(a) Before billing
the department for targeted case management services, a provider of those
services shall bill the recipient's alternate resources under
7
AAC 160.200. After it receives notification from each
third party of the amount, if any, that the third party will pay, the provider
of targeted case management services may seek payment from Medicaid for the
remaining cost of service.
(b) The
department will base payment for targeted case management services on a
prospective monthly encounter rate, computed with data from base year 2004, as
follows:
(1) using the base year's reported
units of contact for the specified service categories identified by the
department, the department will determine the average annual proportion of time
participating grantees spent providing case management services;
(2) the department will compute the annual
portion of case manager salaries and benefits attributed to case management,
using the base year's reported expenditures for each individual providing case
management services, and then, using the proportion determined in (1) of this
subsection, the department will compute the average portion of salaries and
benefits attributed to case management versus other activities;
(3) to the number reached in (2) of this
subsection, the department will add the portion of other operating costs,
including travel, supplies, telephone, and occupancy costs, attributed to case
management;
(4) to the number
reached in (3) of this subsection, the department will add direct supervisory
costs, computed by using the base year's reported expenditures for each
individual who provides direct supervision to case managers, and then, using
the proportion determined in (1) of this subsection, computing the portion of
salaries and benefits attributed to direct supervision of case managers versus
other activities;
(5) to the number
reached in (4) of this subsection, the department will add the average indirect
administrative costs of provider organizations, computed by using the base
year's reported expenditures for indirect administrative costs, and then, using
the proportion determined in (1) of this subsection, computing the portion of
indirect administrative costs attributed to case management versus other
activities;
(6) the department will
divide the sum of the results reached in (2) - (5) of this subsection by the
total number of statewide case managers to obtain the total annual cost per
case manager; the department will determine the total number of statewide case
managers by calculating the portion of direct service provider full-time
equivalents dedicated to case management, using the base year's actual reported
full-time equivalents and the proportion determined in (1) of this
subsection;
(7) the department will
divide the total annual cost per case manager, as computed in (6) of this
subsection, by 12 to obtain the monthly statewide average cost per case
manager;
(8) using the base year's
average actual number of children served per case manager, the department will
divide the monthly statewide average cost per case manager by the statewide
average number of children served by each case manager per month;
(9) the calculated rate from base-year data
will be annually updated by 2.7 percent for inflation on July 1 of each
year;
(10) for state fiscal year
2020, the department will not apply the inflation adjustment described in (9)
of this subsection.
(c)
A provider of targeted case management services may only bill the encounter
rate once per child per month and must keep documentation to verify that
practice.
