Ala. Admin. Code r. 262-X-11-.01

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

Section 262-X-11-.01 - Sexual Assault Examination Payment Program

Program Description: This section provides for payment of the initial forensic examination which is performed on victims of sexual violence for the purpose of obtaining evidence to potentially pursue criminal charges against sexual assault offenders and for the prevention and treatment of sexually transmitted infections. Adult and child sexual assault examinations may be paid pursuant to the below sections.

(1) AUTHORITY

(a)Code of Ala. 1975, § 15-23-5(24) (1995), which provides:

1. The commission shall have all the powers and privileges of a corporation and all of its business shall be transacted in the name of the commission. In addition to any other powers and duties specified elsewhere in this article, the commission shall have the power to: Provide for the cost of medical examinations for the purpose of gathering evidence and treatment for preventing sexually tranmitted infections in sexual abuse crimes and offenses.

(2) DEFINITIONS

(a) Sexual Assault Nurse Examiner: a registered nurse who has received specialized training or certification that qualifies him/her to conduct sexual assault examinations for adult and child victims of sexual assault for the purpose of gathering and preserving evidence for potential use in a criminal prosecution. A Sexual Assault Nurse Examiner may also administer prophylaxis against sexually transmitted infections.

(b) Sexual Assault Examination: a physical examination performed by a registered nurse or physician in a hospital or medical clinic or a Sexual Assault Nurse Examiner in a SANE facility on adult victims of sexual assault for the purpose of gathering and preserving evidence for potential use in a criminal prosecution and the treatment and prevention of sexually transmitted infections.

(c) Sexual Assault Nurse Examiner Fee: Fee paid for the professional services of a Sexual Assault Nurse Examiner.

(d) SANE Facility: A community or hospital-based program that provides for the collection and preservation of evidence in cases of sexual violence, as well as the treatment and prevention of sexually transmitted infections in a compassionate, victim-sensitive setting.

(e) Child Sexual Assault Examination: a physical examination performed by a registered nurse or physician in a hospital or medical clinic or a Sexual Assault Nurse Examiner in a SANE facility on a child victim of sexual assault who is less than eighteen years of age for the purpose of gathering and preserving evidence for potential use in a criminal prosecution and the treatment and prevention of sexually transmitted infections.

(3) COLLATERAL SOURCE

(a) Any expense associated with a sexual assault examination covered or paid by a collateral source will not be reimbursed by the Commission.

(b)Code of Ala. 1975, § 15-23-3(13) (1995) defines collateral source as follows:

1. COLLATERAL SOURCE. Source of income, financial or other benefits or advantages for economic loss other than the compensation paid by the compensation commission which the claimant has received or is entitled to receive or is readily available to the claimant, from any one or more of the following:

(i) The offender.

(ii) The government of the United States or any agency thereof, in the form of benefits, such as Social Security, Medicare and Medicaid, a state or any of its political subdivisions or an instrumentality of two or more states, unless the law providing for the benefits or advantages makes them excessive or secondary to benefits under this article.

(iii) Any temporary nonoccupational disability insurance.

(iv) Workers' compensation.

(v) Wage continuation programs of any employer.

(vi) Proceeds of a contract of insurance payable to the claimant for loss which the victim sustained because of the criminally injurious conduct.

(vii) A contract providing prepaid hospital and other health care services or benefits for disability.

(c) Any collateral source available for the payment of a sexual assault examination must be utilized prior to submitting a sexual assault examination to the Commission's Sexual Assault Examination Payment Program.

1. A hospital, medical clinic, or SANE facility should not bill the victim of sexual violence for the sexual assault examination. Alabama Attorney General Troy King's Protocol for the Examination and Treatment of Victims of Sexual Assault states "victims should not be billed for sexual assault examinations." Alabama Attorney General Troy King's Protocol for the Examination and Treatment of Victims of Sexual Assault, page 20.

(4) ELIGIBILITY AND PAYMENT PROCEDURES

(a) Sexual assault examinations performed on or after July 27, 1995, may be considered for payment.

(b) Exams Performed in Hospitals and Medical Clinics

1. Sexual assault examinations performed by a registered nurse or physician in a hospital or medical clinic for the purpose of gathering evidence and treating and preventing sexually transmitted infections will be considered for payment.

(i) Hospitals and medical clinics must submit the current version of an UB form, itemized bill, and medical records.

2. Sexual assault examinations performed in a hospital or medical clinic will be reviewed to determine the reasonableness and eligibility of the charges.

(i) If after the Commission's review of the charges, they are found to be charged at an excessive rate and/or not rendered for the purpose of gathering evidence and/or treating and preventing sexually transmitted infections, the charges will be denied for payment.

3. If after the Commission's review of the charges, it is determined that they do not comply with the Alabama Attorney General's Protocol for the Examination and Treatment or Victims of Sexual Assault, the charges will be denied for payment.

(c) Exams Performed by a Sexual Assault Nurse Examiner (SANE) .

1. Each itemized bill or statement for a sexual assault examination will be considered for payment in the order that it is received.

2. Each itemized bill or statement will be reviewed for accuracy and to determine the appropriate payment category. The itemized bill or statement will be paid based upon the payment category the Commission determines is appropriate.

3. The Commission will provide reimbursement for "Jane Doe" sexual assault examinations performed on adult victims.

4. The Commission will not reimburse for "Jane Doe" sexual assault examinations for children.

5. Each itemized bill or statement must identify the International Classification of Diseases (ICD-9) code.

6. Each billed procedure, service or supply/ medication must be itemized.

7. Each billed procedure, service or supply/ medication must include the appropriate Physicians' Current Procedural Terminology (CPT) code.

8. The initial forensic examination will be considered for payment. Only services rendered and medications provided "for the purpose of gathering evidence and treatment for preventing sexually transmitted infections in sexual abuse crimes and offenses" will be considered pursuant to the Commission's Sexual Assault Examination Payment Policy.

9. Each itemized bill or statement must include a copy of the completed Sexual Assault Information Form (AL102) that is included in the State of Alabama Collection Kit provided by the Alabama Department of Forensic Sciences or equivalent documentation. Alabama Department of Forensic Sciences provides collection kits free of charge and payment will not be provided for the kits.

10. Signed, written confirmation from an employee of the SANE facility that the sexual assault was reported to the Department of Human Resources (DHR) or law enforcement must be provided in cases in which the victim is a minor. If confirmation is not received, the sexual assault examination will not be considered for payment.

(d) Referrals from Hospitals and Medical Clinics

1. When a hospital or medical clinic refers a victim of sexual violence to a SANE facility, the SANE facility will be paid for the cost of the sexual assault examination.

2. When a hospital or medical clinic and a SANE facility perform a sexual assault examination for the same incident, the SANE facility will be paid for the cost of the sexual assault examination. If the hospital or medical clinic administered medication and the SANE facility did not administer medication, the hospital or medical clinic may be paid the difference between the cost of an exam with medication and the cost of an exam without medication for the appropriate payment category.

3. The Commission will not pay a hospital or medical clinic and a SANE facility a duplicate fee for the same incident through the Sexual Assault Examination Payment Program.

(5) COLLECTION OF EVIDENCE WITHIN 72 HOURS

(a) If it is determined that the sexual assault took place more than 72 hours prior to the sexual assault examination, the use of an evidence collection kit may not be necessary. Alabama Attorney General' Alabama Protocol for the Examination and Treatment of Victims of Sexual Assault.

1. The reasonableness of the charges for sexual assault examinations performed after 72 hours will be determined on a case-by-case basis.

(i) The age, mental capacity, and the victim's ability to seek a sexual assault examination within 72 hours of the assault will be considered when making a determination regarding the reasonableness of a sexual assault exam performed more than 72 hours after the sexual assault.

(6) INELIGIBLE EXPENSES

(a) The following expenses are not eligible pursuant to the Commission's Sexual Assault Examination Payment Program:

1. treatment for injuries;

2. medication for any purpose other than the treatment and prevention of sexually transmitted infections;

3. hospital admissions.

(b) All sexual assault victims should be provided a crime victims' compensation application. Expenses that are ineligible pursuant to the Commission's Sexual Assault Examination Payment Program may be eligible for crime victims' compensation benefits.

(7) FALSE REPORTS

(a) The Commission will not compensate for a sexual assault examination if it is determined that a rape or sexual assault did not occur. Examples of false reports include, but are not limited to, consensual sexual contact and no sexual contact.

(8) SEXUAL ASSAULT EXAMINATIONS CONDUCTED ON ALLEGED PERPETRATORS/OFFENDERS

(a) The Commission does not provide for the cost of sexual assault examinations performed on alleged perpetrators/offenders.

(9) SEXUAL ASSAULT EXAMINATION PAYMENT CATEGORIES

(a) Child Sexual Assault Examination Without Medication -$400

1. This fee includes exam, nurse examiner fee, pregnancy test, microscopic sperm screening, 14 Fr Foley Hymenal Exam, and drug screen.

2. If the itemized bill is less than $400, the lesser amount of the itemized bill will be paid.

(b) Adult Sexual Assault Examination Without Medication -$400

1. This fee includes exam, nurse examiner fee, pregnancy test, microscopic sperm screening, 14 Fr Foley Hymenal Exam, and drug screen.

2. If the itemized bill is less than $400, the lesser amount of the itemized bill will be paid.

(c) Adult Sexual Assault Examination with Medication -$550

1. This fee includes exam, nurse examiner fee, pregnancy test, microscopic sperm screening, 14 Fr Foley Hymenal Exam, drug screen, and all medications except HIV prophylaxis.

2. If the itemized bill is less than $550, the lesser amount of the itemized bill will be paid.

(d) Child Sexual Assault Examination with Medication -$550

1. This fee includes exam, nurse examiner fee, pregnancy test, microscopic sperm screening, 14 Fr Foley Hymenal Exam, drug screen, and all medications except HIV prophylaxis. 2, If the itemized bill is less than $550, the lesser amount of the itemized bill will be paid.

(e) Sexual Assault Examinations Conducted Away from Office/Clinic Base - $300

(f) Lab Processing Fee - $50

1. A lab processing fee may be paid for testing for sexually transmitted infections for sexual assault examinations performed at a hospital or SANE Clinic. Documentation of the testing must be provided in order to issue payment for a lab processing fee.

(i) The Commission does not provide compensation for lab or specimen collection fees.

(10) HIV PROPHYLAXIS

(a) The Commission may consider payment for the cost of providing HIV prophylaxis for victims of sexual violence through its Sexual Assault Examination Payment Program. Payment for HIV prophylaxis may be reduced when payment is made by insurance or other collateral sources.

1. If it is determined that a victim of sexual violence is at risk for exposure to HIV, the Commission may provide payment for a 28-day drug regimen of HIV prophylaxis to a SANE facility, hospital, medical clinic, pharmacy, or victim of sexual violence.

2. The Commission may provide payment for one follow-up medical visit to monitor tolerance of the HIV prophylaxis by a victim of sexual violence. The amount of payment for this expense will be decided on a case-by-case basis and it will be determined based on the reasonableness of the charges. (Additional medical care may be considered for payment if the victim of sexual violence files a regular crime victim's compensation application.)

3. If a victim of sexual violence has health insurance, the pharmacy, hospital, or medical clinic filling the prescription for HIV prophylaxis must first seek payment of the expense from the health insurance provider.

(b) The Commission will not reimburse for HIV prophylaxis if the nature of the assault does not support the treatment protocol.

(c) HIV Prophylaxis Payment Limitations

1. Truvada (28-day supply): $1,546.52

2. Isentress 400 mg (28-day supply): $1,473.72

3. Retrovir (28-day supply): $ 554.60

4. Epivir (28-day supply): $ 498.00

5. Tivicay (28-day supply): $1,825.99

Ala. Admin. Code r. 262-X-11-.01

New Rule: Filed October 6, 2004; effective November 10, 2004. New Rule: Filed October 6, 2004; effective November 10, 2004. Amended: Filed February 6, 2014; effective March 13, 2014.

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 08, May 29, 2015, eff. 6/11/2015.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 07, April 29, 2016, eff. 5/21/2016.

Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 02, November 30, 2016, eff. 12/23/2016.

Amended by Alabama Administrative Monthly Volume XXXVII, Issue No. 07, April 30, 2019, eff. 5/25/2019.

Amended by Alabama Administrative Monthly Volume XLI, Issue No. 06, March 31, 2023, eff. 5/15/2023.

Author: Kim Martin

Statutory Authority:Code of Ala. 1975, § 15-23-5(14).