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Legislations

IDEA

The Individuals with Disabilities Education Act (IDEA) is a law that provides Free and Appropriate Education (FAPE) to children with disabilities and guarantees special education and related services for those children, ultimately protecting the rights of these children and their families (The Office of Special Education and Rehabilitative Services, n.d.). 

The statute provides information of how a child with a disability is defined, as well as the evaluation process needed in order to determine eligibility and track the child’s progress. Furthermore, the statute highlights the importance of focusing on functional performance in relation to the general education curriculum, addressing barriers and the services available to remove those barriers (IDEA, 2004).

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  • Part B outlines special education and related services for children ranging from three to 21 years (The Office of Special Education and Rehabilitative Services, n.d.)

    • Addresses the barriers children with disabilities face to allow them to progress and partake in the general education process (IDEA, 2004). ​

    • OT is defined as a related service.

  • Part C of the law ensures early intervention services for the families of children from birth through the age of two (The Office of Special Education and Rehabilitative Services, n.d.).

    • An at-risk infant or toddler is defined as “an individual under 3 years of age who would be at risk of experiencing a substantial developmental delay if early intervention services were not provided to the individual” (IDEA, 2004, § 1432).​

    • The individualized family service plan team identify the early intervention services that are aimed at meeting the developmental needs of an infant or toddler with a disability, in at least one of the following areas: “physical development; cognitive development; communication development; social or emotional development; or adaptive development” and include occupational therapy services among many services. (IDEA, 2004, § 1432).

 

Rehabilitation Act of 1973

Section 504

If a child does NOT qualify for special education services under IDEA they may still qualify for certain educationally related occupational services such as reasonable accommodations, environmental adaptations, and other appropriate materials and equipment can be recommended and provided to meet specific educational needs in a general education setting in order to facilitate their right to FAPE under Section 504 of the Rehabilitation Act of 1973 (U.S. Department of Education, 2010).

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Section 504 assures children with qualified disabilities are not subjected to discrimination of any sort in any program that receives funds from the Department of Education, which includes public school districts, institutions of higher education, and other state and local education agencies (U.S. Department of Education, 2010)

CHIP

According to Medicaid.gov (n.d.), the Children’s Health Insurance Program (CHIP) provides medical coverage to children ages 19 and younger whose parents’ income is too high to qualify for Medicaid. States have the flexibility to design their own programs, so the benefits vary by state. 

Social Security Act

  • According to the Social Security Administration (n.d.), the Social Security Act is composed of multiple amendments that provide medical coverage to families who are at or below the poverty line, individuals aged 65 and older, and some individuals with qualifying disabilities. Of this legislative act came Medicare and Medicaid. “Therapy services are a covered benefit in §§1861(g), 1861(p), 1861(s)(2)(D), and 1861(ll) of the Social Security Act” (Centers for Medicare and Medicaid Services, 2012, p. 4).

  • According to the Centers for Medicare and Medicaid (2012), there are a number of conditions for coverage and payment by Medicare and Medicaid. Such components include providing therapy services based on individual needs, documenting a thorough plan of care, and providing services to individuals who are under the direct supervision of, and received therapy orders from, a physician or nurse practitioner.

  • According to the Centers for Medicare and Medicaid (2012), treatment programs and specific interventions must target anticipated goals and expected outcomes as they relate to the targeted occupational performance deficits.

  • According to the Centers for Medicare and Medicaid (2012), progress reports must reflect the justification for therapy services as deemed medically necessary and relevant.

  • "Services should be appropriate type, frequency, intensity, and duration or the individual needs for the patient and the needs of the patient are dependent upon the occupational roles they must to fulfill" (Centers for Medicare and Medicaid, 2012, p. 20). 

Medicare

  • According to Medicare.gov (n.d.), Medicare is a federal health insurance program for people who are over the age of 65, younger aged individuals with disabilities, and individuals with end stage renal disease (ESRD) (Medicare.gov, n.d.).

  • Medicare is compose of four parts: Part A or hospital insurance, Part B or medical insurance, Part D or prescription drug coverage, and Part C or the Medicare Advantage Plan (Medicare.gov, n.d.).

  •  Medicare Part A covers inpatient care in a hospital which includes rehabilitation services such as occupational therapy as long as the doctor makes an official order of a stay for two or more midnights of “medically necessary inpatient hospital care to treat your illness or injury, and the hospital formally admits you” (Medicare.gov, n.d.).

  • Medicare Part B “helps pay for medically necessary outpatient physical and occupational therapy, and speech-language pathology services but requires “your therapist or therapy provider to confirm that your therapy services are medically reasonable and necessary” (Medicare.gov, n.d.).

  • Once the OT services hit the $2,010 allowable amount, the therapy provider will need to add a special notation to your therapy claims stating that the “therapy services are reasonable and necessary” and that the “medical record includes information to explain why the services are medically necessary” (Medicare.gov, n.d.).

Medicaid

  • Medicaid is both state and federally funded, and provides medical coverage to family households with limited income (Medicaid.gov, n.d.)

  • Occupational therapy is only considered an optional benefit.

  • According to AOTA (2017), Medicaid reimburses for occupational therapy services provided in a school setting that are deemed medically necessary if the student is enrolled in the Medicaid program.

  • Medicaid is a program funded by both the states and federal government to provide medical coverage to mandatory eligibility groups, which includes low income families, certain pregnant women and children, and those receiving supplemental security income (Medicaid.gov, n.d.).

  • Medicaid provides health coverage and fund assistance to the people in family households with limited income and assets (Medicaid.gov, n.d.).

  • AOTA (n.d.) further stated that, federal law requires each state to provide a very broad set of health services covered by Medicaid, however, each state is able to design the specific programs of Medicaid.

  • Though OT is federally recognized as a covered service, states have the ability to make it an optional benefit, or reimburse for only specific occupational therapy services they deem medically necessary.

  • Optional benefits include prescription drugs, case management, occupational therapy, and physical therapy (Medicaid.gov, n.d.).

  • According to Medicaid.gov, mandatory benefits include inpatient and outpatient hospital series, physician series, laboratory and x-ray services and home health services.

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Social Security Administration (n.d.). The Social Security Act of 1935. Retrieved from https://www.ssa.gov/history/35act.html

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Centers for Medicare and Medicaid Services (2012). Physical, occupational, and speech therapy services. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medical-Review/Downloads/TherapyCapSlidesv10_09052012.pdf

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Medicare.gov. (n.d.). What’s Medicare?. Retrieved from https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare

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Medicaid.gov (n.d.). Medicaid. Retrieved from https://www.medicaid.gov/medicaid/index.html

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American Occupational Therapy Association. (2017). Guidelines for occupational therapy services in early intervention and schools. The American Journal of Occupational

Therapy, 71, 1-10. Retrieved from https://search.proquest.com/docview/1985896867?accountid=37862

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American Occupational Therapy Association (n.d.). Medicaid. Retrieved from https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Pay/medicaid.aspx

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Individuals With Disabilities Education Act, 20 U.S.C. § 1400 (2004).

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The Office of Special Education and Rehabilitative Services. (n.d.). IDEA: Individuals with Disabilities Education Act. Retrieved from https://sites.ed.gov/idea/

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Medicaid.gov (n.d.). CHIP. Retrieved from https://www.medicaid.gov/chip/index.html

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U.S. Department of Education (2010). Free appropriate public education for students with disabilities: Requirements under section 504 of the Rehabilitation Act of 1973. Retrieved

from https://www2.ed.gov/about/offices/list/ocr/docs/edlite-FAPE504.html#note3

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Achondo, Brusco, Deol, Kim, & Vartanian

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