7 AAC 43.040. Rates of payment

(a) By providing a service to a Medicaid recipient and billing the division for that service, an enrolled provider signifies agreement to comply with applicable department regulations. A provider may not charge

(1) for any administrative cost related to participation in the Medicaid program; or

(2) a higher rate for any unit of service provided to a Medicaid recipient than the provider charges others, except for Medicare.

(b) Except as provided in (c) of this section, the department will pay an enrolled provider for a service at the lowest of the

(1) billed charges;

(2) rate identified in the fee schedule established under this chapter, as applicable for the particular provider type or service; or

(3) provider's lowest charge that is advertised, quoted, posted, or billed for that unit of service and provided on the same date regardless of the payment source or method of payment; the provider's lowest charge includes any discounted price offered to any other purchaser of services, but does not include

(A) any single contract that contains a discounted rate for a service or group of services and the contract does not exceed 20 percent of a provider's annual gross income;

(B) a reduced rate for a service or group of services the provider offers to the provider's employees as part of an employee benefit package; or

(c) If a provider establishes in writing a sliding fee scale that is based upon income for families and individuals with income equal to or less than 250 percent of the applicable federal poverty guidelines for this state, the division will not consider the fees applicable to those families or individuals in determining the provider's lowest charge per service under (b) (3) of this section.

(d) For purposes of this section, "federal poverty guidelines for this state" refers to the poverty guidelines for Alaska established by the United States Department of Health and Human Services at 63 Fed. Reg. 9236 (February 24, 1998), as amended from time to time, and adopted by reference.

History: Eff. 8/18/79, Register 71; am 5/5/84, Register 90; am 6/30/84, Register 90; readopt 8/7/96, Register 139; am 2/1/97, Register 141; am 6/26/98, Register 146; am 11/8/98, Register 148; am 4/19/2001, Register 158; am 9/29/2005, Register 175

Authority: AS 47.05.010

AS 47.05.012

AS 47.07.040

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.040 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

On March 3, 2003, as required by AS 44.62.245 and AS 47.05.012 , the department gave notice that the following amended version of material, previously adopted by reference in 7 AAC 43.020, would be in effect on April 1, 2003: the United States Department of Health and Human Services poverty guidelines established in 68 Fed. Reg. 6456-6458 (February 7, 2003). The amended version may be reviewed at the Department of Health and Social Services, Division of Medical Assistance, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska, 99503-7167.

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