Alabama Administrative Code

Children's Specialty Clinic Services are specialty-oriented services that are provided by an interdisciplinary team to children who are eligible for EPSDT services and are experiencing developmental problems. Children's Specialty Clinic Services means preventive, diagnostic, ther…

(1) Eligible persons may receive Children's Specialty Clinic Services through providers who are under contractual agreement with Medicaid to provide services to children eligible for EPSDT services. (2) Providers under this section are clinics that are organized apart from any ho…

(1) All persons under twenty-one (21) years of age who have been certified as being eligible for Medicaid, who are eligible for EPSDT services, and are experiencing developmental problems are eligible for Children's Specialty Clinic Services. (2) Alabama Medicaid Agency Administr…

(1) Children's Specialty Clinic Services do not include services that have been rendered under other Medicaid programs. (2) Children's Specialty Clinic Services are covered when provided by a Medicaid enrolled children's specialty clinic provider. (3) Covered children's specialty…

(1) Children's Specialty Clinics will be reimbursed by as follows: (a) Governmental providers will be reimbursed by an encounter rate based on reasonable allowable costs, as defined by OMB Circular A-87, and established by the Medicaid Agency based on completion of the required c…

(1) Medicaid recipients shall not be required to pay and providers may not collect a copayment for any of these services. Refer to Rule No. 560-1-X-.25(3) for copay information. Author: Notes Ala. Admin. Code r. 560-X-61-.06 New Rule: Filed April 8, 1996; effective May 13, 1996. …

(1) Eligible Medicaid recipients are not to be billed for covered services once the recipient has been accepted as a Medicaid patient. (2) The provider is responsible for any follow-up with the fiscal agent or Medicaid on denied claims. (3) The recipient is not responsible for an…

(1) The provider shall not disclose, except to duly authorized representatives of federal or state agencies, any information concerning an eligible recipient except upon written consent of the recipient, his attorney, or his/her guardian, or upon subpoena from a court of appropri…

(1) The provider shall make available to the Alabama Medicaid Agency at no charge all information regarding claims for services provided to eligible recipients. The provider shall permit access to all records and facilities for the purpose of claim audit, program monitoring, and …

(1) Every person or entity who is operating or may operate as a Collaborator shall possess a certificate (Certificate to Collaborate) issued by the Medicaid Agency qualifying such person or entity to collaborate as set forth in Section 22-6-163 of the Code of Ala. 1975. A Collabo…

(1) The Medicaid Agency shall actively monitor and supervise the collective negotiations, bargaining, and cooperation among Collaborators that have been issued Certificates to Collaborate by the Medicaid Agency and Regional Care Organizations (RCOs) in accordance with Sections 22…

(1) A regional care organization and an organization with probationary regional care organization certification shall have a governing board of directors composed of the following members: (a) Twelve members shall be persons representing risk-bearing participants in the regional …

A citizens' advisory committee shall advise the organization on ways the organization may be more efficient in providing quality care to Medicaid beneficiaries. In addition, an advisory committee shall carry out other functions and duties assigned to it by a regional care organiz…

(1) An organization may receive probationary certification as a regional care organization (Probationary Certification) upon submission of an application to the Medicaid Agency that satisfies the requirements of the Medicaid Administrative Code and Sections 22-6-150, et seq., Cod…

(1) The Medicaid Agency shall actively monitor and supervise the collective negotiations, bargaining, and cooperation among Collaborators as defined in Section 22-6-150(4) of the Code of Ala. 1975, and each organization that receives probationary certification as a regional care …

(1) The Medicaid Agency may contract for specific case-management services with an organization that the Medicaid Agency has granted probationary regional care organization certification on such terms and conditions required by the Medicaid Agency. (2) Probationary certified regi…

(1) A regional care organization (RCO) and an organization with probationary RCO certification shall adopt a conflict of interest policy for directors and officers. The conflict of interest policy shall require all directors and officers of conduct their activities as directors o…

(1) Each regional care organization shall create a provider standards committee which shall review and develop the performance standards and quality measures required of a provider by the regional care organization. (2) The performance standards reviewed and developed by a provid…

(1) In accordance with Section 22-6-153(c) of the Alabama Code, the minimum fee-for-service reimbursement rates that a regional care organization shall pay providers for applicable Medicaid services provided to a Medicaid beneficiary shall be the prevailing Medicaid fee-for-servi…

(1) All provider contracts of an organization granted probationary or final certification as a regional care organization shall be subject to review and/or approval of the Medicaid Agency. (2) Any Medicaid provider who is dissatisfied with any term or provision of the agreement o…

(1) Definitions - As referenced in this Chapter of the Alabama Medicaid Administrative Code the following terms shall be defined as follows: (a) Primary medical provider (PMP) is defined as one of the following: 1. Family practitioner 2. Federally Qualified Health Center 3. Gener…

(1) Pursuant to Section 22-6-154, Code of Ala. 1975, the Medicaid Agency shall have a quality assurance committee appointed by the Medicaid Commissioner. (a) The members of the committee shall serve two-year terms. (b) At least 60 percent of the members shall be physicians who pr…

(1) The Medicaid Agency shall have a regional care organization performance monitoring and improvement process that includes at a minimum: (a) The review of monthly, quarterly and annually-reported quality and performance data, including outcomes and quality measures adopted by t…

(1) The certificate of an organization as a probationary regional care organization or as a full regional care organization (referred to collectively hereafter in this rule as "certificate") may be terminated by the Medicaid Agency, in its sole discretion, for nonperformance of c…

(1) Subject to Section 22-6-159(c), Code of Ala. 1975, each organization with probationary regional care organization certification ("probationary RCO") shall, not later than October 1, 2015, have demonstrated to the Medicaid Agency's approval that it has met or will meet the sol…

(1) Each regional care organization ("RCO") shall provide to the Medicaid Agency a periodic financial report setting forth information concerning the RCO's restricted reserves, capital and surplus, and such other information as the Medicaid Agency may require, in such form and co…

(1) A regional care organization ("RCO") shall be deemed to be in a hazardous financial condition if the continued operation of the RCO is determined by the Medicaid Agency to be hazardous to the RCO's enrollees, participating providers, or the State. The Medicaid Agency may in i…

(1) An organization seeking full certification as a regional care organization (referred to herein also as "applicant") shall be incorporated as a nonprofit corporation under Alabama law. The certificate of formation of the organization shall mandate that: (a) No part of the orga…

(1) A regional care organization (RCO) with a grievance concerning the Medicaid Agency as addressed in Section 22-6-153(e) of the Alabama Code, shall abide by the following procedures. (2) For the purposes of this rule, a "RCO grievance" means any dispute or claim of a RCO agains…

(1) Duty to Provide Information to Enrollees and Potential Enrollees (a) Regional Care Organizations and alternate care providers (hereinafter collectively referred to as "organizations") shall adopt policies and procedures designed to clearly and thoroughly explain the process t…

(1) Each organization that intends to enter into a risk contract with the Medicaid Agency shall be subject to a readiness assessment period. The readiness assessment period shall commence on January 1, 2015 and shall conclude with the Medicaid Agency's award or denial of full reg…

(1) This rule is promulgated pursuant to Section 22-6-153(d) of the Code of Ala. 1975, to establish a grievance and appeal system consisting of a grievance process, appeal process, and access to the Medicaid Agency's fair hearing system (the "grievance system") for enrollees in a…

(1) Bases for Imposition of Sanctions on RCOs. The Medicaid Agency may impose sanctions on a regional care organization ("RCO") if the Medicaid Agency determines in its sole discretion that the RCO has violated an applicable federal or state law or regulation, the Alabama Medicai…

(1) The proceeds of a surplus note issued by an RCO in compliance with this rule shall be eligible to be reported as capital or surplus or restricted reserves required by Rule No. 560-X-62-.16. Such a surplus note shall not be treated as a liability of the RCO for purposes of a d…

(1) The Medicaid Agency shall actively monitor and supervise each regional care organization's ("RCO") activities including, but not limited to, key staffing, governance, provider services and materials, network adequacy, claims processing and payment, solvency, financial, care c…

(1) The Medicaid Agency shall follow the procedures outlined in this Rule in the event any of the following occurs: (a) A regional care organization with probationary or full certification (collectively referred to as RCOs) has its certification terminated in a Medicaid region; (…

(1) Nursing Facility - An institution which is licensed by the Alabama State Board of Health as a nursing facility and is primarily engaged in providing nursing care and related services for residents who require medical and nursing care, rehabilitation services for the rehabilit…

(1) A supplemental fee-for-service payment will be paid to Medicaid-certified nursing facilities that provide care to Medicaid eligible ventilator-dependents- and/or qualified tracheostomy residents. (2) The supplemental fee-for-service payment will promote quality care and ensur…

(1) (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 XVIIII of th…

(1) Admission is limited to ventilator-dependent and/or qualified tracheostomy residents. (2) The ventilator-dependent resident and/or qualified tracheostomy resident must meet the current nursing facility level of care criteria established by Medicaid. (3) All of the following c…

(1) All nursing facilities that desire to receive a supplemental fee-for-service payment for providing services to ventilator-dependent and/or qualified tracheostomy Medicaid residents must execute an Addendum to the current Nursing Facility Provider Agreement with the Alabama Me…

In addition to the requirements described in Rule No. 560-X-.63 -.05 above, the nursing facility that desires to receive a supplemental fee-for-service payment for ventilator-dependent and/or qualified tracheostomy residents must: (1) Be enrolled as a Medicaid-certified facility.…

The nursing facility must meet the following quality standards established by the Alabama Medicaid Agency: (1) Staffing levels that correlate with the number of ventilator-dependent residents. (2) Respiratory therapy staff available in-house 24 hours a day-employee or contractual…

(1) Each nursing facility must ensure that the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being are provided to the resident, in accordance with the comprehensive assessment and plan of care. Notes Ala. Admin. …

(1) The Alabama Medicaid Agency will not limit participation to any nursing facility that desires to provide services to ventilator-dependent or qualified tracheostomy residents unless the following conditions exist: (a) Termination of the nursing facility's Medicaid certificatio…

(1) The nursing facility daily per diem rate will continue to be made in accordance with Chapter 22, Nursing Facility Reimbursement of the Alabama Medicaid Administrative Code. (2) The request for additional reimbursement for a ventilator-dependent or qualified tracheostomy resid…

For claim filing limitations refer to Alabama Medicaid Administrative Code, Rule No. 560-X-1-.17. Notes Ala. Admin. Code r. 560-X-63-.11 New Rule: Filed December 12, 2011; effective January 16, 2012. Author: Marilyn F. Chappelle, Director, Long Term Care Division Statutory Author…

Notes Ala. Admin. Code r. 560-X-64-.01 Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 09, June 30, 2016, eff. 7/25/2016. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 09, June 29, 2018, eff. 7/26/2018. Author: Stephanie Lindsay, Administrat…

Notes Ala. Admin. Code r. 560-X-64-.02 Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 09, June 30, 2016, eff. 7/25/2016. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 09, June 29, 2018, eff. 7/26/2018. Author: Stephanie Lindsay, Administrat…

(1) An Integrated Care Network (ICN) shall have a governing board of directors composed of the following members: (a) Sixty percent (60%) of the members shall be persons representing risk-bearing participants in the ICN. A participant bears risk by contributing cash, capital, or …