HB22-1260: Medically Necessary Services in Schools

No, there are other functional healthcare services that may need to be provided within the school setting such as Augmentative and Alternative Communication Specialist, a Feeding Therapist, an Occupational Therapist, or a Speech-Language Pathologist.

The Bill references “medical necessity” defined by Medicaid or private insurance or as defined by the American Medical Association (AMA). The AMA defines medical necessity as “healthcare services or products … for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is … clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily … for the convenience of the patient, treating physician, or other healthcare provider” [emphasis added]. Therefore, there must be a medical need for the services to be rendered in the school setting.

Services typically prescribed by a child’s Pediatrician to support growth developmentally, socially, cognitively, affectively, and physically while ameliorating risks to safety. In short, the skills kids need to access the world so they may find their place, hold a job, and navigate relationships and society.

Medical necessity as defined in Colorado Code of Regulations 8.076.1.8 means a Medical Assistance program good or service: a. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all; b. Is provided in accordance with generally accepted professional standards for health care in the United States; c. Is clinically appropriate in terms of type, frequency, extent, site, and duration; d. Is not primarily for the economic benefit of the provider or primarily for the convenience of the client, caretaker, or provider; e. Is delivered in the most appropriate setting(s) required by the client’s condition; f. Is not experimental or investigational; and g. Is not more costly than other equally effective treatment options. Medical necessity for EPSDT services is defined under 8.282.4.E For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b – g.

For kids, the definition also cannot be more restrictive or more restrictively applied than the EPSDT standard: “necessary health care, diagnostic services, treatment, and other measures…to correct or ameliorate defects along with physical and mental illnesses and other conditions discovered by the screening services, whether or not such services are covered under the State plan.”

In some cases, yes; but unfortunately, for many children, the answer is no. Schools typically provide basic medical services but more often, they only provide services deemed necessary for the child to benefit from a basic education. For some children, medically necessary services go far beyond that. Education is very, very important, but only one of a variety of domains we need to address to help children become as independent in life as possible

These services are already mandated to be provided through private insurance and Medicaid’s Early Periodic Screening and Diagnostic Testing (EPSDT) programs. The cost will not be borne by the schools, and in fact, could reduce long term costs to schools due to improved behaviors and reduced long-term needs.

Schools can ensure safety in the same way they do now for volunteers, parents, and contracted outside providers into the schools: by using the school’s current policies and procedures. Schools are allowed to require background checks for any providers at the school, as well as any other legal paperwork and safety precautions. Schools also have the ability to deny access to certain providers for any reason, as long as the child’s services can still be met.

No. Only licensed or credentialed providers recognized by Colorado law to provide such services would be eligible to provide medically necessary services in schools. Even if a parent happened to be a licensed or credentialed provider, they would still not be allowed to provide services to their own children in school. Speech and Language Pathologists, Occupational Therapists, Board Certified Behavior Analysts, and other licensed individuals would constitute the majority of medical providers participating in this service.

No, 504 plans and Individualized Education Plans (IEPs) address educational access and very limited medical needs such as insulin delivery with a child with diabetes. In contrast, medical necessity is much broader and is defined by a Pediatrician’s, or other relevant prescribing physician’s, prescription. Even the definitions of some conditions are different for schools than they are for medical providers, as is the case for Autism Spectrum Disorder (ASD). Furthermore, even when a child has a medical diagnosis of ASD, many children are denied

IEPs because the IEP Team determines that their symptoms do not prevent the child from “receiving reasonable educational benefit from general education”.

Colorado Department of Education Definition: “A child with an Autism Spectrum Disorder (ASD) has a developmental disability significantly affecting verbal and non-verbal social communication, social interaction, engagement in repetitive activities and stereotyped movements, and resistance to environmental changes or changes in daily routines which prevents the child from receiving reasonable educational benefit from general education [italics added]. ECEA 2.08(1)” https://www.cde.state.co.us/cdesped/iep_forms#disabilitycategories 

Medical Definition: Diagnostic Criteria for 299.00 Autism Spectrum Disorder To meet diagnostic criteria for ASD according to DSM-5, a child must have persistent deficits in each of three areas of social communication and interaction plus at least two of four types of restricted, repetitive behaviors (visit https://www.cdc.gov/ncbddd/autism/hcp-dsm.html for specific verbiage).

No, the School Health Services Program differs significantly from this bill. That program is optional. In contrast, this legislation would require the school to either hire the staff at no cost to the district (as they can bill Medicaid or commercial insurance) to deliver all medically necessary services relevant to the school location OR to allow outside appropriate health care providers into the school under their control.

Currently, only 45% of school districts participate in the new Medicaid program. It also burdens the IEP team with determining which services to allow, and then how much of the service to allow. It is estimated that less than 10% of medically necessary services are provided to our children under this new model, with rural areas experiencing the worst of the losses.

Yes. If a child has medically necessary treatment needs as determined by a Pediatrician or other appropriate prescribing physician that must be provided in the school setting.

Not only do kids spend a third of their lives in school settings, but schools are also where they make most of their friends, learn most of the skills to hold jobs later in life, emotionally establish their identity among their peers, and set the foundation for good choices and healthy habits. Services that target these outcomes cannot be taught to some kids in clinics; they must be taught in the real world, where the kids spend their days. Making children leave school for hours at a time to learn these skills is restrictive, denies their advancement, and is significantly less effective for many. This is especially true for children with ASD who may struggle to transfer knowledge and skills gained in one setting (such as a clinic) to another setting (such as

a school). Children need to be themselves, which means learning among their peers and in a normal setting.

No, in almost all cases, these medical services should be delivered in a “push in model”, meaning the Qualified Healthcare Practitioner should be delivering treatment in the setting that the child requires support, such as in classroom support for interfering behaviors that exceed the school district’s ability to remediate/support. This will actually lead to improved educational outcomes, increased time in the learning setting while reducing disciplinary actions that remove a child from the learning setting (e.g. reduce in school and out of school suspensions), and increase the number of children that can successfully attend public schools that are currently attending “Out of District Placements” due to the districts being unable to meet their needs thereby reducing District costs

The child’s team would meet to discuss how best to deliver the treatment so as to reduce any possible interference or disruption to that setting. This is already done by District Personnel who are providing related services such as Occupational Therapy or Speech Therapy in the classroom setting in a push in model.

No, medical treatment in the school setting should not require a change of placement or impact LRE any more than if services are provided in a push in model or pull out model delivered by the school district. This would be equivalent to a Speech Therapist or OT employed by the school district to provide educational services in a push in model in the classroom with that professional providing treatment in the classroom setting and coordinating care with the teacher and other professionals on the team.