Frequently Asked Questions

States generally have broad flexibility to identify the providers of a covered Medicaid service, including their qualifications, although specific federal provider qualifications do apply for certain services. 

In the 1997 school-based services guidance, CMS instructed States that they could not rely on ED provider qualifications for Medicaid reimbursement or establish different provider qualifications for school-based and non-school-based providers within Medicaid. We have updated that guidance (see the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming) in order to give States greater flexibility to cover services provided by school-based health care providers whose provider qualifications under State and local law might vary from the qualifications for non-school-based providers of the same services, or whose scope of practice might be limited under State or local law to the school setting. Under this updated approach, States should not impose provider qualifications that are unique to Medicaid-covered services. For example, if a school-based provider is qualified under State or local law to provide counseling to any child (or any child in the school system), the State cannot impose additional provider qualification requirements under State law as a condition for receiving Medicaid payment for counseling provided to a Medicaid beneficiary.

If the State has included school-based providers as qualified providers of specific services in the Medicaid State plan, then individual school-based providers may seek to become Medicaid providers. For example, States may determine that counseling provided under the rehabilitative services benefit may be provided by licensed psychologists, social workers, family therapists, professional counselors, as well as certified school psychologists or school social workers who may not have the same qualifications. In some circumstances, a practitioner may be enrolled individually as a Medicaid provider and may either bill directly for the services they furnish or, consistent with 42 C.F.R. § 447.10(g), reassign their right to payment to the school or an agency contracted by the school to provide Medicaid-covered services. In other circumstances, the LEA or agency contracted by the school to provide Medicaid-covered services may be enrolled as a Medicaid provider and may be considered the “furnishing provider” for services provided by its employees. 

We recommend referring to your State, local, or other generally applicable licensure or certification requirements, including certification by the Federal, State, or local department of education or national accrediting bodies. 

Provider training provided by the Medicaid agency or its contracted designee regarding Medicaid covered services, or aimed at improving the delivery of Medicaid services, is reimbursable as a Medicaid administrative expenditure. This could include, for example, training for case managers, individuals who develop and coordinate person-centered care planning, primary care practitioners, or hospital discharge planners. Costs incurred by the providers to meet continuing education and advanced training requirements cannot be claimed as a Medicaid administrative expenditure; as described above, in some circumstances such costs may be reflected in provider rates.  Regulations at 45 C.F.R. Part 75 provide the relevant cost regulations.  Additional discussions on the inclusion of training costs in rate development and other regulations surrounding allowable and unallowable costs in Medicaid are in the CMCS Information Bulletin dated 7/13/2011.