Current through Register Vol. 43, No. 02, November 27, 2024
(1) Case
Management Services.
(a) Case management is a
system under which responsibility for locating, coordinating, and monitoring a
group of services rests with a designated person or organization. A case
manager is responsible for outreach, intake and referral, diagnosis and
evaluation, assessment, care plan development, and implementing and tracking
services to an individual. Case management services may be used to locate,
coordinate, and monitor necessary and appropriate services. Case management
activities may also be used to assist in the transition of an individual from
institutional settings prior to discharge into the community. All E/D waiver
recipients will receive case management services.
(b) A person providing Case Management
Services must meet the qualifications as specified in the approved waiver
document.
(c) Case Management
Services must be on the Plan of Care as a waiver service. Waiver services not
listed on the Plan of Care and the Service Authorization Form will not be paid.
Payments rendered for services not documented on the individual's Plan of Care
and the Service Authorization Form will be recovered.
(d) Case management will be provided by a
case manager employed by or under contract with the state agencies as specified
in the approved waiver document. The case manager must meet the qualifications
as specified in the approved waiver document.
(2) Homemaker Services.
(a) Homemaker Services are general household
activities that include meal preparation, food shopping, bill paying, routine
cleaning, and personal services. They are provided by a trained homemaker when
the individual regularly responsible for these activities is temporarily absent
or unable to manage the home and care for the recipient.
(b) A person providing Homemaker Services
must meet the qualifications of a Homemaker Attendant as specified in the
approved waiver document.
(c)
Medicaid will not reimburse for activities performed which are not within the
scope of services.
(d) Homemaker
Services must be documented on the recipient's Plan of Care and Service
Authorization Form. No payment will be made for services not documented on the
Plan of Care and the Service Authorization Form. Payments rendered for services
not documented on the individual's Plan of Care and the Service Authorization
Form will be recovered.
(3) Personal Care Services.
(a) Personal Care Services are those services
prescribed by a physician in accordance with a plan of treatment to assist a
patient with basic hygiene and health support activities. These services
include assistance with bathing, dressing, ambulation, eating, reminding client
to take medications, and securing health care from appropriate
sources.
(b) A person providing
Personal Care Services must be employed by a certified Home Health Agency or
other agency approved by the Alabama Medicaid Agency and supervised by a
licensed nurse, and meet the qualifications of a Personal Care Attendant as
specified in the approved waiver document. This person may not be a relative,
as defined by the Health Care Financing Administration, of the
recipient.
(c) Medicaid will not
reimburse for activities performed which are not within the scope of
services.
(d) No payment will be
made for services furnished by a member of the recipient's family.
(e) Personal Care Services must be documented
on the recipient's Plan of Care and Service Authorization Form. No payment will
be made for services not documented on the Plan of Care and the Service
Authorization Form. Payments rendered for services not documented on the
individual's Plan of Care and the Service Authorization Form will be
recovered.
(4) Adult Day
Health Services with and without Transportation.
(a) Adult Day Health Service provides social
and health care in a community facility approved to provide such care. Health
education, self-care training, therapeutic activities, and health screening
shall be included in the program.
(b) Transportation between the individual's
place of residence and the Adult Day Health Center can be provided as a
component of Adult Day Health Service. Health education, self-care training,
therapeutic activities, and health screening shall be included in the
program.
(c) Adult Day Health is
provided by facilities that meet the minimum standards for Adult Day Health
Centers as described in Appendix C of the Home- and Community-Based Waiver for
the Elderly and Disabled. The state agencies contracting for Adult Day Health
Services must determine that each facility providing Adult Day Health meets the
prescribed standards.
(d) Medicaid
will not reimburse for activities performed which are not within the scope of
services.
(e) Adult Day Health
Services must be documented on the recipient's Plan of Care and Service
Authorization form. No payment will be made for services not documented on the
Plan of Care and the Service Authorization Form. Payments rendered for services
not documented on the individual's Plan of Care and the Service Authorization
Form will be recovered.
(5) Respite Care Services [Skilled and
Unskilled].
(a) Respite Care is given to
individuals unable to care for themselves on a short-term basis because of the
absence or need for relief of those persons normally providing the care.
Respite Care is provided in the individual's home and includes supervision,
companionship and personal care of the individual. Respite is intended to
supplement not replace care provided to waiver clients. Respite is not an
entitlement. It is based on the needs of the individual client and the care
provided by the primary caregiver.
(b) A person providing Respite Care must meet
the qualifications as specified in the approved waiver document.
(c) Respite Care may be provided by a
companion/ sitter, personal care attendant, home health aide, homemaker, LPN,
or RN, depending upon the care needs of the individual. All other waiver
services except case management will be disconnected during the in-home respite
period.
(d) Payment will not be
made for Respite Care furnished by a member of the recipient's family; may not
exceed 720 hours or 30 days per waiver year (October 1 through September 30);
must not be used to provide continuous care while the primary caregiver is
employed or attending school.
(e)
Medicaid will not reimburse for activities performed which are not within the
scope of services.
(f) Respite Care
services must be documented on the recipient's Plan of Care and Service
Authorization Form. No payment will be made for services not documented on the
Plan of Care and the Service Authorization Form. Payments rendered for services
not documented on the individual's Plan of Care and the Service Authorization
Form will be recovered.
(6) Companion Services.
(a) Companion Service is non-medical
assistance, observation, supervision and socialization, provided to a
functionally impaired adult. Companions may provide limited assistance or
supervise the individual with such tasks as: activities of daily living, meal
preparation, laundry, and shopping, but do not perform these activities as
discrete services. The Companion may also perform housekeeping tasks which are
incidental to the care and supervision of the individual. Companion service is
provided in accordance with a therapeutic goal as stated in the Plan of Care,
and is not purely diversional in nature. The therapeutic goal may be related to
client safety and/or toward promoting client independence or toward promoting
the mental or emotional health of the client.
(b) A person providing Companion Services
must meet the qualifications as specified in the approved waiver
document.
(c) Other service
definitions include accompanying a client to a medical appointment, grocery
shopping or picking up prescription medications. The Companion Service is
available to only those clients living alone. Companion Services cannot be
provided at the same time as other approved waiver services except for Case
Management Services. Companion Services must not exceed four (4) hours daily.
Payment will not be made for companion services furnished by a member of the
recipient's family.
(d) Medicaid
will not reimburse for activities performed which are not within the scope of
services.
(e) Companion Service is
not an entitlement. It is based on the needs of the individual
client.
(f) Companion Services must
be documented on the recipient's Plan of Care and Service Authorization form.
No payment will be made for services not documented on the Plan of Care and the
Service Authorization Form. Payments rendered for services not documented on
the Plan of Care shall be recovered.
(7) Home Delivered Meals.
(a) Home Delivered Meals are provided to an
eligible individual age 21 or older who is unable to meet his/her nutritional
needs. It must be determined that the nutritional needs of the individual can
be addressed by the provision of Home Delivered Meals.
(b) This service will provide at least one
(1) nutritionally sound meal per day to adults unable to care for their
nutritional needs because of a functional disability/dependency and who require
nutritional assistance to remain in the community, and do not have a caregiver
available to prepare a meal for them.
(c) This service will be provided as
specified in the care plan and may include seven (7) or fourteen (14) frozen
meals per week. Clients will be authorized to receive one (1) unit of service
per week. One unit of service is a 7-pack of frozen meals. Clients may be
authorized to receive two (2) units of service per week will receive two
7-packs of frozen meals or one 7-pack of frozen meals and one 7-pack of
breakfast meals.
(d) In addition to
the frozen meals, the service may include the provision of two (2) or more
shelf-stable meals (not to exceed six (6) meals per six-month period) to meet
emergency nutritional needs when authorized in the recipient's care
plan.
(e) One frozen meal will be
provided on days a client attends the Adult Day Health Centers. Meals provided,
as part of this service, shall not constitute a "full nutritional regimen
(three meals per day)".
(f) All
menus must be reviewed and approved by the Meals Services Coordinator, a
Registered Dietitian with licensure to practice in the State of Alabama and
employed by the Operating Agency.
(g) The meals must be prepared and/or
packaged, handled, transported, served, and delivered according to all
applicable health, fire, safety, and sanitation regulations.
(h) Home Delivered Meals must be documented
on the recipient's Plan of Care and Service Authorization Form. No payment will
be made for services not documented on the Plan of Care and the Service
Authorization Form. Payments rendered for services not documented on the
individual's Plan of Care and the Service Authorization Form will be
recouped.
(i) During times of the
year when the State is at an increased risk of disaster from hurricanes,
tornadoes, or ice/snow conditions, the meals vendor will be required to
maintain, at a minimum, a sufficient inventory to operate all frozen meals
delivery routes for two days. In the event of an expected storm or disaster,
the Meals Coordinator will authorize implementation of a Medicaid approved
Disaster Meal Services Plan.
(8) Home Modification Services.
(a) Home Modification Services provide
physical adaptations to the home which are necessary to ensure the health,
welfare, and safety of individuals, or which enable individuals to function
with greater independence in the home, and without this service the individual
would require institutionalization.
(b) Providers of Home Modification Services
must meet the qualifications as specified in the approved waiver
document.
(c) Home Modification
Services may include the installation of ramps and grab-bars, widening of
doorways to accommodate medical equipment, and supplies which are necessary for
the welfare of the individual. Excluded are those adaptations or improvements
to the home which are not of direct medical or remedial benefit to the waiver
recipient, adaptations which add to the total square footage of the home, any
type of construction affecting the structural integrity of the home, and
changes to the existing electrical components of the home.
(d) Home Modification Services shall be
provided by a licensed contractor and must be in accordance with state and
local building codes requirements, and the Americans with Disabilities Act
Accessibility Guidelines (ADAAG).
(e) Home Modification Services must be
documented on the recipient's Plan of Care and Service Authorization Form. No
payment will be made for services not documented on the Plan of Care and the
Service Authorization Form. Payments rendered for services not documented on
the individual's Plan of Care and Service Authorization Form shall be
recovered.
(f) Home Modification
Services require prior authorization by the Operating Agency.
(g) Limits on Home Modification Services are
$5,000 per waiver participant per lifetime. Any expenditures over the $5,000
lifetime limit must be approved by the Alabama Medicaid Agency.
(9) Personal Emergency Response
System (Installation and Monitoring/Monthly).
(a) Personal Emergency Response System (PERS)
is an electronic service which enables high-risk recipients to secure help in
the event of an emergency. PERS services are limited to those individuals who
live alone, or who are alone for significant parts of the day, without an
available caretaker. The recipient may wear a portable "help" button which
allows flexibility in mobility. The system is connected to a patient's phone
and programmed to signal a response center once a patient's "help" button is
activated. By providing recipients immediate access to assistance, PERS serves
to prevent institutionalization.
(b) PERS Monitoring/Monthly covers the
monthly fee after the PERS system has been installed.
(c) PERS providers must meet the
qualifications as specified in the approved waivers. PERS must be provided by
trained professionals. The PERS staff must complete a two-week training period
for familiarization with the monitoring system and proper protocol to provide
appropriate response action.
(d)
Initial setup, installation, and monitoring of PERS must be documented on the
recipient's Plan of Care and Service Authorization Form. No payment will be
made for services not documented on the Plan of Care and Service Authorization
Form. Payments rendered for services not documented on the individual's Plan of
Care and Service Authorization Form will be recovered.
(e) Only one installation of PERS per
recipient shall be approved. Exception to this limitation shall be considered
on an individual basis for circumstances such as relocations.
(10) Medical Supplies.
(a) Medical Supplies are supplies necessary
to maintain health and safety in the home environment and to prevent further
deterioration of a condition such as decubitus ulcers.
(b) Medical Supplies must be prescribed by a
physician and be documented on the Plan of Care and Service Authorization
Form.
(c) Providers of Medical
Supplies must meet the qualifications as specified in the approved waiver
document and shall have signed provider agreements with the Operating
Agency.
(d) Medical Supplies shall
be billed monthly, quarterly, or annually. The yearly allotment cap shall not
exceed $1,200.00. If billed monthly, the monthly cap amount shall not exceed
$100.00. If billed quarterly, the quarterly cap amount shall not exceed
$300.00. Total cap amounts shall not rollover to another month, quarter, or
year.
(e) Medical Supplies must be
documented on the recipient's Plan of Care and Service Authorization Form. No
payment will be made for services not documented on the Plan of Care and the
Service Authorization Form. Payments rendered for services not documented on
the individual's Plan of Care and the Service Authorization Form will be
recovered.
(f) State Plan EPSDT
services shall be exhausted prior to any use of waiver services for individuals
under the age of 21.
(11) Assistive Technology and Durable Medical
Equipment.
(a) Assistive Technology and
Durable Medical Equipment includes devices, pieces of equipment, or products
that are modified or customized and are used to increase, maintain, or improve
functional capabilities of individuals with disabilities. The service may also
be provided to assist an individual to transition from an institutional level
of care to the Home and Community-Based Waiver and to maintain a recipient
safely in the community.
(b)
Assistive Technology and Durable Medical Equipment includes any service that
directly assists a disabled individual in the selection, acquisition, or use of
an assistive technology device, including evaluation of need, acquisition,
selection, design, fitting, customization, adaptation, and
application.
(c) Assistive
Technology and Durable Medical Equipment can include, but are not limited to
wheelchairs, reachers, Hoyer lift, bath benches, etc. Items shall meet
applicable standards of manufacture, design, and installation.
(d) Assistive Technology and Durable Medical
Equipment must be ordered by the physician. The prescription shall be
maintained in the case file.
(e)
Assistive Technology and Durable Medical Equipment must be medically necessary.
Medically necessary means that the service is directed toward the maintenance,
improvement, or protection of health or toward the diagnosis and treatment of
illness or disability. A provider's medical records must substantiate the need
for the service, and findings and information shall support medical
necessity.
(f) Providers of
Assistive Technology and Durable Medical Equipment must meet the qualifications
as specified in the approved waiver document, be licensed individuals or
businesses capable of supplying the needed equipment and/or supplies and have a
signed provider agreement with the Operating Agency.
(g) Upon completion of the service, the
recipient must sign and date a form acknowledging receipt of the
service.
(h) Assistive Technology
and Durable Medical Equipment requires prior authorization and approval by the
Operating Agency. The maximum allowed for this service is $2,000 per year per
waiver recipient up to a total of $10,000 per waiver participant's
lifetime.
(i) State Plan EPSDT
services will be exhausted prior to any use of waiver services for individuals
under the age of 21.
(j) Assistive
Technology and Durable Medical Equipment must be documented on the recipient's
Plan of Care and Service Authorization Form. No payments will be made for
services not documented on the Plan of Care and Service Authorization Form.
Payments rendered for services not documented on the individual's Plan of Care
and Service Authorization Form will be recovered.
(12) Skilled Nursing Services.
(a) Skilled Nursing Services provide skilled
medical observation and nursing services by a Registered Nurse (RN) or Licensed
Practical Nurse (LPN) who will perform their duties in compliance with the
Alabama Nurse Practice Act and the Alabama State Board of Nursing.
(b) Skilled Nursing Services provide skilled
medical monitoring, direct care, and interventions for individuals with skilled
nursing needs to maintain home support to avoid or delay institutionalization.
It is not intended to be provided seven (7) days a week/24 hours a
day.
(c) Skilled Nursing Services
shall be provided according to guidelines as specified in the approved waiver
document.
(d) LPNs may provide
skilled care for the recipient if a licensed physician prescribes the service.
LPNs work under the supervision of RNs. The RN must make monthly supervisory
visits to evaluate the appropriateness of services rendered by an
LPN.
(e) Skilled Nursing Services
under the waiver will not duplicate skilled nursing under the mandatory home
health benefit in the State Plan. If a waiver recipient meets the criteria to
receive home health benefits, home health should be utilized first and
exhausted before waiver services are utilized.
(f) Skilled Nursing Services must be
documented on the recipient's Plan of Care and Service Authorization Form. No
payment will be made for Skilled Nursing Services not documented on the Plan of
Care and the Service Authorization Form. Payments rendered for services not
documented on the individual's Plan of Care and the Service Authorization Form
shall be recovered.
(13)
Pest Control Services.
(a) Pest Control
Services provide chemical eradication of pests by a State of Alabama Business
Licensed and Certified professional in a waiver participant's primary
residence, which could be a participant living in his/her own private home or
apartment who is responsible for his/her own rent or mortgage or a participant
living with a primary caregiver.
(b) Pest Control Services include assessment
or inspection, application of chemical-based pesticide and follow up
visits.
(c) Pest Control Service is
limited to one series of treatments per lifetime by a licensed and certified
pest control company and excludes lodging during the chemical eradication
process, all associated preparatory housework, and the replacement of household
items. Additional treatments may be approved if the lack of such treatments
would jeopardize the participants' ability to live in the community. If
additional treatments are needed, the State will evaluate that participant's
living situation to determine if the community arrangement is appropriate and
supports their health and safety.
(d) Providers of Pest Control Services must
meet the qualifications as specified in the approved waiver document and have a
signed provider agreement with the Operating Agency.
(e) A unit is a series. Pest Control Services
must be documented on the recipient's Plan of Care and Service Authorization
Form. No payment will be made for services not documented on the Plan of Care
and the Service Authorization Form. Payments rendered for services not
documented on the Plan of Care and Service Authorization Form shall be
recovered.
(14)
Supervisory Visits.
(a) Supervisory Visits are
conducted by Alabama Licensed Registered Nurses or Alabama Licensed Practical
Nurses to monitor DSP staff performance to ensure adherence of waiver
guidelines, quality of service provision to waiver recipients, and recipient
satisfaction with service provision.
(b) Supervisory Visits shall be conducted by
a Registered Nurse (RN) or Licensed Practical Nurse (LPN) who must meet all
federal and state requirements to provide services to eligible Medicaid
recipients under this waiver authority.
(c) Supervisory Visits shall be billed in 15
minutes increments not to exceed 60 minutes or 4 increments every 60
days.
(d) No reimbursement will be
made for attempted or missed visits.
(e) State Plan EPSDT services will be
exhausted prior to any use of waiver services for individuals under the age of
21.
(f) Providers of Supervisory
Visits must meet the qualifications as specified in the approved waiver
document.
(g) Supervisory Visits
must be documented on the recipient's Plan of Care and Service Authorization
Form. No payment will be made for services not documented on the Plan of Care
and the Service Authorization Form. Payments rendered for services not
documented on the Plan of Care and Service Authorization Form shall be
recovered.