Frequently Asked Questions

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.

To exempt services from third party billing requirements, CMS requires the state to have clear and convincing documentation of non-coverage by insurers. There are multiple ways the state may obtain this documentation:

• The state may bill third parties and receive claims rejection notices. However, the state must assure that national billing codes for the items or services are included on claims, or, if local billing codes are used, that national codes and local codes are matched, so that rejection notices accurately reflect non-coverage of the item or service.
• The state may conduct a survey of insurers' benefit packages. The state can demonstrate non-coverage if it confirms with the top ten insurance carriers that their scope of benefits did not cover an item or service. However, since many insurers change their benefit packages on an annual basis, the state would have to confirm continued non-coverage on a yearly basis.
• For insurers not included in a survey, or as an alternative to a survey, the state may establish a precedent file by initially billing the insurer to obtain documentation of non-coverage, so that future claims would not need to be submitted to that insurer. The state would have to confirm continued non-coverage on a yearly basis.
• The state may request verification from the state agency or commission that oversees compliance with state law and regulations governing insurance plans that a certain item or service is never covered in insurance policies available in the state, either for the general population or for a specific population segment (for example, children under age 21).  The state would have to confirm continued prohibition of coverage on a yearly basis.

For more information, please review the Coordination of Benefits and Third Party Liability (COB/TPL) in Medicaid Handbook.

Yes, a state can exempt a service from TPL requirements if it is never covered in the school setting, even if it is otherwise covered by the liable third party. Claims for the service in question delivered in a school setting must always be denied by the third party, and the state needs to maintain annual documentation substantiating that the service is not covered.

For direct services that may be covered and paid for by Medicaid and CHIP, the provider furnishing such services must be enrolled in the State Medicaid or CHIP program, as applicable (see page 26 of the Comprehensive Guide). Providers who are not eligible for or enrolled in Medicaid should generally not be included in the Direct Services cost pool. 

However, a non-Medicaid provider can conduct and claim Medicaid administrative activities. These providers may be included in the Administrative Activities cost pool, with only the time spent performing Medicaid-allowable administrative activities counted towards the allocable costs. In a time study, the providers should code any Medicaid administrative activities completed during their assigned moment so that they are included in the allocation ratio. A description of calculating cost pools is available on pages 87 and 88 of the Comprehensive Guide.

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.