Ala. Admin. Code r. 560-X-63-.10

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

Section 560-X-63-.10 - Reimbursement And Payment Limitations

(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 resident must be submitted to the Alabama Medicaid Agency in writing for prior approval. Each request must include the pertinent sections of the most current Minimum Data Set (MDS) Resident Assessment and attending physician documentation of the medical condition of the ventilator-dependent or qualified tracheostomy resident. The MDS sections must include, but are not limited to: Section I - Active Diagnoses; Section J - Health Conditions; and Section 0 - Special Treatments, Procedures, and Programs.

(3) The nursing facility will be reimbursed the daily per diem rate determined for the nursing facility plus an additional daily payment for the ventilator-dependent or qualified tracheostomy resident.

(4) The supplemental fee-for-service payment will be $120 and indexed annually in accordance with the cost of living increases as prescribed under Rule No. 560-X-22-.07.

(5) The total payment to the nursing facility will be the daily per diem rate plus the supplemental fee-for-service payment.

(6) In computing the daily per diem rate, (i) costs for supplies directly associated with providing ventilator-dependent or qualified tracheostomy care and (ii) salary, benefits, and payroll taxes or contract expenses associated with engaging respiratory therapists shall be excluded as allowable costs.

(7) No additional amount above the current nursing facility rate will be allowed for the resident until it is determined that both the resident and the nursing facility meet the requirements described in this chapter and prior authorization is issued by the Medicaid Agency.

(8) The supplemental fee-for-service payments will be approved for 12-month intervals.

Ala. Admin. Code r. 560-X-63-.10

New Rule: Filed December 12, 2011; effective January 16, 2012.

Author: Marilyn F. Chappelle, Director, Long Term Division

Statutory Authority: State Plan; Title XIX, Social Security Act; and 42 CFR Section 401, et seq., Section 483.75.