Alabama Administrative Code

Alabama Medicaid will cover organ transplants under the following terms and conditions. These terms will apply to all procedures except cornea transplants. (1) Transplants must be performed in the state of Alabama if medically available and appropriate for particular patient and …

(1) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) will be available for Medicaid-eligible recipients under the age of 21 years old. This coverage will be provided for medically necessary health care, diagnosis, treatment and/or other measures described in §1905(a…

(1) Medicaid may create, generate, communicate, store, process, use, and rely upon electronic records and signatures. (2) Medicaid may convert written records to electronic records. (3) When converting written records to electronic records, Medicaid will ensure the electronic rec…

(1) The Veterans Health Care Act of 1992 enacted section 340 B of the Public Health Services Act, "Limitation on Prices of Drugs Purchased by Covered Entities". This Section provides that a manufacturer who sells covered outpatient drugs to eligible 340B entities must sign a phar…

(1) Nursing Facility - An institution which is primarily engaged in providing nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled or sick persons, or on a regular basis health rel…

(1) The Medical Assistance (Title XIX) Plan for Alabama provides for medically necessary nursing facility services, rendered in a facility which meet the licensure requirements of the Department of Public Health and the certification requirements of Title XIX and XVIII of the Soc…

(1) All nursing facilities that desire to enroll and participate in the Alabama Title XIX Medicaid nursing facility program and to receive Medicaid payment for services provided for Medicaid residents must submit the following requirements: (a) Possess certification for Medicare …

(1) Services included in basic (covered) nursing facility charges. (a) All nursing services to meet the total needs of the resident including treatment and administration of medications ordered by the physician. (b) Personal services and (c) Room (semiprivate or ward accommodatio…

(1) Payment for Reservation of Beds in Long Term Care Facilities. (a) Neither Medicaid patients, nor their families, nor their sponsor, may be charged for reservation of a bed for the first four days of any period during which a Medicaid patient is temporarily absent due to admis…

(1) Payments to nursing facilities may be made for therapeutic leave visits to home, relatives, and friends for up to six days per calendar quarter. A therapeutic leave visit may not exceed three days. Visits may not be combined to exceed the three day limit. (2) Payments to ICF/…

(1) The Alabama Medicaid Agency or its designated agent will perform a retrospective review of Medicaid nursing home or ICF/IID facility residents' records to determine appropriateness of admission. Refer to Rule 560-X-10-.11(3)(g) of this Administrative Code for more information…

(1) A physician must perform the specific physician services required by state and federal law. (2) A physician is defined in Section 1861R of the Social Security Act as a doctor of medicine or osteopathy legally authorized to practice medicine and surgery in the state in which h…

(1) Reimbursement will be made in accordance with Chapter 22, Alabama Medicaid Administrative Code. (2) Each nursing facility shall have a payment rate assigned by Medicaid. The patient's available monthly income minus an amount designated for personal maintenance (and in some ca…

(1) Guidelines for nursing facility admission criteria: The principal aspect of covered care relates to the care rendered. The controlling factor in determining whether a person is receiving covered care is the medical supervision that the resident requires. Nursing facility care…

(1) Application of Medicare Coverage: (a) Nursing facility residents, either through age or disability, may be eligible for Medicare coverage up to 100 days. (b) Nursing facilities must apply for eligible Medicare coverage prior to Medicaid coverage. (c) Nursing facilities cannot…

(1) An ICF/IID must comply with the utilization review requirements contained in 42 C.F.R. §§ 456.350-456.438 ("Utilization Review Requirements"). (2) Medicaid or its designee will conduct retrospective audits to ensure the facility complies with the Utilization Review Requiremen…

(1) The admitting or attending physician must certify the necessity of admission of a resident to an intermediate care facility and make a comprehensive medical evaluation, as described in Rule No. 560-X-10-.11(3)(d)3. This evaluation will be maintained by the facility as part of…

The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, specified in 42 CFR 483.10. (1) Exercise of rights. (…

(1) A nursing facility must not use (on a full-time, temporary, per diem, or other basis) any individual as a nurse aide in the facility on or after October 1, 1990, for more than four (4) months unless the individual has completed a training and competency evaluation program, or…

(1) Prior to admission, all individuals seeking admission into a nursing facility must be screened for suspected mental illness (MI), intellectual disability (ID), or a related condition (RC) to determine if the individual's care and treatment needs can most appropriately be met …

(1) The nursing facility shall retain, pursuant to a written agreement, a physician licensed under state law to practice medicine or osteopathy, to serve as medical director on a part-time or full-time basis as is appropriate for the needs of the residents and the facility. (a) I…

Availability of accounting records must be made available in compliance with chapter 22, Alabama Medicaid Administrative Code. Author: Dittra S. Graham, Administrator, LTC Program Management Unit Notes Ala. Admin. Code r. 560-X-10-.18 Rule effective October 1, 1982. Amended: Effe…

(1) The facility must provide routine and emergency drugs and biologicals to its residents. (2) Alabama law prohibits nonlicensed personnel from administering medication. (3) A facility must permit residents to self-administer a drug when the facility determines, in accordance wi…

(1) Nursing facilities located on grounds of state mental hospitals or in the communities must follow the required criteria to meet specific conditions in order to be eligible for federal matching funds for care provided to all individuals eligible under the state plan. (2) The A…

(1) Nursing facilities must monitor the admission of mentally ill residents to their facilities. (a) A nursing facility may not have more than fifty percent (50%) mentally ill residents which is based on the total population of the facility including public and private pay reside…

(1) A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. Factors to be considered include: (a) Dignity (b) Self determination and participation (c) Participation in resident and famil…

(1) The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity as required by 42 C.F.R. § 483.20 and any other applicable state and federal requirements. (2) The 14-day assessment sc…

Each resident must receive the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and plan of care. Each resident must receive and the facility must pro…

(1) The resident has the right to be free from any physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience and not required to treat the resident's medical symptoms. (2) The resident has the right to be free from verbal, sexual, phy…

(1) Definitions. (a) Discharge means movement from an entity that participates in Medicare as a skilled nursing facility (SNF), a Medicare certified distinct part, an entity that participates in Medicaid as a nursing facility (NF), or a Medicaid certified distinct part to a nonin…

The regulations of the Centers for Medicare and Medicaid Services, Department of Health and Human Services at 42 C.F.R. Section 488.400, et seq., as promulgated in 59 Federal Register 56116 (Nov. 10, 1994), and as may be subsequently amended, are adopted by reference. Copies of t…

(1) Financial eligibility will be established in accordance with Chapter 25, Alabama Medicaid Administrative Code. Author: Dittra S. Graham, Administrator, LTC Program Management Unit Notes Ala. Admin. Code r. 560-X-10-.28 Emergency rule: Effective October 1, 1990. Amended: Effec…

For claim filing limitations refer to Alabama Medicaid Administrative Code, Rule No. 560-X-1-.17. Author: Dittra S. Graham, Administrator, LTC Program Management Unit Notes Ala. Admin. Code r. 560-X-10-.29 Emergency rule: Effective October 1, 1990. Amended: Effective February 13,…

Refer to Alabama Medicaid Administrative Code, Chapter 20. Author: Dittra S. Graham, Administrator, LTC Program Management Unit Notes Ala. Admin. Code r. 560-X-10-.30 Emergency rule: Effective October 1, 1990. Amended: Effective February 13, 1991. Amended: Filed August 11, 2003; …

(1) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age twenty-one (21) is a mandatory service of the Medicaid Program intended by Congress to direct attention to the importance of preventive health services and early detection and treatment of…

(1) Early - As early as possible in the life of a child already Medicaid eligible or as soon as possible after a person's eligibility is established, if he or she is under twenty-one (21) years of age; (2) Periodic - At intervals established by Medicaid to assure that disease or …

(1) All persons under twenty-one (21) years of age except SOBRA adult eligibles who have been certified as being eligible for Medicaid are eligible for the EPSDT program. (2) Alabama Medicaid Agency assigns Medicaid identification numbers and issues plastic Medicaid eligibility c…

(1) A manual on the EPSDT Program setting forth in detail the elements of the physical examination, instructions for completion of forms, processes and procedures to follow in administration of local programs and billing instructions will be provided to each EPSDT provider. Failu…

(1) In-state and borderline out-of-state (within 30-mile radius of state line) health care agencies and physicians wishing to participate in the EPSDT Program may request enrollment information from the Alabama Medicaid Agency. Exception: The Fiscal Agent will be responsible for …

(1) The Agency will establish specific health evaluation procedures to be used by screening providers. These procedures and tests will be fully described in the Screening Provider Manual. (2) All procedures and tests included in the Screening Provider Manual must be carried out o…

(1) The Agency will establish a distinct periodicity schedule for screening services, after consultation with recognized medical organizations involved in child health care. This schedule will be published in the Screening Provider Manual. (2) Periodic screening services will be …

(1) Professional nursing staff of the Alabama Medicaid Agency will provide assistance to any screening provider who requests it. (2) The Medicaid staff will assist providers and County Departments of Human Resources with problems in local administration of the EPSDT Program upon …

(1) All participating EPSDT providers will complete the EPSDT Referral for Services form for each individual provider to whom a person is being referred to for further diagnosis and/or treatment. (2) When a screening provider refers a person to a Medicaid participating provider f…

(1) Governmental screening providers (including physicians) will be paid on a negotiated rate basis which will not exceed their actual costs. Nongovernmental screening providers will be paid their usual and customary charge which is not to exceed the maximum allowable rate establ…

(1) Consent for health services for certain minors, and others will be governed by Code of Ala. 1975, Title 22, Chapter 8. (2) All consent forms must be signed by the parent or legal guardian except for clients fourteen (14) years and older who may sign for themselves. Author: La…

(1) Hearing Impaired: (a) Each recipient will be notified of services during a face-to-face verbal interview at which time an individual who communicates via sign language or other methods will be present if needed to pass information to the recipient. (b) Written information wil…

(1) Arrangements have been made with the Clinical Laboratory Administration to have the State Laboratory examine blood specimens for sickle cell anemia and other abnormal hemoglobins, stool specimens for ova and parasites, and scotch tape preparations for pinworms. VDRL, G.C. cul…

(1) OBRA '89 requires that medically necessary health care, diagnosis, treatment and/or other measures described in Section 1905(a) of the Social Security Act be covered under Medicaid if identified in an EPSDT screening whether or not such services are covered in the State Plan.…

(1) Alabama Medicaid Home Health Care services are available for all Medicaid eligible persons of any age who meet the admission criteria on the basis of a reasonable expectation that a patient's medical, nursing, and social needs can adequately be met in the patient's place of r…

(1) To be eligible for home health care, a recipient must meet all of the following criteria: (a) The recipient's illness, injury, or disability prevents the recipient from going to a physician's office, clinic or other outpatient setting for required treatment; as a result, he o…