Alabama Administrative Code

(1) The provider must submit adequate cost data based on financial and statistical records which can be verified by qualified auditors. The cost data must be presented on the accrual basis of accounting. This basis requires that revenue must be allocated to the accounting period …

(1) Personal Fund Management. In accordance with Federal Regulations for Medicare and Medicaid Facilities, a Medical Assistance resident may manage his personal affairs unless a facility accepts the resident's delegation of this responsibility. A resident managing his personal af…

(1) Audit adjustments will be paid or collected by a combination of (a) changing the per diem rate of the facility and (b) a lump sum settlement for the amount under/overpaid for the period prior to the effective date of the per diem rate change. (2) Under/Overpayment situations …

(1) Facility administrators who disagree with the findings of the Medicaid desk audits or field audits may request, in writing, an informal conference at which they may present their positions. Such written requests must be received by Medicaid within thirty (30) days of the date…

(1) Whenever an overpayment of Medicaid reimbursement received by a provider from Medicaid results from the negligence or intentional disregard of Medicaid Reimbursement Principles by the provider or its representatives (but without intent to defraud), there will be deducted from…

(1) Cost Report Preparers. "Cost Report Preparer" includes any person (including a partnership or corporation) who, in return for compensation, prepares or employs another to prepare all or a substantial portion of a Medicaid cost report. A Cost Report Preparer can include both t…

(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 Services Community Waiver Program (CWP) for Persons with Intellectual Disabi…

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

Eligibility criteria for Home and Community-Based Services (HCBS) recipients under the Community Waiver Program (CWP) for Persons with intellectual disabilities shall be the same as eligibility criteria for an intermediate care facility for individuals with intellectual disabilit…

(1) Generally, persons eligible for the level of care provided in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) are those persons who need such level of care because the severe, chronic nature of their mental impairment results in substant…

(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…

(1) Alabama Medicaid Agency will require an individual plan of care for each waivered 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. Client assessment pr…

(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 …

(1) The Medicaid reimbursement for each service provided by a mental health service provider shall be based on a fee-for-service system. Each covered service is identified on a claim by a procedure code. (2) Providers should bill no more than one month's services on a claim for a…

Providers shall make all reasonable efforts to determine if there is a liable third-party source, including Medicare, and in the case of a liable third-party source, utilize that source for payments and benefits prior to applying for Medicaid payments. Third party payments receiv…

(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 thi…

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 …

(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 audi…

The Home and Community-Based CWP Waiver is a cooperative effort between the Alabama Medicaid Agency and the Department of Mental Health. Notes Ala. Admin. Code r. 560-X-43-.13 Adopted by Alabama Administrative Monthly Volume XL, Issue No. 06, March 31, 2022, eff. 5/15/2022. Amend…

(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 cost 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. N…

(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, o…

(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…

(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 who…

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). Notes Ala. Admin. Code r. 560-X-44-.03 Rule effective October 12, 1988. Amended: Filed …

(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 …

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…

(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…

(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 Medi…

(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…

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 …

(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 …

The Home and Community-Based Services Alabama Community Transition Waiver is a cooperative effort between the Alabama Medicaid Agency and the operating agency. Notes Ala. Admin. Code r. 560-X-44-.11 New Rule: Filed February 10, 2012; effective March 16, 2012. Amended by Alabama A…

(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 …

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 e…

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 ou…

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. Notes Ala. Admin. Code r. 560-X-45-.03 Amended by Alabama Administrative Monthly Volume XXXIII, …

(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 N…

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 ind…

(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. Notes Ala. A…

(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 r…

(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 …

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 m…

(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…

(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 d…

(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 …

(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 accommodati…

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 Notes Ala. Admin. Code r. 560-X-46-.06 Emergency rule effective March 30, 1989. Permanent rule …

(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 t…

(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…