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
For direct services that may be covered and paid for by Medicaid and CHIP, the provider furnishing such services must be enrolled in the State Medicaid or CHIP program, as applicable (see page 26 of the Comprehensive Guide). Providers who are not eligible for or enrolled in Medicaid should generally not be included in the Direct Services cost pool.
However, a non-Medicaid provider can conduct and claim Medicaid administrative activities. These providers may be included in the Administrative Activities cost pool, with only the time spent performing Medicaid-allowable administrative activities counted towards the allocable costs. In a time study, the providers should code any Medicaid administrative activities completed during their assigned moment so that they are included in the allocation ratio. A description of calculating cost pools is available on pages 87 and 88 of the Comprehensive Guide.
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).
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.
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.
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.
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.
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)
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.
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:
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
Both the in-service day and the related costs may be excluded from the time study.