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
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.
Examples of vehicle adaptations can include, but are not limited to, special harnesses, wheelchair lifts, ramps, specialized environmental controls, specialized suspension systems, and other modifications to a vehicle as required in a student’s IEP.
For more information about specialized transportation, we encourage you to review the Reimbursement for Specialized Transportation within Medicaid SBS Resource, which is available under the TAC Resources heading on the CMS SBS Resources page.
Yes, provided the following conditions are met. As noted on page 99 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming under section G. Special Considerations for Transportation and Vaccines as SBS:
“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.”
Under the Individuals with Disabilities Education Act (IDEA), if a child with a disability is receiving special education and related services, transportation is included in the child’s IEP, and the IEP Team determines that the parent will be providing transportation, the LEA must reimburse the parents in a timely manner for the costs incurred in providing transportation. See the Office of Special Education Programs’ Questions and Answers on Serving Children with Disabilities Eligible for Transportation, November 2009. The LEA may request Medicaid reimbursement if the parent personal vehicle has been specially adapted consistent with the SBS guidance.
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.
Yes, under Medicaid law and regulations, Medicaid is generally the payer of last resort for school-based services for enrolled students who might also have commercial insurance coverage, a tort settlement, or other third-party resource. Congress intended that Medicaid, as a public assistance program, pay for health care only after a beneficiary’s other health care resources have been exhausted. However, there may be exceptions to the requirement to pursue TPL reimbursement (see Social Security Act § 1902(a)(25), Social Security Act § 1902(a)(25)(a), and 42 C.F.R. § 433.136).
Part B of IDEA provides Federal funds to SEAs, and SEAs subgrant a majority of IDEA funds to LEAs and school districts. IDEA funds assist SEAs and LEAs in providing a free appropriate public education (FAPE) to eligible children (generally ages 3 through 21) with disabilities through the provision of special education and related services. As explained below, Medicaid is a funding source for special education and related services for Medicaid enrolled children.
An Individualized Education Program (IEP) is a written statement for a child with a disability that is developed, reviewed, and revised in accordance with IDEA’s requirements in 34 C.F.R. §§ 300.320 through 300.324. A child’s IEP addresses, among other things, the nature, frequency, duration, and location of a child’s special education, related services, supplementary aids and services, and program modifications and supports for school personnel. Services provided under IDEA Part B are provided at no cost to the child’s parents.
For Medicaid-enrolled children who receive services under IDEA Part B, IDEA specifically requires States to create an interagency agreement or other mechanism that must include provisions stating that the State Medicaid agency financial responsibility precedes the financial responsibility of the LEA (or the State agency responsible for developing the child's IEP). Therefore, Medicaid is payer of first resort (as between Medicaid and LEAs or the State agency responsible for developing the child's IEP for Medicaid-covered services included in the IEP (see section 1903(c) of the Act and IDEA sections 612(e) and 640(c), codified at 20 USC 1412(e) and 1440(c); 34 C.F.R. § 300.154(h); and 42 C.F.R. § 433.139)).
As stated on page 91 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, as required by CMS, the supporting documentation file for each claim of FFP must include, at a minimum, the following:
- Date of service
- Name of recipient
- Medicaid identification number
- Name of provider agency and person providing the service
- Nature, extent, or units of service
- Place of service
Within an IEP many of the above requirements may be found, including:
- Name of recipient/child
- Eligibility for IDEA services and the child’s present level of achievement
- Name of provider agency/LEA
- Nature, extent, or units of service (called the frequency and duration of services)
- Place of service (called either the location or placement)
LEAs should review their State’s guidance for service documentation. Many States require additional information beyond the CMS requirements, such as a diagnosis code.