Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
What is the difference between a reimbursable training and a non-reimbursable training for health providers in the school setting? Similar to clinical supervision, which could fall under general administrative activities as “care
coordination,” what are consistent definitions of when these activities are reimbursable? (see Page 74 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming discussing the exclusion of some provider
training and supervision activities. Assuming that an LEA is a “provider facility”)
Provider training provided by the Medicaid agency or its contracted designee regarding Medicaid covered services, or aimed at improving the delivery of Medicaid services, is reimbursable as a Medicaid administrative expenditure. This could include, for example, training for case managers, individuals who develop and coordinate person-centered care planning, primary care practitioners, or hospital discharge planners. Costs incurred by the providers to meet continuing education and advanced training requirements cannot be claimed as a Medicaid administrative expenditure; as described above, in some circumstances such costs may be reflected in provider rates. Regulations at 45 C.F.R. Part 75 provide the relevant cost regulations. Additional discussions on the inclusion of training costs in rate development and other regulations surrounding allowable and unallowable costs in Medicaid are in the CMCS Information Bulletin dated 7/13/2011.
FAQ ID:166436
SHARE URLIs a formal diagnosis and treatment plan a prerequisite for accessing Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services?
As specified in section 1905(r)(5) of the Act, the EPSDT benefit entitles most eligible Medicaid-enrolled children and adolescents to services and treatments that fit within any of the benefit categories of Medicaid-coverable services listed in section 1905(a) of the Act if medically necessary, as determined by the State, to “correct or ameliorate” identified conditions. A formal diagnosis is not required according to Federal Medicaid rules. State Medicaid agencies determine medical necessity criteria.
FAQ ID:166431
SHARE URLWhat documentation is required for claiming FFP for Medicaid SBS? Does service documentation need to include the Medicaid enrollment status of an individual practitioner (not just the LEA)?
As stated on page 91 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, as required by CMS, the supporting documentation file for each claim of FFP must include, at a minimum, the following:
- Date of service
- Name of recipient
- Medicaid identification number
- Name of provider agency and person providing the service
- Nature, extent, or units of service
- Place of service
Within an IEP many of the above requirements may be found, including:
- Name of recipient/child
- Eligibility for IDEA services and the child’s present level of achievement
- Name of provider agency/LEA
- Nature, extent, or units of service (called the frequency and duration of services)
- Place of service (called either the location or placement)
LEAs should review their State’s guidance for service documentation. Many States require additional information beyond the CMS requirements, such as a diagnosis code.
FAQ ID:162371
SHARE URLIf an RMTS activity indicates the delivery of an evaluation (psychological, therapy, etc.) where medical necessity is determined through documentation, but no plan is developed, is code 4C the appropriate code?
If medical necessity has been determined, Code 4C. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/IEP Service is the correct code. This code should be used when district staff (employees or contracted staff) provide covered direct medical services under the SBS Program where documented on a medical plan other than an IEP/IFSP or where medical necessity has been otherwise established.
FAQ ID:162396
SHARE URLGiven that LEAs no longer use Social Security numbers for identifying students, finding Medicaid identification numbers for students and determining Medicaid eligibility has become challenging. How are CMS and the SBS Technical Assistance Center addressing this issue?
The system used to identify Medicaid members is unique to each State. The Technical Assistance Center can help with research and work with States to identify best practices to address this issue. We recommend the SMA work with LEAs to develop an integrated system used by both entities.
FAQ ID:162406
SHARE URLCan Medicaid covered services furnished in schools be delivered through telehealth?
States have broad flexibility to determine what services can be delivered via telehealth. Further information can be found in the Telehealth Toolkits (COVID-19 & February 2024 Versions), accessible through this link: State Medicaid and CHIP Telehealth Toolkits landing page.
FAQ ID:162401
SHARE URLDoes CMS have suggestions for how to ensure that procedural and diagnostic coding for specific services in the school setting are the same as in other settings?
There are no federal requirements for Current Procedural Terminology or International Classification of Diseases codes for Medicaid billing. States may have their own requirements, however. We advise communication between SMAs, SEAs, and LEAs within a State to ensure proper SBS coding guidance.
FAQ ID:162381
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