reglab/statecodes huggingface dataset:
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 10 - Post Eligibility and Cost of Care › 7 AAC 100.570 - Retroactive cost-of-care adjustments

Current through May 31, 2024
At any time, the department may make a retroactive
					 adjustment to a recipient's cost-of-care liability to compensate for a
					 previously understated or overstated cost-of-care determination. If retroactive
					 adjustment results in a larger liability for the recipient, the department will
					 notify the recipient of the amount of the adjustment before making the
					 adjustment.
Authority:
AS
						47.05.010
AS 47.07.020
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 10 - Post Eligibility and Cost of Care › 7 AAC 100.579 - Definitions related to post-eligibility

Current through May 31, 2024
In
					 7 AAC 100.550 -
					 7 AAC 100.579, unless the context requires
					 otherwise,
(1) "available income"
				  means income to which a community spouse has access and over which a community
				  spouse has control;
(2) "dependent
				  child" means the minor child of the recipient who lives with the community
				  spouse and who may be claimed by either spouse as a dependent for income tax
				  purposes;
(3) "dependent parent"
				  means a parent of either spouse who resides with the community spouse and who
				  may be claimed by either spouse as a dependent for income tax
				  purposes;
(4) "extreme financial
				  duress" means the needs of the individual that are not normally associated with
				  the basic living expenses of an individual living in that community would not
				  be provided if not paid for by the individual, and if not provided would result
				  in the individual being unable to live independently in the
				  community;
(5) "swing-bed facility"
				  means a facility that includes hospital beds that can be used interchangeably
				  to promote either acute, skilled nursing, or intermediate care.
Authority:
AS
						47.05.010
AS 47.07.020
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.600 - Applicability of Medicaid trust provisions

Current through May 31, 2024
(a) The provisions
				  of 7 AAC 100.600 -
				  7 AAC 100.619 apply to an individual who is eligible for
				  Medicaid under an eligibility category identified in
				  7 AAC 100.002(a) - (e). However, an
				  applicant or recipient may not use a recognized Medicaid trust under
				  7 AAC 100.604 to meet income and resource requirements
				  for eligibility categories identified in
				  7 AAC 100.002(e).
(b) For the purposes of
				  7 AAC 100.600 -
				  7 AAC 100.619, an applicant or recipient is the grantor
				  of a trust if
(1) any amount of the
				  applicant's or recipient's assets is used to form all or part of the corpus of
				  the trust; and
(2) the trust is
				  created by
(A) the applicant or
				  recipient;
(B) the applicant's or
				  recipient's spouse;
(C) an
				  individual authorized to act on behalf of the applicant or recipient or
				  applicant's or recipient's spouse; or
(D) a court order.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.602 - General trust rules

Current through May 31, 2024
(a) Except as provided under
				  7 AAC 100.604, if an applicant or recipient is the
				  grantor of a revocable trust,
(1) the entire
				  principal counts as an available resource to the applicant or
				  recipient;
(2) a payment from the
				  trust to, or for the benefit of, the applicant or recipient is income to the
				  applicant or recipient; and
(3) a
				  payment or a partial payment from the trust to a third party that does not
				  benefit the applicant or recipient is a transfer of an asset for less than fair
				  market value under
				  7 AAC 100.510.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.604 - Recognized Medicaid trusts

Current through May 31, 2024
(a) The following
				  three types of recognized Medicaid trusts are exceptions to the general trust
				  requirements in
				  7 AAC 100.602
				  for trusts:
(1) a qualifying income trust
				  authorized under
				  42 U.S.C.
				  1396 p(d)(4)(B) that meets the requirements
				  of
				  7 AAC
				  100.610;
(2) a special needs trust authorized under
				  42 U.S.C.
				  1396 p(d)(4)(A) that meets the requirements
				  of
				  7 AAC
				  100.612;
(3) a pooled trust authorized under
				  42 U.S.C.
				  1396 p(d)(4)(C) that meets the requirements
				  of
				  7 AAC
				  100.614.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.606 - Recognized Medicaid trust; effect on financial eligibility

Current through May 31, 2024
(a) A payment that
				  would otherwise be available to an applicant or recipient that is deposited
				  directly into a recognized Medicaid trust account, or earnings of the trust
				  account that remain in the trust account, is not income for the purposes of
				  determining Medicaid eligibility.
(b) A payment or deposit of an asset
				  belonging to the applicant or recipient that is placed into the applicant's or
				  recipient's special needs trust or pooled trust is not a countable resource for
				  the purposes of determining Medicaid eligibility.
(c) A payment made by the trustee from the
				  trust account to the applicant or recipient is income according to the
				  provisions of this chapter that are applicable to the applicant's or
				  recipient's eligibility category.
(d) For eligibility categories identified
				  under 7 AAC 100.002(b) or (d), a payment made from a recognized
				  Medicaid trust directly to a third-party vendor is not a transfer of asset for
				  less than fair market value and is not income to the applicant or recipient if
				  the payment is not accessible to the applicant or recipient and the payment is
(1) for a product or service that provides a
				  direct and measurable contribution to the applicant or recipient under (g) of
				  this section;
(2) to a medical
				  facility to pay for the applicant's or recipient's cost-of-care obligation;
				  or
(3) for medical care of a
				  community spouse.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.608 - Medicaid reimbursement from a recognized Medicaid trust

Current through May 31, 2024
(a) If a recognized
				  Medicaid trust terminates by death of the recipient or by court order, a
				  recognized Medicaid trust may pay for any outstanding legal and administrative
				  fees associated with establishing and maintaining the trust and trust account
				  before paying the state under (b) of this section.
(b) A recognized Medicaid trust document must
				  provide that upon termination of the trust by death of the recipient, any money
				  remaining in the trust must be paid to the state, up to the amount the state
				  paid in Medicaid benefits for the recipient while the trust existed. If a
				  recipient has received Medicaid in more than one state, the trust document must
				  provide that the money remaining in the trust be distributed to each state in
				  which the recipient received Medicaid based on the state's proportionate share
				  of the total amount of Medicaid benefits paid by all of the states on the
				  recipient's behalf.
(c) If a court
				  terminates a trust before the death of the recipient, the state must be
				  reimbursed according to (b) of this section, or the corpus of the trust must be
				  placed in another recognized Medicaid trust approved by the department. Once a
				  court terminates a recognized Medicaid trust, the trust may not be used
				  again.
(d) A trustee may make
				  advance payments on the trust obligation to reimburse the state. The department
				  will credit each advance payment against the recipient's obligation under (b)
				  of this section.
Authority:
AS
						47.05.010
AS 47.07.020
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.610 - Qualifying income trust

Current through May 31, 2024
To be approved by the department, a qualifying income
					 trust
(1) must consist exclusively of
				  income to the applicant or recipient, including accumulated interest;
(2) must be irrevocable;
(3) may not contain an asset other than
				  income;
(4) must terminate upon a
				  court order or the death of the recipient, whichever is earlier; and
(5) must provide for reimbursement to the
				  state under
				  7 AAC 100.608.
Authority:
AS
						47.05.010
AS 47.07.020
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.612 - Special needs trust

Current through May 31, 2024
(a) To be approved by the department, a
				  special needs trust must
(1) be established
				  for the sole benefit of the applicant or recipient who is under 65 years of age
				  and who is blind under
				  7 AAC 40.140(a) or disabled under
				  7 AAC 40.170(a);
(2) consist exclusively of the income and
				  resources of the applicant or recipient;
(3) be irrevocable;
(4) terminate upon a court order or the death
				  of the recipient, whichever is earlier; and
(5) provide for reimbursement to the state
				  under 7 AAC 100.608.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.614 - Pooled trust

Current through May 31, 2024
(a) To be approved by the department, a
				  pooled trust must
(1) be established and
				  managed by a nonprofit association;
(2) contain the assets of beneficiaries who
				  are blind under
				  7 AAC 40.140(a) or disabled under
				  7 AAC 40.170(a);
(3) maintain a separate account for each
				  beneficiary of the trust; the separate account must be established for the sole
				  benefit of the individual beneficiary; for purposes of this paragraph, a
				  separate account is established for the sole benefit of the beneficiary if no
				  person other than the beneficiary benefits from the trust account or a payment
				  from the trust account during the trust account's existence, except as provided
				  in (6) of this subsection;
(4) be
				  irrevocable;
(5) require that each
				  beneficiary's trust account terminate upon a court order or the death of that
				  beneficiary, whichever is earlier; and
(6) provide that any money remaining in a
				  beneficiary's trust account that is not used by the nonprofit association to
				  maintain the pooled trust be paid to the state, up to the total amount of
				  Medicaid paid on behalf of the beneficiary.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 11 - Medicaid Treatment of Trusts › 7 AAC 100.619 - Definitions

Current through May 31, 2024
In
					 7 AAC 100.600 -
					 7 AAC 100.619, unless the context requires
					 otherwise,
(1) "beneficiary" means an
				  individual designated by a trust document to receive the benefits of the
				  trust;
(2) "irrevocable trust"
				  means a trust that, absent a court order, may not be revoked or modified by a
				  grantor, beneficiary, or trustee;
(3) "recognized Medicaid trust" means a
				  qualifying income trust under
				  7 AAC 100.610, a special needs trust under
				  7 AAC 100.612, or a pooled trust under
				  7 AAC 100.614;
(4) "revocable trust" means a trust that may
				  be revoked or modified by the grantor;
(5) "trust" means a valid legal arrangement,
				  manifested by a trust document or agreement, in which a grantor transfers
				  income or resources to a trustee to be held, managed, or administered by a
				  trustee for the benefit of a beneficiary;
(6) "trustee" means an individual or entity
				  that holds, manages, and administers trust property according to the terms of
				  the trust and for the benefit of a beneficiary.
Authority:
AS
						47.05.010
AS 47.07.020
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 12 - Specialized Medicaid Eligibility Categories › 7 AAC 100.700 - Emergency treatment for aliens

Current through May 31, 2024
(a) An alien who is
				  ineligible for full Medicaid coverage because the alien does not meet the
				  requirements of
				  7 AAC 100.050 may apply for limited coverage under
				  7 AAC 100.002(f) if the alien is a
				  resident of the state under
				  7 AAC 100.060 and would otherwise be eligible under any
				  one of the eligibility categories in
				  7 AAC 100.002(a) - (d).
(b) The following eligibility requirements do
				  not apply to a determination of eligibility under this section:
(1) social security number requirements under
				  7 AAC 100.030;
(2) development of income under
				  7 AAC 100.032;
(3) verification of citizenship and alien
				  status under
				  7 AAC 100.050;
(4) deeming of a sponsor's income or
				  resources under
				  7 AAC 100.136,
				  7 AAC 100.176, or
				  7 AAC 100.400(a) (12).
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 12 - Specialized Medicaid Eligibility Categories › 7 AAC 100.710 - Breast and cervical cancer group

Current through May 31, 2024
(a) To be eligible
				  under 7 AAC 100.002(d) (7), a woman must
(1) at the time of application, have been
				  screened through the department's Breast and Cervical Health Check program or
				  through a similar program from another state that is part of the United States
				  Department of Health and Human Services, Centers for Disease Control and
				  Prevention National Breast and Cervical Cancer Early Detection
				  program;
(2) as a result of the
				  screening under (1) of this subsection, have been determined to need treatment
				  for breast, cervical, or directly related cancer;
(3) be a resident of the state under
				  7 AAC 100.060;
(4) comply with the assignment of rights
				  requirements of
				  7 AAC 100.034;
(5) comply with the requirements of
				  7 AAC 100.050;
(6) be ineligible under all other Medicaid
				  eligibility categories;
(7) be
				  under 65 years of age; and
(8) have
				  no creditable coverage for treatment of breast or cervical cancer.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 13 - Medicare Premium Assistance Categories › 7 AAC 100.750 - Scope of Medicare premium assistance categories

Current through May 31, 2024
(a) The Medicaid
				  coverage available under the eligibility categories listed in
				  7 AAC 100.002(e) is limited to
				  assistance with the cost of Medicare premiums, deductibles, and coinsurance as
				  provided under each category. Medicaid covered services described in 7 AAC 105
				  - 7 AAC 160 are not provided under this section.
(b) Except as otherwise provided in
				  7 AAC 100.750 -
				  7 AAC 100.758, eligibility under
				  7 AAC 100.002(e) is determined under
				  the provisions of 7 AAC 40 listed in
				  7 AAC 100.400(a).
(c) When determining financial eligibility,
				  the department will disregard the annual cost-of-living increase in OASDI
				  benefits that is implemented January 1 of each year, until the federal poverty
				  guidelines for this state are implemented by United States Department of Health
				  and Human Services for that year.
Authority:
AS
						47.05.010
AS 47.07.020
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 13 - Medicare Premium Assistance Categories › 7 AAC 100.752 - Qualified Medicare beneficiary

Current through May 31, 2024
(a) To be eligible
				  for Medicaid coverage as a qualified Medicare beneficiary under
				  7 AAC 100.002(e) (1), an individual
				  must
(1) be eligible for and enrolled in
				  Medicare Part A hospitalization coverage;
(2) have total monthly income that does not
				  exceed 100 percent of the federal poverty guidelines for this state, adopted by
				  reference in
				  7 AAC 100.980;
(3) have countable resources that do not
				  exceed $4,000 for an individual living alone or $6,000 for spouses living
				  together; and
(4) meet all other
				  nonfinancial eligibility requirements under
				  7 AAC 100.400.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 13 - Medicare Premium Assistance Categories › 7 AAC 100.754 - Special low-income Medicare beneficiary

Current through May 31, 2024
(a) To be eligible
				  for Medicaid coverage as a special low-income Medicare beneficiary under
				  7 AAC 100.002(e) (3), an individual
				  must
(1) be eligible for and enrolled in
				  Medicare Part A hospitalization coverage;
(2) have total monthly income that does not
				  exceed 120 percent of the federal poverty guidelines for this state, adopted by
				  reference in
				  7 AAC 100.980;
(3) have countable resources that do not
				  exceed $4,000 for an individual living alone or $6,000 for spouses living
				  together; and
(4) meet all other
				  nonfinancial eligibility requirements under
				  7 AAC 100.400.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 13 - Medicare Premium Assistance Categories › 7 AAC 100.756 - Special low-income Medicare beneficiary qualifying individual

Current through May 31, 2024
(a) To be
				  eligible as a special low-income Medicare beneficiary qualifying individual
				  under 7 AAC 100.002(e) (4), an individual must
(1) be eligible for and enrolled in Medicare
				  Part A hospitalization coverage;
(2) have total monthly income that does not
				  exceed 135 percent of the federal poverty guidelines for this state, adopted by
				  reference in
				  7 AAC 100.980;
(3) have countable resources that do not
				  exceed $4,000 for an individual living alone or $6,000 for spouses living
				  together; and
(4) meet all other
				  nonfinancial eligibility requirements under
				  7 AAC 100.400.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 13 - Medicare Premium Assistance Categories › 7 AAC 100.758 - Qualified disabled and working individual

Current through May 31, 2024
(a) To be eligible
				  for coverage as a qualified disabled and working individual under
				  7 AAC 100.002(e) (2), an individual
				  must
(1) have lost SSDI because of
				  earnings;
(2) continue to have the
				  same blindness or disability that contributed to the individual's former
				  eligibility for SSDI;
(3) be
				  eligible for and enrolled in Medicare Part A hospitalization coverage with the
				  payment of premiums;
(4) have total
				  monthly income that does not exceed 200 percent of the federal poverty
				  guidelines for this state, adopted by reference in
				  7 AAC 100.980;
(5) have countable resources that do not
				  exceed $4,000 for an individual living alone or $6,000 for spouses living
				  together;
(6) meet all other
				  nonfinancial eligibility requirements under
				  7 AAC 100.400; and
(7) be ineligible under all other Medicaid
				  eligibility categories.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 14 - Recipient Rights and Responsibilities, and Program Integrity › 7 AAC 100.900 - Recipient obligation to report changes

Current through May 31, 2024
(a) A Medicaid
				  recipient eligible under
				  7 AAC 100.002(a) or (c) must report to
				  the department any change in the household that may affect the household's
				  eligibility within 10 days after the date the recipient knows of the change.
				  Changes affecting a household or individual included in the household that must
				  be reported under this section include
(1) a
				  new mailing address for the household;
(2) an individual who could be included in
				  the household moving into or out of the home;
(3) acquiring or disposing of a
				  vehicle;
(4) a cash or account
				  balance that exceeds $2,000;
(5)
				  starting or stopping a job;
(6) a
				  change in salary or wage;
(7) a
				  change in employment from part-time to full-time, or from full-time to
				  part-time;
(8) starting, stopping,
				  or changing health insurance coverage;
(9) a single change in unearned income
				  greater than $50; and
(10) a change
				  in a household member's child support obligation.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 14 - Recipient Rights and Responsibilities, and Program Integrity › 7 AAC 100.905 - Special reviews

Current through May 31, 2024
(a) In addition to the Medicaid eligibility
				  review under
				  7 AAC 100.020, the department may conduct a special
				  review of the eligibility of a recipient or recipient's household in the same
				  manner that the department determines the eligibility of a new applicant if the
				  department has reason to question the information on file or the eligibility of
				  the recipient under (b) of this section. As part of a special review, the
				  department may include requiring
(1) that a
				  new application be completed and signed;
(2) an in-person interview;
(3) documentation of all eligibility factors,
				  including those not subject to change; and
(4) a review of any other factor or matter
				  relevant to the recipient's eligibility.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 14 - Recipient Rights and Responsibilities, and Program Integrity › 7 AAC 100.910 - Recovery of Medicaid expenditures

Current through May 31, 2024
(a) The department
				  will issue a written recovery notice to an individual, and will seek to recover
				  Medicaid expenditures from that individual, if Medicaid expenditures are made
				  on behalf of that individual and that individual
(1) is determined under
				  7 AAC 100.912, to have
(A) committed an intentional program
				  violation that resulted in Medicaid expenditures for health care services to
				  which the individual was not entitled;
(B) committed program abuse that resulted in
				  misuse or overuse of Medicaid benefits; or
(C) engaged in conduct
(i) giving rise to an offense under AS 11,
				  AS
				  17.30.080, or
				  AS
				  47.05.210 for which the individual was
				  convicted; and
(ii) related to
				  obtaining Medicaid benefits;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 14 - Recipient Rights and Responsibilities, and Program Integrity › 7 AAC 100.912 - Intentional program violations, program abuse, and criminal offenses

Current through May 31, 2024
(a) If
				  the department has reason to believe that an individual has committed an
				  intentional program violation or program abuse, the department will conduct a
				  full investigation in accordance with
				  42 C.F.R.
				  455.15. If, after a full investigation, the
				  department determines that an individual applying for or receiving Medicaid
				  benefits has committed an intentional program violation or program abuse, the
				  department may
(1) deny an application for
				  Medicaid, subject to a hearing under 7 AAC 49;
(2) proceed with recovery of Medicaid
				  expenditures in accordance with
				  7 AAC 100.910, including a hearing under 7 AAC 49;
				  and
(3) refer the matter to the
				  appropriate authorities for civil or criminal action in a state or federal
				  court.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 7 - Medicaid Assistance Eligibility › Chapter 100 - Medicaid Eligibility › Article 15 - General Provisions › 7 AAC 100.990 - Definitions

Current through May 31, 2024
In this chapter, unless the context requires
					 otherwise,
(1) "AB" means aid to the
				  blind under former 42 U.S.C.
				  1201 (Title X of the Social Security
				  Act);
(2) "adoption" means the
				  establishment of a parent-child relationship between a child and an adult who
				  is not the child's birth parent and that is recognized by law, including an
				  adoption established by order of a state court, an adoption established by
				  order of a tribal court with respect to an "Indian child" within the meaning
				  given in 25 U.S.C.
				  1903 (Indian Child Welfare Act), and an
				  adoption under tribal custom;
(3)
				  "adoptive" means a relationship that exists as a result of an
				  adoption;
(4) "Adult Public
				  Assistance" means the program under
				  AS
				  47.25.430-47.25.615 that provides monthly
				  cash assistance to eligible aged, blind, and disabled persons in need; for
				  purposes of this chapter, "Adult Public Assistance" does not include interim
				  assistance under
				  AS
				  47.25.455;
(5) "advanced nurse practitioner" means an
				  individual
(A) licensed under AS 08.68 as an
				  advanced nurse practitioner; or
(B)
				  who is authorized by federal law to practice as an advanced nurse practitioner
				  without a license issued under AS 08.68, including federal employees and
				  individuals working under contract with the United States;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 1 - Medicaid Program; Scope and Authorization of Service › 7 AAC 105.100 - Covered services

Current through May 31, 2024
The department will pay for a service only if that
					 service
(1) is identified as a covered
				  service in accordance with AS 47.07 and 7 AAC 105 - 7 AAC 160;
(2) is provided to an individual who is
				  eligible for Medicaid under 7 AAC 100 on the date of service;
(3) is ordered or prescribed by a provider
				  authorized to order or prescribe that service under applicable law;
(4) is provided by a person who is enrolled
				  as a Medicaid provider or rendering provider under
				  7 AAC 105.210, or otherwise eligible to receive payment
				  for services under 7 AAC 105 - 7 AAC 160;
(5) is medically necessary as determined by
				  criteria established under 7 AAC 105 - 7 AAC 160 or by the standards of
				  practice applicable to the provider;
(6) has received prior authorization from the
				  department, if prior authorization is required under 7 AAC 105 - 7 AAC 160;
				  and
(7) is not specifically
				  excluded as a noncovered service under 7 AAC 105 - 7 AAC 160.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 1 - Medicaid Program; Scope and Authorization of Service › 7 AAC 105.110 - Noncovered services

Current through May 31, 2024
Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the
					 department will not pay for a service that is
(1) not reasonably necessary for the
				  diagnosis and treatment of an illness or injury, or for the correction of an
				  organic system, as determined upon review by the department or that is not
				  identified in a screening required under
				  7 AAC 110.205;
(2) not properly prescribed or medically
				  necessary in accordance with criteria established under 7 AAC 105 - 7 AAC 160
				  or by standards of practice applicable to the prescribing provider;
(3) incurred for an evaluative or periodic
				  checkup, examination, or immunization
(A) that
				  is in connection with the participation, enrollment, attendance, or
				  accomplishment of a program or activity unrelated to the recipient's physical
				  or mental health or rehabilitation; or
(B) unless it is
(i) an adult preventive service covered under
				  7 AAC 110.800;
(ii) part of an EPSDT screening; or
(iii) required by the department for the
				  purpose of determining eligibility for Medicaid;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 1 - Medicaid Program; Scope and Authorization of Service › 7 AAC 105.120 - Out-of-state covered services

Current through May 31, 2024
(a) Unless
				  otherwise provided in 7 AAC 105 - 7 AAC 160, the department will cover a
				  service provided out of state to the same extent it would cover the service
				  provided in this state if
(1) the service is
				  provided to a recipient who is a resident of this state; and
(2) the department is able to verify one of
				  the following situations:
(A) the recipient
				  requires a medical service that is not available in this state or the provision
				  of that service out of state is more cost-effective;
(B) the medical service is needed due to a
				  medical emergency while a recipient is out of state and the recipient's health
				  would be endangered if the recipient were required to travel to this state for
				  the needed medical service;
(C)
				  laboratory specimens are sent out of state because
(i) the laboratory service is not offered in
				  this state;
(ii) the laboratory
				  service is more readily available out of state; or
(iii) to have the laboratory work performed
				  out of state is more cost-effective.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 1 - Medicaid Program; Scope and Authorization of Service › 7 AAC 105.130 - Services requiring prior authorization

Current through May 31, 2024
(a) Except as
				  otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for
				  the following services unless the department has given prior authorization for
				  the service:
(1) nonemergency, medically
				  necessary transportation and accommodation services;
(2) a specific health care service for which
				  prior authorization is specifically required under 7 AAC 105 - 7 AAC
				  160;
(3) a service that exceeds an
				  annual or periodic service limitation established in 7 AAC 105 - 7 AAC
				  160;
(4) an item of durable medical
				  equipment, supplies, or hearing items identified in 7 AAC 105 - 7 AAC 160 as
				  requiring prior authorization;
(5)
				  respiratory therapy;
(6) home
				  health care services under
				  7 AAC 125.300 -
				  7 AAC 125.399;
(7) home infusion therapy services;
(8) private-duty nursing services;
(9) hospice care services;
(10) magnetic resonance imaging (MRl),
				  magnetic resonance angiogram (MRA), single-photon emission computerized
				  tomography (SPECT), and positron emission tomography (PET);
(11) an inpatient or outpatient procedure or
				  diagnosis, regardless of the length of stay, identified in the English
				  description of diagnoses and procedures in the
Select Diagnoses and
				  Procedures Pre-certification List
, adopted by reference in
				  7 AAC 160.900;
(12) an inpatient hospital continued stay
				  that exceeds an applicable limitation in
				  7 AAC 140.320 on length of hospitalization;
(13) a prescription drug identified on the
Alaska Medicaid Prior-authorized Medications List
, adopted by
				  reference in
				  7 AAC 160.900;
(14) an inpatient psychiatric hospital
				  admission in accordance with
				  7 AAC 140.360;
(15) a residential psychiatric treatment
				  center admission or continued stay in accordance with
				  7 AAC 140.405;
(16) an administrative-wait or swing-bed stay
				  at a general acute care hospital;
(17) a long-term care facility admission or
				  continued stay;
(18) home and
				  community-based waiver services under 7 AAC 130;
(19) personal care services under
				  7 AAC 125.010 -
				  7 AAC 125.199;
(20) behavioral health services identified in
				  7 AAC 135 as requiring prior authorization.
(21) surgical procedures to alter a
				  recipient's body to conform to the recipient's gender identity;
(22) therapy services identified in
				  7 AAC 115.110,
				  7 AAC 115.210,
				  7 AAC 115.310, and
				  7 AAC 115.410 as requiring prior
				  authorization.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 1 - Medicaid Program; Scope and Authorization of Service › 7 AAC 105.140 - Covered services during declared disaster emergency

Current through May 31, 2024
(a) Notwithstanding
				  the provisions of
				  7 AAC 105.610,
				  7 AAC 110.750,
				  7 AAC 120.112,
				  7 AAC 145.400, and
				  7 AAC 145.410, the department may make adjustments to
				  covered services listed under (b) of this section for the length of a declared
				  disaster emergency if
(1) the governor issues
				  a disaster emergency declaration for the state or a region within the state
				  under
				  AS
				  26.23.020;
(2) the federal government issues a related
				  disaster declaration or declaration of national emergency for the state or a
				  region within the state under
				  42 U.S.C.
				  5121-
				  5207 (Stafford
				  Disaster Relief and Emergency Assistance Act) or
				  50 U.S.C.
				  1601-
				  1651
				  (National Emergencies Act) and the Secretary of the United States Department of
				  Health and Human Services invokes authority under
				  42
				  U.S.C. 1320b-5(b) (sec.
				  1135(b) of the Social Security Act), with respect to the secretary's
				  declaration of a public health emergency as described under
				  42
				  U.S.C. 1320b-5(b) and
				  (g)(1), to waive or modify certain
				  requirements of titles XVIII, XIX, and XXI of the Social Security Act as a
				  result of the disaster declaration; and
(3) the state either
(A) applies for and receives an approved
				  disaster relief state plan amendment, authorized under
				  42
				  U.S.C. 1320b-5, based on the disaster
				  emergency declaration, to make the changes provided for in this section;
				  or
(B) has existing state plan
				  authority from CMS to exercise the provisions of (b) of this section during a
				  declared disaster emergency.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.200 - Eligible Medicaid providers

Current through May 31, 2024
(a) Subject to all
				  other requirements of 7 AAC 105 - 7 AAC 160, the following types of providers
				  are eligible to enroll with the department and bill directly for services
				  rendered:
(1) a person with an active license
				  under AS 08, or under the laws of the jurisdiction in which the person provides
				  services, to practice as
(A) a physician,
				  including an osteopath;
(B) a
				  podiatrist;
(C) a
				  dentist;
(D) an
				  optometrist;
(E) a
				  chiropractor;
(F) a pharmacist or
				  retail pharmacy;
(G) a physical
				  therapist;
(H) an occupational
				  therapist;
(I) an
				  audiologist;
(J) a speech-language
				  pathologist;
(K) an advanced
				  practice registered nurse;
(L) a
				  direct-entry midwife;
(M) a
				  dietitian;
(N) a
				  nutritionist;
(O) a
				  psychologist;
(P) a hearing aid
				  dealer;
(Q) a registered nurse
				  anesthetist; or
(R) a behavior
				  analyst;
(S) a clinical social
				  worker;
(T) a marital and family
				  therapist;
(U) a licensed
				  professional counselor;
(V) a
				  licensed dental hygienist who holds an advanced practice permit issued by the
				  Board of Dental Examiners under
				  AS
				  08.32.125;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.210 - Provider enrollment requirements

Current through May 31, 2024
(a) An eligible
				  provider shall enroll with the department before billing the department for
				  payment of services covered under 7 AAC 105 - 7 AAC 160 that are provided to
				  recipients.
(b) To be enrolled in
				  this state, a provider
(1) must submit a
				  completed provider enrollment form and provider information submission
				  agreement on forms provided by the department;
(2) must verify that the provider meets all
				  other applicable requirements of 7 AAC 105 - 7 AAC 160 and all applicable
				  federal and state licensing and certification requirements;
(3) must comply with all federal and state
				  laws as they apply to providing health care or related services to Medicaid
				  recipients in this state, including laws related to recipient confidentiality,
				  electronic transactions, and civil rights;
(4) must assume responsibility for all
				  information and claims submitted to the department by that provider or that
				  provider's billing agent;
(5) must
				  agree to submit claims in the form or format required by the department for
				  claim submission;
(6) must comply
				  with the requirements of
				  AS
				  47.05.300 -
				  47.05.390 and
				  7 AAC 10.900 -
				  7 AAC 10.990 (barrier crimes and conditions; background
				  checks), if applicable to that provider type; and
(7) if an out-of-state provider, must
(A) verify enrollment in the Medicaid program
				  in the jurisdiction in which services are provided if Medicaid enrollment is
				  available for that type of provider in that jurisdiction; or
(B) provide documentation from the
				  jurisdiction in which the provider provides services that Medicaid enrollment
				  is not available in the jurisdiction for that type of provider.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.220 - Provider responsibilities

Current through May 31, 2024
(a) Providing
				  medical or medically related services to recipients or billing the department
				  for those services constitutes agreement by the provider to
(1) comply with all applicable federal and
				  state laws related to providing medical or medically related services to
				  Medicaid recipients in this state, including laws related to recipient
				  confidentiality, electronic transactions, scope of practice, and civil
				  rights;
(2) submit claims in the
				  form or format required by the department for claim submission; and
(3) cooperate in reports, surveys, reviews,
				  or audits conducted by the department.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.230 - Requirements for provider records

Current through May 31, 2024
(a) A provider
(1) shall maintain accurate financial,
				  clinical, and other records necessary to support the services for which the
				  provider requests payment;
(2)
				  shall ensure that the provider's staff, billing agent, or other entity
				  responsible for the maintenance of the provider's financial, clinical, and
				  other records meets the requirements of this section; and
(3) may not submit a claim to the department
				  for payment for services unless to be provider's records are kept and
				  maintained in accordance with this section.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.240 - Request for records

Current through May 31, 2024
(a) At the request of the department, the
				  department's fiscal agent, the Department of Law, or a representative of the
				  United States Department of Health and Human Services, Centers for Medicare and
				  Medicaid Services (CMS), a provider shall provide the records described in
				  7 AAC 105.230(b) - (d). The provider
				  shall provide the records that are the subject of the request
(1) to the person making the request at the
				  address specified in the request;
(2) no later than the deadline for production
				  of the record that is specified in the request, unless the deadline is modified
				  or extended under (c) of this section;
(3) without charge; and
(4) in the form stated in the
				  request.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.250 - Payment from other sources

Current through May 31, 2024
When payment is received by a provider from a recipient,
					 relative, recipient's estate, health insurance, or other source, for a covered
					 service that has been or will be paid for by the department, the provider must
					 refund or credit to the department an equivalent amount, up to the department's
					 liability, or the provider will be subject to recoupment under
					 7 AAC 105.260.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.260 - Recouping an overpayment

Current through May 31, 2024
(a) An overpayment
				  occurs when the department pays a provider
(1) for a service without prior authorization
				  when prior authorization is required under 7 AAC 105 - 7 AAC 160;
(2) an amount that exceeds the maximum
				  dollars or units allowed under 7 AAC 105 - 7 AAC 160;
(3) for a service not covered under 7 AAC 105
				  - 7 AAC 160;
(4) for a service not
				  authorized under the provider's current provider agreement;
(5) for a service paid for by another source,
				  or a service eligible for payment by another source;
(6) in an amount the provider or the
				  department identifies as an overpayment;
(7) in excess of the amount due because of an
				  error or omission of an automated claims processing system;
(8) incorrectly for services that do not meet
				  standards established for payment of services;
(9) who is not an enrolled Medicaid
				  provider;
(10) for a service
				  already paid by the department;
(11) for a service provided to a recipient
				  ineligible for Medicaid under AS 47.07 and 7 AAC 100;
(12) for a service provided to a recipient
				  eligible for Medicaid under AS 47.07 and 7 AAC 100, but ineligible for the
				  service billed to the department;
(13) in excess of the amount due because of
				  the billing practices of the provider; or
(14) for a service that was not
				  rendered.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.270 - First-level provider appeal

Current through May 31, 2024
(a) A provider may
				  request a first-level appeal of a denied or reduced claim or service under this
				  section if no later than 180 days after the date on the remittance advice for
				  the claim, a provider submits to the department's designee
(1) a written request for a first-level
				  appeal of the denied or reduced claim or service that specifies the basis upon
				  which the decision is challenged and includes any supporting
				  documentation;
(2) a copy of the
				  original denied or reduced claim and attachments;
(3) a copy of the remittance advice relating
				  to the denied or reduced claim; and
(4) if applicable, an adjustment or void
				  request completed by the provider correcting the information submitted with the
				  original claim.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.280 - Second-level provider appeal

Current through May 31, 2024
(a) A provider may
				  appeal a first-level appeal decision under
				  7 AAC 105.270(a) - (f) if the provider
				  submits a written request to the department no later than 60 days after the
				  date of the first-level appeal decision.
(b) A provider that appeals a first-level
				  appeal decision under this section shall
(1)
				  include a description of the issue or decision being appealed;
(2) specify the basis upon which the decision
				  is challenged;
(3) submit all
				  information and materials that the provider requests the department to consider
				  in resolving the appeal, including a copy of the first-level appeal decision;
				  and
(4) submit the appeal to the
				  department at the address listed in the department's
Addresses for
				  Second Level Provider Appeals
list, adopted by reference in
				  7 AAC 160.900.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 2 - Provider Enrollment, Rights, and Responsibilities › 7 AAC 105.290 - Reports requested by the department

Current through May 31, 2024
Upon request by the department, a hospital or physician
					 shall provide a full operative report, interpretation of any film, or a
					 pathologist's report on tissue removed. The department will not pay a hospital
					 or physician provider for a procedure that requires an operative report or
					 explanation until that report or explanation is received.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040