Ala. Admin. Code r. 560-X-57-.04

Current through Register Vol. 43, No. 02, November 27, 2024

Section 560-X-57-.04 - Covered Services

(1) Case Management Services.

(a) Case management is a 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 of the funding source for the services to which access is gained. Case management services may be used to locate, coordinate, and monitor necessary and appropriate services. Case management activities may also be used to assist in the transition of an individual from institutional settings prior to discharge into the community.

(b) Case managers are responsible for Person Centered Care Plan (PCCP) development and ongoing monitoring of the provision of waiver services and nonwaiver services included in the recipient's PCCP.

(c) Case management will be provided by a case manager employed by or under contract with the Department of Rehabilitation Services or any other Medicaid approved provider of waiver services that meets the qualifications of Nurse I or Rehabilitation Counselor.

(2) Personal Care Services.

(a) Personal care services are services that provide assistance with eating, bathing, dressing, personal hygiene and activities of daily living. Services may include assistance with preparation of meals but do not include the cost of meals themselves. When specified in the PCCP, this service may also include such housekeeping chores as bed making, dusting and vacuuming, which are incidental to the care furnished, or which are essential to the health and welfare of the individual, rather than the individual's family. Personal care providers must meet State standards for this service.

(b) Personal care services will be provided by individuals employed by a certified Home Health Agency or other health care agencies approved by the Commissioner of the Alabama Medicaid Agency and supervised by a case manager. Persons providing personal care services must meet the qualifications of a personal care attendant and meet provider performance standards.

(c) Services provided to each client are dependent on individual need as set forth in the client's PCCP. Personal care services may not exceed 25 hours per week and may not exceed 1300 hours per waiver year. Medicaid will not reimburse for activities which are not within the Scope of Services.

(3) Environmental Accessibility Adaptations

(a) Environmental accessibility adaptations provide those physical adaptations to the home required by the individual's PCCP which are necessary to ensure the health, welfare, and safety of the individual or which enable the individual to function with greater independence in the home and without which the individual would require institutionalization. The service may also be provided to assist an individual to transition from an institution to the SAIL Waiver, but should not be billed until the first day the client is active on the waiver. Adaptations may include the installation of ramps and grab-bars and/or the widening of doorways in order to accommodate the medical equipment and supplies which are necessary for the welfare of the individual. Excluded are those adaptations or improvements to the home which are not of direct medical or remedial benefit to the waiver client, such as floor covering, roof repair, central air conditioning, etc. Adaptations which add to the total square footage of the home, any type of construction affecting the structural integrity of the home, changes to the existing electrical components of the home or permanent adaptations to rental property are excluded from this benefit. All services shall be provided in accordance with applicable state or local building codes.

(b) Environmental accessibility adaptations will be provided by individuals capable of constructing or installing the needed apparatus. Any construction/installation completed must be in accordance with state and local building codes.

(c) Environmental accessibility adaptations must be prior authorized and approved by the Alabama Medicaid Agency or its designee for prior authorization and must be listed on the client's PCCP. Any expenditure in excess of the maximum allowed amount must be approved by the State Coordinator and the Medicaid designated personnel.

(4) Personal Emergency Response System.

(a) Personal Emergency Response System (PERS) is an electronic service which enables certain high-risk patients to secure help in the event of an emergency. The client may also wear a portable "help" button which will allow for mobility. The system is connected to a patient's phone and programmed to signal a response center once a patient's "help" button is activated.

(b) PERS must be provided by trained professionals. The PERS staff must complete a two-week training period for familiarization with the monitoring system and proper protocol to provide appropriate response action.

(c) Initial setup and installation of PERS must be on the individual's PCCP, prior authorized and approved by the Alabama Medicaid Agency or its designee.

(5) Medical Supplies.

(a) Medical supplies include devices, controls, or appliances, specified in the PCCP, which enable individuals to increase their ability to perform activities of daily living, to maintain health and safety in the home environment, or to perceive, control, or communicate with the environment in which they live. All waiver medical supplies must be prescribed by a physician, be medically necessary and be specified in the PCCP.

(b) Providers of this service will be only those who have signed provider agreements with the Alabama Medicaid Agency and the Department of Rehabilitation Services.

(c) Medical supplies service shall not exceed $2,100.00 annually per recipient.

(6) Minor Assistive Technology

(a) Minor Assistive Technology (MAT) includes supplies, devices, controls or appliances, specified in the PCCP, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control or communicate with the environment in which they live. All MAT supplies must be prescribed by a physician, be medically necessary and be specified in the PCCP. Minor Assistive Technology is necessary to maintain the recipient's health, safety and welfare and to prevent further deterioration of a condition.

(b) Providers of this service will be those who have a signed provider agreement with the Alabama Medicaid Agency and the Department of Rehabilitation Services. Vendors providing MAT/devices should be capable of supplying and providing training in the use of the minor assistive technology/device.

(c) MAT shall not exceed the designated amount of $500.00 per recipient per waiver year.

(7) Assistive Technology.

(a) Assistive technology includes devices, pieces of equipment or products that are modified or customized which are used to increase, maintain or improve functional capabilities of individuals with disabilities. It also includes any service that directly assists an individual with a disability in the selection, acquisition or use of an assistive technology device. Such services may include evaluation of need, acquisition, selection, design, fitting, customizing, adaptation, application, etc. This service must be listed on the individual's PCCP. Items reimbursed with waiver funds shall be in addition to any medical equipment furnished under the State Plan and shall exclude those items which are not of direct medical or remedial benefit to the recipient. The service must be medically necessary to prevent institutionalization or to assist an individual to transition from an institutional level of care to the SAIL Waiver. If the individual fails to transition to the SAIL Waiver, reimbursement will be at the administrative rate. All items shall meet applicable standards of manufacture, design and installation.

(b) Assistive technology and transitional assistive technology services must be prior authorized and approved by the Alabama Medicaid Agency, or its designee and must be listed on the client's PCCP.

(c) Assistive technology services will be provided by licensed individuals or businesses capable of supplying the needed equipment and/or supplies. Assistive technology must be approved by the Alabama Medicaid Agency and must be listed in the individual's PCCP. Providers of this service will be those who meet provider qualifications and who have a signed provider agreement with the Alabama Department of Rehabilitation Services. Upon completion of the service, the client must sign and date a form acknowledging receipt of the service.

(8) Assistive Technology Repairs

(a) Assistive technology repairs will provide for the repair of devices, equipment, or products that were previously purchased by the Alabama Medicaid Agency for the recipient. Repairs include replacement of parts or batteries to allow the equipment to operate.

(b) The provider should be responsible for replacement or repair of the equipment or any part thereof that is found to be nonfunctional because of faulty material or workmanship within the guarantee of the manufacturer without any charge to the recipient or the Alabama Department of Rehabilitation Services. Repairs outside the warranty period will be reimbursed by the operating agency.

(c) Businesses providing this service will possess a business license and also be required to give a guarantee on work performed.

(d) This service must be listed on the recipient PCCP before being provided.

(e) The maximum amount for this service is $2000.00 per recipient annually.

(9) Evaluation for Assistive Technology

(a) Evaluation for assistive technology will provide evaluations and determinations of a client's needs for equipment prescribed by a physician to promote health, safety, and prevent institutionalization or to assist an individual to transition from an institutional level of care to the SAIL Waiver. If the individual fails to transition to the SAIL Waiver, reimbursement will be at the administrative rate.

(b) The individual providing evaluation must be a physical therapist licensed to do business in the State of Alabama and enrolled as a provider with the Alabama Department of Rehabilitation Services. The physical therapist should not have any financial or other affiliation with a vendor, manufacturer, or manufacturer's representative of assistive technology equipment/devices.

(c) A written copy of the physical therapist's evaluation must accompany the prior authorization request and a copy must be kept in the recipient's file. This service must be listed on the recipient's PCCP before being provided.

(10) Personal Assistance Service

(a) Personal assistance services (PAS) are a range of services provided by one or more persons designed to assist an individual with a disability to perform daily activities on and off the job. These activities would be performed by the individual if that person did not have a disability. Such services shall be designed to increase the individual's independence and ability to perform everyday activities. This service will support that population of individuals with physical disabilities who need services beyond personal care and primarily those seeking competitive employment either in their home or in an integrated work setting.

(b) Personal assistance services will be provided by a personal care attendant under the supervision of a registered nurse who meets the Personal Assistance Service staffing requirements. Individuals providing personal care services must meet the qualifications of a personal care attendant and meet provider performance standards.

(11) Unskilled Respite Care

(a) Unskilled Respite Care is provided to individuals unable to care for themselves and is furnished on a short-term basis because of the absence of or need for relief of those persons normally providing care.

(b) Unskilled Respite Care is provided for the benefit of the client and to meet client needs in the absence of the primary caregiver(s) rather than to meet the needs of others in the client's household.

(c) The use of Unskilled Respite Care is based on the needs of the individual client as reflected in the PCCP.

(12) Pest Control. Pest Control Service is the chemical eradication of pests by a professional in a waiver participant's primary residence, the presence of which may limit or prevent the service providers from entering the setting to deliver other critical waiver services.

(1) Pest control services may be provided in a waiver participant's primary residence, which is limited to:

(a) A Participant living in his/her own private house or apartment and who is responsible for his/her own rent or mortgage; or

(b) A participant living with a primary caregiver.

(2) Pest Control Services include the following activities:

(a) Assessment or inspection

(b) Application of Chemical based pesticide

(c) Follow up visit

(3) Pest control services is limited to one series of treatments per lifetime by a licensed and certified pest control company and excludes lodging during the chemical eradication process, all associated preparatory housework, and the replacement of household items. Additional treatments may be approved if the lack of such treatments would jeopardize the participant's ability to live in the community. If additional treatments are needed, the State will evaluate that participant's living situation to determine if the community arrangement is appropriate and supports their health and safety. Limits on Pest Control Services are $3,500 per waiver participant.

Ala. Admin. Code r. 560-X-57-.04

Emergency rule effective April 1, 1992. Permanent rule effective June 12, 1992. Amended: Filed January 5, 1994; effective February 10, 1994. Amended: September 6, 1996; effective October 12, 1996. Amended: File May 11, 2001; effective June 15, 2001. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed March 14, 2007; effective April 18, 2007. Amended: Filed November 9, 2007; effective December 14, 2007. Amended: Filed August 11, 2008; effective September 15, 2008. Amended: Filed May 12, 2009; effective June 16, 2009.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 01, October 30, 2020, eff. 12/14/2020.

Amended by Alabama Administrative Monthly Volume XL, Issue No. 08, May 31, 2022, eff. 7/15/2022.

Author: Keisha Hawkins, Administrator, LTC Healthcare Reform Unit

Statutory Authority:42 C.F.R. § 441, Subpart G and the Home and Community-Based SAIL Waiver.