reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.06 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Patricia Harris, Administrator, LTC
				  Program Management Unit
Statutory Authority:
State Plan;
				  42 CFR
				  §440.70; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.07 - Noncovered Items And Services

Current through Register Vol. 42, No. 9, June 28, 2024
Non-covered items and services include, but are not limited
				to:
(1) Items of a deluxe
			 nature.
(2) Replacement of usable
			 equipment.
(3) Items for use in
			 hospitals, nursing homes, or other institutions. However, DME items may be
			 provided in nursing homes or other institutions for children through the EPSDT
			 Program.
(4) Items for the patient
			 or patient's caregiver's comfort and convenience.
(5) Items not listed as covered by
			 Medicaid.
(6) Rental of equipment,
			 with the following exceptions:
(a) Rental for
			 six months or less, or
(b) Medicare
			 crossover, or
(c) Certain
			 intravenous therapy equipment, or
(d) Short term use due to
			 institutionalization, or
(e) Short
			 term use due to death of a recipient.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.08 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Authors:
Theresa Richburg, Henry C.
				  LeCroy
Statutory Authority:
42 C.F.R.
				  §431.625; State Plan, Attachment 3.2-A;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.09 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Theresa D. Richburg
Statutory Authority:
State Plan;
				  42 C.F.R.
				  §435.10; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.10 - Reimbursement And Signatures

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid will reimburse for only those DME, supply, appliance or POP items
			 indicated on the approval letter from Medicaid or its designee.
(2) Reimbursement will be made for purchases
			 or rentals in accordance with the DME Fee Schedule on the Medicaid
			 website.
(3) Request for
			 reimbursement must be submitted on the appropriate claim form. Please refer to
			 Chapter 14, DME, of the Medicaid Provider Manual.
(4) The provider agrees to accept as payment
			 in full the amount paid by Medicaid for covered items.
(a) The provider (or provider's staff) must
			 advise each patient prior to services being rendered when Medicaid payment will
			 not be accepted and the patient will be responsible for the bill.
(b) The fact that Medicaid payment will not
			 be accepted must be recorded in the patient's record. Refer to Rule No.
			 560-X-1-.07.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.11 - Non-Reimbursement Of DME, Supplies, Appliances And POP

Current through Register Vol. 42, No. 9, June 28, 2024
(1) DME item(s) furnished by a supplier
			 without receipt of an authorization to purchase by Medicaid will not be
			 approved for reimbursement.
(2)
			 Item(s) supplied to an individual who is not eligible during the month in which
			 the item(s) are furnished, are not reimbursable.
(3) Medicaid recipients cannot be reimbursed
			 directly by Medicaid.
Author:
Kelli Littlejohn Newman, PharmD,
				  Director, Clinical Services
Statutory Authority:
42 C.F.R.
				  §447.252; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.12 - Cost-Sharing

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid
			 recipients are required to pay and suppliers are required to collect the
			 designated co-pay amount for the rental or purchase of DME, supplies,
			 appliances and POP, including crossover claims.
(2) The co-payment fee does not apply to in
			 certain situations in accordance with Rule No.
			 560-X-1-.25.
(3) A provider may not deny services to any
			 eligible recipient due to the recipient's inability to pay the cost-sharing
			 amount imposed.
Author:
Kelli Littlejohn Newman, PharmD,
				  Director, Clinical Services
Statutory Authority:
42 C.F.R.
				  §447.50; State Plan, Attachment 4.19-B,
				  page 5; Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.13 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Patricia Harris, Administrator, LTC
				  Program Management Unit
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.70; State Plan, Attachment 4.19-B; and
				  ORBA '89.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.14 - Augmentative Communication Devices

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Coverage is provided for Augmentative
			 Communication Devices (ACD) for eligible individuals who meet criteria set out
			 herein. Prior authorization for the ACD service is required. Requests for prior
			 authorization must be made on the appropriate Alabama Prior Review and
			 Authorization Request Form. The request must include documentation regarding
			 the medical evaluation by the physician and speech language pathologist and
			 recipient information.
(2) ACDs are
			 defined as portable electronic or non-electronic aids, devices, or systems
			 determined to be necessary to assist a Medicaid-eligible recipient to overcome
			 or improve severe expressive speech-language impairments or limitations due to
			 medical conditions in which speech is not expected to be restored, and which
			 enable the recipient to communicate effectively. These impairments include but
			 are not limited to: apraxia of speech, dysarthria, and cognitive communication
			 disabilities. These devices are reusable equipment items which must be a
			 necessary part of the treatment plan consistent with the diagnosis, condition
			 or injury, and not furnished for the convenience of the recipient or his
			 family. ACD components or accessories prescribed or intended primarily for
			 vocational, social, or academic development or enhancement and which are not
			 necessary as described above will not be covered.
(3) The scope of services includes the
			 following elements:
(a) Screening and
			 evaluation,
(b) ACD, subject to
			 limitations, and
(c) Training on
			 use of equipment.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.15 - Oxygen Therapy Coverage

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Oxygen Therapy is covered for the entire Medicaid population based on medical
			 necessity and must be prior authorized by Medicaid. Requests for prior
			 authorization must be made on the appropriate Alabama Prior Review and
			 Authorization Request Form. The request must be accompanied by appropriate
			 medical and other required documentation in accordance with Rule No.
			 560-X-13-.03.
(2) The medical diagnosis must indicate a
			 chronic debilitating medical condition, with evidence that other forms of
			 treatment (such as medical and physical therapy directed at secretions,
			 bronchospasm and infection) were tried without success and that continuous
			 oxygen therapy is required. Oxygen will not be approved for as needed (PRN) use
			 only.
Author:
Kellie Littlejohn Newman, PharmD,
				  Director, Clinical Services
Statutory Authority:
State Plan;
				  42 CFR, Section
				  440.70; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.16 - External Breast Prostheses

Current through Register Vol. 42, No. 9, June 28, 2024
(1) External breast prostheses following
			 mastectomy for breast cancer are covered for all Medicaid-eligible recipients
			 meeting the criteria. Please refer to Chapter 14, DME, or the Medicaid Provider
			 Manual published on Medicaid's website
(2) Providers of external breast prostheses
			 devices for adults must be enrolled as a Medicaid provider and Mastectomy
			 Fitters must be licensed by the Alabama Board of Prosthetics, Orthotics and
			 Pedorthics.
Author:
Kellie Littlejohn Newman, PharmD,
				  Director, Clinical Services
Statutory Authority:
State Plan;
				  42 CFR, Section
				  440.70; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.17 - Wheelchairs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Wheelchairs are
			 a covered benefit for patients who meet full Medicaid eligibility criteria and
			 medical necessity. The patient must meet criteria applicable to wheelchairs
			 pursuant to this chapter, and Chapter 14, DME, of the Medicaid Provider
			 Manual.
(2) All requests for
			 wheelchairs are subject to the Medicaid prior approval provisions in accordance
			 with Rule No.
			 560-X-13-.03 and any additional
			 requirements in Chapter 14, DME, of the Medicaid Provider Manual.
(3) Limitations and Exclusions
(a) Patients may be approved for one manual
			 or power/motorized wheelchair every five years for children ages 0-20 and every
			 seven years for adults ages 21-99 based on medical necessity.
(b) Home, environmental and vehicle
			 adaptations, equipment and modifications are not covered.
(c) Repairs or replacement of parts require
			 prior authorization unless otherwise specified by Medicaid.
(d) Within the five year period for children
			 ages 0-20 and seven year period for adults ages 21-99, Medicaid will not repair
			 or replace equipment that is lost, destroyed, or damaged as a result of misuse,
			 neglect, loss or wrongful disposition or equipment by the recipient, the
			 recipient's caregiver(s), or the provider. At a minimum, examples of equipment
			 misuse, neglect, loss or wrongful disposition by the recipient, recipient's
			 caregiver, or the provider include, but are not limited to the following:
1. Loss of wheelchair or parts.
2. Selling or loaning wheelchair or
			 parts.
3. Damage due to
			 weather.
4. Failure to store the
			 wheelchair in a secure and covered area when not in use.
5. Use on public roadways where the speed
			 limit is greater than 25 miles per hour.
6. Loss, destruction or damage caused by the
			 malicious, intentional or negligent acts.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.18 - Basic Level Prosthetics, Orthotics, And Pedorthics

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Basic level prosthetics, orthotics and
			 pedorthics are covered benefits to Medicaid eligible recipients up to age 65 in
			 a non-institutional and institutional setting. The recipients must meet
			 established Medicaid criteria applicable to prosthetic, orthotic, and pedorthic
			 devices pursuant to this chapter and Chapter 14, DME, of the Medicaid Provider
			 Manual.
(a) For items to be covered,
			 recipients must meet eligibility requirements, the devices must be reasonable
			 and necessary to improve the functioning of a malformed body member or replace
			 an absent body member, and meet all other applicable Medicaid statutory and
			 regulatory requirements.
(b)
			 Providers of prosthetic, orthotic, and pedorthic devices for adults must be
			 enrolled as a Medicaid provider and licensed by the Alabama Board of
			 Prosthetics, Orthotics and Pedorthics.
(c) The provider must be practicing as a
			 prosthetic, orthotic, or pedorthic practitioner in the State of Alabama at an
			 accredited facility.
(d) Provider
			 must keep a copy of the written prescription or order from the primary
			 physician for the prosthetic or orthotic device in the recipient's file for a
			 period of three years plus the current year.
(e) The provider must have documentation of
			 the education follow-up provided to the recipient of the use of the prosthetic
			 and orthotic device in the recipient's file.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.19 - Warranty, Maintenance, And Replacement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All standard DME, appliances, and POP
			 must have a warranty for a minimum of one year; this may include the
			 manufacturer's warranty. If the provider supplies items that are not covered
			 under a warranty, the provider is responsible for repairs, replacements and
			 maintenance for the first year.
(a) The
			 warranty begins on the date of delivery (date of service) to the recipient. A
			 statement of the warranty must be given to the recipient and the provider must
			 keep a copy of the warranty for audit review by Medicaid. Medicaid may request
			 a copy of the warranty.
(b) In the
			 event the supplying provider does not honor or provide the mandatory one year
			 warranty and does not repair the items when needed, Medicaid may impose
			 penalties, to include but not limited to deducting the total cost of the
			 repairs from a check write of the supplying provider, recoupment of
			 reimbursement paid to the provider for the equipment, or termination of the
			 provider's contract.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.20 - Specific DME, Supplies, Appliances, And POP Coverage And Policy Not Otherwise Mentioned

Current through Register Vol. 42, No. 9, June 28, 2024
Specific DME and POP coverage and policy not mentioned in this
				chapter are described in Chapter 14, DME, of the Medicaid Provider Manual, and
				is located on the Medicaid website. Questions related to specific coverage and
				policy should be submitted in writing or email to, Alabama Medicaid Agency,
				Clinical Services and Support, DME Unit.
Author:
Kelli Littlejohn Newman, PharmD,
				  Director, Clinical Services
Statutory Authority:
State Plan;
				  42 CFR Section
				  440.70; and Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.02 - Eligible Individuals

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Eligible individuals are those females of childbearing age and males of any
			 age, including minors who may be sexually active.
(2) In determining recipient eligibility for
			 family planning services, childbearing age is considered to be between 8 and 55
			 years of age.
Authors:
Deborah K. Crawford, Dee
				  Lockridge
Statutory Authority:
State Plan;
				  42 C.F.R. §
											441.20; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.03 - Family Planning Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The following services are covered
			 services when provided by Family Planning providers. Details on criteria
			 required for each type of service is listed in the Family Planning Program
			 Manual.
(a) Initial Visit - an in-depth
			 evaluation of a new patient requiring the establishment of medical records,
			 evaluation of the data obtained, comprehensive history, complete physical
			 examination, appropriate diagnostic lab tests and/or procedures, family
			 planning counseling, and contraceptive management as indicated. Limited to one
			 per provider.
(b) Annual Visit -
			 the reevaluation of an established patient requiring an update to medical
			 records, evaluation of the new data obtained, interim history, complete
			 physical examination, appropriate diagnostic laboratory tests and/or
			 procedures, family planning counseling, and adjustment of contraceptive
			 management as indicated.
(c)
			 Periodic Revisit - a follow-up evaluation of a new or existing family planning
			 condition. Services include a review with update of history, a review of the
			 effectiveness of current contraceptive method with counseling regarding any
			 existing problems and adjustment of contraceptive method to include issuance of
			 supplies as indicated. This visit includes scheduled follow-up, as medically
			 indicated, of chosen birth control method. Limited to no more than four (4)
			 revisits per calendar year.
(d)
			 Home Visit - a brief evaluation by a medical professional in the home of
			 established patients. Services provided include an abbreviated history, weight
			 and blood pressure, and contraceptive counseling with issuance of contraceptive
			 supplies if indicated. A follow-up clinic appointment is scheduled if
			 indicated. Limited to one visit during the 60-day post partum period.
(e) Extended Family Planning Counseling Visit
			 - a separate and distinct counseling service provided at the time of the post
			 partum visit requiring a minimum of 10 minutes of face-to-face contact. Limited
			 to one service during the post examination.
(f) Routine laboratory screening tests such
			 as pregnancy testing, VDRL, gonorrhea culture, Pap smear, hemoglobin or
			 hematocrit and urine check are covered when performed as a part of the
			 initial/annual family planning service.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.04 - Sterilizations

Current through Register Vol. 42, No. 9, June 28, 2024
Surgical procedures for male and female recipients as a method
				of birth control are covered services under the rules and regulations set forth
				below:
(1)
Rules and
			 Regulations Concerning Federal Financial Participation for
			 Sterilization
, effective February 6, 1979, apply in the following
			 instances:
(a) The individual is at least
			 twenty-one (21) years old at the time consent is obtained;
(b) The individual is not a mentally
			 incompetent individual;
(c) The
			 individual has voluntarily given informed consent in accordance with all
			 requirements;
(d) At least 30 days,
			 but not more than 180 days have passed between the date of informed consent and
			 the date of the sterilization, except in the case of premature delivery or
			 emergency abdominal surgery.
(e) An
			 individual may consent to be sterilized at the time of a premature delivery or
			 emergency abdominal surgery if at least 72 hours have passed since informed
			 consent for the sterilization was given. In case of premature delivery, the
			 informed consent must have been given at least 30 days before the expected date
			 of delivery.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.05 - Non-Family Planning Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medically necessary procedures for the
			 treatment of illness or injury which would inevitably have a secondary effect
			 of rendering an individual incapable of reproducing are not classified as
			 family planning procedures. Claims for such procedures are payable based on
			 determination of medical necessity under the same procedures used by the fiscal
			 agent in claims processing.
(2)
			 Sterilization by hysterectomy is not a family planning covered
			 service.
(3) Abortions are not
			 covered as a family planning service. Refer to Chapter 6, Physician's
			 Program.
(4) Hospital charges
			 resulting from recipient deciding not be sterilized after entering the hospital
			 for sterilization purposes cannot be reimbursed as a family planning
			 service.
(5) Removal of IUD because
			 the recipient has a uterine/pelvic infection is not considered a family
			 planning service and is not reimbursable as such.
(6) Colposcopy and biopsy of cervix/vagina
			 performed to identify and treat medical conditions are not considered family
			 planning services.
(7) Medical
			 complications requiring treatment (i.e., perforated bowel) caused by or
			 following a family planning procedure cannot be a covered family planning
			 service.
(8) Any procedure/service
			 provided to a woman who is known to be pregnant cannot be considered a family
			 planning service.
(9) Removal of
			 contraceptive implants due to medical complications are not family planning
			 services; however, the removal may be covered as a medical service through the
			 Physician's Program.
Authors:
Delores Argo, Gail Ellerbrake, Deborah K.
				Crawford, Dee Lockridge
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401,
et
seq
.;
				  441.250, 441.251, 441.252, 441.255; Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.07 - Consent For Health Services For Certain Minors And Others

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Chapter
			 560-X-1,
General,
contains references to the
Code of
			 Ala. 1975
, regarding the rights of minors to consent to any
			 legally authorized medical, dental, or other health services for himself or
			 herself.
(2) Illiterate recipients
			 may give consent for family planning services by making their mark (i.e., X) on
			 the appropriate line. This type of consent for services must be witnessed by an
			 adult with his/her signature after the phrase witnessed by
Authors:
Deborah K. Crawford, Dee
				Lockridge
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-8-1,
et
seq
.; 42 C.F.R.
				  §§401,
et
seq
.,
				  441.20.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.08 - Family Planning Drugs

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The co-payment on prescription drugs, and any indicated refills for Medicaid
			 recipients does
not
apply to drugs and supplies
			 designated as family planning items.
(2) All medically approved family planning
			 drugs and supplies are covered.
Author:
Dee Lockridge
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401,
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.09 - Billing Of Medicaid Recipients By Provider

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Refer to Chapter 1 of this Code for
			 general information regarding providers billing Medicaid recipients.
(2) Medicaid recipients are exempt from
			 CO-payment requirements for family planning services.
Author:
Dee Lockridge
Previous Rule 560-X-14-.09,
Prenatal Services
effective October 1, 1982.
Amended
effective February 9, 1987.
Repealed
effective August 10, 1988.
Amended
Filed
				  July 6, 1995; effective August 12,
				  1995.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §447.15.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.10 - Reports

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid
			 fiscal agent will provide a report on sterilization claims adjudicated to be
			 used for reporting expenditures to the Health Care Financing
			 Administration.
(2) The fiscal
			 agent shall generate a report of Family Planning expenditures to be used for
			 reporting expenditures to the Health Care Financing Administration.
Author:
Dee Lockridge
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401,
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.11 - Family Planning Manual

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 Family Planning Manual detailing the elements of each family planning visit,
			 instructions for completion of forms, and procedures to follow in the
			 administration of the local program are provided to each contracted
			 provider.
(2) Family planning
			 providers will be required to follow procedures outlined in the manual. Failure
			 to do so may result in the recoupment of claims paid to the provider.
Author:
Lockridge
Statutory Authority:
State Plan; 42 C.F.R.,
				  §401,
et
s
eq
.; Title
				  XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.01 - Dental Program - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
(a) The
			 availability of certain dental health care services for eligible children under
			 age 21 is required through the Alabama Medicaid Program as part of the Early
			 and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program.
(b) Certain dental services are provided to
			 pregnant Medicaid eligible individuals over 21.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.02 - Covered Dental Services

Current through Register Vol. 42, No. 9, June 28, 2024
A listing of the covered dental procedures and their
				limitations are included in the Alabama Medicaid Provider Manual, Chapter 13,
				which is provided by the fiscal agent.
Author:
Tina Edwards, Dental
				Program
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.03 - Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Dental care is
			 provided to Medicaid eligible individuals who are under age 21 and are eligible
			 for treatment under the EPSDT Program. Complete details on coverage limitations
			 are contained in Chapter 13 of the Alabama Medicaid Provider Manual. Below are
			 general guidelines.
(2) Dental care
			 under this Program is available either as a result of the EPSDT Referral or as
			 a result of request/need by the recipient. Conditions for each situation are as
			 follows:
(a) EPSDT Referral. If the EPSDT
			 Screening Provider determines a recipient requires dental care or if the
			 recipient is 3 years of age or older and is not currently under the care of a
			 dentist, the recipient must be referred to an enrolled dentist for diagnosis
			 and/or treatment. After the recipient's dental care is initiated, the
			 Consultant's portion of the general referral form must be completed by the
			 dentist and the appropriate copy must be returned to the screening
			 provider.
(b) Recipient Seeking
			 Treatment. If a recipient who has not been screened through the EPSDT Program
			 requests dental care, care may be provided without having an EPSDT Referral. In
			 this situation, after the required care is completed, the dentist should advise
			 the recipient to seek an EPSDT provider to obtain a complete medical
			 assessment.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.04 - Examination

Current through Register Vol. 42, No. 9, June 28, 2024
(Repealed)
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.05 - Prior Authorization

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Certain services require prior authorization. Refer to Chapter 13 of the
			 Alabama Medicaid Provider Manual.
Author:
Sharon Bean, Dental
				Program
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.06 - Participation Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Dental clinics administered by the Alabama Department of Public Health may
			 participate in the program if they are approved by and enter into a vendor
			 agreement (contract) with Medicaid. Providers who meet the Alabama Medicaid
			 Agency enrollment requirements are eligible to participate in the Alabama
			 Medicaid Agency program. An enrollment application may be requested from the
			 Medicaid fiscal agent or downloaded from the Medicaid website at
www.medicaid.alabama.gov
.
			 Completed enrollment applications should be returned to Provider Enrollment at
			 the address indicated on the form. Providers must complete an enrollment or an
			 additional location enrollment application for each practice
			 location.
(2) The Alabama Medicaid
			 Agency will make payment for services to licensed, enrolled dental providers.
			 All providers must meet the requirements to practice dentistry as set forth by
			 the Alabama Dental Practice Act,
Code of Ala. 1975
,
			 Section 34-9-6.
(3) In accordance with federal law, Medicaid
			 providers shall ensure that no person will, on the grounds of race, color,
			 creed, national origin, age or handicap, be denied the benefits of, be excluded
			 from participation in, or be subjected to discrimination under any program of
			 services provided by the Agency. Compliance with Federal Civil Rights and
			 Rehabilitation Acts is required of a provider participating in the Alabama
			 Medicaid Program.
(4) Direct
			 payments are made for allowance charges to providers for covered medical
			 services and supplies furnished eligible Medicaid recipients.
(5) Refer to Chapter 20 concerning third
			 party insurance carriers.
Author:
Charles D. Rush, DMD, Dental
				  Program
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§ 400, 100,
				  441.56.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.07 - Assuring High Quality Care

Current through Register Vol. 42, No. 9, June 28, 2024
Under the provisions of Federal and State law, Medicaid must
				establish a mechanism to ensure that all such care is of good quality and that
				service(s) for which billing was made conforms to that which was done. See
				Chapter 2, Rule No.
				560-X-2-.01(2)(d) and
				(3) for criteria.
Author:
Tina Edwards, Dental
				Program
Previous Rule 560-X-15-.07, Reimbursement, was repealed and
				  Rule 560-X-15-.09, was renumbered as
				  per certification filed May 12, 2004; effective June 16, 2004. No text was
				  changed just renumbered.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.08 - Submitted Charges

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Fees
			 submitted shall not exceed usual, customary, and reasonable rates paid by the
			 non-Medicaid population of the community.
(2) The provider shall not charge Medicaid
			 for services rendered on a no-charge basis to the general public.
(3) If the provider offers discounts or
			 rebate to the general public, a like amount shall be adjusted to the credit of
			 Medicaid on the Medicaid claim form, or such other method as Medicaid may
			 prescribe.
(4) Orthodontic services
			 provided as a continuation of treatment initiated through multidisciplinary
			 clinics administered by Alabama Children's Rehabilitation Service (CRS) or
			 other qualified multidisciplinary clinics are reimbursable if the clinics are
			 approved by and enter into a vendor agreement (contract) with Medicaid. Fees
			 paid for the services shall not exceed the reasonable rates established in the
			 Medicaid statewide profile for medically necessary orthodontic services.
Author:
Tina Edwards, Dental
				Program
Previous Rule 560-X-15-.08, Non-Covered Services -
				  (Including But Not Limited To The Following), was repealed and Rule
				  560-X-15-.10, was renumbered as per certification filed May 12, 2004; effective
				  June 16, 2004.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-15 - DENTAL SERVICES › Section 560-X-15-.09 - Mobile Dental Clinics

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 mobile dental facility or portable dental operation (Mobile Dental Clinic) is
			 any self-contained facility in which dentistry or dental hygiene is practiced
			 which may be moved, towed, or transported from one location to
			 another.
(2) Mobile Dental Clinics
			 shall comply with all Medicaid rules and regulations as set forth in the State
			 Plan, Alabama Medicaid Administrative Code, Code of Federal Regulations and
			 applicable Medicaid billing manuals.
(3) In order to enroll as a Mobile Dental
			 Clinic, an operator shall:
(a) obtain a
			 certificate of registration issued by the Board of Dental Examiners (the
			 Board); and
(b) complete an Alabama
			 Medicaid Provider Enrollment application.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.01 - Pharmacy Services - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The State Plan provides for the payment
			 of certain legend and non-legend drugs prescribed by Doctors of Medicine, and
			 other practitioners including, but not limited to nurse practitioners, dentists
			 and physician assistants who are legally authorized to prescribe these drugs
			 and when dispensed and/or administered by a licensed pharmacist or licensed
			 authorized physician in accordance with state and federal laws.
(2) In accordance with the Medicaid Drug
			 Amendments contained in the Omnibus Budget Reconciliation Act of 1990,
			 (Public Law
			 101-508), the following shall apply: with the
			 exception of allowable published exclusions, only those drugs manufactured by
			 companies having signed rebate agreements with the Secretary of Health and
			 Human Services are compensable. The exclusions are:
(a) DESI and IRS drugs which may be
			 restricted in accordance with Section 1927(d)(2) of the Social Security
			 Act.
(b) Agents when used for
			 anorexia, weight loss, or weight gain except for those specified by the Alabama
			 Medicaid Agency. Selective covered outpatient drugs for all eligible
			 beneficiaries will be covered as listed on the state's website.
(c) Agents when used to promote fertility
			 except for those specified by the Alabama Medicaid Agency. Selective covered
			 outpatient drugs for all eligible beneficiaries will be covered as listed on
			 the state's website.
(d) Agents
			 when used for the symptomatic relief of cough and cold.
(e) Prescription vitamin and mineral
			 products, except prenatal vitamins and fluoride preparations and others as
			 specified by the Alabama Medicaid Agency. Selective covered outpatient drugs
			 for all eligible beneficiaries will be covered as listed on the state's
			 website.
(f) Selective
			 non-prescription covered outpatient drugs for all eligible beneficiaries will
			 be covered as listed on the state's website.
(g) Covered outpatient drugs which the
			 manufacturer seeks to require as a condition of sale that associated test or
			 monitoring services be purchased exclusively from the manufacturer or its
			 designee.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.02 - Requirements For Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A pharmacy must be operating under a
			 permit or license to dispense drugs as issued by the Alabama State Board of
			 Pharmacy or appropriate authority in the state where the service is
			 rendered.
(2) A pharmacy applicant
			 must submit and have approved a pharmacy agreement signed by owner, authorized
			 representative, pharmacist, or dispensing physician.
(3) Pharmacies and dispensing physicians must
			 agree to abide by the rules and regulations of the program; must agree that
			 payment for covered services will be accepted as payment in full.
(4) Pharmacy providers must agree to abide by
			 the rules and regulations of third party billing procedures (See Chapter 20
			 Third Party).
(5) Pharmacy
			 providers must agree to keep records, including prescriptions, to fully
			 disclose extent of services rendered. Records, including purchase invoices,
			 recipient signature logs, etc., should be maintained within the State of
			 Alabama. At a minimum the following records and/or documentation must be
			 available for examination:
(1) prescription
			 files and
(2) invoices.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.03 - Drugs Dispensed By A Physician

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A physician may dispense drugs under the
			 Alabama Medicaid Program if he has a current agreement to dispense drugs with
			 the Alabama Medicaid Agency.
(2)
			 Dispensing physicians are enrolled as drug providers in the pharmacy program
			 only where adequate pharmacy services are not available.
(3) A dispensing physician may be enrolled as
			 a drug provider in the Pharmacy Program only if his practice is located more
			 than 50 miles or 50 minutes from the nearest Medicaid-enrolled pharmacy.
Author:
Lynn Sharp, Associate Director, Policy
				Development Unit
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§401, et
				  seq., 447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.04 - Pharmacy Services In Hospitals

Current through Register Vol. 42, No. 9, June 28, 2024
Hospitals. Payment for drugs for inpatient hospital care under
				the Title XIX Program is based on reasonable cost which allows payment (per
				diem) not to exceed Medicare levels.
Author:
Larry A. Tatum
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§401, et
				  seq., 447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.05 - Long Term Care Facilities

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
(a) The
			 nursing facility must meet the State and Federal Standards and the Title XIX
			 rules and regulations for pharmacy services.
(b) The payment limit for prescription drugs
			 dispensed to patients confined in the Long Term Care facilities must not exceed
			 the upper limits as contained in Rule
			 560-X-16-.06.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.06 - Reimbursement For Covered Drugs And Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid pays for certain legend and
			 non-legend drugs prescribed by practitioners legally licensed by the state of
			 Alabama to prescribe the drugs authorized under the program and dispensed
			 and/or administered by a licensed pharmacist or licensed authorized physician
			 in accordance with state and federal laws as stated in Rule
			 560-X-16-.01.
(a) Notwithstanding specific reimbursement
			 described in this section, payment for covered outpatient drugs (both brand and
			 generic) dispensed by a:
1. Retail community
			 pharmacy
2. Specialty
			 pharmacy
3. Long-term care or
			 institutional pharmacy (when not included as an inpatient stay)
4. 340B eligible entities (including 340B
			 contract pharmacies) not listed on the U.S. Department of Health and Human
			 Services Health Resources & Service Administration (HRSA) 340B Drug Pricing
			 Program Database
5. Indian Health
			 Service, Tribal and Urban Indian pharmacy
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.07 - Out-Of-State Pharmacies

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Under
			 State and Federal regulations, a pharmacy must sign an agreement with Alabama
			 Medicaid Agency. However, when a recipient is in another state and requires
			 service, the following procedure has been adopted.
(2) Pharmacies Bordering Alabama
(a) Pharmacies bordering Alabama may
			 participate in the Alabama Medicaid Program by completing an application for
			 out-of-state pharmacies, and upon certification of the State Board of Pharmacy
			 in that state that the pharmacy is registered and has been issued a
			 permit.
(b) The pharmacy must then
			 sign a Pharmacy Vendor Agreement with Alabama Medicaid Agency and agree to
			 abide by the State pharmacy provider tax law.
(c) Pharmacies bordering Alabama are defined
			 as those pharmacies located not more than 30 miles from the border of
			 Alabama.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.08 - Injections

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Injectable
			 drugs administered by physicians and outpatient hospitals are
			 allowable.
(2) Claims for
			 injectable medication administered by the physician should be made on the
			 physician's claim form and submitted to the fiscal agent for payment.
(3) Claims for injectable medications
			 administered in an outpatient hospital should be made on the UB-8 92 and
			 submitted to the fiscal agent by the outpatient facility.
(4) For information concerning injectable
			 medications administered in renal dialysis facilities, please refer to Rule
			 560-X-24-.05.
(5) The Medicaid Pharmacy Program will review
			 and have final approval of injectable medications and the rate of reimbursement
			 that is billed to the fiscal agent by the physician or outpatient hospital.
Authors:
Sam T. Hardin, Janet B. Young, Larry A.
				Tatum
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§401, et
				  seq., 447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).
The
				amended version of this section by
				Alabama
				Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024,
				filed May 20, 2024 is not yet
				available.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.09 - Prior Authorization And Preferred Drug List. (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Louise Jones, Associate Director, Program
				Management Unit
Statutory Authority:
State Plan Attachment 3.1-A
				  and 4.18-B; Title XIX, Social Security Act; 42 C.F.R. Section 447.331 and
				  Section 401, et seq.; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508)
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.10 - Cost-Sharing

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid
			 recipients are required to pay the designated CO-pay amount for each
			 prescription filled and each refill.
(2) The cost-sharing fee does not apply to
			 family planning drugs and supplies, or to drugs prescribed for recipients under
			 18 years of age, recipients who are in a nursing facility or services furnished
			 to pregnant women.
(3) When a
			 pharmacy fills a prescription for a Medicaid recipient under eighteen (18)
			 years of age, the pharmacist must verify the age of the individual by checking
			 the date of birth on the eligibility card. CO-payment on drug claims for family
			 planning drugs and supplies will be determined by the national drug code
			 numbers. No further indication is necessary on the claim form for a Medicaid
			 recipient under eighteen (18) years of age or for claims submitted for family
			 planning drugs and supplies.
(4)
			 When a pharmacy fills a prescription for a Medicaid recipient residing in a
			 nursing facility in Alabama the pharmacy provider must indicate a large "I" in
			 the CO-pay block on the Medicaid Pharmacy Claim Form or appropriate space for
			 other approved drug claim submission methods (i.e., continuous feed form,
			 tape-to-tape, etc.).
(5) When a
			 pharmacist dispenses a prescription for a Medicaid eligible woman on which the
			 physician has written PREGNANT, the pharmacist shall place a "p" in the CO-pay
			 block on the Medicaid Pharmacy Claim Form or appropriate space for other
			 approved drug claim submission methods (i.e., continuous feed form,
			 tape-to-tape, etc.).
(6) Copayment
			 Collection: Copayment is based on drug ingredient cost of the dispensed
			 prescription. The schedule is furnished by the Medicaid Agency Pharmacy
			 Program.
(7) A provider may not
			 deny services to any eligible individual on account of the individual's
			 inability to pay CO-payment amount.
Authors:
Sam T. Hardin; Larry A.
				Tatum
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act;
				  42 C.F.R.
				  §§
											447.15,
				  447.53,
				  447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508.).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.11 - Pharmacist Consultant Services In Nursing Facilities

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Federal regulations require pharmacy
			 consultant services in nursing facilities as a condition of participation. This
			 requirement recognizes the professional status of the pharmacist and makes him
			 an integral part of the health care team.
(2) The requirement that there be pharmacy
			 consultant services is imposed on the facility as a condition of participation.
			 Thus, compensation is appropriately an arrangement between the facility and the
			 consultant.
Author:
Larry A. Tatum
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act;
				  42 C.F.R.
				  §§447.15,
				  447.53,
				  447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).