Sec. 10.09.94.04. Covered Services

A. The Program covers the following inpatient services at special pediatric hospitals:

(1) A hospital admission determined to be medically necessary for a participant who is stable enough for transfer to a post-acute setting and requires medical or rehabilitative services that:

(a) Cannot be provided at a lower level of care; and

(b) Meets the medical eligibility criteria under Regulation .06 of this chapter;

(2) Administrative days for the length of time certified by the Department or its designee;

(3) Inpatient admissions for intensive occupational therapy, physical therapy, or speech therapy on a regimen which is less than 3 hours per day, 5 days per week, when these services are provided in a unit that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide rehabilitation services; and

(4) Ancillary services.

B. The Program covers the following outpatient hospital services:

(1) Medically necessary services for the provision of diagnostic, curative, palliative, or rehabilitative treatment; and

(2) For a participant younger than 21 years old, physical therapy, occupational therapy, speech therapy, and audiology services if:

(a) The therapy provider develops a written plan of treatment in collaboration with the participant’s primary care physician and the participant or the parent or guardian of the participant;

(b) The service is provided according to the plan of treatment; and

(c) The services provider sends an update of the plan of treatment to the participant’s primary care physician every 90 days.