Tag: OT

School Services That Can Be Billed to Medicaid

Posted on by Nicol Walsh

Brief Overview:

  • This information is good to know for families of students with Individualized Education Programs (IEPs) and Individualized Family Service Plans (IFSP) when those students have Apple Health (Medicaid/CHIP) for their health insurance.
  • Schools can bill Medicaid for many common IEP and IFSP services. When schools do this, they don’t have to spend special education funds on these services and can use that money to pay for other special education needs.
  • Medicaid billing can be complicated and difficult, and not all schools in WA State do it.
  • Parents can advocate for their student’s school to join the WA State Health Care Authority School-Based Services Program to bill Medicaid and free up money in the special education budget. Parents and caregivers can learn to advocate and resources for that are listed in the article.

Full Article

Individualized services that children receive through their IEP or IFSP may be covered by Medicaid. Medicaid will pay for health-related services in an Individual Education Program (IEP) or Individual Family Service Plan (IFSP) if they are already Medicaid-covered services, if the student qualifies for Medicaid for health insurance.

The Individuals with Disabilities Education Act (IDEA) requires that Medicaid be the primary payer to schools and providers of services included in an IEP or IFSP. (This means that if a school doesn’t use special education funds to pay for these services, Medicaid should be billed before any other insurance or individual.)

Which individualized services will Medicaid pay for?

  • An evaluation to see if a student is eligible for special education (if the student is found eligible)
  • Re-evaluations for special education
  • Nursing/health services
  • Physical Therapy
  • Occupational Therapy
  • Speech Pathology/Audiology
  • Mental Health Care
  • Other health services that schools provide, and Medicaid covers, as long as it’s included in an IEP or IFSP

Will Medicaid pay for services in a 504 plan?

If a student with a 504 plan needs medical services as part of their plan to receive a Free Appropriate Public Education (FAPE), Medicaid will not be the primary payer—but after a school bills any other potential payers (such as private health insurance), a school can bill Medicaid for any remaining costs.

If your student has Medicaid (Apple Health) or CHIP for health insurance, school health services like mental health care, substance use disorder services and monitoring medication can be covered by Medicaid, even if they are not included in a student’s IEP, IFSP, or 504 plan.

If a Local Education Agency (LEA, or school district) runs early childhood programs like Early Head Start, Head Start, or school-based preschool, schools can bill Medicaid for Medicaid-eligible Early and Periodic Screening, Diagnostic and Treatment benefits (EPSDT), even if they are not in a child’s IFSP. This ensures that children in these programs get these essential screening and well-child services.

Why is billing Medicaid important?

When Medicaid pays for services, schools do not have to use special education dollars for those services. Instead, special education dollars can be used for expenses like hiring adequate support staff, adaptive or communication technology, durable mobility supports, and enhanced accessibility supports for inclusive student activities.

How do schools get Medicaid to pay for these services?

Washington State public school districts, educational service districts (ESDs), public charter schools, and tribal schools are all eligible to participate in the School Based Health Services program at Washington State’s Health Care Authority (HCA).

Each school district that wants to bill Medicaid signs a contract with the state Medicaid agency and the Health Care Authority. School districts submit their costs for Medicaid-covered services to the state’s Health Care Authority (HCA), which reimburses their costs while billing Medicaid for those services. School or district staff are responsible to fill out the Medicaid claim forms with the proper billing codes. Staff need to take specific training to do this.

Some schools decide not to bill Medicaid and use special education funds for these services. Why?

Unlike healthcare providers, schools are not set up to bill programs like Medicaid. The billing process can be complicated and time-consuming (for example, the billing guide that HCA provides to schools who want to bill Medicaid is 57 pages long).

In 2023, a new federal law (the Bipartisan Safer Communities Act) required Medicaidto make the billing process easier for schools; in May 2023, the Centers for Medicare and Medicaid Services (CMS) announced new guidance on this topic, which was sent to all states.

The Network for Public Health Law says the law made “important and substantial changes to reimbursement for school-based Medicaid services”. The law requires updates to outdated Medicaid billing guides and gives more help to states and local education agencies (LEAs, or school districts) who want Medicaid to reimburse them for school-based healthcare services. The law also made grants available to states to “implement, enhance or expand school-based programs” for healthcare (HHS) and for programs run by the Department of Education.

One purpose of the new law was to make billing Medicaid simpler and less expensive for schools. A second purpose was to encourage states to allow schools to use Medicaid for more types of healthcare services. The law also provides grants and other funding for mental health services for students.

As of July 2024, the Health Care Authority is still examining the new guidance to see if they want to make changes to the School-Based Health Care Services program.

Parents may think it makes sense to use Medicaid funds rather than special education funds for IEP/IFSP services. This chart from the Health Care Authority lists the schools and districts who have contracted with HCA and get Medicaid reimbursement for school-based health services. (current as of June 2024).

If a school or district is not listed, what are some ways parents can advocate for a school to start billing Medicaid?

  • Ask the school principal or superintendent about the reasons for not billing Medicaid. Ask what would need to change for the district to start Medicaid billing. This information is useful for gathering support from other parents and school personnel, and for getting policymakers to make the change.
  • There are national and statewide organizations that want to expand the use of Medicaid to pay for school-based services for all Medicaid-eligible students, not only students with IFSPs/IEPs. Parents may wish to visit their websites, learn about what they want to change, and contact these organizations for information about advocacy and organizing other parents around this topic.
  • District-wide decisions and policies are often made locally by a district’s administration team, the School Board, or both together. Contact information for district administration will be on the district’s website (and possibly on the school’s website). Contact information for school boards is usually available on a town or city government’s website, and sometimes on the district’s website.
  • Does the school or district have a Special Education PTA? If so, this group of parents and educators may be a good way to find other people interested in this topic. If not, a school’s Parent Teacher Organization (PTO) is also a useful resource. List of WA State Special Education PTAs.
  • When parent advocate groups ask for change, it can be very helpful to offer assistance to help make their request a reality. Can parent volunteers be used in any way to make the change easier? What other creative assistance might be helpful? Discussions with district administration and school boards about “why this won’t work” will let you know where and what type of help is needed.
  • Many organizations which support families, including families whose child or children have disabilities can offer advice or training for parents who want to advocate about the need for services in schools. This list is a starting point—you may find other groups or organizations which are not on the list.

Special Education is a Service, Not a Place

Posted on by Nicol Walsh

A Brief Overview

  • A student with a disability has the right to a Free Appropriate Public Education (FAPE) in the Least Restrictive Environment (LRE). General education spaces and curriculum are LRE.
  • Services are generally portable, and special education is delivered to the student to enable access to FAPE within the LRE to the maximum extent appropriate.
  • Federal law protects a student’s right to FAPE within the LRE in light of a child’s circumstances, not for convenience of resource allocation.
  • The TIES Center at the University of Minnesota partnered with the Haring Center for Inclusive Education at the University of Washington to build a resource for families and schools writing IEPs to support students within general education: Comprehensive Inclusive Education: General Education and the Inclusive IEP.

Full Article

An ill-informed conversation about special education might go something like this:

  • Is your child in special education?
  • Yes.
  • Oh, so your student goes to school in that special classroom, by the office…in the portable…at the end of the hall…in a segregated room?

This conversation includes errors in understanding about what special education is, how it is delivered, and a student’s right to be included with general education peers whenever and wherever possible.

This article intends to clear up confusion. An important concept to understand is in the headline:

Special Education is a service, not a place!

Services are portable, so special education is delivered to the student in the placement that works for the student to receive a Free Appropriate Public Education (FAPE), in light of the child’s circumstances. A student with a disability has the right to FAPE in the Least Restrictive Environment (LRE).

General education is the Least Restrictive Environment. An alternative placement is discussed by the student’s Individualized Education Program (IEP) team if access to FAPE is not working for the student in a general education setting with supplementary aids and supports.

Keep in mind that genuine inclusion doesn’t just meet a seat in the classroom. Adult support, adaptations to the learning materials, individualized instruction, and more are provided to support access to education within the LRE.

Here is some vocabulary to further understanding:

  • FAPE: Free Appropriate Public Education. The entitlement of a student who is eligible for special education services.
  • IDEA: Individuals with Disabilities Education Act. The entitlement to FAPE is protected by this law that allocates federal funds to support eligible students.
  • LRE: Least Restrictive Environment. A student eligible for special education services has a right to FAPE in the LRE to the maximum extent appropriate. General education is the least restrictive, and an alternative placement is discussed when data indicate that supplementary aids and supports are not working to enable access to FAPE in general education.
  • IEP: Individualized Education Program. School staff and family caregivers make up an IEP team. The team is responsible to develop a program reasonably calculated to enable a student to make progress appropriate toward IEP goals and on grade-level curriculum, in light of the child’s circumstances. Based on a student’s strengths and needs (discovered through evaluation, observation, and review of data), the team collaborates to decide what services enable FAPE and how to deliver those services. Where services are delivered is the last part of the IEP process, and decisions are made by all team members, unless family caregivers choose to excuse some participants or waive the right to a full team process.
  • Equity: When access is achieved with supports so the person with a disability has a more level or fair opportunity to benefit from the building, service, or program. For example, a student in a wheelchair can access a school with stairs if there is also a ramp. A person with a behavioral health condition might need a unique type of “ramp” to access equitable learning opportunities within general education.
  • Inclusion: When people of all abilities experience an opportunity together, and individuals with disabilities have supports they need to be contributing participants and to receive equal benefit. Although IDEA does not explicitly demand inclusion, the requirement for FAPE in the Least Restrictive Environment is how inclusion is built into special education process.
  • Placement: Where a student learns. Because the IDEA requires LRE, an IEP team considers equity and inclusion in discussions about where a student receives education. General education placement is the Least Restrictive Environment. An IEP team considers ways to offer supplementary aids and supports to enable access to LRE. If interventions fail to meet the student’s needs, the IEP team considers a continuum of placement alternatives—special education classrooms, alternative schools, home-bound instruction, day treatment, residential placement, or an alternative that is uniquely designed. 
  • Supplementary Aids and Supports: The help and productivity enhancers a student needs. Under the IDEA, a student’s unique program and services are intended to enable access to FAPE within LRE. Note that an aid or a support is not a place and therefore cannot be considered as an aspect of a restrictive placement. To the contrary, having additional adult support might enable access to LRE. This topic was included in the resolution of a 2017 Citizen Complaint in Washington State. In its decision, OSPI stated that “paraeducator support is a supplementary aid and service, not a placement option on the continuum of alternative placements.”

Note that the IDEA protects a student’s right to FAPE within LRE in light of a child’s circumstances, not in light of the most convenient way to organize school district resources. Placement is individualized to support a student’s strengths and abilities as well as the needs that are based in disability.

Tip: Families can remind the IEP team to Presume Competence and to boost a student from that position of faith. If the team presumes that a student can be competent in general education, how does it impact the team’s conversation about access to FAPE and placement?

LRE does not mean students with disabilities are on their own

To deliver FAPE, a school district provides lessons uniquely designed to address a student’s strengths and struggles (Specially Designed Instruction/SDI). In addition, the IEP team is responsible to design individualized accommodations and modifications. (Links in this paragraph take you to three PAVE training videos on these topics.)

  • Accommodations: Productivity enhancers. Examples: adjusted time to complete a task, assistive technology, a different mode for tracking an assignment or schedule, accessible reading materials with text-to-speech or videos embedded with sign language…
  • Modifications: Changes to a requirement. Examples: an alternative test, fewer problems on a worksheet, credit for a video presentation or vision board instead of a term paper.

Note that accommodations and modifications are not “special favors.” Utilizing these is an exercise of civil rights that are protected by anti-discrimination laws that include the Rehabilitation Act of 1973 (particularly Section 504 as it relates to school) and the Americans with Disabilities Act (ADA—particularly Title II).

Related Services may support LRE and other aspects of equitable access

An IEP may include related services (occupational therapy, speech, nursing, behavioral or mental health support, parent training, transportation, and more). For some students, related services may be part of the support structure to enable inclusion in the Least Restrictive Environment. If an IEP includes related services, then the IEP team discusses how and where they are delivered.

A tool to support inclusion

The TIES Center at the University of Minnesota partnered with the Haring Center for Inclusive Education at the University of Washington to build a resource to support families and schools in writing IEPs that support students within general education classrooms: Comprehensive Inclusive Education: General Education and the Inclusive IEP.

The resource includes a variety of tools and recommendations for how school and family teams can approach their meetings and conversations to support the creation and provision of a program that recognizes:

  • Each child is a general education student. 
  • The general education curriculum and routines and the Individual Education Program (IEP) comprise a student’s full educational program.
  • The IEP for a student qualifying for special education services is not the student’s curriculum.

Who is required on an IEP team?

Keep in mind that IEP teams are required to include staff from general education and special education (WAC 392-172A-03095). All team members are required for formal meetings unless the family signs consent for those absences. Here’s a key statement from the TIES Center resource:

“The IEP is intended to support a student’s progress in general education curriculum and routines, as well as other essential skills that support a student’s independence or interdependence across school, home, and other community environments.  A comprehensive inclusive education program based upon these principles is important because without that focus, a student’s learning opportunities and school and post-school outcomes are diminished. In order to create an effective comprehensive inclusive education program, collaboration between general educators, special educators, and families is needed.”

LRE decisions follow a 4-part process

OSPI’s website includes information directed toward parents: “Placement decisions are made by your student’s IEP team after the IEP has been developed. The term ‘placement’ in special education does not necessarily mean the precise physical building or location where your student will be educated. Rather, your student’s ‘placement’ refers to the range or continuum of educational settings available in the district to implement her/his IEP and the overall amount of time s/he will spend in the general education setting.”

Selection of an appropriate placement includes 4 considerations:

  1. IEP content (specialized instruction, goals, services, accommodations…)
  2. LRE requirements (least restrictive “to the maximum extent appropriate”)
  3. The likelihood that the placement option provides a reasonably high probability of helping a student attain goals
  4. Consideration of any potentially harmful effects the placement option might have on the student, or the quality of services delivered

What are placements outside of general education?

If a student is unable to access appropriate learning (FAPE) in general education because their needs cannot be met there, then the IEP team considers alternative placement options. It’s important to note that a student is placed in a more restrictive setting because the student needs a different location within the school, not because it’s more convenient for adults or because it saves the school district money.

According to IDEA, Sec. 300.114, “A State must not use a funding mechanism by which the State distributes funds on the basis of the type of setting in which a child is served that will result in the failure to provide a child with a disability FAPE according to the unique needs of the child, as described in the child’s IEP.”

IEP teams may discuss whether there’s a need for a smaller classroom setting or something else. Keep in mind that a home-based placement is a very restrictive placement because it segregates a student entirely from their peers.

The continuum of placement options includes, but is not limited to:

  • general education classes
  • general education classes with support services and/or modifications
  • a combination of general education and special education classes
  • self-contained special education classes
  • day treatment, therapeutic school specializing in behavioral health
  • private placement outside of the school district (non-public agency/NPA)
  • residential care or treatment facilities (also known as NPAs)
  • alternative learning experience (ALE)
  • home-based placement  

School districts are not required to have a continuum available in every school building. A school district, for example, might have a self-contained setting or preschool services in some but not all locations. This gives districts some discretion for choosing a location to serve the placement chosen by an IEP team.

Placement and location are different

Note that the IEP team determines the placement, but the school district has discretion to choose a location to serve the IEP.

For example, an IEP team could determine that a student needs a day treatment/behavioral health-focused school in order to access FAPE—an appropriate education. If the IEP team chooses a Day Treatment placement, then the school district is responsible to find a location to provide that placement. Following this process, a public-school district might pay for transportation and tuition to send a student to a private or out-of-district facility. If a request for a specialized placement is initiated by the family, there are other considerations.

OSPI’s website includes this information:

“… if you are requesting that your student be placed in a private school or residential facility because you believe the district is unable to provide FAPE, then you must make that request through a due process hearing.”

Resources about inclusionary practices

An agency called Teaching Exceptional Children Plus features an article by a parent about the value of inclusion in general education. The January 2009 article by Beth L. Sweden is available for download online: Signs of an Inclusive School: A Parent’s Perspective on the Meaning and Value of Authentic Inclusion.

Understood.org offers an article and a video about the benefits of inclusion.

An agency that promotes best-practice strategies for school staff implementing inclusive educational programming is the IRIS Center, a part of Peabody College at Vanderbilt University in Nashville, Tenn.

As stated earlier, The TIES Center at the University of Minnesota partnered with the Haring Center for Inclusive Education at the University of Washington to build a resource for families and schools writing IEPs to support students within general education: Comprehensive Inclusive Education: General Education and the Inclusive IEP.

The Inclusionary Practices Family Engagement Collaborative is a partnership of four non-profit organizations committed to strengthening family-school partnerships to support culturally-responsive approaches that center the experiences of students with disabilities. Watch recorded trainings offered to help you start the conversation.

Related Services in School and Beyond can Support a Child’s Development and Learning

Posted on by Nicol Walsh

A Brief Overview

  • At school, related services help children with disabilities benefit from their special education by providing extra help and support. Options for related services are described in state law (WAC 392-172A-01155).
  • If a child with public health insurance needs specific therapies to meet medical needs, their insurance company is obligated to support those needs. Medical necessity is described in state law (WAC 182-500-0070).
  • Sometimes a service meets educational and medical needs. In those situations, the school might bill Medicaid directly, with parent permission. Families can learn more about School-Based Health Services (SBHS) and ask if their school is participating in this optional program.
  • Washington’s Office of Superintendent of Public Instruction (OSPI) issued guidance in August 2022 to clarify that all parts of a student’s IEP begin with the start of school unless an IEP team has agreed to shift something to meet a student-centered need. Schools may not delay the start of related services for their own reasons related to scheduling or resources.
  • For federal information about the range of options for related services provided by the school, see parentcenterhub.org.

Full Article

Children with disabilities have a range of needs that may be educational, medical, or both. As they grow, develop, and learn, those needs can shift. How family, school, and medical providers respond can impact how much progress the child makes in their emerging skills. This article includes information to help families understand how therapeutic services may be provided at school or elsewhere.

What are related services?

Schools call services that lie outside the scope of traditional teaching “related services.” Another term is “ancillary services.” Related services help children with disabilities benefit from their special education by providing extra help and support.

Therapies for disabilities that impact physical movement or speech are common. Transportation provided through the special education system also is a common related service. Less common in Washington State are in-school mental health services or counseling for behavioral health conditions. Various possibilities are listed in state law (WAC 392-172A-01155). Here are examples from the Washington Administrative Code (WAC):

  • Occupational, Physical, Speech Therapies
  • Counseling
  • Psychological Services
  • Behavioral Services
  • School Social Worker
  • Special Transportation
  • Parent Training

What does parent training mean?

Notice that the final option on this list is parent training. This service might mean the school helps parents understand the special needs of their child or something about their child’s development. Through the related service of parent training, the school can teach family members to help their child practice emerging skills when they’re at home.

Who provides a related service, and who pays?

A related service may be provided by any professional who is trained to assess and/or serve a specific need for a child with a disability condition that affects their learning or development.

When therapeutic services are paid for through medical insurance, they generally must meet a standard of being “medically necessary.” Keep reading for more information about therapeutic services available through the medical system.

Services are provided at school when they are determined to be “educationally necessary.” In those cases, the school district is responsible for payment.

Sometimes a service is both medically and educationally necessary. Sometimes schools seek parent consent to bill the student’s insurance to fund all or part of a related service. Washington State’s Health Care Authority (HCA) manages a program to reimburse schools for services provided to students who are eligible for Apple Health when those services are delivered as part of their Individualized Education Program (IEP).

Tip: See HCA’s website page about School-Based Health Services (SBHS) and consider asking your school if they are participating in this optional program. The guidebook includes information about allowable services. Note that Applied Behavior Analysis (ABA) therapy is explicitly excluded as a reimbursable service through the state’s SBHS program. Most other therapeutic options are reimbursable, including a range of mental health services.

A related service might be part of evaluation

Sometimes a related service is needed to assess a student because school staff do not have the expertise to properly understand a disability condition in order to make service recommendations. “Medical services for diagnostic or evaluation purposes” are written into federal law (IDEA Section 1432) as something an IEP can provide.

Keep in mind that special education evaluations must be comprehensive, in order to identify all of a child’s special education and related service needs, not just those that relate to the IEP eligibility category.

Families can seek an Independent Educational Evaluation (IEE) if they disagree with the methods or conclusions of a school district special education evaluation. PAVE provides an article and sample letter for requesting an IEE.

Related services support FAPE

The federal law that governs special education services is the Individuals with Disabilities Education Act (IDEA). The IDEA makes clear that its list of related services (see below) includes possibilities and options but does not include every related service a student might need. Other therapeutic services might be included in the IEP if they are educationally necessary.

Access and equity are protected by various educational and civil rights laws; anything that helps a student access school-related opportunities can be included as part of a student’s services. Extracurricular activities and school-sponsored sports count.

An IEP is a written commitment for the school to serve a student’s educational needs. Educational needs might be academic, social-emotional, or something else.  They might have to do with how the student functions or adapts to the environment of school.

Educational needs are determined through a comprehensive evaluation and a collaborative process that includes family, school staff, and anyone else with knowledge of the student and their disability-related needs. If an IEP team decides that a service is necessary for the student to access their right to a Free Appropriate Public Education (FAPE), then the school district is responsible to deliver those services.

IDEA does not expressly require that the IEP team include related services personnel. However, if a particular need or related service is discussed in an IEP meeting, it would be appropriate for the provider to attend. IDEA states that, at the discretion of the parent or the public agency, “other individuals who have knowledge or special expertise regarding the child, including related services personnel as appropriate” may be part of a child’s IEP team.

School-based related services might include, but are not limited to:

  • speech-language pathology and audiology services
  • interpreting services
  • psychological services
  • physical and occupational therapy
  • recreation, including therapeutic recreation
  • early identification and assessment of disabilities in children
  • counseling services, including rehabilitation counseling
  • orientation and mobility services for blindness/low vision
  • medical services for diagnostic or evaluation purposes
  • school health services and school nurse services
  • social work services in schools
  • parent counseling and training

The national Center for Parent Information and Resources (parentcenterhub.org) provides additional information about each of these possible related services and what they might look like for a student receiving them as part of an Individualized Education Program (IEP).

IEP services start on Day 1 unless the student needs something different

Washington’s Office of Superintendent of Public Instruction (OSPI) issued guidance in August 2022 to clarify that all parts of a student’s IEP begin with the start of school unless an IEP team has agreed to shift something to meet a student-centered need.

According to OSPI, “School districts are reminded that they cannot arbitrarily determine when special education and related services will begin or schedule them to begin after the start of the school year for some providers.”

OSPI’s guidance references a parent complaint and the state’s decision that schools cannot delay the start of certain services because of provider availability or district scheduling preferences. If it’s in the IEP, then the school is responsible to provide the service on all scheduled days that the student attends school. If services aren’t provided as scheduled by the IEP, then the IEP team can discuss how and when the student will receive compensatory services to make up the missed time.

Families have the right to file a complaint with the state if the school does not fully serve their student’s IEP. One option is the community complaint: PAVE provides a video describing that process. Another option is Due Process. The Procedural Safeguards describe all dispute resolution options that are free for families and protected rights under federal and state laws. 

Options for therapeutic services through the Medicaid system

If a child needs specific therapies to meet medical needs, their insurance company is obligated to support those needs. For children younger than 21 with Medicaid (Apple Health in Washington), medical necessity is determined through assessments that are a protected benefit called Early Screening and Periodic Screening, Diagnostic and Treatment (EPSDT). This screening process is overseen by the National Academy for State Health Policy (NASHP).

For help navigating complex medical issues, families can request case management from their insurance provider. Calling the number on your insurance card and asking if there a form for requesting case management is a way to begin. Sometimes a case manager is automatically assigned if claims become complex and expensive.

Medical criteria are different than school criteria. While school-based services are built to support a student’s educational access, EPSDT determinations are made to support safety and health in the home and community. Here are examples:

  • Physical Therapy (PT) at school might support adapted physical education (PE) or help the student navigate the school building or curriculum. Outside of school, PT can support navigating the home, community, recreational activities, and more.
  • Speech/language services at school are tailored to help the student achieve goals on their Individualized Education Program (IEP) or access their curriculum. Outside of school, speech/language services can expand to support communication for daily living and might be paired with Occupational Therapy (OT), for example, to work on feeding issues, sensory aversions, breathing challenges, alternative communication systems, and more.

Services to support access to school, home, and community might intertwine, and the school district might choose to bill Medicaid for reimbursement, with the family’s signed consent.

TIP: If the school is going to bill insurance, families may want to find out if the insurance company has a reimbursement limit for the service. If the child is getting a similar service in and out of school, care coordination is important to make sure all the services will be paid. Insurance may be willing to pay for more services if it’s clear which are for school-based needs and which are medical. Those details also may be important to note if services are denied and the family wants to appeal the denial through a medical or special education complaint option.

What meets the standard of medical necessity?

The Washington Administrative Code (WAC 182-500-0070) describes medical necessity. If a service is likely to prevent, diagnose, or treat an identified condition that is causing major life impacts, then it may meet the standard. The WAC says medical necessity is:

“…a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction.”

The same WAC goes on to say that all federally funded insurance is obligated to pay for a service if it’s the most reasonable option available to serve the need. That standard is met when:

“There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service.”

The same WAC also explains that a chosen course of treatment might mean a choice to track a condition through observation or offer no treatment. The WAC says:

“For the purposes of this section, ‘course of treatment’ may include mere observation or, where appropriate, no medical treatment at all.” 

A medical specialist, therapist, or pediatrician might assess the child to determine whether a specific service is medically necessary. In some situations, a case manager from the state’s Developmental Disabilities Administration (DDA) may make the determination.

What about private insurance?

Families with insurance through an employer or the healthcare exchange will need to ask their provider for specific information about what therapeutic services are covered. A company’s human resources department is another place to ask about coverages and whether there is a choice of health plan with more allowable options. School-based services may be the only option for some, as medical parity laws do not protect all possible therapeutic services.

Here are a places to get support in understanding your health plan and navigating access to services:

Insurance denials for employer-based plans can be appealed through:

PAVE’s Family to Family (F2F) Health Information Center provides additional information and resources through it’s website, Family Voices of Washington. Click Get Help at wapave.org to request individualized support.