Ala. Admin. Code r. 560-X-52-.16

Current through Register Vol. 42, No. 10, July 31, 2024

Section 560-X-52-.16 - Application Process

(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 case manager will assist the recipient to make financial application and ensure that the appropriate documents are completed and routed to the appropriate Medicaid District Office if the individual is not already eligible and enrolled in an applicable Medicaid aid category. Financial eligibility must be certified by Medicaid.

(3) The Waiver Coordinator will complete the level of care determination and the case manager will develop the plan of care.

(4) The operating agency is required to adhere to all federal and state guidelines in the determination of the level of care approval.

(5) The operating agency or its designee (case manager), will ensure that the applicant has been screened and assessed to determine if the services provided through the LAH Waiver will meet the applicant's needs in the community.

(6) The Alabama Department of Mental Health (ADMH) 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 Living at Home Waiver.

(7) The Alabama Medicaid Agency will provide to the ADMH/MR the approved Level of Care criteria and policies and procedures governing the level of care determination process.

(8) ADMH/MR may utilize Medicaid staff for consultation on questionable admissions and annual redeterminations prior to a final decision being rendered.

(9) The Alabama Medicaid Agency will conduct a retrospective review on a monthly basis of a random sample of individuals served under the Living at Home 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. The Waiver Quality Assurance Unit conducts a 5% sample of plans of care and related documents annually for each provider.

(10) 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.

(11) The Alabama Medicaid Agency may seek recoupment from ADMH/MR for other services reimbursed by Medicaid for those individuals whom Medicaid determines would not have been eligible for the Living at Home Waiver services or Medicaid eligibility but for the certification of waiver eligibility by ADMH.

(12) The operating agency or its designee will develop a plan of care that includes waiver as well as non-waiver services.

(13) Upon receipt of the financial award letter from the Alabama Medicaid Agency, the LTC Admissions Notification Form should be completed and forwarded to Medicaid's Fiscal Agent electronically. Medicaid's Fiscal Agent will either accept or reject the transmission of the LTC Admissions Notification Form. The operating agency or its designee will receive notice of the status of applications transmitted the next business day following the transmission.

(14) If Medicaid's Fiscal Agent accepts the transmission, the information is automatically written to the Level of Care file. The operating agency or its designee can begin rendering services and billing the Alabama Medicaid Agency for services rendered.

(15) If Medicaid's Fiscal Agent rejects the transmission, the operating agency or its designee must determine the reason for the rejection and retransmit the LTC Admissions Notification Form.

(16) Neither the Alabama Medicaid Agency nor Medicaid's Fiscal Agent will send out the LTC-2 Notification letters. The record of successful transmission will be the record of "approval" to begin rendering service.

(17) For applications where the level of care is questionable, providers may submit the applications to the Long Term Care Quality Assurance Unit for review by a nurse and/or a Medicaid physician.

(18) Once the individual's information has been added to the Level of Care File, changes can only be made by authorized Medicaid staff.

Ala. Admin. Code r. 560-X-52-.16

New Rule: Filed July 14, 2003; effective August 18, 2003. Amended: Filed May 11, 2007; effective June 15, 2007.

Amended by Alabama Administrative Monthly Volume XXXII, Issue No. 09, June 30, 2014, eff. 7/16/2014.

Author: Samantha McLeod, Associate Director, Long Term Care Specialized Waiver Programs

Statutory Authority: Social Security Act §1915(c); 42 C.F.R.

Section 441, Subpart G-Home and Community-Based Services: Waiver Requirements.