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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.

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Are there examples of SPAs that can be used to implement school-based services?

Yes, examples of approved SPAs for States that expanded services beyond IDEA services (e.g., Arizona, Colorado, Illinois, New Mexico) can be found on CMS' website at the following link: https://www.medicaid.gov/resources-for-states/medicaid-state-technical-assistance/medicaid-and-school-based-services/technical-assistance-materials/index.html

It's important to note that each State, District of Columbia, and territory is unique, and it is crucial to ensure that the SPA aligns with the specific needs and laws of the State.

FAQ ID:162416


Given 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


Can 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


What are the objectives of the TAC, and how can stakeholders best engage with and contact the TAC? Furthermore, what types of support can stakeholders expect to receive from the TAC?

Generally, the TAC goals are to:

  • Support SMAs, SEAs, LEAs, and school-based entities seeking to expand their capacity for providing Medicaid SBS.
  • Help states reduce administrative burden and simplify billing for, LEAs, in particular small and rural LEAs, and support compliance with Federal requirements regarding billing, payment, and recordkeeping, including by aligning direct service billing and school-based administrative claiming payment systems.
  • Support state entities in obtaining reimbursement for providing and expanding Medicaid SBS, including a comprehensive list of best practices and examples of approved methods that SMAs and LEAs have used to pay for, and increase the availability of, assistance under Medicaid, including expanding State programs to include all Medicaid-enrolled students, providing EPSDT services in schools, utilizing telehealth, coordinating with community-based mental health and substance use disorder treatment providers and organizations, coordinating with managed care entities, and supporting the provision of culturally competent and trauma-informed care in school settings
  • Ensure ongoing coordination and collaboration between states, ED, and CMS regarding Medicaid SBS.
  • Provide guidance with regard to utilization of various funding sources.

Please email the TAC at SchoolBasedServices@cms.hhs.gov for any questions about Medicaid SBS or technical assistance.

FAQ ID:162331


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


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


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


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


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


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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