§ 51535.5. Local Educational Agency (Lea) Services.

(a) Reimbursement to LEA Providers is limited to the specified set of LEA Services defined in Section 51190.4 and set forth in Section 51360.

(b) LEA Services shall be reimbursable only when provided to an LEA eligible beneficiary, as defined in Section 51190.1; by an LEA Practitioner, as defined in Section 51190.3; and subject to the limitations of this section.

(c) When a beneficiary is covered by a managed care plan contract the following applies:

(1) If the beneficiary does not have an IEP or an IFSP, the LEA Provider may be reimbursed for LEA Services for which the plan is not capitated under the managed care plan contract;

(2) If the beneficiary has an IEP or an IFSP, the LEA Provider may be reimbursed for LEA Services rendered according to the IEP or IFSP as well as LEA Services for which the plan is not capitated under the managed care plan contract.

(d) Any claims for LEA services, as defined in Section 51190.4, rendered by an LEA Practitioner shall conform with the standards set forth in Welfare and Institutions Code, Section 14115.

(e) LEA Providers shall adhere to and comply with all federal and state third party liability requirements prior to billing Medi-Cal, including but not limited to policy directives issued by the federal Department of Health and Human Services and Health Care Financing Administration and those standards found in 42 United States Code Section 1396a(a)(25); 42 Code of Federal Regulations Section 433.139; Welfare and Institutions Code, Sections 14005, 14023.7, 14124.90; and Title 22, California Code of Regulations, Section 51005 and Article 15 commencing with Section 50761.

(f) LEA Services are reimbursable subject to the following limitations:

(1) Notwithstanding Section 51304, reimbursable LEA Services, as set forth in Section 51360(b)(1) through (8) are limited to medically necessary services up to a maximum of twenty-four (24) services per twelve- (12) month period for an LEA eligible beneficiary by one LEA Provider.

(2) Any LEA Services beyond limits in (1) above shall be provided only as authorized and documented as medically necessary in one of the following:

(A) The Individualized Education Plan (IEP), as set forth in Education Code, Section 56340 et seq., for special education students documents the need for additional services, and is maintained in the school's records; or

(B) The Individualized Family Service Plan (IFSP), as set forth in Government Code, Section 95020, for special education students documents the need for additional services, and is maintained in the school's records; or (C) The Individualized Health and Support Plan (IHSP), meaning a plan for assessment and treatment of students with disabilities or disorders other than those who have been diagnosed as eligible for special education and are therefore treated under an IEP. The IHSP documents the need for additional services, and is maintained in the school's records.

(g) Reimbursement for LEA Services shall not exceed the maximum allowances listed in this section.

(1) Additional 15 minute period means any complete 15 minute period immediately following the maximum minutes allowed for the initial service unit.

(h) Maximum allowances for LEA Services are as follows: Procedure Maximum Code Allowance X4900 LEA health and mental health evaluation and health and mental health education $19.13 X4905 LEA physical therapy - initial service unit (20-90 minute range) 36.66 X4910 LEA physical therapy - each additional 15 minutes 7.20 X4915 LEA occupational therapy - initial service unit (20-90 minute range) 36.66 X4920 LEA occupational therapy - each additional 15 minutes 7.20 Procedure Maximum Code Allowance X4925 LEA speech pathology and audiology services - initial service unit (15-45 minute range) 23.76 X4930 LEA speech pathology and audiology services - each additional 15 minutes 11.88 X4935 LEA psychology and counseling services - initial service unit (15-90 minute range) 39.91 X4940 LEA psychology and counseling services - each additional 15 minutes 9.97 X4945 LEA nursing services - initial service unit (15-90 minute range) 32.34 X4950 LEA nursing services each additional 15 minutes 8.09 X4955 LEA school health aide services (15-90 minute range) 6.06 X4960 LEA medical transportation (per trip) 18.54 X4965 LEA mileage (per mile) 1.30 X4970 LEA case management -low cost (per 15 minute increments) 12.38 X4975 LEA case management -moderate cost (per 15 minute increments) 14.40 X4980 LEA case management -high cost (per 15 minute increments) 16.42

(i) The amount payable to the LEA Provider shall be the lesser of either:

(1) the billed amount of charges or

(2) The above listed maximum allowance multiplied by the federal medical assistance percentage (FMAP) for California that is effective on the date of payment.

(j) The amount payable in (i) above shall be reduced by any or all of the following:

(1) Any processing charges withheld by the State as stated in the contract between Department of Health Services and the LEA Provider; or

(2) Any third-party collections.

HISTORY

1. New section filed 12-22-93 as an emergency; operative 12-22-93 (Register 93, No. 52). A Certificate of Compliance must be transmitted to OAL by 4-22-94 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 12-22-93 order transmitted to OAL 4-20-94 and filed 6-2-94 (Register 94, No. 22).

3. Amendment of subsections (h) and (i)(2), repealer and new subsection (k) and amendment of Note filed 7-16-2002; operative rates for services provided on or after 8-1-2000 pursuant to Stats. 2000, c. 52, Items 4260-101-0001 and 0890 (Register 2002, No. 29).

4. Certificate of Compliance as to 7-16-2002 order, including repealer of subsection (k), transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).

5. Editorial correction restoring inadvertently deleted first line of subsection (h) (Register 2006, No. 47).

Note

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14000, 14005, 14018.2, 14023.7, 14053, 14059, 14077, 14088.16, 14100.2, 14105, 14106, 14115, 14124.1, 14124.5, 14124.90, 14132, 14133, 14133.1, 14134, 14136.5 and 14170, Welfare and Institutions Code; Section 56340 et seq., Education Code; Section 95020, Government Code; 42 United States Code Section 1396a(a)(25); 42 Code of Federal Regulations Section 433.139; and Statutes of 2000, Chapter 52, Items 4260-101-0001 and 0890.