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Frequently Asked Questions

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.

Showing 31 to 40 of 810 results

Does the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming supersede previous guidance and apply to all entities participating in Medicaid Administrative Claiming (MAC)?

Yes, States are expected to apply the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming guidance to all MAC programs for all entities. Both previous guidance documents issued by CMS, including the 1997 School-based Services Technical Review Guide and the 2003 School-based Administrative Claiming Guide, are superseded by the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.

FAQ ID:162336

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Are there any Federal laws that restrict charter and/or private schools from engaging in a RMTS for the purpose of administrative and/or direct service claiming?

As stated on page 44 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, if public charter schools are funded predominantly by State and local funds, including local tax revenue or appropriations, similar to other governmental entities, they may be eligible to provide the non-federal share of Medicaid or CHIP expenditures through CPEs.

However, other school entities that are not units of State or local government, including private schools, would not be considered governmental entities under 42 CF.R. § 433.51(b) and § 457.220. Direct payments to private or non-governmental educational institutions for Medicaid and CHIP SBS are available but are typically funded by State appropriations to the Medicaid/CHIP agency. Private and other non-governmental school entities may not participate directly in a CPE. However, an LEA that is a unit of government can contract with providers to provide eligible Medicaid/CHIP services to children in private entities, and CPE the contracted costs, as long as the arrangement adheres to the requirements discussed on page 43 in the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.

In addition to a cost methodology, LEAs that are units of government may also transfer the non-federal share funds via intergovernmental transfers (IGTs) to the SMA for services provided in private schools as long as the provider receives and retains the entire Medicaid payment described in the Medicaid State plan.

FAQ ID:162341

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CMS has communicated a recommendation for a 15 percent oversampling. Is this intended to become standard practice, or is it to be regarded as a suggestion?

CMS’ longstanding standard policy has been to recommend a 15 percent oversampling for RMTS to ensure a valid response rate of at least 85 percent or include all nonresponses as non-Medicaid and unallowable.

In general, all completed responses should be used in an RMTS. However, CMS allows for the use of an alternate methodology in cases where the TSIP specifies an oversample to ensure an adequate number of valid responses for the treatment of time study nonresponses are achieved. The alternate methodology CMS historically has approved uses an 85 percent valid response rate. CMS recommends an oversample of 15 percent to ensure an adequate number of valid responses are received and to meet the required precision level. Per page 113 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, an oversample may be used only to compensate, not substitute, for the potential number of nonresponses.

FAQ ID:162346

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What should a LEA do if nonresponses in a RMTS are greater than 15%?

If the valid response rate is above 85 percent, nonresponses may be discarded and not included in the time study results. However, if the valid response rate is below 85 percent, regardless of the 15 percent oversample, CMS has required all non-responses to be included and coded as non-Medicaid.

FAQ ID:162351

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The 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming encourages States to use a zero-notice approach and indicates that CMS may recognize up to two days prior notice, as appropriate to the circumstances. The guide also indicates that CMS recognizes that, in certain circumstances, no prior notification will result in a significant non-response rate. For example, in some rural areas where internet access is weak, under a zero-notice policy, participants may not be informed of their moment until after the moment has occurred. What is CMS’s policy regarding time study notification and response time?

CMS’s general standard regarding time study notification and response time is up to two-day upfront notification and up to a two-day response period. CMS is also willing to work with States that are not immediately able to meet these standards to work out a plan to eventually get to no more than a two-day upfront notification and a two-day response period. If a State believes that up to two days prior notice and two days response is not achievable, the State can propose an alternative to CMS and provide its rationale. CMS will consider additional time for prior notification and/or response time upon request from a State in such circumstances.

FAQ ID:162361

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If a State has already implemented the +/-5 percent overall error rate, is there a requirement to submit any documentation to CMS for review and/or approval?

No, if your State's CMS-approved TSIP already adheres to the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming on page 112, then the State does not need to amend its TSIP for error rates. We do recommend States look closely at their previously approved Time Study methodology to ensure full compliance with all applicable Federal requirements as discussed in the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.

FAQ ID:162366

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What 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

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Is a State required to revise its existing SBS claiming methodologies in response to the new flexibilities offered in the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming?

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

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Does 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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Can a State pay a fee schedule rate and treat the fee schedule rate as if it is a cost methodology?

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

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