Ala. Admin. Code r. 560-X-40-.04

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

Section 560-X-40-.04 - Payment Methodology For Covered Services

(1) Governmental providers will be paid on a negotiated rate basis which will not exceed actual costs and which will meet all requirements of OMB Circular A-87. Nongovernmental providers will be reimbursed on a negotiated rate basis which will not exceed the upper limitations of 42 C.F.R. Section 447.325. The following documentation must be maintained in the recipient's record when billing for services:

(a) There must be a current comprehensive service plan which identifies the medical, nutritional, social, educational, transportation, housing and other service needs which have not been adequately accessed and a time frame to reassess service needs.

(b) Services must consist of at least one of the following activities:

1. Establishment of the comprehensive case file for development and implementation of an individualized service plan to meet the assessed service needs of the recipient;

2. Assisting the recipient in locating needed service providers and making the necessary linkages to assure the receipt of services identified in the service plan;

3. Monitoring the recipient and service providers to determine that the services received are adequate in meeting the identified needs; or

4. Reassessment of the recipient to determine services needed to resolve any crisis situation resulting from changes in the family structure, living conditions, or other events.

(2) For target group 4 (Foster Children) and target group 7 (Adult Protective Service Individuals), reimbursement will be as follows:

(a) Reimbursement rates will be established based on cost as determined by the quarterly Social Services Work Sampling Study. Rates will be adjusted annually based on the results of the previous four quarters. Random Moment Sampling may not be used as a method of documenting services provided to recipients. The Work Sampling Study must provide an audit train that identifies each client whose case is included in the data used for rate formulation and identifies that at least one of the services listed above in (b) 1, 2, 3, or 4 has been provided.

(b) A maximum of one unit of case management services will be reimbursed per month for each eligible recipient receiving case management services. A unit of case management service is defined as at least one telephone or face to face contact for the purpose of providing at least one of the services listed above in (b)1, 2, 3, or 4 with the recipient, a family member, significant other, or agency from which the client receives or may receive services. All contacts must be documented in the client's record and must be for the coordination or linkage of services for a specific identified recipient.

(3) Reimbursement for services provided by other governmental agencies will be based on actual costs as follows:

(a) Agencies will submit an annual cost report not later than sixty (60) days following the close of their fiscal year. This report will indicate not only the costs associated with providing the service but also statistical data indicating the units of service provided during the fiscal year.

(b) Cost reports will be reviewed for reasonableness and an average cost per unit of service will be computed.

(c) The average cost, trended for any expected inflation, will be used as the reimbursement rate for the succeeding year.

(d) If the cost report indicates any underpayment or overpayments for services during the reporting year, a lump sum adjustment will be made.

(e) New rates will be effective as of January 1 of each year.

(4) The Medicaid reimbursement for each service provided by a case management service provider shall not exceed the maximum allowable amount established by Medicaid as found in 42 C.F.R. Section 447.304.

(5) Actual reimbursement will be based on the rates in effect on the date of service.

Author: Dittra Skipper, Administrator, Project Development/Policy Unit, Long Term Division

Ala. Admin. Code r. 560-X-40-.04

Filed July 12, 1988. Amended: Filed May 6, 1994; effective June 14, 1994. Amended: Filed September 6, 1995; effective October 11, 1995. Amended: Filed February 5, 2001; effective March 12, 2001.

Statutory Authority:42 C.F.R., Section 447.325; OMB Circular A-87; Section 1915 (g); Social Security Act; State Plan for Medical Assistance Attachment 3.1-A, Supplement 1; OMB NO. 0939-0193.