Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 1058. Amounts of reimbursement for home and community-based waiver services

7 AAC 43.1058. Amounts of reimbursement for home and community-based waiver services

(a) The department will reimburse a provider of home and community-based waiver services that is enrolled under 7 AAC 43.1090 according to the rates and methodologies set out in this section.

(b) For care coordination services provided under 7 AAC 43.1041, the department will reimburse a unit of service at the lesser of the

(1) amount charged by the provider to the public; or

(2) maximum allowable amount specified for that unit of service in Table I-5 of the home and community-based waiver services: care coordination section of the Alaska Medicaid Provider Billing Manual; the descriptions and billing codes for those services are provided in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2003, as amended from time to time, and adopted by reference; the June 2003 revision of Table I-5 of the home and community-based waiver services: care coordination section of the Alaska Medicaid Provider Billing Manual is adopted by reference.

(c) For specialized medical equipment and supplies provided under 7 AAC 43.1055, the department will reimburse a unit at the lesser of the

(1) amount charged by the provider to the public; or

(2) maximum allowable amount specified for that unit in Table I-4 of the durable medical equipment (DME) and supplies section of the Alaska Medicaid Provider Billing Manual or in the department's Letter DME FYO2-004; the descriptions and billing codes for those items are provided in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2003, as amended from time to time, and adopted by reference; the September 1999 revision of Table I-4 of the durable medical equipment (DME) and supplies section of the Alaska Medicaid Provider Billing Manual is adopted by reference; the department's Letter DME FY02-004, dated March 13, 2002 is adopted by reference.

(d) For specialized private duty nursing services provided under 7 AAC 43.1051, the department will reimburse a unit of service at the lesser of the

(1) amount charged by the provider to the public; or

(2) rate described in 7 AAC 43.456.

(e) For environmental modification services provided under 7 AAC 43.1054, the department will reimburse at 100 percent of billed charges to a home and community-based services provider. In addition, the department will reimburse the provider an administrative fee of two percent of the billed charges or $50, whichever is greater, if the provider

(1) is certified and enrolled under 7 AAC 43.1090(b)(1)(J); and

(2) acts as an organized health care delivery system under 42 C.F.R. 447.10 for the purpose of overseeing the purchase of an environmental modification for a recipient.

(f) For chore services provided under 7 AAC 42.1042, adult day services provided under 7 AAC 43.1043, day habilitation services provided under 7 AAC 43.1045, residential habilitation services provided under 7 AAC 43.1046, supported employment services provided under 7 AAC 43.1047, intensive active treatment services provided under 7 AAC 43.1048, respite care services provided under 7 AAC 43.1049, transportation services provided under 7 AAC 43.1052, or meals services provided under 7 AAC 43.1053, the department will base reimbursement for a unit of service upon the

(1) rates established in Table I-4 of the home and community-based waiver services: home and community-based agency section of the Alaska Medicaid Provider Billing Manual; the June 2003 revision of Table I-4 of the home and community-based waiver services: home and community-based agency section of the Alaska Medicaid Provider Billing Manual is adopted by reference; or

(2) allowable direct service costs, as established under 7 AAC 43.1060, for the service provided, and allowances to compensate the provider for the provider's allowable administrative and general costs, as established under 7 AAC 43.1060, associated with providing the service; however, the department will not include an allowance under this paragraph for any administrative or general costs for

(A) out-of-home daily respite care services or family-directed respite care services under 7 AAC 43.1049;

(B) meals services under 7 AAC 43.1053; or

(C) any services provided by a home and community-based services provider acting as an organized health care delivery system under 42 C.F.R. 447.10.

(g) In determining reimbursement rates under (f) of this section, the department will consider only those costs identified in 7 AAC 43.1060 that are anticipated to be paid or borne by the provider. In evaluating the reasonableness of a provider's projected costs under (f) of this section and 7 AAC 43.1060, the department may conduct cost comparisons for similar services or items of expense and deny any cost that appears to be excessive.

(h) For residential supported living services provided under 7 AAC 43.1044, a residential supported living services provider may seek reimbursement for a unit of service either at the rate determined under (f) of this section or at the rate determined under this subsection. The department will base reimbursement under this subsection upon the following:

(1) for a provider that is licensed as an assisted living home under AS 47.33 for fewer than six residents, the department will use a base service rate of $44.52 per day;

(2) for a provider that is licensed as an assisted living home under AS 47.33 for six or more residents and does not provide 24-hour awake staff, the department will use a base service rate of $56.10 per day;

(3) for a provider that is licensed as an assisted living home under AS 47.33 for six or more residents and provides 24-hour awake staff, the department will use a base service rate of $67.68 per day;

(4) the amount of reimbursement to a provider under (1) - (3) of this subsection will be decreased by 26 percent of the base service rate per day if a recipient also receives adult day services under 7 AAC 43.1043 for three or more days in a seven-day period;

(5) the amount of reimbursement to a provider under (1) - (3) of this subsection will be increased by $17.37 per day if the recipient's needs warrant the hiring or designation of additional staff by the provider to augment the care given to the recipient;

(6) a base service rate under (1) - (3) of this subsection will be adjusted to reflect regional differences in the cost of doing business, based on the region in which the provider is located; based upon the designated planning regions described in Table 1 of the Alaska Commission on Aging State Plan for Services 2001 - 2003, dated June 14, 2001 and adopted by reference, the rate adjustments are as follows:

(A) for the Anchorage region - no adjustment;

(B) for the southcentral region, other than Anchorage - 1.04;

(C) for the southeast region - no adjustment;

(D) for the interior region - 1.15;

(E) for the southwest region - 1.33;

(F) for the northwest region - 1.38;

(7) a service rate under (1) - (6) of this subsection will be adjusted to increase the rate by $8.65 per day; this increase is not subject to the regional adjustment under (6) of this subsection;

(8) subject to the availability of appropriations, a service rate determined under (1) - (6) of this subsection will be adjusted by the department by, and effective at the same time as, a cost of living percentage increase in benefit amounts under 42 U.S.C. 1382f.

(i) With the approval of the department, a residential supported living services provider that offers to provide service to a recipient at a rate lower than the rate determined under (f) or (h) of this section may be reimbursed at the lower rate.

(j) If a recipient has been determined eligible for Medicaid coverage under 7 AAC 43.020(a) (3)(B), the recipient's income, exclusive of the personal needs allowance and other deductions described in (k) of this section, is a prior resource for home and community-based waiver services. Once the department has determined the recipient's monthly liability under (k) of this section, the recipient shall pay that liability toward the cost of care for home and community-based waiver services. If a recipient is receiving residential supported living services under 7 AAC 43.1044, the recipient shall pay the liability first to the recipient's residential supported living services provider, and second to other home and community-based services providers if any monthly liability remains.

(k) The department will determine the recipient's monthly liability to pay for home and community-based waiver services by subtracting the following deductions from the recipient's monthly income:

(1) a personal needs allowance equal to the

(A) monthly income limit set in AS 47.07.020 (b)(6), if the recipient is not a resident of an assisted living home licensed under AS 47.33; or

(B) monthly income limit set in AS 47.07.020 (b) minus $260, if the recipient is a resident of an assisted living home licensed under AS 47.33;

(2) a deduction for mandatory withholding from earned or unearned income to cover federal, state, and local taxes;

(3) a deduction for taxes not subject to withholding but owed and paid;

(4) a deduction for income actually garnisheed for child support owed for the month of the recipient's liability; the deduction in this paragraph does not apply to any amount of garnishment for which another deduction is provided in this subsection;

(5) a deduction for the amount of income needed to raise a spouse's income to the highest amount allowable under 42 U.S.C. 1396r-5(d)(3)(C) for a minimum monthly maintenance needs allowance;

(6) a deduction for an amount to maintain a family member, as defined in 42 U.S.C. 1396r-5(d)(1), in the home; if the family member is

(A) living with the recipient's spouse, the amount of the deduction will be calculated by subtracting the family member's monthly income from one-third of the highest amount allowable under 42 U.S.C. 1396r-5(d)(3)(C) for a minimum monthly maintenance needs allowance; or

(B) not living with the recipient's spouse, the deduction will be calculated by subtracting the family member's monthly income from the income standard applicable under 42 U.S.C. 1 396u-1 (b) to a household of the same size in which adults are not included for purposes of determining eligibility for Medicaid;

(7) a deduction for medical expenses; for purposes of this paragraph "medical expenses" means

(A) Medicare and other health insurance premiums that the recipient pays; and

(B) incurred but unpaid medical expenses not covered by Medicaid, by the Chronic and Acute Medical Assistance (CAMA) program under 7 AAC 48, or by private health insurance, including unpaid medical expenses outstanding before a recipient receives home and community-based waiver services.

( l ) Notwithstanding 7 AAC 43.1060, the department will not approve an increase in the amount of reimbursement per unit of service for a service whose per unit amount of reimbursement has been determined using the methodology in (f)(2) of this section until July 1, 2006.

(m) Repealed 8/21/2005.

History: Eff. 5/15/2004, Register 170; am 6/27/2004, Register 170; am 7/1/2005, Register 175; am 8/21/2005, Register 175

Authority: AS 47.05.010

AS 47.07.030

Editor's note: Table I-5 of the home and community-based waiver services: care coordination section, Table I-4 of the durable medical equipment (DME) and supplies section, and Table I-4 of the home and community-based waiver services: home and community-based agency section of the Alaska Medicaid Provider Billing Manual, adopted by reference in 7 AAC 43.1058, may be obtained by contacting the Department of Health and Social Services, Division of Health Care Services, P.O. Box 110601, Juneau, Alaska 99811-0601.

The United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2003, adopted by reference in 7 AAC 43.1058, may be obtained by contacting the Superintendent of Documents, United States Government Printing Office, Washington, DC 20402, and may be reviewed at the Department of Health and Social Services, Division of Health Care Services, P.O. Box 110601, Juneau, Alaska 99811-0601.

The Alaska Commission on Aging State Plan for Services: 2001 - 2003, Table 1, adopted by reference in 7 AAC 43.1058 may be obtained by contacting the Department of Health and Social Services, Division of Senior and Disability Services, P.O. Box 110680, Juneau, Alaska, 99811-0680. The Alaska Commission on Aging State Plan for Services: 2001 - 2003 is also posted on the Department of Health and Social Services, Alaska Commission on Aging's Internet web site at http://www.alaskaaging.org.