Alabama Administrative Code Chapter 560-X-45 — Nurse-Family Partnership

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-45-.01 Nurse-Family Partnership - General

Nurse-Family Partnership (NFP) nurse visiting services are available to eligible pregnant Medicaid recipients. These services include care coordination, assessments and screenings, case management, and preventative health education and counseling. NFP is a nationally recognized evidence-based model that has demonstrated improved health outcomes and is maintained by the National Service Organization (NSO). These improved outcomes can ultimately help reduce health care costs over the mother and child’s lifespans. NFP nurse visiting services are:

(1) Tailored to each woman’s needs.

(2) Delivered in the home setting, via telehealth, or in an alternative community setting as indicated by client need.

(3) Provides case management activities for the woman through the prenatal and postpartum periods and through the infant’s second birthday.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: June 11, 2003; effective July 16, 2003. Amended: Filed October 12, 2005; effective November 16, 2005. Amended: Filed July 12, 2018; effective August 26, 2018. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.

Ala. Admin. Code r. 560-X-45-.02 Recipient Eligibility

NFP services are available for Medicaid eligible persons who:

(1) Are referred to a qualified, Agency enrolled, NFP provider by the recipient’s assigned Alabama Coordinated Health Network (ACHN), and

(2) Meet the NFP model eligibility requirements as established by the NSO and outlined in the Alabama Medicaid Provider Billing Manual.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed October 12, 2005; effective November 16, 2005. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.

Ala. Admin. Code r. 560-X-45-.03 Provider Requirements For Participation

Billing providers must be NSO network partners approved to implement the NFP Program within a specific region(s) with a current Annual Fidelity Support Letter on file with the Agency.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Repealed and New Rule: Filed October 12, 2005; effective November 16, 2005. Amended: Filed April 10, 2015; effective May 15, 2015. Amended: Filed July 12, 2018; effective August 26, 2018. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.

Ala. Admin. Code r. 560-X-45-.04 Provider Termination And/Or Change Of Ownership

(1) A participating NFP provider has the right to withdraw from the Medicaid program after submitting written notice to Medicaid of its intent at least thirty (30) days in advance.

(2) The State may terminate the NFP provider's participation in the Medicaid program if they lose NSO certification for any reason, and in cases involving fraud or willful or grossly negligent non-compliance.

(3) Medicaid must be notified in writing within thirty (30) days of the date of agency owner and/or name change. The existing contract will be terminated, and a new contract must be signed to continue participation in the Medicaid program.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• New Rule: Filed October 12, 2005; effective November 16, 2005. Amended: Filed April 10, 2015; effective May 15, 2015. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.

Ala. Admin. Code r. 560-X-45-.05 Covered Services

NFP services can be provided through the prenatal and postpartum periods (Maternal Only Phase) and up until the infant’s second birthday (Maternal/Infant Phase). Case Management Activities for both phases must include:

(1) Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social, and/or other services. Each assessment must include:

(a) assessing client history;

(b) identifying the individual’s needs and completing related documentation; and

(c) gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary) to form a complete assessment of the eligible individual.

(2) Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:

(a) specifies the goals and actions to address the medical, educational, social, and/or other services needed by the individual;

(b) includes activities such as ensuring the active participation of the eligible individual and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and

(c) identifies a course of action to respond to the assessed needs of the eligible individual.

(3) Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including activities that help link the individual with medical, educational, and social providers or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.

(4) Monitoring and follow-up activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs. These activities may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Monitoring must be conducted at least one annual monitoring, to determine whether the following conditions are met:

(a) services are being furnished in accordance with the individual’s care plan;

(b) services in the care plan are adequate; and

(c) changes in the needs or status of the individual are reflected in the care plan.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed October 12, 2005; effective November 16, 2005. Amended: Filed April 10, 2015; effective May 15, 2015. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.
• Editor's note: Previous Rule 560-X-45-.04 was renumbered to Rule 560-X-45-.05 as per certification filed October 12, 2005; effective November 16, 2005.

Ala. Admin. Code r. 560-X-45-.06 NFP Visits

(1) A qualified NFP visit is a contact with the recipient in-person either at their home or other location of the recipient’s choosing or via telehealth when appropriate.

(2) Monthly documentation of active recipient participation and provider engagement is required.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed October 12, 2005; effective November 16, 2005. Amended: Filed July 12, 2018; effective August 26, 2018. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.
• Editor's note: Previous Rule 560-X-45-.05 was renumbered to Rule 560-X-45-.06 as per certification filed October 12, 2005; effective November 16, 2005.

Ala. Admin. Code r. 560-X-45-.07 NFP Records

(1) The NFP provider shall make available to the Alabama Medicaid Agency, at no charge, all information describing services provided to eligible recipients and shall permit access to all records and facilities for the purpose of claims audit, program monitoring, and utilization review by duly authorized representatives of Federal and State agencies. Complete and accurate records (including, but not limited to, medical, psychiatric, and fiscal records) which fully disclose the extent of the service shall be maintained by the NFP. Said records shall be retained for the period of time required by State and Federal laws.

(2) In addition to all NSO mandated data elements, NFP records must contain documentation of:

(a) name of recipient;

(b) a recipient Medicaid ID;

(c) the NFP Client ID;

(d) dates of services;

(e) name of provider agency and person providing services;

(f) nature, start and end time, extent or units of services provided;

(g) place(s) of service; and

(h) weeks of gestation or weeks postpartum at time of visit.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed October 12, 2005; effective November 16, 2005. Amended: Filed July 12, 2018; effective August 26, 2018. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.
• Editor's note: Previous Rule 560-X-45-.07 was renumbered to Rule 560-X-45-.08 as per certification filed October 12, 2005; effective November 16, 2005.

Ala. Admin. Code r. 560-X-45-.08 Billing Nurse-Family Partnership Services By Providers

(1) NFP Providers may submit a claim to Medicaid once each month. At least one qualifying visit must occur prior to the submission of the claim.

(2) The NFP provider agrees to accept as payment in full the amount paid for covered NFP services.

(3) Medicaid will not reimburse for any direct care services (i.e. wound care, medication administration, etc.) rendered by an NFP provider.

History

• Author: John Majors, Associate Director, Maternity and Family Planning
• Authority: Title XIX, Social Security Act; 42 C.F.R. Section 440.169(b); and State Plan.
• Repealed and New Rule: Filed February 19, 1999; effective March 26, 1999; operative May 1, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed October 12, 2005; effective November 16, 2005. Amended: Filed July 12, 2018; effective August 26, 2018. Repealed: Published December 31, 2019; effective February 14, 2020. New Rule: Published June 30, 2022; effective August 14, 2022.
• Editor's note: Previous Rule 560-X-45-.07 was renumbered to Rule 560-X-45-.08 as per certification filed October 12, 2005; effective November 16, 2005.