reglab/statecodes huggingface dataset:
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-.05 - Qualifications Of Staff Who Will Serve As Review Team For Medical Assistance

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The nurse shall
			 be a graduate of a licensed school of nursing with a current state
			 certification as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
			 This person shall have knowledge and training in the area of intellectual
			 disabilities with a minimum of two (2) years' experience.
(2) The social worker shall be a graduate of
			 a four-year college with an emphasis in social work. This person shall have
			 knowledge and training in the area of intellectual disabilities with a minimum
			 of two (2) years' experience.
(3)
			 The psychologist shall be a Ph.D. in Psychology. This person shall be a
			 licensed psychologist with general knowledge of test instruments used for
			 individuals with intellectual disabilities with a minimum of two (2) years'
			 experience.
(4) Other professional
			 disciplines which may be represented on the assessment team as necessary
			 depending on the age, functional level, and physical disability of the clients
			 are as follows:
(a) Special
			 Education
(b) Speech
			 Pathologist
(c)
			 Audiologist
(d) Physical
			 Therapist
(e) Optometrist
(f) Occupational Therapist
(g) Vocational Therapist
(h) Recreational Specialist
(i) Pharmacist
(j) Doctor of Medicine
(k) Psychiatrist
(l) Other skilled health
			 professionals
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COMMUNITY-BASED WAIVER FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-35-.06 - Financial Accountability (REPEALED)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Laura Walcott, Administrator, LTC
				  Program Management Unit.
Statutory Authority:
42 C.F.R. §441 ; 45
				  C.F.R. Part 95 ; OMB Circular A-87, 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-.07 - Individual Assessments

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Alabama Medicaid Agency will require an individual plan of care for each
			 wavered service recipient. Such plan, entitled "Individual Habilitation Plan"
			 (IHP), is subject to review by the Alabama Medicaid Agency and Department of
			 Health and Human Services. Client assessment procedures in place in the Alabama
			 Department of Mental Health, which are based on eligibility criteria for
			 ICF/IIDs developed jointly by DMH and the Alabama Medicaid Agency, will be
			 utilized by the Department of Mental Health (or its contract service providers)
			 in screening for eligibility for the wavered services as an alternative to
			 institutionalization. Whether performed by a qualified practitioner in the
			 Department of Mental Health, its contract service providers, or provided by
			 qualified (Diagnostic and Evaluation Team) personnel of the individual/agency
			 arranging the service, review for "medical assistance" eligibility
			 determination will be based on client assessment data, and the criteria for
			 admission to an ICF/IID, as described in Rule No.
			 560-X-35-.03. Re-evaluation of
			 clients shall be performed on an annual basis. Written documentation of all
			 assessments will be maintained in the client's case file and subject to review
			 by the Alabama Medicaid Agency and Department of Health and Human
			 Services.
(2) The Alabama Medicaid
			 Agency will give notice of services available under the waiver as required by
			 federal regulations, particularly to primary care givers for the target group,
			 including but not limited to, programs operated by Alabama Department of Mental
			 Health, the statewide network of community MH centers, and to other appropriate
			 care-giving agencies such as county department of human resources offices,
			 hospitals, hospital associations, and associations for individuals with
			 intellectual disabilities.
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
42 C.F.R. § 441,
				  Subpart G; Home- and Community-Based Waiver for the Mentally Retarded and
				  Developmentally Disabled.
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-.08 - Informing Beneficiaries Of Choice

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Alabama Medicaid Agency will be
			 responsible for assurances that beneficiaries of the waiver service program
			 will be advised of the feasible service alternatives and be given a choice of
			 which type of service--institutional or home- and/or community-based
			 services--they wish to receive.
(2)
			 Residents of long-term care facilities for whom home- and community-based
			 services become a feasible alternative under this waiver will be advised of the
			 available alternative at the time of review. Applicants for SNF, ICF, ICF/IID
			 services, or a designated responsible party with authority to act on the
			 applicant's behalf, will be advised of feasible alternatives to
			 institutionalization at the time of their entry into a treatment system wherein
			 an alternative is professionally determined to be feasible. All applicants
			 found eligible for home- and community-based services will be offered the
			 alternative unless there is reasonable expectation that services required for
			 the applicant would cost more than institutional care. Provisions for fair
			 hearings for all persons eligible for services under this waiver will be made
			 known and accessible to potential eligibles in accordance with Fair Hearings
			 Procedures in place in the Alabama Medicaid Program.
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
42 C.F.R. § 441,
				  Subpart G; Home- and Community-Based Waiver for the Mentally Retarded and
				  Developmentally Disabled.
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-.09 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid reimbursement for each
			 service provided by a mental health service provider shall be based on a
			 fee-for-service system. Each covered service is identified on a claim by a
			 procedure code.
(2) Providers
			 should bill no more than one month's services on a claim for a recipient. There
			 may be multiple claims in a month, but no single claim may cover services
			 performed in different months. For example, October 15, 1990, to November 15,
			 1990, would not be allowed. If the submitted claim covers dates of service,
			 part or all of which were covered in a previously paid claim, it will be
			 rejected.
(3) Payment will be based
			 on the number of units of service reported for HCPCS codes.
(4) All claims for services must be submitted
			 within 12 months from the date of service.
(5) Accounting for actual cost and units of
			 services provided during a waiver year must be accomplished on HCFA's form 372.
			 The following accounting definitions will be used to capture reporting data,
			 and the audited figures used in establishing new interim fees:
(a) A waiver year consists of 12 consecutive
			 months starting with the approval date specified in the approved waiver
			 document.
(b) An expenditure occurs
			 when cash or its equivalent is paid in a quarter by a state agency for waiver
			 benefits. For a public/governmental provider, the expenditure is made whenever
			 it is paid or recorded, whichever is earlier. Noncash payments, such as
			 depreciation, occur when transactions are recorded by the state
			 agency.
(c) The services provided
			 by a direct service provider agency is reported and paid by dates of service.
			 Thus, all services provided during the 12 months of the waiver year will be
			 attributed to that year.
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-.10 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
Providers shall make all reasonable efforts to determine if
				there is a liable third party source, including Medicare, and in the case of a
				liable third party source, utilize that source for payments and benefits prior
				to applying for Medicaid payments. Third party payments received after billing
				Medicaid for service for a Medicaid recipient shall be refunded to the Alabama
				Medicaid Agency.
Author:
Willie J. Johnson
Statutory Authority:
42 C.F.R., §441,
				  Subpart G; Home- and Community-Based Waiver for the Mentally Retarded and
				  Developmentally Disabled.
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-.11 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Payment made by the Medicaid Program to a provider shall be considered to be
			 payment in full for covered services rendered.
(2) No Medicaid recipient shall be billed for
			 covered Medicaid services for which Medicaid has been billed.
(3) No person or entity, except a liable
			 third party source, shall be billed for covered Medicaid services.
Author:
Willie J. Johnson
Statutory Authority:
42 C.F.R. §441,
				  Subpart G; Home- and Community-Based Waiver for the Mentally Retarded and
				  Developmentally Disabled.
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-.12 - Confidentiality

Current through Register Vol. 42, No. 9, June 28, 2024
Providers shall not use or disclose, except to duly authorized
				representatives of federal or state agencies, any information concerning an
				eligible recipient except upon the written consent of the recipient, his/her
				attorney, or his/her guardian, or upon subpoena from a court of appropriate
				jurisdiction.
Author:
Willie J. Johnson
Statutory Authority:
42 C.F.R. §§441,
				  Subpart G; Home- and Community-Based Waiver for the Mentally Retarded and
				  Developmentally Disabled.
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-.13 - Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Department
			 of Mental Health shall make available to the Alabama Medicaid Agency at no
			 charge, all information regarding claims submitted and paid for services
			 provided eligible recipients and shall permit access to all records and
			 facilities for the purpose of claims audit, program monitoring, and utilization
			 review by duly authorized representatives of federal and state agencies.
			 Complete and accurate medical/psychiatric and fiscal records which fully
			 disclose the extent of services shall be maintained by the clinic. Said records
			 shall be retained for the period of time required by state and federal
			 laws.
(2) Sign-in log, service
			 receipt, or some other written record shall be used to show the date and nature
			 of services; this record shall include the Recipient's signature.
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.
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-.14 - Service Providers

Current through Register Vol. 42, No. 9, June 28, 2024
The Home and Community-Based ID Waiver is a cooperative effort
				between the Alabama Medicaid Agency and the Department of Mental
				Health.
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
The Home- and
				  Community-Based Waiver for Persons with Intellectual Disabilities.
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-.16 - Cost For Services

Current through Register Vol. 42, No. 9, June 28, 2024
The cost for services to individuals who qualify for Home and
				Community-Based care under the waiver program will not exceed on an average per
				capita basis the total expenditures that would be incurred for such individuals
				if Home and Community-Based services were not available.
Author:
Mattie Jackson, Director, LTC Healthcare
				  Reform Development Division
Statutory Authority:
42 C.F.R. Section
				  441, Subpart G; and the Home and
				  Community-Based Waiver for Persons with Intellectual Disabilities.
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-.17 - Fair Hearings

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 individual receiving a Notice of Action (denial, termination, suspension,
			 reduction in services) from the operating agency (OA), may request an appeal if
			 he/she disagrees with the decision. The Notice of Action explains the reason
			 for the denial, termination, suspension, or reduction in waiver services and
			 the appeal rights made available to them.
(2) If an individual/guardian chooses to
			 appeal an adverse decision, they may choose to appeal to the Department of
			 Mental Health (DMH) Associate Commissioner of the Developmental Disabilities
			 Division no later than 15 calendar days after the effective date printed on the
			 Notice of Action.
(3) Services will
			 continue until the final outcome of the hearing for those individuals who are
			 already receiving services when they submit an appeal within 10 days after the
			 effective date of action unless:
(a) It is
			 determined at the hearing that the sole issue is one of Federal or State law or
			 policy; and
(b) The agency promptly
			 informs the beneficiary in writing that services are to be terminated or
			 reduced pending the hearing decision.
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-.18 - Appeal Procedure (Fiscal Audit) (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Laura Walcott, Administrator, LTC
				  Program Management Unit
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G and the Home and Community-Based Waiver for Persons with Mental
				  Retardation.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.02 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Financial
			 eligibility is limited to those individuals receiving SSI, individuals deemed
			 to be receiving SSI, the optional categorically needy at a special income level
			 of 300 percent of the Federal Benefit Rate (FBR) who are receiving HCBS waiver
			 services, individuals receiving State Supplementation, and individuals
			 receiving State or Federal Adoption Subsidies.
(2) Medical eligibility is determined based
			 on current admission criteria for nursing facility care as described in Rule
			 No. 560-X-10-.10.
(3) No waiver services will be provided to
			 recipients in a hospital or nursing facility. Discharge planning by a case
			 manager is a reimbursable service.
(4) The Alabama Medicaid Agency or its
			 operating agencies acting on Medicaid's behalf may also deny home- and
			 community-based services if it is determined that an individual's health and
			 safety is at risk in the community; if the cost of serving an individual on the
			 waiver exceeds the cost of caring for that individual in a nursing facility; if
			 the individual does not cooperate with a provider in the provision of services;
			 or if an individual does not meet the goals and objectives of being on the
			 waiver program.
(5) The Alabama
			 Medicaid Agency is restricted by the waiver to serving the estimated annual
			 unduplicated number of beneficiaries approved by CMS.
Author:
Ginger Wettingfeld, Administrator, LTC
				  Project Development/Program Support Unit
Statutory Authority:
42 CFR Part 441, Subpart G;
				  Home- and Community-Based Waiver for the Elderly and
				  Disabled.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.03 - Operating Agency

Current through Register Vol. 42, No. 9, June 28, 2024
The Home- and Community-Based Waiver for the Elderly and
				Disabled is a cooperative effort among the Alabama Medicaid Agency, and the
				Alabama Department of Senior Services. The State affirms that it will abide by
				all terms and conditions set forth in the waiver.
Author:
Monica Abron, Associate Director, LTC
				  Program Management Unit
Statutory Authority:
The Home- and
				  Community-Based Waiver for the Elderly and Disabled.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.04 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Case
			 Management Services.
(a) Case management is a
			 system under which responsibility for locating, coordinating, and monitoring a
			 group of services rests with a designated person or organization. A case
			 manager is responsible for outreach, intake and referral, diagnosis and
			 evaluation, assessment, care plan development, and implementing and tracking
			 services to an individual. Case management services may be used to locate,
			 coordinate, and monitor necessary and appropriate services. Case management
			 activities may also be used to assist in the transition of an individual from
			 institutional settings prior to discharge into the community. All E/D waiver
			 recipients will receive case management services.
(b) A person providing Case Management
			 Services must meet the qualifications as specified in the approved waiver
			 document.
(c) Case Management
			 Services must be on the Plan of Care as a waiver service. Waiver services not
			 listed on the Plan of Care and the Service Authorization Form will not be paid.
			 Payments rendered for services not documented on the individual's Plan of Care
			 and the Service Authorization Form will be recovered.
(d) Case management will be provided by a
			 case manager employed by or under contract with the state agencies as specified
			 in the approved waiver document. The case manager must meet the qualifications
			 as specified in the approved waiver document.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.05 - Costs For Services

Current through Register Vol. 42, No. 9, June 28, 2024
The costs for services to individuals who qualify for home- and
				community-based care under the waiver program will not exceed, on an average
				per capita basis, the total expenditures that would be incurred for such
				individuals if home- and community-based services were not available.
Author:
Willie J. Johnson
Statutory Authority:
42 C.F.R. Part 441, Subpart
				  G; Home- and Community-Based Waiver for the Elderly and Disabled.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.06 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The case
			 manager will receive referrals from hospital, nursing homes, physicians, the
			 community and others for persons who may be eligible for home- and
			 community-based services. For institutional residents residing in a facility
			 for at least 90 days who are interested in transitioning into the community,
			 the case manager should review referrals and intake information. This process
			 will take place during the 180 consecutive day transition period.
(2) An initial assessment will be completed
			 by the case manager in conjunction with the applicant's physician. This
			 document will reflect detailed information regarding social background, living
			 conditions, and medical problems of the applicant. A redetermination assessment
			 must be completed annually to determine eligibility.
(3) The case manager, in conjunction with the
			 applicant's physician and the client and/or caregiver will develop a plan of
			 care. All services will be furnished pursuant to a written plan of care.
			 Payment will not be made for waiver services furnished prior to the development
			 of the plan of care. The plan of care will include objectives, services,
			 provider of services, and frequency of services. Changes to the original plan
			 of care are to be made as needed to adequately care for an individual.
			 Revisions to the plan of care and the reasons for changes must be documented in
			 the client's case record. Services provided must be documented on the client's
			 care plan which is subject to the review of the Alabama Medicaid Agency. The
			 plan of care must be reviewed by the case manager as often as necessary and
			 administered in coordination with the recipient's physician.
(4) The Alabama Medicaid Agency has delegated
			 the medical level of care determination to qualified trained individuals at the
			 Operating agency.
(5) Medicaid
			 requires the providers to submit an application in order to document dates of
			 service provisions to long term care recipients.
(a) The long term care admission notification
			 file maintains these dates of service.
(b) The applications will be automatically
			 approved through systematic programming.
(c) The Alabama Medicaid Agency will perform
			 random audits on a percentage of records to ensure that documentation supports
			 the medical level of care criteria, physician certification, as well as other
			 state and federal requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.08 - Fair Hearings

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 individual whose application to the waiver program is denied or waiver
			 participants whose services are terminated, suspended, or reduced based on Rule
			 No. 560-X-36-.02, may request an
			 appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the
			 Alabama Medicaid Administrative Code.
(2) E&D waiver participants will be given
			 at least a ten-day notice before termination, suspension, or reduction of
			 service.
(3) If an
			 individual/guardian chooses to appeal the decision, a written request for an
			 informal conference must be received by the Operating Agency within 30 days
			 from the effective date of the notice. Services may continue for waiver
			 participants until the final outcome of the administrative appeal process, if
			 the written request is received within 10 days after the effective date of the
			 action.
(4) If the
			 individual/guardian is dissatisfied with the Informal Conference decision, a
			 Fair Hearing may be requested. A written request for a Fair Hearing must be
			 received no later than 30 days from the date of the Informal Conference
			 decision notice.
(5) If the
			 individual/guardian is dissatisfied with the Fair Hearing decision, he/she may
			 appeal pursuant to the provisions of the Alabama Administrative Procedure
			 Act.
(6) The Operating Agency will
			 take the lead role for the Informal Conferences, Fair Hearings, and subsequent
			 judicial appeals. Medicaid legal counsel and program staff will function as
			 support staff.
Author:
Monica Abron, Associate Director, LTC
				  Program Management Unit
Statutory Authority:
42 CFR Part 431, Subpart
				  E.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.09 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medical pays providers the actual cost to
			 provide the service. Each covered service is identified on a claim by a HCPC
			 code. Respite care will have one code for skilled and another for unskilled.
			 Home delivered meals will also have one code and two modifiers. Frozen meals
			 and shelf stable meals will be billed with a modifier. Breakfast meals will be
			 billed without a modifier.
(2) For
			 each recipient, the claim will allow span billing for a period up to one month.
			 There may be multiple claims in a month, but no single claims can cover
			 services performed in different months. If the submitted claim covers days of
			 service part or all of which were covered in a previously paid claim, it will
			 be rejected. Payment will be based on the number of units of service reported
			 for each HCPC code.
(3) The basis
			 for the cost will usually be based on audited past performance with
			 consideration being given to the health care index and renegotiated contracts.
			 The interim cost may also be changed if a provider can show that an unavoidable
			 event(s) has caused a substantial increase or decrease in the provider's
			 cost.
(4) The operating agencies as
			 specified in the approved waiver document are governmental agencies; therefore,
			 within one hundred and twenty days from the end of a waiver year, the interim
			 cost for services must be adjusted to cost and the claims for the services
			 provided during that year reprocessed to adjust payments to the actual cost
			 incurred by each operating agency. Thus the cost for each service for each
			 operating agency may differ. Since the actual cost incurred by each operating
			 agency sets a ceiling on the amount it can receive, no claims with dates of
			 service within that year will be processed after the adjustment is
			 made.
(5) Accounting for actual
			 cost and units of services provided during a waiver year must be accomplished
			 on CMS 372 Report. The following accounting definitions will be used to capture
			 reporting data, and the audited figures used in establishing new interim cost:
(a) A waiver year consists of the twelve
			 months following the start of any waiver year.
(b) An expenditure occurs when cash or its
			 equivalent is paid in a quarter by a state agency for waiver benefits. For a
			 public (governmental) provider, the expenditure is made whenever it is paid or
			 recorded, whichever is earlier. Non-cash payments, such as depreciation, occur
			 when transactions are recorded by the state agency.
(c) The services provided by operating
			 agencies are reported and paid by dates of service. Thus, all services provided
			 during the twelve months of the waiver year will be attributed to that
			 year.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.10 - Confidentially

Current through Register Vol. 42, No. 9, June 28, 2024
Providers shall not use or disclose, except to duly authorized
				representatives of federal or state agencies, any information concerning an
				eligible recipient except upon the written consent of the recipient, his or her
				attorney, and/or guardian, or upon subpoena from a court of appropriate
				jurisdiction.
Author:
Patricia Harris, Administrator, LTC
				Program Management Unit
Statutory Authority:
42 C.F.R. §441,
				  Subpart G-Home and Community-Based Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.11 - Appeal Procedure For Fiscal Audit

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Fiscal audits of the Elderly and Disabled
			 Waiver Services are conducted by the Provider Audit Division of Medicaid. At
			 the completion of the field audit there will be an exit conference with the
			 operating agency to explain the audit findings. The operating agency will have
			 the opportunity to express agreement or disagreement with the findings. The
			 field audit and the comments of the operating agency are reviewed by the
			 Provider Audit Division and a letter is prepared making the appropriate
			 findings official. If the operating agency deems that the findings are not
			 justified, it may request an informal conference with the Director of the
			 Provider Audit Division.
(2) The
			 request for an informal conference must be in writing and received by Medicaid
			 within 30 days from the date of the official audit letter. This letter must
			 specify the findings that are contested and the basis for the contention. This
			 letter should be addressed to the attention of:
Director
Provider Audit Division.
(3) The decisions of the Provider Audit
			 Division made as a result of the informal conference will be forwarded to the
			 operating agency by letter. If the operating agency believes that the results
			 of the informal conference are still adverse, it may request a fair hearing.
			 The request must be in writing and received by Medicaid within 15 days from the
			 date of the informal conference decision letter.
Author:
Ginger Wettingfeld, Administrator, LTC
				  Project Development/Program Support Unit
Statutory Authority:
42 CFR Section 431, Subpart
				  E.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED › Section 560-X-36-.12 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
The Third Party Division, Alabama Medicaid Agency, is
				responsible for fulfilling the requirements pertaining to third party
				liability. The purpose of the Third Party Division is to ensure that Medicaid
				is the payor of the last resort. Providers shall make all reasonable efforts to
				determine if there is a liable third party source, including Medicare, and in
				the case of a liable third party source, utilize that source for payments.
				Third party payments received after billing Medicaid for service for a Medicaid
				recipient shall be refunded to the Alabama Medicaid Agency within sixty days of
				receipt of Medicaid payment. For further information concerning Third Party
				Liability refer to Administrative Code Chapter 20.
Author:
Ginger Wettingfeld, Administrator, LTC
				  Project Development/Program Support Unit
Statutory Authority:
42 CFR Section 433, Subpart
				  D; Section 1902(a)(25), Social Security Act;
Code of Ala.
				  1975
, §
										22-6-6.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid
			 Agency may, at its discretion, and in consultation with local communities,
			 organize and develop area specific systems as part of an overall managed care
			 system.
(a) Flexibility. Since community
			 needs and resources differ from area to area, the Medicaid Agency will maintain
			 the flexibility to design plans which are consistent with local needs and
			 resources.
(b) Waiver Programs.
			 Plans may be either voluntary or mandatory pursuant to waiver(s) granted by the
			 Centers for Medicare and Medicaid Services (CMS). Some plans may start as
			 voluntary and subsequently become mandatory. All required federal waivers
			 and/or approvals must be obtained by the Medicaid Agency before any system or
			 contract can become effective.
(c)
			 State Plan Programs. Amendments to the state plan must be approved by CMS
			 before any system or contract can become effective.
(d) Models. The Medicaid Agency may utilize
			 one or more managed care systems established in 42 C.F.R. Part 438 or approved
			 by CMS, including but not limited to, health maintenance organizations (HMO),
			 managed care organizations (MCO), prepaid ambulatory health plans (PAHPs),
			 prepaid Inpatient health plans (PIHP), primary care case management systems
			 (PCCM), and/or primary care case management entities (PCCM entity).
(e) Purpose. The purposes of managed care are
			 to:
(i) Ensure needed access to health
			 care;
(ii) Provide health
			 education;
(iii) Promote continuity
			 of care;
(iv) Strengthen the
			 patient/physician relationship; and
(v) Achieve cost efficiencies.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.02 - Primary Care Case Management (PCCM)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Under this model of managed care, each
			 patient/recipient is assigned to a primary medical provider (PMP) who is a
			 physician who is responsible for managing the recipient's health care needs.
			 This management function neither reduces nor expands the scope of covered
			 services.
(a) PCCM services means case
			 management related services that include location, coordination, and monitoring
			 of primary health care services; and are provided under a contract between
			 Medicaid and the PMP or the OMP group.
(b) PCCM services may be offered by the state
			 as a mandatory option under the Medicaid state plan; with the exception of
			 beneficiaries who are dually eligible for Medicare and Medicaid, American
			 Indians/Alaska Natives, or children with special health care needs.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.03 - Prepaid Inpatient Health Plans. (PIHP)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A prepaid inpatient health plan (PIHP) is
			 one that provides services to enrolled recipients on a capitated basis but does
			 not qualify as a HMO.
(2) Capitated
			 PIHPs do not need to meet the requirements of §1903(m)(2)(A) of the Social
			 Security Act if services are less than fully comprehensive. Comprehensive
			 services are defined as:
(a) Inpatient
			 hospital services and one or more services or groups of services as follows:
1. Outpatient hospital services;
2. Laboratory and X-ray services;
3. Nursing Facility (NF) services;
4. Physician services;
5. Home health services;
6. Rural health clinic services;
7. FQHC services;
8. Early and periodic screening, diagnostic,
			 and treatment (EPSDT) services; and
9. Family planning services.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.04 - Health Maintenance Organizations. (HMO)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Health Maintenance Organizations (HMO)
			 means any entity or corporation that undertakes to provide or arrange for basic
			 health care services through an organized system which combines the delivery
			 and financing of health care to enrollees. The organization shall provide
			 physicians services directly through physician employees or under contractual
			 arrangements with either individual physicians or a group of physicians. The
			 organization shall provide basic health care services directly or under
			 contractual arrangements. When reasonable and appropriate, the organization may
			 provide physician services and basic health care services through other
			 arrangements. The organization may provide, or arrange for, health care
			 services on a prepayment or other financial basis.
(2) Covered services shall be provided to
			 each eligible enrollee and will be reimbursed on a monthly capitation
			 basis.
(3) The HMO is required to
			 obtain a Certificate of Authority to operate as a HMO in the State of Alabama,
			 issued by the Department of Insurance prior to providing services. HMOs must
			 obtain a Certificate of Need (CON) or a letter of non-reviewability from the
			 State Health Planning Agency. When applicable, the HMO may also be required to
			 participate in an Invitation to Bid process as directed by the Medicaid
			 Agency.
(4) The HMO shall make
			 adequate provisions against the risk of insolvency as contained in the Code of
			 Alabama Section
			 27-21A-12 and as specified in the
			 contract between the HMO and Medicaid. The HMO must ensure that individuals
			 eligible for benefits are never held liable for debts of the plan.
(5) HMOs desiring to participate as a managed
			 care provider should contact the Medical Services Division at Medicaid. HMOs
			 must submit written documentation for approval which includes, but is not
			 limited to, the following:
(a) Description of
			 services to be provided
(b)
			 Marketing Plan and any marketing materials to be used by the Plan
(c) Quality Assurance Plan
(d) Enrollment Plan
(e) Education Plan
(f) Copy of Certificate of
			 Authority
(g) Copy of Certificate
			 of Need or letter of non-reviewability
(h) Examples of subcontract to be utilized by
			 the plan
(i) Proposed enrollment
			 sites
(j) Enrollment area
(k) Grievance procedures
All of the above information must be sent before the review can
				be completed.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.06 - Family Planning Waiver (Repealed - Moved to 560-X-14-.06)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Kim Davis-Allen, Director, Medical
				  Services Division
Statutory Authority:
Section 1115(a); Sections
				  1902(a)(10)(b), (e)(5) and (6) of the Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.07 - Alabama Coordinated Health Network Program

Current through Register Vol. 42, No. 9, June 28, 2024
The Alabama Medicaid Agency is responsible for the development
				and oversight of the Alabama Coordinated Health Network (ACHN) program that
				will consolidate the existing case management programs of Maternity Care,
				Health Homes, and portions of Family Planning into seven Primary Care
				Coordination Management Entities that provides seamless, care coordination that
				focuses on quality and improved health outcomes.
The ACHN program will operate in seven regions. Effective
				October 1, 2019, the following designations of geographic boundaries have been
				established for ACHN locations:
1.
			 Central, which includes the following counties: Autauga, Butler, Chilton,
			 Crenshaw, Dallas, Elmore, Lowndes, Marengo, Montgomery, Perry, and
			 Wilcox.
2. East, which includes the
			 following counties: Blount, Calhoun, Cherokee, Clay, Cleburne, Coosa, DeKalb,
			 Etowah, Randolph, St. Clair, Talladega, and Tallapoosa.
3. Jefferson and Shelby, which includes the
			 following counties: Jefferson and Shelby.
4. Northeast, which includes the following
			 counties: Cullman, Jackson, Limestone, Madison, Marshall, and Morgan.
5. Northwest, which includes the following
			 counties: Bibb, Colbert, Fayette, Franklin, Greene, Hale, Lamar, Lauderdale,
			 Lawrence, Marion, Pickens, Sumter, Tuscaloosa, Walker, and Winston.
6. Southeast, which includes the following
			 counties: Barbour, Bullock, Chambers, Coffee, Covington, Dale, Geneva, Henry,
			 Houston, Lee, Macon, Pike, and Russell.
7. Southwest, which includes the following
			 counties: Baldwin, Choctaw, Conecuh, Clarke, Escambia, Mobile, Monroe, and
			 Washington.
Author:
Bob Kurtts, Health Systems Manager,
				  Network and Quality Assurance Division
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; C.F.R. Part 438; C.F.R. §438.700 et.seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.08 - Sanctions Under The Alabama Coordinated Health Network Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Bases for
			 Imposition of Sanctions on Alabama Coordinated Health Network Entity. The
			 Medicaid Agency may impose sanctions on an Alabama Coordinated Health Network
			 Entity ("Entity") if the Medicaid Agency determines in its sole discretion that
			 the Entity has violated any applicable federal or state law or regulation, the
			 Alabama Medicaid State Plan, the contract between the Medicaid Agency and the
			 Entity and the exhibits thereto (the "contract"), any policies, procedures,
			 written interpretations, or other guidance of the Medicaid Agency, or for any
			 other applicable reason described in 42 C.F.R. Part 438, Subpart I or the
			 contract, including but not limited to a determination by the Medicaid Agency
			 that an Entity acts or fails to act as follows:
(a) Acts to discriminate among Els on the
			 basis of their health status or need for health care services (including
			 termination of enrollment or refusal to reenroll an EI, except as permitted
			 under the Alabama Medicaid program, or any practice that would reasonably be
			 expected to discourage enrollment by Els whose medical condition or history
			 indicates probable need for substantial future medical services);
(b) Misrepresents or falsifies information
			 that it furnishes to Agency or to CMS;
(c) Misrepresents or falsifies information
			 that it furnishes to an EI, Potential EI, or health care Provider;
(d) Distributes directly, or indirectly
			 through any agent or independent contractor, marketing materials that have not
			 been approved in writing by the Agency or that contain false or materially
			 misleading information;
(e) Fails
			 to submit a Corrective Action Plan (CAP) that is acceptable to the Agency
			 within the time period specified by the Agency's written notice or does not
			 implement or complete the corrective action within the established time
			 period;
(f) Violates, as determined
			 by the Agency, any requirement of sections 1932 or 1905(t) of the Social
			 Security Act or any implementing regulations; or
(g) Violates, as determined by the Agency,
			 any applicable requirement of the Alabama Code or the Alabama Medicaid
			 Administrative Code.
(h)
			 Unauthorized use of information.
(i) Failure to safeguard confidential
			 information of Providers, Els or the Medicaid program.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.10 - Payments To Primary Care Physicians And Delivering Healthcare Professionals Participating With The Alabama Coordinated Health Network

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Primary Care
			 Physician (PCP) Groups.
(a) To participate
			 with an Alabama Coordinated Health Network (ACHN), a PCP Group must engage with
			 the ACHN as follows:
1. PCP Groups must sign
			 two agreements beyond their Medicaid enrollment:
(i) A PCP Group Agreement with Alabama
			 Medicaid; and
(ii) One agreement
			 with an ACHN entity.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Ambulatory
			 surgical services are those procedures typically performed on an inpatient
			 basis which call be performed safely on an outpatient or ambulatory surgical
			 center (ASC) basis.
(2) Ambulatory
			 surgical center services shall be reimbursed by means of a predetermined fee
			 established by the Alabama Medicaid Agency. All ambulatory surgical center
			 procedures shall be reimbursed at the lesser of the predetermined rate for the
			 procedure less the copay amount. The fee is established at levels estimated to
			 approximate the costs incurred by providers generally in providing covered
			 services.
(3) Ambulatory surgical
			 center services shall be limited to three (3) visits per calendar year.
Author:
Statutory Authority:
42
				  C.F.R. §§
											416.2, 416.39,
				  416.40.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.02 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order to
			 participate in the Title XIX Medicaid Program and to receive Medicaid payment
			 for services, ASC providers must meet all of the following requirements:
(a) Certification for participation in the
			 Title XVIII Medicare Program;
(b)
			 Approval by the appropriate licensing authorities;
(c) Compliance with Title VI of the Civil
			 Rights Act of 1964 and with Section 504 of the Rehabilitation Act of 1973;
			 and
(d) Submit a letter requesting
			 enrollment, a copy of a transfer agreement with an acute care facility (refer
			 to Rule 560-X-38-.05 for details), and
			 enter into a contract with the Alabama Medicaid Agency.
(e) Reimbursement is limited to services
			 provided directly by the facility's staff in accordance with the capability as
			 specified on the HCFA-377.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.03 - Payment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payment shall
			 be made for a surgical procedure performed on a Medicaid recipient only if the
			 procedure is on the approved list.
(2) Ambulatory surgical center services are
			 items and services furnished by an outpatient ambulatory surgery center in
			 connection with a covered surgical procedure.
(3) Rates of reimbursement for ambulatory
			 surgical center services include, but are not limited to:
(a) Nursing, technician and related
			 services;
(b) Use of an ambulatory
			 surgery center;
(c) Lab and X-ray,
			 drugs, biologicals, surgical dressings, splints, casts, appliances, and
			 equipment directly related to the provision(s) of the surgical
			 procedure(s);
(d) Diagnostic or
			 therapeutic services or items directly related to the provision of a surgical
			 procedure;
(e) Administrative,
			 record keeping, and housekeeping items and services; and
(f) Materials for anesthesia.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.04 - Covered Surgical Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Covered surgical procedures are those
			 procedures that meet the following standards:
(a) Those surgical procedures which are
			 commonly performed on an inpatient basis in hospitals, but may be safely
			 performed in an ambulatory surgical center setting;
(b) Those surgical procedures which are
			 limited to those requiring a dedicated operating room and generally requiring a
			 post-operative recovery room or short-term (not overnight) convalescent room;
			 and
(c) Those surgical procedures
			 which are not otherwise excluded under 42 C.F.R. § 405.310 or other
			 regulatory requirements.