits in the life of the student;

    2. (2) Evaluations of:

       1. a. Sensorimotor abilities;
       2. b. Self-care activities;
       3. c. Capacity for independence;
       4. d. Physical capacity for prevocational and work tasks; and
       5. e. Play and leisure performance;

    3. (3) Specific occupational therapy techniques involving:

       1. a. Improving skills for ADLs;
       2. b. The fabrication and application of splinting devices;
       3. c. Sensorimotor activities;
       4. d. The use of specifically designed manual and creative activities;
       5. e. Guidance in the selection and use of adaptive equipment; and
       6. f. Specific exercises to enhance functional performance and physical capabilities needed for work activities; and
    4. (4) Other services determined by an occupational therapist to be medically necessary and appropriate.

19. (s) Billable categories of occupational therapy services shall include the following:

    1. (1) Occupational therapy, evaluation;
    2. (2) Occupational therapy, individual;
    3. (3) Occupational therapy, group; and
    4. (4) Supplies and equipment necessary for the provision of covered occupational therapy services.

20. (t) Physical therapy services shall include:

    1. (1) Any evaluations to determine a student's level of physical functioning, including performance tests to measure strengths, balance, endurance, and range of motion;
    2. (2) Any treatment services, evaluations, or assessments which might utilize therapeutic exercises or the modalities of heat, cold, water, and electricity, for the purpose of preventing, restoring, or alleviating a lost or impaired physical function;
    3. (3) Other services, including supplies and equipment, determined by a physical therapist to be medically necessary and appropriate for a student's physical therapy; and
    4. (4) Physical therapy services performed by a physical therapy assistant carrying out a therapy plan developed by the physical therapist.

21. (u) Physical therapy services shall be provided by:

    1. (1) A physical therapist who is a graduate of a program of physical therapy approved by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Physical Therapy Association or its equivalent and licensed to practice in the state of NH or the state in which they practice; or
    2. (2) A physical therapy assistant as defined in RSA 328-A:2, VIII who is under the direction of a licensed physical therapist pursuant to (1) above.
22. (v) Physical therapy services shall be medically necessary.

23. (w) Billable categories of physical therapy services shall include the following:

    1. (1) Physical therapy, evaluation;
    2. (2) Physical therapy, individual;
    3. (3) Physical therapy, group; and
    4. (4) Supplies and equipment necessary for the provision of covered physical therapy services.
24. (x) Psychiatric services shall be medically necessary for the evaluation, assessment, diagnosis, and treatment of mental or emotional conditions.

25. (y) Psychiatric services shall be provided by:

    1. (1) A psychiatrist who is a physician licensed to practice in NH as defined in RSA 135-C:2, XIII, or the state in which they practice and either board certified or board eligible according to the most recent regulations of the American Board of Psychiatry and Neurology, Inc. or its successor organization; or
    2. (2) An APRN with a psychiatric specialty pursuant to RSA 326-B:18.

26. (z) Billable categories of psychiatric services shall include the following:

    1. (1) Psychiatric evaluation and diagnosis; and
    2. (2) Psychiatric treatment.
27. (aa) Psychological services shall require an order and be medically necessary for the evaluation, diagnosis, treatment, and counseling of mental or emotional illnesses, symptoms, or conditions.

28. (ab) Psychological services shall be provided by:

    1. (1) A psychologist who is a school psychologist or associate school psychologist certified by the state board of education in NH or in the state in which they practice and licensed by the NH board of psychologists or another state’s board of psychology;
    2. (2) A psychologist or associate psychologist licensed by the NH board of psychologists or licensed by another state’s board of psychology;
    3. (3) A physician;
    4. (4) APRNs with a psychiatric specialty pursuant to RSA 326-B:18;
    5. (5) Psychotherapists acting within the scope of their licensure; or
    6. (6) A master licensed alcohol and drug counselor (MLADC) for co-occurring mental health and substance use disorders.

29. (ac) Billable categories of psychological services shall include the following:

    1. (1) Psychological testing and evaluation;
    2. (2) Psychodiagnostic testing;
    3. (3) Psychological counseling, individual treatment;
    4. (4) Psychological counseling, group treatment; and
    5. (5) Family counseling, during which the student shall be present at 51% of the counseling session.

30. (ad) Mental health services, other than psychiatric and psychological services, shall:

    1. (1) Be covered if they are medically necessary and ordered; and

    2. (2) Include, but not be limited to:

       1. a. Behavior management;
       2. b. Individual counseling;
       3. c. Group counseling;
       4. d. Family counseling, during which the student shall be present at 51% of the counseling session; and
       5. e. Crisis intervention.

31. (ae) Persons providing mental health services shall be:

    1. (1) A psychologist who is a school psychologist or associate school psychologist certified by the state board of education in NH or in the state in which they practice and licensed by the NH board of psychologists or another state’s board of psychologist;
    2. (2) A mental health practitioner or a psychotherapist as defined in RSA 330-A:2, VII and VIII, respectively;
    3. (3) A psychologist licensed by the board of psychologists pursuant to RSA 329-B; or
    4. (4) An APRN with a psychiatric specialty pursuant to RSA 326-B:18.
32. (af) Substance use disorder (SUD) treatment and recovery support services shall be provided by the licensed qualified providers described in He-W 513, and in accordance with the requirements in He-W 513.

33. (ag) Applied behavior analysis (ABA) shall be covered for individuals with the following diagnoses:

    1. (1) Autism spectrum disorder; or
    2. (2) Pervasive developmental disability.

34. (ah) ABA shall be provided by:

    1. (1) A BCBA appropriately certified by the national Behavior Analyst Certification Board, and if supervising others, have a supervisory certification issued by the national Behavior Analyst Certification Board and be acting within the scope of that certification;
    2. (2) A rehabilitation assistant, as defined by (al), under the appropriate supervision of (1) above;
    3. (3) A board certified assistant behavior analyst (BCABA), under the appropriate supervision of (1) above; or
    4. (4) A registered behavior technician (RBT), under the appropriate supervision of (1) above.

35. (ai) Billable categories of ABA shall include the following:

    1. (1) Behavior identification assessment; and
    2. (2) Adaptive behavior treatment.

36. (aj) ABA services shall be recommended by a licensed clinician who has experience in the diagnosis and treatment of autism spectrum disorder or pervasive developmental disorder and holds at least one of the following educational degrees and valid license:

    1. (1) Physician;
    2. (2) Psychologist;
    3. (3) Nurse practitioner specializing in developmental medicine; or
    4. (4) Physician’s associate specializing in developmental medicine.

37. (ak) Rehabilitative assistance services shall include the following:

    1. (1) Mobility assistance such as positioning, transfers, correct application of ankle-foot orthosis, bracing or orthotic devices, range of motion, fall prevention, safety risk precautions, and physical therapy carry-over tasks as directed by the licensed physical therapist;
    2. (2) Communication assistance such as assistance with sign language, prompting to facilitate expressive and receptive language, assistance with AAC devices and other such devices that ameliorate communication limitations, and speech language carry-over tasks as directed by the licensed speech language pathologist;
    3. (3) Assistance with the implementation of behavioral management plans to increase adaptive behavioral functioning and carry-over tasks as directed by the mental health practitioner or BCBA;
    4. (4) Nutrition such as assistance with eating, cutting food, food preparation, and safe eating plan carry-over tasks as directed by the speech language pathologist or occupational therapist;
    5. (5) Cueing, prompting, and guiding, when provided as part of the assistance with ADLs, communication, or behavior management;
    6. (6) Assistance with adaptive or assistive devices when linked to the student’s medical condition;
    7. (7) Assistance with the use of DME when linked to the student’s medical condition;
    8. (8) Medication administration to the extent allowable under RSA 326-B and pursuant to Nur 404.07 when the rehabilitative assistant has been trained by a nurse in medication administration, and the nurse has delegated the task of medication administration to the rehabilitative assistant;
    9. (9) Personal care services such assistance with ADL and IADL and assistance with occupational therapy, physical therapy, or speech language carry-over tasks;
    10. (10) Carry-over of therapy skills training as delegated by a speech language pathologist, physical therapist, and occupational therapist;
    11. (11) Observation and reporting of signs of distress in the student’s medical condition as trained by a registered nurse;
    12. (12) Implementation of safe eating plans and g-tube feedings as delegated by a registered nurse with applicable training;
    13. (13) Maintaining a safe environment to assure the student’s safety concerns are met for the student, other students, and staff; and
    14. (14) Any other remedial services that are included in the student’s care plan as medically necessary for the maximum reduction of a student's physical or mental disabilities, excluding educational and social activities such as classroom instruction and academic tutoring.

38. (al) Rehabilitative assistants shall:

    1. (1) Either:

       1. a. Be certified pursuant to Ed 504.05 or Ed 504.06, requirements and certification for paraeducators;
       2. b. Have qualifications determined by the department to be equivalent to the requirements for certification under Ed 504.05 or 504.06; or
       3. c. Be other licensed clinicians; and

    2. (2) If applicable for the tasks delegated to the rehabilitative assistant or if required by law have knowledge in the following areas:

       1. a. Personal care and nutrition;
       2. b. Infection control and universal precautions designed to prevent the transmission of infectious diseases;
       3. c. Safety and emergency procedures, including basic first aid and 911 protocols; and
       4. d. Proper lifting techniques.
39. (am) Rehabilitative assistants shall provide rehabilitation assistance services in accordance with Ed 1113.12.
40. (an) Rehabilitative assistance services shall be medically necessary and require an order.

41. (ao) Provision of rehabilitative assistance services shall be reviewed by a licensed clinician designated by the enrolled school provider’s care plan team every 30 days. Documentation for the 30-day review shall include:

    1. (1) The type of contact including face to face, observation, or telephone call;
    2. (2) Areas covered such as duties and expectations, and skills development;
    3. (3) A list of trainings completed within the past 30 days;
    4. (4) Issues identified, if any, and action to be taken;
    5. (5) Date of current session;
    6. (6) Date of next session;
    7. (7) Attestation that the services were provided; and
    8. (8) Licensed clinician signature and attestation that the services were conducted in accordance with the care plan.
42. (ap) Speech and language services shall be covered services if they are services, supplies, or equipment ordered by a licensed audiologist or licensed speech-language pathologist or a speech-language specialist certified by the department of education, as described in RSA 326-F:3, IV(b) to be medically necessary for the evaluation, diagnosis, or treatment of speech, language, and hearing disorders which result in communication disabilities.
43. (aq) Speech and language services shall include services performed by speech language assistants listed in (ar) below carrying out a therapy plan developed by the speech language pathologist and speech-language specialists certified by the department of education, as described in RSA 326 F:3, IV(b).

44. (ar) Speech and language services shall be provided by:

    1. (1) A speech-language pathologist who is either:

       1. a. Licensed pursuant to RSA 326-F to practice in NH, which shall be considered equivalent to having met the requirements for the American Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence in Speech-Language Pathology; or

       2. b. Licensed in the state in which they practice and have one of the following:

          1 A Certificate of Clinical Competence from the ASHA;

          2 Completed the equivalent educational requirements and work experience necessary for the certificate; or

          3 Completed the academic program and is acquiring supervised work experience to qualify for the certificate;

    2. (2) A speech-language assistant as defined in RSA 326-F:1, XI working under the direction of a licensed speech-language pathologist pursuant to (2) above; or
    3. (3) A certified speech-language specialist as described at RSA 326-F:3, IV(b).

45. (as) Billable categories of speech and language services shall include the following:

    1. (1) Individual speech or language evaluation;
    2. (2) Speech or language, individual treatment;
    3. (3) Speech or language, group treatment; and
    4. (4) Supplies and equipment necessary for the provision of covered speech and language services.
46. (at) Audiology services shall be medically necessary for the prevention or rehabilitation of hearing impairment or restoration of a student with a hearing impairment to their best possible functional level and be provided by an audiologist.

47. (au) Billable categories of audiology services shall include the following:

    1. (1) Individual hearing evaluation;
    2. (2) Hearing therapy, individual treatment;
    3. (3) Hearing therapy, group treatment; and
    4. (4) Supplies and equipment necessary for the provision of covered hearing services.
48. (av) Vision services shall be medically necessary for the prevention or rehabilitation of visual impairment or restoration of a student with a visual impairment to their best possible functional level and be provided by an optometrist licensed under RSA 327, a physician licensed under RSA 329 with a specialty in ophthalmology, or an optician licensed under RSA 327-A.
49. (aw) EPSDT comprehensive and age-appropriate medical assessments and screenings of a student’s physical and mental status, including vision and hearing screenings shall be provided in accordance with the requirements pursuant to He-W 546.05.
50. (ax) Services that are not covered or have coverage limits under the NH medicaid state plan shall be covered through the EPSDT benefit when medically necessary, coverable under Section 1905(a) of the Social Security Act, and requested in accordance with the requirements of He-W 546.

51. (ay) Except as indicated in (ba) below, the following shall be examples of services subject to the requirements of He-W 546:

    1. (1) Rehabilitative assistance services;
    2. (2) Applied behavior analysis;
    3. (3) Personal care services for individuals under the age of 21;
    4. (4) Wrap around services;
    5. (5) Case management services; and
    6. (6) Other optional services listed in 1905(a) of the Social Security Act and not included in the NH medicaid state plan or included as a covered service under this part.

52. (az) The following services shall not be subject to the prior authorization requirements of He-W 546:

    1. (1) Rehabilitative assistance services;
    2. (2) Applied behavior analysis; and
    3. (3) Personal care services for individuals under the age of 21.
53. (ba) Any services not listed as covered under the NH medicaid state plan or services with coverage limits shall be given independent review by the department for coverage based on medical necessity in accordance with the EPSDT benefit pursuant to He-W 546.

54. (bb) Specialized transportation shall be a billable service as follows:

    1. (1) Transportation shall be listed in the student’s IEP as a required service and the student shall be physically in the vehicle for the transportation to be billable to medicaid;

    2. (2) Transportation shall be considered a required service if:

       1. a. The student requires transportation in a vehicle specially adapted to serve the needs of the disabled student, including a specially adapted school bus; or
       2. b. The student resides in an area that does not have school bus transportation, such as those areas in close proximity to a school, but has a medical need for transportation that is noted in the IEP;

    3. (3) The following transportation may be billed as a medicaid service:

       1. a. Transportation to and from school only on a day when the student receives a medicaid coverable service at school during the school day; and
       2. b. Transportation to and from a medicaid coverable service in the community during the school day;
    4. (4) The medicaid coverable service in (3)a. and (3)b. above shall be listed in the student’s IEP as a required service; and

    5. (5) In addition to the documentation required by He-W 589.06, transportation providers shall maintain a daily transportation log to include:

       1. a. Student’s name;
       2. b. Date of service;
       3. c. Clear indication that the student is being transported either one-way or round-trip;
       4. d. The total number of students on the bus, both in the morning and the afternoon;
       5. e. The total miles the bus traveled, both in the morning and the afternoon;
       6. f. Driver’s name; and
       7. g. Driver’s signature.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98 New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99 New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07 New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a)-(d), (f)-(h), (j), (k), (m), (n), (p), (r), (t), (v)-(x), (z)-(ad) and (af); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; ss by #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19 (and #11165 effective again pursuant to RSA 541-A:18, V); ss by #12861, EMERGENCY RULE, eff 8-28-19 New. #12994, eff 2-21-20 (formerly He-M 1301.04) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35