Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-43 - HOME AND COMMUNITY-BASED SERVICES COMMUNITY WAIVER PROGRAM (CWP) FOR PERSONS WITH INTELLECTUAL DISABILITIES › Section 560-X-43-.14 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama
			 Medicaid Agency will provide the operating agency with the approved level of
			 care determination process.
(2) The
			 operating agency will review the applicant's eligibility status to determine if
			 the applicant is medically and financially eligible for waiver services. The
			 targeted case manager will assist the recipient to make financial application
			 and ensure that the appropriate documents are completed and routed to the
			 appropriate Medicaid District Office.
(3) All recipients who are applying for a
			 Home and Community Based Services (HCBS) waiver who are financially approved by
			 the Department of Human Resources or are under the age of 65 and have not been
			 determined disabled must have a disability determination made by the Medical
			 Review team of the Alabama Medicaid Agency.
(4) If a disability determination has been
			 made, the Regional Office should complete a slot confirmation form (Form
			 376).
(5) The Qualified
			 Intellectual Disabilities Professional (QIDP) will complete the level of care
			 determination and the plan of care development.
(6) The operating agency will be required to
			 adhere to all federal and state guidelines in the determination of the level of
			 care approval.
(7) During the
			 assessment, it must be determined that "without waiver services the client is
			 at risk of institutionalization."
(8) The operating agency or its designee
			 (case manager), will ensure that the applicant has been screened and assessed
			 to determine if the services provided through the ID Waiver will meet the
			 applicant's needs in the community.
(9) The Alabama Department of Mental Health
			 (ADMH) is responsible for the assessment, evaluation of admissions,
			 readmissions, and annual redeterminations for eligible participants receiving
			 home and community-based services in accordance with the provisions of the Home
			 and Community-Based Waiver for Persons with Intellectual
			 Disabilities.
(10) The Alabama
			 Medicaid Agency will provide to the ADMH the approved Level of Care criteria
			 and policies and procedures governing the level of care determination process.
(11) The ADMH will designate a
			 qualified medical professional to approve the level of care and develop the
			 Plan of Care.
(12) ADMH may utilize
			 Medicaid staff for consultation on questionable admissions and annual
			 redeterminations prior to a final decision being rendered.
(13) The Alabama Medicaid Agency will conduct
			 a retrospective review on a monthly basis of a random sample of individuals
			 served under the Home and Community Based Services Community Waiver Program
			 (CWP) for Persons with Intellectual Disabilities to determine appropriate
			 admissions and annual redeterminations. This review includes whether
			 appropriate documentation is present and maintained and whether all state and
			 federal medical necessity and eligibility requirements for the program are met.
			 The LTC Waiver Quality Improvement Unit conducts a random sample of plans of
			 care and related documents annually.
(14) The Alabama Medicaid Agency will
			 initiate recoupment of payment for services when it determines that state and
			 federal, medical necessity, and eligibility requirements are not met.
(15) The Alabama Medicaid Agency may seek
			 recoupment from ADMH for other services reimbursed by Medicaid for those
			 individuals whom Medicaid determines would not have been eligible for the Home
			 and Community-Based Services Community Waiver Program for Persons with
			 Intellectual Disabilities or Medicaid eligibility but for the certification of
			 waiver eligibility by ADMH.
(16)
			 The operating agency or its designee will develop a plan of care that includes
			 waiver as well as non-waiver services.
(17) Upon receipt of the financial award
			 letter from the Alabama Medicaid Agency, the LTC Admissions Notification Form
			 should be completed and forwarded to Medicaid's Fiscal Agent electronically.
			 Medicaid's Fiscal Agent will either accept or reject the transmission of the
			 LTC Admissions Notification Form. The operating agency or its designee will
			 receive notice of the status of applications transmitted the next business day
			 following the transmission.
(18) If
			 Medicaid's Fiscal Agent accepts the transmission, the information is
			 automatically written to the Long-Term Care file. The operating agency or its
			 designee can begin rendering services and billing the Alabama Medicaid Agency
			 for services rendered.
(19) If
			 Medicaid's Fiscal Agent rejects the transmission, the operating agency or its
			 designee must determine the reason for the rejection and retransmit the LTC
			 Admissions Notification Form.
(20)
			 Neither the Alabama Medicaid Agency nor Medicaid's Fiscal Agent will send out
			 the LTC-2 Notification letters. The record of successful transmission will be
			 your record of "approval" to begin rendering service.
(21) For applications where the level of care
			 is questionable, you may submit the applications to the LTC Medical and Quality
			 Review Unit for review by a nurse and/or a Medicaid physician.2
(22) Once the individual's information has
			 been added to the Long-Term Care File, changes can only be made by authorized
			 Medicaid staff.
Author:
Mattie Jackson, Associate Director,
				  Specialized Waiver Units, LTC Healthcare Reform Division
Statutory Authority:
Section 1915(c) Social
				  Security Act; 42 C.F.R. Section 441, Subpart G; and the Home and
				  Community-Based Waiver for Persons with Intellectual Disabilities.