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
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.
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.
Per 45 C.F.R. § 75.430(i)(5), a Random Moment Time Study (RMTS) is a type of “substitute system” used for determining and documenting time spent on, and therefore the costs of, Medicaid administrative and direct service activities. Per page 108 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, a RMTS is a statistically valid sampling methodology that can be used by States and LEAs to determine how much time eligible staff spend performing Medicaid reimbursable work activities. The RMTS is used to determine a statistic that is applied to salary and fringe benefits for qualified providers and reported on a cost report for direct medical services. A RMTS is generally used in an allocation of a cost pool to allowable medical, administrative (if applicable), and unallowable moments that is further allocated to Medicaid using a Medicaid Eligibility Ratio (MER). The RMTS and supporting documents become part of the documentation for the claim. The RMTS is used to determine a statistic that is applied to salary and fringe benefits for qualified providers and to other payable costs that are reported on a cost report for direct medical services.
A RMTS must reflect all of the time and activities (whether allowable or unallowable under Medicaid) performed by school employees. The RMTS sample universe (or Participant List) should include all staff who potentially perform Medicaid direct services or administrative activities. LEAs should consider both job title and job function when determining which individual staff members should be included in which cost pool.
No, while an RMTS is typically used to identify and allocate cost, it is not the only option. States also have the flexibility to utilize an alternative methodology for reimbursement and/or allocation, provided there is appropriate documentation for CMS review of the chosen methodology. Regulations on personnel expenses in 45 C.F.R. § 75.430(i) require that charges to federal awards must be based on records that reflect the actual work performed. The records must:
- be supported by a system of internal controls that provides reasonable assurance charges are accurate, allowable, and properly allocated,
- reflect the total activity for which the employee is compensated,
- encompass both federally assisted and all other activities for which the employee is compensated, and
- support the distribution of the employee's salary or wages among specific activities or cost objectives.
As stated on page 44 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, if public charter schools are funded predominantly by State and local funds, including local tax revenue or appropriations, similar to other governmental entities, they may be eligible to provide the non-federal share of Medicaid or CHIP expenditures through CPEs.
However, other school entities that are not units of State or local government, including private schools, would not be considered governmental entities under 42 CF.R. § 433.51(b) and § 457.220. Direct payments to private or non-governmental educational institutions for Medicaid and CHIP SBS are available but are typically funded by State appropriations to the Medicaid/CHIP agency. Private and other non-governmental school entities may not participate directly in a CPE. However, an LEA that is a unit of government can contract with providers to provide eligible Medicaid/CHIP services to children in private entities, and CPE the contracted costs, as long as the arrangement adheres to the requirements discussed on page 43 in the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.
In addition to a cost methodology, LEAs that are units of government may also transfer the non-federal share funds via intergovernmental transfers (IGTs) to the SMA for services provided in private schools as long as the provider receives and retains the entire Medicaid payment described in the Medicaid State plan.
CMS’ longstanding standard policy has been to recommend a 15 percent oversampling for RMTS to ensure a valid response rate of at least 85 percent or include all nonresponses as non-Medicaid and unallowable.
In general, all completed responses should be used in an RMTS. However, CMS allows for the use of an alternate methodology in cases where the TSIP specifies an oversample to ensure an adequate number of valid responses for the treatment of time study nonresponses are achieved. The alternate methodology CMS historically has approved uses an 85 percent valid response rate. CMS recommends an oversample of 15 percent to ensure an adequate number of valid responses are received and to meet the required precision level. Per page 113 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, an oversample may be used only to compensate, not substitute, for the potential number of nonresponses.