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.

Yes, under both IDEA and FERPA, a public agency may accept digital or electronic signatures when obtaining parental consent to disclose PII from the child’s educational records. Such electronic consent must: 1) identify and authenticate a particular person as the source of the electronic consent; and 2) indicate such person’s approval of the information contained in the electronic consent.

As discussed in Section IV. C of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, State Medicaid/CHIP agencies may share applicant and beneficiary information with schools enrolled as Medicaid or CHIP providers, or other Medicaid or CHIP providers, when the use or disclosure of the information is for purposes directly connected with the administration of the Medicaid or CHIP State plan, including establishing eligibility, providing services, or billing for services. Yes; An LEA or a school enrolled as a Medicaid or CHIP provider may receive beneficiary information on the condition that the school adheres to confidentiality standards comparable to those of the SMA or the State CHIP agency. The SMA and the State CHIP agency (in accordance with 42 C.F.R. § 457.1110(b)), as well as recipients of applicant and beneficiary information, must safeguard this information in accordance with the requirements of 42 C.F.R. part 431, subpart F confidentiality when they receive, use, or disclose applicant or beneficiary information. 

One of these requirements is that the SMA or State CHIP agency must obtain permission from the individual, or their family, before responding to a request for information from an outside source, as set forth in 42 C.F.R. § 431.306(d). The Medicaid consent for billing purposes is separate from the FERPA and IDEA consent provisions. 

IDEA child find requires States to ensure that all children with disabilities residing in the State who need special education and related services are identified, located, and evaluated, regardless of the severity of the disability, and includes identification of children who are suspected of having a disability. States are responsible for implementing child find activities for all children with disabilities residing in the State, including those children who are experiencing homelessness or are wards of the State, highly mobile and migrant children, English learners, and parentally placed private school children with disabilities, as well as those suspected of having developmental delays as defined in 34 C.F.R. § 300.8(b). 

Child find activities are defined in 34 C.F.R. § 300.111 and typically involve a screening process to determine whether the child should be referred for an evaluation to determine eligibility for special education and related services. States must identify, locate, and evaluate all children with disabilities residing in the State and who may need special education and related services.
 

Yes, some child find activities could be covered in Medicaid. Child find activities may involve a formal screening process to determine whether the child should be referred for an evaluation to determine whether a child has a disability and the nature and extent of the special education and related services that the child needs. In a scenario where a child is enrolled in Medicaid, a screening or initial evaluation could be coverable under a 1905(a) benefit category. As specified in section 1905(r)(5) of the Act, EPSDT 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. For a child who is not yet enrolled in Medicaid, the child find activities such as screenings and evaluations would not be covered.

More on Child Find is available at the Department of Education’s website. 
 

The 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming (p. 15) has language that states that “coverable services also include child find evaluations and reevaluations.” Medicaid may cover child find screening, evaluations, and reevaluations in certain circumstances (see FAQ on Child Find Activities).

Examples of child find activities can include: 
For preschool- and school-aged children: Public awareness campaigns by the LEA or in partnership with a school’s parent teacher association that include information provided in languages spoken in the community and that target a wide audience, including parents and families, daycare and early childhood education providers, summer camps, medical providers, homeless shelters, religious institutions, and kindergarten roundup (i.e., events hosted by elementary schools to facilitate a child’s transition from home to formal education).

For older children: 

• Locally administered assessments that measure student academic growth.
• Screening private school students and home school students.
• Meeting with mental health practitioners.
• Sharing information with nonprofit organizations that focus on families and children.
• Coordinating with State agencies that provide services to children and young adults.

Other activities can include the LEA’s outreach efforts and interagency collaboration with housing programs, such as those funded by the U.S. Department of Housing and Urban Development, that help to identify children who are homeless and may be in need of special education.

If the state is limiting Medicaid coverage to those services included in the IEP/Individualized Family Service Plan (IFSP), then child find services that do not result in an IEP/IFSP being issued are generally not Medicaid coverable services.  If the state has broader coverage beyond services described in an IEP/IFSP, then child find services could be coverable regardless of whether an IEP/IFSP has been issued.
Managed Care 

Each State’s approach to expanding SBS can vary depending on factors such as which services are being expanded and the source of funding. While there are many different types of managed care arrangements, State Medicaid agencies (SMAs) have flexibility in determining how services are provided. SMAs may elect to deliver some services through managed care plans (MCPs) and other services through an FFS delivery system; in fact, the majority of States do not include SBS in managed care and cover them under an FFS delivery system. If SBS is included in a managed care delivery system, the MCP contract must clearly describe which services and administrative activities are included under the contract, to avoid duplication of payment and performance of assigned responsibilities. This requires enough specificity to avoid confusion about what is included in a covered benefit and whether the MCP is responsible for covering the benefit. Any Medicaid benefits not covered under the MCP contract remain the responsibility of the SMA to cover. We also remind States that State plan administrative activities not related to the plan’s furnishing of services may not be incorporated into the Medicaid managed care capitation rates.

CMS strongly encourages State Medicaid/CHIP agencies to proactively establish and/or strengthen relationships between MCPs, schools/LEAs, and school-based providers. State Medicaid agencies can require MCPs to establish relationships, strengthen partnerships, and coordinate care with school-based providers, including school-based health centers, in their managed care contracts, including through contractual managed care performance standards. Please refer to pages 30-32 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming for more information.
 

States with Medicaid MCPs may have one of two arrangements to pay for school-based services. 

• States may delegate the full scope of services to the MCP, which is then responsible for ensuring that services are available and accessible both in schools and in the community. 
• States may exclude some or all SBSs from the services covered by their MCPs, and instead States are paying schools or LEAs directly via a fee-for-service delivery system, while MCPs pay for community-based services. 

In all cases, the Medicaid MCP must ensure that covered children receive the medically necessary services to which they are entitled under EPSDT. According to 42 CFR § 438.208, MCPs are responsible for coordination and continuity of care. For children who receive services in school, the MCP should coordinate with schools to ensure that any community-based medically necessary services are provided, while avoiding any duplication of services. MCPs should not be categorically or otherwise inappropriately disqualifying or decreasing community-based medically necessary services solely on the basis that the service is also being provided in a school setting. If the MCP is inappropriately disqualifying or decreasing medically necessary services, the State should remind the MCP of its contractual obligations. If the MCP is denying authorization for medically necessary services or decreasing the authorization of these medically necessary services, that would constitute an adverse benefit determination for which appeal rights are granted under Medicaid. 

We also remind states of our expectations related to EPSDT.  When a managed care delivery system is used to deliver some or all services required under the EPSDT benefit, states must identify, define, and specify the amount, duration, and scope of each service that the MCP is required to offer in their managed care plan contract. For example, if a MCP is expected to provide the full range of preventive, screening, diagnostic, and treatment services required, it must be clearly stated and described in the contract between the state and the plan. Alternatively, states may exclude some EPSDT services from a managed care delivery system and retain responsibility for them in an FFS delivery system, or contract with another MCP to provide those services.   Any benefits not provided by the MCP remain the responsibility of the state Medicaid agency, and if a plan excludes benefits over contractually specified limits, the state retains responsibility for medically necessary services above those limits.  Additionally, in accordance with 42 CFR 438.208(b), MCPs are required to implement procedures to deliver care to and coordinate services, including school-based services, with the services the enrollee receives from another managed care plan, in FFS Medicaid and from community and social support providers.

For services provided in schools to Medicaid-covered children on an IEP/IFSP, Medicaid is the “payer of first resort” for Medicaid covered services, as described in 34 C.F.R. Section §300.154 "Methods of ensuring service." Because special education and related services on an IEP must be provided at no cost to the parent, the LEA may not bill Medicaid if doing so would prevent the child from obtaining Medicaid services outside of the school. Therefore, under both IDEA and Medicaid, the SMA must ensure that they and their MCPs work with SEAs and LEAs to ensure that children can access Medicaid services both under the child’s IEP and as medically necessary outside of the school setting.

States generally have broad flexibility to identify the providers of a covered Medicaid service, including their qualifications, although specific federal provider qualifications do apply for certain services. 

In the 1997 school-based services guidance, CMS instructed States that they could not rely on ED provider qualifications for Medicaid reimbursement or establish different provider qualifications for school-based and non-school-based providers within Medicaid. We have updated that guidance (see the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming) in order to give States greater flexibility to cover services provided by school-based health care providers whose provider qualifications under State and local law might vary from the qualifications for non-school-based providers of the same services, or whose scope of practice might be limited under State or local law to the school setting. Under this updated approach, States should not impose provider qualifications that are unique to Medicaid-covered services. For example, if a school-based provider is qualified under State or local law to provide counseling to any child (or any child in the school system), the State cannot impose additional provider qualification requirements under State law as a condition for receiving Medicaid payment for counseling provided to a Medicaid beneficiary.

If the State has included school-based providers as qualified providers of specific services in the Medicaid State plan, then individual school-based providers may seek to become Medicaid providers. For example, States may determine that counseling provided under the rehabilitative services benefit may be provided by licensed psychologists, social workers, family therapists, professional counselors, as well as certified school psychologists or school social workers who may not have the same qualifications. In some circumstances, a practitioner may be enrolled individually as a Medicaid provider and may either bill directly for the services they furnish or, consistent with 42 C.F.R. § 447.10(g), reassign their right to payment to the school or an agency contracted by the school to provide Medicaid-covered services. In other circumstances, the LEA or agency contracted by the school to provide Medicaid-covered services may be enrolled as a Medicaid provider and may be considered the “furnishing provider” for services provided by its employees. 

We recommend referring to your State, local, or other generally applicable licensure or certification requirements, including certification by the Federal, State, or local department of education or national accrediting bodies.