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
Examples of reimbursable school-based prevention services were provided during our November 14 webinar, Expanding Preventive Behavioral Health Services in Schools. The slides and recording from this webinar are available on the Medicaid SBS Events page. General examples can be found on slides 15-16, and examples from specific states can be found on slides 20-23.
In accordance with 42 CFR 440.230(d), state Medicaid programs may establish appropriate medical necessity criteria and other utilization controls, such as prior authorization, for covered Medicaid services. The State Medicaid agency provides documentation of what can serve as medical necessity for health education and how health education services can be documented as medically necessary.
States may choose whether to allow the periodicity schedule as documentation of medical necessity for screening and preventive services. Some states have opted to include language for EPDST services that include using schedules or medical society guidelines to establish EPSDT medical necessity.
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.
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.