reglab/statecodes huggingface dataset:
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-.06 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The 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. For institutional residents residing in a facility
			 for at least 90 days who are interested in transitioning into the community,
			 the case manager should thoroughly review referrals and intake information.
			 This process will take place during the 180 consecutive day transition
			 period.
(2) An initial assessment
			 will be completed by the case manager in conjunction with the applicant's
			 physician. This document will reflect detailed information regarding social
			 background, living conditions, and medical problems of the applicant. A copy of
			 this document will be submitted to the operating agency, Alabama Department of
			 Rehabilitation Services (ADRS), for approval.
(3) The case manager, in conjunction with the
			 applicant's physician, client and/or caregiver will develop a PCCP. The PCCP
			 will include objectives, services, provider of services, and frequency of
			 service. Changes to the original PCCP are to be made as needed to adequately
			 care for an individual. Reasons for changes must be documented on the client's
			 care plan which is subject to the review of the Alabama Medicaid Agency. The
			 PCCP must be reviewed by the case manager as often as necessary and
			 administered in coordination with the recipient's physician.
(4) The Alabama Medicaid Agency has delegated
			 the medical level of care determination to qualified trained individuals at
			 ADRS.
(5) Medicaid requires the
			 providers to submit an application in order to document dates of service
			 provision to long term care recipients.
(a)
			 The long-term care file maintains these dates of service.
(b) The applications will be automatically
			 approved through systematic programming.
(c) The Alabama Medicaid Agency will perform
			 random audits on a percentage of records to ensure that documentation supports
			 the medical level of care criteria, physician certification, as well as other
			 state and federal requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.08 - Fair Hearings

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 individual whose application to the waiver program is denied or waiver
			 participants whose services are terminated, suspended, or reduced based on Rule
			 No. 560-X-57-.02, may request an
			 appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the
			 Alabama Medicaid Administrative Code.
(2) SAIL Waiver participants will be given at
			 least a ten-day notice before termination of service.
(3) If an individual/guardian chooses to
			 appeal the decision, a written request for an informal conference must be
			 received by the Operating Agency within 30 days from the effective date of the
			 notice. Services may continue for waiver participants until the final outcome
			 of the administrative appeal process, if the written request is received within
			 10 days after the effective date of the action.
(4) If the individual/guardian is
			 dissatisfied with the Informal Conference decision, a Fair Hearing may be
			 requested. A written request for a Fair Hearing must be received no later than
			 30 days from the date of the Informal Conference decision notice.
(5) If the individual/guardian is
			 dissatisfied with the Fair Hearing decision, he/she may appeal pursuant to the
			 provisions of the Alabama Administrative Procedure Act.
(6) The Operating Agency will take the lead
			 role for the Informal Conferences, Fair Hearings, and subsequent judicial
			 appeals. Medicaid legal counsel and program staff will function as support
			 staff.
Author:
Renee R. Adams, Administrator, LTC
				  Program Management Unit
Statutory Authority:
42 C.F.R. §431,
				  Subpart E.
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-.09 - Appeal Procedure For Medicaid Fiscal Audits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Fiscal audits of the SAIL Waiver Services
			 are conducted by the Provider Audit Division of Medicaid. At the completion of
			 the field audit there will be an exit conference with the operating agency to
			 explain the audit findings. The operating agency will have the opportunity to
			 express agreement or disagreement with the findings. The field audit and the
			 comments of the operating agency are reviewed by the Associate Director of the
			 Provider Audit Division and a letter is prepared making the appropriate
			 findings official. If the operating agency deems that the findings are not
			 justified, they may request an informal conference with the Director of the
			 Provider Audit Division.
(2) To
			 request the informal conference, the operating agency must submit a letter
			 within thirty days from the date of the official audit letter. This letter must
			 specify the findings that are contested and the basis for the contention. This
			 letter should be addressed to:
Attn: Director
Provider Audit Division
Alabama Medicaid Agency
501 Dexter Avenue
Post Office Box 5624
Montgomery, Alabama 36103-5624
(3) The decisions of the Director, Provider
			 Audit Division made as a result of the informal conference will be forwarded to
			 the operating agency by letter. If the operating agency believes that the
			 results of the informal conference are still adverse, they will have 15 days
			 from the date of the letter to request a fair hearing.
Author:
Latonda Cunningham, Administrator, LTC
				  Project Development/Program Support Unit
Statutory Authority:
42 C.F.R. §431,
				  Subpart E.
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-.10 - 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) The
			 rate will be based on audited past performance with consideration being given
			 to the medical care portion of the consumer price index and renegotiated
			 contracts. Interim fees may be changed if a provider can show that an
			 unavoidable event(s) has caused a substantial increase or decrease in the
			 provider's cost.
(3) All claims for
			 services must be processed within six months after end of waiver year. At the
			 end of the waiver year, the operating agency will be audited and a final rate
			 will be calculated based on actual allowable cost for the year divided by the
			 number of services provided during the year. Any difference between the actual
			 allowable cost and the revenues received based on the interim rate will be
			 adjusted.
(4) Accounting for actual
			 cost and units of services provided during a waiver year must be accomplished
			 on CMS-372 reports. The following accounting definitions will be used in
			 establishing new interim fees:
(a) A waiver
			 year consists of the 12 months following the start of any waiver
			 year.
(b) An expenditure occurs
			 when cash or its equivalent is paid in a quarter by a state agency for waiver
			 benefits. For a public (governmental) provider, the expenditure is made
			 whenever it is paid or recorded, whichever is earlier. Non-cash payments, such
			 as depreciation, occur when transactions are recorded by the State
			 agency.
(c) The services provided
			 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-57 - HOME AND COMMUNITY-BASED SERVICES FOR THE STATE OF ALABAMA INDEPENDENT LIVING (SAIL) WAIVER › Section 560-X-57-.11 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
The Third Party Section, Alabama Medicaid Agency is responsible
				for fulfilling the requirements pertaining to third party liability. The
				purpose of the Third Party Section is to ensure that Medicaid is the last
				payor. Providers shall make all reasonable efforts to determine if there is a
				liable third party source, including Medicare, and in the case of a liable
				third party source, utilize that source for payments. Third party payments
				received after billing Medicaid for service for a Medicaid recipient shall be
				refunded to the Alabama Medicaid Agency within sixty days of receipt of
				Medicaid payment. For further information concerning Third Party Liability
				refer to Administrative Code Chapter 20 or the Homebound Policy and Procedures
				Manual Chapter 7.
Author:
Richard Ahlgren
Statutory Authority:
42 C.F.R. §§432,
				  433; §1902(a)(25), Social Security Act;
Code of Ala.
				  1975
, §
										22-6-6.
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-.12 - Confidentially

Current through Register Vol. 42, No. 9, June 28, 2024
Providers shall not use or disclose, except to duly authorized
				representatives of federal or state agencies, any information concerning an
				eligible recipient except upon written consent of the recipient, his or her
				attorney, and/or guardian, or upon subpoena from a court of appropriate
				jurisdiction.
Author:
Patricia A. Harris, Administrator, LTC
				Program Management Unit
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G-Home and Community-Based Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.01 - Authority And Purpose (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.02 - Description Of Services (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Melody Tompkins, Program Manager, LTC
				  Policy Advisory Unit
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.03 - Eligibility (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Melody Tompkins, Program Manager, LTC
				  Policy Advisory Unit
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.04 - Costs For Services (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Felecia Barrow, Associate Director, LTC
				  Project Development Unit
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.05 - Application Process (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.06 - Informing Beneficiaries Of Choice (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Melody Tompkins, Program Manager, LTC
				  Policy Advisory Unit
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.07 - Fair Hearings (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.08 - Payment Methodology For Covered Services (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Melody Tompkins, Program Manager, LTC
				  Policy Advisory Unit
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.09 - Confidentiality (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Felecia Barrow, Associate Director, LTC
				  Project Development Unit
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.10 - Records (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs.
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.11 - Enrollment (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Samantha McLeod, Associate Director, LTC
				  Specialized Waiver Programs.
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-58 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUALS DIAGNOSED WITH HIV/AIDS AND RELATED ILLNESS (REPEALED) › Section 560-X-58-.12 - Enrollment (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Felecia Barrow, Associate Director, LTC
				  Project Development Unit.
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 Provider-Based Rural Health Clinic (PBRHC) is a rural health clinic that is an
			 integral and subordinate part of a hospital, skilled nursing facility, or a
			 home health agency participating in Medicare and is operated with other
			 departments of the provider under common licensure, governance, and
			 professional supervision.
(2)
			 Provider-Based Rural Health Clinics' claim(s) filing limit shall be 365 days
			 from date of service. Claims received after this time limit will be treated as
			 outdated in accordance with Rule
			 560-X-1-.17.
Author:
Carol Akin, Associate Director,
				Clinic/Ancillary Services
Statutory Authority:
42 C.F.R. Section
				  405.2401 -.2472, Section 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.02 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order to
			 participate in the Title XIX (Medicaid) Program, and to receive Medicaid
			 payment, a Provider-Based Rural Health Clinic, including satellite clinics
			 must:
(a) request an enrollment packet from
			 our Fiscal Agent Provider Enrollment Unit;
(b) be certified for participation in the
			 Title XVIII (Medicare) Program;
(c)
			 obtain certification by the appropriate State survey agency;
(d) be in compliance with the Clinical
			 Laboratory Improvement Amendment (CLIA) testing for all laboratory sites;
			 and
(e) be operating in accordance
			 with applicable Federal, State and local laws.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.03 - Provider-Based Rural Health Clinic Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Services covered in the Provider-Based
			 Rural Health Clinic are:
(a) Medically
			 necessary diagnostic and therapeutic services and supplies that are an incident
			 to such services or as an incident to a physician's service and that are
			 commonly furnished in a physician's office or a physician home visit;
(b) Basic laboratory services essential to
			 the immediate diagnosis and treatment of the patient that must include but are
			 not limited to the six (6) tests that must be provided directly by the rural
			 health clinic:
1. Chemical examinations of
			 urine by stick or tablet methods or both (including urine ketones)
2. Hemoglobin or hematocrit
3. Blood glucose
4. Examination of stool specimens for occult
			 blood
5. Pregnancy tests,
			 and
6. Primary culturing for
			 transmittal to a certified laboratory
(c) Medical emergency procedures as a first
			 response to life threatening injuries and acute illness.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.04 - Other Ambulatory Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The following services are covered as
			 other ambulatory services furnished in a Provider-Based Rural Health Clinic and
			 are considered rural health clinic services:
(a) Dental services;
(b) Eyeglasses;
(c) Hearing Aids;
(d) Prescribed devices;
(e) Prosthetic devices;
(f) Durable medical equipment;
(g) Family Planning;
(h) Prenatal;
(i) EPSDT (Early and Periodic Screening,
			 Diagnosis and Treatment); and
(j)
			 Preventive Health Education.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.05 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Provider-Based
			 Rural Health Clinics will be reimbursed under a prospective payment system as
			 described in Section 1902(aa) of the Social Security Act. Refer to Alabama
			 Administrative Code Chapter 60.
(2)
			 Inpatient and outpatient surgery is reimbursed as fee for service and is
			 subject to the routine benefit limitations and policies as stated in Chapter 6
			 of the Administrative Code.
Author:
Carol Akin, Associate Director,
				Clinic/Ancillary Services
Statutory Authority:
State Plan, Attachment
				  4.19-B, page 1; 42 C.F.R.
				  Section 405.2401 -.2472, Section 410.152,
				  Section 413 Subpart D, Section 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.06 - Medicare Deductible And Coinsurance

Current through Register Vol. 42, No. 9, June 28, 2024
For Provider-Based Rural Health Clinic services, Medicare
				deductible and/or coinsurance will be reimbursed up to the full amount of the
				Medicaid encounter rate.
Author:
Carol Akin, Associate Director,
				Clinic/Ancillary Services
Statutory Authority:
State Plan, Attachment
				  4.19-B, page 10.
				  42 C.F.R. Section
				  405.2410; Section 413 Subpart D.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.07 - Change Of Ownership

Current through Register Vol. 42, No. 9, June 28, 2024
The provider must notify Medicaid within thirty (30) days of
				the date of ownership change of a Provider-Based Rural Health Clinic. The
				existing contract will be automatically assigned to the new owner. The new
				owner shall then be required to execute a new contract with Medicaid as soon as
				possible after the change of ownership, but in no event later than thirty (30)
				days after the new owner receives notification of Medicare certification. If
				the new owner fails to execute a new contract with Medicaid within this tine
				period; then the clinic's contract shall terminate.
Author:
Statutory Authority:
42 C.F.R. Section
				  405.2470, Section 405.2436-.2438.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.08 - Copayment (Cost Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid and Medicare/Medicaid related recipients are required to pay and
			 Provider-Based Rural Health Clinics are required to collect the established
			 copayment amount for each clinic visit.
(2) The cost-sharing requirement does not
			 apply to services provided for the following:
(a) Recipients under 18 years of
			 age;
(b) Emergencies;
(c) Pregnancy;
(d) Family Planning;
(e) Nursing home residents;
(f) American Indians.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-59 - PROVIDER-BASED RURAL HEALTH CLINIC SERVICES › Section 560-X-59-.09 - Billing Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 provider agrees to accept as payment in full the amount paid by the State, plus
			 any copayment amount required to be paid by the recipient, for covered items
			 and further agrees to make no additional charge or charges for covered items to
			 the recipient.
(2) A provider may
			 bill the recipient for the copayment amount and for noncovered Medicaid
			 services.
Author:
Statutory Authority:
42 C.F.R. Section
				  447.15; State Plan, Attachment 4.18-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.01 - Provider Based Rural Health Clinic Reimbursement - Preface

Current through Register Vol. 42, No. 9, June 28, 2024
This Chapter states the Medicaid policy regarding Provider
				Based Rural Health Clinics (hereinafter referred to as PBRHCs) reimbursement
				and establishes the accepted procedures whereby reimbursement is made to PBRHC
				providers. Because of the length and complexity of this Chapter, it has been
				divided into sections to facilitate its utilization.
Author:
Statutory Authority:
Code of Ala.
				  1975
, State Plan; Title XIX, Social Security Act,
				  42 C.F.R. Sections
				  405.2460 - .2472 and 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.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 PBRHCs 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 PBRHC'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 PBRHC'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 clinics furnishing like covered
			 services?
(d) Is the cost related
			 to covered services and necessary to the operation of a clinic?
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.04 - Reimbursement Methodology

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 Medicaid prospective payment system (PPS) for Provider Based Rural Health
			 Clinics (PBRHCs) was enacted into law under section 702 of the Medicare,
			 Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. As
			 described in section 1902(aa) of the Social Security Act, PBRHCs will be paid
			 under a prospective payment system effective January 1, 2001. The rate setting
			 period is from October 1 through September 30th.
(2) Prior to enactment of BIPA PBRHCs were
			 reimbursed by the ratio of cost to charges. With the implementation of BIPA,
			 PBRHC providers that provided Medicaid covered services will submit a cost
			 report with their normal year end for the cost report period ending in 2000.
			 This cost report will be settled. For the period January 1, 2001, through
			 September 30, 2001, Alabama Medicaid Agency will pay PBRHCs 100% of the average
			 of their reasonable costs of providing Medicaid covered services during FY 1999
			 and FY 2000, adjusted to take into account any increase (or decrease), see
			 paragraph (4) below, in the scope of services furnished during FY 2001 by the
			 PBRHC (calculating the payment amount on a per visit basis). Beginning in FY
			 2002, and for each fiscal year thereafter, each PBRHC is entitled to the
			 payment amount (on a per visit basis) to which the PBRHC was entitled to in the
			 previous fiscal year, increased by the percentage increase in the Medicare
			 Economic Index (MEI) for primary care services, and adjusted to take into
			 account any increase (or decrease) in the scope of services furnished by the
			 PBRHC during that fiscal year. To determine reasonable cost an 80th percentile
			 cost ceiling will be applied. The cost ceiling applied to the cost per
			 encounter for PBRHCs reimbursement is derived as follows:
(a) The PBRHCs are listed in ascending order
			 based on their respective computed cost per encounter.
(b) The number of PBRHCs is multiplied by 80%
			 to determine the position of the PBRHC that represents the 80th percentile. If
			 the 80th percentile does not fall on a whole number, the Agency will round up
			 or down to the nearest whole number. If the number falls on .0 to .49, we will
			 round down. If the number falls on .50 or higher, we will round up. Thus, 80%
			 of the PBRHCs will have computed costs per encounter that are equal to or less
			 than those of the 80th percentile PBRHC. Likewise, the remaining PBRHCs will
			 have computed costs per encounter in excess of the costs of the 80th
			 percentile.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.05 - 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 PBRHC's facility and administration and management
			 of the PBRHC.
(2) Examples of
			 Overhead Costs include, but are not limited to:
(a) Salaries and benefit costs of the
			 administration staff (Owners' compensation will 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-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.06 - 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 clinic 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. Deferred compensation plans will be limited to 7 1/2% of
			 allowable annual salaries.
(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.
(e) Medicaid will not
			 recognize employee stock ownership plans or stock bonus plans.
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-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.07 - 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.
			 Reimbursement to employees for the use of their personal vehicles will be
			 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 PBRHC 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. These rates will be applied on
			 a per provider basis regardless of the number 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 clinic.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.09 - 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 the Provider
			 Reimbursement Manual shall be applicable in determining whether a Related Party
			 relationship exists.
Author:
Statutory Authority:
Code of Ala.
				  1975
, State Plan, Title XIX, Social Security Act,
				  42 C.F.R. Sections
				  405.2460 - .2472 and 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.10 - Chain Operations

Current through Register Vol. 42, No. 9, June 28, 2024
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.
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.
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:
Code of Ala.
				  1975
, State Plan; Title XIX, Social Security Act,
				  42 C.F.R. Sections
				  405.2460 - .2472 and 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.11 - 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-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.12 - 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-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.14 - 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 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 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 he 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 copy of the report of
			 audit will be forwarded to the Reimbursement and Rate Analysis Section when the
			 report of audit is mailed to the facility. After the thirty (30) day
			 notification period is up and no request for an informal conference has been
			 received, a new rate will be calculated based on audit adjustments in the
			 report of audit. The new rate will be effective for billing purposes on the 1st
			 day of the following month. A final audit computation sheet will be prepared.
			 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 of the rate change is
			 computed by applying the adjustment of the rate to the total Medicaid days in
			 the overpayment/underpayment period.
Author:
Statutory Authority:
Code of Ala.
				  1975
, State Plan; Title XIX, Social Security Act,
				  42 C.F.R. Sections
				  405.2460 - .2472 and 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.15 - 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 the Provider
			 Audit Section at Medicaid within thirty (30) days of the date on which Medicaid
			 mails the audit report, or new 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
			 the Legal Counsel at the Medicaid Agency 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:
Code of Ala.
				  1975
, State Plan; Title XIX, Social Security Act,
				  42 C.F.R. Sections
				  405.2460 - .2472 and 447.371.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.17 - 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.