1. (1) Covered services.

   1. (a) General.

      1. 1. School-based services covered by the MA program are services described in this section that are provided by a school district or CESA.
      2. 2. The school district or CESA shall ensure that individuals who deliver the services, whether employed directly by or under contract with the school district or CESA, are licensed under ch. PI 34, Trans 301 or ch. 441, Stats.
      3. 3. Notwithstanding s. DHS 106.13 (intro.) and (1) (c), requirements under chs. DHS 101 to 108 as they relate to school-based services, to the extent consistent with 42 CFR ch. IV, may be waived if they are inconsistent with other federal education mandates.
      4. 4. Consultation, case monitoring and coordination related to developmental testing under the individuals with disabilities education act, 20 USC 1400 to 1485, are included in the MA-covered services described in this subsection when an IEP results from the testing. Consultation, case monitoring and coordination for IEP services are also included in the covered services described in this subsection.
   2. (b) Speech, language, hearing and audiological services. Speech, language, hearing and audiological services for a member with a speech, language or hearing disorder that adversely affects the individual’s functioning are covered school-based services. These services include evaluation and testing to determine the individual’s need for the service, recommendations for a course of treatment, treatment, and coaching. The services may be delivered to an individual or to a group of 2 to 7 individuals. These services must be prescribed or referred by a provider certified under ch. DHS 105, and acting within the scope of their practice under applicable statutes and rules that govern the provider’s practice. The services shall be performed by or under the direction of a speech and language pathologist or by an audiologist licensed by the department of public instruction, and shall be identified in the member’s treatment plan.
   3. (c) Occupational therapy services. Occupational therapy services which identify, treat, or compensate for medical problems that interfere with age-appropriate functional performance are covered school-based services. These services include evaluation to determine the individual’s need for occupational therapy, recommendations for a course of treatment, rehabilitative, active or restorative treatment services, and coaching. The services may be delivered to an individual or to a group of 2 to 7 individuals. These services must be prescribed by a provider certified under ch. DHS 105, and acting within the scope of their practice under applicable statutes and rules that govern the provider’s practice. The services shall be performed by or under the direction of an occupational therapist licensed by the department of public instruction and shall be identified in the member’s treatment plan.
   4. (d) Physical therapy services. Physical therapy services which identify, treat, or compensate for medical problems are covered school-based services. These services include evaluation to determine the individual's need for physical therapy, recommendations for a course of treatment, therapeutic exercises and rehabilitative procedures, and coaching. The services may be delivered to an individual or to a group of 2 to 7 individuals. These services must be prescribed by a provider certified under ch. DHS 105, and acting within the scope of their practice under applicable statutes and rules that govern the provider’s practice. The services shall be performed by or under the direction of a physical therapist licensed by the department of public instruction and identified in the member’s treatment plan.
   5. (e) Nursing services. Professional nursing services relevant to the member’s medical needs are covered school-based services. These services include evaluation and management services, including screens and referrals for treatment of health needs; treatment; medication management; and explanations given of treatments, therapies and physical or mental conditions to members, family members, or school district or CESA staff. The services shall be performed by a registered nurse licensed under s. 441.06, Stats., or a licensed practical nurse licensed under s. 441.10, Stats., or be delegated under nursing protocols pursuant to ch. N 6. The services shall be prescribed or referred by a provider acting within the scope of their practice under applicable statutes and rules that govern the provider’s practice. The services shall be identified in the member’s treatment plan.
   6. (f) Psychological, counseling, social work, behavioral and mental health services. Psychological counseling and social work services relevant to the member’s mental health needs with the intent to reasonably improve the member’s functioning are covered school-based services. These services include testing, assessment and evaluation that appraise cognitive, emotional and social functioning and self-concept; therapy or treatment that plans, manages and provides a program of psychological counseling or social work services to individuals with psychological or behavioral problems; and crisis intervention. The services may be delivered to an individual or to a group of 2 to 10 individuals. The services shall be performed by a school psychologist, school counselor, school social worker, or other practitioner licensed and authorized by the department of public instruction. The services shall be identified in the member’s treatment plan.
   7. (g) Developmental testing and assessments under IDEA. Developmental testing and assessments under the individuals with disabilities education act (IDEA), 20 USC 1400 to 1485, are covered school–based services. These services include evaluations, tests and related activities that are performed to determine if motor, speech, language or psychological problems exist, or to detect developmental lags for the determination of eligibility under IDEA. The services are also covered when performed by a therapist, psychologist, social worker, counselor or nurse licensed by the department of public instruction, as part of their respective duties.
   8. (h) Transportation. Transportation services provided to individuals who require special transportation accommodations are covered school–based services if the member receives a school–based service other than transportation on the day transportation is provided. These services include transportation from the member’s home to and from school on the same day if the school–based service is provided in the school, and transportation from school to a service site and back to school or home if the school–based service is provided at a non–school location, such as at a hospital. Transportation shall be performed by a school district, CESA or contracted provider. The service shall be included in the treatment plan. The covered service that the member is transported to and from shall meet MA requirements for that service under ch. DHS 105 and this chapter.
   9. (i) Durable medical equipment. Durable medical equipment except equipment covered in s. DHS 107.24 is a covered service if the need for the equipment is identified in the member’s treatment plan, the equipment is member-specific, the equipment is not duplicative of equipment the member currently owns and the equipment is for the member’s use at school and home. Only durable medical equipment related to speech-language pathology, physical therapy or occupational therapy will be covered under the school based services benefit. The member, not the school district or the CESA, shall own the equipment.
   10. (j) Personal care and attendant care. Services defined under s. DHS 107.112 (1) (b) 4., 6. to 9., and 11. to 13 are covered services when rendered by a provider qualified under 42 CFR 440.167.
   11. (k) Physician services. Physician services that are covered under s. DHS 107.06 (1) that are relevant to the member’s medical needs and provided by a school district or CESA are covered school-based services. The services shall be performed by a physician or other provider operating within the scope of their practice, with prescribing authority granted under s. 441.16 (2), Stats., and shall be identified in the member’s treatment plan.
   12. (L) Dental services. Preventive dental services including oral evaluations, oral assessments, application of fluoride, and dental sealants are covered services when provided by a dentist or dental hygienist as described in s. DHS 105.06 (1) and (2) and identified in the member’s treatment plan.

2. (2) Limitations.

   1. (a) Age limit. School-based services may only be provided to MA-eligible recipients between 3 and 21 years of age, or for the school term during which an MA-eligible recipient becomes 21 years of age.

   2. (b) Medically necessary. School-based services shall be medically necessary. In this paragraph “medically necessary” has the meaning prescribed in s. DHS 101.03 (96m) and in addition means services that:

      1. 1. Identify, treat, manage or address a medical problem or a mental, emotional or physical disability.
      2. 2. Are identified in a member’s treatment plan.
      3. 3. Are necessary for a recipient to benefit from special education.
      4. 4. Are referred or prescribed by a physician or advanced practice nurse, as defined under s. N 8.02 (1), with prescribing authority granted under s. 441.16 (2), Stats., where appropriate, or a psychologist, where appropriate.

3. (3) Non-covered services. Services not covered as school-based services are the following:

   1. (a) Art, music and recreational therapies.
   2. (b) Services that are strictly educational, vocational or pre-vocational in nature, or that are otherwise without a defined medical component.
   3. (c) Services that are not in the member’s treatment plan.
   4. (d) Services performed by a provider not specifically certified under s. DHS 105.53.
   5. (e) General classroom instruction and programming.
   6. (f) Staff development.
   7. (g) In-school services to school staff and parents.
   8. (h) General research and evaluation of the effectiveness of school programs.
   9. (i) Administration or coordination of gifted and talented programs or student assistance programs.
   10. (L) Durable medical equipment covered under s. DHS 107.24.
   11. (m) Non-medical feeding.

History

History: Emerg. cr. eff. 6-15-96; cr. Register, January, 1997, No. 493, eff. 2-1-97; correction in (2) (b) 3. made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; CR 03-033: am. (1) (a) 4., (b) to (i), (2) (a) and (b) 2. Register December 2003 No. 576, eff. 1-1-04; corrections in (1) (a) 2., (b), (c), (d), (f), (g) and (2) (b) 3. made under s. 13.93 (2m) (b) 7., Stats., Register October 2004 No. 586; corrections in (1) (a) 3., (h), (2) (b) (intro.), and (3) (d) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; correction in (1) (b) to (d) made under s. 13.92 (4) (b) 7., Stats., Register November 2018 No. 755; correction in (1) (b) made under s. 35.17, Stats., Register August 2022 No. 800; EmR2512: emerg. am. (1) (b) to (i), cr. (1) (j) to (L), am. (2) (b) 2., (3) (c), r. (3) (j), (k), eff. 8-11-25; CR 25-078: am. (1) (b) to (i), cr. (1) (j) to (L), am. (2) (b) 1. to 3., (3) (a) to (i), r. (3) (j), (k), am. (3) (L) Register April 2026 No. 844, eff. 5-1-26.