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
A diagnosis is not a federal requirement to bill Medicaid for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, however, a state Medicaid Agency may set their own requirements for local education agencies (LEA) to follow when billing for EPSDT services. A CMS Informational Bulletin (CIB) from August 18, 2022, provides information about leveraging Medicaid in the delivery of behavioral health services to youth and encourages states to avoid requiring a behavioral health diagnosis for the provision of EPSDT services. However, services must meet requirements for medical necessity, and all other Medicaid rules and regulations must be followed in any setting for Medicaid services.
States will have a process to prevent payment for duplication of services. Local education agencies (LEA) and providers should consult the state Medicaid agency to see if services provided in schools and in the community are seen as duplicative or complementary. The state Medicaid agency can also provide information on the intersection between service limitations for a community provider such as an approved number of nursing hours and hours provided in school.
Due to Medicaid’s federal and state partnership, there are no statutes or regulations requiring state Medicaid agencies (and their managed care organizations) to use any specific coding set in the Medicaid program. State Medicaid agencies have the authority to adopt a code set for use by their plans and providers that best meets their program needs.
1905(a) of the Social Security Act lists all benefit categories that may be covered by state Medicaid programs. The following link provides a list of the 1905(a) mandatory and optional state plan benefits: Mandatory & Optional Medicaid Benefits.
Yes, Screening, Brief Intervention, and Referral to Treatment (SBIRT) can be delivered in schools and reimbursed by Medicaid. SBIRT may be covered under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements and multiple 1905(a) benefit categories, such as preventive or rehabilitative services. The state Medicaid agency determines state plan coverage and payment options for these types of services.
There are two types of National Provider Identifiers (NPI): one for individual providers and one for organizational providers. Both types have specific criteria and requirements that need to be met. Inquiries related to obtaining an NPI number can be directed to AdministrativeSimplification@cms.hhs.gov.
The list of services on Medicaid.gov comes from 1905(r)(1)(B) of the Social Security Act, which specifies that screening services provided under EPSDT “shall at a minimum include—
(i) a comprehensive health and developmental history (including assessment of both physical and mental health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the schedule referred to in section 1928(c)(2)(B)(i) for pediatric vaccines) according to age and health history,
(iv) laboratory tests (including lead blood level assessment appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).”
This list of services is a minimum, not a comprehensive list of services that may be covered under EPSDT. 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 Social Security Act if medically necessary, as determined by the State, to “correct or ameliorate” identified conditions.
Therefore, schools and other providers may perform and bill for some EPSDT services without providing all of the minimum services listed in 1905(r)(1)(B). EPSDT services include comprehensive examinations, vaccinations, screening for common childhood health conditions, screening and treatment for mental health conditions, and other services.
If SBS are excluded from a state’s managed care delivery system and covered under an FFS delivery system, the claims must be submitted directly to the state’s Medicaid FFS program. As page 45 of the Comprehensive Guide describes, under an FFS delivery system, "providers submit claims for the services that they provide to the State Medicaid agency through billing systems and receive payments at the applicable fee schedule rate for a service."
LEAs and school-based providers must only contract with MCPs to become network providers if the state includes SBS in a managed care delivery system. However, regardless of whether SBS are included in managed care, there are several regulations on the coordination of care, and states and MCPs should coordinate with LEAs as necessary. For example, 42 CFR 438.208(b)(2) requires that MCPs coordinate services covered by the MCP with services that their enrollees receive through FFS or other MCPs; the services provided through FFS or another MCP could include services delivered in schools.
Medicaid will pay for services and treatments that fit within any of the 1905(a) benefit categories of the Social Security Act (The Act). Medicaid-enrolled children can receive a broad range of the Early and Periodic Screening Diagnosis and Treatment (EPSDT) services as defined in 1905(r) of the Act, even if the services are not otherwise available under the State Medicaid Plan. For Medicaid-enrolled students with an IEP/IFSP, Medicaid is the payer of first resort for Medicaid-covered services included in the IEP/IFSP (see section 1903(c) of the Act and IDEA sections 1412(e) and 1440(c), codified at 20 USC 1412(e) and 1440(c); 34 CFR 300.154(h); and 42 CFR 433.139). While all EPSDT services can be provided in schools, not all school services will fall under the EPSDT benefit. The Medicaid EPSDT benefit and qualifying covered state plan services would also not be available to individuals over the age of 21, unless the state has opted to cover the services in one of the 1905(a) benefits of Medicaid.
Page 44 of the Comprehensive Guide describes that State Plan Amendments (SPAs) for SBS generally include “a comprehensive section describing the types of providers and school staff involved in providing SBS.” For more information about the requirements for a SPA, states are encouraged to use the Readiness Checklist Tool, available on the CMS School-Based Services Resources page under TAC Resources.
Generally, State Medicaid agencies are required to use the cost avoidance method when probable TPL exists. For services that are not included in a student’s IEP or IFSP under IDEA, schools and school-based providers must meet federal and state Medicaid requirements by billing the third-party health insurance before billing Medicaid to determine the extent of the insurer’s liability. However, when the claim is for medical child support services or preventive pediatric services covered in the Medicaid State Plan, SMAs use the “pay and chase” method instead.
As stated on page 106 of the Comprehensive Guide,
“Using the ‘pay and chase’ method, the State Medicaid agency pays the claims submitted by providers and then seeks reimbursement from the liable third parties. Reimbursement must be sought unless it is determined that recovery of reimbursement would not be cost-effective in accordance with threshold amounts that have been established by the State Medicaid agency.”
If the SMA determines that recovery of third-party reimbursement will not be cost-effective, it can choose to terminate recovery efforts. More information about the termination of recovery efforts can be found at 42 CFR 433.139(f). This regulation specifies that the Medicaid State Plan must include the threshold amount.
“The State plan must specify the threshold amount or other guideline that the agency uses in determining whether to seek recovery of reimbursement from a liable third party or describe the process by which the agency determines that seeking recovery of reimbursement would not be cost-effective.”