Frequently Asked Questions

Yes, a state can exempt a service from TPL requirements if it is never covered in the school setting, even if it is otherwise covered by the liable third party. Claims for the service in question delivered in a school setting must always be denied by the third party, and the state needs to maintain annual documentation substantiating that the service is not covered.

No, IEP meetings and the initial creation of an IEP should be coded under Code 3. School Related and Educational Activities. Page 134 of the Comprehensive Guide defines Code 3 as including: “Developing, coordinating, and monitoring the IEP for a student, which includes ensuring annual reviews of the IEP are conducted, parental sign-offs are obtained, and the actual IEP meetings with the parents.”

IEP meetings are performed to meet the IDEA statute and regulations, and therefore are educational in nature. When health professionals attend an IEP meeting, the focus of the meeting is on a student’s needs that impact their educational attainment, so these activities continue to be classified as educational. Education is not the same cost center as Medicaid allowable activities and the costs are therefore excluded from Medicaid reimbursement.

However, it is important to note that Medicaid will reimburse for assessments to evaluate the child’s medically necessary treatment needs when performed by a practitioner whose scope of practice includes referrals for treatment.

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.

When conducting medical/health assessments/evaluations as part of the development of an IEP or IFSP, Code 4C. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/ IEP service, is the correct code. Because the services are not due to an IEP, but rather result in an IEP, Code 4C is utilized instead of Code 4B. Code 4C should be used when providing direct medical services when documented on a medical plan other than an IEP/IFSP or where medical necessity has been otherwise established. These direct services may be delivered to an individual and/or group in order to ameliorate a specific condition and are performed in the presence of the student(s).

The State Medicaid Agency determines if medical necessity can be presumptive when services are preventive in nature and targeted at a general population group.  Medical necessity criterion is determined by the state in accordance with 42 CFR 440.230(d).   
 

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.