Alabama Administrative Code

(1) General - In order for an AFDC-related individual to be eligible for Medicaid, he or she must meet the AFDC financial criteria in effect in 1996. An SSI-related individual or couple must not have total countable resources in excess of $2,000 for an individual or $3,000 for a …

(1) Ownership interest in Real Property -- Establishment of ownership interest may be obtained by: (a) Assessment notice; (b) Recent tax file; (c) Current mortgage statement; (d) Deed; (e) Report of title search; (f) Wills, court records, or relationship documents which show righ…

(1) Cash -- Cash on hand is always counted as liquid resource except when it is a business asset necessary to the operation of a trade or business that is excluded as necessary for self-support or under an approved plan for achieving self-support in the case of the blind or disab…

(1) An individual, or the spouse of such individual, who is an applicant or recipient of either institutional Medicaid or home and community-based waiver services, who transfers an asset at any time on or after the "look-back date", as defined in paragraph (9)(j), for less than f…

(1) The income limit for the institutional Medicaid program and certain home and community-based waiver programs is determined by the Agency and published in the State Plan for Medical Assistance. The income limit is equal to 300 percent of the current SSI benefit amount payable …

(1) In addition to the rules covered in Rules 560-X-25-.05 through .11 the following criteria must also be met for an individual to qualify for Medicaid in a Title XIX institution: (a) The individual must be certified as needing the level of care received in an institution and as…

(1) The earliest date of entitlement for Medicaid is the first day of the month of application for assistance under one of the categorical programs, provided the individual meets all factors of eligibility for that month. The individual who is eligible on the first day of the mon…

For adults in need of protective services (as defined by Code of Ala. 1975, §§ 38-9-2, et seq.), property may be excluded during the period from the date the petition is filed to the date of the court order, but in no event for a period to exceed 120 days. Author: Aljanetta C. Ru…

(1) Pregnant women are defined as "women who are pregnant or post-partum, with household income at or below 141% of the Federal Poverty Level (FPL)". Medicaid coverage under MAGI-related coverage groups is available for pregnant women meeting the requirements listed below: (a) Th…

(1) Parents and Other Caretaker Relatives (POCR) (a) Parents and Other Caretaker Relatives is a Medicaid eligibility coverage group available to parents and other caretaker relatives of dependent children with household income at or below 13% of the federal poverty level (FPL). P…

(1) The Medicare Catastrophic Coverage Act (MCCA) of 1988 provides for the special treatment of income and resources of a married couple. The special treatment is to protect the income and resources for the maintenance needs of the community spouse while the spouse is in a medica…

(1) The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), established the Medicare Prescription Drug Program, also known as Medicare Part D, making prescription drug coverage available to Medicare beneficiaries. The MMA also provides extra help in the f…

(1) Any properly authorized person over 18 years of age may practice before the Agency. This includes, but is not limited to: (a) Attorneys. (b) Accountants. (c) Officers or employees of a provider. (d) An adult friend or relative of a recipient or applicant. (e) The legal guardi…

Any person appearing on behalf of another must have written authority to do so. If the person being represented is unable to sign an authorization, it must be signed by his or her legal guardian, if there is one, or if there is none, then by a member of his or her immediate famil…

Any attorney or public accountant who is under suspension or revocation of his or her license shall not represent any person before the Agency, except members of his or her immediate family, unless and until his or her license is restored. Author: Notes Ala. Admin. Code r. 560-X-…

(1) Information regarding Medicaid applicants and recipients is required to be safeguarded by Section 1902(a)(7) of the Social Security Act (SSA), 42 CFR Part 431 Subpart F, the Health Insurance Portability and Accountability Act (HIPAA), and 45 CFR Part 164 . Confidential materi…

(1) The following materials or categories of information are declared to be confidential and the same shall not be released to persons outside the Medicaid Agency except as noted below: (a) Minutes of the Utilization Review Committee (URC); (b) Claims Processing Manual; (c) Perso…

The following forms are presented as reference and to illustrate examples of official forms referred to within the rules contained in the Alabama Medicaid Agency Administrative Code. Copies of all official forms utilized by the Alabama Medicaid Agency may be obtained free-of-char…

(1) Deciding about your health care. (b) If you are 19 or older, the law says you have the right to decide about your medical care. (c) If you are very sick or badly hurt, you may not be able to say what medical care you want. (d) If you have an advance directive, your doctor and…

The following terms and definitions are presented as reference to accompany and clarify the rules contained in this Administrative Code of the Alabama Medicaid Agency. (1) Abuse - shall be any act or action taken by a recipient or provider which has a detrimental effect upon the …

(1) The State Plan provides that the office of the Governor acting through Medicaid, will be responsible for fulfillment of hearing provisions for all matters pertaining to the Medical Assistance Program under Title XIX. An opportunity for a fair hearing shall be granted to any i…

(1) A fair hearing is a face-to-face hearing by an impartial State Hearing Officer at a time and place reasonably convenient for the complainant and attended by the complainant or his authorized representatives who may call witnesses or examine witnesses called by others. (2) A d…

(1) The procedures contained herein have been adopted by Medicaid to settle formal complaints of persons who are receiving care under the Medicaid program or who have been denied care under this program because of eligibility standards, or for providers who desire a fair hearing …

(1) A hearing shall be impartially conducted and held at a time and place which is reasonably convenient for the parties, and written notice of such time and place shall be given by the Director, Hearings, or the designated Hearing Officer, at least ten (10) calendar days before …

(1) Documentary Hearings are based solely upon the written or printed evidence presented to the Hearing Officer by both the complainant and the agency. Complainants should therefore submit complete records of all claims filed, correspondence, rejections, forms and attachments at …

(1) Prompt, definitive, and final administrative action will be taken within sixty (60) days between the request for a hearing and the rendering of the decision, unless there are extenuating circumstances that require additional time. If the hearing is not completed within 60 day…

(1) If the request tor a hearing, in the opinion of Medicaid legal counsel, presents only a legal issue, and the validity of the controlling law or regulation is not challenged in the hearing request, a fair hearing request may be denied. (2) If eligibility of a provider or a rec…

(1) The commissioner, upon an express finding or determination that there exists an immediate danger to the public health, safety, or welfare, requires adoption of a rule upon fewer than 35 days' notice or that action is required by or to comply with a federal statute or regulati…

During the period that an emergency rule is in effect the Agency shall give notice of and promulgate a permanent rule to replace the emergency rule, unless the emergency rule is one designed to fill a specific need or to solve a specific problem and that need or problem is not ex…

(1) Any person or organization affected by an existing rule or statute governing the Alabama Medicaid program may request a declaratory ruling. (2) The petition for declaratory ruling form found in Chapter 28 must be used. Copies are available from the Agency. (3) If a petition c…

The provisions of Title 42 of the Code of Federal Regulations relating to the Medicaid Program; the Alabama State Plan for Medical Assistance under Title XIX of the Social Security Act; as all of the same may be amended are hereby adopted by reference as a part of this Code. Auth…

(1) A form for petitioning for a new rule, for the repeal of an existing rule, and for the change or modification of a rule is included in Chapter 28. This form must be used. Copies are available from the Agency. (2) Action on such a petition shall be within 60 days of receipt by…

Federal regulations require that the state make provisions for handling of recoupments, estate recoveries and liens. The Alabama Medicaid Agency will actively seek recovery of all misspent Medicaid funds and correctly paid benefits recoverable under federal law. Notes Ala. Admin.…

The purpose of the recoupments, estate recoveries and liens effort is to assure that the state and federal dollars allocated for medical assistance are spent only on those individuals/recipients (hereinafter "recipients") who meet all eligibility criteria; to correct erroneous pa…

Notes Ala. Admin. Code r. 560-X-33-.03 Rule effective October 1, 1982. Repealed by Alabama Administrative Monthly Volume XXXIV, Issue No. 03, December 31, 2015, eff. 1/25/2016. Author: Statutory Authority: Social Security Act, Title XIX; State Plan; 42 C.F.R. Parts 450, 455; Code…

(1) Direct Reimbursement - At the time of original identification of the expected amount of recoupment, a letter will be sent to the recipient/authorized representative or provider outlining the allegations and stating the amount of reimbursement and the specific dates when overp…

(1) Under the estate recoveries provisions in §1917(b) of the Act, the Alabama Medicaid Agency ("Agency") shall seek adjustment or recovery of any medical assistance correctly paid on behalf of the following categories of recipients: (a) Permanently Institutionalized Recipients o…

(1) The Alabama Medicaid Agency ("Agency") will place a lien and may foreclose upon real property of the following recipients to the extent allowed by 42 U.S.C. §1396p: (a) Permanently Institutionalized Recipients of any age who are inpatients in a nursing facility, ICF/IID, or o…

A person aggrieved by a proposed or actual Agency action may request a hearing in accordance with Chapter 3 of the Alabama Medicaid Administrative Code. A recoupment action will not be abated during the time for a requesting a hearing. The Agency may at its discretion suspend a r…

The Alabama Medicaid Agency will pay for services provided by independent radiology facilities that are enrolled by contract under the following conditions: (1) The services must be medically necessary. (2) The patient must be eligible for Medicaid at the time the services are re…

Radiology services are professional and technical radiological services - (a) ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by state law; (b) provided in an office or si…

(1) Independent radiology facilities must meet the following requirements for participation in the Alabama Medicaid Program: (a) Be certified for participation with Medicare. (b) Be independent of any hospital, clinic, or physician's office. (c) Be licensed in the state where loc…

For time limits on claims submission, refer to the Radiology Services Billing Manual. (1) Claims for radiology services must contain a valid diagnosis code. (2) Claims submitted must contain the provider number of the radiology facility that actually performed the service. (3) Cl…

For guidelines on submitting claims to Medicaid when a third party is involved, refer to the Radiology Services Billing Manual. Author: Alabama Medicaid Agency Notes Ala. Admin. Code r. 560-X-34-.05 New Rule: Filed September 8, 1998; effective October 13, 1998. Statutory Authorit…

(1) Providers should not send recipients bills or statements for covered services once the recipient has been accepted as a Medicaid patient. (2) Providers may send a notice to the recipient stating their claim is still outstanding if the notice indicates in bold letters, "THIS I…

(1) Home and Community Based Services (HCBS) for persons with intellectual disabilities are provided by the Alabama Medicaid Agency to persons who are Medicaid-eligible under the Home and Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver) requirements a…

Home and Community-Based Services (HCBS) under the Home and Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver) are defined as Title XIX Medicaid-funded services provided to individuals with intellectual disabilities who, without these services, would re…

Eligibility criteria for Home and Community-Based Services (HCBS) recipients under the Waiver for Persons with Intellectual Disabilities (ID Waiver) shall be the same as eligibility criteria for an intermediate care facility for individuals with intellectual disabilities (ICF/IID…

(1) Generally, persons eligible for the level of care provided in an ICF/IID are those persons who need such level of care because the severe, chronic nature of their mental impairment results in substantial functional limitations in three or more of the following areas of life a…

(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) year…