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
The State Medicaid Agency determines if medical necessity can be presumptive when services are preventive in nature and targeted at a general population group. Medical necessity criterion is determined by the state in accordance with 42 CFR 440.230(d).
The 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming defines IDEA/IEP services where direct services may be delivered to an individual and/or group to ameliorate a specific condition and are performed in the presence of the student(s). All direct medical services should be outlined in the Medicaid State Plan and questions about specific classroom-based interventions should be directed to the State Medicaid Agency.
There is no federal requirement for a plan of care. However, states may establish requirements for a plan of care in order to prove medical necessity.
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.
No federal requirements prevent billing for personal care services (PCS) delivered to a group of students. The definitions of Code 4b. Direct Medical Services – Covered as IDEA/IEP Services and Code 4c. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/IEP Service, found on pages 135-137 of the Comprehensive Guide, both state that “services may be delivered to an individual and/or a group.” However, a state may choose to limit covered services in the Medicaid State Plan to restrict billing for group services. CMS allows schools to bill for all Medicaid-covered services, as defined in the Medicaid State Plan, delivered by qualified providers to Medicaid-enrolled students.
If an activity is incidental to the provision of personal care services, then it can be included. For example, a beneficiary may have a personal care attendant (PCA) to assist with toileting and eating throughout the day. If the beneficiary has moments of inattentiveness and needs to be redirected, the PCA could do that.
However, if the student only needs redirection to complete educational tasks, that would not be considered personal care services. Activities provided for educational instruction would not be regarded as personal care. If a student exhibits the need for special assistance with educational instruction, they should be evaluated so the appropriate services that would best meet those needs can be identified.
As specified in section 1905(r)(5) of the Act, 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 Act if medically necessary, as determined by the State, to “correct or ameliorate” identified conditions. A formal diagnosis is not required according to Federal Medicaid rules. State Medicaid agencies determine medical necessity criteria.
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.