reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.10 - Management And Administrative Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Costs of a management or administrative
			 nature, including but not limited to those costs outlined in Rule
			 560-X-22-.10(3),
			 will be reported as such on the Medicaid Cost Report. Salaries of
			 administrative personnel which would duplicate employee salary expenses in
			 other cost centers cannot be allocated to such nonadministrative cost
			 centers.
(2) Customarily, owner
			 compensation results from a distribution of the profits. However, when the
			 owner provides a
necessary
service to the facility,
			 he/she can justifiably be compensated at a reasonable rate, then that owner
			 compensation is an allowed cost. "Reasonable compensation" must meet the
			 criteria of being paid to an employee who performs a necessary function in a
			 facility and must be in an amount which would ordinarily be paid for comparable
			 services in a comparable facility. To be "necessary," a function must be one
			 that if that employee were not performing it, another would have to be employed
			 to do so, and, additionally, the function must be directly related to providing
			 nursing facility services.
(3)
			 Examples of Allowable Management and Administrative Costs include, but are not
			 limited to:
(a) Salaries and Bonuses:
1. Administrator.
2. Assistant Administrator.
3. Accountant.
4. Bookkeeper.
5. Computer Operator.
6. Medical Records Clerk.
7. Personnel Officer.
8. Secretary.
9. Typist.
10. Clerks.
11. Receptionist.
12. Telephone/Operator/Switchboard.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.12 - Laundry Expense

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Allowable costs will be limited to the laundry costs which are ordinary and
			 necessary to the operation of a nursing facility and will not include costs
			 associated with the personal laundry of patients.
(2) Examples of such costs include, but are
			 not limited to, the following:
(a) Salaries
			 and employee benefits attributable to laundry personnel.
(b) Supplies and materials used in providing
			 laundry services.
(c) One and one
			 half percent (1.5%) of Fair Rental to be applied to laundry.
(d) Costs directly attributable to the
			 delivery of laundry.
(e) Charges by
			 an outside laundry.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.14 - Property Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order
			 for any property costs to be reimbursed through the Medicaid program, capital
			 expenditures must be approved under applicable Certificate of Need regulations
			 by appropriate state and/or federal agencies. Capital expenditures, as used in
			 this chapter, means new construction, major renovations, bed additions, or
			 replacement beds in a nursing facility.
(2) Effective September 1, 1991, a Fair
			 Rental System will be used to reimburse property costs. The Fair Rental System
			 reduces the wide disparity in the cost of capital payments for basically the
			 same service and makes the cost of capital payment fairer to all participants
			 in the program. The Fair Rental System is a rate of return on current asset
			 values and will be used in lieu of depreciation and/or lease payments on land,
			 buildings, and major movable equipment normally used in providing patient
			 care.
(3) The following factors
			 will be used to arrive at a "Rate of Return on Current Asset Values":
The current yield on 30 year U. S. Treasury Bonds*
A risk premium for ownership 1.5%
A Gross Rental Factor 2.5%
*Latest yield as of June 30
(4) The amount of $25,000 per bed will be
			 used to reflect the standard value per bed as of September 1, 1991. This
			 standard value reflects the allowable cost of a newly constructed facility to
			 include land, buildings, and all major movable equipment needed to place the
			 facility in operation.
(5) Current
			 asset values are found by taking the standard value of $25,000 per bed and
			 reducing that amount by 1% for each year, or fraction thereof for partial
			 years, of age for a maximum of 50 years. A minimum value of $12,500 per bed
			 will be applied as a floor. Once these values have been set, they will be
			 subject to rebasing yearly using the Marshall-Swift Valuation Service data.
			 They will not be subject to further reduction for age.
(6) Net asset values are found by taking
			 current asset values and reducing them by outstanding allowable debt for land,
			 building, and equipment. Allowable debt is determined by subtracting any escrow
			 funds related to the debt from the current balance due. The remainder will be
			 considered allowable debt up to the amount of the facility's current asset
			 value.
(7) The following property
			 costs will normally not be reimbursed under this Fair Rental System:
(a) depreciation and
(b) rent for land, buildings, and
			 equipment.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.15 - New Facility, Change In Ownership, Or Change In Category Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A provider who
			 constructs, leases, or purchases a facility, or has a change in category of
			 care, can request reimbursement based on an operating budget, subject to the
			 ceiling established under Rule 560-X-2-.05 of this chapter. In this event, the
			 facility will be subject to a retroactive adjustment based on the difference
			 between budgeted and actual allowable costs. These actual allowable costs will
			 be reported on a complete interim cost report. If this interim report should
			 span June 30, the Agency may accept this report as the interim and regular cost
			 report. In this instance, the report will be used to settle the budgeted period
			 and also to set the next year's prospective rate. If the Agency accepts this
			 report as the June 30 regular report, the due date shall be September 15; if
			 not, the due date will be 60 days after the end of the interim period as
			 specified by the Agency.
(2) The
			 difference between budgeted and/or projected costs in these instances will be
			 subject to settlement within thirty (30) days after written notification by
			 Medicaid to the provider of the amount of the difference.
(3) Upon voluntary or involuntary complete
			 withdrawal of a facility participating in the Medicaid program, the provider
			 will be subject to a retroactive adjustment based upon the difference between
			 the amount of reimbursement paid by Medicaid and the actual allowable costs
			 incurred by the former provider during the following periods:
(a) If the effective date of the withdrawal
			 is less than six (6) months after the preceding July 1, a retroactive
			 adjustment will be made for the current fiscal year and for the immediately
			 preceding fiscal year.
(b) If the
			 effective date of the withdrawal is six (6) months or more after the preceding
			 July 1, a retroactive adjustment will be made for the current fiscal year
			 only.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.16 - Return On Equity Capital

Current through Register Vol. 42, No. 9, June 28, 2024
Effective September 1, 1991, Return on Equity will no longer be
				used in rate computation. This does not relieve the provider of the
				responsibility of maintaining adequate records to account for receivables,
				prepaids, and payables.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R. §§
											447.200 - .272,
et seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.18 - Costs To Related Parties

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Allowable costs incurred by a provider
			 for services or goods provided by related parties will not exceed the net cost
			 of the services or goods to that related party, and that cost cannot exceed the
			 fair market value of the items or services involved.
(2) The provisions of HIM-15 shall be
			 applicable in determining whether a related party relationship
			 exists.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R. §§
											447.200 - .272,
et seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.19 - Receipts Which Offset Or Reduce Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Certain income items or receipts must be
			 used to either offset costs or reduce total reported costs. Typical, but not
			 all inclusive, examples of such transactions are:
(a) Purchase discounts, rebates or
			 allowances.
(b) Recoveries or
			 indemnities on losses (i.e., insurance proceeds).
(c) Sale of scrap or incidental
			 services.
(d) Sale of medical
			 supplies (other than to patients).
(e) Medicare Part B - Income.
(f) Sale of meals.
(g) Cash contributions and donations
			 designated by a donor for paying specific operating costs.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.20 - Chain Operations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 chain organization consists of a group of two or more nursing facilities which
			 are owned, leased, or through any other device controlled by related
			 organizations or individuals. The home office of a chain organization is not a
			 provider in itself; therefore, its costs may not be directly reimbursed by the
			 program. The home office organization will be treated as a "related party" to
			 participating nursing facilities for purposes of this chapter. Only the home
			 office's actual cost of providing management services is permitted to be
			 allocated to the providers and then only to the extent that they do not
			 duplicate services already provided in the nursing facility. Costs that would
			 not be allowable if directly claimed by a provider will not be allowed as an
			 allocation from a home office.
(2)
			 It is not considered appropriate for the taxpayers of Alabama to pay more for
			 the operation of a nursing facility owned or operated by a chain than would be
			 paid for an individually operated nursing facility. A chain operated facility
			 is expected to be more efficient and economical to operate than an individually
			 operated facility.
(3) If a home
			 office provides centralized laundry, maintenance, and purchasing services to
			 facilities, the actual costs of providing these services will be charged to the
			 facilities to which the services are provided. The facility will report these
			 costs in the appropriate cost center on its cost report.
(4) Maintenance, Central Purchasing, and
			 Laundry.
(a) Examples of home office costs
			 associated with providing these services include:
1. Maintenance (Plant Operations Cost
			 Center):
(i) Salaries and Benefits.
(ii) Supplies.
(iii) Materials.
(iv) Travel expense subject to limitations
			 contained in Rule
			 560-X-22-.13.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.21 - Cost Allocation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Multiple use facilities, such as hospital-nursing facilities or retirement
			 home-nursing facilities, will
allocate
all allowable
			 costs which are not directly associated with a specific revenue producing
			 department.
(2) Examples of costs
			 which are usually allocated include, but are not limited to:
(a) Depreciation.
(b) Administrative and General.
(c) Employee Health and Welfare.
(d) Plant Operations.
(e) Laundry and Linen.
(f) Housekeeping.
(g) Medical Records.
(h) Dietary.
(i) Social Services.
(j) Pharmacy.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.22 - Unallowable Expenses

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 General:
(a) All payments to providers for
			 services rendered must be based on the reasonable cost of such services covered
			 by the Alabama State Plan. It is the intent of the program that providers will
			 be reimbursed the reasonable costs which
must
be
			 incurred in providing quality patient care. Implicit in the intent that
			 reasonable costs be paid are the expectations that the provider seeks to
			 minimize costs and that costs do not exceed what a prudent and cost-conscious
			 buyer pays for a given item of service or product. If costs are determined to
			 exceed the level that prudent buyers incur in the absence of clear evidence
			 that the higher costs were unavoidable, the excess costs are not
			 allowable.
(b) Costs related to
			 patient care include necessary and proper costs involved in developing and
			 maintaining the efficient operation of patient care facilities. Necessary and
			 proper costs related to patient care are those which are usual and accepted
			 expenses of similar providers.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.24 - Accounting Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 provider must submit adequate cost data based on financial and statistical
			 records which can be verified by qualified auditors. The cost data must be
			 presented on the accrual basis of accounting. This basis requires that revenue
			 must be allocated to the accounting period in which it is earned and expenses
			 must be charged to the period in which they are incurred, regardless of when
			 cash is received or disbursed.
(2)
			 Cost information as developed by the provider must be current, accurate, and in
			 sufficient detail to support payments made for supplies, services, or assets.
			 This includes all ledgers, books, records, and original evidence of costs which
			 pertain to the costs reported. Financial and statistical records should be
			 maintained in a consistent manner from one period to another; however, the
			 regard for consistency should not preclude a desirable change in accounting
			 procedures provided that full disclosure of significant changes is
			 made.
(3) The following records and
			 documentation must be kept by the provider and
must
be
			 available for audit inspection by Medicaid:
(a) General Ledger.
(b) Disbursements Journal.
(c) Cash Receipts Journal.
(d) Payroll Journal.
(e) Working Trial Balance and Adjusting
			 Entries.
(f) Patients Personal
			 Funds Records.
(g) Patient
			 Admission and Discharge Records.
(h) Purchases Journal (For facilities larger
			 than 100 beds).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.25 - Patient Personal Fund Accounts

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Personal Fund Management. In accordance
			 with federal regulations for Medicare and Medicaid facilities, a medical
			 assistance patient may manage his personal affairs unless a facility accepts
			 the patient's delegation of this responsibility. A patient managing his
			 personal affairs may voluntarily have a facility hold custody of his
			 funds.
(2) Voluntary Patient
			 Delegation of Responsibility to the Facility. There are three (3), and possibly
			 more, specific categories of Medical Assistance patients who may voluntarily
			 delegate to the facility the management of personal financial affairs:
(a) Persons receiving social security checks
			 or other income which is applicable under medical assistance to the cost of
			 services less a thirty dollar ($30.00) per month personal care
			 allowance.
(b) Persons receiving a
			 check from the Department of Human Resources for a twenty-three dollar ($23.00)
			 per month personal care allowance.
(c) Persons receiving donated funds from
			 their family or friends which are not applicable to the cost of services. In
			 the event these persons voluntarily delegate the management or custody of such
			 funds to the facility, proper management and accountability for the funds must
			 be provided by the facility.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.26 - Audit Adjustment Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Audit adjustments will be paid or
			 collected by a combination of (1) changing the per diem rate of the facility
			 and (2) a lump sum settlement for the amount under/over paid for the period
			 prior to the effective date of the per diem rate change.
(2) Under/Overpayment situations arising from
			 the audit of a terminating cost report will be paid or recouped by a lump sum
			 settlement.
(3) All adjustments
			 will be subject to the limitations set out in this chapter and subject to the
			 appropriate ceilings.
(4)
			 Collection procedures will be applied only after the facility has been given
			 thirty (30) days in which to disagree with any of the disallowances contained
			 in the report of audit.
(5) A final
			 audit computation sheet [See Schedule 26-A at end of chapter] will be forwarded
			 to each facility with the report of audit. An adjusted per diem rate will be
			 stated in the report of audit and will be computed based on the audit
			 adjustment. This new per diem rate will be effective for billing purposes on
			 the 1st day of a month, allowing for the thirty (30) day notification period
			 and a reasonable amount of time for processing the report of audit. The
			 effective date of the rate change will be shown in Item I of the final audit
			 computation worksheet. The remaining portion of the audit settlement will be
			 collected or paid in a lump sum amount as shown in the final audit computation
			 sheet for items II, III, and IV. This lump sum amount for the months prior to
			 the effective date (underpayment or overpayment period) of the rate change is
			 computed by applying the adjustment per patient day (Part II) to the total
			 Medicaid days in the overpayment/ underpayment period (Part III, e). The lump
			 sum amount due to the provider or Medicaid is shown on the last item in Part
			 IV.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R. §§
											447.200 - .272,
et seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.27 - Appeals

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Facility
			 administrators who disagree with the findings of the Medicaid desk audits or
			 field audits may request, in writing, an informal conference at which they may
			 present their positions. Such written requests must be received by Medicaid
			 within thirty (30) days of the date on which Medicaid mails the audit report,
			 or new reimbursement rate, as the case may be, to the provider.
(2) Administrators who believe that the
			 results of the informal conference are adverse to their facility may ask, in
			 writing, for a fair hearing, which will be conducted in accordance with
			 Medicaid regulations. Such written requests must be received by Medicaid within
			 fifteen (15) days of the date on which Medicaid mails to the provider its
			 determination on the issues presented at the informal conference.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R. §§
											447.200 - .272,
et seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.28 - Negligence Penalty

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Whenever an
			 overpayment of Medicaid reimbursement received by a provider from Medicaid
			 results from the negligence or intentional disregard of Medicaid Reimbursement
			 Principles by the provider or its representatives (but without intent to
			 defraud), there will be deducted from any reimbursement thereafter due the
			 provider a penalty equal to 5% of such overpayment.
(2) If any part of such an overpayment by
			 Medicaid to the provider is due to fraud on the part of the provider or any of
			 its representatives, there will be deducted from any subsequent reimbursement
			 due the provider on proof of fraud, a penalty equal to 50% of the
			 overpayment.
(3) The penalties
			 imposed under Rule
			 560-X-22-.28(l)(2)
			 shall be in addition to and shall in no way affect Medicaid's right to also
			 recover the entire amount of the overpayment caused by the provider's or its
			 representative's negligence or intentional disregard of the Medicaid
			 Reimbursement Principles or fraud.
(4) Whenever the cost of a good or service
			 has been previously disallowed as the result of a desk audit of a provider's
			 cost report and/or a field audit by Medicaid and such cost has not been
			 reinstated by voluntary action of Medicaid, as the result of an administrative
			 hearing, or by a court order, such costs shall not thereafter be included as an
			 allowable cost on a Medicaid cost report. The inclusion by the provider or its
			 representative of such a cost on a subsequent cost report, unless the provider
			 is actively pursuing an administrative or judicial review of such disallowance,
			 will be considered as negligent and/or intentional disregard of the Medicaid
			 Reimbursement Principles and subject to the 5% penalty imposed by Rule
			 560-X-22-.28(l)
			 based upon the amount of overpayment which
has or which would have
			 resulted
from the inclusion of such cost had its inclusion not
			 been detected. Such inclusion shall also be subject to the provisions of Rule
			 560-X-22-.29 relating to
			 intentional or negligent disregard of the Medicaid Reimbursement
			 Principles.
(5) For purposes of the
			 preceding paragraph, a provider shall be considered as having included a
			 previously disallowed cost on a subsequent year's cost report if the cost
			 included is attributable to the same type good or service under substantially
			 the same circumstances as that which resulted in the previous disallowance.
			 Examples of such prohibited inclusions include, but are not limited to:
(a) Inclusion of the Portion of rental
			 payment previously disallowed as being between related parties.
(b) Inclusion of an amount of compensation
			 which has previously been disallowed as unreasonable during a prior
			 period.
(c) Inclusion of a cost not
			 related to patient care which has previously been disallowed.
(d) Improper classification or allocation of
			 costs to cost centers.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.29 - Cost Report Preparers

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Cost Report Preparers. "Cost Report Preparer" includes any person (including a
			 partnership or corporation) who, in return for compensation, prepares or
			 employs another to prepare all or a substantial portion of a Medicaid cost
			 report. A cost report preparer can include both the actual preparer of the
			 report as well as his or her employer. Where more than one person aids in
			 filling out a Medicaid cost report, the one who has primary responsibility for
			 the preparation of the report will usually be a preparer, while those involved
			 only with individual portions of the report will usually not be preparers. Any
			 person who supplies enough information and advice so that the actual completion
			 of the return is a mere mechanical or clerical matter is a cost report preparer
			 even though the person doesn't actually place or review the placement of the
			 information on the cost report.
(2)
			 Refusal of Cost Reports. Medicaid will refuse to accept cost reports prepared
			 by a cost report preparer who:
(a) Has shown a
			 pattern of negligent disregard of the principles established by or incorporated
			 by reference into this Code;
(b)
			 Prepares a cost report evidencing an intentional disregard of the Medicaid
			 Reimbursement Principles;
(c) Has
			 given false or misleading information, or participated in giving false or
			 misleading information to any Medicaid employee, the Alabama Medicaid Agency,
			 or to any hearing officer authorized to conduct hearings with regard to
			 Medicaid reimbursement issues, knowing such information to be false or
			 misleading. "Information" includes facts or other information contained in
			 testimony, Medicaid Cost Reports, financial statements, affidavits,
			 declarations, or any other documents or statements, written or oral.
(d) Medicaid will treat any cost report
			 prepared by a cost report preparer who has been determined to be ineligible to
			 prepare Medicaid cost reports as incomplete and shall promptly return any such
			 cost report to the provider on whose behalf the report has been prepared. The
			 receipt by Medicaid of such cost reports shall not satisfy, suspend, or stay
			 the requirements of this chapter relating to the timely filing of Medicaid Cost
			 Reports.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Appendix 560-X-22-A - FORMS

Current through Register Vol. 42, No. 9, June 28, 2024
APPENDIX A FORMS
1. Patient Count and Analysis Sheet
2. Mileage Log
3. Final Audit Computation
4. Composite Estimated Useful Lives of
			 Depreciable Hospital Assets
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.01 - Introduction

Current through Register Vol. 42, No. 9, June 28, 2024
(1) This chapter of
			 the
Alabama Medicaid Administrative
Code
has been promulgated by the Alabama Medicaid
			 Agency (Medicaid) as a guide for providers of Medicaid hospital care. This
			 chapter is applicable to all hospitals participating in the Alabama Medicaid
			 Program.
(See history at end of
				  chapter.)
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.02 - Definitions And Basic Concepts

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Access Payment: A payment by the Medicaid
			 program to an eligible hospital for inpatient and outpatient hospital care
			 provided to a Medicaid recipient.
(2) Hospital: For purposes of Medicaid base,
			 access and DSH payments for the period from October 1 through September 30 a
			 facility, which is licensed as a hospital under the laws of the State of
			 Alabama, provides 24-hour nursing services, and is primarily engaged in
			 providing, by or under the supervision of doctors of medicine or osteopathy,
			 inpatient services for the diagnosis, treatment, and care or rehabilitation of
			 persons who are sick, injured, or disabled.
(3) Cost Report: The electronic cost report
			 (ECR) filing of the CMS Form 2552-96 and 2552-10 Hospital and Hospital Health
			 Care Complex Cost Report, as defined in CMS Provider Reimbursement Manual (PRM)
			 15-11 (hereinafter referred to as "CMS form 2552").
(4) Privately Owned and Operated Hospital:
			 For purposes of Medicaid base, access and DSH payments for the period from
			 October 1 through September 30 a hospital in Alabama other than:
(a) Any hospital that is owned and operated
			 by the federal government;
(b) A
			 hospital that is a state agency or unit of state government, including without
			 limitation a hospital owned by a state agency or a state university.
(c) A hospital created and operating under
			 the authority of a governmental unit which has been established as a public
			 corporation pursuant to Chapter 21 of Title 22 or Chapter 95 of Title 11, or a
			 hospital otherwise owned and operated by a unit of local government.
(d) A hospital that limits services to
			 patients primarily to rehabilitation services as authorized by Alabama
			 Administrative Code
			 410-2-4-.08; or
(e) A hospital granted a Certificate of Need
			 as a Long Term Acute Care Hospital as defined by Alabama Administrative Code
			 410-2-4-.02(8).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.03 - Inpatient Medicaid Base Payment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For the period October 1 through
			 September 30 each hospital shall receive an inpatient Medicaid base (per diem)
			 payment, in accordance with the following:
(a) Medicaid shall pay a base (per diem)
			 amount to each hospital from all sources except DSH payments as described in
			 the Alabama Medicaid Agency State Plan and amendments the retoas currently
			 approved by the Hospital Serviced and Reimbursement Panel.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.04 - Inpatient Hospital Access Payments

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For the period October 1 through
			 September 30, the amount available for inpatient hospital access payments shall
			 be calculated as described in the Alabama Medicaid Agency State Plan and
			 amendments thereto as currently approved by the Hospital Services and
			 Reimbursement Panel.
See history at end of chapter.
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.06 - Disproportionate Share Hospital (DSH) Payments

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For the period from October 1 to
			 September 30, qualified hospitals, in accordance with
			 42 CFR
			 433.51(b), will be paid a
			 DSH payment as described in the Alabama Medicaid Agency State Plan and
			 amendments thereto as currently approved by the Hospital Services and
			 Reimbursement Panel.
See history note at end of
				  chapter.
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.07 - Calculation Of Medicaid Prospective Payment Inpatient Rate For Out-Of-State Hospitals

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Payment for inpatient services provided by allout-of-state hospitals shall be
			 calculated as described in the Alabama Medicaid Agency State Plan and
			 amendments thereto as currently approved by the Hospital Services and
			 Reimbursement Panel.
(See history at end of chapter.) Previous Rule .07,Grants,
				  Gifts, Private Donations Or The Income From Such Items,And Income From
				  Endowments was repealed and Rule .17 was renumbered to .07 as per certification
				  filed November 10, 2010; effective December 15,
				  2010.
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.08 - Outpatient Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Certified emergency room visits must be properly documented by the attending
			 licensed physician, nurse practitioner or physician assistant in the medical
			 record.
(2) Outpatient Medicaid
			 Base Payments. Outpatient Medicaid Base Payments will be calculated as
			 described in the Alabama Medicaid Agency State Plan and amendments thereto as
			 currently approved by the Hospital Services and Reimbursement Panel.
(3) Outpatient Access Payments. Outpatient
			 Access Payments will be calculated as described in the Alabama Medicaid Agency
			 State Plan and amendments thereto as currently approved by the Hospital
			 Services and Reimbursement Panel.
See history at end of
				  chapter.
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.09 - Medicare Catastrophic Coverage Act Day And Cost Outliers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Day Outliers -
			 The Alabama Medicaid Agency does not impose durational limits for medically
			 necessary inpatient services provided to children under the age of 6 years in
			 hospitals deemed by the Agency as disproportionate and under the age of 1 in
			 all hospitals. Because we pay for all medically necessary days of care for
			 these children, we meet the day outlier requirement of the Medicare
			 Catastrophic Coverage Act and no additional payments are available.
(2) Cost Outliers
(a) A cost outlier for an extremely costly
			 length of stay for a child under age 6 receiving medically necessary services
			 in a hospital deemed by the Alabama Medicaid Agency as disproportionate share
			 and under age 1 in all hospitals, is defined as a claim for payment for a
			 discharged child for allowable services rendered from the date of admission to
			 the date of discharge which meets the following criteria:
(b) The Medicaid allowed charges per day for
			 the length of stay for Medicaid eligible children as outlined above must exceed
			 four times the hospital's mean total charge per day as established by Medicaid
			 from Agency paid claim data.
(c)
			 Payment of Cost Outliers. The sum of allowed charges in excess of four times
			 the mean total charge per day shall be multiplied by the hospital's current
			 rate period percent of total Medicaid cost to total Medicaid charges (per
			 Worksheet C of the Medicaid Cost Report) to establish the amount to be paid as
			 a cost outlier. The outlier payment per Medicaid eligible child as outlined
			 above shall be limited to $10,000 per discharge and a total of $50,000 during
			 the per diem rate cycle October 1 through September 30.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.10 - The CMS 2552-96 Cost Report

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama Medicaid Agency uses the
			 electronic cost report (ECR) filing of the Form CMS-2552 Hospital and Hospital
			 Health Care Complex Cost Report, as defined in CMS Provider Reimbursement
			 Manual (PRM) 15-11 along with all accompanying schedules, forms and supporting
			 information (hereinafter referred to as "Form CMS 2552) for its Medicaid
			 program and all acute care hospitals must submit this report for fiscal years
			 as described in the Alabama Medicaid Agency State Plan and amendments thereto
			 as currently approved by the Hospital Services and Reimbursement
			 Panel.
(2) All Medicaid data
			 completed. The due date corresponds with the Medicare intermediary.
(3) Any extension or change to report period
			 must be reported to the Medicaid Provider Audit Division in writing.
(4) Late Filing - If a complete uniform cost
			 report is not filed by the due date, the hospital shall be charged a penalty of
			 one hundred dollars per day for each calendar day after the due date.
See history note at end of chapter.
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.11 - Other Matters

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The total
			 Medicaid cost per diems can be adjusted if the hospital experiences
			 extraordinary circumstances which may include, but are not limited to, an Act
			 of God, war, or civil disturbance. Adjustments to reimbursement rates may be
			 made in these and related circumstances at the discretion of the Alabama
			 Medicaid Commissioner.
(2) New
			 Hospital Facilities - A new facility shall submit a budget of cost for Medicaid
			 inpatient services for its initial cost reporting period. The Alabama Medicaid
			 Agency will determine a per diem rate from this budget. After the budget
			 period, an actual cost report will be filed for the budgeted period. The
			 Alabama Medicaid Agency will calculate a per diem rate in order to determine if
			 any under or overpayment has been made to the hospital.
(3) In a transfer which constitutes a change
			 of ownership, the old and new providers shall reach an agreement between
			 themselves concerning trade accounts payable, accounts receivable, and bank
			 deposits. Medicaid will pay the new provider for unpaid claims for services
			 rendered both prior to and after the change of ownership. The new provider
			 shall be liable to Medicaid for unpaid amounts due Medicaid from the old
			 provider.
(See history note at end of chapter.) Previous Rule .11, Cost
				  to Related Organizations was repealed and Rule .20 was renumbered to .11 as per
				  certification filed November 10, 2010; effective December 15,
				  2010.
Author:
Keith Boswell, Director, Provider
				  Audit/Reimbursement
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§ 401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.12 - Computation Of Return On Equity Capital (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of
				  chapter.)
Author:
Susan Mims
Statutory Authority:
State Plan, Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.13 - Costs Related To Patient Care (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Authors:
Susan Mims, Vicki W. Huff
Statutory Authority:
State Plan, Attachment
				  4.19A; Title XIX, Social Security Act; 42 C.F.R. §§ 401,
et seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.14 - Cost Finding And Apportionment Of Medicaid Cost Of Services (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of
				  chapter.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§ 401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.15 - Cost Reporting Of Medicaid Cost Of Services (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of
				  chapter.)
Authors:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.16 - Calculation Of Medicaid Prospective Payment Rates For Inpatient Claims (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of
				  chapter.)
Authors:
Susan Mims, Vicki W. Huff, Luann
				  McQueen
Statutory Authority:
State Plan; §1923,
				  Title XIX, Social Security Act; 42 C.F.R. §401,
et
				  seq
. Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.17 - Calculation Of Medicaid Prospective Payment Inpatient Rate Or Out-Of-State Hospitals (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of chapter.) Rule was renumbered to
				  .07 as per certification filed November 10, 2010; effective December 15,
				  2010.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.18 - Audit (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of
				  chapter.)
Author:
Susan Mims
Statutory Authority:
State Plan, Title XIX,
				  Social Security Act, 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.19 - Appeals (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of
				  chapter.)
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.20 - Other Matters (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
(See history note at end of chapter.) Rule was renumbered to
				  .11 as per certification filed November 10, 2010; effective December 15,
				  2010.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42 C.F.R. §§ 447.251-271,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-23 - HOSPITAL REIMBURSEMENT PROGRAM › Section 560-X-23-.21 - Determination Of Final Prospective Rate And Settlement Of Related Medicaid Cost Reports (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Original Chapter 560-X-23 (Rules
				  560-X-23-.01 through
				  560-X-23-.08) effective September
				  30, 1982.
Repealed and new chapter adopted in lieu thereof
effective June 9, 1986.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.01 - End Stage Renal Disease (ESRD) Services-General

Current through Register Vol. 42, No. 9, June 28, 2024
End Stage Renal Disease (ESRD) services are outpatient
				maintenance services, which may be provided by a freestanding ESRD facility or
				a renal dialysis center.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42
				  C.F.R.
				  §405.2102(e).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.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 payment
			 for services, ESRD facilities/centers must meet all the following requirements:
(a) Certification for participation in the
			 Title XVIII Medicare Program;
(b)
			 Approval by the appropriate licensing authority;
(c) Compliance with Title VI of the Civil
			 Rights Act of 1964 and with Section 504 of the Rehabilitation Act of
			 1973;
(d) Submission of a letter
			 requesting enrollment; and execution of a contract with the Alabama Medicaid
			 Agency;
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.03 - Coverage For Outpatient Maintenance Dialysis

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Maintenance dialysis treatments are
			 covered when they are provided by a Medicaid enrolled ESRD hospital-based renal
			 dialysis center or freestanding ESRD facility. The most common elements of a
			 dialysis treatment are overhead costs, personnel services (administrative
			 services, registered nurse, licensed practical nurse, technician, social
			 worker, dietician), equipment and supplies, use of a dialysis machine and its
			 maintenance, ESRD related laboratory tests, certain injectable drugs such as
			 heparin and its antidote, and biologicals. Reimbursement will be based on a
			 composite rate consisting of these elements.
(2) Hemodialysis is defined as the removal of
			 certain elements from the blood by virtue of the difference in the rates of
			 their diffusion through a semipermeable membrane while the blood is being
			 circulated outside the body. Limited to 156 sessions per year which provides
			 for three sessions per week.
(3)
			 Peritoneal dialysis is defined as a process by which waste products and excess
			 fluids are removed from the blood, but unlike hemodialysis where the blood
			 passes through a machine, peritoneal dialysis is done inside the body. There
			 are two types of peritoneal dialysis that will be covered.
(a) Continuous cycling peritoneal dialysis
			 (CCPD), which requires a machine, and
(b) Continuous ambulatory peritoneal dialysis
			 (CAPD), which does not require a machine. CAPD is a continuous dialysis process
			 that uses the patient's peritoneal membrane as a dialyzer. CCPD and CAPD are
			 furnished on a continuous basis, not in discrete sessions, and will be paid a
			 daily rate, not on a per treatment basis.
Author:
Jerri Jackson, RN Analyst, Institutional
				Services Unit
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.04 - Laboratory Services

Current through Register Vol. 42, No. 9, June 28, 2024
Laboratory tests listed below are considered routine and are
				included as part of the composite rate of reimbursement. All other medically
				necessary lab tests are considered nonroutine and must be billed directly by
				the actual provider of service.
(a)
			 Hemodialysis
1. Per treatment - All
			 hematocrit and clotting time tests furnished incidentally to dialysis
			 treatments.
2. Weekly - Prothrombin
			 time for patients on anticoagulant therapy; serum creatinine, BUN.
3. Monthly
Serum Calcium Serum Biocarbonate
Serum Potassium Serum Phosphorous
Serum Chloride Total Protein
Alkaline Phosphatase LDH
SGOT
Monthly.