Frequently Asked Questions

While CMS encourages a zero-notice approach, CMS’ standard is up to 2 days prior notice of a time study moment. CMS will also allow up to 2 business days for participants to respond to the moment. If a state believes that up to 2 days prior notice (and 2 days response) is insufficient, the state should propose an alternative approach to CMS and provide its rationale. CMS understands that states may be limited by technology, geography, and/or funding to meet this time study criteria. CMS will attempt to understand the state’s limitations in reviewing time study proposals. In those instances where a state requests a longer response window, the state should provide details on the timeframe in which moments have historically been completed (i.e., within 24 hours, 48 hours, 72 hours, or beyond). This data, along with a plan for how and when the state will come into compliance with CMS policy, will be analyzed to determine whether to grant an exception. In those instances where CMS approves an exception, the state should take extra measures in its review of time study results to ensure all responses are reported in a non-biased manner and that all responses accurately reflect the activity the participant was performing during the assigned moment.

No, specialized transportation does not include transportation in a non-specialized vehicle with an aide. The Comprehensive Guide clarifies on page 99 that:

"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."

For more information about specialized transportation, we recommend you view our Reimbursement for Specialized Transportation Within Medicaid School-Based Services resource on the CMS School-Based Services Resources page.

The requirement to perform a time study during vacation periods depends on the circumstances the LEA or the claiming unit faces. Each time study is independent, and the sample universe is determined before it is conducted; therefore, only employees performing Medicaid-related activities would be included in the sample universe for that time study period. The Random Moment Time Study (RMTS) must include LEAs that seek to bill and/or be paid for services. If the LEA does not want to participate in providing services, it will not be included in the sample universe.

Any LEA that bills for Medicaid services during any vacation period must be included in the RMTS for the period in question to ensure that all services allocable to Medicaid are captured. However, suppose an LEA will not bill for any services during the vacation period in question and does not include any vacation period expenditures in the cost report. In that case, they may be excluded from the study sample for that period. (For more information, see page 114 of the Comprehensive Guide)

If an activity is incidental to the provision of personal care services, then it can be included. For example, a beneficiary may have a personal care attendant (PCA) to assist with toileting and eating throughout the day. If the beneficiary has moments of inattentiveness and needs to be redirected, the PCA could do that.
However, if the student only needs redirection to complete educational tasks, that would not be considered personal care services. Activities provided for educational instruction would not be regarded as personal care. If a student exhibits the need for special assistance with educational instruction, they should be evaluated so the appropriate services that would best meet those needs can be identified. 
 

CMS encourages states to have contingency plans in place for situations when routine RMTS procedures cannot be followed. Such contingency plans can include manual (hand-written) recording of moments by staff if they cannot access the systems typically used for RMTS responses. States are encouraged to present other possible solutions to CMS for consideration and discussion as needed.

If the 85 percent valid response rate is not achieved, all non-responses are required to be included and coded as non-Medicaid. CMS is available to work with states on contingencies if a cyberattack occurs.

No federal requirements prevent billing for personal care services (PCS) delivered to a group of students. The definitions of Code 4b. Direct Medical Services – Covered as IDEA/IEP Services and Code 4c. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/IEP Service, found on pages 135-137 of the Comprehensive Guide, both state that “services may be delivered to an individual and/or a group.” However, a state may choose to limit covered services in the Medicaid State Plan to restrict billing for group services. CMS allows schools to bill for all Medicaid-covered services, as defined in the Medicaid State Plan, delivered by qualified providers to Medicaid-enrolled students. 

Generally, the sample universe should include any days for which staff are paid, including in-service days. However, suppose an LEA chooses to exclude certain days (e.g., because no students are in attendance and no students will be receiving services). In that case, it must also exclude the costs associated with those days from the cost pool.

The Comprehensive Guide describes two options for the treatment of staff in-service days on the RMTS on page 112: 

1. The in-service days can be included among the potential days to be randomly sampled, with the related costs included in the cost pool; or

2. Both the in-service day and the related costs may be excluded from the time study.

There is no prohibition on claiming for administrative activities if the LEA does not also provide direct services. LEAs may choose to participate in only administrative activities, only direct services, or both administrative and direct services.

An LEA can claim the full scope of administrative activities without providing proof of a paid service. Please see Example 3 on page 27 of the Comprehensive Guide:

• Example 3. The school is not a participating provider. The school program refers Medicaid-eligible children to participating Medicaid providers in the community. If the school performs administrative activities related to the services billed to Medicaid by community providers, the costs of such activities are allowable under the Medicaid program. Such activities would be reported under the appropriate Medicaid-related activity code.

Many states choose to use a separate time study for each cost pool. The state then can apply all the resulting percentages from each time study to that one cost pool when claiming. However, it is also permitted to include multiple cost pools in one time study. If a state elects to include multiple cost pools in one time study, each allocation percentage must only be applied to the applicable cost pool. (See page 125 of the Comprehensive Guide.) 

If a state elects to include multiple cost pools within one time study, the moments must be apportioned between the cost pools based on the number of individuals in each cost pool or some other methodology (e.g., using the total costs of each cost pool); provided that all the moments in the time study add up to at least the minimum required sample size (i.e., number of moments) for statistical accuracy and validity. The procedure for determining the number of moments sampled from each cost pool should be described in the Time Study Implementation Plan submitted to CMS.

For example, suppose 443 moments are spread across all staff with an equal probability of being distributed to perform each activity. In that case, the resulting allocation percentages from the time study must be applied to the costs for the entire universe of participants in the time study. All applicable staff would be treated as one cost pool.

On the other hand, a state could divide the universe of staff participating in the time study into different cost pools and still conduct one time study for all staff. In that case, each group of individuals performing similar activities (i.e., each cost pool) should be assigned an applicable fraction of the 443 moments in the time study. The resulting time study allocation percentages would be applied to each cost pool individually.
 

The Comprehensive Guide notes that invalid moments do not affect the response rate either way. Invalid responses do not count towards or against the 85% response rate because they are removed from the results. Page 122 of the Comprehensive Guide states that moments received during unpaid time off are considered invalid responses. Employees on unpaid time off or who have left their positions and have not been replaced should be removed from the sample to avoid distorting the time study results. As these moments are considered invalid, it is correct that they should be excluded from both the numerator and denominator of the 85% RMTS response rate calculation.