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
States will have a process to prevent payment for duplication of services. Local education agencies (LEA) and providers should consult the state Medicaid agency to see if services provided in schools and in the community are seen as duplicative or complementary. The state Medicaid agency can also provide information on the intersection between service limitations for a community provider such as an approved number of nursing hours and hours provided in school.
A diagnosis is not a federal requirement to bill Medicaid for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, however, a state Medicaid Agency may set their own requirements for local education agencies (LEA) to follow when billing for EPSDT services. A CMS Informational Bulletin (CIB) from August 18, 2022, provides information about leveraging Medicaid in the delivery of behavioral health services to youth and encourages states to avoid requiring a behavioral health diagnosis for the provision of EPSDT services. However, services must meet requirements for medical necessity, and all other Medicaid rules and regulations must be followed in any setting for Medicaid services.
1905(a) of the Social Security Act lists all benefit categories that may be covered by state Medicaid programs. The following link provides a list of the 1905(a) mandatory and optional state plan benefits: Mandatory & Optional Medicaid Benefits.
Yes, Screening, Brief Intervention, and Referral to Treatment (SBIRT) can be delivered in schools and reimbursed by Medicaid. SBIRT may be covered under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements and multiple 1905(a) benefit categories, such as preventive or rehabilitative services. The state Medicaid agency determines state plan coverage and payment options for these types of services.
The list of services on Medicaid.gov comes from 1905(r)(1)(B) of the Social Security Act, which specifies that screening services provided under EPSDT “shall at a minimum include—
(i) a comprehensive health and developmental history (including assessment of both physical and mental health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the schedule referred to in section 1928(c)(2)(B)(i) for pediatric vaccines) according to age and health history,
(iv) laboratory tests (including lead blood level assessment appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).”
This list of services is a minimum, not a comprehensive list of services that may be covered under EPSDT. The EPSDT benefit entitles most eligible Medicaid-enrolled children and adolescents to services and treatments that fit within any of the benefit categories of Medicaid-coverable services listed in section 1905(a) of the Social Security Act if medically necessary, as determined by the State, to “correct or ameliorate” identified conditions.
Therefore, schools and other providers may perform and bill for some EPSDT services without providing all of the minimum services listed in 1905(r)(1)(B). EPSDT services include comprehensive examinations, vaccinations, screening for common childhood health conditions, screening and treatment for mental health conditions, and other services.
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.
Medicaid will pay for services and treatments that fit within any of the 1905(a) benefit categories of the Social Security Act (The Act). Medicaid-enrolled children can receive a broad range of the Early and Periodic Screening Diagnosis and Treatment (EPSDT) services as defined in 1905(r) of the Act, even if the services are not otherwise available under the State Medicaid Plan. For Medicaid-enrolled students with an IEP/IFSP, Medicaid is the payer of first resort for Medicaid-covered services included in the IEP/IFSP (see section 1903(c) of the Act and IDEA sections 1412(e) and 1440(c), codified at 20 USC 1412(e) and 1440(c); 34 CFR 300.154(h); and 42 CFR 433.139). While all EPSDT services can be provided in schools, not all school services will fall under the EPSDT benefit. The Medicaid EPSDT benefit and qualifying covered state plan services would also not be available to individuals over the age of 21, unless the state has opted to cover the services in one of the 1905(a) benefits of Medicaid.
Page 44 of the Comprehensive Guide describes that State Plan Amendments (SPAs) for SBS generally include “a comprehensive section describing the types of providers and school staff involved in providing SBS.” For more information about the requirements for a SPA, states are encouraged to use the Readiness Checklist Tool, available on the CMS School-Based Services Resources page under TAC Resources.
Yes, all the provider types listed may be eligible Medicaid providers if allowed by state statute. As stated on page 29 of the Comprehensive Guide, “States generally have broad flexibility to identify the providers of a covered Medicaid service, including their qualifications. When identifying provider qualifications for Medicaid-covered services, States may refer to State, local, or other generally applicable licensure or certification requirements, including certification by the federal, state, or local ED or national accrediting bodies.”
42 CFR Part 440 Subpart A, specifically 441.10, details requirements and limits applicable to specific services. For general services provisions, definitions and requirements, please refer to 42 CFR Part 440 and 441.