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
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.
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 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming (p. 15) has language that states that “coverable services also include child find evaluations and reevaluations.” Medicaid may cover child find screening, evaluations, and reevaluations in certain circumstances (see FAQ on Child Find Activities).
Services not included in a student’s IEP are not considered the same as IDEA services under section 1903(c) of the Act. CMS does not consider LEAs to be legally liable third parties to the extent they are acting to ensure that students receive needed medical services to access a “free appropriate public education” (FAPE) consistent with section 504 of the Rehabilitation Act. Therefore, LEAs may bill Medicaid for non-IEP services students receive only after they bill any outside legally liable third parties (pursuant to Social Security Act § 1902(a)(25)). States, however, may exempt certain items or services from TPL requirements when submission of claims for those items or services would always result in denial because the general insurance industry does not cover them. CMS requires the State to have clear and convincing annual documentation of non-coverage by insurers. If a State has documentation, there is no need to further verify by submitting claims, because there would be no liable third party and Medicaid TPL rules would not come into play. The controlling regulation is found at 42 C.F.R. § 433.139(b)(1), which states that “the establishment of third-party liability takes place when the agency receives confirmation from a provider or a third-party resource indicating the extent of third-party liability.” For more information on third-party liability, please refer to pages 103-107 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.
The 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming provides information pertaining to school-based services covered through separate CHIP, Title XXI-funded Medicaid expansion CHIP, and Medicaid. Information about the options and requirements for school-based services provided through separate CHIPs is provided throughout the guide. There is also a dedicated CHIP section on pages 38-39 of the guidance that specifically addresses what is available under separate CHIPs.
Generally, any separate CHIP-covered service may be provided in a school setting to children enrolled in the State’s separate CHIP. There are no limitations on the delivery system states may use to provide separate CHIP-covered services to separate CHIP-enrolled students.
CMS is still exploring possible arrangements for SBS under separate CHIPs. For questions about the applicability of specific policies outlined in the SBS Guide to separate CHIPs, please reach out to the CMS SBS Technical Assistance Center for additional information. We encourage States that are interested in expanding separate CHIP claiming in schools to discuss their plans with CMS to help determine the best mechanism to accomplish the State’s goals.
All inquiries for the TAC and CMS regarding Medicaid School-Based Services and the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming should be directed to the TAC mailbox at SchoolBasedServices@cms.hhs.gov. More information on where to send SPA submission packages, including submission systems, pages, and CMS 179 Forms, can be found on Slide 9 of the following CMS Training Slides: https://www.medicaid.gov/state-resource-center/downloads/spa-and-1915-waiver-processing/training-slides.pdf
First, the activities must be allowable as State program administrative activities. Secondly, the State and/or claiming unit must implement a methodology to properly identify and allocate Medicaid’s portion of cost associated with the allowable State program administrative activity. Finally, the identification and allocation of this cost must be documented in the State’s Public Assistance Cost Allocation Plan (PACAP). According to 45 C.F.R. § 95.517, State Medicaid agencies (SMAs) that intend to claim for allowable administrative activities must have an approved PACAP. As the PACAP is primarily used by the Federal cognizant agency to allocate cost incurred by one direct federal awardee, yet funded by another federal awardee, there may be instances where costs applicable to allowable State program activities are incurred and funded by the SMA. In this instance, the State may identify and allocate the cost via a Medicaid Administrative Claiming (MAC) Plan and include a reference to the identification and allocation of the cost via the MAC Plan in its PACAP.
Yes, States are expected to apply the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming guidance to all MAC programs for all entities. Both previous guidance documents issued by CMS, including the 1997 School-based Services Technical Review Guide and the 2003 School-based Administrative Claiming Guide, are superseded by the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.
CMS’s general standard regarding time study notification and response time is up to two-day upfront notification and up to a two-day response period. CMS is also willing to work with States that are not immediately able to meet these standards to work out a plan to eventually get to no more than a two-day upfront notification and a two-day response period. If a State believes that up to two days prior notice and two days response is not achievable, the State can propose an alternative to CMS and provide its rationale. CMS will consider additional time for prior notification and/or response time upon request from a State in such circumstances.
No, if your State's CMS-approved TSIP already adheres to the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming on page 112, then the State does not need to amend its TSIP for error rates. We do recommend States look closely at their previously approved Time Study methodology to ensure full compliance with all applicable Federal requirements as discussed in the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.