reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.04 - 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:
Felecia S. Barrow, Associate Director, LTC
				Project Development Unit
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G and the Home and Community-Based Technology Assisted Waiver for
				  Adults.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.05 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 targeted case manager will receive referrals from hospitals, nursing homes,
			 physicians, the community and others for persons who may be eligible for home
			 and community-based services.
(2)
			 An assessment document will be completed by the targeted 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 copy of this document will be submitted to the
			 Alabama Medicaid Agency for approval.
(3) The targeted case manager, in conjunction
			 with the applicant's physician will develop a plan of care. The plan of care
			 will include objectives, services, provider of services, and frequency of
			 service. The plan of care must be submitted to the Alabama Medicaid Agency for
			 approval. Changes to the original plan of care are to be made as needed to
			 adequately care for an individual. Reasons for changes must be documented on
			 the client's plan of care, which is subject to the review of the Alabama
			 Medicaid Agency. The plan of care must be reviewed by the targeted case manager
			 as often as necessary and administered in coordination with the recipient's
			 physician.
(4) The targeted case
			 manager will coordinate completion of the medical need admissions form with the
			 applicant's physician and the financial application form for submission to the
			 Alabama Medicaid Agency.
(5)
			 Medicaid will review the medical application and determine if the individual
			 meets the criteria for nursing facility care, in accordance with Rule No.
			 560-X- 10-.10 of the Alabama Medicaid Administrative Code and submit the
			 "Waiver/Slot Confirmation Form" to the District Office for processing financial
			 determination.
(a) If approved, the applicant
			 and the targeted case manager will be notified in writing.
(b) If denied, the applicant and the targeted
			 case manager will be notified and the reconsideration process will be explained
			 in writing as described in Rule No.
			 560-X-10-.14.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.06 - 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-54-.02 may request an
			 appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the
			 Alabama Medicaid Administrative Code, as modified by the below
			 provisions.
(2) Home and
			 Community-Based Services waiver participants will be given at least a ten-day
			 notice before termination, suspension or reduction of services.
(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:
Luzenia Lawson, Associate Director, Long
				  Term Care, Quality Review Unit
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G and the Home and Community-Based Technology Assisted Waiver for
				  Adults.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.07 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payments made by Medicaid to providers
			 will be on a fee-for-service basis. Each covered service is identified on a
			 claim by a procedure code.
(2)
			 Payment will be based on the number of units of service reported on the claim
			 for each procedure code.
(3)
			 Accounting for actual cost and units of services provided during a waiver year
			 must be captured CMS 372 Report. 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. Non-cash
			 payments, such as depreciation, occur when transactions are recorded by the
			 state agency or the provider.
(c)
			 The services provided by an operating agency are 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-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.08 - 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:
Felecia S. Barrow, Associate Director, LTC
				Project Development Unit
Statutory Authority:
Section 1915(c), Social
				  Security Act, 42 C.F.R. Section 441, Subpart G.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.09 - Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama
			 Medicaid Agency shall maintain all information regarding claims submitted and
			 paid for services provided eligible recipients. Said records shall be retained
			 for the period of time required by state and federal laws.
(2) A sign-in log, service receipt, or some
			 other record shall be used to show the date and nature of services; this record
			 shall include the Recipient's signature or designated signature
			 authority.
(3) Providers must
			 retain records that fully disclose the extent and cost of services provided to
			 the eligible recipients for a three-year period. These records must be
			 accessible to the Alabama Medicaid Agency and appropriate state and federal
			 officials.
(4) There must be a
			 clear differentiation between waiver services and non-waiver services. There
			 must be a clear audit trail from the point a service is provided through
			 billing and reimbursement. The Alabama Medicaid Agency and Centers for Medicare
			 and Medicaid Services and the operating agencies must be able to review the
			 Plan of Care to verify the exact service and number of units provided, the date
			 the service was rendered, and the direct service provider for each recipient.
			 There must be a detailed explanation of how waiver services are segregated from
			 ineligible waiver costs.
Author:
Ginger Wettingfield, Director LTC
				  Healthcare Reform Division
Statutory Authority:
Section 1915 (c), Social
				  Security Act, 42C.F.R.
Section 441, Subpart G.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.10 - Enrollment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid's
			 fiscal agent enrolls providers of waiver services and issues provider contracts
			 to applicants who meet the licensure and/or certification requirements of the
			 State of Alabama, the Code of Federal Regulations and the
Alabama
			 Medicaid Provider Manual
.
(2) General enrollment instructions and
			 information can be found in Chapter 2, "Becoming a Medicaid Provider", of the
Alabama Medicaid Provider Manual
. Failure to provide accurate
			 and truthful information or intentional misrepresentation may result in action
			 ranging from denial of application to permanent exclusion and criminal
			 prosecution.
Author:
Felecia S. Barrow, Associate Director, LTC
				Project Development Unit
Statutory Authority:
Section 1915(c), Social
				  Security Act, 42 C.F.R. Section 441, Subpart G.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.11 - Informing Individuals Of Choice

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama Medicaid Agency will be
			 responsible for ensuring 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. 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:
Felecia S. Barrow, Associate Director, LTC
				Project Development Unit
Statutory Authority:
Section 1915(c), Social
				  Security Act, 42 C.F.R. Section 441, Subpart G.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-55 - PERINATAL REGIONAL DIRECTORS › Section 560-X-55-.01 - Authority And Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Perinatal Regional Directors serve as a liaison between the provider community,
			 Medicaid eligible pregnant women and infants, the Department of Public Health
			 and the Alabama Medicaid Agency.
(2) The purpose of providing these services
			 is to ensure availability of and access to care for the benefit of Medicaid
			 eligible recipients.
Author:
Sylisa Lee-Jackson, Associate Director,
				  Maternity, Plan First and Nurse Midwife Programs
Statutory Authority:
42 C.F.R. §
											431.615; State Plan, Attachment
				  4.16-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-55 - PERINATAL REGIONAL DIRECTORS › Section 560-X-55-.02 - Qualifications Of A Perinatal Regional Director

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A Perinatal Regional Director must meet
			 the requirements of a registered nurse as defined by the State Personnel
			 Department and will be governed by such rules and regulations.
(2) Hiring practices will be accomplished by
			 the Department of Public Health. Required performance reviews will be
			 accomplished by the Perinatal Regional Director assigned supervisor within the
			 Health Department.
(3) The
			 Department of Public Health will be responsible for assuring that the
			 professionals who provide such services meet the requirements as outlined in
			 the cooperative agreement.
Author:
Sylisa Lee-Jackson, Associate Director,
				  Maternity, Plan First and Nurse Midwife Programs
Statutory Authority:
42 C.F.R. §
											431.615; State Plan, Attachment
				  4.16-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-55 - PERINATAL REGIONAL DIRECTORS › Section 560-X-55-.03 - Functions Of Perinatal Regional Directors

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Perinatal Regional Directors are required
			 to spend their billable time working on the goal of reducing infant's deaths
			 and illness among Medicaid insured infants. Services included, but are not
			 limited to, the following types of service:
(a) Fetal and infant mortality review (FIMR)
			 to identify contributing factors to infant morbidity and mortality;
(b) Community-based projects to address the
			 factors that contribute to infant deaths as identified through FIMR, evaluation
			 of available resources, identification of areas of need, and the development of
			 new resources in areas of identified need.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-55 - PERINATAL REGIONAL DIRECTORS › Section 560-X-55-.04 - Auditing Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
An annual report is produced by the Alabama Department of
				Public Health outlining the findings of the Infant Mortality and Morbidity
				initiative. The Medicaid Agency may perform audits of Regional Director
				activities.
Author:
Sylisa Lee-Jackson, Associate Director,
				  Maternity, Plan First and Nurse Midwife Programs
Statutory Authority:
42 C.F.R. §
											431.615; State Plan, Attachment
				  4.16-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-55 - PERINATAL REGIONAL DIRECTORS › Section 560-X-55-.05 - Payment For Services

Current through Register Vol. 42, No. 9, June 28, 2024
The Department of Public Health will be reimbursed for
				providing these services as specified in the Memorandum of Understanding with
				the Medicaid Agency.
Author:
Sylisa Lee-Jackson, Associate Director,
				  Maternity, Plan First and Nurse Midwife Programs
Statutory Authority:
42 C.F.R. §
											431.615; State Plan, Attachment
				  4.16-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.01 - Federally Qualified Health Center Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
This Chapter states the Medicaid policy regarding Federally
				Qualified Health Centers, hereinafter referred to as FQHCs, reimbursement and
				establishes the accepted procedures whereby reimbursement is made to FQHC
				providers. Because of the length and complexity of this Chapter, it has been
				divided into sections to facilitate its utilization.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42
				  C.F.R. §
											405.2401 -.2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.02 - Introduction

Current through Register Vol. 42, No. 9, June 28, 2024
(1) This Chapter of
			 the Alabama Medicaid Administrative Code has been published by the Alabama
			 Medicaid Agency (Medicaid) to accommodate program needs and the administrative
			 needs of FQHCs and to help ensure that the reasonable cost regulations are
			 uniformly applied state wide without regard to where covered services are
			 furnished.
(2) The Alabama Medicaid
			 Program is administered by Medicaid under the direction of the Governor's
			 Office. Reimbursement principles for FQHC's are outlined in the following
			 sections of this Chapter. These principles, hereinafter referred to as
			 "Medicaid Reimbursement Principles," are a combination of generally accepted
			 accounting principles, principles included in the State Plan, Medicare (Title
			 XVIII) Principles of Reimbursement, and principles and procedures published by
			 Medicaid to provide reimbursement of provider costs which must be incurred by
			 efficiently and economically operated FQHC's. These principles are not intended
			 to be all inclusive, and additions, deletions, and changes to them will be made
			 by Medicaid as required. Providers are urged to familiarize themselves fully
			 with the following information, as cost reports must be submitted to Medicaid
			 in compliance with this Chapter and other provisions of the Medicaid
			 Administrative Code.
(3) If the
			 Medicaid Administrative Code is silent on a given point, Medicaid will normally
			 rely on appropriate OMB circulars (i.e., OMB A87, OMB 122, OMB 128, OMB 133),
			 Medicare (Title XVIII) Principles of Retrospective Reimbursement and, in the
			 event such Medicare Principles provide no guidance, Medicaid may impose other
			 reasonability tests. The tests include, but are not limited to, such tests as:
(a) Does the cost as reported comply with
			 generally accepted accounting principles?
(b) Is the cost reasonable on its own
			 merit?
(c) How does the cost
			 compare with that submitted by similarly sized centers furnishing like covered
			 services?
(d) Is the cost related
			 to covered services and necessary to the operation of a center?
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.03 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Accrual Method of Accounting
- Revenues must be
			 allocated to the accounting period in which they are earned and expenses must
			 be charged to the period in which they are incurred. This must be done
			 regardless of when cash is received or disbursed.
(2)
Chapter
- This
			 Chapter (Chapter Fifty-Six) of the Alabama Medicaid Agency Administrative
			 Code.
(3)
Costs Not
			 Related to Patient Care
- Costs not related to patient care are
			 costs which are not appropriate or necessary and proper in developing and
			 maintaining the operation of patient care facilities and activities. Such costs
			 are not allowable in computing reimbursable costs.
(4)
Costs Related to Patient
			 Care
- These include all necessary and proper costs which are
			 appropriate and helpful in developing and maintaining the operation of patient
			 care facilities and activities.
(5)
Covered Costs
- Allowable direct and indirect costs
			 that are reasonable and necessary in rendering covered health care services. To
			 be recognized, costs (as indicated in the State Plan) must be identified in
			 auditable accounting records and allocated on a reasonable basis between the
			 delivery of covered type services and all other center activities.
(6)
Depreciation
-
			 That amount which represents a portion of the depreciable asset's cost or other
			 basis which is allocable to a period of operation.
(7)
Encounters
-
			 Encounters are face-to-face contacts between a patient and a health
			 professional for the provision of medically necessary services.
(a)
Ancillary
			 Encounter
- Face-to-face contact between a patient and a health
			 professional for lab or x-ray services only.
(b)
Dental Encounter
- Face-to-face contact between a patient and a health professional for the
			 provision of dental services.
(c)
Medical Encounter
- Face-to-face contact between a
			 patient and a health professional for the provision of medical services (i.e.,
			 physician, physician assistant, nurse practitioner).
(d)
EPSDT, Family Planning, or
			 Prenatal Encounter
-Face-to-face contact to receive services
			 within the parameters of the program guidelines.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.05 - Reserved (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42
				  C.F.R., §
											405.2401 - .2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.06 - Encounters

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Encounters are
			 face-to-face contacts between a patient and a health professional for the
			 provision of medically necessary services. Contacts with more than one health
			 professional and multiple contacts with the same health professional, that take
			 place on the same day and at a single location, constitute a single encounter
			 unless the patient, subsequent to the first encounter, suffers illness or
			 injury requiring additional diagnosis or treatment. This does not apply to
			 dental service; however, dental services are limited to one dental encounter
			 per date of service. Therefore, a patient can have one dental encounter and one
			 other encounter on the same day. Services incident to an encounter are
			 inclusive.
(2) Encounters are
			 classified as either billable or non-billable. Billable encounters are visits
			 for face-to-face contact between a patient and a health professional in order
			 to receive medically necessary services such as lab services, x-ray services
			 (including ultrasound and EKG), dental services, medical services, EPSDT
			 services, family planning services, and prenatal services. Billable encounters
			 are forwarded to the Fiscal Agent for payment through the proper filing of
			 claims forms. Non-billable encounters are visits for face-to-face contact
			 between a patient and health professional for services other than those listed
			 above (i.e., visits to social worker, LPN). Such services include, but are not
			 limited to, administering injections only, blood pressure checked only, and TB
			 skin testing. Non-billable encounters can not be forwarded to the Fiscal Agent
			 for payment. The costs of the non-billable encounters will be included in the
			 allowable costs; however, the non-billable encounter will not be counted as an
			 encounter on the cost report.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act,
				  42 C.F.R.
				  §405.2401 - .2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.07 - Overhead Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Overhead
			 costs are those costs not directly related to patient care. Overhead costs are
			 those costs related to the FQHC's facility and administration and management of
			 the FQHC.
(2) Examples of Overhead
			 Costs include, but are not limited to:
(a)
			 Salaries and benefit costs of the administration staff (Owners compensation
			 should be limited to reasonable cost - i.e., that which would be paid to an
			 unrelated employee performing the same function).
(b) Accounting and Auditing
1. Routine Bookkeeping
2. Preparation of cost reports
3. Auditing and related statements
(c) Nominal meeting expenses for
			 Board Members
(d) Legal costs
			 related to patient care
(e) Data
			 Processing
1. Owned
2. Rented
3. Outside purchased service
(f) Housekeeping
(g) Maintenance
(h) Security
(i) Supplies
(j) Malpractice Insurance
(k) General Insurance
(l) Telephone
(m) Utilities (power, gas, and
			 water)
(n) Rent
(o) Maintenance and Repairs
(p) Depreciation
(q) Amortization
(r) Mortgage Interest
(s) Other Interest
(t) Medical Records
(u) Home Office Cost (if
			 appropriate)
(v) Management fees
			 not exceeding the cost of the provider of the services and not excluded under
			 another section of this Chapter
(w)
			 Other costs, if appropriate
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.08 - Personnel Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Orientation
			 and On-The-Job Training. The costs of orientation and on-the-job training are
			 recognized as normal operating costs and are allowable. Ordinarily, such
			 training would be imparted within the center setting. If, however, the training
			 requires outside instructions, costs of such training are allowable, if
			 reasonable.
(2) Fringe Benefits.
			 Fringe benefits are amounts paid to, or on behalf of, an employee, in addition
			 to direct salary or wages, and from which the employee or his beneficiary
			 derives a personal benefit before or after the employee's retirement or
			 death.
(3) The costs of fringe
			 benefits must be reasonable and related to patient care Medicaid recognizes the
			 following fringe benefits:
(a) Facility
			 contributions to certain deferred compensation plans, if the plan does not
			 favor top management.
(b) Facility
			 contributions to certain pension plans, if the plan does not favor top
			 management.
(c) Paid vacation or
			 leave, paid holidays, paid sick leave, voting leave, court or jury duty leave,
			 all of which generally are included in employee earnings.
(d) Cost of health and life insurance
			 premiums paid or incurred by the facility if the benefits of the policy inure
			 to the employee or his beneficiary, if the plan does not favor top management.
			 Other items not enumerated above may represent fringe benefits. However, before
			 any other item is treated as a fringe benefit, refer it to the Medicaid Agency
			 for approval.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.09 - Travel Expense

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Travel
			 expense incurred by a facility to send employees (except physicians, which is
			 covered below) to attend a required educational workshop within the state which
			 increases the quality of medical care and/or the operating efficiency of the
			 facility is an allowable cost. Workshops on medical techniques, health
			 applications, data processing, clinic accounting and cost finding, and other
			 administrative activities are examples of the types of workshops for which
			 travel expense will be recognized. Travel expense incurred by a facility to
			 send physician employees to attend educational workshops for licensure
			 requirements is an allowable cost if the workshop is held within the state. Any
			 physician educational costs above the licensure requirements is an unallowable
			 cost. Travel that is necessary and that is directly related to the operation of
			 the clinic claiming reimbursement for the expense will be an allowable cost for
			 reimbursement purposes pursuant to the following specific provisions.
(a) Automobile
1. Reimbursement will be based on a standard
			 mileage rate and will be limited to mileage which is documented by log entries
			 prepared in accordance with either of the attached sample logs. (See Schedules
			 9A and 9B found at end of chapter.) Reimbursement to employees for the use of
			 their personal vehicles will he limited to the lessor of the actual
			 reimbursement to the employee or the standard mileage rate per section (1)(a)3
			 of this rule. All log entries must be made at the time of travel, and log
			 entries will be subject to verification during audit. Failure to timely and
			 accurately account for travel mileage will result in a disallowance of this
			 cost.
2. Commuting mileage between
			 the commuter's residence and the FQHC is not allowable mileage for
			 reimbursement purposes. Non-patient care travel is also not
			 allowable.
3. The standard mileage
			 rate is as follows: The IRS mileage rates in effect on January 1 of the
			 calendar year in which the cost report is filed (January 1, 1991 for cost
			 reports filed as of September 30, 1991). These rates will be applied on a per
			 provider basis regardless of the number or type of vehicles used.
4. No reimbursement will be made or
			 considered for unusual or impractical vehicles, which include but are not
			 limited to aircraft, motorcycles, farm equipment and other vehicles not
			 necessary to the efficient operation of the center. Vehicles used as clinics to
			 provide for the delivery of Health Services for the Homeless, under the
			 direction of Public Health Grant 340, will not be reimbursed mileage; but, will
			 be reimbursed for gas, oil, depreciation, interest, insurance, taxes, and
			 repair and maintenance.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.11 - Costs To Related Parties

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Allowable costs incurred by a provider
			 for services or goods provided by Related Parties will not exceed the net cost
			 of the services or goods to that Related Party, and that cost cannot exceed the
			 fair market value of the items or services involved.
(2) Under no circumstances will rent paid to
			 a Related Party be includable in allowable costs. In such cases, lessor's costs
			 may be included in allowable costs provided that such costs do not exceed the
			 fair market value of the leased assets.
(3) The provisions of HIM-15 shall be
			 applicable in determining whether a Related Party relationship exists.
Author:
Statutory Authority:
State Plan, Title XIX,
				  Social Security Act, 42 C.F.R. §405.240.1 - .2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.12 - Chain Operations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 chain organization consists of a group of two or more health care facilities
			 which are owned, leased, or through any other device, controlled by one
			 organization. Chain organizations include, but are not limited to, chains
			 operated by proprietary organizations and chains operated by various religious,
			 charitable, and governmental organizations. A chain organization may also
			 include business organizations which are engaged in other activities not
			 directly related to health care.
(2) The home office of a chain is not a
			 provider in itself; therefore, its costs may not be directly reimbursed by the
			 program. The relationship of the home office to the Medicaid program is that of
			 a related organization to participating facilities. Home offices usually
			 furnish central management and administrative services such as centralized
			 accounting, purchasing, personnel services management direction and control,
			 and other services. To the extent the home office furnishes services related to
			 patient care to a facility, the reasonable costs of such services are
			 includable in the facility's cost report and are reimbursable as part of the
			 facility's costs. Where the home office of the chain provides no services
			 related to patient care, no home office cost may be recognized in determining
			 the allowable costs of the facilities in the chain.
(3) Very often the home office of a chain
			 organization charges the facility in the chain a management fee for the
			 services the home office furnishes. Management fees charged between related
			 organizations are not allowable costs, and such fees must be deleted from the
			 facility's cost report. However, where management fees between related
			 organizations are disallowed, the home office's reasonable costs for providing
			 the services related to patient care are includable as allowable costs of the
			 facility.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42
				  C.F.R. §
											405.2401 -.2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.13 - Unallowable Expenses

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 General
(a) All payments to providers for
			 services rendered must be based on the reasonable cost of such services covered
			 by the Alabama State Plan. It is the intent of the program that providers will
			 be reimbursed the reasonable costs which must be incurred in providing quality
			 patient care. Implicit in the intent that reasonable costs be paid are the
			 expectations that the provider seeks to minimize costs and that costs do not
			 exceed what a prudent and cost-conscious buyer pays for a given item of service
			 or product. If costs are determined to exceed the level that prudent buyers
			 incur in the absence of clear evidence that the higher costs were unavoidable,
			 the excess costs are not allowable.
(b) Costs related to patient care include
			 necessary and proper costs involved in developing and maintaining the efficient
			 operation of patient care facilities. Necessary and proper costs related to
			 patient care are those which are usual and accepted expenses of similar
			 providers.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.14 - Accounting Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 provider must submit adequate cost data based on financial and statistical
			 records which can be verified by qualified auditors. The cost data must be
			 presented on the accrual basis of accounting. This basis requires that revenue
			 must be allocated to the accounting period in which it is earned and expenses
			 must be charged to the period in which they are incurred, regardless of when
			 cash is received or disbursed.
(2)
			 Cost and statistical information as developed by the provider must be current,
			 accurate, and in sufficient detail to support payments made for supplies,
			 services, or assets. This includes all ledgers, books, records, and original
			 evidence of costs which pertain to the costs reported. Financial and
			 statistical records should be maintained in a consistent manner from one period
			 to another; however, the regard for consistency should not preclude a desirable
			 change in accounting procedures provided that full disclosure of significant
			 changes is made.
(3) The following
			 records and documentation must be kept by the provider and must be available
			 for audit inspection by Medicaid:
(a) General
			 Ledger
(b) Disbursements
			 Journal
(c) Cash Receipts
			 Journal
(d) Payroll
			 Journal
(e) Working Trial Balance
			 and Adjusting Entries
(f) Patient
			 Records
(g) Purchases
			 Journal
(h) Time Sheets
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.16 - Audit Adjustment Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Audit adjustments will be paid or
			 collected by a combination of (1) changing the encounter rate of the facility
			 and
(2) a lump sum settlement for
			 the amount under/over paid for the period prior to the effective date of the
			 encounter rate change.
(2)
			 Under/Overpayment situations arising from the audit of a terminating cost
			 report will be paid or recouped by a lump sum settlement.
(3) All adjustments will be subject to the
			 limitations set out in this Chapter and subject to the appropriate
			 ceilings.
(4) Collection procedures
			 will be applied only after the facility has been given thirty (30) days in
			 which to disagree with any of the disallowances contained in the report of
			 audit.
(5) A final audit
			 computation sheet will be forwarded to each facility with the report of audit.
			 An adjusted encounter rate will be stated in the report of audit and will be
			 computed based on the audit adjustments. This new encounter rate will be
			 effective on the first day of a month, allowing for the thirty (30) day
			 notification period and a reasonable amount of time for processing the report
			 of audit. The effective date of the rate change will be shown on the final
			 audit computation worksheet. The remaining portion of the audit settlement will
			 be collected or paid in a lump sum amount. This lump sum amount for the months
			 prior to the effective date (underpayment or overpayment period) of the rate
			 change is computed by applying the adjustment per encounter to the total paid
			 Medicaid encounters in the overpayment/underpayment period.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act, 42
				  C.F.R. §
											405.2401 -.2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.17 - Appeals

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Facility
			 administrators who disagree with the findings of the Medicaid desk audits or
			 field audits may request, in writing, an informal conference at which they may
			 present their positions. Such written requests must be received by Medicaid
			 within thirty (30) days of the date on which Medicaid mails the audit report,
			 or new encounter rate, as the case may be, to the provider.
(2) Administrators who believe that the
			 results of the informal conference are adverse to their facility may ask, in
			 writing, for a Fair Hearing, which will be conducted in accordance with
			 Medicaid Regulations. Such written requests must be received by Medicaid within
			 fifteen (15) days of the date on which Medicaid mails to the provider its
			 determination on the issues presented at the informal conference.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act,
				  42 C.F.R.
				  §405.2401 - .2429.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.19 - Cost Report Preparers

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Cost Report Preparers. "Cost Report Preparer" includes any person (including a
			 partnership or corporation) who, in return for compensation, prepares or
			 employs another to prepare all or a substantial portion of a Medicaid cost
			 report. A Cost Report Preparer can include both the actual preparer of the
			 report as well as his or her employer. Where more than one person aids in
			 filling out a Medicaid cost report, the one who has primary responsibility for
			 the preparation of the report will usually be a preparer, while those involved
			 only with individual portions of the report will usually not be preparers. Any
			 person who supplies enough information and advice so that the actual completion
			 of the return is a mere mechanical or clerical matter is a Cost Report Preparer
			 even though the person doesn't actually place or review the placement of the
			 information on the cost report.
(2)
			 Refusal of Cost Reports. Medicaid will refuse to accept cost reports prepared
			 by a Cost Report Preparer who:
(a) Has shown a
			 pattern of negligent disregard of the principles established by or incorporated
			 by reference into this Code;
(b)
			 Prepares a cost report evidencing an intentional disregard of the Medicaid
			 Reimbursement Principles;
(c) Has
			 given false or misleading information, or participated in giving false or
			 misleading information to any Medicaid employee, the Alabama Medicaid Agency,
			 or to any hearing officer authorized to conduct hearings with regard to
			 Medicaid reimbursement issues, knowing such information to be false or
			 misleading. "Information" includes facts or other information contained in
			 testimony, Medicaid Cost Reports, financial statements, affidavits,
			 declarations, or any other documents or statements, written or oral.
(d) Medicaid will treat any cost report
			 prepared by a Cost Report Preparer who has been determined to be ineligible to
			 prepare Medicaid cost reports as incomplete and shall promptly return such Cost
			 Report to the provider on whose behalf the report has been prepared. The
			 receipt by Medicaid of such cost reports shall not satisfy, suspend, or stay
			 the requirements of this Chapter relating to the timely filing of Medicaid Cost
			 Reports.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.01 - Authority And Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Home
			 and community-based services for the SAIL Waiver are provided by the Alabama
			 Medicaid Agency to disabled individuals who would otherwise require
			 institutionalization in a nursing facility. These services are provided through
			 a Medicaid waiver under the provisions of Section 1915(c) of the Social
			 Security Act.
(2) The purpose of
			 providing home and community-based services to individuals at risk of
			 institutional care is to protect the health, safety, and dignity of those
			 individuals while reducing Medicaid expenditures for institutional
			 care.
(3) Home and Community-Based
			 Services for the SAIL Waiver are provided in compliance with the provisions of
			 the HCBS Settings Final Rule (CMS 2249-F/2296- F). These provisions require the
			 following:
(a) Services may only be provided
			 in settings that:
1. Are integrated in and
			 support full access to the greater community, including opportunities to seek
			 employment and work in competitive integrated settings, engage in community
			 life, control personal resources, and receive services in the community, to the
			 same degree of access as individuals not receiving Medicaid HCBS;
2. Are selected by the individual from among
			 setting options;
3. Ensure
			 individual rights of privacy, dignity and respect, and freedom from coercion
			 and restraint;
4. Optimize autonomy
			 and independence in making life choices including but not limited to, daily
			 activities, physical environment, and with whom to interact; and
5. Facilitate choice regarding services and
			 who provides them.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.02 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Financial
			 eligibility is limited to those individuals receiving SSI, individuals
			 receiving State Supplementation, SSI related protected groups deemed to be
			 eligible for SSI/Medicaid, and Special Home and Community-Based waiver disabled
			 individuals whose income is not greater than 300% of the SSI Federal Benefit
			 Rate.
(2) Medical eligibility is
			 determined based on current admission criteria for nursing facility level of
			 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. However, case management
			 activities are available to assist recipients interested in transitioning from
			 an institution into a community setting. Case management activities to
			 facilitate the transition are limited to a maximum of 180 days prior to
			 discharge into the community.
(4)
			 The Alabama Medicaid Agency or its operating agency, Alabama Department of
			 Rehabilitation Services, acting on Medicaid's behalf may 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 the Centers for Medicare and
			 Medicaid Services.
(6) The
			 eligibility age criteria is 18 years and above, with physical disabilities not
			 associated with the process of aging and with onset prior to age 63.
Author:
Antionette Hardy, Administrator, LTC
				  Healthcare Reform Unit
Statutory Authority:
42 C.F.R. § 441,
				  Subpart G and the Home and Community-Based SAIL Waiver.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.03 - Operating Agencies

Current through Register Vol. 42, No. 9, June 28, 2024
The Home and Community-Based SAIL Waiver is a cooperative
				effort between the Alabama Medicaid Agency and the Alabama Department of
				Rehabilitation Services.
Author:
Patricia A. Harris, Administrator, LTC
				Program Management Unit
Statutory Authority:
The Home and
				  Community-Based Homebound Waiver.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.04 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Case
			 Management Services.
(a) Case management is a
			 system of providing services which will assist waiver recipients in gaining
			 needed waiver and other state plan services, as well as needed medical, social,
			 educational, and other appropriate services, regardless of the funding source
			 for the services to which access is gained. 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.
(b) Case managers are
			 responsible for Person Centered Care Plan (PCCP) development and ongoing
			 monitoring of the provision of waiver services and nonwaiver services included
			 in the recipient's PCCP.
(c) Case
			 management will be provided by a case manager employed by or under contract
			 with the Department of Rehabilitation Services or any other Medicaid approved
			 provider of waiver services that meets the qualifications of Nurse I or
			 Rehabilitation Counselor.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.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:
Richard Ahlgren
Statutory Authority:
42 C.F.R. §441,
				  Subpart G and Home and Community-Based Homebound Waiver.