Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.16 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama
			 Medicaid Agency will provide the operating agency with the approved level of
			 care determination process.
(2) The
			 operating agency will review the applicant's eligibility status to determine if
			 the applicant is medically eligible for waiver services. The target case
			 manager will assist the recipient to make financial application and ensure that
			 the appropriate documents are completed and routed to the appropriate Medicaid
			 District Office if the individual is not already eligible and enrolled in an
			 applicable Medicaid aid category. Financial eligibility must be certified by
			 Medicaid.
(3) The Waiver
			 Coordinator will complete the level of care determination and the case manager
			 will develop the plan of care.
(4)
			 The operating agency is required to adhere to all federal and state guidelines
			 in the determination of the level of care approval.
(5) The operating agency or its designee
			 (case manager), will ensure that the applicant has been screened and assessed
			 to determine if the services provided through the LAH Waiver will meet the
			 applicant's needs in the community.
(6) The Alabama Department of Mental Health
			 (ADMH) is responsible for the assessment, evaluation of admissions,
			 readmissions, and annual redeterminations for eligible participants receiving
			 home and community based services in accordance with the provisions of the
			 Living at Home Waiver.
(7) The
			 Alabama Medicaid Agency will provide to the ADMH/MR the approved Level of Care
			 criteria and policies and procedures governing the level of care determination
			 process.
(8) ADMH/MR may utilize
			 Medicaid staff for consultation on questionable admissions and annual
			 redeterminations prior to a final decision being rendered.
(9) The Alabama Medicaid Agency will conduct
			 a retrospective review on a monthly basis of a random sample of individuals
			 served under the Living at Home Waiver to determine appropriate admissions and
			 annual redeterminations. This review includes whether appropriate documentation
			 is present and maintained and whether all state and federal medical necessity
			 and eligibility requirements for the program are met. The Waiver Quality
			 Assurance Unit conducts a 5% sample of plans of care and related documents
			 annually for each provider.
(10)
			 The Alabama Medicaid Agency will initiate recoupment of payment for services
			 when it determines that state and federal, medical necessity, and eligibility
			 requirements are not met.
(11) The
			 Alabama Medicaid Agency may seek recoupment from ADMH/MR for other services
			 reimbursed by Medicaid for those individuals whom Medicaid determines would not
			 have been eligible for the Living at Home Waiver services or Medicaid
			 eligibility but for the certification of waiver eligibility by ADMH.
(12) The operating agency or its designee
			 will develop a plan of care that includes waiver as well as non-waiver
			 services.
(13) Upon receipt of the
			 financial award letter from the Alabama Medicaid Agency, the LTC Admissions
			 Notification Form should be completed and forwarded to Medicaid's Fiscal Agent
			 electronically. Medicaid's Fiscal Agent will either accept or reject the
			 transmission of the LTC Admissions Notification Form. The operating agency or
			 its designee will receive notice of the status of applications transmitted the
			 next business day following the transmission.
(14) If Medicaid's Fiscal Agent accepts the
			 transmission, the information is automatically written to the Level of Care
			 file. The operating agency or its designee can begin rendering services and
			 billing the Alabama Medicaid Agency for services rendered.
(15) If Medicaid's Fiscal Agent rejects the
			 transmission, the operating agency or its designee must determine the reason
			 for the rejection and retransmit the LTC Admissions Notification
			 Form.
(16) Neither the Alabama
			 Medicaid Agency nor Medicaid's Fiscal Agent will send out the LTC-2
			 Notification letters. The record of successful transmission will be the record
			 of "approval" to begin rendering service.
(17) For applications where the level of care
			 is questionable, providers may submit the applications to the Long Term Care
			 Quality Assurance Unit for review by a nurse and/or a Medicaid
			 physician.
(18) Once the
			 individual's information has been added to the Level of Care File, changes can
			 only be made by authorized Medicaid staff.
Author:
Samantha McLeod, Associate Director,
				  Long Term Care Specialized Waiver Programs
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R.
Section 441, Subpart G-Home and Community-Based Services:
				  Waiver Requirements.