Ala. Admin. Code r. 560-X-44-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-44-.06 - Application Process

(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 plan to transition into the community, the transition coordinator will thoroughly review the referrals and intake information.

(3) An initial assessment will be completed by the transition coordinator in conjunction with the applicant's physician. This document will reflect detailed information regarding social background, preferences living conditions, and medical issues of the applicant. A copy of this document will be submitted to the operating agency for approval.

(4) The case manager, in conjunction with the applicant's physician, client and/or caregiver will develop a Plan of Care. The Plan of Care will include objectives, services, provider of services, and frequency of service. Changes to the original Plan of Care are to be made as needed to adequately care for an individual. Reasons for changes must be documented on the client's Plan of Care which is subject to the review of the Alabama Medicaid Agency. The Plan of Care must be reviewed by the case manager as often as necessary and administered in coordination with the recipient's physician.

(5) The Alabama Medicaid Agency has delegated the medical level of care determination to qualified trained individuals at the operating agency.

(6) The Alabama Medicaid Agency requires the operating agency to submit an application in order to document dates of service provision to long term care recipients.

(a) The long-term care software maintains these dates of service.

(b) The applications will be automatically approved through systematic programming.

(c) Medicaid will perform random audits on a percentage of records to ensure that documentation supports the medical level of care criteria, physician certification, as well as other state and federal requirements.

(7) The operating agency is responsible for the assessment, evaluation of admissions, readmissions, and annual redeterminations for eligible participants receiving home and community-based services in accordance with the provisions of the ACT Waiver.

(8) The Alabama Medicaid Agency will provide to the operating agency the approved level of care criteria and policies and procedures governing the level of care determination process.

(9) The operating agency will designate a qualified medical professional to approve the level of care and develop the Plan of Care.

(10) Admissions, readmissions and annual redeterminations must be certified by a physician licensed to practice in Alabama.

(11) The Alabama Medicaid Agency will conduct a monthly retrospective review of a random sample of individuals served under the ACT Waiver to determine appropriate admissions and annual redeterminations. This review includes whether appropriate documentation is present and maintained and whether all state and federal medical necessity and eligibility requirements for the program are met.

(12) The Alabama Medicaid Agency will initiate recoupment of payment for services when it determines that state and federal, medical necessity, and eligibility requirements are not met.

(13) The Alabama Medicaid Agency may seek recoupment from the operating agency for other services reimbursed by Medicaid for those individuals whom Medicaid determines would not have been eligible for ACT Waiver services or Medicaid eligibility but for the certification of waiver eligibility by the operating agency.

Ala. Admin. Code r. 560-X-44-.06

Rule effective October 12, 1988. Amended: Filed July 6, 1995; effective August 12, 1995. Emergency Rule effective October 1, 1996. Amended: Filed December 9, 1996; effective January 14, 1997. Repealed: Filed January 9, 2004; effective February 13, 2004. New Rule: Filed February 10, 2012; effective March 16, 2012.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 08, May 31, 2018, eff. 6/25/2018.

Author: Ginger Wettingfeld, Director, LTC Healthcare Reform

Statutory Authority:42 CFR Section 441, Subpart G and the ACT Waiver.