Stellar Therapy Services

Medicaid School-Based Services 2024 and beyond…

Published by

TracyC

on

From Centers for Medicare & Medicaid Services (CMS)

Kate Ginnis
Senior Policy Advisor for
Children and Youth, Office
of the Center Director

Richard Kimball
Technical Director for Division
of Reimbursement Policy,
Financial Management Group

Medicaid School-Based Services 2024 and Beyond…

Child and adolescent access to care continues as an administration priority.

It is a top priority to strengthen and expand access to Medicaid and the Children’s Health Insurance Program (CHIP).

  • Schools are important providers of Medicaid direct medical services & administrative activities for children
  • Medicaid and CHIP cover more than half of all children in the United States
    • Can help continued enrollment
  • SBS can include all services covered under Early & periodic screening, diagnostic, and treatment (EPSDT), including physical and behavioral health care
  • Schools are not primarily medical providers- need help to bill Medicaid
    • It is CMS’s goal to help states ease the administrative burden on schools, to promote the delivery of SBS

BSCA and EPSDT

Section 11004 of the Bipartisan Safer Communities Act charged CMS with:

  • Identifying gaps and deficiencies regarding state compliance with EPSDT requirements
  • Providing technical assistance to states to address such gaps and deficiencies
  • Issuing guidance (EPSDT SHO letter) on Medicaid coverage requirements, including best practices for ensuring children and youth have access to comprehensive health care services
  • Issuing a Report to Congress on the activities, findings, and actions taken based on the review findings

EPSDT Background

– The EPSDT requirement is a cornerstone of Medicaid and CHIP program coverage of child health services.
– EPSDT is designed to ensure that children and youth can access the health care they need, when they need it, so that health problems are averted or diagnosed and
treated as early as possible.
– Section 1905(a)(4)(B) and 1905(r) of the Social Security Act entitles eligible children under the age of 21 to Medicaid coverage of health care, diagnostic services, treatment, and other measures described in section 1905(a) that are medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions, whether or not such services are covered under the state plan.

EPSDT SHO letter

  • The letter provides policy guidance, effective strategies to ensure access, and best practices states can employ for EPSDT-eligible children.
  • The letter clarifies policy implementation, including strategies and best practices for delivery of a comprehensive EPSDT program.
  • Key topic: Promoting EPSDT Awareness and Accessibility
    – Requirements to inform beneficiaries and families about EPSDT
    – Provision of EPSDT support services (transportation, appointment scheduling)
    – Improving health care accessibility using care coordination and case management
    – Requirements to ensure consideration of EPSDT in Medicaid policies and procedures such as prior authorization and fair hearings
    – Meeting requirements related to EPSDT and managed care

Compliance Date- CIB 2023

“If States are not already adhering to applicable federal standards andnrequirements as discussed in this guide, CMS expects that States submit state plan amendments (SPAs), administrative claiming plan amendments (MACs), and/or
amendments to time study implementation plans (TSIPs) to comply as soon as possible, but no later than the start of the first quarter at least three years after the publication date of the guide.” July 1, 2026

Limiting SBS

CMS will never advise a state to categorically deny ANY service just because it is given in a school setting

  • Must follow all Medicaid rules and regulations & medically necessity
  • Especially for children under the guarantee of services for EPSDT
  • States can manage and administer their Medicaid program within the parameters of the federal Medicaid rules and regulations

Coordinating Services in MC

Call for Assistance

  • Any reports of denial of services
    – Need specific information
    • State, MCP, type of service, LEA, IDEA (IEP) or other plan of care, any other info!
    • Email: schoolbasedservices@cms.hhs.gov
  • Any kudos!
  • Feedback loop with SMAs/MCPs
    – MCPs want to work on duplication issue

Build capacity to bill Medicaid

  • Enroll providers in Medicaid per State Plan
  • Ensure documentation (including access to IEPs/504 plans)
  • Ensure Big 3 rehabilitative services are signed by Physician or other licensed providers (OLP)
  • Use economies of scale-intermediate school districts
  • Use Best Practices!

Funding = Services

How fully funding LEAs fully can immensely enhance efforts to expand access

  • Certified Public Expenditures (CPEs) -provide 100% of Federal Financial Participation (FFP) to support LEAs- “CMS strongly encourages State Medicaid agencies to do so in order to ensure providers are reimbursed for their incurred costs of furnishing Medicaid-covered services” p.43
  • “Medicaid claims for the costs of administrative activities and direct
    medical services may not include fees for contractor services that are based on, or include, contingency fee arrangements”

“45 C.F.R. § 75.459(a) states: Costs of professional and consultant services rendered by persons who are members of a particular profession or possess a special skill, and who are not officers or employees of the non-Federal entity, are allowable, subject to paragraphs (b) and (c) of this section when reasonable in relation to the services rendered and when not contingent upon recovery of the costs from the Federal Government. (Emphasis added.)” p.72

Areas to focus to ensure compliance

All relevant policies & policy documents w/ New Guide

SPAs- reimbursement & coverage, TSIPs, MACs, Public assistance cost allocation plans (PACAPs), etc.,

  • ANY cost methodology (not approved in past 2-3 years)
    • ALL regular school days
    • Defining cost pools
    • Contractor costs- indirect costs, inclusion in time study? (random moment time study – RMTS), allocations (not tuition based)
    • Cost-based rates – paying a rate to justify cost
  • Most likely, any flexibility
    • +/- 2-day notification for RMTS (TSIP)
    • Interim payments – PCPM (per child per month), roster billing, etc.,
    • Fee for service (FFS) rates paying above the community rate
  • Most Specialized Transportation methodologies
    • 1-way trips, defining cost pools, etc.,
  • Providers- adding providers or services that are new
    • Not changing codes for most part (provider manual)
    • Enrolled in Medicaid, referring providers for rehabilitative services

Submitting Materials to CMS

  • SPAs must be submitted by 9/30/26 (end of quarter) to retain the effective date of 7/1/26
  • CMS through OneMAC:
    – New SPAs and RAI (request for additional info) responses:
    https://onemac.cms.gov
    – Old email: spa@cms.hhs.gov
  • TSIPs/MACs should be submitted by 6/30/26
  • Other materials (e.g., PACAPs submitted to
    HHS Cost Allocation Services) may need more
    time

TSIP Requirements

  • Medicaid Enrollment Ratio (MER)- no more sub-groups
    – e.g., IEP kids that receive a medical service
  • MER- access to IEPs/504 Plans other plans or documentation in an audit
  • Up to 2-day prior notification & Up to 2-day response period
    – We encourage an immediate response: we will recognize up to 2-days prior notice or response period, as appropriate to the circumstances
    – Frequently Asked Questions (FAQs) Link
  • Any Medicaid activities during the summer/vacation periods must be in time study
    – ALL time and activities (whether allowable or unallowable under Medicaid) performed by school employees, including summer/vacation periods
    – ALL school days must be included in the time study

Optional TSIP Flexibilities

Decreasing Administrative Burden
  • RMTS- 1 step process (no MER)
  • 2% to 5% error rate for direct medical service
    – 2401 to 385 sampled moments
    – Advantages/disadvantages of tradeoff
  • A substitution policy for filling vacancies or replacing staff during the time study period
  • Use other reasonable allocations

What CMS does not require…

Medical plans of care (POCs)

If IEPs/POCs are used for medical necessity = must be accessible to auditors

CPT or HCPCS codes

States are required to administer and manage their Medicaid programs for proper oversight

  • State requirements
  • Policy/administrative determinations (not in state plan)

Documentation & Audits

Maintain adequate documentation

  • Minimum documentation for Medicaid/IDEA – chart in the Guide
  • Access to IEPs/POCs to justify allocations & document medical necessity
  • RMTS moments- thoroughly documenting activity & coding correctly

Reminder! HHS Office of the Inspector General (OIG) is an independent agency – CMS has no influence over OIG audits

Cautionary Notes

SBS is subject to all regulations & rules of Medicaid

  • Rehabilitation services: 440.110 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.
    • …services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary
  • Providers that are eligible to enroll under the state plan, must enroll in Medicaid. There is no discretion to not require enrollment based solely on the site of service.
    • Social Security Act 1902(a)(78), all providers furnishing, ordering, prescribing, referring, or certifying eligibility for Medicaid services must be enrolled in Medicaid and bill for their services. See also, 1902(kk)(7) (requiring enrollment of ordering or referring providers)

Specialized Transportation

  • Only for IDEA students- transport to schools is primarily education
  • Isolate cost pool for specially adapted vehicles
  • Allocate using 1-way trip ratio
  • SBS Specialized Transportation- TAC will be doing more on this later in the year around best practices

The Future! 2025 & Beyond…

SBS Resource Spotlight

SBS Policy Guidance

SBS Resources

Leave a Reply

Previous Post
Next Post

Discover more from Stellar Therapy Services

Subscribe now to keep reading and get access to the full archive.

Continue reading