Alabama Administrative Code

In order to be eligible to elect hospice care under Medicaid, an individual must be: (1) Medicaid eligible for full benefits. (2) Certified by a physician as terminally ill and require hospice services which are medically necessary for the palliation or are medically necessary fo…

(1) If an individual meets the eligibility requirements for hospice care, he or she must file a written election certification statement (Medicaid Hospice Election and Physician's Certification, Form 165) with a particular hospice within two calendar days after hospice care begin…

An individual shall waive all rights to Medicaid services that are covered under Medicare for the duration of the election of hospice care for the following services: (1) Hospice care provided by a hospice other than the hospice designated by the recipient, unless provided under …

(1) An individual or representative may revoke the individual's election of hospice care at any time during an election period. If an individual revokes the hospice election, any days remaining in that election period are forfeited. (2) The hospice shall provide the Alabama Medic…

(1) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received. The change of the designated hospice is not a revocation of the election for the period in which it is made. (2) To ch…

(1) The following services are covered hospice services when provided by qualified personnel: (a) Nursing care (b) Medical social services (c) Physician services (d) Counseling services (e) Short-term inpatient care (f) and biologicals Medical appliances and supplies, including d…

(1) With the exception of payment for direct patient care services by physicians, payment is made to the hospice for all covered services related to the treatment of the recipient's terminal illness for each day during which the recipient is Medicaid eligible and under the care o…

The basic payment rates for hospice care are designed to reimburse the hospice for the costs of all covered services related to the treatment of the beneficiary's terminal illness, including the administrative and general supervisory activities performed by physicians who are emp…

(1) Payment made by the Medicaid program for hospice care services shall be considered payment in full. (2) The patient or responsible party shall not be billed in full or in part for any service reimbursed under any service component of the Medicaid Hospice Care Program. Service…

(1) A third party is another insurance company or agency that may be responsible for paying all or part of the cost for medical services provided to a Medicaid recipient. Some examples of third parties are Medicare, CHAMPUS, CHAMPVA, major medical insurance, dental insurance, can…

(1) The provider of hospice care shall not 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 attorney, or his guardian, or upon subpoena from a …

(1) The provider of hospice care shall furnish the Alabama Medicaid Hospice Care Program with requested information regarding claims submitted to the Medicaid Program and shall permit access to all Medicaid records and facilities for the purpose of claims audit, program monitorin…

(1) Home and Community-Based Services (HCBS) under the Home and Community-Based Living at Home (LAH) Waiver for individuals with intellectual disabilities are provided by the Alabama Medicaid Agency to persons who are Medicaid-eligible under the waiver and who would, but for the …

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

Medical eligibility for HCBS under the LAH Waiver is limited to those individuals that meet the ICF/IID level of care. No HCBS under the LAH Waiver will be provided to a recipient residing in an institutional facility, or who has a primary diagnosis of mental illness, or whose he…

(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…

The financial accountability of providers for funds expended on home and community-based services must be maintained and provide a clearly defined audit trail. Providers must retain records that fully disclose the extent and cost of services provided to eligible recipients throug…

(1) Alabama Medicaid Agency will require an individual plan of care for each waiver 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. The Alabama Medicaid A…

(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) Actual reimbursement will be based on the rate in effect on the date of service. (2) Rates will be established and reported to the Alabama Medicaid Agency's fiscal agent for claims submitted for payment. (3) Payment will be based on the number of units of service reported for…

(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…

(1) Medicaid's fiscal agent enrolls providers of waiver services and issues provider agreements to applicants who meet the licensure and/or certification requirements of the state of Alabama, the Code of Federal Regulations and the Alabama Medicaid Provider Manual. (2) General en…

(1) The cost for services to individuals who qualify for home and community-based care under the waiver program will not exceed a cap of $25,000 per client per year with the exception that crisis intervention services are not included in the cap. Further, the waiver program will …

(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) 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 eligible for waiver services. The target cas…

The Program of All-inclusive Care for the Elderly (PACE) is a unique managed care benefit for the frail elderly population provided by a not-for-profit or public entity. The focus is to assist individuals to continue living independently at home in their communities as long as po…

As used in this Rule, the following definitions apply: (1) PACE - Programs of All-inclusive Care for the Elderly. (2) PACE Organization (PO) - entity that has an agreement with Medicaid and CMS to operate a PACE program. (3) PACE Center - facility operated by a PO where primary c…

(A) General Rule. The PACE program provides for medically necessary services. To enroll in a PACE program, an individual must meet eligibility requirements specified in this section. To continue to be eligible for PACE, an individual must meet the annual recertification requireme…

(A) Enrollment Process (1) Intake Process. Intake is an intensive process during which PACE staff members make one or more visits to a potential participant's place of residence and the potential participant may make one or more visits to the PACE center. At a minimum, the intake…

(A) Voluntary Disenrollment (1) A PACE participant may voluntarily disenroll from the program without cause at any time. (B) Involuntary Disenrollment (1) Reasons for involuntary disenrollment. A participant may be involuntarily disenrolled for any of the following reasons. (a) T…

(1) Services provided under PACE must include all Medicaid and Medicare services and covered items, as well as any services for each participant determined to be necessary by the Interdisciplinary Team. Provided services must include comprehensive medical, health, and social serv…

(1) An initial comprehensive assessment and a detailed written plan of care must be established for each participant immediately upon his or her enrollment in the PACE program. The Interdisciplinary Team is responsible for implementing, coordinating, monitoring, and documenting t…

(1) The Participants Bill of Rights is to be written to promote and protect the rights of participants. Written policies and procedures are to be implemented to ensure that participants, their representatives, and PO staff understand the rights of the participant. Upon enrollment…

(1) An Interdisciplinary Team, comprised of members as listed in §460.102, is to be established for each PACE center. Participants are to be assigned to the Team located at the center he or she attends upon enrollment for an assessment so that the needs of each participant can be…

(1) An entity that wishes to become a PO must complete an application that describes how the entity meets all the requirements to be a PO. The application must be submitted to, and approved by, AMA and CMS. AMA will include an assurance with the application sent to CMS that the e…

(1) A PO must be (or be a distinct part of) an entity of a city, county, state, or tribal government, or a private not-for-profit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986. (2) A Program Director must be employed, or con…

(1) A written marketing plan that includes measurable enrollment objectives and a tracking system for effectiveness must be established and maintained by the PO. (2) Information must be provided to the public regarding the PO and the marketing materials must be free of material i…

(1) A written data-driven plan for the Quality Assessment and Performance Improvement Program must be developed, implemented, and maintained by a PO. The plan must include all services provided by the PO, identify areas for maintaining and improving delivery of services and care,…

(1) Annual reviews of a PO will be conducted by AMA and CMS to ensure compliance. Onsite visits will be conducted every two years at a minimum. The scope of the reviews includes, but not limited to, the following: (a) Onsite visits, including but not limited to1. Review of Partic…

(1) A PO must collect data, maintain records, and submit reports as specified by AMA and CMS in the PACE agreement to enable monitoring of the operation, cost, quality, and effectiveness of the program and establishment of payment rates. (2) Written procedures must be established…

(1) AMA will make a monthly capitation payment to a PO for each Medicaid participant enrolled in the program and will be generated by the Medicaid Management Information System (MMIS). The monthly capitation payment will be a fixed amount, regardless of changes in a participant's…

(1) Penalties and sanctions may be imposed by CMS for a PO if it is determined that the PO has committed any of the violations listed n §460.40. Penalties and/or sanction will be imposed in addition to any other remedies authorized by law. (2) CMS may also elect to suspend the en…

(1) CMS or AMA may terminate a PO agreement at anytime for cause due to, but not limited to, circumstances listed in §460.50 (b) and (c). (2) If CMS or AMA terminates a PO agreement, the PO will first be provided a reasonable opportunity to develop and implement a corrective acti…

(1) Home and community-based services for the Technology Assisted Waiver for Adults are provided by the Alabama Medicaid Agency to individuals with disabilities 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 SSI, SSI related protected groups deemed to be eligible for SSI/Medicaid (widow/widower, Disabled Adult Child, Continuous (Pickle) Medicaid) and special home and community-based optional categorically needy group…

(1) Personal Care/Attendant Services.(a) Personal Care/Attendant Service (PC/AS) provides in-home and out-of-home (job site) assistance with eating, bathing, dressing, caring for personal hygiene, toileting, transferring from bed to chair and vice versa, ambulation, maintaining c…

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…