Medical & Educational Models
Medical Model
The medical model is typically utilized by occupational therapists in outpatient pediatric settings.
These are the main occupations addressed by OT
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activities of daily living,
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instrumental activities of daily living, and
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play
Under this model, Federal, State insurance programs, and private/ commercial insurances are the main sources of reimbursement. OT practitioners must meet both "state and federal licensure requirements and public and private funding requirements" (Indiana Transition Initiative, 2008, para. 1).
According to Indiana Transition Initiative (2008), a physician determines the need for therapy services and provides a referral for occupational therapy, however the child’s insurance company may determine the amount of therapy that can be provided and the medical necessity of services. Services are paid for by either the parent, client, insurance company, or by governmental assistance. Documentation requirements to prove medical necessity are determined by the payor of services, and reimbursement is influenced by the payor's guidelines (Indiana Initiative, 2008; Centers for Medicare and Medicaid, n.d.; Social Security System, n.d.) The Social Security Act (1935) provide medical coverage through Medicare and Medicaid a to children in an outpatient setting, and both programs provide specific guidelines as to what services are considered medically necessary and therefore, reimbursable.
Educational Model
The educational model is typically utilized in school-based practice, where occupations needed to be a successful student are the primary occupations addressed. Th services are provided for free through federal legislation as long as the child meets certain qualifications.
According to Individuals with Disabilities Education Act (IDEA, 2004), OT is considered a related service. These related services are provided in a Special Education setting to assist children in the learning process by targeting educational performance and providing adaptations as necessary to improve performance."Therapies that are included as related services under IDEA 04 are provided by public schools at no cost to the parent" (Indiana Transition Initiative, 2008, para. 7).
OT services must be educationally, developmentally, or functionally relevant and must lead to the development or improvement of a child’s performance or function related to academics. OT goals and recommendations must align with general education curriculum [special education curriculum] and extracurricular activities.
In order for children to qualify for occupational therapy in a school setting, their impairment must interfere with academic performance. The goal of the occupational therapist in a school setting is to support a child’s academic performance and not provide rehabilitation service (Bazyk & Cahill, 2015).
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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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Indiana Transition Initiative (2008). Educational - Medical - Developmental Therapy Models.
Retrieved from http://www.doe.in.gov/sites/default/files/specialed/educational-medical-developomenal-model-family.pdf
Individuals With Disabilities Education Act, 20 U.S.C. § 1400 (2004).
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Knowles, M.S. (1970). The modern practice of adult education: Andragogy versus pedagogy. New York: New York Association Press
