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
Generally, yes, but how this is achieved is dependent on the reimbursement methodology the State has approved for SBS in its Medicaid State plan. If SBS in a State are paid through fee for service (FFS), then each billed service is claimed and paid as provided in the State plan, regardless of when it occurs.
If a State has a cost methodology in the State plan that uses a time study, the time study must include 100% of providers’ billable time and account for their regular schedules in the methodology and in the time study implementation plan (TSIP). In this case, the providers’ schedules should include after-school hours for programs that are intended to be captured. If these programs are contracted, the contracted costs must also be included in the cost report. If a State does not currently have these programs included in their approved SBS reimbursement methodology, the methodology may have to be amended to capture the additional services. This may include revisions to the SPA, TSIP, PACAP, or other documents, as needed.
In the case of summer activities (i.e., non-regular school days when schools are not capturing any Medicaid services), a time study should be performed to cover these periods. Anytime there are Medicaid services performed and captured in a cost methodology, that time needs to be accounted for in the CMS-approved TSIP, and the allocations explained in the SPA. This is especially true for children with Individualized Education Programs (IEPs) who are eligible for Medicaid and require special education and related services after school hours, on weekends, and/or extended school year services (defined in 34 C.F.R § 300.106). SMAs must have procedures in effect that allow for time studies to capture 100% of providers’ time delivering extended school year services. No estimations of Medicaid services can be calculated for vacation or other periods not covered in the time study.
The formula for State FMAP is established in statute and there is currently no FMAP specific to SBS. The FMAP for direct medical services provided in schools is the same as applicable for Medicaid or CHIP services provided in other service settings. Expenditures for Medicaid administrative activities are generally available at a 50% matching rate, with higher rates for certain activities as specified in the Social Security Act (the Act). Expenditures for CHIP administrative activities, including health services initiatives (HSIs) are available at the Title XXI enhanced or eFMAP and subject to a 10% limit on administrative expenditures.
A Notice of Funding Opportunity (NOFO) was published in the Federal Register at https://www.govinfo.gov/app/collection/FR/ on January 24, 2024. Applications for grant funding were due March 25, 2024. Please contact the MedicaidSBSPlanningGrants@cms.hhs.gov mailbox for more information.
The new flexibilities for SBS are policy options available to States, but are not required. If States have questions, we encourage them to reach out to the SBS email SchoolBasedServices@cms.hhs.gov to engage in any needed technical assistance.
States should review the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming to ensure that their current SBS policies are consistent with all federal requirements. States are required to submit any necessary changes to their SPAs, TSIP, MAC Plan, PACAP, etc., to adhere to all applicable federal requirements as discussed in the 2023 Comprehensive Guide as quickly as possible, if changes are needed, with the expectation that any necessary changes will be requested and approved by July 1, 2026. CMS encourages states to start the submission process as soon as possible to allow for optimal time for review and necessary revisions. If the State has questions about compliance, CMS is available to assist. We encourage them to reach out to the SBS email SchoolBasedServices@cms.hhs.gov to engage in any needed technical assistance.
Under section 438.370, the enhanced match of 75 percent is available for the EQR-related activities described in section 438.358 if all of the following conditions are met:
- The EQR activity is performed on a managed care organization (MCO) by an entity meeting the requirements of a qualified EQRO in section 438.354 or its subcontractor;
- The activity is performed pursuant to a contract approved by CMS; and
- The activity is performed in accordance with a protocol issued by CMS.
FFP at the 50 percent matching rate is available for mandatory and optional EQR-related activities for PIHPs, PAHPs, and affected PCCM entities, regardless of whether the activities were conducted by an EQRO or another entity. FFP at the 50 percent matching rate is also available for EQR and related activities performed for MCOs that are conducted by an entity that is not a qualified EQRO. This is a change from previous regulations, under which the enhanced match was available for EQR of PIHPs to the same extent as MCOs. This provision took effect May 6, 2016.
Supplemental Links:
Regardless of whether an EQRO contract is approved before or after May 6, 2016, the change in FFP for EQR-related activities was effective May 6, 2016 for expenditures incurred by the state on or after May 6, 2016. Per general CMS-64 claiming principles, a state incurs an expenditure that may be claimed on the CMS-64 on the date the state pays the EQRO for the completed performance of the contracted EQR-associated activity.
The change to the FFP match rate for expenditure reporting takes effect in the middle of a quarter, which means that states must ensure that claims for expenditures for EQR activities affected by the change in FFP which were paid before May 6th and claims for expenditures which were paid on or after May 6th are reported separately. For only the quarter ending June 30, 2016, the CMS-64 EQRO Line 17 will allow states to report state expenditures associated with PIHP EQRO activities paid prior to May 6, 2016 and claim the enhanced 75 percent match. State expenditures associated with PIHP EQRO activities paid on or after May 6th must be claimed at the 50 percent matching rate.
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CMS expects to first issue revised protocols for the current mandatory and optional EQR-related activities in the Fall of 2017. We expect to issue the protocol for the new mandatory EQR activity relating to the validation of network adequacy later in 2017 or early 2018. States will have up to one year from the publication of the protocol to implement the new mandatory EQR activity.
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For questions related to state expenditure reporting and claiming instructions for EQR activities, please contact your CMS regional office financial representative. For specific external quality review questions, including what activities qualify for enhanced match, please contact the Division of Quality and Health Outcomes at ManagedCareQualityTA@cms.hhs.gov.
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Yes. We remind states that the requirement that the final capitation rate be specified in the contract is not a new requirement, see section 438.6(c)(2)(ii) of the 2002 final rule. The amount of payment for performance-in this context, the final capitation rate-is a primary component of any contract and must be included for purposes of verifying claims for Federal Financial Participation (FFP) on the CMS-64. In the Final Rule at page 27595, in the context of risk adjustment, CMS suggested that the payment terms under the contract could be identified in an appendix, or additional supporting documentation, to the contract for ease of updating the information when risk adjustment is applied. The state must submit a formal contract amendment when the final capitation rates differ from the payment terms in an approved contract.