reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.19 - Administration Of Medication

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 facility must provide routine and emergency drugs and biologicals to its
			 residents.
(2) Alabama law
			 prohibits nonlicensed personnel from administering medication.
(3) A facility must permit residents to
			 self-administer a drug when the facility determines, in accordance with the
			 comprehensive assessment, that a resident is a good candidate, when the
			 resident demonstrates that he or she can securely store, safely administer and
			 accurately record the administration of drugs, and the facility reassesses the
			 residents ability to self-administer drugs at least every three months.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.17, Administration of
				  Medication, was renumbered to Rule 560-X-10-.19, as per certification filed
				  August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq., 483.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.20 - Conditions Under Which Nursing Facilities Are Not Classified As Mental Disease Facility Under Title XIX

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Nursing facilities located on grounds of state mental hospitals or in the
			 communities must follow the required criteria to meet specific conditions in
			 order to be eligible for federal matching funds for care provided to all
			 individuals eligible under the state plan.
(2) The Alabama Medicaid Agency is
			 responsible for coordinating with the proper agencies concerning the mental
			 disease classification of nursing facilities. Facilities are NOT considered
			 institutions for mental disease if they meet the following criteria:
(a) The facility is established under state
			 law as a separate institution organized to provide general medical care and
			 does offer and provide such care.
(b) The facility is licensed separately under
			 a state law governing licensing of medical institutions other than mental
			 institutions.
(c) The facility is
			 operated under standards which meet those for nursing facilities established by
			 the responsible state authority.
(d) The facility is operated under policies
			 which are clearly distinct and different from those of the mental institutions
			 and which require admission of patients from the community who need the care it
			 provides.
(e) The facility is dual
			 certified under Title XVIII and XIX.
(f) The facility is not maintained primarily
			 for the care and treatment of individuals with mental disease.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.21 - Admission Of Mentally Ill Residents To Nursing Facilities

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nursing
			 facilities must monitor the admission of mentally ill residents to their
			 facilities.
(a) A nursing facility may not
			 have more than fifty percent (50%) mentally ill residents which is based on the
			 total population of the facility including public and private pay
			 residents.
(b) If a facility does
			 have more than fifty percent (50%) mentally ill residents, it will be
			 designated as an institution for mental diseases for Medicaid payment
			 purposes.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.22 - Quality Of Life

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A facility
			 must care for its residents in a manner and in an environment that promotes
			 maintenance or enhancement of each resident's quality of life. Factors to be
			 considered include:
(a) Dignity
(b) Self determination and
			 participation
(c) Participation in
			 resident and family groups
(d)
			 Participation in other Activities
(e) Accommodation of needs
(f) Activities
(g) Social Services
(h) Environment
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.23 - Resident Assessment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 facility must conduct initially and periodically a comprehensive, accurate,
			 standardized, reproducible assessment of each resident's functional capacity as
			 required by 42 C.F.R. §
									483.20 and any other applicable state and
			 federal requirements.
(2) The
			 14-day assessment schedule requirements in
			 42 C.F.R.§
									483.20 apply to all long-term care
			 facilities. The Agency will recoup claims if the 14-day schedule requirements
			 in 42 C.F.R.§
									483.20 are not met.
Rule
				  560-X-10-.21, Resident
				  Assessment, was renumbered to Rule 560-X-10-.23, as per certification filed
				  August 11, 2003; effective September 15,
				  2003.
Author:
Dittra S. Graham, Administrator, LTC
				  Program Management Unit; Robin Arrington, Associate Director, LTC Provider
				  Recipient/Services Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§ 401,
et
seq
., 483.20; Omnibus Budget Reconciliation Act of
				  1987.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.24 - Quality Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
Each resident must receive the necessary nursing, medical and
				psychosocial services to attain and maintain the highest possible mental and
				physical functional status, as defined by the comprehensive assessment and plan
				of care. Each resident must receive and the facility must provide the necessary
				care and services to attain or maintain the highest practicable physical,
				mental and psychosocial well-being, in accordance with the comprehensive
				assessment and plan of care.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.22, Quality of Care,
				  was renumbered to Rule 560-X-10-.24, as per certification filed August 11,
				  2003; effective September 15, 2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq., 483.25; Omnibus Budget
				  Reconciliation Act of 1987.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.25 - Resident Behavior And Facility Practices

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The resident has the right to be free
			 from any physical restraints imposed or psychoactive drug administered for
			 purposes of discipline or convenience and not required to treat the resident's
			 medical symptoms.
(2) The resident
			 has the right to be free from verbal, sexual, physical or mental abuse,
			 corporal punishment and involuntary seclusion.
(3) The facility must develop and implement
			 written policies and procedures that prohibit mistreatment, neglect or abuse of
			 residents.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.23, Resident Behavior
				  and Facility Practices, was renumbered to Rule 560-X-10-.25, as per
				  certification filed August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; Omnibus Budget Reconciliation Act of 1987; 42 C.F.R.
				  §401, et seq., 483.13.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.26 - Transfer And Discharge Rights

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Definitions.
(a) Discharge means movement from an entity
			 that participates in Medicare as a skilled nursing facility (SNF), a Medicare
			 certified distinct part, an entity that participates in Medicaid as a nursing
			 facility (NF), or a Medicaid certified distinct part to a noninstitutional
			 setting when the discharging facility ceases to be legally responsible for the
			 care of the resident.
(b) Resident
			 means a resident of a SNF or NF or any legal representative of the
			 resident.
(c) Transfer means
			 movement from an entity that participates in Medicare as a SNF, a Medicare
			 certified distinct part, an entity that participates in Medicaid as a NF or a
			 Medicaid certified distinct part to another institutional setting when the
			 legal responsibility for the care of the resident changes from the transferring
			 facility to the receiving facility. A transfer is not the movement from one
			 certified bed in the facility to another certified bed in the same
			 facility.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.27 - Enforcement Of Compliance For Long-Term Care Facilities With Deficiencies

Current through Register Vol. 42, No. 9, June 28, 2024
The regulations of the Centers for Medicare and Medicaid
				Services, Department of Health and Human Services at
				42 C.F.R. Section
				488.400, et seq., as promulgated in 59
				Federal Register 56116 (Nov. 10, 1994), and as may be subsequently amended, are
				adopted by reference. Copies of these regulations may be obtained from the U.S.
				Government Printing Office, Washington, DC 20402-9328. Copies are also
				available from Medicaid at a cost of $2.50.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.25, Enforcement of
				  Compliance for Long-Term Care Facilities with Deficiencies, was renumbered to
				  Rule 560-X-10-.27, as per certification filed August 11, 2003; effective
				  September 15, 2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, §1919;
				  42 C.F.R.
				  §§442.1, et seq., 431.151, et seq.,
				  441.11, 489.53; Code of Ala. 1975, §§
										22-6-20, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.28 - Financial Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Financial eligibility will be established in accordance with Chapter 25,
			 Alabama Medicaid Administrative Code.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.26, Financial
				  Eligibility, was renumbered to Rule 560-X-10-.28, as per certification filed
				  August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.29 - Claim Filing Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
For claim filing limitations refer to Alabama Medicaid
				Administrative Code, Rule No.
				560-X-1-.17.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.27, Claim Filing
				  Limitations, was renumbered to Rule 560-X-10-.29, as per certification filed
				  August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.45, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.30 - Third Party Payment Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
Refer to Alabama Medicaid Administrative Code, Chapter
				20.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.28, Third Party Payment
				  Procedures, was renumbered to Rule 560-X-10-.30, as per certification filed
				  August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§433.135,
				  433.138,
				  433.139.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.01 - Early And Periodic Screening, Diagnosis, And Treatment For Individuals under Twenty-One (21)-General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Early and Periodic Screening, Diagnosis,
			 and Treatment (EPSDT) of Individuals Under Age twenty-one (21) is a mandatory
			 service of the Medicaid Program intended by Congress to direct attention to the
			 importance of preventive health services and early detection and treatment of
			 disease in children eligible for medical assistance.
(2) The Alabama Medicaid Agency:
(a) Will provide for a combination of written
			 and oral methods designed to effectively inform all EPSDT eligible individuals
			 (or their families) about the EPSDT program. Generally, this information will
			 be provided within 60 days of the individual's initial Medicaid eligibility
			 determination and in the case of families which have not utilized EPSDT
			 services, annually thereafter.
(b)
			 Will using clear and nontechnical language, provide information about the
			 following: the benefits of preventive health care, the services available under
			 the EPSDT program, and how to obtain these services.
(c) Will inform recipients that the services
			 provided under the EPSDT program are without cost to eligible individuals under
			 21 years of age. Exception: Copayment is required of individuals from eighteen
			 (18) to under twenty-one (21).
(d)
			 Will provide other medically necessary health care, diagnostic, treatment
			 and/or other measures described in section 1905(a) of Title XIX to correct or
			 ameliorate defects, physical and mental illnesses and conditions discovered
			 during a screening.
(e) Will inform
			 individuals that necessary transportation and scheduling assistance are
			 available upon request.
(f) Will
			 provide an extensive outreach program for EPSDT recipients.
(g) In conjunction with the Alabama
			 Department of Human Resources, will jointly develop an agreement covering the
			 responsibilities of the county Departments of Human Resources, county Health
			 Departments and other screening providers for EPSDT.
Author:
Laurie McEnery
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.02 - Major Components Of EPSDT

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Early - As early as possible in the life
			 of a child already Medicaid eligible or as soon as possible after a person's
			 eligibility is established, if he or she is under twenty-one (21) years of
			 age;
(2) Periodic - At intervals
			 established by Medicaid to assure that disease or disability is not incipient
			 or present in persons eligible for the EPSDT services;
(3) Screening - Assessment of the physical
			 and mental health of all persons under twenty-one (21) years of age who are
			 Medicaid eligible;
(4) Diagnosis -
			 Further study of persons to determine the nature or cause of disease or
			 abnormality to provide a frame of reference for treatment;
(5) Treatment - Any Treatment available under
			 the Alabama Medicaid Program including eyeglasses, hearing aids and other
			 necessary health care, diagnostic services to correct or ameliorate defects,
			 physical and mental illnesses and conditions discovered during a screening.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §441.50; OBRA '89 §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.03 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All persons
			 under twenty-one (21) years of age except SOBRA adult eligibles who have been
			 certified as being eligible for Medicaid are eligible for the EPSDT
			 program.
(2) Alabama Medicaid
			 Agency assigns Medicaid identification numbers and issues plastic Medicaid
			 eligibility cards to persons eligible for benefits.
(3) In providing services and filing a claim
			 for medical payment, it is required that a person be eligible in the month in
			 which the service is rendered.
(4)
			 Alabama Medicaid Agency Administrative Code, Chapter One, General, contains
			 information about the identification of Medicaid recipients.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §441.50; OBRA '89 §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.04 - EPSDT Manual

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A manual on
			 the EPSDT Program setting forth in detail the elements of the physical
			 examination, instructions for completion of forms, processes and procedures to
			 follow in administration of local programs and billing instructions will be
			 provided to each EPSDT provider. Failure to follow the procedures and
			 requirements as outlined in the manual may result in recoupment of the funds
			 paid to the provider.
(2) EPSDT
			 off-site screening providers must follow the Protocols and Procedures for EPSDT
			 as listed in the EPSDT Manual. Failure to comply may result in recoupment of
			 the funds paid to the provider and/or termination from participation in the
			 program.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §441.56(d).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.05 - Providers Of Screening Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In-state and borderline out-of-state
			 (within 30-mile radius of state line) health care agencies and physicians
			 wishing to participate in the EPSDT Program may request enrollment information
			 from the Alabama Medicaid Agency. Exception: The Fiscal Agent will be
			 responsible for enrolling any Title XVIII (Medicare) providers that wish to
			 enroll as a QMB-only provider.
(2)
			 All providers of screening services must enter into an agreement with Alabama
			 Medicaid Agency to participate in the EPSDT Program as a screening provider.
			 Exception: QMB-only providers. Each off-site location will require a separate
			 application, a separate contract, and will be assigned a provider number
			 distinct from any other the provider may have with Medicaid.
(3) All health care agencies enrolled shall
			 be under the direction of a duly-licensed physician, a currently licensed
			 registered nurse, or a certified nurse practitioner who shall be responsible
			 for assuring that requirements of participation are met and that the procedures
			 established by the Medicaid program are carried out.
(4) Screening programs conducted under the
			 direction of a registered nurse or certified nurse practitioner must have a
			 licensed physician acting as medical consultant.
(5) EPSDT services may be offered by
			 School-Based screening providers.
Author:
Lynn Sharp, Associate Director, Policy
				Development, Medical Services Division
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R. Section
				  400.203, Section
				  441.56.
				  Medicare Catastrophic Coverage Act of 1988 ( Public Law 100-360). OBRA
				  '89-Section 6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.06 - Procedures And Tests In The Screening Examination

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Agency will establish specific health
			 evaluation procedures to be used by screening providers. These procedures and
			 tests will be fully described in the Screening Provider Manual.
(2) All procedures and tests included in the
			 Screening Provider Manual must be carried out on each person screened and must
			 be recorded in the case history of the individual.
(3) Where it is not possible to carry out all
			 procedures and tests, this fact must be recorded in the case history of the
			 individual, including the reason such procedure or test was not carried
			 out.
(4) Requirements in this
			 paragraph are subject to federal and state audits and documentation in the
			 records will be examined in on-site visits from time to time. Failure to meet
			 these requirements may result in recoupment of the funds paid to the provider.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §441.56(d); OBRA '89
				  §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.07 - Screening Schedule

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Agency will establish a distinct periodicity schedule for screening services,
			 after consultation with recognized medical organizations involved in child
			 health care. This schedule will be published in the Screening Provider
			 Manual.
(2) Periodic screening
			 services will be provided at intervals that meet reasonable standards of
			 medical practice in accordance with those described for well-child care in the
			 Guidelines for Health Supervision of American Academy of Pediatrics.
(3) Interperiodic screenings are covered when
			 medically necessary to determine the existence of suspected physical or mental
			 illnesses or conditions.
(4) An
			 EPSDT Intensive Developmental Diagnostic Assessment is a multidisciplinary
			 comprehensive screening limited to infants 0 to under two years of age, and is
			 also limited to two per recipient per lifetime. These screenings are in
			 addition to the routine periodic screenings and must be performed by a
			 qualified EPSDT Intensive Developmental Diagnostic Assessment Screening
			 provider, as approved and enrolled by Medicaid.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §441.50; OBRA '89 §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.08 - Consultation Services To Screening Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Professional nursing staff of the Alabama
			 Medicaid Agency will provide assistance to any screening provider who requests
			 it.
(2) The Medicaid staff will
			 assist providers and County Departments of Human Resources with problems in
			 local administration of the EPSDT Program upon request, or as need is
			 identified in on-site visits to screening providers.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42
				  C.F.R. §441.61.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.09 - EPSDT Referral For Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All participating EPSDT providers will
			 complete the EPSDT Referral for Services form for each individual provider to
			 whom a person is being referred to for further diagnosis and/or
			 treatment.
(2) When a screening
			 provider refers a person to a Medicaid participating provider for diagnosis
			 and/or treatment, all treatment services will be considered for reimbursement,
			 above current limitations. However, the services rendered must be medically
			 necessary to treat or ameliorate a condition or diagnosis identified in a
			 screen.
(3) The referring provider
			 must document within the patient's medical history or physical examination
			 portion of the medical record the condition(s) identified during an EPSDT
			 Screening examination which requires a referral. Notation of the condition on
			 the EPSDT referral form alone will not be considered sufficient documentation.
			 Medicaid has the right to recoup payment for the screening service from the
			 referring provider, when a referral is made for a condition not documented in
			 the medical history or physical examination portion of the medical
			 record.
(4) Alabama Medicaid Agency
			 Administrative Code, Chapter One, General, contains information about extended
			 benefits as a result of an EPSDT screening and referral.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42
				  C.F.R. §441.61; OBRA '89
				  §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.10 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Governmental
			 screening providers (including physicians) will be paid on a negotiated rate
			 basis which will not exceed their actual costs. Nongovernmental screening
			 providers will be paid their usual and customary charge which is not to exceed
			 the maximum allowable rate established by Medicaid.
(2) In screening a recipient, the provider's
			 contract screening cost will cover the following services: unclothed physical
			 examination; vital signs; heights and weights; family, medical, mental health
			 and immunization histories, vision and hearing testing; developmental
			 assessment including anticipatory guidance and nutritional assessment;
			 hematocrits or hemoglobins; and follow-up of all referred conditions to ensure
			 whether or not treatment has been initiated.
(3) Providers may submit claims for
			 immunization, TB skin test and treatment on the day of screening. These charges
			 submitted on the CMS 1500 form are in addition to the screening charge, but no
			 office visit should be charged at that time.
Author:
Kaye Melnick, Program Manager, EPSDT,
				  Medical Services Division
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan; 42 C.F.R.
				  §
											441.50; OBRA '89 §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.11 - Consent For Health Services For Certain Minors And Others

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Consent for
			 health services for certain minors, and others will be governed by Code of Ala.
			 1975, Title 22, Chapter 8.
(2) All
			 consent forms must be signed by the parent or legal guardian except for clients
			 fourteen (14) years and older who may sign for themselves.
Author:
Laurie McEnery
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §441.56. Code of Ala. 1975.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.12 - Notification Procedures For Handicapped Individuals Eligible For EPSDT

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Hearing
			 Impaired:
(a) Each recipient will be notified
			 of services during a face-to-face verbal interview at which time an individual
			 who communicates via sign language or other methods will be present if needed
			 to pass information to the recipient.
(b) Written information will be given to both
			 the recipient and the individual who communicates with him.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.13 - State Laboratory Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Arrangements have been made with the
			 Clinical Laboratory Administration to have the State Laboratory examine blood
			 specimens for sickle cell anemia and other abnormal hemoglobins, stool
			 specimens for ova and parasites, and scotch tape preparations for pinworms.
			 VDRL, G.C. cultures, throat culture and blood lead level may also be done at no
			 cost to the provider.
(2) Payment
			 is made by Medicaid to the laboratories who have been enrolled as Medicaid
			 providers for examination of specimens submitted by screening agencies and
			 physicians.
(3) Care should be
			 taken to see that the correct Medicaid number is entered on the label or form
			 accompanying such specimens.
Author:
Laurie McEnery
ER No. 560-X-11-15 EPSDT Extended Inpatient Care filed
				  December 20, 1988; effective January 1, 1989 through March 14, 1989. No
				  permanent rule adopted.
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42
				  C.F.R. §441.61; OBRA '89
				  §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-11 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT FOR INDIVIDUALS UNDER 21 › Section 560-X-11-.14 - EPSDT Referred Service Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) OBRA '89 requires that medically
			 necessary health care, diagnosis, treatment and/or other measures described in
			 Section 1905(a) of the Social Security Act be covered under Medicaid if
			 identified in an EPSDT screening whether or not such services are covered in
			 the State Plan. If services are not ordinarily provided as a Medicaid benefit
			 for children under age 21, the providers of the service will be enrolled to
			 provide "EPSDT only" referred care. An EPSDT referral form must be maintained
			 by the provider for services provided as a result of a screening.
(a) EPSDT-only providers include: physical
			 therapists, occupational therapists, speech therapists, licensed behavior
			 analysts, chiropractors, podiatrists, psychologists, licensed professional
			 counselors, licensed marriage and family therapists, licensed social workers,
			 private duty nurses, air transportation, environmental lead investigators, and
			 personal care services.
(b)
			 Enrollment: In state and borderline out-of-state (within 30-mile radius of the
			 Alabama state line) are eligible to enroll as EPSDT-only providers.
(c) Documentation: EPSDT-only services are
			 covered by Alabama Medicaid when medically necessary and when done to correct
			 or ameliorate a defect, physical or mental illness or other conditions
			 identified during an EPSDT Screening Exam. EPSDT-only providers must develop a
			 plan of treatment and have it readily available at all times for review in the
			 recipient's medical record. The plan of treatment should contain but is not
			 limited to the following information:
1.
			 Recipient's name,
2. Recipient's
			 current Medicaid number,
3. Date of
			 EPSDT Screening,
4. Referring
			 physician's name,
5.
			 Diagnosis(es),
6. Date of onset or
			 acute exacerbation, if applicable,
7. Type of surgery performed, if
			 applicable,
8. Date of surgery, if
			 applicable,
9. Functional status
			 prior to treatment and expected status after treatment, if
			 applicable,
10. Frequency and
			 duration of treatment, if applicable,
11. Modalities, if applicable, and
12. For ulcers, the location, size and depth
			 should be documented, if applicable.
(d) Retrospective Review: Medicaid's
			 Surveillance and Utilization Review Program will review medical records
			 retrospectively to determine the appropriateness of the service rendered.
			 Medicaid may discontinue and/or recoup payment for the treatment or service if
			 any of the following circumstances have occurred:
1. An EPSDT screening was not
			 performed,
2. The
			 condition/diagnosis noted on the EPSDT referral form does not relate to the
			 treatment performed, and
3. The
			 EPSDT screening form is not valid. (EPSDT screening referral forms are valid
			 only for the time specified by the referring provider or up to a maximum of
			 twelve (12) months).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.01 - Home Health Care-General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Alabama Medicaid Home Health Care
			 services are available for all Medicaid eligible persons of any age who meet
			 the admission criteria on the basis of a reasonable expectation that a
			 patient's medical, nursing, and social needs can adequately be met in the
			 patient's place of residence.
(2)
			 Anyone may refer a person who is in need of home health care, under the care of
			 a physician, and in need of part-time nursing, to a participating agency.
Author:
Georgette Harvest, Associate Director,
				Project Development/Policy Unit, Long Term Care Division
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. 9440.70 ; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.02 - Admission Criteria

Current through Register Vol. 42, No. 9, June 28, 2024
(1) To be
			 eligible for home health care, a recipient must meet all of the following
			 criteria:
(a) The recipient's illness,
			 injury, or disability prevents the recipient from going to a physician's
			 office, clinic or other outpatient setting for required treatment; as a result,
			 he or she would, in all probability, have to be admitted to a hospital or
			 nursing home because of complications arising from lack of treatment.
(b) The recipient is unable to function
			 without the aid of supportive devices, such as crutches, a cane, wheelchair or
			 walker and requires the use of special transportation or the assistance of
			 another person.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.03 - Provider Requirements For Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Only instate agencies are eligible for
			 participation.
(2) A home health
			 agency is a public agency, private non-profit organization or proprietary
			 agency which is primarily engaged in providing part-time or intermittent
			 skilled nursing services and home health aide services to patients in their
			 homes.
(3) To become a Medicaid
			 home health care provider, the home health agency must:
(a) Be certified to participate as a Medicare
			 provider;
(b) Be certified by the
			 Division of Health Care Facilities of the Alabama Department of Public Health
			 as meeting specific statutory requirements and as meeting the Conditions of
			 Participation;
(c) Request in
			 writing to Alabama Medicaid Agency (Medicaid) to become a provider of Medicaid
			 home health care, and enclose a copy of the agency's most recent cost study
			 report showing discipline costs; and
(d) Agree to sign and to comply with the
			 terms set forth in the agreement with Medicaid.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.04 - Provider Termination And/Or Change Of Ownership

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A participating agency has the right to
			 withdraw from the Medicaid program after giving written notice to Medicaid of
			 its intent at least thirty (30) days in advance.
(2) The state may terminate the home health
			 agency's participation in the Medicaid program in cases involving fraud or
			 willful or grossly negligent noncompliance.
(3) Medicaid must be notified in writing
			 within thirty (30) days of the date of agency owner and/or name change. The
			 existing contract will be terminated and a new contract must be signed if the
			 agency desires to continue participation in the Medicaid program.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §434.6; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.05 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) If
			 ordered by the patient's physician or non-physician practitioner (NPP), and
			 authorized by Medicaid, a professional registered nurse employed by a certified
			 home health agency can provide part-time or intermittent nursing services to a
			 patient.
(a) The registered nurse is
			 responsible for a nursing care plan, which is made in accordance with the
			 written plan of care.
(b)
			 Restorative, preventive, maintenance, and supportive services are
			 covered.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.06 - Noncovered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) There
			 is no coverage under the Medicaid Home Health care plan for visits by
			 paramedical personnel, physical therapists, speech therapists, occupational
			 therapists, and inhalation therapists.
(2) Sitter service, private duty nursing
			 service, medical social workers, and dietitians are not covered by
			 Medicaid.
(3) Supervisory visits
			 made by a professional registered nurse to evaluate appropriateness of services
			 being rendered to a patient by an LPN, aide, or orderly and considered as
			 administrative cost to the agency and may not be billed as skilled nursing
			 services.
(4) The registered nurse
			 will provide and document in the case record on-site supervision of the LPN,
			 home health aide, or orderly at least every 60 days. The registered nurse will
			 conduct on-site supervision more frequently if warranted by complaints or
			 suspicion of substandard performances by the worker.
Author:
Samantha McLeod, Administrator, LTC
				Program Management Unit
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §441.15; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.07 - Supplies, Appliances, And Equipment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Such items as are specified by Medicaid
			 are available for use in the home.
(2) See the chapter covering supplies,
			 appliances, and durable medical equipment for further information.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §440.70; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.08 - Certification And Recertification

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An eligible Medicaid recipient may be
			 considered for home health services (i.e., nursing services and home health
			 aide services) upon the initial written prescription or order signed and place
			 by a physician licensed in the State of Alabama or an authorized non-physician
			 practitioner (NPP).
(2) The
			 ordering physician or NPP must sign and place the initial prescription or order
			 for home health services only after the required face-to-face visit with the
			 recipient is conducted.
(3)
			 Subsequent written prescriptions or orders for refills, ancillary supplies,
			 repairs or services, or re-certifications do not require the ordering
			 physician's or NPP's signature or an additional face-to-face visit.
(4) Either an authorized physician or one of
			 the following authorized non-physician practitioners working under a
			 collaborative agreement under Alabama law must conduct the required
			 face-to-face visit and write the initial prescription or order for home health
			 services:
(a) Certified registered nurse
			 practitioners or clinical nurse specialists;
(b) Certified nurse midwifes;
(c) Physician assistants (PA) under the
			 supervision of the physician; or
(d) Attending acute or post-acute physicians,
			 if recipients are admitted to home health services immediately after discharge
			 from an acute or post-acute stay.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.09 - Visits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A visit is a
			 personal contact in the place of residence of a patient made for the purpose of
			 providing a covered service by a health worker on the staff of a certified
			 Medicaid home health agency.
(a) Home health
			 care visits to Medicaid recipients must be medically necessary and in
			 accordance with a Medicaid Home Health Certification form established by a
			 licensed physician or non-physician practitioners (NPP). Home Health records
			 are subject to onsite audits and desk reviews by the professional staff of the
			 Alabama Medicaid Agency.
(b) Home
			 health care visits are limited to one hundred four (104) per calendar
			 year.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.10 - Medicare/Medicaid Eligible Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Persons eligible for Medicare and
			 Medicaid are entitled to all services available under both programs, but a
			 claim must be filed with Medicare if the services are covered by Medicare. A
			 patient may not receive home visits under both programs simultaneously. If
			 Medicare terminates coverage, Medicaid may provide visits.
(2) Medicare deductibles and co-insurance
			 amounts for eligible Medicare/Medicaid recipients are not applicable for Home
			 Health services. (Section 930 - PL 96-499)
Author:
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §431.625; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-12 - HOME HEALTH › Section 560-X-12-.11 - Billing Of Medicaid Recipients By Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Home Health Agency agrees to accept
			 as payment in full the amount paid for covered home health services, and cannot
			 make any additional charges to the recipient, sponsor, or family of the
			 recipient.
(2) Medicaid recipients
			 may be billed by providers for noncovered services. See Rule
			 560-X-12-.06 for a listing of
			 noncovered services.
(3) Medicaid
			 recipients may be billed for home health services provided by agencies which do
			 not have a contract with the Alabama Medicaid Program.
Author:
Henry C. LeCroy
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §447.15; State Plan.
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-.01 - Durable Medical Equipment, Supplies, Appliances, Prosthetics, Orthotics And Pedorthics-General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Durable Medical Equipment (DME),
			 supplies, and appliances are available as Medicaid program benefits to eligible
			 Medicaid beneficiaries for use in any setting in which normal life activities
			 take place.
(2) The covered DME,
			 supplies, and appliances, and Prosthetics, Orthotics and Pedorthics (POP) are
			 for medical therapeutic purposes, and must be ordered by the prescriber in
			 connection with the plan of treatment, and the items will minimize the
			 necessity for hospitalization, nursing home, or other institutional care. The
			 prescriber of these items must comply with
			 42 C.F.R. §
									440.70 as well as all other federal and state
			 rules and regulations in order to receive reimbursement.
(3) DME is equipment:
(a) that can withstand repeated
			 use;
(b) is primarily and
			 customarily used to serve a medical purpose;
(c) generally is not useful to a person in
			 the absence of an illness, disability or injury; and
(d) can be removable or reusable.
All requirements of the definition must be met before an item
				can be considered to be DME.
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-.02 - Participating Agencies And Suppliers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Participating providers (also referred to
			 as "all providers mentioned in this chapter" or "provider") are those Home
			 Health Agencies, pharmacies, DME, supply, appliance and POP suppliers
			 contracted with Medicaid for this program.
(2) Participating providers must meet the
			 Medicare criteria as specified in the regulations of the Centers for Medicare
			 and Medicaid Services, Department of Health and Human Services at
			 42
			 C.F.R. Section 424.57, which regulations are
			 adopted by reference. Copies of these regulations may be obtained from the U.S.
			 Government Printing Office, Washington, DC 20402-9328.
(3) Medicaid's fiscal agent enrolls providers
			 and issues provider contracts to applicants who meet the licensure or
			 certification requirements of the State of Alabama, Code of Federal
			 Regulations, Alabama Medicaid Administrative Code, and Alabama Medicaid
			 Provider Manual.
(4) All providers
			 within this chapter should contact the applicable licensing or accreditation
			 board(s) to determine the licensure requirements for each of the specialties.
			 The appropriate documentation must be submitted during the Alabama Medicaid
			 provider enrollment or re-enrollment process. If the appropriate licensure
			 documentation is not submitted, the provider will not be assigned the selected
			 specialty. Please refer to Chapter 14, DME, of the Medicaid Provider Manual for
			 additional licensure information.
(5) All providers mentioned in this chapter,
			 except pharmacy providers as outlined in subparagraph (d) (ii) below, must
			 submit the following documentation to the Medicaid fiscal agent prior to
			 enrollment:
(a) Copy of a current Home
			 Medical Equipment (HME) license or documentation that the provider meets an
			 exemption to the licensure requirements outlined in
Code of Ala.
			 1975
, §
									34-14C-5;
(b) copy of a current business
			 license;
(c) copy of the approved
			 Medicare enrollment application or Medicare enrollment letter; and
(d) copies of the Medicare Accreditation and
			 the Medicare Surety Bond(s).
1. Effective
			 October 1, 2010, all participating providers are required to have a $50,000
			 Surety Bond for each National Provider Identifier (NPI) unless the provider
			 meets an exemption in paragraph (6) below. In order to qualify for the
			 exemption in (6) (f) below, the provider must have a Surety Bond for three
			 years prior.
2. Pharmacy providers
			 seeking to enroll as Alabama Medicaid DME providers are required to submit
			 their Medicare enrollment letter only. They are not required to submit a
			 Medicare Surety Bond, Medicare Accreditation letter or Medicaid Surety
			 Bond.
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-.04 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Hattie Nettles, Associate Director, LTC
				  Policy Advisory 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-.05 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Hattie M. Nettles, Associate Director,
				  LTC Policy Advisory Unit
Statutory Authority:
State Plan;
				  42 C.F.R.
				  §440.70; Title XIX, Social Security
				  Act.