Ala. Admin. Code r. 560-X-36-.09

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

Section 560-X-36-.09 - Payment Methodology For Covered Services

(1) Medical pays providers the actual cost to provide the service. Each covered service is identified on a claim by a HCPC code. Respite care will have one code for skilled and another for unskilled. Home delivered meals will also have one code and two modifiers. Frozen meals and shelf stable meals will be billed with a modifier. Breakfast meals will be billed without a modifier.

(2) For each recipient, the claim will allow span billing for a period up to one month. There may be multiple claims in a month, but no single claims can cover services performed in different months. If the submitted claim covers days of service part or all of which were covered in a previously paid claim, it will be rejected. Payment will be based on the number of units of service reported for each HCPC code.

(3) The basis for the cost will usually be based on audited past performance with consideration being given to the health care index and renegotiated contracts. The interim cost may also be changed if a provider can show that an unavoidable event(s) has caused a substantial increase or decrease in the provider's cost.

(4) The operating agencies as specified in the approved waiver document are governmental agencies; therefore, within one hundred and twenty days from the end of a waiver year, the interim cost for services must be adjusted to cost and the claims for the services provided during that year reprocessed to adjust payments to the actual cost incurred by each operating agency. Thus the cost for each service for each operating agency may differ. Since the actual cost incurred by each operating agency sets a ceiling on the amount it can receive, no claims with dates of service within that year will be processed after the adjustment is made.

(5) Accounting for actual cost and units of services provided during a waiver year must be accomplished on CMS 372 Report. The following accounting definitions will be used to capture reporting data, and the audited figures used in establishing new interim cost:

(a) A waiver year consists of the twelve months following the start of any waiver year.

(b) An expenditure occurs when cash or its equivalent is paid in a quarter by a state agency for waiver benefits. For a public (governmental) provider, the expenditure is made whenever it is paid or recorded, whichever is earlier. Non-cash payments, such as depreciation, occur when transactions are recorded by the state agency.

(c) The services provided by operating agencies are reported and paid by dates of service. Thus, all services provided during the twelve months of the waiver year will be attributed to that year.

(6) Provider's costs shall be divided between benefit and administrative cost for service. The benefit portion is included in the cost for service. The administrative portion will be divided in twelve equal amounts and will be invoiced by the provider directly to the Alabama Medicaid Agency. Since administration is relatively fixed, it will not be a rate per claim, but a set monthly payment. As each waiver year is audited, this cost, like the benefit cost, will be determined and lump sum settlement will be made to adjust that year's payments to actual cost.

Ala. Admin. Code r. 560-X-36-.09

Emergency rule effective December 4, 1987. Permanent rule effective March 12, 1988. Amended: effective June 6, 1990. Amended: Filed August 7, 1995; effective September 12, 1995. Amended: Filed July 14, 1999; effective August 18, 1999. Amended: Filed May 10, 2002; effective June 14, 2002. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed October 16, 2004; effective November 16, 2004. Amended: Filed May 12, 2005; effective June 16, 2005. Amended: Filed September 11, 2008; effective October 16, 2008.

Author: Patricia Harris, Administrator, LTC Program Management Unit

Statutory Authority:42 CFR § 440.180; The Home- and Community-Based Waiver for the Elderly and Disabled; 45 CFR, Subpart 95; OMB Circular A-87.