Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-36 - HOME - AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND DISABLED
Section 560-X-36-.09 - Payment Methodology For Covered Services
Current through Register Vol. 43, No. 02, November 27, 2024
(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:
(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.
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.