7 AAC 145.520 - Home and community-based waiver services payment rates
(a) The department
will pay a home and community-based waiver services provider in accordance with
the rates and methodologies set out in this section.
(b) For care coordination services provided
under 7 AAC 130.240,
(1) the department will pay a unit of service
at the lesser of the
(A) amount charged by
the provider to the public; or
(B)
rates established in the department's Chart of Waiver Services
Rates, adopted by reference in
7
AAC 160.900;
(2) the payment rates listed in the
Chart of Waiver Services Rates for care coordination services
provided under
7
AAC 130.240(b)(1) and (2) will be
re-established at least every four years using a modeled rate methodology as
noted in the department's Rate-Setting Methodology for Personal Care
Services, Community First Choice Services, Long-Term Services and Supports
Targeted Case Management Services, and Waiver Services, adopted by
reference in
7
AAC 160.900, that includes components for salaries,
fringe benefits, administrative/general, and caseload size; and
(3) each July 1 that the payment rates for
care coordination services in the Chart of Waiver Services
Rates are not re-established under (2) of this subsection, the rates
will be adjusted as provided in
7
AAC 145.525(b).
(c) For specialized medical equipment and
supplies provided under
7
AAC 130.305, the department will pay at the lesser of
the
(1) amount charged by the provider in
accordance with
7
AAC 145.020; or
(2) maximum allowable amount specified for
that item in the Specialized Medical Equipment Fee Schedule,
adopted by reference in
7
AAC 160.900.
(d) For specialized private duty nursing
services provided under
7
AAC 130.285, the department will pay a unit of service
at the lesser of the
(1) amount charged by
the provider in accordance with
7
AAC 145.020; or
(2) rate described in
7
AAC 145.250.
(e) For environmental modification services
provided under
7
AAC 130.300, the department will pay at 100 percent of
billed charges to a home and community-based waiver services provider that
oversees the purchase and installation of an environmental modification for a
recipient. In addition, the department will pay the provider an administrative
fee of two percent of the billed charges or $100, whichever is greater, if the
provider is
(1) certified under
7
AAC 130.220(a)(1)(K); and
(2) an organized health care delivery system
under 42 C.F.R. Pa11447.
(f) For adult day services provided under
7
AAC 130.250, residential supported-living services
provided under
7
AAC 130.255, day habilitation services provided under
7
AAC 130.260, residential habilitation services
provided under
7
AAC 130.265, employment services provided under
7
AAC 130.270, intensive active treatment services
provided under
7
AAC 130.275, respite care services provided under
7
AAC 130.280, transportation services provided under
7
AAC 130.290(a), or meal services
provided under
7
AAC 130.295, the department will pay a unit of service
at the lesser of . . .
(1) the amount charged
by the provider in accordance with
7
AAC 145.020; or
(2) rates established in the department's
Chart of Waiver Services Rates adopted by reference in
7
AAC 160.900.
(g) For the types of service listed in (f) of
this section other than intensive active treatment services provided under
7
AAC 130.275, if the provider's average per-unit
allowed amount for the type of service, for claims with dates of service after
June 30, 2009 and before October 1, 2009, and processed before February 3,
2010, is higher than the rate established under (f) of this section, the
recipient care rate until July 1, 2026 is the average per-unit allowed amount
for the period after June 30, 2009 and before October 1, 2009.
(h) A qualified recipient receiving
residential supported-living services under
7
AAC 130.255 that are assigned procedure code T2031 in
the Healthcare Common Procedure Coding System (HCPCS), adopted
by reference in
7
AAC 160.900, or group-home habilitation services under
7
AAC 130.265 that are assigned procedure code T2016 in
the Healthcare Common Procedure Coding System, is eligible
for, in addition to the qualified recipient's daily rate provided under (f) and
(g) of this section, an acuity add-on rate at the daily rate established in the
Chart of Waiver Services Rates, adopted by reference in
7
AAC 160.900. For purposes of this subsection, a
qualified recipient is a recipient for whom the department has given prior
authorization under
7
AAC 130.267 for additional services.
(i) If a recipient has been determined
eligible for Medicaid coverage under
7
AAC 100.002(d)(8), the recipient's
income, exclusive of the personal needs allowance and other deductions
described in
7
AAC 100.550 -
7
AAC 100.579 is a prior resource for home and
community-based waiver services. Once the department has determined the
recipient's monthly cost-of-care amount under
7
AAC 100.554, the recipient or the recipient's
representative, on behalf of the recipient, shall pay that liability under
7
AAC 100.552.
Notes
Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040
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