Contact your Local Cost Recovery Specialist for additional information.

 

• To provide for the detection of any physical and mental problems in individuals under the age of 21 as early as possible through comprehensive medical screenings in accordance with prescribed standards; and
• To provide for appropriate and timely diagnostic and/or other services to correct or ameliorate any acute or chronic conditions found before the health problems become more complex and their treatment more costly.

The Delaware Medical Assistance Program (DMAP) shall pay for a covered service provided to an eligible Medicaid client or to a person who is later found to be eligible at the time he or she received the service. To be eligible for payment, a school based health service must:

• Be determined by prevailing community standards or customary practice and usage to: 
• Be medically necessary 
• Be appropriate and effective for the medical needs of the individual 
• Meet quality and timeliness standards 
• Be the most cost-effective health service available for the medical needs of the individual 
• Represent an effective and appropriate use of DMAP funds 
• Be within the service limits specified by the DMAP 
• Be personally furnished by personnel who meet the necessary requirements and credentials

The following covered services shall be reimbursable to Medicaid eligible clients or persons who are later found to be eligible at the time he or she received the service.

To be eligible, a school-based health service must:

• Be medically necessary 
• Be appropriate and effective for the medical needs of the individual 
• Meet quality and timeliness standards 
• Be the most cost-effective health service available for the medical needs of the individual 
• Represent an effective and appropriate use of the Delaware Medical Assistance Program (DMAP) funds 
• Be within the service limits specified by the DMAP 
• Be personally furnished by personnel who meet the necessary requirements and credentials described in the School-Based Policy Manual.

The following services shall not be covered:

• Physical therapy services provided without a physician referral 
• Services provided but not documented in the individual's treatment plan or student record.  An exception to this is the provision of nursing and psychological services that are unplanned or emergency in nature. 
• Canceled visits or appointments not kept. 
• Services that are solely educational, vocational, or career-oriented. 
• Services that are solely recreational in nature. 
• Services rendered which are not provided directly to the eligible individual or family member, or on behalf of the individual.  Indirect services such as attendance at staff meetings, staff supervision, etc. are non-covered services.