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
The list of services on Medicaid.gov comes from 1905(r)(1)(B) of the Social Security Act, which specifies that screening services provided under EPSDT “shall at a minimum include—
(i) a comprehensive health and developmental history (including assessment of both physical and mental health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the schedule referred to in section 1928(c)(2)(B)(i) for pediatric vaccines) according to age and health history,
(iv) laboratory tests (including lead blood level assessment appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).”
This list of services is a minimum, not a comprehensive list of services that may be covered under EPSDT. The EPSDT benefit entitles most eligible Medicaid-enrolled children and adolescents to services and treatments that fit within any of the benefit categories of Medicaid-coverable services listed in section 1905(a) of the Social Security Act if medically necessary, as determined by the State, to “correct or ameliorate” identified conditions.
Therefore, schools and other providers may perform and bill for some EPSDT services without providing all of the minimum services listed in 1905(r)(1)(B). EPSDT services include comprehensive examinations, vaccinations, screening for common childhood health conditions, screening and treatment for mental health conditions, and other services.
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.
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.
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.
States with Medicaid MCPs may have one of two arrangements to pay for school-based services.
- States may delegate the full scope of services to the MCP, which is then responsible for ensuring that services are available and accessible both in schools and in the community.
- States may exclude some or all SBSs from the services covered by their MCPs, and instead States are paying schools or LEAs directly via a fee-for-service delivery system, while MCPs pay for community-based services.
In all cases, the Medicaid MCP must ensure that covered children receive the medically necessary services to which they are entitled under EPSDT. According to 42 CFR § 438.208, MCPs are responsible for coordination and continuity of care. For children who receive services in school, the MCP should coordinate with schools to ensure that any community-based medically necessary services are provided, while avoiding any duplication of services. MCPs should not be categorically or otherwise inappropriately disqualifying or decreasing community-based medically necessary services solely on the basis that the service is also being provided in a school setting. If the MCP is inappropriately disqualifying or decreasing medically necessary services, the State should remind the MCP of its contractual obligations. If the MCP is denying authorization for medically necessary services or decreasing the authorization of these medically necessary services, that would constitute an adverse benefit determination for which appeal rights are granted under Medicaid.
We also remind states of our expectations related to EPSDT. When a managed care delivery system is used to deliver some or all services required under the EPSDT benefit, states must identify, define, and specify the amount, duration, and scope of each service that the MCP is required to offer in their managed care plan contract. For example, if a MCP is expected to provide the full range of preventive, screening, diagnostic, and treatment services required, it must be clearly stated and described in the contract between the state and the plan. Alternatively, states may exclude some EPSDT services from a managed care delivery system and retain responsibility for them in an FFS delivery system, or contract with another MCP to provide those services. Any benefits not provided by the MCP remain the responsibility of the state Medicaid agency, and if a plan excludes benefits over contractually specified limits, the state retains responsibility for medically necessary services above those limits. Additionally, in accordance with 42 CFR 438.208(b), MCPs are required to implement procedures to deliver care to and coordinate services, including school-based services, with the services the enrollee receives from another managed care plan, in FFS Medicaid and from community and social support providers.
For services provided in schools to Medicaid-covered children on an IEP/IFSP, Medicaid is the “payer of first resort” for Medicaid covered services, as described in 34 C.F.R. Section §300.154 "Methods of ensuring service." Because special education and related services on an IEP must be provided at no cost to the parent, the LEA may not bill Medicaid if doing so would prevent the child from obtaining Medicaid services outside of the school. Therefore, under both IDEA and Medicaid, the SMA must ensure that they and their MCPs work with SEAs and LEAs to ensure that children can access Medicaid services both under the child’s IEP and as medically necessary outside of the school setting.