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-.15 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama
			 Medicaid Agency will provide the operating agency with the approved level of
			 care determination process.
(2) The
			 operating agency will review the applicant's eligibility status to determine if
			 the applicant is medically and financially eligible for waiver services. The
			 targeted case manager will assist the recipient to make financial application
			 and ensure that the appropriate documents are completed and routed to the
			 appropriate Medicaid District Office.
(3) All recipients who are applying for an
			 HCBS waiver who are financially approved by the Department of Human Resources
			 or are under the age of 65 and have not been determined disabled must have a
			 disability determination made by the Medical Review team of the Alabama
			 Medicaid Agency.
(4) If a
			 disability determination has been made, the Regional Office should complete a
			 slot confirmation form (Form 376).
(5) The Qualified Intellectual Disabilities
			 Professional (QIDP) will complete the level of care determination and the plan
			 of care development.
(6) The
			 operating agency will be required to adhere to all federal and state guidelines
			 in the determination of the level of care approval.
(7) During the assessment, it must be
			 determined that "without waiver services the client is at risk of
			 institutionalization."
(8) The
			 operating agency or its designee (case manager), will ensure that the applicant
			 has been screened and assessed to determine if the services provided through
			 the ID Waiver will meet the applicant's needs in the community.
(9) The Alabama Department of Mental Health
			 (ADMH) is responsible for the assessment, evaluation of admissions,
			 readmissions, and annual redeterminations for eligible participants receiving
			 home and community-based services in accordance with the provisions of the Home
			 and Community-Based Waiver for Persons with Intellectual
			 Disabilities.
(10) The Alabama
			 Medicaid Agency will provide to the ADMH the approved Level of Care criteria
			 and policies and procedures governing the level of care determination
			 process.
(11) The ADMH will
			 designate a qualified medical professional to approve the level of care and
			 develop the Plan of Ca re.
(12)
			 ADMH may utilize Medicaid staff for consultation on questionable admissions and
			 annual redeterminations prior to a final decision being rendered.
(13) The Alabama Medicaid Agency will
			 conduct a retrospective review on a monthly basis of a rand om sample of
			 individuals served under the Home and Community Based Waiver for Persons with
			 Intellectual Disabilities to determine appropriate admissions and annual
			 redeterminations. This review includes whether appropriate documentation is
			 present and maintained and whether all state and federal medical necessity and
			 eligibility requirements for the program are met. The LTC Waiver Quality
			 Improvement Unit conducts a random sample of plans of care and related
			 documents annually.
(14) The
			 Alabama Medicaid Agency will initiate recoupment of payment for services when
			 it determines that state and federal, medical necessity, and eligibility
			 requirements are not met.
(15) The
			 Alabama Medicaid Agency may seek recoupment from ADMH for other services
			 reimbursed by Medicaid for those individuals whom Medicaid determines would not
			 have been eligible for the Home and Community - Based Waiver for Persons with
			 Intellectual Disabilities or Medicaid eligibility but for the certification of
			 waiver eligibility by ADMH.
(1 6)
			 The operating agency or its designee will develop a plan of care that includes
			 waiver as well as non - waiver services.
(17) Upon receipt of the financial award letter from the Alabama
			 Medicaid Agency, the LTC Admissions Notification Form should be completed and
			 forwarded to Medicaid's Fiscal Agent electronically. Medicaid's Fiscal Agent
			 will either accept or reject the transmission of the LTC Admissions
			 Notification Form. The operating agency or its designee will receive notice of
			 the status of applications transmitted the next business day following the
			 transmission.
(18) If Medicaid's
			 Fiscal Agent accepts the transmission, the information is automatically written
			 to the Long Term Care file. The operating agency or its designee can begin
			 rendering services and billing the Alabama Medicaid Agency for services
			 rendered.
(19) If Medicaid's Fiscal
			 Agent rejects the transmission, the operating agency or its designee must
			 determine the reason for the rejection and retransmit the LTC Admissions
			 Notification Form.
(20) Neither the
			 Alabama Medicaid Agency nor Medicaid's Fiscal Agent will send out the LTC-2
			 Notification letters. The record of successful transmission will be your record
			 of "approval" to begin rendering service.
(21) For applications where the level of care
			 is questionable, you may submit the applications to the LTC Medical and Quality
			 Review Unit for review by a nurse and/or a Medicaid physician.
(22) Once the individual's information has
			 been added to the Long Term Care File, changes can only be made by authorized
			 Medicaid staff.
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G and the Home and Community-Based Waiver for Persons with Mental
				  Retardation.