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).   
 

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.  

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.

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.

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.

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.

The State Medicaid agency or state laws related to consent protocols and procedures would apply. Please consult the relevant state agencies or your organizational legal counsel.

In states where SBS are included in a Medicaid managed care delivery system, LEAs must contract with MCPs to receive reimbursement for SBS provided to enrollees. Regardless of whether SBS services are included in managed care, MCPs play a key role in coordination of care for all states that utilize a Medicaid managed care delivery system. Under 42 CFR 438.208(b), MCPs are required to coordinate care and services for enrollees across settings, which includes services that are provided in schools.

Working with MCPs can reduce the time LEAs need to spend on administrative issues, such as denied claims, which can improve revenue flow and allow more time for LEA staff to spend on providing health care to students.

For more information, we welcome you to review the slides and recording of the Intersection of Medicaid Managed Care and SBS webinar, available on the Medicaid and School-Based Services Events page.

CMS requires states to provide mandatory training to all time study participants, not only those who are assigned a random moment. Training may occur before or after staff are selected for inclusion in the time study participant list, but must occur before sampling. 

More information on training for participation in the time study, including what training should involve, when training should be conducted, and what documents should be retained related to training can be found within the Considerations for Developing a Time Study Implementation Plan (TSIP) resource document, available on the CMS School-Based Services Resources page.

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.