reglab/statecodes huggingface dataset:
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 145 - Medicaid Payment Rates › Article 11 - Payment Rates; Rural Health Clinic and Federally Qualified Health Center Services › 7 AAC 145.770 - SEMT interim supplemental payment

Current through May 31, 2024
(a) For SEMT, the
				  department will pay an interim supplemental payment that approximates the SEMT
				  costs eligible for federal financial participation claimed through the
				  certified public expenditure (CPE) process.
(b) The department will calculate the interim
				  supplemental payment rate for SEMT on an annual basis per cost report. The
				  department will pay one interim payment not later than the end of the second
				  quarter following the cost report submission.
(c) The department will determine the interim
				  supplemental payments using the most recently filed cost reports provided under
				  7 AAC 145.760. The cost reports will be used to determine an average cost per
				  qualifying medical transport, using the following calculation:
(1) the sum of a participating provider's
				  allowable direct and indirect costs for ground, air, and water medical
				  transport services will be divided by the number of medical transports,
				  separated into ground, air, and water services by the service-specific
				  components, to determine a participating provider's average cost per medical
				  transport for each ground, air, or water service;
(2) the average cost per medical transport
				  for each ground, air, or water service will be multiplied by the number of
				  qualifying Medicaid fee-for-service emergency medical transports to determine
				  allowable Medicaid emergency medical transportation costs;
(3) the allowable Medicaid emergency medical
				  transportation costs will be offset by Medicaid revenue for fee-for-service
				  (FFS) and third party liability (TPL) for Medicaid emergency medical
				  transports, to calculate the Medicaid emergency medical transportation costs
				  that have not been paid by any other source;
(4) the calculated Medicaid emergency medical
				  transportation costs not paid by any other source will be multiplied by the
				  federal medical assistance percentage (FMAP), within the meaning given in
				  42
				  U.S.C. 1396d(b) (sec.
				  1905(b), Title XIX, Social Security Act), to determine the interim
				  payment.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 145 - Medicaid Payment Rates › Article 11 - Payment Rates; Rural Health Clinic and Federally Qualified Health Center Services › 7 AAC 145.790 - SEMT administrative fee

Current through May 31, 2024
(a) The provider
				  must pay the department an administrative fee to cover the cost of the SEMT
				  program.
(b) The fee is equal to
				  the state general fund cost to the department to administer the SEMT program.
				  The department will use the fee to pay the required state match for federal
				  funding.
(c) The fee is a flat fee
				  per Medicaid emergency medical transports for the service period in the cost
				  reports submitted during the time period preceding the June 15 due date of the
				  fee.
(d) The department will
				  establish the administrative fee as follows:
(1) the first administrative fee per Medicaid
				  emergency medical transport is the state general fund cost of the SEMT program
				  starting from until the following March 31 after the first SEMT cost {effective
				  date of regulations} reports are submitted to the department, divided by the
				  number of SEMT Medicaid emergency medical transports that is obtained from the
				  Medicaid Management Information System (MMIS), described in
				  42 C.F.R.
				  433.111(b), as determined
				  after the cost report submission for the SEMT providers for the service period
				  matching the cost reports submitted during the same time period as the state
				  general fund costs;
(2) in
				  subsequent years, the administrative fee is the state general fund cost of the
				  SEMT program during the most recent April 1 through March 31, divided by the
				  number of SEMT Medicaid emergency medical transports that is obtained from the
				  Medicaid Management Information System (MMIS), as determined after the cost
				  report submission for the SEMT providers for the service period matching the
				  cost reports submitted during the same time period as the state general fund
				  costs.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 145 - Medicaid Payment Rates › Article 11 - Payment Rates; Rural Health Clinic and Federally Qualified Health Center Services › 7 AAC 145.799 - Definitions

Current through May 31, 2024
(1) "allowable cost" means an expenditure
				  that meets the test of the appropriate Executive Office of the President of the
				  United States' Office of Management and Budget (0MB) circular;
(2) "cognizant agency" means the federal
				  agency with the largest dollar value of a direct federal award with a
				  governmental unit or component;
(3)
				  "department" means the Department of Health and Social Services;
(4) "desk review" means an analysis of cost
				  report data submitted by a provider to determine whether costs are reasonable
				  and allowable for reimbursement under federal and state regulations;
(5) "direct costs" means costs included under
				  45
				  C.F.R. 75.413 that may be
(A) identified specifically with a particular
				  final cost objective, such as a federal award or other internally or externally
				  funded activity, to meet emergency medical transportation requirements;
				  or
(B) directly assigned, with a
				  high degree of accuracy, to an activity described in (A) of this
				  paragraph;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.010 - Purpose of prospective payment system

Current through May 31, 2024
The purpose of this chapter is to implement the provisions of
				  AS
				  47.07.040 and
				  47.07.070-47.07.900.
Authority:
AS
					 47.05.010
AS 47.07.040
AS 47.07.070
AS 47.07.071
AS 47.07.073
AS 47.07.074
AS 47.07.075
AS 47.07.900
AS
					 47.25.195
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.020 - Applicability of prospective payment system

Current through May 31, 2024
(a) All health
				facilities seeking payment from the department for services provided to
				Medicaid recipients in this state are subject to the provisions of this
				chapter.
(b) To receive a change in
				a prospective payment rate, a health facility must obtain the department's
				approval in accordance with the procedures set out in this chapter.
Authority:
AS
					 47.05.010
AS
					 47.07.070
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.030 - Establishment of prospective rates

Current through May 31, 2024
(a) The department
				will establish prospective per-day payment rates in accordance with
				7 AAC 150.210 for facilities not less than annually for
				each facility subject to the per-day reimbursement methodology.
(b) The department will establish prospective
				per-stay Diagnosis Related Groups (DRG) payment rates in accordance with
				7 AAC 150.250 for facilities not less than triennially
				for each facility subject to the DRG reimbursement methodology.
(c) The department may establish temporary
				prospective per-day or per-stay payment rates. The final rate approved by the
				department supersedes the temporary rate, and the department will adjust
				payments in accordance with the final rate.
Authority:
AS
					 47.05.010
AS
					 47.07.070
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.040 - Prospective rates defined

Current through May 31, 2024
(a) Prospective
				payment rates are units of payment the department will pay to enrolled
				facilities that render services to Medicaid recipients. A facility may not
				charge the department an amount that exceeds the charge to the general public
				for the same service.
(b)
				Prospective payment rates are per-day rates for
(1) inpatient services rendered in general
				acute care hospitals, except as provided in (c) of this section, specialty
				hospitals, and inpatient psychiatric hospitals; and
(2) long-term care facilities.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.110 - Methodology and criteria for proportionate share payments to privately owned or operated hospitals

Current through May 31, 2024
(a) To implement
				the provisions of 42 U.S.C.
				1396 b regarding federal financial
				participation under Medicaid, and subject to legislative appropriations for
				that purpose, the department will make a private hospital proportionate share
				payment to, and will require under (2) - (4) of this subsection that specific
				services be performed by, a hospital that qualifies under (1) of this
				subsection in order to ensure continued access to hospital services, and in
				order to secure for the state in accordance with
				AS
				47.07.040 the optimum federal participation
				for inpatient hospital services in the state's medical assistance program. The
				following procedures and requirements apply to a proportionate share payment
				under this subsection:
(1) to qualify to
				receive a private hospital proportionate share payment under this subsection, a
				hospital must
(A) be enrolled as a Medicaid
				provider of inpatient hospital services;
(B) be located within the state;
(C) be a privately owned facility;
				and
(D) submit to the department
				the Medicaid reporting forms for the qualifying year from the
Medicaid
				Hospital and Long-Term Care Facility Reporting Manual
, adopted by
				reference in
				7 AAC 160.900;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.120 - Methodology and criteria for proportionate share payments to state-owned or state-operated hospitals

Current through May 31, 2024
(a) To implement
				the provisions of 42 U.S.C.
				1396 b regarding federal financial
				participation under Medicaid, and subject to legislative appropriations for
				that purpose, the department will make a state hospital proportionate share
				payment to, and may require specific services to be performed by, a hospital
				that qualifies under (1) of this subsection in order to ensure continued access
				to inpatient and outpatient hospital services or other health services, and in
				order to secure for the state in accordance with
				AS
				47.07.040, the optimum federal participation
				for inpatient hospital services in the state's medical assistance program. The
				following procedures and requirements apply to a proportionate share payment
				under this subsection:
(1) to qualify for a
				state hospital proportionate share payment under this subsection, a hospital
				must be
(A) a state-owned or state-operated
				Medicaid provider of inpatient hospital services; and
(B) located within the state;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.140 - Processing of annual year-end report

Current through May 31, 2024
(a) The department
				will process facilities' annual year-end reports required by
				7 AAC 150.130(c) in the manner set out
				in (a) - (e) of this section, unless the facility is a rural health clinic or
				ambulatory surgical center. Each annual year-end report will be date-stamped
				upon receipt by the department. The department will acknowledge the date of
				receipt in a written notice.
(b) No
				more than 20 days after receipt of an annual year-end report, the department
				will review the report to determine whether all required forms are
				complete.
(c) Written notice will
				be provided by mail or electronic mail to the facility during the 20-day review
				period if the department determines that the annual year-end report does not
				contain all required and completed forms. If the department does not provide
				written notice during the 20-day period, the department will treat the year-end
				report as complete. In the notice, the department will clearly identify the
				deficiencies and the time by which the corrected or modified annual year-end
				report must be received by the department. The department will give the
				facility at least seven days following receipt of the notice to return to the
				department the corrected or modified annual year-end report.
(d) If the data requested under (c) of this
				section is returned to the department during the specified period, the
				department will make reasonable efforts to continue the processing of the
				annual year-end report as if a delay had not occurred.
(e) If the department determines under (b) of
				this section that the annual year-end report is complete, the department will
				begin processing and verifying the data contained in the report and prepare
				findings and recommendations as needed.
(f) A copy of the department's findings and
				recommendations will be provided by mail or electronic mail to the facility not
				less than 30 days before the date set for the public hearing to consider the
				facility's proposed prospective payment rate.
(g) A facility may submit a response to the
				department's findings and recommendations. The response must be received by the
				department not less than five days before the date set for the public hearing
				to consider the facility's proposed prospective payment rate.
(h) If a facility is an ambulatory surgical
				center, the department will prepare findings and recommendations in the manner
				set out in (f) and (g) of this section.
Authority:
AS
					 47.05.010
AS 47.07.070
AS 47.07.071
AS
					 47.07.073
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.150 - Adjustment factors

Current through May 31, 2024
(a) To calculate
				adjustment factors for facility fiscal years, the department will use the most
				recent quarterly publication of Global Insight's
Healthcare Cost
				Review
available 60 days before the beginning of a facility's fiscal
				year, as follows:
(1) for general acute care,
				specialty, and inpatient psychiatric hospitals' noncapital allowable costs, the
				department will utilize the Global Insight Hospital Market Basket;
(2) for general acute care, specialty, and
				inpatient psychiatric hospitals' allowable capital costs and allowable home
				office capital costs will be adjusted using the most recent CMS base year PPS
				Hospital Capital Input Price Index (IPI) reported in the IHS Markit Health Care
				Costs, Building Cost Index;
(3) for
				long-term care facilities' noncapital allowable costs, the department will
				utilize the CMS Nursing Home without Capital Market Basket;
(4) long-term care facilities' allowable
				capital costs, and allowable home office capital costs will be adjusted using
				the Skilled Nursing Facility Total Market Basket Capital Cost
				component.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.160 - Methodology and criteria for approval or modification of a payment rate

Current through May 31, 2024
(a) The department
				will use the following methodology and criteria in reviewing and establishing
				prospective payment per-day and percentage-of-charges rates for the Medicaid
				program:
(1) the department will consider the
				following with the relative importance of each criterion being a matter of
				department discretion:
(A) whether the costs
				are related to patient care and are attributable to the Medicaid
				program;
(B) whether the payment
				rate is reasonably related to costs;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.170 - Allowable reasonable operating costs

Current through May 31, 2024
(a) Allowable costs
				for prospective per-day and percentage of charges rates are the costs from the
				appropriate base year's Medicare cost report, in accordance with Medicare
				requirements and regulations, as audited or adjusted in accordance with this
				section. The department will consider only costs that are consistent with
				efficient, cost-effective management and operations. Only operating costs that
				are directly related to the delivery of health care services to Medicaid
				patients will be allowed for the purpose of rate setting.
(b) Operating costs are the costs of
				providing health care services to Medicaid patients that are necessary and
				reasonable and that are not excluded by this section. The following costs are
				excluded or otherwise limited as set out in this subsection:
(1)
advertising cost:
the cost
				of advertising, which includes marketing, is allowable only to the extent that
				the advertising is directly related to the care of patients at the facility;
				the reasonable cost of only the following types of advertising and marketing is
				allowable:
(A) announcing the opening of or
				change of name of a facility;
(B)
				recruiting for personnel;
(C)
				advertising for the procurement or sale of items;
(D) obtaining bids for construction or
				renovation;
(E) advertising for a
				bond issue;
(F) informational
				listing of the provider in a telephone directory;
(G) listing a facility's hours of
				operation;
(H) advertising
				specifically required as part of a facility's accreditation process;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.180 - Methodology and criteria for additional payments as a disproportionate share hospital

Current through May 31, 2024
(a) A qualifying
				hospital that provides services to a disproportionate share of low-income
				patients with special needs is eligible for Medicaid payments as a
				disproportionate share hospital (DSH). These payments are in addition to the
				Medicaid payment rate established under
				7 AAC 150.160 or
				7 AAC 150.190. The department will not award payments
				under this section to a qualifying hospital in a total amount that exceeds the
				facility-specific limit calculated under (e)(3) of this section.
(b) To qualify for additional payments under
				this section as a DSH, a hospital must meet the following criteria for each
				qualifying year:
(1) the hospital must be a
				general acute care hospital, a critical access hospital, a specialty hospital,
				or an inpatient psychiatric hospital;
(2) unless it qualifies for the exception set
				out in 42 U.S.C.
				1396r-4(d)(2), the
				hospital must meet the obstetrical staffing requirements of
				42 U.S.C.
				1396r-4(d), and must
				provide the names and Medicaid provider numbers of at least two obstetricians
				who meet the requirements of that section;
(3) the hospital must have a minimum Medicaid
				utilization rate of not less than one percent for the qualifying year; for
				purposes of this paragraph, the Medicaid utilization rate is calculated by
				dividing the hospital's number of Medicaid-eligible inpatient days by the
				hospital's total number of inpatient days provided to all patients;
(4) not later than October 1 of the calendar
				year that precedes the payment period, the hospital must submit to the
				department the following forms and documentation:
(A) the Medicare cost report filed for the
				qualifying year;
(B) Medicaid
				reporting forms for the qualifying year from the
Medicaid Hospital and
				Long-Term Care Facility Reporting Manual,
adopted by reference in
				7 AAC 160.900, including the audited financial
				statements for the facility;
(C) an
				uninsured care log for the qualifying year for each patient having uninsured
				care; the log must be prepared and submitted in electronic spreadsheet format
				using the
Medicaid Log of Uninsured Care Reporting Form,
adopted by reference in
				7 AAC 160.900; the hospital must certify the log as
				accurate in an electronic attachment with the submission of the uninsured care
				log; with respect to uninsured care, the log must specify, in sufficient detail
				for the department to verify the information,
(i) total charges;
(ii) each admission date;
(iii) the number of patient days;
(iv) any payments made by the patient, or on
				behalf of the patient by a third party, for services;
(v) each discharge date;
(vi) each service type;
(vii) each payment designation; and
(viii) each date service was provided for
				outpatient hospital services.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.190 - Optional payment rate methodology and criteria for small facilities

Current through May 31, 2024
(a) The provisions
				of this section apply to a small facility that
(1) had 4,000 or fewer acute care patient
				days at an general acute care, specialty, or inpatient psychiatric hospital or
				at a combined general acute care hospital-nursing facility or had 15,000 or
				fewer Medicaid nursing facility days at a nursing facility that is not combined
				with a general acute care hospital during the small facility's fiscal year that
				ended 12 months before the beginning of the prospective year;
(2) elects to participate in rate setting
				under (c) of this section; and
(3)
				is not a general acute care hospital reimbursed under the Diagnosis Related
				Groups (DRG) payment methodology under
				7 AAC 150.250.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.210 - Procedure for establishment of rates

Current through May 31, 2024
(a) Based on
				consideration of the documents submitted by the facility, audit or review of
				the facility the facility's responses to audit or review testimony at the
				public hearing, and the requirements of AS 47.07 and 7 AAC 105 - 7 AAC 160, the
				department staff that oversees Medicaid payment rates shall establish the
				prospective payment rate in a written determination. The department shall send
				a copy of the written determination and a certificate showing the date the
				determination was mailed or etectronically delivered to the facility.
(b) The department staff that oversees
				Medicaid payment rates may reconsider a prospective payment rate upon the
				department staffs own motion or at the facility's request. A facility seeking
				reconsideration shall file a request for reconsideration not later than 30 days
				after the date the written determination was mailed or electronically delivered
				to the facility. The department staff shall deny a request for reconsideration
				as untimely if the request was filed later than 30 days after the date the
				written determination was mailed or electronically delivered to the facility.
				The notice of denial of reconsideration or the decision on reconsideration must
				be accompanied by a certificate showing the date the written determination was
				mailed or electronically delivered.
(c) A request for reconsideration under (b)
				of this section must be filed at the Anchorage office of the department with
				the staff that oversees Medicaid payment rates.
The address for filing requests for reconsideration under
					 7 AAC 150.210 is Department of Health and Social
					 Services, Office of Rate Review, 3601 C Street, Suite 978, Anchorage, Alaska
					 99503.
Authority:
AS
					 47.05.010
AS
					 47.07.070
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.220 - Administrative appeal

Current through May 31, 2024
(a) Not later than
				30 days after a written determination under
				7 AAC 150.210(a) is mailed or
				electronically delivered to a facility, a facility aggrieved by that
				determination may request reconsideration under
				7 AAC 150.210(b) or may file a written
				notice of appeal with the commissioner. In the notice of appeal, the facility
				must
(1) set out a statement of
				issues;
(2) identify the basis for
				the facility's contention that the written determination of the prospective
				payment rate is incorrect;
(3)
				specify the relief requested;
(4)
				provide a name, address, telephone number, and other contact information for
				the facility representative designated as the point of contact for the appeal;
				and
(5) include a certificate
				showing the date the appeal was mailed or electronically
				delivered.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.230 - Appeal procedures

Current through May 31, 2024
(a) If a notice of appeal satisfies the
				requirements of
				7 AAC 150.220, the department will file, in accordance
				with the prehearing schedule established under (c) of this section, and with
				both the administrative law judge that the office of administrative hearings
				(AS
				44.64.010)  assigns to the matter and the
				facility representative designated under
				7 AAC 150.220(a) (4) or (b)(4) as the
				point of contact, a written response setting out the department's position with
				respect to each of the points raised in the appeal. In the response, the
				department will state clearly the defenses it intends to assert.
(b) Not later than 10 days after receiving a
				notice of appeal that satisfies the requirements of
				7 AAC 150.220, the commissioner will refer the appeal to
				the office of administrative hearings (AS
				44.64.010)  for a hearing in accordance with
				2 AAC 64.100 -
				2 AAC 64.990.
(c) No more than 45 days after receiving the
				notice of assignment, the administrative law judge shall conduct a prehearing
				conference, at which time a schedule shall be established that sets prehearing
				deadlines and a date for the hearing. The schedule shall provide for a hearing
				on the administrative appeal under
				7 AAC 150.220(a) or (b) to begin no
				more than 120 days after the written notice of appeal was received by the
				commissioner, unless the facility requests a delay or the administrative law
				judge finds good cause for the delay. The administrative law judge may find
				good cause for the delay under
				AS
				47.07.075(b)(1) and this
				subsection in circumstances such as the following:
(1) the administrative law judge finds that
				the facility waived its right to a timely hearing under this section;
(2) the parties stipulated to the hearing
				being held at a later date;
(3) the
				facility failed to file the statement of issues described in (a) of this
				section at the time that the notice of appeal was initially filed;
(4) the facility amended its statement of
				issues after initial filing;
(5)
				the administrative law judge finds that strict adherence to the 120-day time
				limit for a hearing would work injustice.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.240 - Exceptional relief to prospective payment rate setting

Current through May 31, 2024
(a) If application
				of the methodology in
				7 AAC 145.700 or in
				7 AAC 150.040 -
				7 AAC 150.190 and
				7 AAC 150.250 results in a permanent prospective payment
				rate that does not allow reasonable access to quality patient care provided by
				an efficiently and economically managed facility, the facility may apply to the
				deputy commissioner for exceptional relief from the rate-setting
				methodology.
(b) To apply for
				exceptional relief under (a) of this section, at a minimum the facility's
				application must include
(1) the amount by
				which the facility estimates that the prospective payment rate should be
				increased to allow reasonable access to quality patient care provided by an
				efficiently managed facility;
(2)
				the reasons and the need for the exceptional relief requested, including any
				resolution by the facility's governing body to support the reasons offered, and
				why such a rate increase cannot be obtained through the existing rate-setting
				regulations;
(3) the description of
				management actions taken by the facility to respond to the situation on which
				the exceptional relief request is based;
(4) the audited financial statement for the
				facility for the most recently completed facility fiscal year and financial
				data, including a statement of income and expenses, a statement of assets,
				liabilities, and equities, and a monthly facility cash flow analysis, for the
				fiscal year for which the exception is requested;
(5) a detailed description of recent efforts
				by the facility to offset the deficiency by securing revenue sharing, charity
				or foundation contributions, or local community support;
(6) an analysis of community needs for the
				service on which the exception request is based;
(7) a detailed analysis of the options of the
				facility if the exception is denied by the deputy commissioner;
(8) a plan for future action to respond to
				the problem; and
(9) an analysis of
				how many Medicaid patients will lose access to Medicaid services available to
				the general public in the same geographic area if exceptional relief is not
				granted.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 150 - Prospective Payment System; Other Payment › 7 AAC 150.990 - Definitions

Current through May 31, 2024
(1) "adjusted
				Medicare cost report" means a base year's Medicare cost report that has been
				adjusted in accordance with
				7 AAC 150.170 or
				7 AAC 150.200;
(2) "All Patient Refined Diagnosis Related
				Groups" or "APR DRG" means a type of classification system used to assign
				inpatient stays to a Diagnosis Related Group (DRG), under which a grouping
				algorithm utilizes the diagnoses code, procedure code, patient birthdate,
				patient age, patient gender, admission date, discharge date, and discharge
				status to assign a DRG code to each claim;
(3) "assets" means all economic resources of
				a health facility, recognized and measured in conformity with generally
				accepted accounting principles; in this paragraph, "assets" include certain
				deferred charges that are not resources but that are recognized and measured in
				accordance with generally accepted accounting principles;
(4) "audit" means the systematic inspection
				of accounting records involving analyses, tests, or confirmations;
(5) "base year" means the facility's fiscal
				year ending 12 months before the fiscal year for which prospective payment
				rates are to be re-based;
(6)
				"budget" and "budgeting" mean the financial data for, and the process of,
				developing a capital budget for annual submission to the department, by a
				facility that has received a certificate of need for the facility's prospective
				fiscal year or for a facility that has a rate established under
				7 AAC 150.160(i)(3)(B);
(7) "capital" means capital-related costs as
				determined in accordance with
				42 C.F.R.
				413.130 -
				413.153, governing the Medicare
				cost report;
(8) "certificate" or
				"certificate of need" means a certificate of need required by and approved
				under AS 18.07 and 7 AAC 07;
(9)
				"charges" means amounts that patients are billed for health care services
				provided by a facility;
(10)
				"charity care" means health care services that
(A) a facility does not expect to result in
				cash payments; and
(B) result from
				a facility's policy to provide health care services free of charge to an
				individual who meets certain financial criteria;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 155 - Tribal Health Programs › 7 AAC 155.010 - Tribal health program payment methodology

Current through May 31, 2024
Notwithstanding any other payment provisions of 7 AAC 105 - 7
				  AAC 160, the department will pay a tribal health program using
(1) the Indian Health Service encounter
				rates, adopted by reference in
				7 AAC 160.900; or
(2) the payment methodology applicable to a
				nontribal provider in 7 AAC 145, if the tribal health program has elected,
				under 25 U.S.C
				1645, to use that payment methodology for a
				selected range of services covered under 7 AAC 105 - 7 AAC 160.
Authority:
AS
					 47.05.010
AS 47.07.030
AS
					 47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 155 - Tribal Health Programs › 7 AAC 155.030 - Certified health providers

Current through May 31, 2024
A certified health
				provider is a
(1) community health
				aide;
(2) community health
				practitioner;
(3) behavioral health
				aide; or
(4) behavioral health
				practitioner.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 155 - Tribal Health Programs › 7 AAC 155.040 - Certified health provider encounter rate

Current through May 31, 2024
(a) The department
				will pay a single statewide certified health provider encounter rate for the
				services of a
(1) community health aide or
				community health practitioner certified by the Community Health Aide Program
				Certification Board; and
(2)
				behavioral health aide or behavioral health practitioner certified by the
				Behavioral Health Aide Program Certification Board.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 1 - Program Integrity and Quality Assurance › 7 AAC 160.100 - Program integrity

Current through May 31, 2024
The department or its designee shall provide for and
					 operate program integrity activities designed to promote the economical and
					 effective administration of the department's Medicaid program. These activities
					 may include the following:
(1)
				  operation of a surveillance, utilization, and review subsystem within the
				  department's system to manage Medicaid information;
(2) audit activities designed to investigate
				  fraud, abuse, over-utilization or Medicaid program compliance by
				  providers;
(3) utilization review
				  under 7 AAC 160.140;
(4) coordination with the Department of Law,
				  the United States Department of Justice, and the United States Office of
				  Inspector General.
Authority:
AS
						47.05.010
AS 47.05.200
AS 47.07.030
AS 47.07.040
AS
						47.07.074
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 1 - Program Integrity and Quality Assurance › 7 AAC 160.110 - Fiscal audit

Current through May 31, 2024
(a) The department or its designee shall
				  conduct fiscal audits of Medicaid providers their subcontractors, and their
				  grantees. A provider that bills the department is responsible for ensuring that
				  records related to the services bined are kept by employees, subcontractors,
				  and grantees, are maintained in accordance with7 AAC 105.230, and are made available when requested by the
				  department.
(b) For purposes of
				  this section, a fiscal audit may include a desk audit, a field audit, or both,
				  to determine the provider's compliance with the requirements of
				  42 U.S.C.
				  1396, AS 47.05, AS 47.07,  42 C.F.R. Part 430
				   -  42 C.F.R. Part 498, and 7  AAC 105 - 7 AAC 160.
(c) For purposes of conducting an audit under
				  this section, the provider must allow the department or its designee, the
				  federal government, or the Department of Law access to original financial,
				  clinical, and other records documenting care provided to Medicaid
				  recipients.
(d) Except as provided
				  in (e) of this section, the department or its designee will give a provider 30
				  days' advance notice of an audit to be conducted under this section. The notice
				  will
(1) advise the provider that the
				  department or its designee intends to conduct an audit of the provider's
				  records;
(2) specify the place
				  where the audit is to be conducted;
(3) specify the records that the provider
				  must produce for purposes of the audit;
(4) specify the date by which the provider
				  must produce the records and the address to which the records are to be
				  delivered or inspected; and
(5)
				  advise the provider that the provisions of
				  7 AAC 105.240 apply to the production of the records
				  requested.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 1 - Program Integrity and Quality Assurance › 7 AAC 160.115 - Duty of a provider to identify and repay self-identified overpayments

Current through May 31, 2024
(a) An enrolled
				  provider who bills the department for services rendered during a calendar year
				  shall conduct, once every two years, a review or audit of a statistically valid
				  random sample of claims submitted to the department for reimbursement, unless
				  the provider is being audited under
				  AS
				  47.05.200(a). The universe
				  of claims from which the random sample is drawn must be all claims that are
				  billed with dates of service during the calendar year for the provider and that
				  may be identified at the taxpayer identification level. As part of the
				  self-review or self-audit, a provider shall establish appropriate corrective
				  actions for any deficiencies identified.
(b) A biennial review or audit conducted
				  under this section shall be conducted not earlier than one year following the
				  end of the calendar year to allow for timely filing of all claims.
(c) The provider may use any widely accepted
				  statistical software, such as RAT-STATS, developed by the United States
				  Department of Health and Human Services, Office of Inspector General, to assist
				  in sample size determination, and sample selection, using a minimum of a 90-
				  percent confidence interval.
(d) If
				  a provider identifies overpayments through the biennial review or audit, the
				  provider shall report each overpayment to the department not later than 10
				  business days after identification of that overpayment. Overpayment reports
				  shall be submitted to the Department of Health and Social Services, Office of
				  the Commissioner, Medicaid Program Integrity. In this subsection, "business
				  day" means a day other than Saturday, Sunday, or a legal holiday under AS
				  44.12.010.
(e) A provider who was
				  reimbursed
(1) $30,000 or greater for
				  services during the year shall submit a report to the department detailing the
				  claims audited or reviewed together with the results of that review or audit;
(2) $10,000 or greater but less
				  than $30,000 is not required to submit the report to the department but must
				  have the report available for review by the department;
(3) less than $10,000 is not required to
				  produce a report but shall have an attestation form on file and available for
				  review by the department.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 1 - Program Integrity and Quality Assurance › 7 AAC 160.120 - Use of statistical sampling

Current through May 31, 2024
The department its designee, or a provider may use
					 statistically valid sampling methodologies to
(1) select Medicaid claims for review or
				  audit; and
(2) calculate
				  overpayment amounts to providers that are subject to a provider self-review or
				  self-audit under
				  AS
				  47.05.235 and 7 AAC 160.115, a fiscal audit
				  under 7 AAC 160.110 or a quality assurance program review under
				  7 AAC 160.140.
Authority:
AS
						47.05.010
AS
						47.05.235
AS
						47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 1 - Program Integrity and Quality Assurance › 7 AAC 160.130 - Appeal

Current through May 31, 2024
(a) A provider may appeal the findings of a
				  final audit conducted under
				  7 AAC 160.110 and determinations of overpayment amount
				  under the audit. A provider may requeste reconsideration of the audit findings
				  before a formal appeal. If a provider requests reconsideration, the provider
				  may still request a formal appeal under this section by requesting the appeal
				  not later than 30 days after the date of the notice of decision on
				  reconsideration.
(b) An appeal
				  under this section must
(1) be made in writing
				  and submitted to the Commissioner's Office, Department of Health and Social
				  Services, P.O. Box 110601, Juneau, Alaska 99811-0601;
(2) be submitted to the commissioner no more
				  than 30 days after the date of the letter transmitting the provider's final
				  audit report;
(3) contain a
				  description of the finding or determination being appealed, a copy of the
				  determination, and the basis upon which the final audit report is challenged;
				  and
(4) include all information and
				  materials, including any new information that the provider requests the
				  commissioner to consider in resolving the appeal.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 1 - Program Integrity and Quality Assurance › 7 AAC 160.140 - Quality assurance program

Current through May 31, 2024
(a) The department,
				  through each division responsible for the administration of the Medicaid
				  program, will establish a quality assurance program to ensure provider
				  compliance with AS 47.05, AS 47.07, and 7 AAC 105 - 7 AAC 160.
(b) Under the quality assurance program, the
				  department will conduct program reviews of providers. If the department
				  proposes adverse action as a result of the review, the department will issue a
				  written report of the findings to the provider.
(c) If the department finds in the written
				  report under (b) of this section that the provider has not complied with AS
				  47.05, AS 47.07, or 7 AAC 105 - 7 AAC 160, the department may take one or more
				  of the following actions:
(1) give the
				  provider notice under
				  7 AAC 105.440 that the department proposes to
				  immediately suspend a provider's participation in the Medicaid
				  program;
(2) find grounds under
				  7 AAC 105.400 to sanction the provider under
				  7 AAC 105.410;
(3) require that the provider be subject to a
				  financial audit if there is a reasonable basis to conclude that the provider
				  has received payments in excess of what is authorized under the Medicaid
				  program;
(4) require the provider
				  to issue a corrective action plan to address a written report of findings
				  issued under (b) of this section;
(5) initiate other administrative or other
				  civil actions;
(6) refer the matter
				  to
(A) another state, federal, or local
				  agency; and
(B) applicable
				  certifying and accrediting agencies.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 2 - Third-Party Liability; Estate Recovery › 7 AAC 160.200 - Third-party resources

Current through May 31, 2024
(a) The department will pay for a service,
				  prescription drug, or supply only to the extent it is a covered service under
				  AS
				  47.07.030 and 7 AAC 105 - 7 AAC 160 and only
				  after the recipient has made full use of any other third-party resources
				  available to pay for that service, prescription drug, or supply. A third-party
				  resource includes
(1) workers' compensation
				  under a law or plan of the United States or a particular
				  jurisdiction;
(2) private,
				  employer-based, or public health insurance;
(3) a prepaid health plan;
(4) a program or health plan of the federal
				  government, including
(A) Veterans
				  Administration benefits,
(B) the
				  TRICARE military health plan under
				  10 U.S.C.
				  1071 -
				  1110 for active duty military
				  personnel, reservists, dependents, and retirees, or other military health plan;
				  and
(C) Medicare;
(5) the fishermen's fund
				  (AS
				  23.35.060);
(6) automobile insurance, including uninsured
				  or underinsured motorist insurance;
(7) an indemnity policy; and
(8) another jurisdiction's Medicaid or other
				  medical assistance program.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 2 - Third-Party Liability; Estate Recovery › 7 AAC 160.210 - Estate recovery

Current through May 31, 2024
(a) At the time of application, the
				  department will notify each applicant for medical assistance that the estate of
				  an individual who received medical assistance benefits may be subject to a
				  claim for recovery under
				  AS
				  47.07.055 and
				  7 AAC 160.210 -
				  7 AAC 160.250.
(b) When the state determines under
				  7 AAC 160.220 that a recipient who is subject to estate
				  recovery under
				  AS
				  47.07.055 cannot be expected to return home
				  or has died, the department will determine
(1) the estimated value of the
				  estate;
(2) if there is a surviving
				  spouse or other estate beneficiaries; and
(3) if proceeding with recovery in accordance
				  with (c) of this section will be permissible and cost effective.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 2 - Third-Party Liability; Estate Recovery › 7 AAC 160.220 - Liens

Current through May 31, 2024
(a) For purposes of
				  AS
				  47.07.055(a)(3), if a
				  recipient resides in a medical institution for at least 120 consecutive days,
				  the department will give the recipient
(1)
				  notice of its intent to determine that the recipient is not reasonably expected
				  to be discharged from the institution and return home; and
(2) an opportunity for a hearing regarding
				  that determination.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 2 - Third-Party Liability; Estate Recovery › 7 AAC 160.230 - Appealing a lien

Current through May 31, 2024
(a) After receiving a notice under
				  7 AAC 160.220(e) from the department,
				  the recipient, legal representative of the recipient, or estate beneficiary may
				  file an appeal with the department to
(1)
				  contest the amount of recoverable medical assistance identified by the
				  department;
(2) contest whether the
				  real property is a part of the recipient's estate; or
(3) request a waiver of recovery for undue
				  hardship.