reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.08 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The rehabilitative services provider shall make all reasonable efforts to
			 determine if there is a liable third party source, including Medicare, and in
			 the case of liable third party source, utilize that source for payments and
			 benefits prior to applying for Medicaid payments.
(2) Third party payments received after
			 billing Medicaid for service for a Medicaid recipient shall be returned to the
			 Alabama Medicaid Agency.
Author:
Lynn Sharp
Statutory Authority:
42 C.F.R.
				  §433.135; Social Security Act, Title
				  XIX; State Plan for Medical Assistance, Attachment 4.19-B.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.09 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Payment made by Medicaid to a rehabilitative services provider shall be
			 considered to be payment in full for covered services rendered.
(2) No Medicaid recipient shall be billed for
			 covered Medicaid services in part or in full for those services rendered,
			 billed, and paid to the provider by the Medicaid fiscal agent. These services
			 are exempt from copays.
(3) No
			 person or entity, except a liable third party source, shall be billed for
			 covered Medicaid services in part or in full.
Author:
Lynn Sharp, Associate Director,
				Institutional Services
Statutory Authority:
42 C.F.R.
				  §447.15; Social Security Act, Title XIX;
				  State Plan for Medical Assistance, Attachment 3.1-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.10 - Confidentiality

Current through Register Vol. 42, No. 9, June 28, 2024
A rehabilitative services provider shall not use or disclose,
				except to duly authorized representatives of federal or state agencies, any
				information concerning a recipient, except upon the written consent of the
				recipient, his attorney, his guardian, or upon subpoena from a court of
				appropriate jurisdiction.
Author:
Lynn Sharp
Statutory Authority:
42 C.F.R.
				  §431.306; Social Security Act, Title
				  XIX; State Plan for Medical Assistance, Attachment 3.1-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.11 - Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 rehabilitative services provider shall make available to the Alabama Medicaid
			 Agency at no charge all information regarding claims submitted and paid for
			 services provided eligible recipients and shall permit access to all records
			 and facilities for the purpose of claims audit, program monitoring, and
			 utilization review by duly authorized representatives of federal and state
			 agencies. Complete and accurate rehabilitative and fiscal records which fully
			 disclose the extent of the service shall be maintained by the provider. Said
			 records shall be retained for a period of three years plus the current year
			 and/or until completion of any audit.
(2) Documentation of Medicaid clients'
			 signatures may be entered on a sign-in log, service receipt or any other record
			 that can be used to indicate the recipient 's signature and the date of
			 service. Treatment Plan Review, ACT, PACT, Behavioral Health Placement
			 Assessment, crisis intervention, psychoeducational services, Mental Health Care
			 Coordination, and any non-face to face services that can be provided by
			 telephone do not require recipient signatures.
(3) Documentation failing to meet the minimum
			 standards noted in the Medicaid Provider Manual, Rehabilitation Services,
			 Chapter 105, will result in recoupment of payments.
Author:
Karen M. Smith, Associate Director,
				  Mental Health Programs
Statutory Authority:
42 C.F.R. §
											431.17; Social Security Act, Title XIX; State
				  Plan for Medical Assistance, Attachment 3.1-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Federally
			 Qualified Health Centers (FQHCS) are defined as health care centers which meet
			 one of the following requirements:
(a)
			 receives a grant under Section 329, 330, 340, or 340A of the Public Health
			 Services Act;
(b) meets the
			 requirements for receiving such a grant as determined by the Secretary based on
			 the recommendations of the Health Resources and Services Administration within
			 the Public Health Service;
(c)
			 qualifies through waivers of the requirements described above as determined by
			 the secretary for good cause; or
(d) functions as outpatient health programs
			 or facilities operated by a tribe or tribal organization under the Indian
			 Self-Determination Act ( Public Law 93-638).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.02 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order to
			 participate in the Title XIX Medicaid Program and to receive Medicaid payments,
			 a FQHC must:
(a) Submit a complete enrollment
			 packet to the Fiscal Agent, including a list of all satellite centers and
			 addresses.
(b) Submit appropriate
			 documentation from the Department of Health and Human Services, Public Health
			 Services, that the FQHC meets one of the requirements as stated in Rule No.
			 560-X-48-.01(1).
(c) Submit a budgeted cost report for its
			 initial cost reporting period and thereafter when there is a change in the
			 provider's scope of practice.
(d)
			 Federally Funded Health Centers which are Medicare certified must also submit
			 copies of Medicare certification.
(e) Certify compliance with Title VI of the
			 Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and
			 with the Age Discrimination Act of 1975.
(f) Be in compliance with the Clinical
			 Laboratory Improvement Amendments of 1988 (CLIA), for all laboratory testing
			 sites.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.03 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Federally
			 Qualified Health Centers (FQHCs) will be reimbursed under a prospective payment
			 system as described in Chapter 56 of the Administrative Code.
(2) Inpatient and outpatient surgery is
			 reimbursed as fee for service and is subject to the routine benefit limitations
			 and policies as stated in Chapter 6 of the Administrative Code.
(3) FQHCs that are enrolled as Pharmacy
			 providers (take home drugs) are reimbursed in accordance with routine benefit
			 limitations and policies as stated in Chapter 16 of the Administrative
			 Code.
Author:
Calvin Binion, Associate Director,
				  State, Agency,
Vision, & Clinic Services
Statutory Authority:
State Plan, Attachment
				  4.19-B; Title XIX,
Social Security Act; 42 C.F.R. §§ 413,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.04 - Change Of Ownership

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid must be notified within thirty (30) days of the date of a FQHC
			 ownership change. The existing contract will be automatically assigned to the
			 new owner, and the new owner shall then be required to execute a new contract
			 with Medicaid as soon as possible after the change of ownership, but in no
			 event, later than thirty (30) days after notification of grant disposition. If
			 the new owner fails to execute a contract with Medicaid within this time
			 period, the contract shall terminate.
(2) The new owner may choose to accept the
			 established reimbursement rate or submit a budgeted cost report to the Medicaid
			 Agency. Refer to Chapter 56 of the Administrative Code for details.
Author:
Vicki Huff
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§431.107,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.05 - Medicare Deductible And Coinsurance

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Coinsurance will be paid up to the
			 established Medicaid reimbursement rate for each FQHC.
Author:
Vicki Huff
Statutory Authority:
State Plan, Attachments
				  3.1-A, 3.2-A; Title XIX, Social Security Act;
				  42 C.F.R.
				  §405.2462(3).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.06 - Copayment (Cost-Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid and Medicare/Medicaid related recipients are required to pay and the
			 FQHCs are required to collect the established copayment amount for each medical
			 encounter.
(2) The cost-sharing
			 amount does not apply to services provided for the following:
(a) Recipients under 18 years of
			 age
(b) Emergencies
(c) Pregnancy
(d) Family Planning
(e) Nursing home residents
(f) American Indians
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.07 - Billing Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 provider agrees to accept as payment in full the amount paid by Medicaid, plus
			 any copayment amount required to be paid by the recipient for covered items,
			 and further agrees to make no additional charge or charges for covered items to
			 the recipient.
(2) Billing
			 recipients for services not paid by Medicaid due to provider correctable errors
			 on submitted claims or the untimely filing of claims is not
			 permissible.
(3) A provider may
			 bill the recipient for the copayment amount, for noncovered Medicaid services,
			 and for services provided to a recipient who has exhausted his/her benefit
			 limits.
Author:
Vicki Huff
Statutory Authority:
42 C.F.R.
				  §447.15; State Plan, Attachment 4.18-A;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-48 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 560-X-48-.08 - Patient's Signature

Current through Register Vol. 42, No. 9, June 28, 2024
(1) While
			 a recipient signature is not required on individual claim forms, all providers
			 must obtain a signature to be kept on file, e.g., release forms or
			 sign-in-sheets, as verification that the recipient was present on the date of
			 service for which the provider seeks payment. Exceptions to the recipient
			 signature are listed below.
(a) Illiterate
			 recipients may make their mark, for example, "X" witnessed by someone with
			 their dated signature after the phrase "witnessed by."
(b) Interested parties other than the FQHC
			 may sign claim forms for recipients who are not competent to sign because of
			 age, mental, or physical impairment.
(c) For services rendered in a licensed
			 facility setting, other than the provider's office, the recipient's signature
			 on file in the facility's record is acceptable.
(d) When payment has been made on claims for
			 which the recipient signature is not available and one of the above exceptions
			 is not applicable, the funds paid to the provider covering this claim will be
			 recovered.
Author:
Vicki Huff
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nurse
			 practitioners who are certified by the appropriate national organization as a
			 family nurse practitioner, pediatric nurse practitioner, women's health care
			 practitioner, or neonatal nurse practitioner are eligible to participate in the
			 Alabama Medicaid Program.
(2) A
			 nurse practitioner who is employed by and reimbursed by a facility that
			 receives reimbursement from the Alabama Medicaid Program for services provided
			 by the nurse practitioner (i.e. hospital, rural health clinic, etc.) may not
			 enroll, if their services are already being paid through that facility's cost
			 report.
Author:
Elizabeth Huckabee, Associate Director,
				  Medical Services
Statutory Authority:
State Plan; Attachment
				  3.1A, Section 6405 Omnibus Budget Reconciliation Act of 1989 (Public
				  Law 101-239); Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.02 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order to
			 participate in the Alabama Medicaid Program, a nurse practitioner must complete
			 an enrollment application which is obtained from the Agency's Fiscal
			 Agent.
(2) The completed
			 application must be returned to the Fiscal Agent for processing along with the
			 following information:
(a) Proof of current
			 Alabama registered nurse licensure card.
(b) Copy of current certification as a
			 certified registered nurse practitioner in the appropriate area of the
			 practice, family, pediatric or neonatal from a national certifying agency
			 recognized by Medicaid.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.03 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nurse
			 practitioners may only bill and be directly reimbursed for those services that
			 are listed in the provider billing manual.
(2) In order for services to be covered,
			 nurse practitioners must be under the supervision of a licensed physician.
Author:
Debra Moore
Statutory Authority:
State Plan, Attachment
				  3.1-A, Section 6405 Omnibus Budget Reconciliation Act of 1989 (Public
				  Law 101-239); Title XIX Social Security Act;
				  42 C.F.R.
				  §431.51;
Code of Ala.
				  1975
, §
										34-21-1.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.04 - Limitations On Services

Current through Register Vol. 42, No. 9, June 28, 2024
Limitations on services provided by nurse practitioners are the
				same as those for a physician and will be counted in the physician visit quota.
				See Rule 560-X-6-.14.
Author:
Debra Moore
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, Attachment 3.1-A,
				  42 C.F.R.
				  §440.230.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.05 - Billing Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
A nurse practitioner may bill Medicaid recipients for the copay
				amount, for Medicaid noncovered services and for services provided to a
				recipient who has exhausted his/her yearly limitations. Conditional collections
				to be refunded post payment by Medicaid and partial charges for balance of
				Medicaid allowed reimbursement are not permissible. Billing recipients for
				services not paid by Medicaid due to provider correctable errors on claims
				submission or untimely filing is not permissible.
Author:
Debra Moore
Statutory Authority:
42 C.F.R.
				  §447.15; State Plan, Attachment 4.18A;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.06 - Third Party Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
Nurse practitioners are required to identify recipients who are
				covered by third party resources and to obtain payment from those resources in
				accordance with Chapter 20 of the
Medicaid Administrative
				Code.
Author:
Debra Moore
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §1902(a)(25), 401, Social Security Act;
Code of
				  Ala. 1975
, §
										22-6-6.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-49 - CERTIFIED NURSE PRACTITIONER PROGRAM › Section 560-X-49-.07 - Copayment. (Cost-Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid recipients are required to pay, and nurse practitioners are required
			 to collect, the designated copayment amount on each visit. The copayment amount
			 does not apply to services provided for the following:
(a) Pregnancy
(b) Nursing home residents
(c) Inpatient hospital visits
(d) Recipients under 18 years of
			 age
(e) Surgery fees
(f) Physical therapy
(g) Family planning
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Preventive
			 Health Education Services are services provided by a physician or other
			 licensed practitioner of the healing arts (within the scope of practice), or by
			 other qualified providers, which are designed to prevent disease, disability,
			 or other health conditions or their progression; to prolong life; and to
			 promote physical and mental health and efficiency.
(a) Prenatal and Pregnancy Prevention
			 Education.
1. Prenatal Education consists of
			 a series of classes which teach pregnant women about the process of pregnancy,
			 healthy lifestyles, and prenatal care. These services are covered for Medicaid
			 eligible pregnant women only.
2.
			 Adolescent Pregnancy Prevention Education consists of a series of classes which
			 teach nonpregnant adolescents about consequences of unintended pregnancy,
			 methods of family planning, and decision making skills. These services are
			 covered for all Medicaid eligible non-pregnant individuals of childbearing age
			 who are eligible for services under the Early and Periodic Screening, Diagnosis
			 and Treatment (EPSDT) Program, regardless of sex or previous
			 pregnancy.
3. The purpose of these
			 services is to reduce unintended adolescent pregnancies; decrease the rate of
			 infant mortality; decrease the incidence of maternal complications, low birth
			 weight babies, and other factors associated with the illness, disability or
			 handicap, and deaths among infants and small children.
Author:
Dee Lockridge
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.02 - Provider Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Eligible persons may receive preventive health education services through
			 providers who are under contractual agreement with Medicaid to provide these
			 services.
(2) Providers include
			 clinics or other organizations which utilize licensed practitioners of the
			 healing arts within the scope of practice under state law and/or federal
			 regulations as described in section
			 560-X-50-.02(4).
(3) In cases where there is no licensing
			 board for the instructors listed in
			 560-X-50-.02(4),
			 the instructor must either work under the personal supervision of a physician
			 or work in a facility that provides the services under the direction of a
			 physician, such as in a clinic or outpatient hospital. "Under the supervision
			 of" denotes that the physician is familiar with the Medicaid approved
			 preventive information being presented to recipients and is available to the
			 preventive health instructor by telephone, fax, or in person at the time the
			 instructor is providing the preventive health education service. Providers must
			 supply Medicaid with the name and resume of the physician supervising the
			 instructor and maintain documentation sufficient to demonstrate their
			 availability to the instructors.
(4) Professional instructors of the provider
			 must meet the following qualifications (according to specialty) as listed
			 below:
(a) A health educator must have
			 graduated from an accredited four-year college or university with major course
			 work in public health, health education, community health, or health/physical
			 education/recreation with a concentration in health.
(b) A social worker must be licensed by the
			 Alabama Board of Social Work Examiners.
(c) A registered nurse must be licensed by
			 the Alabama Board of Nursing as a Registered Nurse.
(d) A nurse practitioner must have
			 successfully completed a supplemental program in an area of specialization, and
			 must be licensed by the Alabama Board of Nursing as a Registered Nurse and be
			 issued a certificate of approval to practice as a Certified Registered Nurse
			 Practitioner in the area of specialization.
(e) A nurse midwife must be licensed by the
			 Alabama Board of Nursing as a Registered Nurse and a Certified Nurse
			 Midwife.
(f) A nutritionist must be
			 licensed as a Registered Dietitian by the American Dietetic
			 Association.
(g) A nutritionist
			 associate must have graduated from a four-year college or university with major
			 course work in nutrition or dietetics.
(h) A professional counselor must be licensed
			 by the Alabama Board of Examiners in Counseling.
(i) A health instructor must have a
			 bachelor's degree with extensive experience in providing instruction in
			 preventive health education supplemented by a training program approved by the
			 Alabama Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.03 - Recipient Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Eligibility of recipients for preventive health education services varies
			 according to the type of service being provided.
(a) Prenatal Education services are limited
			 to those Medicaid eligible females who are pregnant (as evidenced by physical
			 examination or a positive pregnancy test).
(b) Adolescent Pregnancy Prevention Education
			 is available to all Medicaid eligible non-pregnant individuals of childbearing
			 age who are eligible for services under the Early and Periodic Screening,
			 Diagnosis and Treatment (EPSDT) Program, regardless of sex or previous
			 pregnancy.
Author:
Dee Lockridge
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.04 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Preventive Health Education Services do not include services for which payment
			 shall be made under other provisions.
(2) Preventive Health Education Services are
			 covered when provided by a Medicaid enrolled preventive health education
			 service provider.
(a) Prenatal Education
			 visits are limited to 12 visits per recipient during each two-year period
			 beginning with the first date of service.
(b) Adolescent Pregnancy Prevention Education
			 visits are unlimited.
Author:
Dee Lockridge
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.05 - Copayment. (Cost Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
Medicaid recipients shall not be required to pay and providers
				may not collect a copayment for any of these services. Refer to Rule
				560-X-1-.25 for copay
				information.
Author:
Dee Lockridge
Statutory Authority:
State Plan for Medical
				  Assistance, Attachment 4.19B, page 12; Title XIX, Social Security Act;
				  42
				  C.F.R. §440.130.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.06 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 provider shall not charge Medicaid for services rendered on a no-cost basis to
			 the general public except where such services are provided pursuant to Section
			 1903(c) of the Social Security Act or such services are provided by Title V
			 Grantee pursuant to Section 1902(a)(11)(B) of the Social Security
			 Act.
(2) Eligible Medicaid
			 recipients are not to be billed for covered services once the recipient has
			 been accepted as a Medicaid patient.
(3) It is the responsibility of the provider
			 to follow-up with the fiscal agent or Medicaid on denied claims.
(4) The recipient is not responsible for any
			 difference between billed charges and Medicaid allowed charges.
(5) The recipient may be billed for
			 noncovered services.
(6) Preventive
			 Health Education Services shall be billed on the HCFA 1500 claim form,
			 utilizing locally assigned procedure codes. The appropriate ICD-9-CM diagnosis
			 code shall be indicated on the claim form.
(7) Reimbursement to governmental agency
			 providers will be based on a negotiated rate not to exceed actual costs as
			 would occur through the efficient and economic operation by the provider.
			 Reimbursement to nongovernmental providers will be based on Medicaid's
			 established fee schedule, not to exceed the prevailing rate in the locality for
			 comparable services offered under comparable conditions.
(8) Claims submitted for which there is no
			 documentation, or for charges in excess or in violation of the provider's
			 contractual agreement, are subject to recoupment by the agency, and to referral
			 for investigation and possible prosecution for fraud.
Author:
Dee Lockridge
Statutory Authority:
State Plan for Medical
				  Assistance; Title XIX, Social Security Act;
				  42 C.F.R.
				  §447.15.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.07 - Confidentiality

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The provider
			 shall not disclose, except to duly authorized representatives of federal or
			 state agencies, any information concerning an eligible recipient except upon
			 written consent of the recipient, his attorney, or his/her guardian, or upon
			 subpoena from a court of appropriate jurisdiction. See Rule 560-X-30-.05, Third
			 Party, for additional requirements regarding release of information.
(2) The provider must safeguard clinical
			 records against loss, destruction, and/or unauthorized use.
Author:
Dee Lockridge
Statutory Authority:
State Plan for Medical
				  Assistance; Title XIX, Social Security Act;
				  42 C.F.R.
				  §431.306.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-50 - PREVENTIVE HEALTH EDUCATION › Section 560-X-50-.08 - Maintenance Of Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 provider shall make available to the Alabama Medicaid Agency at no charge all
			 information regarding claims for services provided to eligible recipients. The
			 provider shall permit access to all records and facilities for the purpose of
			 claims audit, program monitoring, and utilization review by duly authorized
			 representatives of federal and state agencies. Complete and accurate fiscal
			 records which fully disclose the extent and cost of services shall be
			 maintained by the provider.
(2) The
			 provider shall maintain documentation of Medicaid clients' signatures. These
			 signatures may be entered on a sign-in log, service receipt, or any other
			 record that can be used to indicate the clients' signatures and dates of
			 service.
(3) All records shall be
			 maintained for a period of at least three (3) years plus the current fiscal
			 year. If audit, litigation, or other legal action by or on behalf of the state
			 or federal government has begun but is not completed at the end of the three
			 (3) year period, or if audit findings, litigation, or other legal action have
			 not been resolved at the end of the three (3) year period, the records shall be
			 retained until resolution and finality thereof. Such records shall be kept in a
			 form that will facilitate the establishment of a complete audit trail in the
			 event such items are audited.
Author:
Dee Lockridge
Statutory Authority:
State Plan for Medical
				  Assistance; Title XIX Social Security Act;
				  42 C.F.R.
				  §§431.17,
				  433.32.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.01 - Hospice Care - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Hospice care services are available if medically necessary for full Medicaid
			 eligible recipients certified as being terminally ill. Medical certification is
			 required by the individual's attending physician; however, if the recipient
			 does not have a primary attending physician, certification may be given by the
			 Hospice Team physician or the hospice medical director. Certification of the
			 terminal illness of an individual who elects hospice shall be based on the
			 attending physician, hospice team physician, or hospice medical director's
			 clinical judgment regarding the normal course of the individual's illness.
			 Certification of terminal illness must include specific findings and other
			 medical documentation including, but not limited to, medical records, lab
			 x-rays, pathology reports, etc. Hospice care means services which are necessary
			 for the palliation or management of the terminal illness and related
			 conditions.
(2) Alabama Medicaid
			 Hospice Care services are subject to Medicare special election periods
			 applicable to hospice care.
Medicaid will utilize the most recent benefit periods
				established by the Medicare Program.
Author:
Felicia Fisher, Administrator, LTC
				  Provider/Recipient Services Unit, Long Term Care Division
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §
											418.20; State Medicaid Manual; State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.02 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Hospice
means a public agency or private organization or a
			 subdivision of either that is primarily engaged in providing care to terminally
			 ill individuals, meets the Medicare conditions of participation for hospices
			 and has a valid Medicaid provider agreement.
(2)
Attending physician
means a
			 doctor of medicine or osteopathy who is identified by the individual at the
			 time he or she elects to receive hospice care as having the most significant
			 role in the determination and delivery of the individual's medical
			 care.
(3)
Election
			 statement
means a written statement electing hospice care filed by a
			 recipient, or his representative, with a hospice.
(4) An
election period
is a
			 predetermined timeframe for which an individual may elect to receive Medicaid
			 coverage of hospice care during the individual's lifetime. Election periods
			 consist of:
(a) An initial 90-day
			 period.
(b) A subsequent 90-day
			 period.
(c) A subsequent 60-day
			 period.
(d) Unlimited subsequent
			 extensions of 60-day periods during the individual's lifetime.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.03 - Provider Eligibility And Certification Of Terminal Illness Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A provider of
			 hospice services shall meet the definition of hospice in Rule No.
			 560-X-51-.02(1).
(2) The provider shall participate in Title
			 XVIII (Medicare) and shall be certified under Medicare standards.
(3) Within two days after hospice care is
			 initiated, the provider shall obtain terminally ill certification statements on
			 all recipients and shall maintain them for the duration of hospice care. If the
			 hospice does not obtain a written certification as described, verbal
			 certification may be obtained, but written certification must be obtained no
			 later than 30 days after care is initiated. For each subsequent period, the
			 hospice may submit written certification as early as 15 days before the
			 subsequent period begins, but in no event may the written certification be
			 submitted later than two calendar days after the beginning of a subsequent
			 period.
The hospice must not recertify an individual who reaches a point
			 of stability and is no longer considered terminally ill. The individual must
			 return to traditional Medicaid benefits.
(4) All services shall be provided under a
			 written plan of care established and maintained for each individual admitted to
			 a hospice program, and the care provided shall be in accordance with the
			 plan.
(5) In addition to the
			 completion of a provider enrollment agreement, a hospice must also submit the
			 following information to the Alabama Medicaid Agency or its designee:
(a) A letter from the State licensing unit
			 showing the permit number and effective date of permit.
(b) A document from the licensing unit
			 showing that the hospice meets requirements for the Medicare program.
(c) A signed document indicating that the
			 hospice is in compliance with Title VI of the Civil Rights Act of 1964, Section
			 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of
			 1975.
(d) A copy of the written
			 notification to the hospice from the Medicare fiscal intermediary showing the
			 approved reimbursement rate, the fiscal year end, and the Medicare provider
			 number.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.05 - Election Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) If an
			 individual meets the eligibility requirements for hospice care, he or she must
			 file a written election certification statement (Medicaid Hospice Election and
			 Physician's Certification, Form 165) with a particular hospice within two
			 calendar days after hospice care begins. An election may also be filed by a
			 representative as defined in Rule
			 560-X-51-.02(9).
(2) An election to receive hospice care will
			 be considered to continue through the initial election period and through one
			 subsequent election period without a break in care as long as the individual:
(a) Remains in the care of a
			 hospice.
(b) Does not revoke the
			 election provisions under Rule
			 560-X-51-.07.
(c) Remains eligible for full Medicaid
			 benefits in Alabama.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.06 - Waiver Of Other Benefits

Current through Register Vol. 42, No. 9, June 28, 2024
An individual shall waive all rights to Medicaid services that
				are covered under Medicare for the duration of the election of hospice care for
				the following services:
(1) Hospice
			 care provided by a hospice other than the hospice designated by the recipient,
			 unless provided under arrangements made by the designated hospice.
(2) Any Medicaid services that are related to
			 the treatment of the terminal condition for which hospice care was elected or a
			 related condition or services that are equivalent to hospice care except for
			 services:
(a) Provided by the designated
			 hospice.
(b) Provided by another
			 hospice under arrangements made by the designated hospice.
(c) Provided by the individual's attending
			 physician if that physician is not an employee of the designated hospice and
			 does not receive compensation from the hospice for those services.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.07 - Election Revocation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 individual or representative may revoke the individual's election of hospice
			 care at any time during an election period. If an individual revokes the
			 hospice election, any days remaining in that election period are
			 forfeited.
(2) The hospice shall
			 provide the Alabama Medicaid Hospice Care Program a copy of the form used to
			 revoke the individual's election for Medicaid coverage of hospice care for the
			 remainder of that election period.
(3) Upon revocation of the election of
			 Medicaid coverage of hospice care, an otherwise Medicaid eligible recipient
			 resumes Medicaid coverage of the benefits waived when hospice care was elected.
Author:
Theresa D. Richburg
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §418.28; State Medicaid Manual; State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.08 - Change Of Hospice

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 individual or representative may change, once in each election period, the
			 designation of the particular hospice from which hospice care will be received.
			 The change of the designated hospice is not a revocation of the election for
			 the period in which it is made.
(2)
			 To change the designation of hospice provider, the individual or representative
			 must file a signed statement that includes the following information:
(a) The name of the hospice from which care
			 has been received.
(b) The name of
			 the hospice from which the individual plans to receive care.
(c) The effective date of the change.
A copy of this statement must be provided to the hospice
				provider and to the Alabama Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.09 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 following services are covered hospice services when provided by qualified
			 personnel:
(a) Nursing care
(b) Medical social services
(c) Physician services
(d) Counseling services
(e) Short-term inpatient care
(f) and biologicals Medical appliances and
			 supplies, including drugs
(g) Home
			 health aide services and homemaker services
(h) Physical therapy, occupational therapy,
			 and speech-language pathology
(i)
			 Nursing home room and board
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.11 - Reimbursement For Physician Services

Current through Register Vol. 42, No. 9, June 28, 2024
The basic payment rates for hospice care are designed to
				reimburse the hospice for the costs of all covered services related to the
				treatment of the beneficiary's terminal illness, including the administrative
				and general supervisory activities performed by physicians who are employees of
				or working under arrangements made with the hospice. Group activities, which
				include participation in the establishment of plans of care, supervision of
				care and services, periodic review and updating of plans of care, and
				establishment of governing policies are included in the reimbursement rates for
				routine home care, continuous home care, and inpatient respite care. Direct
				patient care services by physicians are reimbursed as follows:
(1) Payment for direct patient care services
			 rendered by physicians employed by or working under arrangements made with the
			 hospice may be billed by the physician with the hospice provider indicated as
			 the payee. Services furnished voluntarily by physicians where the hospice has
			 no payment liability are not reimbursable.
(2) Services provided by the patient's
			 attending physician who is not an employee of, or receiving compensation from
			 the hospice for services provided for the hospice, will be paid to that
			 physician in accordance with the usual billing procedures for physicians.
Author:
Theresa D. Richburg
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §418.304; State Medicaid Manual; State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.12 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Payment made by the Medicaid program for hospice care services shall be
			 considered payment in full.
(2) The
			 patient or responsible party shall not be billed in full or in part for any
			 service reimbursed under any service component of the Medicaid Hospice Care
			 Program. Services that are not considered hospice care and non-covered Medicaid
			 services may be billed to the individual.
(3) Co-payments may not be imposed with
			 respect to hospice service rendered to Medicaid recipients.
(4) No person or entity, except a third party
			 resource, shall be billed, in part or in full, for Medicaid covered
			 services.
(5) For dually eligible
			 recipients for whom Medicare is the primary payer for hospice services,
			 Medicaid may be billed for coinsurance amounts for:
(a) Drugs and biologicals furnished by the
			 hospice while the recipient is not an inpatient at 5% of the cost of the drug
			 or biological not to exceed $5.00 per prescription.
(b) Inpatient respite care equal to 5% of the
			 payment made by CMS for a respite care day.
Author:
Pricilla Miles, Associate Director, LTC
				Program Management Unit
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.13 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 third party is another insurance company or agency that may be responsible for
			 paying all or part of the cost for medical services provided to a Medicaid
			 recipient. Some examples of third parties are Medicare, CHAMPUS, CHAMPVA, major
			 medical insurance, dental insurance, cancer insurance, automobile insurance,
			 and worker's compensation.
(2)
			 Medicaid shall be considered the "payer of last resort." The hospice provider
			 must bill all third parties which might pay for services provided before
			 billing Medicaid.
(3) See Chapter
			 20, Third Party, for additional Third Party procedures.
Author:
Theresa D. Richburg
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42
				  C.F.R. §418.56(d);
				  State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.14 - Confidentiality

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The provider of
			 hospice care shall not disclose, except to duly authorized representatives of
			 federal or state agencies, any information concerning an eligible recipient,
			 except upon the written consent of the recipient, his attorney, or his
			 guardian, or upon subpoena from a court of appropriate jurisdiction. See Rule
			 560-X-20-.05, Third Party, for
			 additional requirements regarding release of information.
(2) The hospice must safeguard the clinical
			 record against loss, destruction, and unauthorized use.
Author:
Theresa D. Richburg
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §§418.52,
				  418.74(6)(b);
				  State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.15 - Audits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The provider of
			 hospice care shall furnish the Alabama Medicaid Hospice Care Program with
			 requested information regarding claims submitted to the Medicaid Program and
			 shall permit access to all Medicaid records and facilities for the purpose of
			 claims audit, program monitoring, and utilization review by duly authorized
			 representatives of federal and state agencies.
(2) Complete and accurate medical and fiscal
			 records that fully disclose the extent of the services and billings shall be
			 maintained by the provider of hospice care. Said records shall be retained for
			 the period of time required by state and federal laws.
Author:
Theresa D. Richburg
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42
				  C.F.R. §418.74; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.03 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
Medical eligibility for HCBS under the LAH Waiver is limited to
				those individuals that meet the ICF/IID level of care. No HCBS under the LAH
				Waiver will be provided to a recipient residing in an institutional facility,
				or who has a primary diagnosis of mental illness, or whose health and safety is
				at risk in the community. Thus, HCBS under the LAH Waiver will be available to
				persons with intellectual disabilities who would be eligible for institutional
				services under
				42 C.F.R.
				§
									435.217.
Financial eligibility for HCBS under the LAH Waiver is limited
				to the following individuals:
Individuals receiving SSI.
SSI related protected groups deemed to be eligible for
				SSI/Medicaid (i.e., Widow/Widower, Disabled Adult Child, Continuous (Pickle)
				Medicaid).
Parent and Other Caretaker Relatives (POCR).
Federal and State adoption subsidy individuals.
Special HCBS waiver disabled individuals whose income is not
				greater than 300% of the SSI Federal Benefit Rate.
Persons with intellectual disabilities who meet categorical
				(including
				42 C.F.R. §
									435.120), medical, and/or social requirements
				for Title XIX coverage will be eligible for HCBS under the LAH waiver.
				Applicants found eligible shall not be required to apply income above the
				personal needs allowance reserved to institutional recipients toward payment of
				care.
Entire chapter was repealed as per certification filed
				  December 7, 1995; effective January 11,
				  1996.
Author:
Samantha McLeod, Associate Director,
				  Long Term Care Specialized Waiver Programs
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.04 - Characteristics Of Persons Requiring ICF/IID Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Generally, persons eligible for the level
			 of care provided in an ICF/IID are those persons who need such level of care
			 because the severe, chronic nature of their mental impairment results in
			 substantial functional limitations in three or more of the following areas of
			 life activity:
(a) Self Care
(b) Receptive and expressive
			 language
(c) Learning
(d) Self-direction
(e) Capacity for independent living
(f) Mobility