Covered and Noncovered Services : Covered Services and Requirements

A Comprehensive Overview

Through the SBS benefit, Medicaid-enrolled SBS providers may request reimbursement from Wisconsin Medicaid for medically necessary covered SBS provided to children eligible for Medicaid and BadgerCare Plus.

SBS must be identified in the child's written treatment plan and certain requirements must be met. Covered services include:

• Dental services.
• Developmental testing and assessments when resulting in a created or revised treatment plan.
• Nursing and physician services.
• OT.
• PT.
• Psychological services, counseling, social work, and mental health services.
• SLP, audiology, and hearing.
• Transportation.

Consultation, monitoring, and coordination are not separately reimbursable. Payment for these services is included in the reimbursement rate for the previously listed covered services.

BadgerCare Plus Postpartum Program Coverage

Pregnant members enrolled in BadgerCare Plus keep their health care coverage for 12 months after the end of their pregnancy, per 2025 Wisconsin Act 102. These members are eligible for all covered services during this postpartum period as part of their care.

Eligibility

Most full-benefit BadgerCare Plus or Medicaid members enrolled on their last day of pregnancy are eligible for an estimated 365 days of postpartum BadgerCare Plus coverage (The window of coverage occurs for 365 days through the end of the month in which the 365th day falls. For example, if the end of a qualifying member's pregnancy occurred on April 14, 2026, their postpartum coverage period would be complete on April 30, 2027).

If someone is already enrolled in BadgerCare Plus or Medicaid but does not report a pregnancy until after it has ended, they may still qualify for postpartum coverage, but they must be enrolled in the month in which the pregnancy ended.

If someone applies for coverage after their pregnancy has ended, they are eligible for 12-months of postpartum coverage if they obtain retroactive coverage for the month in which the pregnancy ended.

Exceptions

Members will not qualify for the 12-month BadgerCare Plus postpartum coverage period if any of these statements are true:

• They were enrolled in the BadgerCare Prenatal Program.
• They were only enrolled in BadgerCare through presumptive eligibility, also known as Express Enrollment.
• Their pregnancy ended before January 1, 2026.

Circumstances when coverage may end

The 12-month postpartum coverage period can end prior to the 12 months only if the member:

• Gained eligibility based on incorrect information or agency error.
• Asks to disenrolled from coverage.
• Moves outside of Wisconsin.
• Dies.

Community-Based Therapies and School-Based Services

In addition to covering SBS, Wisconsin Medicaid reimburses community-based therapists separately for services not provided under the SBS benefit that are not in the member's SBS written treatment plan.

To determine medical necessity, community-based therapy providers are required to obtain PA for services that could also be reimbursed under the SBS benefit. The medical necessity of SBS is reviewed in the treatment plan process, whereas medical necessity is reviewed in the PA process for community therapists.

When adjudicating PA requests for community-based therapies, the medical necessity of services and other criteria including, but not limited to, whether the service is appropriate and cost-effective are considered. As part of the PA process, community therapists submit the child's treatment plan with their request to provide services. Medicaid consultants review the treatment plan in addition to all other required material and records to determine if the child is already receiving services that meet the child's therapy needs. The treatment plan is not the only material considered when determining medical necessity.

Wisconsin Medicaid's professional consultants do not base approval or denial of PA requests on whether the school pursues reimbursement through the SBS benefit. The consultants who review PA requests for community therapies:

• Do not review the SBS claims information.
• Approve community therapy based on medical necessity and not on financial limitations.
• Review each child's SBS written treatment plan and any other information regarding therapies received at the school, in the home, or elsewhere when community (non-school-based services) services are requested, regardless of whether or not the school seeks SBS reimbursement.

Wisconsin Medicaid requires schools and other health care providers to work together to ensure that the child receives coordinated services.

Note: PT, OT, and SLP services provided to a member in school do not affect when PA must be requested by community-based therapists under BadgerCare Plus and Wisconsin Medicaid.

Cotreatment

OT, PT, and SLP providers each provide a unique approach to the member's treatment. Cotreatment (the simultaneous treatment by two providers of different therapy disciplines during the same time period) may be provided only in circumstances where it is medically necessary to optimize the member's rehabilitation. When cotreatment occurs, providers are required to document in the child's record why individual treatment from a single therapist does not provide maximum benefit to the member and why two different therapies that treat simultaneously are required.

Covered Attendant Care Services

Attendant care services include a range of human assistance provided to students with a disability and/or chronic condition. The assistance enables them to accomplish tasks in the educational setting that they would normally do for themselves if they did not have a disability or chronic condition. Assistance may be in the form of hands-on assistance (for example, actually performing an attendant care task for the student) or cuing the student so that they perform the task by themselves. Such assistance most often relates to performance of ADLs. IADLs may also be covered if they:

• Are medically necessary.
• Are listed in the written SBS treatment plan.
• Are not academic in nature.
• Are related to functional goals and needs of students.
• Are provided to a student as a district implements the student's treatment plan.

The following attendant care services are reimbursable under the SBS benefit when claims are submitted by Medicaid-enrolled SBS providers:

• Preparing food, assisting with and monitoring eating, feeding, and swallowing.
• Performing routine personal hygiene (for example, hand washing, brushing teeth, combing hair, grooming, and showering).
• Dressing.
• Toileting and diapering.
• Transferring.
• Performing routine care of personal assistive devices (for example, eyeglasses, wheelchairs, communication boards).
• Supervision and cuing of activities.

These services are not covered as attendant care services under SBS:

• Services of a bus aide during transportation.
• Skilled services that may be performed only by a health professional.

Attendant care services are covered when provided to members enrolled in Medicaid and provided by Wisconsin DPI-licensed staff and billed by a Medicaid-enrolled SBS provider.

Covered Dental Services

Certain dental services may be covered as SBS when medically necessary and provided to a Medicaid-eligible child by dentists or dental hygienists operating within their scope of practice as described in Wis. Admin. Code §§ DHS 105.06(1) and 105.06(2).

This includes:

• Performing oral evaluations.
• Performing oral assessments.
• Applying fluoride and dental sealants (when provided by a dentist or dental hygienist).

Covered Nursing Services

Nursing services must be appropriate for the child's medical needs and specifically identified in the child's written treatment plan. Covered nursing services under the SBS benefit are described in Wis. Admin. Code § DHS 107.36. Services include:

• Evaluation and management services, including screens and referrals for health needs
• Treatment
• Medication management

All time that a nurse spends conducting activities with the child that are included in the child's treatment plan may be submitted to Wisconsin Medicaid for reimbursement.

Like all SBS, nursing services identified in the treatment plan must have outcome-based goals. The goals must be detailed in either the treatment plan if there are student goals or in the IHP if there are nursing goals. Goals for medication management must be identified as well (for example, seizure medication to prevent and/or treat seizures).

The child's treatment plan must identify:

• Each specific nursing service (for example, medication management, suctioning, dressing changes, nebulization treatment, G-tube feeding).
• The personnel, by name, who will perform the services.

DME related to nursing services are not covered SBS. Consult with a DME provider to determine whether equipment will be covered under the DME benefit.

Covered Occupational Therapy Services

OT services are covered when they identify, treat, rehabilitate, restore, improve, or compensate for medical problems that interfere with age-appropriate functional performance. The following services are covered if they are medically necessary and identified in the child's written treatment plan:

• Evaluation and re-evaluation to determine the child's need for OT (if the service results in the development or revision of a treatment plan), recommendations for a course of treatment, and providing direct treatment interventions
• Individual therapy/treatment or group therapy/treatment in groups of two to seven children
• Medical equipment identified in the treatment plan that is intended for only one child for use at school and home

Covered Physical Therapy Services

PT services are covered when they identify, treat, rehabilitate, restore, improve, or compensate for medical problems. The following services are covered if they are medically necessary and identified in the child's written treatment plan:

• Evaluation and re-evaluation to determine the child's need for PT (if the service results in the development or revision of a treatment plan), recommendations for a course of treatment, and providing direct treatment interventions
• Individual therapy/treatment or group therapy/treatment in groups of two to seven children
• Medical equipment identified in the treatment plan that is intended for only one child for use at school and home

Covered Physician Services

Certain physician services may be covered as SBS when medically necessary and provided to a Medicaid-eligible child by physicians or other providers:

• Operating within their scope of practice under Wis. Admin. Code § N 8.02(1) with prescribing authority granted under Wis. Stat. § 441.16(2).
• Providing services identified in the member?s treatment plan as defined in Wis. Admin. Code § DHS 105.53(3)(a)3..

This includes:

• Performing evaluation and management services.
• Screening and referring for treatment of health needs.
• Providing treatment.
• Performing medication management.
• Explaining treatments, therapies, and physical or mental conditions to family members, school districts, or the CESA.

Covered Psychological, Counseling, Social Work, and Mental Health Services

Psychological, counseling, social work, and mental health services include diagnostic or active treatments intended to reasonably improve the child's physical or mental condition. The following services are covered if they are medically necessary and identified in the child's written treatment plan:

• Diagnostic testing and evaluation that assesses cognitive, emotional, and social functioning and self-concept
• Therapy and treatment that plans, manages, and provides a program of psychological services, counseling, social work, or mental health services to children with psychological or behavioral problems
• Crisis intervention
• Treatment, psychological counseling, social work, and mental health services to individuals or groups of two to 10 individuals

Covered Services Provided by Teachers

As stated in s. 1905(a) of the Social Security Act, Wisconsin Medicaid can reimburse providers only for medical services. Therefore, under the SBS benefit, Wisconsin Medicaid can reimburse teachers only for the following types of services:

• Written Treatment Plan Meetings. Wisconsin Medicaid will only reimburse for teacher or staff attendance at treatment plan meetings if the teacher or staff member is a health or pupil services practitioner.
• Delegated nursing acts. Although Wis. Stats. § 118.29, allows school staff to dispense medication without it being a delegated nursing act, Wisconsin Medicaid only covers a medically related service provided by a teacher (or other school personnel) when it is a delegated nursing act by the school nurse and documented as such.

Covered Speech and Language Pathology, Audiology, and Hearing Services

SLP, audiology, and hearing services are covered for children with speech, language, or hearing disorders that adversely affect the child's functioning. The following services are covered if they are medically necessary and identified in the child's written treatment plan:

• Evaluation and re-evaluation to determine the child's need for SLP, audiology, and/or hearing services (if the service results in the development or revision of a treatment plan); recommendations for a course of treatment; and providing direct treatment interventions.
• Individual therapy/treatment or group therapy/treatment in groups of two to seven children.
• Medical equipment identified in the treatment plan that is intended for only one child for use at school and home.

Reimbursement of SLP Evaluations

Consistent with Wis. Admin. Code §§ DHS 107.36(b),(c), and (d), an evaluation or testing to assess the child's need for a therapy service performed in person or via audio-visual telehealth may be reimbursed when the evaluation or testing results are considered during the development or revision of a treatment plan. The student must qualify under IDEA in some disability category. The evaluation or testing does not need to result in that specific therapy service being added to the treatment plan.

Reimbursement of SLP Treatment

ForwardHealth will reimburse for coaching services when the therapist uses clinical judgment to assess student performance and the caretaker response to coaching results in direct service to the student during the therapy session. ForwardHealth confirms that speech and language therapy services rendered through telehealth may be reimbursed when a parent or caregiver is needed to assist the child during the therapy session. ForwardHealth only reimburses for services when the child is present.

Covered Transportation Services

School-based transportation services are covered based on criteria set by the federal CMS.

SBS providers may submit claims for specialized medical transportation that a child would not otherwise receive in the course of attending school. Specialized medical transportation, which must be listed in the child's written treatment plan, means a child must be transported on a physically modified vehicle (for example, a vehicle with a wheelchair lift, ramp, or special harness).

Wisconsin Medicaid reimburses SBS providers for transportation only on days when a child is receiving a covered SBS (other than transportation) in these situations:

• Transportation to and from school when a child receives a covered SBS at school.
• Transportation to and from an off-site location to receive a covered SBS if the child is in school that day. In this case, transportation between school and home is not covered.

Definition of Covered Services

Delegation of Nursing Services

Medicaid-covered nursing services are performed by an RN, LPN, or are delegated under nursing protocols, according to Wis. Admin. Code ch. N 6. Only RNs may delegate nursing services to an LPN or individual without a medical license. The RN who delegates these services is required to follow nursing protocols pursuant to Wis. Admin. Code ch. N 6, including training, evaluation, and supervision.

Medication Administration

An exception to the rules of nursing delegation in schools is medication administration. Wisconsin law allows school staff without a medical license to administer medication provided all protocols of Wis. Stats. §§ 118.29 and 118.291, are followed. An RN is required to:

• Develop medication administration policies and procedures.
• Train staff in medication administration.

Formal nursing delegation is not uniformly required but the determination of need to do so must be made by an RN. However, because Wisconsin Medicaid can only reimburse providers for medical services, under the SBS benefit medication administration by unlicensed school staff is only covered when it is a delegated nursing act by the RN and is documented as such.

Delegation of Occupational Therapy Services

Covered OT services are performed by or under the direction of a licensed DPI occupational therapist.

Licensed OT providers may only delegate to certified OTAs those portions of a child's therapy that are consistent with the OTA's education, training, and experience. Licensed OT providers are required to have direct, face-to-face contact with OTAs on the premises at least every 14 days.

Supervision of Certified OTAs

ForwardHealth accepts supervision of certified OTAs in schools conducted via audio-visual telehealth.

Reimbursement of OT Evaluations

Consistent with Wis. Admin. Code §§ DHS 107.36(b),(c), and (d), an evaluation or testing to assess the child's need for a therapy service performed in person or via audio-visual telehealth may be reimbursed when the evaluation or testing results are considered during the development or revision of a written treatment plan. The student must qualify under IDEA in some disability category. The evaluation or testing does not need to result in that specific therapy service being added to the treatment plan.

Reimbursement of OT Treatment

ForwardHealth will reimburse for coaching services when the therapist uses clinical judgment to assess student performance and the caretaker response to coaching results in direct service to the student during the therapy session. ForwardHealth confirms that OT services rendered through telehealth may be reimbursed when a parent or caregiver is needed to assist the child during the therapy session. ForwardHealth only reimburses for services when the child is present.

Delegation of Physical Therapy Services

Licensed PT providers may only delegate to PTAs those portions of a child's therapy that are consistent with the PTA's education, training, and experience. Licensed PT providers are required to have direct, face-to-face contact with PTAs on the premises at least every 14 days.

Supervision of Certified PTAs

ForwardHealth accepts supervision of certified PTAs in schools conducted via audio-visual telehealth.

Reimbursement of PT Evaluations

Consistent with Wis. Admin. Code §§ DHS 107.36(b),(c), and (d), an evaluation or testing to assess the child's need for a therapy service performed in person or via audio-visual telehealth may be reimbursed when the evaluation or testing results are considered during the development or revision of a written treatment plan. The student must qualify under IDEA in some disability category. The evaluation or testing does not need to result in that specific therapy service being added to the treatment plan.

Reimbursement of PT Treatment

ForwardHealth will reimburse for coaching services when the therapist uses clinical judgment to assess student performance and the caretaker response to coaching results in direct service to the student during the therapy session. ForwardHealth confirms that PT services rendered through telehealth may be reimbursed when a parent or caregiver is needed to assist the child during the therapy session. ForwardHealth only reimburses for services when the child is present.

Developmental Testing Services and Assessments

Coverage of Other Developmental Testing Services and Assessments

Other developmental testing, assessments, and consultations are covered when resulting in a new or revised written treatment plan. These services must be performed face-to-face with the child by a licensed health professional. Staff providing these services must be DPI licensed.

Covered school-based developmental and testing services include evaluations, tests, and related activities performed to:

• Determine if motor, speech, language, or psychological problems exist.
• Detect developmental lags in the determination of eligibility under IDEA.

School-based testing and assessment services performed by qualified providers are included in the covered SBS for their respective professional areas and should be billed accordingly.

Provider Qualifications

Other developmental testing, assessments, and consultation services must be performed by the following providers:

• Clinically trained mental health professional
• Counselor
• Nurse
• Physician
• Psychologist
• Social worker
• Speech-language pathologist, occupational therapist, or physical therapist
• Assistant working under the direction of a qualified speech-language pathologist, occupational therapist, or physical therapist

This testing and assessment for teachers is only covered when it results in a new or revised treatment plan. All providers are required to be DPI licensed.

Emergencies

Certain program requirements and reimbursement procedures are modified in emergency situations. Emergency services are defined in Wis. Admin. Code § DHS 101.03(52), as those services that are necessary to prevent the death or serious impairment of the health of the individual. Emergency services are not reimbursed unless they are covered services.

Additional definitions and procedures for emergencies exist in other situations, such as dental and mental health.

Program requirements and reimbursement procedures may be modified in the following ways:

• PA or other program requirements may be waived in emergency situations.
• Non-U.S. citizens may be eligible for covered services in emergency situations.

Face-to-Face Time

Providers are required to document and may submit claims only for face-to-face encounter time with the child for all SBS. Wisconsin Medicaid reimburses only face-to-face time spent with the child for all covered SBS.

Face-to-face time is the time any SBS personnel, both teachers and medical professionals, spend with the child present in the course of providing a covered service. This includes:

• Time to obtain and update a history with the child present
• Direct observation of the child
• Written treatment plan team testing and assessment — only for the time when the SBS health professional is in direct contact with the child
• Delivery of the treatment plan services
• Treatment plan meetings — only for the time when the child is present at the meeting

Non-Face-to-Face Time

Wisconsin Medicaid does not pay separately for any non-face-to-face time; payment for non-face-to-face time is included in the reimbursement rates for face-to-face services. Non-face-to-face time includes the time that providers spend in preparation and follow-up without the child present, including:

• Reviewing and scoring records and tests
• Writing reports
• Communication and consultation (without the child present) related to the treatment plan team or treatment plan service with other professionals, staff, and parents
• Meeting with parents regarding the treatment plan (without the child present)

Medical Necessity

Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.

SBS are considered medically necessary when the service identifies, treats, manages or addresses a medical problem or a mental, emotional, or physical disability. All eligible Medicaid-enrolled students with general health care service needs who have any of the following written treatment plans are eligible for SBS:

• IEP
• IFSP
• 504 Plan
• Individualized Health Plan
• Behavioral Health Plan
• Other plans developed by a medical professional within their scope of practice where medical necessity has been established, as defined by Wis. Admin. Code § DHS 101.03(96m).

Member Payment for Covered Services

Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.

If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.

Nursing Tasks Reimbursable for Full-Time Health Aides

A school or a medical provider acting within the scope of their practice may deem it necessary for a child to have a full-time aide. However, Wisconsin Medicaid will not reimburse for all of the aide's time. Wisconsin Medicaid will reimburse SBS providers only for the times associated with performing specific covered nursing tasks (for example, G-tube feeding, suctioning, medication management) identified in the written treatment plan.

Time spent on educational tasks or monitoring the child is not covered and will not be reimbursed even though a full-time aide may be required. Educational tasks include:

• Vocabulary development.
• Reinforcement of classroom instruction.
• Rote learning skills (for example, counting, name printing, coin labeling).

Examples of monitoring include having an aide present in case the child has a seizure or behavior outburst. Only time spent performing face-to-face covered nursing tasks identified in the treatment plan can be reimbursed.

Prescription and Other Coverage Requirements

To be covered by ForwardHealth, certain SBS must be:

• Outlined in an annual prescription, order, or referral written by a provider acting within their scope of practice to refer, order, or prescribe.
• Included in the child's written treatment plan. (Note: For testing procedures, documentation of the rationale for testing must also be included in the child's record.)

These requirements apply to these SBS:

• Attendant care services
• Nursing services
• OT services
• PT services
• SLP, audiology, and hearing services

Note: These services do not require a prescription, but they must be included in a child's written treatment plan:

• Dental services
• Physician services
• Psychological, counseling, social work, and mental health services
• Transportation services (also must be provided on the same day as another Medicaid-covered service in order to be covered)

Program Requirements

For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including—but not limited to—medical necessity, PA, claims submission, prescription, and documentation requirements.

Psychological, Counseling, Social Work, and Mental Health Services Provider Qualifications

Counseling, social work, psychological, and mental health services must have been ordered or recommended by a physician or other licensed practitioner with the authority to do so under their state license in order to be covered as SBS.

Counseling and social work services must be performed by a licensed DPI counselor or social worker. Psychological services must be performed by a licensed DPI school psychologist. Mental health services must by performed by clinically trained mental health professionals.

Services That Do Not Meet Program Requirements

As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.

Examples of covered services that do not meet program requirements include the following:

• Services for which records or other documentation were not prepared or maintained
• Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
• Services that fail to comply with requirements or state and federal statutes, rules, and regulations
• Services that Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
• Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
• Services provided by a provider who fails or refuses to provide access to records
• Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS

Speech and Language Pathology, Audiology, and Hearing Services Provided Under Supervision

The federal CMS requires certain guidelines to be met for federal reimbursement of services that are provided under the direction of a qualified speech-language pathologist or audiologist. To ensure funding, school districts and CESAs are required to comply with the federal guidelines.

SBS provided under the direction or supervision of a speech-language pathologist or audiologist must meet certain requirements.

A supervising speech-language pathologist or audiologist:

• Must meet Medicaid's specific licensing and enrollment requirements.
• Must see each member at the beginning of and periodically during treatment, be familiar with the treatment plan, have continued involvement in the care provided, and review the need for continued services throughout treatment.
• Must assume professional responsibility for the services provided under their direction.
• Must ensure that the individual working under their direction can contact them as necessary during the course of treatment.
• May not supervise more service providers than is reasonable, ethical, and in keeping with professional practice in order to permit the supervising speech-language pathologist or audiologist to adequately fulfill their supervisory obligations and to ensure quality care.

The entity employing the supervisory speech-language pathologist or audiologist is responsible for ensuring:

• That these standards are met.
• That appropriate documentation is maintained to prove that the above requirements were met.
• That there is appropriate documentation of services provided by the supervising speech-language pathologist or audiologist and by the individuals working under the direction of the supervising speech-language pathologist or audiologist.

Speech and Language Pathology Provider Qualifications

Medicaid reimbursement is available for SLP services only if provided by or under the direction of a practitioner who has completed the educational requirements and the work experience necessary for the ASHA certificate, and has passed the Praxis exam in SLP.

Testing and Assessment Procedures

ForwardHealth covers only for testing, assessment, or other procedures conducted for the purpose of determining a child's need for covered SBS when performed by providers who meet ForwardHealth's credential and licensing requirements.

ForwardHealth does not cover:

• Any component of any procedure that does not result in the provision of covered SBS, regardless of the provider type.
• Procedures conducted by special education teachers, diagnostic teachers, directors of special education, or other school staff, unless such staff qualifies as one of the health or pupil services practitioners who meet ForwardHealth's credential and licensing requirements.

Note: Consistent with Wis. Admin. Code §§ DHS 107.36(b),(c), and (d), an evaluation or testing to assess the child's need for a therapy service performed in person or via audio-visual telehealth may be reimbursed when the evaluation or testing results are considered during the development or revision of a student's written treatment plan. The student must qualify under IDEA in some disability category. The evaluation or testing does not need to result in that specific therapy service being added to the student's treatment plan.

Transportation Policy

Transportation to School and from School

A child's transportation to and from a school enrolled as an SBS provider is a covered service only if all these conditions are met:

• The child receives a covered SBS identified in the child's written treatment plan at the school on the day the transportation is provided.
• The SBS provider is financially responsible for providing the transportation.
• The child's medical need for the particular type of transportation is identified in the child's treatment plan.
• One of the following:
  • The vehicle is equipped with and the child requires a ramp or lift.
  • An aide is present and the child requires the aide's assistance in the vehicle.
  • The child has behavioral problems that do not require the assistance of an aide but that preclude the child from riding on a standard school bus.

Off-Site Transportation

A child's transportation to and from a site other than the child's "home" school is a covered service only if all the following conditions are met:

• The child receives a covered SBS identified in the child's treatment plan at the site on the day the transportation is provided.
• The SBS provider is financially responsible for providing the transportation.
• One of the following:
  • Transportation is from the school to an off-site provider and back to school or home.
  • Transportation is between home and a "special school." A special school is a school that requires that a child have a disability in order to be enrolled, including, but not limited to, the Wisconsin School for the Deaf or the Wisconsin School for the Visually Handicapped, as defined in Wis. Admin. Code ch. PI 12.

Transportation Provider Qualifications

Covered specialized medical transportation services must be performed by a school or school-contracted transportation provider.

Transportation Services Limitations

Written treatment plans must include only specialized medical transportation services that a child would not otherwise receive in the course of attending school. For example, a child with special education needs who rides the standard school bus to school with children without disabilities should not have transportation listed in their treatment plan, and the cost of that bus ride must not be billed to Wisconsin Medicaid as an SBS.

When specialized medical transportation services are included in the child's treatment plan, providers may seek reimbursement only under the SBS benefit. Claims for school-based transportation services, as described in the treatment plan, cannot be submitted to Wisconsin Medicaid by SMV providers or billed to a county by county common carrier providers.

Written Treatment Plan

The SBS benefit only covers services that are listed in the written treatment plan. Each public school child who receives SBS must have a written treatment plan. The written treatment plan:

• Is developed, reviewed, and revised in accordance with Wis. Stats. § 105.03.
• Identifies the special education needs and related services for the child.

Written Treatment Plan Meetings

Wisconsin Medicaid will reimburse providers for a written treatment plan meeting as a direct medical service only when all of the following conditions are met:

• The meeting is attended by one of the following health or pupil services practitioners:
• Advanced practice nurses and registered nurses
• Clinically trained mental health professionals as defined in Wis. Admin. Code § PI 34.0375
• Counselors
• Dentists or dental hygienists operating within their scope of practice as described in Wis. Admin. Code §§ DHS 105.06(1) and 105.06(2)
Physicians or other providers operating within their scope of practice under Wis. Admin. Code § N 8.02(1) with prescribing authority granted under Wis. Stat. § 441.16(2), providing services identified in the member's treatment plan as defined in Wis. Admin. Code § DHS 105.53(3)(a)3
• Psychologists
• Social workers
• Speech-language pathologists, occupational therapists, or physical therapists
• Assistants working under the direction of a qualified speech-language pathologist, occupational therapist, or physical therapist
• The child is present at the meeting.
• The resulting treatment plan includes covered services.
• The parts of the meeting for which reimbursement is claimed are limited to time periods during which provision of covered treatment plan services is discussed.
• Reimbursement claims are limited to the amount of time spent by health or pupil services practitioners.