reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.06 - Resident Days

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A resident
			 day is incurred when any one of the following conditions have been met:
(a)
Care is rendered to a
			 resident in the facility
. This results when a resident is rendered
			 services between the census taking hour (12:00 midnight) on two (2) successive
			 days. The following procedure illustrates the proper method of determining the
			 number of resident days resulting from care rendered to residents in the
			 facility, using the midnight census method:
1.
			 Number of residents in the facility at midnight.
2. Add/subtract residents admitted/discharged
			 (including deaths) prior to midnight of the following day (Exception - a
			 resident admitted and discharged on the same day counts as a resident day). The
			 provider may bill for the date of admission, but not for the day of
			 discharge.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.07 - Management And Administrative Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Costs of a management or administrative
			 nature, including but not limited to those costs outlined in Rule (3), will be
			 reported as such on the Medicaid Cost Report. Salaries of administrative
			 personnel which would duplicate employee salary expenses in other cost centers
			 cannot be allocated to such nonadministrative cost centers. Administrative
			 compensation is limited to 10% of net allowable other cost, plus use allowance
			 (if applicable).
(2) Customarily,
			 owner compensation results from a distribution of the profits. However, when
			 the owner provides a necessary service to the facility, and he/she can
			 justifiably be compensated at a reasonable rate, then that owner compensation
			 is an allowed cost. "Reasonable compensation" must meet the criteria of being
			 paid to an employee who performs a necessary function in a facility and must be
			 in an amount which would ordinarily be paid for comparable services in a
			 comparable facility. To be "necessary," a function must be one that if that
			 employee were not performing it, another would have to be employed to do so,
			 and additionally, the function must be directly related to providing ICF/IID
			 services.
(3) Examples of Allowable
			 Management and Administrative Costs include, but are not limited to:
(a) Salaries and Bonuses
1. Administrator
2. Assistant Administrator
3. Accountant
4. Bookkeeper
5. Computer Operator
6. Medical Records Clerk
7. Personnel Officer
8. Secretary
9. Typist
10. Clerks
11. Receptionist
12. Telephone Operator Switchboard
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.08 - Interest Expense

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Necessary
			 and reasonable interest expense is an allowable cost. In order to be considered
			 necessary, the interest must be incurred on a loan made to satisfy a financial
			 need directly related to resident care. Loans which result in excess funds or
			 which are not related to resident care are not considered to be necessary. In
			 order to be considered reasonable, the interest rate cannot be in excess of
			 that which a prudent borrower would agree to pay, and the lender must not be
			 related to the borrower. The provisions of HIM-15 (Medicare Provider
			 Reimbursement Manual) shall be applicable in determining whether a loan is
			 between related parties. Interest paid by the provider to owners, partners,
			 stockholders, or other persons related to the provider is not an allowable
			 cost. However, the principal amount of such loans will be included in equity
			 capital for the purpose of computing the return on equity payable to
			 proprietary providers. This will be done in computing a proprietary provider's
			 return on equity, by eliminating the liability from the deduction from assets,
			 thereby increasing the equity.
(2)
			 Bond discounts or premiums will be amortized over the life of the bond issue
			 using the straight line method and such amortization will be treated as
			 interest. Amortization will be added to interest expense in the case of
			 discounts and deducted from interest expense in the case of premiums.
(3)
(a)
			 Interest incurred during the period of construction on funds borrowed to
			 construct or enlarge existing facilities must be capitalized as a part of the
			 cost of the facility. The period of construction is considered to extend to the
			 date the facility is put into use for resident care. Where a bond issue is
			 involved, any bond discount and expense, or bond premium amortized during the
			 period of construction must be capitalized and included in the cost of the
			 facility constructed.
(b) If a debt
			 which was incurred to finance the construction, expansion, renovation or
			 acquisition of an ICF/IID facility is refinanced, allowable interest on the
			 refinanced portion of the original loan will be limited to the interest which
			 would have been allowed under the original financing arrangement, and any
			 additional interest on the refinanced portion will be an unallowable
			 cost.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.09 - Laundry Expense

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Allowable
			 costs will be limited to the laundry costs which are ordinary and necessary to
			 the operation of an ICF/IID facility and will not include costs associated with
			 the personal laundry of residents (if the facility charges for resident
			 personal laundry).
(2) Examples of
			 such costs include, but are not limited to, the following:
(a) Laundry salaries and employee benefits
			 attributable to laundry personnel.
(b) Supplies and materials used in providing
			 laundry services.
(c) Depreciation
			 on equipment used in providing laundry services.
(d) Costs directly attributable to the
			 delivery of laundry.
(e) Charges by
			 an outside laundry.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.12 - New Facility Or Change In Ownership

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A provider who constructs, leases, or
			 purchases a facility may request reimbursement based on an operating budget,
			 subject to the ceiling established under Rules
			 560-X-42-.04 and
			 560-X-42-.05 of this Chapter. In
			 this event, the facility will be subject to a retroactive adjustment based on
			 the difference between budgeted and actual allowable costs. These actual
			 allowable costs will be reported on a complete interim cost report. If this
			 interim report should span September 30, the Agency may accept this report as
			 the interim and regular cost report. In this instance, the report will be used
			 to settle the budgeted period and also to set the next year's prospective rate.
			 If the Agency accepts this report as the September 30 regular report, the due
			 date shall be November 30; if not, the due date will be 60 days after the end
			 of the interim period as specified by the Agency.
(2) The difference between budgeted and/or
			 projected costs in these instances will be subject to settlement within thirty
			 (30) days after written notification by Medicaid to the provider of the amount
			 of the difference.
(3) Upon
			 voluntary or involuntary complete withdrawal of a facility participating in the
			 Medicaid program, the provider will be subject to a retroactive adjustment
			 based upon the difference between the amount of reimbursement paid by Medicaid
			 and the actual allowable costs incurred by the former provider during the
			 following periods:
(a) If the effective date
			 of the withdrawal is less than six (6) months after the preceding October 1st,
			 a retroactive adjustment will be made for the current fiscal year and for the
			 immediately preceding fiscal year.
(b) If the effective date of the withdrawal
			 is six (6) months or more after the preceding October 1st, a retroactive
			 adjustment will be made for the current fiscal year only.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.13 - Return On Equity Capital

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An allowance for reasonable return on
			 equity capital invested and used in providing patient care is allowable as an
			 element of the reasonable cost of services rendered by a proprietary
			 provider.
(2) Equity capital is the
			 difference between the net assets and net liabilities of a provider, adjusted
			 for any asset or liability not related to patient care and any other
			 non-allowable item provided for elsewhere in this Chapter.
(3) The amount of Net Working Capital
			 (current assets minus current liabilities) which is includable in the
			 computation of return on equity capital shall not exceed 1/9th of the
			 provider's allowable costs for the fiscal year in issue.
(4) Providers that are members of chain
			 operations must also include in equity capital a proportionate share of the
			 equity capital, whether negative or positive, of the home office and/or
			 directly related organizations. Amounts due to and from members of a chain, the
			 home office, or any related service organization must be eliminated in
			 computing equity capital.
(5)
			 Unless specifically stated otherwise in this Chapter or HIM-15, current assets
			 and current liabilities will be determined in accordance with generally
			 accepted accounting principles. Accounts must be maintained by the accrual
			 method of accounting in compliance with Rule
			 560-X-42-.21. Accounts not
			 maintained accordingly will result in equity capital not being included in the
			 provider's rate computation until the required documentation of those accounts
			 is provided Medicaid. Examples of assets and liabilities included in the
			 determination of equity capital are as follows:
(a) Cost of fixed assets such as land,
			 buildings and equipment, reduced by accumulated depreciation.
(b) Net working Capital (all other assets
			 minus all other liabilities except specific exclusions).
1. Assets.
(i) Cash on hand in banks.
(ii) Current accounts receivable will include
			 only those accounts for which diligent, documented effort is being made to
			 collect.
(iii) Notes
			 Receivable.
(iv) Other
			 Receivables.
(v)
			 Inventory.
(vi) Deposits on
			 Leases.
(vii) Bond Discounts (net
			 amortization).
(viii) Prepaid
			 Expenses (except prepaid life and auto insurance premiums).
(ix) Other Assets.
2. Liabilities.
(i) Current Accounts Payable (payables over
			 one year old may be adjusted as Medicaid deems necessary).
(ii) Notes Payable.
(iii) Salaries and Fees Payable (must be paid
			 within 75 days of the balance sheet date).
(iv) Payroll Taxes Payable.
(v) Deferred Income (must be received within
			 75 days of the balance sheet date).
(vi) Ad Valorem Taxes Payable.
(vii) Accrued Federal and State Income
			 Taxes.
(viii) Accrued
			 Expenses.
(ix) Bond Premiums (net
			 of amortization).
(x) Other
			 Debts.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.15 - 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, including an appropriate amount of equity capital, 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:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.250 - .255.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.16 - Receipts Which Offset Or Reduce Costs

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Certain income items or receipts must be
			 used to either offset costs or reduce total reported costs. Typical, but not
			 all-inclusive, examples of such transactions are:
(a) Purchase discounts, rebates or
			 allowances.
(b) Recoveries or
			 indemnities on losses (i.e., insurance proceeds).
(c) Sale of scrap or incidental
			 services.
(d) Sale of medical
			 supplies (other than to residents).
(e) Medicare Part B - Income.
(f) Sale of meals.
(g) Vending machines.
(h) Meal income (from meals served to guests
			 or employees).
(i) other expenses
			 not appropriate in developing and maintaining adequate resident care
			 facilities.
(j)
			 Contributions/donations.
(k)
			 Federal Revenue (Designated).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.17 - Chain Operations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 chain organization consists of a group of two or more ICF/IID facilities which
			 are owned, leased, or through any other device controlled by related
			 organizations or individuals. The home office of a chain organization is not a
			 provider in itself; therefore, its costs may not be directly reimbursed by the
			 program. The home office organization will be treated as a "related party" to
			 participating ICF/IID facilities for purposes of this Chapter. Only the home
			 office's actual cost of providing management services is permitted to be
			 allocated to the providers and then only to the extent that they do not
			 duplicate services already provided in the ICF/IID facility. Costs that would
			 not be allowable if directly claimed by a provider will not be allowed as an
			 allocation from a home office.
(2)
			 It is not considered appropriate for the taxpayers of Alabama to pay more for
			 the operation of an ICF/IID facility owned or operated by a chain than would be
			 paid for an individually operated ICF/IID. A chain operated facility is
			 expected to be more efficient and economical to operate than an individually
			 operated facility.
(3) If a home
			 office provides centralized laundry, maintenance, and purchasing services to
			 facilities, the actual costs of providing these services will be charged to the
			 facilities to which the services are provided. The facility will report these
			 costs in the appropriate cost center on its cost report.
(4) Maintenance, Central Purchasing, and
			 Laundry.
(a) Examples of home office costs
			 associated with providing these services include:
1. Maintenance
(i) Salaries and Benefits
(ii) Supplies
(iii) Materials
(iv) Travel expense subject to limitations
			 contained in Rule
			 560-X-42-.10
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.18 - Cost Allocation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Multiple use facilities will
allocate
all allowable
			 costs which are not directly associated with a specific revenue-producing
			 department.
(2) Examples of costs
			 which are usually allocated include, but are not limited to:
(a) Depreciation
(b) Administrative and General
(c) Employee Health and Welfare
(d) Plant Operations
(e) Laundry and Linen
(f) Housekeeping
(g) Medical Records
(h) Dietary
(i) Social Services
(j) Pharmacy
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.19 - 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
			 resident 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 resident care include
			 necessary and proper costs involved in developing and maintaining the efficient
			 operation of resident care facilities. Necessary and proper costs related to
			 resident care are those which are usual and accepted expenses of similar
			 providers.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.21 - 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 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) Residents Personal
			 Funds Records
(g) Resident
			 Admission and Discharge Records
(h)
			 Purchases Journal (For facilities larger than 100 beds)
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.22 - Resident Personal Fund Accounts

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Personal Fund Management. In accordance
			 with Federal Regulations for Medicare and Medicaid Facilities, a Medical
			 Assistance resident may manage his personal affairs unless a facility accepts
			 the resident's delegation of this responsibility. A resident managing his
			 personal affairs may voluntarily have a facility hold custody of his
			 funds.
(2) Voluntary Resident
			 Delegation of Responsibility to the Facility. There are at least three (3)
			 specific categories of Medical Assistance residents who may voluntarily
			 delegate to the facility the management of personal financial affairs.
(a) Persons receiving Social Security checks
			 or other income which is applicable under Medical Assistance to the cost of
			 services less a thirty dollar ($30.00) per month personal care
			 allowance.
(b) Persons receiving a
			 check from the Department of Human Resources for a twenty-three dollar ($23.00)
			 per month personal care allowance.
(c) Persons receiving donated funds from
			 their family or friends which are not applicable to the cost of services. In
			 the event these persons voluntarily delegate the management or custody of such
			 funds to the facility, proper management and accountability for the funds must
			 be provided by the facility.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.23 - 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
(a) changing
			 the per diem rate of the facility and
(b) a lump sum settlement for the amount
			 under/overpaid for the period prior to the effective date of the per diem rate
			 change.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.24 - 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 reimbursement 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:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.250 - .255.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.25 - Negligence Penalty

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Whenever an
			 overpayment of Medicaid reimbursement received by a provider from Medicaid
			 results from the negligence or intentional disregard of Medicaid Reimbursement
			 Principles by the provider or its representatives (but without intent to
			 defraud), there will be deducted from any reimbursement thereafter due the
			 provider a penalty equal to 5% of such overpayment.
(2) If any part of such an overpayment by
			 Medicaid to the provider is due to fraud on the part of the provider or any of
			 its representatives, there will be deducted from any subsequent reimbursement
			 due the provider on proof of fraud, a penalty equal to 50% of the
			 overpayment.
(3) The penalties
			 imposed under Rule
			 560-X-42-.25 of this Code shall
			 be in addition to and shall in no way affect Medicaid's right to also recover
			 the entire amount of the overpayment caused by the provider's or its
			 representative's negligence or intentional disregard of the Medicaid
			 Reimbursement Principles or fraud.
(4) Whenever the cost of a good or service
			 has been previously disallowed as the result of a desk audit of a provider's
			 cost report and/or a field audit by Medicaid and such cost has not been
			 reinstated by voluntary action of Medicaid, as the result of an administrative
			 hearing, or by a Court, such costs shall not thereafter be included as an
			 allowable cost on a Medicaid cost report. The inclusion by the provider or its
			 representative of such a cost on a subsequent cost report, unless the provider
			 is actively pursuing an administrative or judicial review of such disallowance,
			 will be considered as negligent and/or intentional disregard of the Medicaid
			 Reimbursement Principles and subject to the 5% penalty imposed by Rule
			 560-X-42-.25 (.02) of this Code
			 based upon the amount of overpayment which
has or which would have
			 resulted
from the inclusion of such cost had its inclusion not
			 been detected. Such inclusion shall also be subject to the provisions of Rule
			 560-X-42-.25 (.02) relating to
			 intentional or negligent disregard of the Medicaid Reimbursement
			 Principles.
(5) For purposes of the
			 preceding paragraph, a provider shall be considered as having included a
			 previously disallowed cost on a subsequent year's cost report if the cost
			 included is attributable to the same type good or service under substantially
			 the same circumstances as that which resulted in the previous disallowance.
			 Examples of such prohibited inclusions include, but are not limited to:
(a) Inclusion of the portion of rental
			 payment previously disallowed as being between related parties.
(b) Inclusion of an amount of compensation
			 which has previously been disallowed as unreasonable during a prior
			 period.
(c) Inclusion of a cost not
			 related to resident care which has previously been disallowed.
(d) Improper classification or allocation of
			 costs to cost centers.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.26 - 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 any 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-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.02 - Description Of Services

Current through Register Vol. 42, No. 9, June 28, 2024
Home and Community-Based Services (HCBS) under the Home and
				Community-Based Community Waiver Program (CWP) for Persons with intellectual
				disabilities are defined as Title XIX Medicaid-funded services provided to
				individuals with intellectual disabilities who, without these services, would
				require services in an intermediate care facility for individuals with
				intellectual disabilities (ICF/IID). These HCBS under the CWP Waiver will
				provide health, social, and related support needed to ensure optimal
				functioning of individuals with intellectual disabilities within a community
				setting. The Administering Agency may provide or subcontract for any HCBS under
				the CWP Waiver. To qualify for Medicaid reimbursement, each individual HCBS
				must be necessary to prevent institutionalization of the waiver recipient. Each
				provider of HCBS must have a signed provider contract, meet provider
				qualifications and comply with all applicable State and Federal laws and
				regulations. Services that are reimbursable through Medicaid's EPSDT Program
				shall not be reimbursed as HCBS under the CWP Waiver. The following are
				specific HCBS available under the CWP Waiver:
(1) Breaks and Opportunities (Respite)
			 Services
(a) A service provided to a waiver
			 participant that lives with family or other natural supports who are providing
			 support, care and supervision to the waiver participant. This service is
			 provided for time-limited periods when the family or other natural supports are
			 temporarily unable to continue to provide support, care and supervision to the
			 waiver participant. This service can be provided in the waiver participant's
			 home or the pre-approved private home of the Breaks and Opportunities service
			 provider. The Breaks and Opportunities service is provided with two equally
			 important goals which include:
(1) sustaining
			 the family/natural support living arrangement and support-giving arrangement;
			 and
(2) providing the waiver
			 participant with opportunities to continue his/her regular activities and
			 relationships and/or to explore new opportunities and meet new people with the
			 Breaks and Opportunities service provider.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.03 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
Eligibility criteria for Home and Community-Based Services
				(HCBS) recipients under the Community Waiver Program (CWP) for Persons with
				intellectual disabilities shall be the same as eligibility criteria for an
				intermediate care facility for individuals with intellectual disabilities
				(ICF/IID). Thus, HCBS under the CWP Waiver will be available to persons with
				intellectual disabilities who would be eligible for institutional services
				under
				42 C.F.R.
				§
									435.217 and who are now eligible under
				435.120. Persons with intellectual disabilities who meet categorical (including
				42 C.F.R. §
									435.120), medical, and/or social requirements
				for Title XIX coverage will be eligible for HCBS under the CWP Waiver.
				Applicants found eligible shall not be required to apply income above the
				personal needs allowance reserved to institutional recipients toward payment of
				care.
(1) Financial eligibility for
			 HCBS under the CWP Waiver is limited to those individuals receiving SSI, Parent
			 and Other Caretaker Relatives (POCR), Pregnant Women, Infants and Children
			 under Age 19, Children with Non IV-Adoption Assistance (Over age 21), Children
			 with Non IV-Adoption Assistance, Former Foster Care, Reasonable Classification
			 of Individuals under Age 21, SSI related protected groups deemed to be eligible
			 for SSI/Medicaid (i.e., Widow/Widower, Disabled Adult Child, Continuous
			 (Pickle) Medicaid), federal and state adoption subsidy individuals, and special
			 home and community-based optional categorically needy group whose income is not
			 greater than 300 percent of the SSI federal benefit rate.
(2) Medical eligibility for HCBS under the
			 CWP Waiver is limited to those individuals that meet the ICF/IID level of care.
			 No HCBS under the CWP Waiver will be provided to a recipient residing in an
			 institutional facility, or who has a primary diagnosis of mental illness, or
			 whose health and safety is at risk in the community.
(3) Financial determinations and
			 redeterminations for HCBS under the CWP Waiver shall be made by the Alabama
			 Medicaid Agency, the Department of Human Resources or the Social Security
			 Administration, as appropriate. In addition to the financial and medical
			 eligibility criteria, the Alabama Medicaid Agency is limited to the number of
			 recipients who can be served by the CWP Waiver.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G and the Home and Community-Based Waiver for Persons with Intellectual
				  Disabilities.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.04 - Characteristics Of Persons Requiring ICF/IID Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Generally, persons eligible for the level
			 of care provided in an Intermediate Care Facility for Individuals with
			 Intellectual Disabilities (ICF/IID) are those persons who need such level of
			 care because the severe, chronic nature of their mental impairment results in
			 substantial functional limitations in three or more of the following areas of
			 life activity:
(a) Self-Care
(b) Receptive and expressive
			 language
(c) Learning
(d) Self-direction
(e) Capacity for independent living
(f) Mobility
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.05 - Qualifications Of Staff Who Will Serve As Review Team For Medical Assistance

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The nurse shall
			 be a graduate of a licensed school of nursing with a current state
			 certification as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
			 This person shall have knowledge and training in the area of intellectual
			 disabilities with a minimum of two (2) years' experience.
(2) The social worker shall be a graduate of
			 a four-year college with an emphasis in social work. This person shall have
			 knowledge and training in the area of intellectual disabilities with a minimum
			 of two (2) years' experience.
(3)
			 The psychologist shall be a PH.D. in Psychology. This person shall be a
			 licensed psychologist with general knowledge of test instruments used for
			 individuals with intellectual disabilities with a minimum of two (2) years'
			 experience.
(4) Other professional
			 disciplines which may be represented on the assessment team as necessary
			 depending on the age, functional level, and physical disability of the clients
			 are as follows:
(a) Special
			 Education
(b) Speech
			 Pathologist
(c)
			 Audiologist
(d) Physical
			 Therapist
(e) Optometrist
(f) Occupational Therapist
(g) Vocational Therapist
(h) Recreational Specialist
(i) Pharmacist
(j) Doctor of Medicine
(k) Psychiatrist
(l) Other skilled health
			 professionals
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.06 - Individual Assessments

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Alabama Medicaid Agency will require an individual plan of care for each
			 waivered service recipient. Such plan, entitled "Individual Habilitation Plan"
			 (IHP), is subject to review by the Alabama Medicaid Agency and Department of
			 Health and Human Services. Client assessment procedures in place in the Alabama
			 Department of Mental Health, which are based on eligibility criteria for
			 Intermediate Care Facilities for Individuals with Intellectual Disabilities
			 (ICF/IIDs) developed jointly by the Alabama Department of Mental Health (ADMH)
			 and the Alabama Medicaid Agency, will be utilized by ADMH (or its contract
			 service providers) in screening for eligibility for the waivered services as an
			 alternative to institutionalization. Whether performed by a qualified
			 practitioner in ADMH, its contract service providers, or provided by qualified
			 (Diagnostic and Evaluation Team) personnel of the individual/agency arranging
			 the service, review for "medical assistance" eligibility determination will be
			 based on client assessment data, and the criteria for admission to an ICF/IID,
			 as described in Rule No.
			 560-X-43-.03. Re-evaluation of
			 clients shall be performed on an annual basis. Written documentation of all
			 assessments will be maintained in the client's case file and subject to review
			 by the Alabama Medicaid Agency and Department of Health and Human
			 Services.
(2) The Alabama Medicaid
			 Agency will give notice of services available under the waiver as required by
			 federal regulations, particularly to primary care givers for the target group,
			 including but not limited to, programs operated by ADMH, the statewide network
			 of community MH centers, and to other appropriate care-giving agencies such as
			 county Department of Human Resources offices, hospitals, hospital associations,
			 and associations for individuals with intellectual disabilities.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Authority:
Section 1915(c) Social Security Act;
				  42 C.F.R. Section 441, Subpart G; and the Home and Community-Based Waiver for
				  Persons with Intellectual Disabilities.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.07 - Informing Beneficiaries Of Choice

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Alabama Medicaid Agency will be
			 responsible for assurances that beneficiaries of the waiver service program
			 will be advised of the feasible service alternatives and be given a choice of
			 which type of service-institutional or home- and/or community-based
			 services-they wish to receive.
(2)
			 Residents of long-term care facilities for whom home- and community-based
			 services become a feasible alternative under this waiver will be advised of the
			 available alternative at the time of review. Applicants for SNF, ICF, ICF/IID
			 services, or a designated responsible party with authority to act on the
			 applicant's behalf, will be advised of feasible alternatives to
			 institutionalization at the time of their entry into a treatment system wherein
			 an alternative is professionally determined to be feasible. All applicants
			 found eligible for will be offered the alternative unless there is reasonable
			 expectation that services required for the applicant would cost more than
			 institutional care. Provisions for fair hearings for all persons eligible for
			 services under this waiver will be made known and accessible to potential
			 eligibles in accordance with Fair Hearings Procedures set forth in Rule No.
			 560-X-43-.16.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Authority
: 42 C.F.R. Section 441, Subpart G and
				  the Home- and Community-Based Waiver for Persons with Intellectual Disabilities
				  and Developmentally Disabled.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.08 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid reimbursement for each
			 service provided by a mental health service provider shall be based on a
			 fee-for-service system. Each covered service is identified on a claim by a
			 procedure code.
(2) Providers
			 should bill no more than one month's services on a claim for a recipient. There
			 may be multiple claims in a month, but no single claim may cover services
			 performed in different months. For example, October 15, 1990, to November 15,
			 1990, would not be allowed. If the submitted claim covers dates of service,
			 part or all of which were covered in a previously paid claim, it will be
			 rejected.
(3) Payment will be based
			 on the number of units of service reported for HCPCS codes.
(4) All claims for services must be submitted
			 within 12 months from the date of service.
(5) Accounting for actual cost and units of
			 services provided during a waiver year must be accomplished on HCFA's form 372.
			 The following accounting definitions will be used to capture reporting data,
			 and the audited figures used in establishing new interim fees:
(a) A waiver year consists of 12 consecutive
			 months starting with the approval date specified in the approved waiver
			 document.
(b) An expenditure occurs
			 when cash or its equivalent is paid in a quarter by a state agency for waiver
			 benefits. For a public/governmental provider, the expenditure is made whenever
			 it is paid or recorded, whichever is earlier. Noncash payments, such as
			 depreciation, occur when transactions are recorded by the state
			 agency.
(c) The services provided
			 by a direct service provider agency arereported 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-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.09 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
Providers shall make all reasonable efforts to determine if
				there is a liable third-party source, including Medicare, and in the case of a
				liable third-party source, utilize that source for payments and benefits prior
				to applying for Medicaid payments. Third party payments received after billing
				Medicaid for service for a Medicaid recipient shall be refunded to the Alabama
				Medicaid Agency.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Unit
Statutory Authority:
42 CFR, Section 433,
				  Subpart D - Third Party Liability.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.10 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Payment made by the Medicaid Program to a provider shall be considered to be
			 payment in full for covered services rendered.
(2) No Medicaid recipient shall be billed for
			 covered Medicaid services for which Medicaid has been billed.
(3) No person or entity, except a liable
			 third-party source, shall be billed for covered Medicaid services.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Statutory Authority:
42 CFR Section 447, Subpart
				  A - Payments: General Provisions.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.11 - 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:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Statutory Authority:
42 CFR Section
				  431.306, Subpart F - Safeguarding Information
				  on Applicants and Recipients.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.12 - Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Department
			 of Mental Health shall make available to the Alabama Medicaid Agency at no
			 charge, all information regarding claims submitted and paid for services
			 provided eligible recipients and shall permit access to all records and
			 facilities for the purpose of claims audit, program monitoring, and utilization
			 review by duly authorized representatives of federal and state agencies.
			 Complete and accurate medical/psychiatric and fiscal records which fully
			 disclose the extent of services shall be maintained by the clinic. Said records
			 shall be retained for the period of time required by state and federal
			 laws.
(2) Sign-in log, service
			 receipt, or some other written record shall be used to show the date and nature
			 of services; this record shall include the Recipient's signature.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Statutory Authority:
Section 1915(c) Social
				  Security Act; 42 C.F.R.
				  Section 431.107, Subpart C - Administrative
				  Requirements: Provider Relations; and the Home and Community-Based Waiver for
				  Persons with Intellectual Disabilities.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.13 - Service Providers

Current through Register Vol. 42, No. 9, June 28, 2024
The Home and Community-Based CWP Waiver is a cooperative effort
				between the Alabama Medicaid Agency and the Department of Mental
				Health.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Statutory Authority:
Section 1915(c) Social
				  Security Act; 42 C.F.R.
				  Section 441, Subpart G; and the Home and
				  Community-Based Waiver for Persons with Intellectual Disabilities.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.15 - Cost For Services

Current through Register Vol. 42, No. 9, June 28, 2024
The cost for services to individuals who qualify for Home and
				Community-Based care under the waiver program will not exceed on an average per
				capita basis the total expenditures that would be incurred for such individuals
				if Home and Community-Based services were not available.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Unit, LTC Healthcare Reform Division
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R.
				  Section 441, Subpart G and the Home and
				  Community-Based Waiver for Persons with Intellectual Disabilities.