reglab/statecodes huggingface dataset:
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-.16 - Fair Hearings

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 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-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.01 - Authority And Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Home
			 and Community-Based Services for the Alabama Community Transition Waiver are
			 provided by the Alabama Medicaid Agency to elderly and disabled individuals who
			 would otherwise require institutionalization in a nursing facility. These
			 services are provided through a Medicaid waiver under the provisions of Section
			 1915(c) of the Social Security Act.
(2) The purpose of the ACT Waiver is to
			 enable individuals, who currently reside in a nursing facility, the opportunity
			 to transition out of the facility and receive home and community based services
			 in the community. A second target population would be individuals currently
			 being served on one of Alabama's other Home and Community-Based Services
			 programs whose condition is such that their current program is not meeting
			 their needs and admission to an institution is eminent if the ACT Waiver were
			 not an option to better serve their needs.
(3) Home and Community-Based Services for the
			 ACT 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-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.02 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Financial
			 eligibility is limited to those individuals receiving Supplemental Security
			 Income, individuals receiving State Supplementation, SSI related protected
			 groups deemed to be eligible for SSI/Medicaid, and Special Home and
			 Community-Based waiver disabled individuals whose income is not greater than
			 300% of the SSI Federal Benefit Rate.
(2) Medical eligibility is determined based
			 on current admission criteria for nursing facility level of care as described
			 in Rule No.
			 560-X-10-.10.
(3) The Alabama Medicaid Agency or its
			 operating agency, acting on Medicaid's behalf may deny home and community-based
			 services if:
(a) If it is determined that an
			 individual's health and safety is at risk in the community;
(b) The cost of serving an individual on the
			 waiver exceeds the cost of caring for that individual in a nursing
			 facility;
(c) The individual does
			 not cooperate with a provider in the provision of services;
(d) The individual does not meet the goals
			 and objectives of being on the waiver program.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.03 - Operating Agencies

Current through Register Vol. 42, No. 9, June 28, 2024
The Home and Community-Based Services Alabama Community
				Transition (ACT) Waiver is a cooperative effort between the Alabama Medicaid
				Agency and the Alabama Department of Senior Services(ADSS).
Author:
Ginger Wettingfeld, Director, LTC
				  Healthcare Reform Division
Statutory Authority:
The Home and
				  Community-Based Services ACT Waiver.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.04 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Case
			 Management Services
(a) Case Management is a
			 comprehensive system of providing services which will assist waiver recipients
			 in gaining needed waiver and other state plan services, as well as needed
			 medical, social, educational, and other appropriate services, regardless of the
			 funding source for the services to which access is gained. Case Management
			 services may be used to locate, coordinate, and monitor necessary and
			 appropriate services. Case Management activities will also be used to assist in
			 the transition of an individual from an institutional setting to the community.
			 Case Management activities to facilitate transition are limited to a maximum of
			 180 days prior to discharge into the community.
(b) Case managers are responsible for Plan of
			 Care development and ongoing monitoring of the provision of waiver services and
			 non-waiver services included in the recipient's Plan of Care.
(c) Case management will be provided by a
			 case manager employed by or under contract with the operating agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.05 - Costs For Services

Current through Register Vol. 42, No. 9, June 28, 2024
The costs for services to individuals who qualify for home and
				community-based care under the waiver program will not exceed, on an average
				per capita basis, the total expenditures that would be incurred for such
				individuals if home and community-based services were not
				available.
Author:
Ginger Wettingfeld, Associate Director,
				  LTC Project Development Unit
Statutory Authority:
42 CFR Section 441, Subpart
				  G and the Home and Community-Based ACT Waiver.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.06 - Application Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Medicaid Agency will receive referrals from hospitals, nursing homes,
			 physicians, the community and others for persons who may be eligible for
			 Alabama Community Transition Waiver home and community-based
			 services.
(2) For institutional
			 residents residing in a facility who plan to transition into the community, the
			 transition coordinator will thoroughly review the referrals and intake
			 information.
(3) An initial
			 assessment will be completed by the transition coordinator in conjunction with
			 the applicant's physician. This document will reflect detailed information
			 regarding social background, preferences living conditions, and medical issues
			 of the applicant. A copy of this document will be submitted to the operating
			 agency for approval.
(4) The case
			 manager, in conjunction with the applicant's physician, client and/or caregiver
			 will develop a Plan of Care. The Plan of Care will include objectives,
			 services, provider of services, and frequency of service. Changes to the
			 original Plan of Care are to be made as needed to adequately care for an
			 individual. Reasons for changes must be documented on the client's Plan of Care
			 which is subject to the review of the Alabama Medicaid Agency. The Plan of Care
			 must be reviewed by the case manager as often as necessary and administered in
			 coordination with the recipient's physician.
(5) The Alabama Medicaid Agency has delegated
			 the medical level of care determination to qualified trained individuals at the
			 operating agency.
(6) The Alabama
			 Medicaid Agency requires the operating agency to submit an application in order
			 to document dates of service provision to long term care recipients.
(a) The long-term care software maintains
			 these dates of service.
(b) The
			 applications will be automatically approved through systematic
			 programming.
(c) Medicaid 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-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.07 - 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-44-.02, may request an
			 appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the
			 Alabama Medicaid Administrative Code, as modified by the below
			 provisions.
(2) ACT waiver
			 participants will be given at least a ten-day notice before termination,
			 suspension or reduction of services.
(3) If an individual/guardian chooses to
			 appeal the decision, a written request for an informal conference must be
			 received by the Operating Agency within 30 days from the effective date of the
			 notice. Services may continue for waiver participants until the final outcome
			 of the administrative appeal process, if the written request is received within
			 10 days after the effective date of the action.
(4) If the individual/guardian is
			 dissatisfied with the Informal Conference decision, a Fair Hearing may be
			 requested. A written request for a Fair Hearing must be received no later than
			 30 days from the date of the Informal Conference decision notice.
(5) If the individual/guardian is
			 dissatisfied with the Fair Hearing decision, he/she may appeal pursuant to the
			 provisions of the Alabama Administrative Procedure Act.
(6) The Operating Agency will take the lead
			 role for the Informal Conferences, Fair Hearings and subsequent judicial
			 appeals. Medicaid legal counsel and program staff will function as support
			 staff.
Author:
Mattie M. Jackson, Program Manager, LTC
				  Program Management Unit.
Statutory Authority:
Social Security Act
				  §1915(c); 42 CFR Section 431, Subpart E.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.08 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payments made by the Alabama Medicaid
			 Agency to providers will be on a fee-for-service basis. Each covered service is
			 identified on a claim by a procedure code.
(2) Accounting for actual cost and units of
			 services provided during a waiver year must be captured on CMS Form 372. The
			 following accounting definitions will be used to capture reporting data, and
			 the audited figures used in establishing new interim fees:
(a) A waiver year consists of 12 consecutive
			 months starting with the approval date specified in the approved waiver
			 document.
(b) An expenditure occurs
			 when cash or its equivalent is paid in a quarter by a state agency for waiver
			 benefits. For a public/governmental provider, the expenditure is made whenever
			 it is paid or recorded, whichever is earlier. Non-cash payments, such as
			 depreciation, occur when transactions are recorded by the state
			 agency.
(c) The services provided
			 by a direct service provider agency is 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-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.09 - 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 legal representative, or upon subpoena from a court of appropriate
				jurisdiction.
Author:
Ginger Wettingfeld, Associate Director,
				  LTC Project Development Unit
Statutory Authority:
Social Security Act
				  §1915(c);
				  42 CFR Section
				  431.306, Subpart F-Home and Community-Based
				  Services: Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.10 - Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The operating
			 agency 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. Said records shall be
			 retained for the period of time required by state and federal laws.
(2) A sign-in log, service receipt, or other
			 record shall be used to show the date and nature of services; this record shall
			 include the recipient's signature or designated signature authority.
(3) Providers must retain records that fully
			 disclose the extent and cost of services provided to the eligible recipients
			 for a five-year period. These records must be accessible to the Alabama
			 Medicaid Agency and appropriate state and federal officials.
(4) There must be a clear differentiation
			 between waiver services and non-waiver services. There must be a clear audit
			 trail from the point a service is provided through billing and reimbursement.
			 The Alabama Medicaid Agency and Centers for Medicare and Medicaid Services
			 (CMS) must be able to review the Plan of Care to verify the exact service and
			 number of units provided, the date the service was rendered, and the direct
			 service provider for each recipient. There must be a detailed explanation of
			 how waiver services are segregated from ineligible waiver costs.
Author:
Ginger Wettingfeld, Director, LTC
				  Healthcare Reform
Statutory Authority:
Social Security Act
				  §1915(c); 42 CFR Section 441, Subpart G-Home and Community-Based Services:
				  Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.11 - Service Providers

Current through Register Vol. 42, No. 9, June 28, 2024
The Home and Community-Based Services Alabama Community
				Transition Waiver is a cooperative effort between the Alabama Medicaid Agency
				and the operating agency.
Author:
Ginger Wettingfeld, Director, LTC
				  Healthcare Reform
Statutory Authority:
Social Security Act
				  §1915(c); 42 CFR Section 441, Subpart G-Home and Community-Based Services:
				  Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-44 - HOME AND COMMUNITY-BASED SERVICES FOR THE ALABAMA COMMUNITY TRANSITION (ACT) WAIVER › Section 560-X-44-.12 - Enrollment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama
			 Department of Senior Services or its designee enrolls providers of waiver
			 services who meet the licensure and/or certification requirements of the
			 Alabama Community Transition Waiver.
(2) For unique goods and services, or
			 one-time purchases, a provider may enroll with the operating agency at the
			 operating agency's discretion. If a provider enrolls directly with the
			 operating agency, the operating agency will be solely responsible for the
			 legitimacy and performance of the provider.
Author:
Ginger Wettingfeld, Director, LTC
				  Healthcare Reform
Statutory Authority:
Social Security Act
				  §1915(c); 42 CFR Section 441, Subpart G-Home and Community-Based Services:
				  Waiver Requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.01 - Nurse-Family Partnership - General

Current through Register Vol. 42, No. 9, June 28, 2024
Nurse-Family Partnership (NFP) nurse visiting services are
				available to eligible pregnant Medicaid recipients. These services include care
				coordination, assessments and screenings, case management, and preventative
				health education and counseling. NFP is a nationally recognized evidence-based
				model that has demonstrated improved health outcomes and is maintained by the
				National Service Organization (NSO). These improved outcomes can ultimately
				help reduce health care costs over the mother and child's lifespans. NFP nurse
				visiting services are:
(1) Tailored to
			 each woman's needs.
(2) Delivered
			 in the home setting, via telehealth, or in an alternative community setting as
			 indicated by client need.
(3)
			 Provides case management activities for the woman through the prenatal and
			 postpartum periods and through the infant's second birthday.
Author:
John Majors, Associate Director,
				  Maternity and Family Planning
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.169(b); and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.02 - Recipient Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
NFP services are available for Medicaid eligible persons
				who:
(1) Are referred to a qualified,
			 Agency enrolled, NFP provider by the recipient's assigned Alabama Coordinated
			 Health Network (ACHN), and
(2) Meet
			 the NFP model eligibility requirements as established by the NSO and outlined
			 in the Alabama Medicaid Provider Billing Manual.
Author:
John Majors, Associate Director,
				  Maternity and Family Planning
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.169(b); and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.03 - Provider Requirements For Participation

Current through Register Vol. 42, No. 9, June 28, 2024
Billing providers must be NSO network partners approved to
				implement the NFP Program within a specific region(s) with a current Annual
				Fidelity Support Letter on file with the Agency.
Author:
John Majors, Associate Director,
				  Maternity and Family Planning
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.169(b); and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.04 - Provider Termination And/Or Change Of Ownership

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A participating NFP provider has the
			 right to withdraw from the Medicaid program after submitting written notice to
			 Medicaid of its intent at least thirty (30) days in advance.
(2) The State may terminate the NFP
			 provider's participation in the Medicaid program if they lose NSO certification
			 for any reason, and in cases involving fraud or willful or grossly negligent
			 non-compliance.
(3) Medicaid must
			 be notified in writing within thirty (30) days of the date of agency owner
			 and/or name change. The existing contract will be terminated, and a new
			 contract must be signed to continue participation in the Medicaid
			 program.
Author:
John Majors, Associate Director,
				  Maternity and Family Planning
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.169(b); and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.05 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
NFP services can be provided through the prenatal and
				postpartum periods (Maternal Only Phase) and up until the infant's second
				birthday (Maternal/Infant Phase). Case Management Activities for both phases
				must include:
(1) Comprehensive
			 assessment and periodic reassessment of individual needs to determine the need
			 for any medical, educational, social, and/or other services. Each assessment
			 must include:
(a) assessing client
			 history;
(b) identifying the
			 individual's needs and completing related documentation; and
(c) gathering information from other sources
			 such as family members, medical providers, social workers, and educators (if
			 necessary) to form a complete assessment of the eligible individual.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.06 - NFP Visits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A qualified
			 NFP visit is a contact with the recipient in-person either at their home or
			 other location of the recipient's choosing or via telehealth when
			 appropriate.
(2) Monthly
			 documentation of active recipient participation and provider engagement is
			 required.
Previous Rule
				  560-X-45-.05 was renumbered to
				  Rule 560-X-45-.06 as per certification filed October 12, 2005; effective
				  November 16, 2005.
Author:
John Majors, Associate Director,
				  Maternity and Family Planning
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.169(b); and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.07 - NFP Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The NFP
			 provider shall make available to the Alabama Medicaid Agency, at no charge, all
			 information describing services provided to 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 records (including, but
			 not limited to, medical, psychiatric, and fiscal records) which fully disclose
			 the extent of the service shall be maintained by the NFP. Said records shall be
			 retained for the period of time required by State and Federal laws.
(2) In addition to all NSO mandated data
			 elements, NFP records must contain documentation of:
(a) name of recipient;
(b) a recipient Medicaid ID;
(c) the NFP Client ID;
(d) dates of services;
(e) name of provider agency and person
			 providing services;
(f) nature,
			 start and end time, extent or units of services provided;
(g) place(s) of service; and
(h) weeks of gestation or weeks postpartum at
			 time of visit.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-45 - NURSE-FAMILY PARTNERSHIP › Section 560-X-45-.08 - Billing Nurse-Family Partnership Services By Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) NFP Providers
			 may submit a claim to Medicaid once each month. At least one qualifying visit
			 must occur prior to the submission of the claim.
(2) The NFP provider agrees to accept as
			 payment in full the amount paid for covered NFP services.
(3) Medicaid will not reimburse for any
			 direct care services (i.e. wound care, medication administration, etc.)
			 rendered by an NFP provider.
Previous Rule
				  560-X-45-.07 was renumbered to
				  Rule 560-X-45-.08 as per certification filed October 12, 2005; effective
				  November 16, 2005.
Author:
John Majors, Associate Director,
				  Maternity and Family Planning
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R. Section
				  440.169(b); and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.01 - General Conditions Of Participation

Current through Register Vol. 42, No. 9, June 28, 2024
Swing beds are defined as hospital beds that can be used for
				either skilled nursing facility (SNF) or hospital acute care levels of care on
				an as needed basis if the hospital has obtained a swing bed approval from the
				Department of Health and Human Services. Swing bed hospitals must:
(a) Have fewer than 100 beds (excluding
			 newborn and intensive care beds) and be located in a rural area as defined by
			 the Census Bureau based on the most recent census;
(b) Be Medicare certified as a swing bed
			 provider;
(c) Have a certificate of
			 need for swing beds;
(d) Be
			 substantially in compliance with SNF conditions of participation for patient
			 rights, 42 CFR
§405.1121(K)(2)(3)(4)(7)(8)(10)(11)(13)(14); specialized
				rehabilitation services, 42
				CFR §
										405.1126(a)(b)(c); dental
				services, 42 CFR §405.1129 ; social services,
				42 CFR §
										405.1130; patient activities, 42 CFR
				§405.1131 ; and discharge planning, 42 CFR §405.1137(h) . Most other
				SNF conditions would be met by virtue of the facilities compliance with
				comparable conditions of participation for hospitals;
(e) Must not have in effect a 24 hour nursing
			 waiver granted under 42 CFR §405.1910(c);
(f) Must not have had a swing bed approval
			 terminated within the two years previous to application for swing bed
			 participation;
(g) Be in compliance
			 with Title VI of the Civil Rights Act of 1964, Section 504 of the
			 Rehabilitation Act of 1973, and the Age Discrimination Act of 1975;
			 and
(h) Execute an Alabama Medicaid
			 Agency provider agreement.
(2) Refer to
			 Chapter 10 for detailed information on SNF policies and procedures which will
			 be applicable for swing beds.
Author:
Vicki Huff
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.02 - Enrollment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers
			 wishing to enroll must submit a written request to Medicaid and
(a) Proof of current hospital licensure if
			 not already on file at Medicaid,
(b) Proof of current Medicare swing bed
			 certification if not already on file at Medicaid,
(c) Proof of a CON if not on file at
			 Medicaid.
Each request will be reviewed for completeness and accuracy
				prior to approval of the application.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.03 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Swing bed
			 services are reimbursed on a per diem basis at the average rate per patient day
			 paid by Medicaid to SNF/ICF Combination facilities for routine services
			 furnished during the previous calendar year. There shall be no year end cost
			 settlement. Refer to Chapter 22 for details on rate computation.
(2) Ancillary services such as lab, x-ray,
			 and prescription drugs must be billed and reimbursed separately under the
			 appropriate program areas. For example, x-ray services provided in the
			 outpatient department of the hospital should be billed as outpatient hospital
			 services. These services will be subject to routine benefit
			 limitations.
(3) The per diem rate
			 includes routine supplies and over the counter medications such as
			 acetaminophen, aspirin, antacids, antidiarrheals, laxatives, and stool
			 softeners which are routinely used in the care of patients.
(4) Medicaid may pay the Medicare Part A
			 coinsurance for dually eligible or QMB recipients who qualify under Medicare
			 rules for skilled level of care. An amount equal to that applicable to Medicare
			 Part A coinsurance, but not greater than the average nursing facility rate will
			 be paid.
Author:
Vicki Huff
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, Attachment 3.1-A, 4.19-D;
				  42 CFR
				  §§447.280,
				  413.114,
				  413.53.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.04 - Level Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order to
			 receive swing bed services recipients must require SNF level of care on a daily
			 basis. The skilled services provided must be ones that, on a practical basis,
			 can only be provided on an inpatient basis.
(2) A condition that does not ordinarily
			 require skilled care may require this care because of a special medical
			 condition. Under such circumstances the service may be considered skilled
			 because it must be performed by or supervised by skilled nursing or
			 rehabilitation personnel.
(3) The
			 restoration potential of a patient is not the deciding factor in determining
			 whether skilled services are needed. A patient may need skilled services to
			 prevent further deterioration or preserve current capabilities.
(4) Swing bed admissions not covered by
			 Medicare because they do not meet medical criteria shall also be considered
			 noncovered by Medicaid. Therefore, these services cannot be reimbursed as a
			 straight Medicaid service.
Author:
Vicki Huff
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, Attachment 3.1-A, 4.19-B;
				  42 CFR
				  §§409.30,
				  409.31,
				  409.32,
				  456.600.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.05 - Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Swing bed
			 services include care ordinarily provided by a SNF facility (Refer to Chapter
			 10). Such services include but are not limited to:
(a) Nursing care provided by or under the
			 supervision of a registered nurse.
(b) Bed and board in a semiprivate room.
			 Private accommodations may be utilized if the patient's condition requires that
			 he/she be isolated, the facility has no ward or semiprivate rooms, or all
			 semiprivate rooms were full at the time of admission and remain so during the
			 recipient's stay.
(c) Over the
			 counter drugs including acetaminophen, aspirin, antacids, antidiarrheals, and
			 stool softeners which are routinely used in the care of patients.
(d) Personal services and supplies ordinarily
			 furnished by the facility for the comfort and cleanliness of the
			 patient.
(e) Nursing and treatment
			 supplies as ordered by the patient's physician or as required for quality
			 nursing care. These include, but are not limited to, needles, syringes,
			 catheters, catheter trays, drainage bags, indwelling catheters, enema bags,
			 normal dressing, special dressings (such as ABD pads and pressure dressings)
			 intravenous administration sets, normal intravenous fluids (such as glucose,
			 D5W, D10W).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.06 - Benefit Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
Swing bed services are unlimited as long as the recipient meets
				the SNF level of care medically and all other eligibility criteria which
				includes financial criteria.
Author:
Vicki Huff
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, Attachment 3.1-A, 4.19-D; 42 CFR §§409, Subpart C;
				  Omnibus Budget Reconciliation Act of 1987, Section 4005(b)(2).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.07 - Billing Of Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) No
			 eligible Alabama Medicaid recipient is to receive a bill or statement for swing
			 bed services once that recipient has been accepted as a Medicaid patient,
			 except for the appropriate patient liability as described in Chapter
			 25.
(2) It is the responsibility of
			 the provider to follow up with the fiscal agent and/or Medicaid, and not the
			 recipient, on any problem or unpaid claim.
(3) A provider agrees to accept as payment in
			 full the amount paid by the state, plus any patient liability amount to be paid
			 by the recipient, for covered services, and further agrees to make no
			 additional charge or charges for covered services to the recipient, sponsor, or
			 family of the recipient.
(4)
			 Providers may bill eligible recipients for noncovered services; i.e., private
			 room accommodation charges incurred due to recipient's request, or personal
			 comfort items requested by the recipient.
Author:
Vicki Huff
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, 3.1-A, 4.19-D;
				  42 C.F.R.
				  §§447.15,
				  447.50,
				  447.55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.08 - Admission And Periodic Review

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid Medical and Quality Review
			 Unit or designee will perform admission review of all Medicaid admissions to
			 ensure the necessity and appropriateness of the admission and that a physician
			 has certified on the date of admission, the need for swing bed care. Medicaid
			 or its designee will certify the level of care required by the patient at the
			 time of admission by utilizing Form 199.
(2) For applications which are not approved
			 by the Medical and Quality Review Unit or its designee, a Medical Director,
			 will review and either approve or deny the medical eligibility.
(3) Recipients must meet Skilled Nursing
			 Facility (SNF) medical and financial requirements for swing bed admissions just
			 as they are required for SNF admissions. Refer to Chapter 10 and Chapter
			 25.
(4) For recipients who receive
			 retroactive Medicaid eligibility while utilizing swing bed services, the
			 hospital should furnish all doctors' orders, progress and nurses' notes for the
			 time in question to Medicaid's fiscal agent.
(5) Medical approvals may be issued by the
			 Medicaid Medical and Quality Review Unit or designee if the information
			 provided to Medicaid documents the need for SNF care and the recipient meets
			 criteria set forth in Rule
			 560-X-10-.10 for SNF care.
(a) The admission application packet must be
			 sent to the Medicaid Medical and Quality Review unit or designee within 60 days
			 from the date Medicaid coverage is sought and consist of: a fully completed
			 Medicaid Status Notification Form 199 including all documentation certified by
			 the applicant's attending physician to support the need for nursing home level
			 of care. Refer to Rule
			 560-X-10-.10 and .13, for
			 in-depth information.
(b) Once the
			 Form 199 has been reviewed and approved medically, the facility is notified by
			 a letter advising that the patient is medically eligible for swing bed
			 services.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.09 - Inspection Of Care/Utilization Review (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Vicki Huff
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, Attachment 4.19-D; 42 CFR §§456.300 and
				  456.600.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-46 - HOSPICE CARE › Section 560-X-46-.10 - Patient Agreements

Current through Register Vol. 42, No. 9, June 28, 2024
Providers of swing bed care must execute a Nursing
				Facility/Patient Agreement for each Medicaid patient on admission and when any
				financial terms change. This agreement is executed for patients already
				eligible for Medicaid and patients who are applying for Medicaid eligibility.
				The patient or sponsor will be furnished a copy of the completed agreement and
				a copy is maintained in the facility's files for audit purposes. Refer to
				560-X-10-.12 for additional
				information on patient agreements.
Author:
Vicki Huff
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan, Attachment 4.19D; 42 CFR §405.1121.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.01 - Authority And Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Rehabilitative services are specialized services of a medical or remedial
			 nature delivered by uniquely qualified practitioners designed to treat or
			 rehabilitate persons with mental illness or substance abuse diagnoses. These
			 services will be provided to recipients on the basis of medical
			 necessity.
(2) Direct services may
			 be provided in the client's home, a supervised living situation, organized
			 community settings, such as community centers, health clinics, nursing homes,
			 etc. Direct services can be provided in any setting, except in licensed
			 hospital beds, that is convenient for both the client and staff member, that
			 affords an adequate therapeutic environment, and that protects the client's
			 rights to privacy and confidentiality.
Author:
Lynn Sharp
Statutory Authority:
42
				  C.F.R. §440.130(d);
				  Social Security Act, Title XIX; Omnibus Budget Reconciliation Act of 1987, P.L.
				  100-203, §4105 ; State Plan for Medical Assistance, Attachment
				  3.1-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.02 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Financial
			 eligibility is limited to individuals eligible for Medicaid under the Alabama
			 State Plan.
(2) Treatment
			 eligibility is limited to individuals with a diagnosis, assigned by a licensed
			 physician, a licensed psychologist, a licensed physician's assistant, a
			 certified registered nurse practitioner, a licensed professional counselor or
			 associate licensed counselor of mental illness or substance abuse as listed in
			 the most current International Classification of Diseases - Clinical
			 Modification (ICD-CM). The Z codes are not covered for adult rehabilitative
			 treatment services; however, the intake evaluation and diagnostic assessment
			 will be covered even if the resulting diagnosis is a Z code. For treatment
			 services provided to children under 21 or adults receiving DHR protective
			 services, the only Z code covered for reimbursement is Z65.9, problem related
			 to unspecified psychosocial circumstances.
(3) Providers of rehabilitative services
			 shall meet the following eligibility requirements:
(a) Shall be in full compliance with
			 applicable federal and state laws and regulations including compliance with the
			 requirements expressed in the current version of the Medicaid Provider Manual,
			 Rehabilitative Services, Chapter 105;
(b) Shall submit evidence to Medicaid of full
			 compliance with
			 560-X-47-.03; and have such
			 compliance approved in advance; and
(c) Shall execute the Medicaid
			 non-institutional provider agreement with appropriate attachments.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.03 - Service Providers

Current through Register Vol. 42, No. 9, June 28, 2024
To participate in the Alabama Medicaid Program, rehabilitative
				services providers must meet the following requirements. Service providers must
				demonstrate that they meet the criteria in either (1), (2), or (3), and both
				(4) AND (5) below.
(1) A provider must
			 be certified as a 310-board community mental health center by DMH and must have
			 demonstrated the capacity to provide access to the following services through
			 direct provision or referral arrangements:
(a) Inpatient services through referral to
			 community hospitals and through the attending physician for community
			 hospitalizations
(b) Substance
			 abuse services including intensive outpatient services and residential
			 services
(c) Must submit an
			 application to and receive approval from DMH to provide mental health
			 rehabilitative services under the Medicaid Rehabilitative Option
			 program.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.04 - Minimum Qualifications For Mental Health, Substance Abuse, And Child And Adolescent Services/Adult Protective Services Professional Staff

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Mental Health
			 MI Professional Staff qualifications are delineated within the specifications
			 for each covered mental health rehabilitation service as described in the
			 applicable Alabama Medicaid Agency Provider Manual, MI/SA Rehabilitative
			 Services, Chapter 105.
(2)
			 Substance Abuse Professional Staff qualifications are delineated within the
			 specifications for each covered mental health rehabilitation service as
			 described in the applicable Alabama Medicaid Agency Provider Manual, MI/SA
			 Rehabilitative Services, Chapter 105.
(3) Alabama Department of Human Resources
			 Child and Adolescent Services/Adult Protective Services Professional Staff
			 qualifications are delineated within the specifications for each covered mental
			 health rehabilitation service as described in the applicable Alabama Medicaid
			 Agency Provider Manual, MI/SA Rehabilitation Services, Chapter 105.
(4) Alabama Department of Youth Services
			 Child and Adolescent Services Professional Staff Qualifications are delineated
			 within the specifications for each covered mental health rehabilitation service
			 as described in the current version of the Alabama Medicaid Agency Provider
			 Manual, MI/SA Rehabilitative Services, Chapter 105.
(5) Mental Health ASD Professional Staff
			 qualifications are delineated within the specifications for each covered mental
			 health rehabilitation service as described in the applicable Alabama Medicaid
			 Agency Provider Manual, ASD Rehabilitative Services, Chapter 110.
Author:
Karen M. Smith, Associate Director,
				  Mental Health Programs
Statutory Authority:
42
				  C.F.R. §
											440.130(d);
				  Social Security Act, Title XIX; Omnibus Budget Reconciliation Act of 1987, P.L.
				  100-203, §4105; State Plan for Medical Assistance, Attachment
				  3.1-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.05 - Requirements For Client Intake, Treatment Planning, And Service Documentation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Requirements for intake, treatment planning, and service documentation are
			 detailed in the Medicaid Provider Manual, Rehabilitative Services, Chapter 105,
			 Section 105.2.3. Manuals may be downloaded from the Medicaid website at
www.medicaid.alabama.gov.
(2) Documentation in the client's
			 record for each session, service, or activity for which Medicaid reimbursement
			 is requested shall comply with any applicable certification or licensure
			 standards and shall include, at a minimum:
(a)
			 the identification of the specific services rendered;
(b) the date and the amount of time that the
			 services were rendered;
(c) the
			 signature of the staff person who rendered the services;
(d) the identification of the setting in
			 which the services were rendered;
(e) a written assessment of the client's
			 progress, or lack thereof, related to each of the identified clinical issues
			 discussed.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.06 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Only
			 the rehabilitative services delineated in the applicable Alabama Medicaid
			 Agency Provider Manual, Rehabilitation Services, Chapter 105 shall qualify for
			 reimbursement under this program.
(2) A complete description of each covered
			 service along with benefit limitations is contained in the Medicaid Provider
			 Manual, Rehabilitative Services, Chapter 105. Quarterly manual updates may be
			 downloaded from the Medicaid website: medicaid.state.al.us.
(3) Services shall be provided in a manner
			 that meets the supervisory requirements of the respective certifying or
			 licensing authority or as authorized by state law.
Author:
Karen M. Smith, Associate Director,
				  Mental Health Programs
Statutory Authority:
42
				  C.F.R. §
											440.130(d);
				  Social Security Act, Title XIX; Omnibus Budget Reconciliation Act of 1987, P.L.
				  100-203, §4105; State Plan for Medical Assistance, Attachment
				  3.1-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-47 - REHABILITATIVE SERVICES › Section 560-X-47-.07 - Payment Methodology

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 statewide maximum payment will be calculated for each service designated by a
			 procedure code recognized by the Alabama Medicaid Agency as a covered
			 service.
(2) The Medicaid
			 reimbursement for each service provided by a rehabilitative services provider
			 shall be based on the following criteria in accordance with the methodology
			 described below:
(a) For procedure codes with
			 an assigned Medicare rate (i.e. CPT codes), the proposed rate will be the
			 current published Medicare Physician Fee Schedule Rate for Alabama.
(b) For procedure codes without an assigned
			 Medicare Rate on the Physician Fee Schedule (i.e. HCPCS) codes, the
			 reimbursement will be 'By Report'. 'By Report' means paying a percentage of
			 billed charges. The percentage is derived by dividing the previous state fiscal
			 year's total Medicaid reimbursement (total allowed charge) for services
			 included in the Physician Fee Schedule by the previous state fiscal years total
			 Medicaid billings.
1. Percentage = Total
			 'Allowed Amount'/Total 'Billed Amount'
2. Average Billed Amount = Total 'Billed
			 Amount'/ Total 'Allowed Quantity'
3. Proposed Rate = Percentage times Average
			 Billed Amount
(c) For
			 procedure codes with no utilization one of the three methods below will be
			 used.
1. Current rate that the Rehabilitative
			 Services State Agencies utilizes.
2. Current rate from another state for same
			 service.
3. For those services that
			 need rate different from current Alabama or other state rate a financial cost
			 model will be used to calculate rate.