reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.05 - Ancillary Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medically necessary take-home drugs must be billed under the pharmacy program
			 by the actual provider of services.
(2) Routine parenteral items are included in
			 the facility composite rate and may not be billed separately.
(3) Nonroutine injectables administered by
			 the facility may be billed by the facility actually providing this service.
			 Nonroutine injectables are defined as those given to ameliorate an acute
			 condition such as arrhythmia or infection.
(4) Routine drugs or injectables administered
			 in conjunction with dialysis procedures are included in the facility's
			 composite rate and shall not be billed separately. These include but are not
			 limited to the following:
Heparin Glucose
Protamine Dextrose
Mannitol Antiarrythmics
Saline Antihistamines
Pressor drugs Antihypertensives
(5) The administration fee for injectables is
			 included in the facility's composite rate for dialysis and must not be billed
			 separately under a physician provider number.
(6) Reimbursement for procedures cannot
			 exceed the allowable amount under Medicaid. The following procedures are
			 nonroutine and must be billed by the actual provider of service.
(a) 5-76061 - Bone Survey - annually
			 (roent-genographic method or photon absorptrometric procedure for bone mineral
			 analysis)
(b) 5-71020 - Chest X-ray
			 - every six months
(c) 6-95900 -
			 Nerve Conductor Velocity test (Peroneal NCV) - every three months
(d) 6-93000 - EKG - every three months
Author:
Vicki W. Huff
Authority:
State Plan, 4.19-E, Title XIX, Social
				Security Act; 42 C.F.R.
				§§
											416.61,
				416.65,
				416.120.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.06 - Out-Of-State Travel (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Luann C. McQueen
Authority:
State Plan; Title XIX, Social Security
				Act; Alabama Medicaid Agency Administrative Code, Rule
				560-X-1-.15.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.07 - Physician Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 physician services rendered to each outpatient maintenance dialysis patient
			 (regardless of the patient's mode of or setting for dialysis) shall be billed
			 on a monthly capitation basis.
(2)
			 Services not covered by the monthly capitation payment (MCP) and which are
			 reimbursed in accordance with usual and customary charge rules are limited to:
(a) Declotting of shunts
(b) Covered physician services furnished to
			 hospital inpatients by a physician who elects not to receive the MCP for these
			 services.
(c) Nonrenal related
			 physician services. These services may be furnished either by the physician
			 providing renal care or by another physician. They may not be incidental to
			 services furnished during a dialysis session, or office visit necessitated by
			 the renal condition.
Author:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.08 - Medicare Deductible And Coinsurance

Current through Register Vol. 42, No. 9, June 28, 2024
Payment for renal dialysis crossover claims shall be made on
				the basis of a ratio of costs to charges as developed by Medicaid.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §447.300.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-24 - RENAL DIALYSIS › Section 560-X-24-.09 - Billing And Sending Statement To Eligible Alabama Medicaid Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) No eligible
			 Alabama Medicaid recipient is to receive a bill or statement for covered
			 services or items, once that recipient has been accepted as a Medicaid
			 patient.
(2) The provider may send
			 a notice to the recipient stating their claim is still outstanding, provided
			 the notice indicates in bold letters, "THIS IS NOT A BILL."
(3) It is the responsibility of the provider
			 to follow up with the fiscal agent and/or Medicaid, and not the recipient, on
			 any problem or unpaid claim.
(4)
			 The recipient is not responsible for the difference of covered charges billed
			 and amount paid by Medicaid for covered charges.
(5) Provider may bill eligible recipients for
			 noncovered services.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.15,
				  447.50,
				  447.55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.01 - Governing Authorities

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In
			 determining eligibility for Medicaid, the Agency's rules and regulations are
			 governed by the Social Security Act (hereinafter referred to as the Act),
			 Titles XVI and XIX; 20 C.F.R. (Part 416); 42 C.F.R. (Part 435); and the Alabama
			 State Plan for Medical Assistance.
(2) Any part of the Code of Federal
			 Regulations cited herein is adopted by reference as a part of the Rule in which
			 it is cited.
Author:
Statutory Authority:
Code of Ala. 1975, §
										41-22-9.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.02 - Administrative Responsibilities

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The Alabama Medicaid Agency determines eligibility for individuals for the
			 following programs:
(a) All Medicaid programs
			 in accordance with Titles XIX and XXI of the Act except those listed in (2) and
			 (3) below; and,
(b) Low Income
			 Subsidy (LIS) under Medicare Part D in accordance with the rules under the
			 Medicare Prescription Drug, Improvement and Modernization Act of 2003
			 (MMA).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.06 - Financial Eligibility Criteria-Resources

Current through Register Vol. 42, No. 9, June 28, 2024
(1) General - In order for an AFDC-related
			 individual to be eligible for Medicaid, he or she must meet the AFDC financial
			 criteria in effect in 1996. An SSI-related individual or couple must not have
			 total countable resources in excess of $2,000 for an individual or $3,000 for a
			 couple. An individual covered under the Qualified Medicare Beneficiary Program
			 created by the Medicare Catastrophic Coverage Act of 1988, the Specified Low
			 Income Medicare Beneficiary Program created by the Omnibus Budget
			 Reconciliation Act of 1990, or the Qualifying Individual Programs created by
			 the Balanced Budget Act of 1997 must not have total countable resources in
			 excess of three times the SSI resource limit. Resource standards for Qualified
			 Medicare Beneficiaries, Specified Low Income Medicare Beneficiaries and
			 Qualifying Individuals are a federal requirement but are not an eligibility
			 requirement for Alabama's Medicare Savings Programs.
(a) Liquid vs. Non-liquid Resources.
			 Resources are those assets including both real and personal property which an
			 individual or couple possess. It includes all liquid (spendable) assets, as
			 well as non-liquid assets. Non-liquid resources are assets which are neither
			 cash nor financial instruments. They are resources which cannot be converted to
			 cash within 20 days.
(b) Income vs.
			 Resources. Income is anything of value an individual/couple
receives
during a month. Resources are the assets such
			 as those described above, which the individual/couple already has at the
			 beginning of a month in which eligibility for Medicaid is being determined. An
			 item cannot be counted as both income and a resource in the same
			 month.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.07 - Development Of Ownership Interest In Nonliquid Resources For SSI-Related Individuals

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Ownership interest in Real Property -- Establishment of ownership interest may
			 be obtained by:
(a) Assessment
			 notice;
(b) Recent tax
			 file;
(c) Current mortgage
			 statement;
(d) Deed;
(e) Report of title search;
(f) Wills, court records, or relationship
			 documents which show rights of an heir to the property after death of the
			 former owner.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.09 - Transfer Of Assets Affecting Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An individual, or the spouse of such
			 individual, who is an applicant or recipient of either institutional Medicaid
			 or home and community-based waiver services, who transfers an asset at any time
			 on or after the "look-back date", as defined in paragraph (9)(j), for less than
			 fair market value for the purpose of establishing or maintaining eligibility
			 will cause the individual to be charged with the difference between the fair
			 market value of the asset and the amount of any compensation received. The
			 difference is referred to as uncompensated value and is counted toward the
			 resource limit of the individual for a period of time determined in accordance
			 with paragraph (5).
(a) When there is an
			 institutionalized married couple and only one applies for Medicaid, any
			 transfers of assets for less than fair market value within the "look-back date"
			 made by the applicant and /or non-applying spouse affects the applicant's
			 eligibility. In these situations, the applying spouse will incur the entire
			 penalty period.
(b) If at a later
			 time the applicant's spouse, who initially did not apply, makes an application,
			 the remaining penalty period would be apportioned between them. Any fractional
			 remainder will be served by either spouse.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.11 - Additional Criteria For Institutional Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In addition to the rules covered in Rules
			 560-X-25-.05 through .11 the
			 following criteria must also be met for an individual to qualify for Medicaid
			 in a Title XIX institution:
(a) The
			 individual must be certified as needing the level of care received in an
			 institution and as having a continuing need for institutionalized
			 care.
(b) The individual must be in
			 a facility certified to participate in the Medicaid program and which has a
			 current provider agreement with the Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.12 - Periods Of Entitlement

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The earliest date of entitlement for Medicaid is the first day of the month of
			 application for assistance under one of the categorical programs, provided the
			 individual meets all factors of eligibility for that month. The individual who
			 is eligible on the first day of the month is entitled to Medicaid for the full
			 month.
(2) An exception to (1),
			 above, is Retroactive Medicaid Coverage. Individuals who have incurred medical
			 expenses for the three months immediately preceding the month of application
			 for Medicaid or the three months prior to the receipt of the first SSI check
			 (for SSI cases), may become eligible for Medicaid benefits during that time
			 provided all eligibility requirements are met for each month.
Author:
Denise Banks, Associate Director, Policy
				  and Training, Beneficiary Services Division
Statutory Authority:
Social Security Act, Titles
				  IV-A, XVI, XIX;
42 C.F.R.
				  §
											435.914; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.13 - Adults In Need Of Protective Services

Current through Register Vol. 42, No. 9, June 28, 2024
For adults in need of protective services (as defined by Code
				of Ala. 1975, §§
								38-9-2, et seq.), property may be
				excluded during the period from the date the petition is filed to the date of
				the court order, but in no event for a period to exceed 120 days.
Author:
Aljanetta C. Rugley, Policy/Research
				Specialist, Policy Program Implementation, Certification Support
				Division
Statutory Authority:
Code of Ala. 1975,
				  §§
										38-9-2, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.14 - Pregnant Women And Children Age 0 - 18 With Income Equal To Or Below 141%

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Pregnant
			 women are defined as "women who are pregnant or post-partum, with household
			 income at or below 141% of the Federal Poverty Level (FPL)".
Medicaid coverage under MAGI-related coverage groups is
				available for pregnant women meeting the requirements listed below:
(a) The household income must be equal to or
			 less than 141% of the current federal poverty level. A standard income
			 disregard of 5% of the federal poverty level is applied if the individual is
			 not eligible for coverage due to excess income.
(b) Self-attestation must be accepted for
			 pregnancy unless there is information that is not reasonably compatible with
			 such attestation.
(c) The
			 individual must be pregnant or post-partum.
(d) The person to be covered must be living
			 in Alabama and must be a United States citizen or meet alienage
			 requirements.
(e) Any private
			 insurance benefits must be assigned to the State.
(f) Application must be made for any other
			 benefits for which the person's family appears eligible.
(g) Changes in income and/or living
			 arrangements must be reported at annual review.
(h) The person to be covered must furnish or
			 apply for a Social Security number.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.16 - Income And Resources Of A Married Couple For Institutional Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicare
			 Catastrophic Coverage Act (MCCA) of 1988 provides for the special treatment of
			 income and resources of a married couple. The special treatment is to protect
			 the income and resources for the maintenance needs of the community spouse
			 while the spouse is in a medical institution or nursing facility. In
			 determining Medicaid eligibility for an institutionalized spouse, the
			 provisions of this section supersede any other inconsistent provisions of this
			 chapter, including the determination of income and resources.
(2) For purposes of this section, the
			 following definitions apply:
(a) SPOUSE -
			 Person legally married to another under State law. The SSI definition as
			 applied to the QMB/SLMB cases is not applicable to spousal cases. Legal
			 marriage is a traditional marriage conducted by legal authority or a common law
			 marriage recognized by a court and entered into prior to January 1,
			 2017.
(b) INSTITUTIONALIZED SPOUSE
			 (IS) - Legally married person who resides in a medical institution or nursing
			 facility and can reasonably be expected to continue to reside in the medical
			 institution or nursing facility for a continuous period.
(c) COMMUNITY SPOUSE (CS) - Legally married
			 person who is not living in a medical institution or nursing facility, and has
			 a spouse residing in a medical institution or nursing facility for a continuous
			 period.
(d) CONTINUOUS PERIOD OF
			 INSTITUTIONALIZATION - At least 30 consecutive days of institutionalization in
			 qualified medical institutions and/or nursing facilities.
(e) OTHERWISE AVAILABLE INCOME - Income that
			 would be used to determine eligibility without benefit of disregards (including
			 federal, state and local taxes) - gross income as defined by SSI.
(f) MAINTENANCE NEEDS STANDARDS - Income
			 standards against which community spouses' and other family members' incomes
			 are compared for purposes of determining the amount that can be allocated in
			 the post-eligibility calculation.
(g) MONTHLY MAINTENANCE NEEDS ALLOWANCE - The
			 minimum income the community spouse is entitled to have each month. This is an
			 amount deducted in the post-eligibility calculation of income for maintenance
			 needs of the community spouse (if both spouses agree to the allocation) or
			 other dependent family members to meet their needs in the community.
(h) SPOUSAL SHARE - The set total value
			 amount of resources protected for the community spouse. The Spousal Share is
			 the greater of the Minimum Protected Resource Amount or one-half of the total
			 value of the married couple's combined countable resources, not to exceed the
			 Maximum Protected Resource Amount.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.17 - Low Income Subsidy (LIS)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicare Prescription Drug,
			 Improvement and Modernization Act of 2003 (MMA), established the Medicare
			 Prescription Drug Program, also known as Medicare Part D, making prescription
			 drug coverage available to Medicare beneficiaries. The MMA also provides extra
			 help in the form of a Low-Income Subsidy (LIS) to apply to the premium cost
			 associated with Medicare Part D. Individuals qualifying for LIS will receive
			 full or partial assistance with the monthly Medicare Part-D premium, the yearly
			 deductible, and prescription co-payments depending on the income, family size,
			 and resources of the beneficiary.
(2) Medicare beneficiaries with full
			 Medicaid, SSI recipients, and Medicare beneficiaries participating in the
			 Medicare Savings Programs (QMB, SLMB, QI) will be deemed to be eligible for
			 LIS, and do not have to make a separate application. Medicare beneficiaries
			 with limited income and resources who do not fall into one of the deemed
			 subsidy groups must make application for the LIS Program through the Social
			 Security Administration or the Medicaid Agency. If an individual or couple
			 completes the Social Security Administration's LIS application at a Medicaid
			 site, or forwards a completed Social Security Administration LIS application to
			 a Medicaid site, the Medicaid Agency will forward the completed application to
			 the Social Security Administration's LIS processing center. If an applicant
			 insists upon a formal LIS determination by Medicaid, the applicant must
			 complete a Medicaid LIS application and submit the required verification to the
			 Medicaid Agency.
(3) Individuals
			 must be entitled to Medicare Part A (Hospital Insurance) and/or Part B
			 (Medicare Insurance) and enroll in a prescription drug plan that services their
			 area.
See 2006 Subsidy Eligible Groups at
				http://www.alabamaadministrativecode.state.al.us/docs/med/Microsoft%20Word%20-%2025MED.pdf
(4) The following eligibility
			 criteria must be met:
(a) Resource limits are
			 effective using SSI criteria
1. Individual at
			 or below $10,000 plus $1,500 burial exclusion
2 Couples at or below $20,000 plus $3,000
			 burial exclusion
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-26 - RULES OF PRACTICE BEFORE AGENCY › Section 560-X-26-.01 - Rules of Practice before Agency

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Any properly authorized person over 18
			 years of age may practice before the Agency. This includes, but is not limited
			 to:
(a) Attorneys.
(b) Accountants.
(c) Officers or employees of a
			 provider.
(d) An adult friend or
			 relative of a recipient or applicant.
(e) The legal guardian of a recipient or
			 applicant.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-26 - RULES OF PRACTICE BEFORE AGENCY › Section 560-X-26-.02 - Authority of Representative

Current through Register Vol. 42, No. 9, June 28, 2024
Any person appearing on behalf of another must have written
				authority to do so. If the person being represented is unable to sign an
				authorization, it must be signed by his or her legal guardian, if there is one,
				or if there is none, then by a member of his or her immediate family,
				preferably his or her sponsor. A form for this purpose is available from the
				Medicaid Agency. It is entitled "Appointment of Representative." A copy is
				contained in Chapter 28 of this Code. While use of that form is preferred, the
				Agency will accept any typed or written authorization and appointment notice
				that: (1) expressly authorizes the representative to receive notices in the
				person's stead; (2) expressly authorizes the receipt of confidential Medicaid
				information; (3) contains the person's typed or printed name and Medicaid
				number (or Social Security number, if there is no Medicaid number).
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-4(a)(2).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-26 - RULES OF PRACTICE BEFORE AGENCY › Section 560-X-26-.03 - Practice By Suspended Representative

Current through Register Vol. 42, No. 9, June 28, 2024
Any attorney or public accountant who is under suspension or
				revocation of his or her license shall not represent any person before the
				Agency, except members of his or her immediate family, unless and until his or
				her license is restored.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-4(a)(2).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-27 - CONFIDENTIAL MATERIALS › Section 560-X-27-.01 - Confidential Materials - Applicant And Recipient Data

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Information regarding Medicaid applicants
			 and recipients is required to be safeguarded by Section 1902(a)(7) of the
			 Social Security Act (SSA), 42 CFR Part 431 Subpart F, the Health Insurance
			 Portability and Accountability Act (HIPAA), and 45 CFR Part 164 . Confidential
			 materials or categories of information relating to Medicaid applicants and
			 recipients include, but are not limited to, the following:
(a) Lists of names, addresses, and Medicaid
			 eligibility numbers;
(b) Medical
			 services provided;
(c) Social and
			 economic conditions and circumstances;
(d) Medicaid or other State or Federal
			 government agency evaluation of personal information;
(e) Medicaid data, including but not limited
			 to, diagnosis and past history of disease or disability;
(f) Fair hearing records.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-27 - CONFIDENTIAL MATERIALS › Section 560-X-27-.02 - Confidential Materials - Other Items

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The following materials or categories of
			 information are declared to be confidential and the same shall not be released
			 to persons outside the Medicaid Agency except as noted below:
(a) Minutes of the Utilization Review
			 Committee (URC);
(b) Claims
			 Processing Manual;
(c) Personnel
			 records of Agency personnel;
(d)
			 Any communications, documents or materials by and between Agency legal counsel
			 and Medicaid Agency personnel which come within the protection of the
			 attorney-client privilege under the common law of Alabama.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-28 - FORMS USED BY AGENCY › Section 560-X-28-.02 - Summary Of State Law Regarding Advanced Directives

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Deciding about your health
			 care.
(b) If you are 19 or older, the
			 law says you have the right to decide about your medical care.
(c) If you are very sick or badly hurt, you
			 may not be able to say what medical care you want.
(d) If you have an advance directive, your
			 doctor and family will know what medical care you want if you are too sick or
			 hurt to talk or make decisions.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-29 - DEFINITIONS OF TERMS USED IN RULES › Section 560-X-29-.01 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
The following terms and definitions are presented as reference
				to accompany and clarify the rules contained in this Administrative Code of the
				Alabama Medicaid Agency.
(1) Abuse -
			 shall be any act or action taken by a recipient or provider which has a
			 detrimental effect upon the Alabama Medicaid Program and which is not provided
			 for or anticipated under the provisions of the Alabama Medicaid Program. The
			 following examples shall constitute prima facie evidence, though not conclusive
			 evidence, of abuse of the Alabama Medicaid Program:
(a) Failure to make any payment due Medicaid
			 from any third-party recovery.
(b)
			 Having knowledge that an individual other than the authorized recipient, has
			 used a Medicaid eligibility card to obtain benefits provided by the Alabama
			 Medicaid Program and not reporting this unauthorized use to Medicaid within a
			 reasonable period of time not to exceed 60 days;
(c) Failure to correct deficiencies in
			 provider operations after receiving written notice of these deficiencies from
			 Medicaid.
(d) Failure to repay
			 identified over-payments or erroneous payments received from
			 Medicaid.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-30 - EMERGENCY RULE PROCEDURES › Section 560-X-30-.01 - Emergency Rule Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The commissioner, upon an express finding or determination that there exists an
			 immediate danger to the public health, safety, or welfare, requires adoption of
			 a rule upon fewer than 35 days' notice or that action is required by or to
			 comply with a federal statute or regulation which requires adoption of a rule
			 upon fewer than 35 days' notice and states in writing his reasons for that
			 finding may proceed without prior notice or hearing to adopt an emergency
			 rule.
(2) An emergency rule may be
			 effective for up to 120 days. The emergency rule shall state its effective
			 dates, both beginning and ending.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-5.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-30 - EMERGENCY RULE PROCEDURES › Section 560-X-30-.02 - Permanent Rule After Emergency Rule

Current through Register Vol. 42, No. 9, June 28, 2024
During the period that an emergency rule is in effect the
				Agency shall give notice of and promulgate a permanent rule to replace the
				emergency rule, unless the emergency rule is one designed to fill a specific
				need or to solve a specific problem and that need or problem is not expected to
				reoccur.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-5(b).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-31 - DECLARATORY RULINGS › Section 560-X-31-.01 - Declaratory Rulings

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Any person
			 or organization affected by an existing rule or statute governing the Alabama
			 Medicaid program may request a declaratory ruling.
(2) The petition for declaratory ruling form
			 found in Chapter 28 must be used. Copies are available from the
			 Agency.
(3) If a petition cannot be
			 acted upon within 45 days of its receipt by the Agency, the petition may be
			 deemed denied as provided by
Code of Ala. 1975
, §
								41-22-11(b), or
			 the petitioner may agree to an extension in order to obtain a ruling. The
			 Agency will advise the petitioner if an extension would aid the Agency. The
			 petitioner need not agree to the extension, but may if a ruling is desired.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-11.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-32 - RULES ADOPTED BY REFERENCE › Section 560-X-32-.01 - Rules Adopted by Reference

Current through Register Vol. 42, No. 9, June 28, 2024
The provisions of Title 42 of the
Code of Federal
				Regulations
relating to the Medicaid Program; the Alabama State
				Plan for Medical Assistance under Title XIX of the Social Security Act; as all
				of the same may be amended are hereby adopted by reference as a part of this
				Code.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-9.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-32 - RULES ADOPTED BY REFERENCE › Section 560-X-32-.02 - Petitions For Adoption, Repeal, Or Change of A Rule

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A form for petitioning for a new rule,
			 for the repeal of an existing rule, and for the change or modification of a
			 rule is included in Chapter 28. This form must be used. Copies are available
			 from the Agency.
(2) Action on such
			 a petition shall be within 60 days of receipt by the Agency.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-8.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
Federal regulations require that the state make provisions for
				handling of recoupments, estate recoveries and liens. The Alabama Medicaid
				Agency will actively seek recovery of all misspent Medicaid funds and correctly
				paid benefits recoverable under federal law.
Author:
Keith Thompson, Director, Third Party
				  Liability
Statutory Authority:
Social Security Act; State
				  Plan; U.S.C. §1396p; 42 C.F.R. Parts 431, 433, and 455;
Code
				  of Ala. 1975
, §§
										22-1-11,
				  22-6-8.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.02 - Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
The purpose of the recoupments, estate recoveries and liens
				effort is to assure that the state and federal dollars allocated for medical
				assistance are spent only on those individuals/recipients (hereinafter
				"recipients") who meet all eligibility criteria; to correct erroneous payments
				to providers; and to recover benefits correctly paid, but recoverable by law.
				This mission will be fulfilled through solicitation of voluntary reimbursement
				and administrative and legal remedies in keeping with limitations set by
				federal guidelines.
Author:
Keith Thompson, Director, Third Party
				  Liability
Statutory Authority:
Social Security Act; State
				  Plan; U.S.C. §1396p; 42 C.F.R. Parts 431, 433, and 455;
Code
				  of Ala. 1975
, §§
										22-1-11,
				  22-6-8.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.03 - Reserved. (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Statutory Authority:
Social Security Act, Title
				  XIX; State Plan; 42 C.F.R. Parts 450, 455;
Code of Ala.
				  1975
, §§
										22-1-11,
				  22-6-8,
				  35-1-2; 45 C.F.R. Parts 233,
				  302.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.04 - Recoupments

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Direct
			 Reimbursement - At the time of original identification of the expected amount
			 of recoupment, a letter will be sent to the recipient/authorized representative
			 or provider outlining the allegations and stating the amount of reimbursement
			 and the specific dates when overpayment or recoverable benefits occurred. The
			 recipient/authorized representative or provider will be offered the opportunity
			 to present evidence to rebut the requirement for recoupment or to submit the
			 reimbursement. If no rebuttal is offered, the original assessment will be
			 presumed correct. The Alabama Medicaid Agency will accept direct reimbursement
			 from the recipient/authorized representative or provider to satisfy the
			 recoupment.
(2) Time Payment Plan
(a) Recipient Recoupment-Upon sufficient
			 justification, the Alabama Medicaid Agency may allow a time payment plan. The
			 recipient will be required to sign a promissory note not to exceed two
			 years.
(b) Provider Recoupment-Upon
			 sufficient justification, the Alabama Medicaid Agency may allow a time payment
			 plan. The provider will be required to sign a promissory note not to exceed one
			 year.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.05 - Estate Recovery

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Under
			 the estate recoveries provisions in §1917(b) of the Act, the Alabama
			 Medicaid Agency ("Agency") shall seek adjustment or recovery of any medical
			 assistance correctly paid on behalf of the following categories of recipients:
(a) Permanently Institutionalized Recipients
			 of any age who are inpatients in a nursing facility, ICF/IID, or other medical
			 institution, and who must, as a condition of receiving services in the
			 institution under the State plan, apply their income (all but a minimal amount
			 allowed for personal needs) to the cost of care, the Agency shall seek
			 adjustment or recovery from the recipient's estate or upon the sale of the
			 property subject to a lien imposed on account of medical assistance paid on
			 behalf of the recipient.
(b) In the
			 case of a recipient who was 55 or older when the recipient received such
			 medical assistance, the Agency shall seek adjustment or recovery from the
			 recipient's estate for all approved medical assistance in accordance with
			 federal law and the approved State Plan, except for Medicare Cost Sharing as
			 described in
			 42 U.S.C.
			 §1396a(a)
			 (10(E)).
(c) Recipients with Long
			 Term Care Insurance Policies - If a recipient covered under a long-term care
			 insurance policy received benefits for which assets or resources were
			 disregarded in accordance with the Agency's State plan (State Long-Term Care
			 Insurance Partnership), the Agency will not seek adjustment or recovery from
			 the recipient's estate for the amount of assets or resources
			 disregarded.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.06 - Liens

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama
			 Medicaid Agency ("Agency") will place a lien and may foreclose upon real
			 property of the following recipients to the extent allowed by
			 42
			 U.S.C. §1396p:
(a) Permanently Institutionalized Recipients
			 of any age who are inpatients in a nursing facility, ICF/IID, or other medical
			 institution, and who must, as a condition of receiving services in the
			 institution under the State plan, apply their income (all but a minimal amount
			 allowed for personal needs) to the cost of care. (See Chapter 28 for a copy of
			 the form to be used.)
(b) The
			 Agency may not impose a lien on such recipient's home if:
1. The recipient's spouse is residing in the
			 home;
2. The recipient's child
			 under age 21 is residing in the home;
3. A child who is blind or permanently and
			 totally disabled, as defined in
			 42
			 U.S.C. §1382c, of the recipient is
			 residing in the home; or
4. A
			 sibling of the recipient who has an equity interest in the home is currently
			 living in the home and has been residing continuously in the home for at least
			 one year immediately before the date of the recipient's admission to the
			 institution.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-33 - RECOUPMENTS, ESTATE RECOVERIES AND LIENS › Section 560-X-33-.07 - Appeals

Current through Register Vol. 42, No. 9, June 28, 2024
A person aggrieved by a proposed or actual Agency action may
				request a hearing in accordance with Chapter 3 of the Alabama Medicaid
				Administrative Code. A recoupment action will not be abated during the time for
				a requesting a hearing. The Agency may at its discretion suspend a recoupment
				action until after a hearing is held.
Rule .05 was renumbered .07 as per certification filed
				  December 11, 2015; effective January 25, 2016.
Author:
Keith Thompson, Director, Third Party
				  Liability
Statutory Authority:
Social Security Act; State
				  Plan; 42 C.F.R. Parts 431, 433, 455;
AAC Rule
				  560-X-3-.01, et
				  seq
..
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-34 - INDEPENDENT RADIOLOGY SERVICES › Section 560-X-34-.01 - Independent Radiology Services - General

Current through Register Vol. 42, No. 9, June 28, 2024
The Alabama Medicaid Agency will pay for services provided by
				independent radiology facilities that are enrolled by contract under the
				following conditions:
(1) The services
			 must be medically necessary.
(2)
			 The patient must be eligible for Medicaid at the time the services are
			 rendered.
Author:
Alabama Medicaid Agency
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R. Section
				  440.30.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-34 - INDEPENDENT RADIOLOGY SERVICES › Section 560-X-34-.02 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
Radiology services are professional and technical radiological
				services -
(a) ordered and provided by
			 or under the direction of a physician or other licensed practitioner of the
			 healing arts within the scope of his practice as defined by state law;
(b) provided in an office or
			 similar facility other than a hospital outpatient department or clinic; and
(c) provided by a radiology
			 facility that meets the requirements for participation in Medicare.
(1) Radiology services are restricted to
			 those that are described by procedures in the CPT manual (70010-79999) or one
			 of the locally assigned HCPCS codes used only by Medicaid to supplement the
			 listing in the CPT manual.
(2)
			 Providers will be paid only for covered services which they are certified to
			 perform and which they actually perform.
Author:
Alabama Medicaid Agency
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-34 - INDEPENDENT RADIOLOGY SERVICES › Section 560-X-34-.03 - Participation Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Independent radiology facilities must meet the following requirements for
			 participation in the Alabama Medicaid Program:
(a) Be certified for participation with
			 Medicare.
(b) Be independent of any
			 hospital, clinic, or physician's office.
(c) Be licensed in the state where located,
			 when it is required by that state.
(d) Submit to routine audits by
			 Medicaid.
(e) Complete an
			 application with all required attachments.
(f) Sign a provider agreement.
(g) Sign a Direct Deposit Authorization. Sign
			 a Civil Rights Statement of Compliance.
(i) Effective date of enrollment will be the
			 date of Medicare certification. However, providers who request enrollment more
			 than 120 days after certification will be enrolled on the first day of the
			 month the request for enrollment is received.
Author:
Ginger Collum, Program Manager,
				Clinic/Ancillary Services
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-34 - INDEPENDENT RADIOLOGY SERVICES › Section 560-X-34-.04 - Claims Filing Instructions

Current through Register Vol. 42, No. 9, June 28, 2024
For time limits on claims submission, refer to the Radiology
				Services Billing Manual.
(1) Claims
			 for radiology services must contain a valid diagnosis code.
(2) Claims submitted must contain the
			 provider number of the radiology facility that actually performed the
			 service.
(3) Claims must not be
			 submitted using any other provider's number, such as the provider number of the
			 referring physician or hospital.
(4) Claims containing fragmentation of
			 radiology services may be recouped through postpayment review.
Author:
Alabama Medicaid Agency
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R. Section
				  440.30,
				  493.2.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-34 - INDEPENDENT RADIOLOGY SERVICES › Section 560-X-34-.05 - Third Party Payment Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
For guidelines on submitting claims to Medicaid when a third
				party is involved, refer to the Radiology Services Billing Manual.
Author:
Alabama Medicaid Agency
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. Section 401
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-34 - INDEPENDENT RADIOLOGY SERVICES › Section 560-X-34-.06 - Sending Bills And Statements To Medicaid Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers should not send recipients
			 bills or statements for covered services once the recipient has been accepted
			 as a Medicaid patient.
(2)
			 Providers may send a notice to the recipient stating their claim is still
			 outstanding if the notice indicates in bold letters, "
THIS IS NOT A
			 BILL
".
(3) Providers are
			 responsible for follow-up with the fiscal agent or Medicaid on any billing
			 problems or unpaid claims.
(4)
			 Providers agree to accept the amount paid by Medicaid as payment in
			 full.
(5) Recipients are not
			 responsible for the difference between charges billed and the amount paid by
			 Medicaid for covered services.
(6)
			 Recipients may be billed only for the allowable copayment amount, for services
			 not covered by Medicaid, or when benefits have been exhausted.
(7) Providers may not deny services to any
			 eligible recipient due to the recipient's inability to pay the allowable
			 copayment amount.
Author:
Alabama Medicaid Agency
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R. Section
				  447.15,
				  447.50,
				  447.55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-35 - HOME- AND COMMUNITY-BASED WAIVER FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-35-.03 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
Eligibility criteria for Home and Community-Based Services
				(HCBS) recipients under the Waiver for Persons with Intellectual Disabilities
				(ID Waiver) shall be the same as eligibility criteria for an intermediate care
				facility for individuals with intellectual disabilities (ICF/IID). Thus, HCBS
				under the ID Waiver will be available to persons with intellectual disabilities
				who would be eligible for institutional services under
				42 C.F.R.
				§
									435.217 and who are now eligible under
				435.120. Persons with intellectual disabilities who meet categorical (including
				42 C.F.R. §
									435.120), medical, and/or social requirements
				for Title XIX coverage will be eligible for HCBS under the ID Waiver.
				Applicants found eligible shall not be required to apply income above the
				personal needs allowance reserved to institutional recipients toward payment of
				care.
(1) Financial eligibility for
			 HCBS under the ID Waiver is limited to those individuals receiving SSI, Parent
			 and Other Caretaker Relatives (POCR), Pregnant Women, Infants and Children
			 under Age 19, Children with Non IV-Adoption Assistance (Over age 21), Children
			 with Non IV-Adoption Assistance, Former Foster Care, Reasonable Classification
			 of Individuals under Age 21, SSI related protected groups deemed to be eligible
			 for SSI/Medicaid (i.e., Widow/Widower, Disabled Adult Child, Continuous
			 (Pickle) Medicaid), federal and state adoption subsidy individuals, and special
			 home and community-based optional categorically needy group whose income is not
			 greater than 300 percent of the SSI federal benefit rate.
(2) Medical eligibility for HCBS under the ID
			 Waiver is limited to those individuals that meet the ICF/IID level of care. No
			 HCBS under the ID Waiver will be provided to a recipient residing in an
			 institutional facility, or who has a primary diagnosis of mental illness, or
			 whose health and safety is at risk in the community.
(3) Financial determinations and
			 redeterminations for HCBS under the ID Waiver shall be made by the Alabama
			 Medicaid Agency, the Department of Human Resources or the Social Security
			 Administration, as appropriate. In addition to the financial and medical
			 eligibility criteria, the Alabama Medicaid Agency is limited to the number of
			 recipients who can be served by the ID Waiver.
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Program
Statutory Authority:
42 C.F.R. §§ 441,
				  Subpart G; Home- and Community-Based Waiver for Persons with Mental
				  Retardation.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-35 - HOME- AND COMMUNITY-BASED WAIVER FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-35-.04 - Characteristics Of Persons Requiring ICF/IID Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Generally, persons eligible for the level
			 of care provided in an ICF/IID are those persons who need such level of care
			 because the severe, chronic nature of their mental impairment results in
			 substantial functional limitations in three or more of the following areas of
			 life activity:
Self Care
Receptive and expressive language
Learning
Self-direction
Capacity for independent living
Mobility
(2) Services provided in an Intermediate Care
			 Facility for Individuals with Intellectual Disabilities in Alabama are those
			 services that provide a setting appropriate for a functionally individual with
			 an intellectual disability in the least restrictive productive environment
			 currently available. Determination regarding eligibility for ICF/IID care is
			 made by a Qualified Intellectual Disabilities Professional (QIDP). A QIDP is an
			 individual possessing, at minimum, those qualifications in
			 42 C.F.R. Section
			 483.430. Recommended continued stay is made
			 by an interdisciplinary team of a nurse, social worker, and a member of
			 appropriate related discipline, usually a psychologist, and certified by a QIDP
			 and a physician.
(3) ICF/IID care
			 includes those services that address the functional deficiencies of the
			 beneficiaries and that require the skills of a QIDP to either provide directly
			 or supervise others in the provision of services needed for the beneficiary to
			 experience personal hygiene, participate in daily living activities appropriate
			 to his functioning level, take medication under appropriate supervision (if
			 needed), receive therapy, receive training toward more independent functioning,
			 and experience stabilization as a result of being in the least restrictive,
			 productive environment in which he or she can continue his/her individual
			 developmental process.
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
42 C.F.R. § 441,
				  Subpart G; Home- and Community-Based Waiver for Persons with Intellectual
				  Disabilities.