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.
Frequently Asked Questions
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.