Frequently Asked Questions

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.

FAQ ID:162476

Yes, under both IDEA and FERPA, a public agency may accept digital or electronic signatures when obtaining parental consent to disclose PII from the child’s educational records. Such electronic consent must: 1) identify and authenticate a particular person as the source of the electronic consent; and 2) indicate such person’s approval of the information contained in the electronic consent.

FAQ ID:166386

As discussed in Section IV. C of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, State Medicaid/CHIP agencies may share applicant and beneficiary information with schools enrolled as Medicaid or CHIP providers, or other Medicaid or CHIP providers, when the use or disclosure of the information is for purposes directly connected with the administration of the Medicaid or CHIP State plan, including establishing eligibility, providing services, or billing for services. Yes; An LEA or a school enrolled as a Medicaid or CHIP provider may receive beneficiary information on the condition that the school adheres to confidentiality standards comparable to those of the SMA or the State CHIP agency. The SMA and the State CHIP agency (in accordance with 42 C.F.R. § 457.1110(b)), as well as recipients of applicant and beneficiary information, must safeguard this information in accordance with the requirements of 42 C.F.R. part 431, subpart F confidentiality when they receive, use, or disclose applicant or beneficiary information. 

One of these requirements is that the SMA or State CHIP agency must obtain permission from the individual, or their family, before responding to a request for information from an outside source, as set forth in 42 C.F.R. § 431.306(d). The Medicaid consent for billing purposes is separate from the FERPA and IDEA consent provisions. 

FAQ ID:166391

IDEA child find requires States to ensure that all children with disabilities residing in the State who need special education and related services are identified, located, and evaluated, regardless of the severity of the disability, and includes identification of children who are suspected of having a disability. States are responsible for implementing child find activities for all children with disabilities residing in the State, including those children who are experiencing homelessness or are wards of the State, highly mobile and migrant children, English learners, and parentally placed private school children with disabilities, as well as those suspected of having developmental delays as defined in 34 C.F.R. § 300.8(b). 

Child find activities are defined in 34 C.F.R. § 300.111 and typically involve a screening process to determine whether the child should be referred for an evaluation to determine eligibility for special education and related services. States must identify, locate, and evaluate all children with disabilities residing in the State and who may need special education and related services.
 

FAQ ID:166396

The 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming (p. 15) has language that states that “coverable services also include child find evaluations and reevaluations.” Medicaid may cover child find screening, evaluations, and reevaluations in certain circumstances (see FAQ on Child Find Activities).

FAQ ID:166406

States with Medicaid MCPs may have one of two arrangements to pay for school-based services. 

• States may delegate the full scope of services to the MCP, which is then responsible for ensuring that services are available and accessible both in schools and in the community. 
• States may exclude some or all SBSs from the services covered by their MCPs, and instead States are paying schools or LEAs directly via a fee-for-service delivery system, while MCPs pay for community-based services. 

In all cases, the Medicaid MCP must ensure that covered children receive the medically necessary services to which they are entitled under EPSDT. According to 42 CFR § 438.208, MCPs are responsible for coordination and continuity of care. For children who receive services in school, the MCP should coordinate with schools to ensure that any community-based medically necessary services are provided, while avoiding any duplication of services. MCPs should not be categorically or otherwise inappropriately disqualifying or decreasing community-based medically necessary services solely on the basis that the service is also being provided in a school setting. If the MCP is inappropriately disqualifying or decreasing medically necessary services, the State should remind the MCP of its contractual obligations. If the MCP is denying authorization for medically necessary services or decreasing the authorization of these medically necessary services, that would constitute an adverse benefit determination for which appeal rights are granted under Medicaid. 

We also remind states of our expectations related to EPSDT.  When a managed care delivery system is used to deliver some or all services required under the EPSDT benefit, states must identify, define, and specify the amount, duration, and scope of each service that the MCP is required to offer in their managed care plan contract. For example, if a MCP is expected to provide the full range of preventive, screening, diagnostic, and treatment services required, it must be clearly stated and described in the contract between the state and the plan. Alternatively, states may exclude some EPSDT services from a managed care delivery system and retain responsibility for them in an FFS delivery system, or contract with another MCP to provide those services.   Any benefits not provided by the MCP remain the responsibility of the state Medicaid agency, and if a plan excludes benefits over contractually specified limits, the state retains responsibility for medically necessary services above those limits.  Additionally, in accordance with 42 CFR 438.208(b), MCPs are required to implement procedures to deliver care to and coordinate services, including school-based services, with the services the enrollee receives from another managed care plan, in FFS Medicaid and from community and social support providers.

For services provided in schools to Medicaid-covered children on an IEP/IFSP, Medicaid is the “payer of first resort” for Medicaid covered services, as described in 34 C.F.R. Section §300.154 "Methods of ensuring service." Because special education and related services on an IEP must be provided at no cost to the parent, the LEA may not bill Medicaid if doing so would prevent the child from obtaining Medicaid services outside of the school. Therefore, under both IDEA and Medicaid, the SMA must ensure that they and their MCPs work with SEAs and LEAs to ensure that children can access Medicaid services both under the child’s IEP and as medically necessary outside of the school setting.

FAQ ID:166421

States generally have broad flexibility to identify the providers of a covered Medicaid service, including their qualifications, although specific federal provider qualifications do apply for certain services. 

In the 1997 school-based services guidance, CMS instructed States that they could not rely on ED provider qualifications for Medicaid reimbursement or establish different provider qualifications for school-based and non-school-based providers within Medicaid. We have updated that guidance (see the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming) in order to give States greater flexibility to cover services provided by school-based health care providers whose provider qualifications under State and local law might vary from the qualifications for non-school-based providers of the same services, or whose scope of practice might be limited under State or local law to the school setting. Under this updated approach, States should not impose provider qualifications that are unique to Medicaid-covered services. For example, if a school-based provider is qualified under State or local law to provide counseling to any child (or any child in the school system), the State cannot impose additional provider qualification requirements under State law as a condition for receiving Medicaid payment for counseling provided to a Medicaid beneficiary.

If the State has included school-based providers as qualified providers of specific services in the Medicaid State plan, then individual school-based providers may seek to become Medicaid providers. For example, States may determine that counseling provided under the rehabilitative services benefit may be provided by licensed psychologists, social workers, family therapists, professional counselors, as well as certified school psychologists or school social workers who may not have the same qualifications. In some circumstances, a practitioner may be enrolled individually as a Medicaid provider and may either bill directly for the services they furnish or, consistent with 42 C.F.R. § 447.10(g), reassign their right to payment to the school or an agency contracted by the school to provide Medicaid-covered services. In other circumstances, the LEA or agency contracted by the school to provide Medicaid-covered services may be enrolled as a Medicaid provider and may be considered the “furnishing provider” for services provided by its employees. 

We recommend referring to your State, local, or other generally applicable licensure or certification requirements, including certification by the Federal, State, or local department of education or national accrediting bodies. 

FAQ ID:166426

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.

FAQ ID:166431

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. 

FAQ ID:166436

According to page 105 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming for the pay and chase method: 

“If the probable existence of a third party cannot be established or third-party benefits are not available to pay the beneficiary’s medical expenses at the time the claim was filed, the State Medicaid agency will pay the full amount allowed under their payment schedule. If the existence of a third party is determined after the claim is paid, or benefits become available from a third party after the claim is paid, recovery for reimbursement is sought to the limit of legal liability within 60 days from the end of the month in which the existence of the third party is determined.”

Additionally, States may exempt certain items or services from third-party liability (TPL) requirements when submission of claims for those items or services would always result in denial because the general insurance industry does not cover them. CMS requires the State to have clear and convincing documentation of non-coverage by insurers (this documentation must be updated at least annually). If a State has documentation, there is no need to further verify by submitting claims because there would be no liable third party and Medicaid TPL rules would not come into play. The controlling regulation is found at 42 CFR 433.139(b)(1), which states, “The establishment of third party liability takes place when the agency receives confirmation from a provider or a third party resource indicating the extent of third-party liability.” 

When non-coverage has been documented, the State may permit providers to use a specific code on the claim denoting non-coverage by the third party. This code could allow the Medicaid Management Information System (MMIS) to override the cost avoidance edit and pay the claim. The State would have to require providers to maintain documentation to substantiate non-coverage when using override codes and could conduct provider audits to ensure that the provider has appropriate documentation of non-coverage.

Section 1903(c) of the Act permits an exception to the TPL requirements for Medicaid-covered services included in a Medicaid eligible student’s IEP. This means that Medicaid will pay primary, or prior to federal IDEA funds for Medicaid-covered services listed in a student’s IEP. Although the Medicaid program pays first for covered IDEA services, these services are still subject to the TPL requirements applicable to any other services furnished under the State Medicaid program. The State Medicaid agency must still pursue payment for TPL as Medicaid is secondary to all other sources of payment. While this outlines the exception to Federal TPL requirements, States are required to pay and chase when it is cost-effective to do so.

FAQ ID:166441