Frequently Asked Questions

Yes, provided the following conditions are met. As noted on page 99 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming under section G. Special Considerations for Transportation and Vaccines as SBS:

“School-based specialized transportation is defined as transportation to a medically necessary service (as outlined in the IEP of an enrolled Medicaid beneficiary) provided in a specially adapted vehicle that has been physically adjusted or designed to meet the needs of the individual student under IDEA (e.g., special harnesses, wheelchair lifts, ramps, specialized environmental controls, etc.) to accommodate students with disabilities in the school-based setting. Note: the presence of only an aide (on a non-adapted bus/vehicle) or simple seat belts do not make a vehicle specially adapted. Specialized transportation may consist of a specially modified, physically adapted school bus or other vehicle in the specialized transportation cost pool.” 

Under the Individuals with Disabilities Education Act (IDEA), if a child with a disability is receiving special education and related services, transportation is included in the child’s IEP, and the IEP Team determines that the parent will be providing transportation, the LEA must reimburse the parents in a timely manner for the costs incurred in providing transportation. See the Office of Special Education Programs’ Questions and Answers on Serving Children with Disabilities Eligible for Transportation, November 2009. The LEA may request Medicaid reimbursement if the parent personal vehicle has been specially adapted consistent with the SBS guidance.

FAQ ID:162431

Generally, yes, but how this is achieved is dependent on the reimbursement methodology the State has approved for SBS in its Medicaid State plan. If SBS in a State are paid through fee for service (FFS), then each billed service is claimed and paid as provided in the State plan, regardless of when it occurs.

If a State has a cost methodology in the State plan that uses a time study, the time study must include 100% of providers’ billable time and account for their regular schedules in the methodology and in the time study implementation plan (TSIP). In this case, the providers’ schedules should include after-school hours for programs that are intended to be captured. If these programs are contracted, the contracted costs must also be included in the cost report. If a State does not currently have these programs included in their approved SBS reimbursement methodology, the methodology may have to be amended to capture the additional services. This may include revisions to the SPA, TSIP, PACAP, or other documents, as needed.

In the case of summer activities (i.e., non-regular school days when schools are not capturing any Medicaid services), a time study should be performed to cover these periods. Anytime there are Medicaid services performed and captured in a cost methodology, that time needs to be accounted for in the CMS-approved TSIP, and the allocations explained in the SPA. This is especially true for children with Individualized Education Programs (IEPs) who are eligible for Medicaid and require special education and related services after school hours, on weekends, and/or extended school year services (defined in 34 C.F.R § 300.106). SMAs must have procedures in effect that allow for time studies to capture 100% of providers’ time delivering extended school year services. No estimations of Medicaid services can be calculated for vacation or other periods not covered in the time study.

FAQ ID:162421

A Notice of Funding Opportunity (NOFO) was published in the Federal Register at https://www.govinfo.gov/app/collection/FR/ on January 24, 2024. Applications for grant funding were due March 25, 2024. Please contact the MedicaidSBSPlanningGrants@cms.hhs.gov mailbox for more information.

FAQ ID:162436

The formula for State FMAP is established in statute and there is currently no FMAP specific to SBS. The FMAP for direct medical services provided in schools is the same as applicable for Medicaid or CHIP services provided in other service settings. Expenditures for Medicaid administrative activities are generally available at a 50% matching rate, with higher rates for certain activities as specified in the Social Security Act (the Act). Expenditures for CHIP administrative activities, including health services initiatives (HSIs) are available at the Title XXI enhanced or eFMAP and subject to a 10% limit on administrative expenditures.  

FAQ ID:162426

No, generally, States that employ a State plan payment methodology that reimburses a provider for the actual cost of Medicaid services and/or administrative activities may not use a fee schedule rate as a proxy for cost. Instead, states must use cost identification methodologies and supporting documentation methods that are consistent with the requirements of 45 C.F.R. Part 75 and approved by CMS.

When a State relies on a unit of government to fund the non-federal share of Medicaid expenditures through a Certified Public Expenditure (CPE), the reimbursement to the provider is limited to the actual, incurred cost of providing Medicaid services or administrative activities. In those circumstances, a State must use the cost finding and documentation principles that are discussed in 45 C.F.R. Part 75 to determine the amounts that may be reimbursed for Medicaid activities. These costs must be reconciled.

FAQ ID:162391

No, States may opt to maintain their current approach, including a fee schedule approach, if the existing State Plan Amendment (SPA) and underlying implementation mechanisms are compliant with all of the federal requirements discussed in the new SBS Guide. The newly introduced flexibilities are available options for States, but their adoption is not mandatory. If a State wants to depart from its currently approved SBS payment and/or claiming approach, including replacing a current fee schedule methodology or providing higher fee schedule payment amounts, a SPA is necessary.

FAQ ID:162376

The Precertification Pilot was an experiment conducted from October 2017-March 2018 designed to streamline certification and attract new vendors. Unfortunately, the pilot was found to be unscalable across Medicaid. However, key learnings from the pilot will be incorporated into current processes and future experiments around vendor engagement, certification, scalability, and sustainability. The goals the Centers from Medicare & Medicaid Services (CMS) identified at the beginning of the Precertification Pilot process remain the same: reduce the level of effort of certification; shorten the certification timeline; promote modularity and interoperability; reduce risk of system failure; and attract new vendors to the Medicaid IT market. Contact CMS with your ideas for experiments to achieve those goals at MES@cms.hhs.gov.

FAQ ID:95151

As contained in the MECT standard RFP/contract language required by CMS, CMS does not cover activities that the state may require of the IV&V contractor during ongoing O&M. However, as Medicaid is moving away from monolithic single applications, it is expected that states will continuously update and replace modules in their enterprise. Therefore, IV&V should always have a role to ensure successful integration and testing.

FAQ ID:94881

If an organization is performing another role (such as systems integrator, PMO, quality assurance, etc.) on the MMIS or E&E project, it may not perform the IV&V function on the same project. A state may contract the same vendor to perform the IV&V role for both its E&E and MMIS projects.

FAQ ID:94886

To reduce potential conflict of interest, CMS is ensuring that states are arranging IV&V services through contracts that should be owned outside of the agency that owns the MMIS or E&E project. The oversight organization for the IV&V contractor should not be involved in oversight of the development effort, a stakeholder in the business implementation, or the DDI contractor. The IV&V contract monitor should be aware of system development problem solving, reporting, and contractor management. This contract oversight provides true independence between the IV&V contractor and system development teams. This requirement is consistent with other HHS agencies' practices and industry best practices.

FAQ ID:94891