reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.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' nursing 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' social work 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 in psychology.
(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, and
(l) Other skilled health
			 professionals
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.06 - Financial Accountability

Current through Register Vol. 42, No. 9, June 28, 2024
The financial accountability of providers for funds expended on
				home and community-based services must be maintained and provide a clearly
				defined audit trail. Providers must retain records that fully disclose the
				extent and cost of services provided to eligible recipients through the renewal
				period. These records must be accessible to the Alabama Medicaid Agency and
				appropriate state and federal officials. If these records are not available
				within the State of Alabama, the provider will pay all travel costs of the
				auditors to the location of the records.
Author:
Felecia Barrow, Associate Director, LTC
				Project Development Unit
Entire chapter was repealed as per certification filed
				  December 7, 1995; effective January 11,
				  1996.
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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.07 - Individual Assessments

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Alabama Medicaid Agency will require an individual plan of care for each waiver
			 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. The Alabama Medicaid Agency will review recipients'
			 habilitation and care plans and services rendered by a sampling procedure. The
			 review will include appropriateness of care and proper billing procedures.
			 Client assessment procedures in place in the Alabama Department of Mental
			 Health, which are based on eligibility criteria for ICF/IIDs developed jointly
			 by DMH and the Alabama Medicaid Agency, will be utilized by the Department of
			 Mental Health (or its contract service providers) in screening for eligibility
			 for the waiver services as an alternative to institutionalization. Whether
			 performed by a qualified practitioner in the Department of Mental Health, its
			 contract service providers, or provided by qualified (Diagnostic and Evaluation
			 Team) personnel of the individual/agency arranging the service, review for
			 "medical assistance" eligibility determination will be based on client
			 assessment data, and the criteria for admission to an ICF/IID, as described in
			 Rule No. 560-X-35-.03. Re-evaluation of
			 clients shall be performed on an annual basis. Written documentation of all
			 assessments will be maintained in the client's case file and subject to review
			 by the Alabama Medicaid Agency and Department of Health and Human
			 Services.
(2) The Alabama Medicaid
			 Agency will give notice of services available under the waiver as required by
			 federal regulations, particularly to primary care givers for the target group,
			 including but not limited to, programs operated by Alabama Department of Mental
			 Health, the statewide network of community MH centers, and to other appropriate
			 care-giving agencies such as county Department of Human Resources offices,
			 hospitals, hospital associations, and associations for individuals with
			 intellectual disabilities.
Author:
Samantha McLeod, Associate Director,
				  Long Term Care 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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.08 - Informing Beneficiaries Of Choice

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Alabama Medicaid Agency will be
			 responsible for assurances that beneficiaries of the waiver service program
			 will be advised of the feasible service alternatives and be given a choice of
			 which type of service-institutional or home- and/or community-based
			 services-they wish to receive.
(2)
			 Residents of long-term care facilities for whom home and community-based
			 services become a feasible alternative under this waiver will be advised of the
			 available alternative at the time of medical 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 will be offered the alternative unless there is reasonable
			 expectation that services required for the applicant would cost more than
			 institutional care. Provisions for fair hearings for all persons eligible for
			 services under this waiver will be made known and accessible to potential
			 eligibles in accordance with Fair Hearings Procedures in place in the Alabama
			 Medicaid Program.
Author:
Samantha McLeod, Associate Director,
				  Long Term Care 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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.09 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Actual reimbursement will be based on the
			 rate in effect on the date of service.
(2) Rates will be established and reported to
			 the Alabama Medicaid Agency's fiscal agent for claims submitted for
			 payment.
(3) Payment will be based
			 on the number of units of service reported for each HCPC code.
(4) All claims for services must be submitted
			 within one year from the date of service.
(5) Accounting for actual cost and units of
			 services provided during a waiver year must be captured on the CMS 372
			 Report.
Author:
Samantha McLeod, Associate Director,
				  Long Term Care 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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.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:
Felecia Barrow, Associate Director, LTC
				Project Development Unit
Entire chapter was repealed as per certification filed
				  December 7, 1995; effective January 11,
				  1996.
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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.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:
Felecia Barrow, Associate Director, LTC
				Project Development Unit.
Entire chapter was repealed as per certification filed
				  December 7, 1995; effective January 11,
				  1996.
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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.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 services shall be maintained by the clinic. Said records
			 shall be retained for the period of time required by state and federal
			 laws.
(2) A sign-in log complete
			 with the date and nature of services provided must be signed by the recipient.
			 If the recipient is unable to sign, the signature must be obtained by the
			 responsible guardian/caregiver.
Author:
Samantha McLeod, Associate Director,
				  Long Term Care 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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.13 - Provider Enrollment

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid's fiscal agent enrolls providers of waiver services and issues
			 provider agreements to applicants who meet the licensure and/or certification
			 requirements of the state of Alabama, the Code of Federal Regulations and the
Alabama Medicaid Provider Manual
.
(2) General enrollment instructions and
			 information can be found in Chapter 2, "Becoming a Medicaid Provider", of the
Alabama Medicaid Provider Manual
. Failure to provide accurate
			 and truthful information or intentional misrepresentation may result in action
			 ranging from denial of application to permanent exclusion.
Author:
Felecia Barrow, Associate Director, LTC
				Project Development Unit.
Entire chapter was repealed as per certification filed
				  December 7, 1995; effective January 11,
				  1996.
Statutory Authority:
Social Security Act
				  §1915(c); 42 C.F.R. Section 431, Subpart E- Fair Hearings for Applicants
				  and Recipients.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.14 - Cost For Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 cost for services to individuals who qualify for home and community-based care
			 under the waiver program will not exceed a cap of $25,000 per client per year
			 with the exception that crisis intervention services are not included in the
			 cap. Further, 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.
Entire chapter was repealed as per certification filed
				  December 7, 1995; effective January 11,
				  1996.
Author:
Monica Abron, Administrator, 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-52 - HOME AND COMMUNITY-BASED LIVING AT HOME (LH) WAIVER FOR THE MENTALLY RETARDED › Section 560-X-52-.15 - HCBS Waiver Appeal Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An individual receiving a Notice of
			 Action (denial, termination, suspension, reduction in services) from the
			 operating agency (OA), may request an appeal if he/she disagrees with the
			 decision. The Notice of Action explains the reason for the denial, termination,
			 suspension, or reduction in waiver services and the appeal rights made
			 available to them.
(2) If an
			 individual/guardian chooses to appeal an adverse decision, they may choose to
			 appeal to the Department of Mental Health (DMH) Associate Commissioner of the
			 Developmental Disabilities Division no later than 15 calendar days after the
			 effective date printed on the notice of action.
(3) Services will continue until the final
			 outcome of the hearing for those individuals who are already receiving services
			 when they submit an appeal within 10 days after the effective date of action
			 unless:
(a) It is determined at the hearing
			 that the sole issue is of one of Federal or State law or policy; and
(b) The agency promptly informs the
			 beneficiary in writing that services are to be terminated or reduced pending
			 the hearing decision.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.01 - PACE Program - General

Current through Register Vol. 42, No. 9, June 28, 2024
The Program of All-inclusive Care for the Elderly (PACE) is a
				unique managed care benefit for the frail elderly population provided by a
				not-for-profit or public entity. The focus is to assist individuals to continue
				living independently at home in their communities as long as possible. The PACE
				program is a sole source of services for participants. It features a
				comprehensive medical and social service delivery system using an
				interdisciplinary team approach in an adult day health center setting. The
				services are supplemented by in-home and referral services in accordance with
				each participant's needs. Participation in the PACE program is
				voluntary.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit.
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR Part 460.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.02 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
As used in this Rule, the following definitions apply:
(1) PACE - Programs of All-inclusive Care for
			 the Elderly.
(2) PACE Organization
			 (PO) - entity that has an agreement with Medicaid and CMS to operate a PACE
			 program.
(3) PACE Center - facility
			 operated by a PO where primary care is furnished to participants.
(4) State Administering Agency (SAA) - state
			 agency responsible for administering the PACE Program Agreement.
(5) PACE Program Agreement - agreement
			 between the State Administering Agency, CMS and PO for the operation of a PACE
			 program.
(6) Participant -
			 individual who is enrolled in a PACE program.
(7) Medicaid Participant - individual
			 determined eligible for Medicaid who is enrolled in a PACE program.
(8) Medicare Beneficiary - individual who is
			 entitled to Medicare Part A benefits, or is enrolled under Medicare Part B, or
			 both.
(9) Medicare Participant -
			 Medicare beneficiary who is enrolled in a PACE program.
(10) Services - includes items and
			 services.
(11) Contract Year - the
			 term of a PACE program agreement, which is a calendar year, except that the
			 initial contract year may be from 12 to 23 months, as determined by
			 CMS.
(12) Trial Period - the first
			 three contract years in which a PO operates under a PACE program agreement,
			 including any contract year during which the entity operated under a PACE
			 demonstration period.
(13) AMA -
			 Alabama Medicaid Agency.
(14) CMS -
			 Center for Medicare and Medicaid Services.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit.
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3; 4 2 CFR 460.6.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.03 - Eligibility Criteria

Current through Register Vol. 42, No. 9, June 28, 2024
(A)
			 General Rule. The PACE program provides for medically necessary services. To
			 enroll in a PACE program, an individual must meet eligibility requirements
			 specified in this section. To continue to be eligible for PACE, an individual
			 must meet the annual recertification requirements specified in Rule No.
			 560-X-53-.04.
(B) Basic eligibility requirements. To be
			 eligible to enroll in a PACE program, an individual must meet the following
			 eligibility requirements:
(1) Be 55 years of
			 age or older;
(2) Be approved by
			 the Alabama Medicaid Agency to meet the nursing facility level of care as set
			 forth in Rule No.
			 560-X-10-.10;
(3) Reside in the PACE organizations service
			 area;
(4) Be able to live in a
			 community setting at the time of enrollment without jeopardizing his/her health
			 or safety based on criteria set forth in the program agreement; and
(5) Meet any additional program-specific
			 eligibility conditions imposed under its respective PACE program
			 agreement.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.04 - Participant Enrollment

Current through Register Vol. 42, No. 9, June 28, 2024
(A)
			 Enrollment Process
(1) Intake Process. Intake
			 is an intensive process during which PACE staff members make one or more visits
			 to a potential participant's place of residence and the potential participant
			 may make one or more visits to the PACE center. At a minimum, the intake
			 process must include the following activities:
(a) The PACE staff must explain to the
			 potential participant and his or her representative or caregiver the following
			 information:
(i) The PACE program, using a
			 copy of the enrollment agreement, specifically references the elements of the
			 agreement, including but not limited to
			 42 CFR §§
												460.154(e), (i) through (m), and
			 (r);
(ii) The requirement that the PACE
			 organization would be the participant's sole service provider and clarification
			 that the PACE organization guarantees access to services, but not to a specific
			 provider;
(iii) A list of the
			 employees of the PACE organization who furnish care and the most current list
			 of contracted health care providers;
(iv) Monthly premiums, if any;
(v) Any Medicaid spenddown obligations;
			 and
(vi) Post-eligibility treatment
			 of income.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.05 - Participant Voluntary And Involuntary Disenrollment

Current through Register Vol. 42, No. 9, June 28, 2024
(A) Voluntary Disenrollment
(1) A PACE participant may voluntarily
			 disenroll from the program without cause at any time.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.06 - Services For Participants

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Services provided under PACE must include all Medicaid and Medicare services
			 and covered items, as well as any services for each participant determined to
			 be necessary by the Interdisciplinary Team. Provided services must include
			 comprehensive medical, health, and social services for acute and long term
			 care. Services may be provided directly by the PO or by a subcontractor, and
			 must be available 24 hours a day. For guidelines for required services for
			 Medicare and Medicaid Participants, refer to 42 CFR 460, Subpart F.
(2) Enrolled participants must receive their
			 services through the PO. The services are to be provided at the PACE Center,
			 the participant's home, and inpatient facilities. Attendance at a Center is
			 based on the needs and preferences of each participant. A participant may not
			 be discriminated against in receiving services based on race, ethnicity,
			 national origin, religion, sec, age, sexual orientation, mental/physical
			 disability, or source of payment.
(3) A PO must operate at least one PACE
			 center in its service area. The facility is to have sufficient space to ensure
			 routine attendance by participants and to provide adequate services for the
			 participants. If the center does not fulfill these needs, the PO must increase
			 the number of staff and services at the center as needed. If an additional
			 center is needed, it must meet the same requirements as the initial
			 center.
(4) Services to be provided
			 include, but are not limited to, the following:
(a) Primary Care, to include physician and
			 nursing services;
(b) Hospital
			 Care;
(c) Medical Specialty
			 Services;
(d) Prescription
			 Drugs;
(e) Dentistry;
(f) Nursing Home Care;
(g) Personal Care;
(h) Physical Therapy;
(i) Adult Day Care;
(j) Nutritional Counseling;
(k) Social Services;
(l) Laboratory and X-Ray Services;
(m) Transportation.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.07 - Participant Assessment And Plan Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An initial comprehensive assessment and a
			 detailed written plan of care must be established for each participant
			 immediately upon his or her enrollment in the PACE program. The
			 Interdisciplinary Team is responsible for implementing, coordinating,
			 monitoring, and documenting the assessments, reassessments, and the plan of
			 care in the participant's medical records.
(2) The assessment of the participant for the
			 plan of care must be conducted in person by the following members of the
			 Interdisciplinary Team: primary care physician, registered nurse, social worker
			 (Master's level), physical and occupational therapists, recreational therapist
			 or activity coordinator, dietitian, and home care coordinator (42 CFR
			 460.104). Other members of the Team may be
			 included in the assessment as recommended by the initial members of the Team
			 conducting the assessments. The assessments are to be compiled into a single
			 plan of care once completed. During the assessment, female participants must be
			 informed they can choose a qualified specialist to provide routine and
			 preventive health services for women. The assessment must include documentation
			 on the following:
(a) Participant's physical
			 and cognitive function and ability, status of health, behavior, and
			 language;
(b) Medications and
			 treatment needs;
(c) Participant
			 and caregiver's preferences for services;
(d) Availability of socialization and family
			 support;
(e) Nutritional, medical,
			 and dental status;
(f) Environment
			 of and access in to the home;
(g)
			 Psychosocial status.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.08 - Participants Rights

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Participants Bill of Rights is to be written to promote and protect the rights
			 of participants. Written policies and procedures are to be implemented to
			 ensure that participants, their representatives, and PO staff understand the
			 rights of the participant. Upon enrollment, a participant must be verbally
			 informed of his or her rights and all rules and regulations regarding
			 participation in the PACE program. These must also be provided in writing to
			 the participant.
(2) The
			 participants' rights are to be written in English, as well as in any other
			 language that is prominent in the area covered by the PO. The rights are to be
			 displayed in a prominent location within the center.
(3) At a minimum, the rights for participants
			 are to include the rights specified in
			 42 CFR
			 460.112. These rights include, but are not
			 limited to:
(a) Respect and
			 nondiscrimination;
(b) Disclosure
			 of information;
(c) Choice of
			 providers within the PO network;
(d) Access to emergency services;
(e) Participation in decisions for
			 treatment;
(f) Confidentiality and
			 protection of healthcare information;
(g) Fair and efficient process for resolving
			 complaints and appeals.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.09 - Interdisciplinary Team

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 Interdisciplinary Team, comprised of members as listed in §460.102, is to
			 be established for each PACE center. Participants are to be assigned to the
			 Team located at the center he or she attends upon enrollment for an assessment
			 so that the needs of each participant can be met.
(2) Members of the Team must primarily serve
			 PACE participants and are responsible for the initial assessment, reassessments
			 as required, developing a plan of care, and coordinating the care of a
			 participant. The primary care physician on the Team must furnish primary
			 medical care for each participant, and is responsible for managing a
			 participant's medical situations, inpatient care, and use of specialists. Each
			 member is responsible for reporting and documenting the medical, functional,
			 and psychosocial condition of each participant to the Team. Written procedures
			 must be established for use by the Team to ensure confidentiality with the
			 participant between Team members and contractors that provide service for the
			 participant.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit.
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3;
				  42 CFR
				  460.102.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.10 - PACE Organization Enrollment And Agreement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An entity that wishes to become a PO must
			 complete an application that describes how the entity meets all the
			 requirements to be a PO. The application must be submitted to, and approved by,
			 AMA and CMS. AMA will include an assurance with the application sent to CMS
			 that the entity is qualified to be a PO and that AMA is willing to enter into
			 an agreement with the entity. CMS will then evaluate the application based on
			 the information contained in the application, as well as information obtained
			 by onsite visits conducted by CMS and/or AMA.
(2) The proposed service area of the PO must
			 be included in the application. If the proposed area is already serviced by
			 another PO, it may be excluded by CMS and AMA in order to avoid duplication of
			 services and impairing the financial and service viability of an existing
			 PO.
(3) CMS will notify the entity
			 within 90 days from the receipt of the application that the application is
			 approved or denied, or that addition information is required. If the
			 application is denied, the entity will be notified in writing of the reason for
			 the denial and the process for requesting reconsideration by CMS. If additional
			 information is requested, CMS will have an additional 90 days from receipt of
			 the requested information to make a final decision. If CMS fails to make a
			 determination or take any action on the application within 90 days of the
			 receipt of the application or within 90 days of receipt of the additional
			 requested information, the application will be deemed as approved.
(4) An entity, or PO, may submit a request
			 for a waiver of regulatory requirements to meet the needs of the organization
			 or the area it will be servicing. The waiver must be submitted as a separate
			 document and can be submitted with the application. Requirements to the
			 principles listed in 42 CFR 4670.26 will not be waived.
(5) Once an application is approved, an
			 agreement must be signed by the organization, the AMA, and an authorized
			 official of CMS. The agreement is effective for one contract year, but may be
			 extended each year unless any party chooses to terminate the agreement. At a
			 minimum, the agreement must include the information required in
			 42 CFR
			 460.32.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit.
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460 Subpart B and Subpart
				  C.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.11 - PACE Organization Administrative Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A PO must be (or be a distinct part of)
			 an entity of a city, county, state, or tribal government, or a private
			 not-for-profit entity organized for charitable purposes under section 501(c)(3)
			 of the Internal Revenue Code of 1986.
(2) A Program Director must be employed, or
			 contracted with, to be responsible for the oversight and administration of the
			 PO.
(3) A Medical Director must be
			 employed, or contracted with, to be responsible for the delivery of care for
			 participants, clinical outcomes, and the implementation and oversight of
			 quality assessment and improvement program.
(4) An organizational chart must be
			 established and maintained indicating the officials in the PO and any
			 relationship(s) to other organizational entities. AMA and CMS are to be
			 notified in writing of any organizational changes at least 14 days prior to the
			 effective date of the changes.
(5)
			 An identifiable governing body (e.g., a Board of Directors) must be established
			 with full legal authority and responsibility for the following:
(a) Governance and operation of the
			 PO;
(b) Development of
			 policies;
(c) Management and
			 provision of all services;
(d)
			 Establishment of personnel policies, participant health and safety policies,
			 and an operational plan to ensure health and safety of participants;
(e) Fiscal operations;
(f) Quality assessment and improvement
			 program.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.12 - PACE Organization Marketing Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A written marketing plan that includes
			 measurable enrollment objectives and a tracking system for effectiveness must
			 be established and maintained by the PO.
(2) Information must be provided to the
			 public regarding the PO and the marketing materials must be free of material
			 inaccuracies, misleading information, and misrepresentations. The materials
			 must contain information to assist individuals in making an informed decision
			 regarding enrollment and at a minimum must include the following:
(a) A description of the policies and
			 requirements for enrollment and disenrollment for the PACE program;
(b) Procedures for enrollment;
(c) A description of benefits and services
			 provided;
(d) Information regarding
			 premiums;
(e) Notice that all
			 primary and specialized health care, other than emergency services, must be
			 received through the PO or an entity that has been authorized by the
			 PO;
(f) Notice that if services
			 received are not provided or authorized by the PO, that the participant may be
			 fully and personally liable for the costs incurred.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.13 - Quality Assessment And Performance Improvement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A written data-driven plan for the
			 Quality Assessment and Performance Improvement Program must be developed,
			 implemented, and maintained by a PO. The plan must include all services
			 provided by the PO, identify areas for maintaining and improving delivery of
			 services and care, identify development and implementation methods to maintain
			 and improve the quality of care provided, and a plan of action to document and
			 inform appropriate parties of assessment and performance results.
			 Interdisciplinary Team members, PACE staff, and contractors are to be involved
			 in the development and implementation of all activities in the program and made
			 aware of the results of the activities. The plan must be reviewed annually by
			 the governing body of the PO and revisions made as needed.
(2) The Quality Assessment and Performance
			 Improvement Program must include measures that will be used to demonstrate
			 improved performance in the areas described in 460.134. The outcome measures
			 must be based on current clinical practice guidelines and professional practice
			 standards that are applicable to the care of participants in the PACE program.
			 The PO must ensure that all data used is accurate and complete.
(3) The minimum levels of performance for
			 standardized quality measures established by CMS and AMA as specified in the
			 PACE program agreement must be met or exceeded. Areas for improvement should be
			 prioritized based on the severity of the problems identified. Issues that
			 directly or potentially threaten the health and safety of a Participant should
			 be corrected immediately.
(4) A
			 Quality Assessment and Performance Improvement Coordinator must be appointed to
			 oversee the establishment and implementation of the program. Duties of the
			 Coordinator include communication with Participants and caregivers to encourage
			 their participation in the program, including their input regarding their
			 satisfaction with the program.
(5)
			 One or more committees with community input must be established. The duties of
			 the committee(s) include the evaluation of the program's outcome measures and
			 to review the implementation and results of the improvement plan. The
			 committee(s) is to also provide input regarding ethical decision making,
			 including end-of-life issues and implementation of the Patient
			 Self-Determination Act.
(6)
			 External quality assessment and reporting requirements as specified by CMS or
			 AMA in accordance with §460.202 must also be met.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3; 4 2 CFR 460 Subpart H.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.14 - Federal And State Monitoring

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Annual reviews of a PO will be conducted
			 by AMA and CMS to ensure compliance. Onsite visits will be conducted every two
			 years at a minimum. The scope of the reviews includes, but not limited to, the
			 following:
(a) Onsite visits, including but
			 not limited to
1. Review of Participants'
			 charts;
2. Interviews with staff,
			 contractors, Participants, caregivers;
3. Observation of program operations
			 (marketing, services, enrollment and disenrollment procedures, grievances,
			 appeals, etc);
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.16 - Medicaid And Medicare Payments, And Participant Premiums

Current through Register Vol. 42, No. 9, June 28, 2024
(1) AMA will make a
			 monthly capitation payment to a PO for each Medicaid participant enrolled in
			 the program and will be generated by the Medicaid Management Information System
			 (MMIS). The monthly capitation payment will be a fixed amount, regardless of
			 changes in a participant's health or placement into a nursing facility, and
			 will be specified in the agreement. The amount paid will be less than the
			 amount that would be paid if a participant were not enrolled in the PACE
			 program. The capitation payment must be accepted in full for Medicaid
			 participants. The PO may not bill, charge, collect, or receive any other form
			 of payment for the participant unless based on the exceptions listed in
			 §460.182 (c).
(2) CMS will
			 make a monthly capitation payment to the PO for each participant eligible for
			 Medicare. This payment is an all-inclusive payment for Medicare benefits
			 provided to participants. Guidelines for Medicare payments are in
			 §460.180.
(3) A participant
			 cannot be charged a premium if he or she is eligible for Medicaid and Medicare,
			 or for Medicaid only. The premium amount a PO can charge must meet the
			 guidelines in §460.186.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit.
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3; 4 2 CFR 460 Subpart J.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.17 - Sanctions And Enforcement Actions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Penalties and sanctions may be imposed by
			 CMS for a PO if it is determined that the PO has committed any of the
			 violations listed n §460.40. Penalties and/or sanction will be imposed in
			 addition to any other remedies authorized by law.
(2) CMS may also elect to suspend the
			 enrollment of Medicare beneficiaries. CMS may also suspend Medicare payments to
			 the PO or deny payment to AMA for medical assistance for services provided
			 under the PACE agreement. Limitations for civil monetary penalties are
			 addressed in §460.46. The penalties and sanctions imposed will be
			 effective until CMS determines the cause of the violation has been corrected or
			 the violation will not likely recur.
(3) As specified in §460.48, if CMS or
			 AMA determine that a PO is not in compliance, one or more of the following
			 actions will be taken:
(a) Condition the
			 continuation of the PACE agreement upon timely execution of a corrective action
			 plan,
(b) Withhold some or all
			 payments under the PACE agreement until the deficiency is corrected,
(c) Terminate the PACE agreement.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 560-X-53-.18 - Termination Of A PACE Program Agreement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) CMS or AMA may terminate a PO agreement
			 at anytime for cause due to, but not limited to, circumstances listed in
			 §460.50 (b) and (c).
(2) If
			 CMS or AMA terminates a PO agreement, the PO will first be provided a
			 reasonable opportunity to develop and implement a corrective action plan to
			 rectify the reason(s) for the termination. The PO will also be provided a
			 reasonable notice and opportunity for a hearing, including the right to appeal
			 an initial determination, before the agreement is terminated. An agreement may
			 be terminated immediately if it is determined that the health and safety of the
			 Participants are at risk due to the reason(s) for the termination of the
			 agreement.
(3) A PO may terminate
			 an agreement after timely notice to CMS, AMA, and Participants. A 90-day notice
			 must be provided to CMS and AMA. A 60-day notice must be provided to
			 Participants.
(4) A detailed
			 written plan describing actions to be taken for the termination must be
			 developed by the PO. The actions must include written notice to CMS, AMA,
			 Participants, and the community informing them of the termination of the
			 agreement and transition procedures. The PO must assist Participants in
			 obtaining necessary transitional care through referrals and make medical
			 records available to the new providers. Assistance is to be given to
			 Participants for reinstatement of Medicaid and Medicare benefits as applicable.
			 The plan must also include information regarding the termination of marketing
			 and enrollment activities.
Author:
Linda Lackey, Medicaid Administrator,
				  LTC Project Development Unit.
Statutory Authority:
State Plan, Attachment
				  2.2-A, Attachment 3.1-A and Supplement 3; 4 2 CFR 460 Subpart D.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.01 - Authority And Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Home
			 and community-based services for the Technology Assisted Waiver for Adults are
			 provided by the Alabama Medicaid Agency to individuals with disabilities who
			 would otherwise require institutionalization in a nursing facility. These
			 services are provided through a Medicaid waiver under the provisions of Section
			 1915(c) of the Social Security Act for an initial period of three (3) years and
			 for five (5) year periods thereafter upon renewal of the waiver by the Centers
			 for Medicare and Medicaid Services (CMS).
(2) The purpose of providing home and
			 community-based services to individuals at risk of institutional care is to
			 protect the health, safety, and dignity of those individuals while reducing
			 Medicaid expenditures for institutional care.
(3) Home and Community-Based Services for the
			 TA Waiver are provided in compliance with the provisions of the HCBS Settings
			 Final Rule (CMS 2249-F/2296- F). These provisions require the following:
(a) Services may only be provided in settings
			 that:
1. Are integrated in and support full
			 access to the greater community, including opportunities to seek employment and
			 work in competitive integrated settings, engage in community life, control
			 personal resources, and receive services in the community, to the same degree
			 of access as individuals not receiving Medicaid HCBS;
2. Are selected by the individual from among
			 setting options;
3. Ensure
			 individual rights of privacy, dignity and respect, and freedom from coercion
			 and restraint;
4. Optimize autonomy
			 and independence in making life choices including but not limited to, daily
			 activities, physical environment, and with whom to interact; and
5. Facilitate choice regarding services and
			 who provides them.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.02 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Financial
			 eligibility is limited to those individuals receiving SSI, SSI related
			 protected groups deemed to be eligible for SSI/Medicaid (widow/widower,
			 Disabled Adult Child, Continuous (Pickle) Medicaid) 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 is determined based
			 on current admission criteria for nursing facility level of care as described
			 in Rule No.
			 560-X-10-.10. In addition, waiver
			 services are limited to those individuals with complex skilled medical
			 conditions who have a medical history of being ventilator-dependent or who have
			 a tracheostomy.
(3) No waiver
			 services will be provided to recipients in a hospital or nursing
			 facility.
(4) The Alabama Medicaid
			 Agency may also deny home and community-based services if it is determined that
			 an individual's health and safety is at risk in the community; if the
			 individual does not cooperate with a provider in the provision of services; or
			 if an individual fail to meet the goals and objectives of being on the waiver
			 program.
(5) The Alabama Medicaid
			 Agency is restricted by the waiver to serving the estimated annual unduplicated
			 number of beneficiaries approved by the Centers for Medicare and Medicaid
			 Services.
(6) The eligibility age
			 criteria is 21 years and above.
Author:
Ginger Wettingfield, Director LTC
				  Healthcare Reform Division
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart G and the Home and Community-Based Technology Assisted Waiver for
				  Adults.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-54 - HOME AND COMMUNITY-BASED SERVICES FOR INDIVIDUAL UNDER THE TECHNOLOGY ASSISTED (TA) WAIVER FOR ADULTS › Section 560-X-54-.03 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Personal Care/Attendant Services.
(a) Personal
			 Care/Attendant Service (PC/AS) provides in-home and out-of-home (job site)
			 assistance with eating, bathing, dressing, caring for personal hygiene,
			 toileting, transferring from bed to chair and vice versa, ambulation,
			 maintaining continence, medication management and other activities of daily
			 living (ADLs). It may include assistance with independent activities of daily
			 living (IADLs) such as meal preparation, using the telephone, and household
			 chores such as, laundry, bed-making, dusting and vacuuming, which are
			 incidental to the assistance provided with ADLs or essential to the health and
			 welfare of the client rather than the client's family.
(b) PC/AS is designed to increase an
			 individual's independence and ability to perform daily activities and to
			 support individuals with physical disabilities in need of these services as
			 well as those seeking or maintaining competitive employment either in the home
			 or an integrated work setting.
(c)
			 PC/AS is not an entitlement. It is based on the needs of the individual client
			 as reflected in the Plan of Care.