Related Services and the “Medical Exclusion”

This topic brief outlines the requirements under the Individuals with Disabilities Education Act and the regulations implementing Section 504 of the Rehabilitation Act of 1973 that eligible students with disabilities receive “related services,” and discusses the right, as a related service, to assistance with significant health-related needs during the school day.

The Right to Related Services in General

The Individuals with Disabilities Education Act (“IDEA”) requires school systems to provide eligible children with a “free appropriate public education" consisting of "special education” and “related services" (and including an appropriate preschool, elementary or secondary education in the state involved).¹ The regulations implementing section 504 of the Rehabilitation Act of 1973 also call for a "free appropriate public education." Under these regulations, a “free appropriate public education” may consist of either "special education" or "regular education" and "related aids and services."²

The related services mandated by IDEA consist of "[t]ransportation and such developmental, corrective and other supportive services...as may be required to assist a child with a disability to benefit from special education."³ The section 504 regulations do not define the "related aids and services" required for section 504 compliance. However, related services developed and delivered in accordance with IDEA requirements will ordinarily satisfy the §504 requirement as well.⁴

Under both IDEA and §504, the particular related services a child is to receive must be based upon an individualized determination of his or her unique needs — not upon the category of his or her disability.⁵ Thus, for example, a blanket rule or policy that allowed only children with severe emotional disturbance to receive counseling as a related service would violate both laws. In addition, the team developing a child’s Individualized Education Program (“IEP”) must include

• orientation and mobility services for children with visual impairments;

• recreation, including assessment of leisure function, therapeutic recreation services, leisure education and recreation programs in schools and community agencies;

• counseling services provided by qualified social workers, psychologists, guidance counselors or other qualified personnel;

• parent training and counseling aimed at assisting parents in understanding the needs of their child, providing parents with information about child development, and helping them acquire skills to allow them to support implementation of their child’s IEP;

• rehabilitation counseling services;

• early identification and assessment of disabilities in children;

• school health services provided by a qualified school nurse or other qualified personnel; and

• social work services in school, including group and individual counseling with the child and family, working with problems in a child's home, school or community that affect his or her adjustment in school, and mobilizing school and community resources to enable the child to receive maximum benefit from his or her educational program.⁷

These services are not the only ones that qualify as “related services” under IDEA: if a child needs a particular service in order to benefit from special education and the service is a developmental, supportive or corrective one, it is also a "related service" and should be included in the child’s IEP, regardless of whether it is expressly listed in IDEA or its regulations.⁸ For some children, for example, a part or full time aide might constitute a required related service, as might certain equipment or assistive technology, such as a computer or tape recorder.⁹

The “Medical Exclusion” and Assistance with Health-Related Needs In School

As noted above, the IDEA definition of "related services" includes "medical services...for diagnostic and evaluation purposes only."¹⁰ "Medical services," in turn, are defined in the IDEA regulations as "services provided by a licensed physician to determine a child's medically related disability that results in the child's need for special education and related services."¹¹ All other physician services are excluded from the range of related services that school systems must provide. This is known as the “medical exclusion.” On the other hand, if a service can be provided by a non-physician, under these rules, it does not fall under the medical exclusion, and must be included in the IEP and provided if it otherwise meets the definition of a related service.

In the past, disputes have arisen about whether, under these rules, a student has a right to health-related assistance by a non-physician that his or her school district deems too complex, intensive or costly. Two U.S. Supreme Court decisions make it clear that schools must provide necessary in-school assistance with health-related needs, so long as they can be provided by a non-physician.

The first decision, in the 1984 case of Irving Independent School District v. Tatro,¹² required a school system to provide clean intermittent catheterization to a student needing it every three to four hours during the school day. The Court held that if a student cannot attend school unless provided with certain health-related assistance during the school day, such help is a "supportive service" necessary to assist him or her to benefit from special education, and that if it can be provided by a school nurse, trained layperson or other non-physician, it is not an excludable medical service; rather, it is a "school health service" as defined by the IDEA regulations — and so a required related service under IDEA.¹³

The second case, Cedar Rapids Community School District v. Garret F.,¹⁴ was decided in 1999. The student in Garret F. needed a range of assistance with physical needs during the school day, including suctioning of his tracheotomy tube and other tasks related to his use of a ventilator. The school system characterized these as “continuous nursing services” and claimed that they were not required related services but, rather, fell under the medical exclusion because of their intensity and cost. The Supreme Court rejected the school system’s position, holding that the 15 year-old rule of Tatro was sound and applicable. Therefore, the school system had to provide the services Garret F. needed, even if they were “continuous,” and even if they required a nurse. In explaining its decision, the Court stated, "[t]his case is about whether meaningful access to public schools will be assured....It is undisputed that the services at issue must be provided if Garret is to remain in school. Under the statute, our precedent, and the purposes of the IDEA, the District must fund such `related services' in order to help guarantee that students like Garret are integrated into the public schools."¹⁵

NOTES

1. 20 U.S.C. §§1401(8), 1412(a); 34 C.F.R. §300.13.

2. 34 C.F.R. §104.33(b).

3. 20 U.S.C. §1401(22).

4. 34 C.F.R. §104.33(b)(2).

5. See, e.g., Inquiry of Rainforth, 17 Education of the Handicapped Law Report [EHLR] 222 (OSEP 10/24/90) (regarding IDEA); Prescott (AZ) Unified School District No. 1, EHLR 352:540 (OCR 5/22/87) (regarding §504). See also OSEP 11/23/94 Memorandum, supra (IDEA).

6. 34 C.F.R. §300.24(b)(15).

7. 20 U.S.C. §1401(22) and 34 C.F.R. §300.24. Each of these services is further defined in 34 C.F.R. §300.24(b).

8. 34 C.F.R. part 300, App. A, para. 34.

9. Depending upon a student's particular circumstances, a school system might be required to provide a computer or other assistive technology as "special education," as a "related service" or as a "supplementary aid or service" to facilitate his or her education in the regular education setting pursuant to IDEA's least restrictive environment requirements. 34 C.F.R. §300.308. See also Inquiry of Goodman, 16 EHLR 1317 (OSEP 8/10/90).

10. 20 U.S.C. §1401(22).

11. 34 C.F.R. §300.24(b)(4).

12. 468 U.S. 883, 890, 104 S.Ct. 3371, 3376 (1984).

13. Id., 468 U.S. at 892-893, 104 S.Ct. at 3377-3378.

14. 526 U.S. 66, 119 S.Ct. 992.

15. 526 U.S. at 79, 119 S. Ct. at 1000.