Frequently Asked Questions

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.

No, States may opt to maintain their current approach, including a fee schedule approach, if the existing State Plan Amendment (SPA) and underlying implementation mechanisms are compliant with all of the federal requirements discussed in the new SBS Guide. The newly introduced flexibilities are available options for States, but their adoption is not mandatory. If a State wants to depart from its currently approved SBS payment and/or claiming approach, including replacing a current fee schedule methodology or providing higher fee schedule payment amounts, a SPA is necessary.

In order to submit an SPA package, States will formally submit a cover letter that briefly states the intention behind the SPA, a revised Form 179, the revised, applicable State plan pages, and if applicable, a sample cost report with cost report instructions. Please note that CMS does not formally approve the cost report, however the agency’s analysis of it will help to ensure the State is determining cost in a manner consistent with applicable regulation and statutes. Once a State submits an SPA to CMS, the agency has 90 days in which it can approve the SPA, disapprove the SPA, or formally request more information to determine whether the SPA comports with applicable regulations and statutes. If the agency sends a formal request for additional information (RAI), the State then has 90 days to formally respond to the RAI. Once the State responds, CMS has 90 days to either approve or disapprove the SPA.