Frequently Asked Questions

In accordance with 42 CFR 440.230(d), state Medicaid programs may establish appropriate medical necessity criteria and other utilization controls, such as prior authorization, for covered Medicaid services. The State Medicaid agency provides documentation of what can serve as medical necessity for health education and how health education services can be documented as medically necessary.  

The 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming defines IDEA/IEP services where direct services may be delivered to an individual and/or group to ameliorate a specific condition and are performed in the presence of the student(s). All direct medical services should be outlined in the Medicaid State Plan and questions about specific classroom-based interventions should be directed to the State Medicaid Agency.

States may choose whether to allow the periodicity schedule as documentation of medical necessity for screening and preventive services. Some states have opted to include language for EPDST services that include using schedules or medical society guidelines to establish EPSDT medical necessity.

There is no federal requirement for a plan of care. However, states may establish requirements for a plan of care in order to prove medical necessity.

The State Medicaid agency or state laws related to consent protocols and procedures would apply. Please consult the relevant state agencies or your organizational legal counsel.

Medicaid will pay for services and treatments that fit within any of the 1905(a) benefit categories of the Social Security Act (The Act). Medicaid-enrolled children can receive a broad range of the Early and Periodic Screening Diagnosis and Treatment (EPSDT) services as defined in 1905(r) of the Act, even if the services are not otherwise available under the State Medicaid Plan. For Medicaid-enrolled students with an IEP/IFSP, Medicaid is the payer of first resort for Medicaid-covered services included in the IEP/IFSP (see section 1903(c) of the Act and IDEA sections 1412(e) and 1440(c), codified at 20 USC 1412(e) and 1440(c); 34 CFR 300.154(h); and 42 CFR 433.139). While all EPSDT services can be provided in schools, not all school services will fall under the EPSDT benefit. The Medicaid EPSDT benefit and qualifying covered state plan services would also not be available to individuals over the age of 21, unless the state has opted to cover the services in one of the 1905(a) benefits of Medicaid.

Page 44 of the Comprehensive Guide describes that State Plan Amendments (SPAs) for SBS generally include “a comprehensive section describing the types of providers and school staff involved in providing SBS.” For more information about the requirements for a SPA, states are encouraged to use the Readiness Checklist Tool, available on the CMS School-Based Services Resources page under TAC Resources.

In states where SBS are included in a Medicaid managed care delivery system, LEAs must contract with MCPs to receive reimbursement for SBS provided to enrollees. Regardless of whether SBS services are included in managed care, MCPs play a key role in coordination of care for all states that utilize a Medicaid managed care delivery system. Under 42 CFR 438.208(b), MCPs are required to coordinate care and services for enrollees across settings, which includes services that are provided in schools.

Working with MCPs can reduce the time LEAs need to spend on administrative issues, such as denied claims, which can improve revenue flow and allow more time for LEA staff to spend on providing health care to students.

For more information, we welcome you to review the slides and recording of the Intersection of Medicaid Managed Care and SBS webinar, available on the Medicaid and School-Based Services Events page.

Examples of vehicle adaptations can include, but are not limited to, special harnesses, wheelchair lifts, ramps, specialized environmental controls, specialized suspension systems, and other modifications to a vehicle as required in a student’s IEP.

For more information about specialized transportation, we encourage you to review the Reimbursement for Specialized Transportation within Medicaid SBS Resource, which is available under the TAC Resources heading on the CMS SBS Resources page.

Examples of reimbursable school-based prevention services were provided during our November 14 webinar, Expanding Preventive Behavioral Health Services in Schools. The slides and recording from this webinar are available on the Medicaid SBS Events page. General examples can be found on slides 15-16, and examples from specific states can be found on slides 20-23.

CMS requires states to provide mandatory training to all time study participants, not only those who are assigned a random moment. Training may occur before or after staff are selected for inclusion in the time study participant list, but must occur before sampling. 

More information on training for participation in the time study, including what training should involve, when training should be conducted, and what documents should be retained related to training can be found within the Considerations for Developing a Time Study Implementation Plan (TSIP) resource document, available on the CMS School-Based Services Resources page.