Alabama Administrative Code Chapter 660-2-4 — State Supplementation

660 Alabama Department of Human Resources

Ala. Admin. Code r. 660-2-4-.01 General

Prior to January 1, 1974, the State administered the adult category public assistance programs partially funded with federal monies under the Social Security Act. These programs, Old Age Pension (OAP), Aid to the Blind (AB), and Aid to the Permanently and Totally Disabled (APTD), were modified after January 1, 1974, to provide supplementary assistance payments from State funds alone for certain aged, blind, and disabled person. Alabama administers a program meeting the requirements of mandatory supplementation, Public Law 93-66, to provide for payments to all December 1973 recipients of OAP, APTD, and AB (or referred to collectively as State Supplemental) whose income level under SSI during any month (CIL - Current Income Level) is less than their income level as of December 1973 (MIL - Minimum Income Level); make payments equal to at least the difference between the December 1973 income level and the income level under SSI; and maintain the December 1973 income level, reducing it only as a decrease in needs would have caused a decrease in the December 1973 payment had such decrease been reported then. In addition to required or mandatory supplementation, optional payments are made in Alabama to eligible individuals who were not receiving assistance in December 1973. Optional supplementation payments are provided to individuals who receive SSI and to those non-SSI SUP recipients who were receiving optional supplementation payments as of March 7, 1986 provided all such individuals require independent homelife care, formerly personal care (only for persons who were receiving payment for such care as of September 30, 1986), or specialized independent homelife care in their own home or in a foster home licensed or approved by the Department of Human Resources, or care in a Cerebral Palsy Treatment Center (only for persons who were eligible for such care in May 1981).

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983. Emergency amendment effective March 10, 1986. Permanent amendment effective June 17, 1986. Succedent permanent amendment effective September 9, 1986. Succedent permanent amendment effective December 9, 1986. Succedent permanent amendment effective January 15, 1992.

Ala. Admin. Code r. 660-2-4-.02 Administration

The Department has the responsibility for administering the Supplementation Program. All activities must be in compliance with the Civil Rights Act of 1964 and § 504 of the Rehabilitation Act of 1973. The Department of Human Resources is responsible for program policy formulation, monitoring, program planning, standard setting and quality assurance in the administration of the Supplementation Program.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.03 Rights And Responsibilities

(1) Any person has the right to apply for assistance, have his/her eligibility determined, and if found eligible, to receive an established monthly amount. Although persons receiving a direct payment are to use these funds for their personal care needs, there are no restrictions otherwise on their use. The recipient of public assistance funds must assume the responsibilities of furnishing all necessary facts and documentation to establish or reestablish eligibility, advise the Department of any changes in his/her circumstances within 10 days which might affect eligibility and/or the amount of the assistance grant, and to provide the Department with any channel of information concerning his/her affairs that may be determined necessary. An applicant/recipient who refuses to cooperate with the Department by not providing required information, verification or documentation shall be denied/terminated as eligibility cannot be established.

(2) The individual has the right of confidentiality, to receive prompt action, equitable treatment, notification of any case action taken, and to receive a fair hearing (see Chapter 660-1-5, Hearings in the General Administration Division) due to an appeal of case action.

(3) Removed

History

• Authority: Social Security Act Titles XVI and XIX; P.L. 98-369; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38, §§ 41-22-1 through -27.
• Effective June 28, 1983. Emergency amendment effective October 1, 1983. Permanent amendment effective January 9, 1984. Succedent emergency amendment effective January 1, 1985. Succedent permanent amendment effective January 9, 1985. Succedent emergency amendment effective January 1, 1986. Succedent permanent amendment effective March 14, 1986. Succedent emergency amendment effective June 17, 1986. Succedent permanent amendment effective September 9, 1986. Succedent permanent amendment effective December 9, 1986. Succedent emergency amendment effective June 1, 1988. Succedent permanent amendment effective September 13, 1988. Succedent permanent amendment effective January 15, 1992.

Ala. Admin. Code r. 660-2-4-.04 Application And Initial Determination Of_Eligibility

(1) An individual must apply for SSI and learn the decision on that application before he can apply for supplementation under OAP, APTD, or AB. The individual's status with SSA for SSI benefits must be cleared prior to accepting a formal application. If an individual is ineligible for SSI benefits for any reason, he is not eligible for supplementation.

(2) An application is a specific written request on the designated agency application form, which has been completed, dated and signed by the applicant, to have eligibility for Supplementation (SUP) determined. An applicant may withdraw the application for SUP at any time without affecting the right to reapply at any time. Eligibility for SUP must be determined initially at application and at other intervals thereafter as provided in 660-2-4-.08, if the applicant is determined eligible.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983. Emergency amendment effective March 10, 1986. Permanent amendment effective June 17, 1986.

Ala. Admin. Code r. 660-2-4-.05 Definitions: Application Process

The administrative definitions applicable to the application process are as follows:

(a) A proper applicant is a competent adult who is physically able to apply for himself or on behalf of a minor (child under 19) or physically or mentally handicapped adult and who has made application for public assistance to the County Department and whose application has not been disposed of by appropriate County Department action. A proper applicant for a minor who is not in foster care or a physically or mentally handicapped adult is the person with whom he lives and who is responsible for his care, or a legal guardian, committee, or other legal representative. When the minor is mentally competent and between 16 and 19 years old with no legally appointed guardian, committee, or other representative, and he is not in the care of another person, he may be the proper applicant for himself. The proper applicant for a minor who is in foster care under supervision of the County or State Department is the County Director or his/her designee.

(b) An application is the action taken by an individual in filling out and signing an application form requesting assistance. The application may be new (initial) or it may be a reapplication.

(c) An inquiry is a request for information only. An inquiry differs from an application in that the person's intent is to obtain information rather than to receive financial aid.

(d) A referral is cleared as an inquiry. It is a request for information, service, or aid in behalf of an individual. It may be made by an agency, an institution, or another person. The County Department will consider a referral as an inquiry until application is made.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.06 Standard_Of_Promptness

Not more than 45 days in OAP and AB, and not more than 60 days in APTD, shall elapse between the date of application and date the first payment or the notice of denial is mailed. Only the following pending reasons are acceptable for exceeding the standard of promptness:

(a) Agency failure to secure needed verification after repeated attempts. To meet this requirement, all efforts to secure the verification must be documented.

(b) Client's request that application be continued beyond the standard of promptness in order to provide additional information and/or verification.

(c) Failure of client to provide information and verification requested.

(d) Administrative emergencies that could not reasonably be controlled by the agency. (Illness and staff vacancies do not meet this definition.)

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983. Amendment effective September 9, 1985.

Ala. Admin. Code r. 660-2-4-.07 Accrual_Rights

(1) An applicant's right to a money payment accrues on the first day of the month in which his money payment is authorized, provided he was alive and eligible on that day and is eligible on the day the eligibility worker completes the award documents. Payments authorized for the month of application are prorated from the date the application was received.

(2) A recipient's right to a money payment accrues on the first day of each month provided he is alive on that date.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38; SSA-AT-81-34.
• Effective July 18, 1983. Emergency amendment effective April 1, 1984. Permanent amendment effective June 11, 1984. Succedent emergency amendment effective March 1, 1985. Succedent permanent amendment effective April 11, 1985. Succedent permanent amendment effective October 9, 1985.

Ala. Admin. Code r. 660-2-4-.08 Determination Of Continuing Eligibility

The Department must determine the individual's eligibility for continued assistance at any time changes which may affect eligibility are reported by the recipient or collateral sources or when information in the case record appears inconsistent. Additionally, the agreement to provide personal care must be validated at least every 12 months.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983. Emergency amendment effective March 1, 1986. Permanent amendment effective May 28, 1986.

Ala. Admin. Code r. 660-2-4-.09 Definitions Of Terms (Phrases) Used In Continuing Eligibility

The administrative definitions applicable to the determination of continuing eligibility process are as follows:

(a) A recipient is any person who receives a public assistance money payment and/or is certified to the Alabama Medicaid Agency for Medicaid.

(b) Determination of continued eligibility is an investigation to determine that a recipient continues to meet all eligibility requirements.

(c) Determination of Continued Eligibility Process refers to all of the activities involved in the investigation and determination of continuing eligibility for public assistance.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983. Emergency amendment effective March 1, 1986. Permanent amendment effective May 28, 1986.

Ala. Admin. Code r. 660-2-4-.10 Amount Of Assistance Payment

The amount of assistance payment that a person receives is determined by the kind of care he needs, subject to the funds available. When available funds are expended on current recipients, the State Department may freeze the caseload at the number of persons for whom funds are available.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983. Amendment effective September 9, 1985. Emergency amendment effective March 10, 1986. Succedent permanent amendment effective June 17, 1986.

Ala. Admin. Code r. 660-2-4-.11 Payee

The individual applying for or receiving assistance will be the payee of the State SUP payment unless a legal guardian or legal representative has been appointed.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.12 Duplicate_Grants

The needs of an individual shall not be considered in more than one grant simultaneously.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.13 Erroneous Payments

Any overpayments whether agency or client error, fraud or nonfraud, must be reported to the State Department. All necessary steps shall be taken to correct underpayments and to recover overpayments, except those due to agency error, including recoupment from current assistance.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective July 18, 1983. Amendment effective January 9, 1985.

Ala. Admin. Code r. 660-2-4-.14 Advance Notice

(1) A person receiving State SUP must be given or mailed written notification ten days in advance of action to terminate his/her grant or reduce the amount of assistance. In the following situations, ten day advance notice is not necessary, but written notification must be provided to the individual no later than the effective date of action.

(2) Exceptions to advance notice:

(a) The County Department has factual information confirming the death of the recipient.

(b) The County Department receives a clear written statement signed by a recipient that he no longer wishes assistance, or that gives information which requires termination or reduction of assistance; and the recipient has indicated, in writing, that he understands that this must be the consequence of supplying such information.

(c) The recipient has been admitted or committed to a public institution.

(d) The recipient's whereabouts are unknown and agency mail directed to him has been returned by the Post Office indicating no known forwarding address. The recipient's check must, however, be made available to him if his whereabouts became known before the last day of the month covered by the returned check.

(e) The recipient has been accepted for assistance in another county or state and that fact has been established by the County Department previously providing assistance.

(f) The recipient has been placed in skilled nursing care, intermediate care, or long-term hospitalization.

(g) A special allowance granted for a specific period is terminated and the recipient has been informed in writing at the time of award that the allowance shall automatically terminate at the end of the specified period.

(h) The recipient has left, or has been removed from, a foster home, whether or not he will be in another foster home.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983. Amendment effective December 9, 1983.

Ala. Admin. Code r. 660-2-4-.15 General_Eligibility_Criteria

Eligibility on the factors of age, disability, blindness, residence, citizenship, resources, and income is established by Supplemental Security Income (SSI) Program staff based on Title XVI of the Social Security Act.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38; Opinion to Gary Cooper, Commissioner, State Department of Human Resources, under date of September 27, 1979.
• Effective June 28, 1983. Emergency amendment effective March 10, 1986. Permanent amendment effective June 17, 1986.

Ala. Admin. Code r. 660-2-4-.16 Eligibility_Factors_Other_Than_Need

A person meeting general eligibility criteria (1) must be certified as needing independent homelife care, formerly personal care in a private home, or foster home licensed or approved by the Department (only for persons who were receiving payment for such care as of September 30, 1986) or (2) must be certified as needing (on or after October 1, 1986) specialized independent homelife care in a private home, or foster home licensed or approved by the Department; and must be receiving benefits under the Elderly/Disabled Medicaid Waiver Program; and must meet the definition of skilled nursing facility criteria outlined in 660-2-4-.28. The determination of whether an applicant/recipient meets such definition will be made by the Alabama Medicaid Agency after review of the applicant/recipient's medical and social records. Recommendation for care must be made by a legally licensed physician of the person's choice. The applicant/recipient and the provider (as defined in 660-2-4-.29) of care must also sign statements indicating care will be provided and paid for.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983. Amendment effective January 9, 1985. Succedent amendment effective July 9, 1985. Succedent permanent amendment effective September 9, 1986. Succedent permanent amendment effective December 9, 1986. Succedent permanent amendment effective January 9, 1987. Succedent permanent amendment effective January 15, 1992.

Ala. Admin. Code r. 660-2-4-.17 Definition Of Independent Homelife Care

Care from someone else to enable a person to live as independently as possible outside a nursing home. Services considered as enabling a person to live as independently as possible include: help with conducting a prescribed exercise routine; changing bandages or dressings on the advice of the physician; administering prescribed medication; assisting in the use of prostheses or ambulation aids; assistance in locomotion; maintaining an acceptable state of cleanliness; maintaining orientation to time, place, and events; reminding of the need for medication, or other health related functions; and performing other activities needed to help a person care for himself when his illness or disability prevents him from adequately doing so. Companionship for pleasure or convenience rather than protection and necessity is not included in this definition.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983. Succedent permanent amendment effective January 15, 1992.

Ala. Admin. Code r. 660-2-4-.18 Care In Cerebral Palsy Treatment Centers

(1) Eligible recipients receiving care in Cerebral Palsy Treatment Centers who were eligible for optional supplementation as of June 1, 1981 may continue to receive a monthly payment to supplement their other income to help pay for the cost of their care and certain basic needs. "Eligible for" includes persons actually receiving APTD in the Center in June 1981, as well as persons who before June 1981 were: 18 years of age or older and in a Cerebral Palsy Treatment Center and had applied for APTD before June 1981 and were later determined eligible. Eligibility continues only for as long as he remains in the Center and receives SSI, or would receive SSI except for income. (An interruption for any length of time in the stay in the Center has no effect on the person's eligibility upon his return to the Center.)

(2) The amount of the supplement for persons in Cerebral Palsy Treatment Centers who receive SSI is $196 per month. No separate statement of income/resources nor budget is necessary. Persons who do not receive SSI due to income are eligible for a supplement in the amount of the difference between $196 and the amount of income in excess of the SSI federal benefit rate.

History

• Authority: Code of Ala. 1975, Title 38.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.19 Need Requirement - General

To be eligible for SUP based on need an individual must be a recipient of Supplemental Security Income through the Social Security Administration. (See Attachments 660-2-4-.19 a and b.)

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983. Amendment effective September 9, 1985. Succedent emergency amendment effective January 1, 1986. Succedent emergency amendment effective March 10, 1986. Succedent permanent amendment effective April 24, 1986. Succedent permanent amendment effective June 17, 1986. Succedent permanent amendment effective September 9, 1986.

Ala. Admin. Code r. 660-2-4-.20 Resources (Repealed 6/17/86)

Resources (Repealed 6/17/86)

History

• Authority: Social Security Act Titles XVI and XIX; P.L.98-369; 20 C.F.R. 416; 42 C.F.R. 435; 42 U.S.C. 1382 (b); Title XIX State Plan; Code of Ala. 1975, Title 38 and § 35-1-2.
• Effective June 28, 1983. Amendment effective October 9, 1984. Emergency amendment effective January 1, 1985. Succedent permanent amendment effective January 9, 1985. Succedent emergency repealer effective March 10, 1986. Succedent permanent repealer effective June 17, 1986.

Ala. Admin. Code r. 660-2-4-.21 Home Property (Repealed 6/17/86)

Home Property (Repealed 6/17/86)

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983. Amendment effective August 9, 1984. Succedent emergency repealer effective March 10, 1986. Succedent permanent repealer effective June 17, 1986.

Ala. Admin. Code r. 660-2-4-.22 Income (Repealed 6/17/86)

Income (Repealed 6/17/86)

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective June 28, 1983. Emergency repealer effective March 10, 1986. Permanent repealer effective June 17, 1986.

Ala. Admin. Code r. 660-2-4-.23 Medicaid

A non-SSI individual receiving State supplementation is automatically eligible for Alabama Medicaid benefits except for individuals in Cerebral Palsy Treatment Centers. See Chapter 660-2-5.

History

• Authority: 42 C.F.R. 435.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.24 Referral_To_Social_Services

At any time the worker suspects abuse or neglect of any child or adult, he must immediately refer the case to the appropriate service unit. All persons receiving State supplementation are referred to the service unit when problems or needs of individuals are evidenced or services are desired.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective June 28, 1983.

Ala. Admin. Code r. 660-2-4-.25 Social Security Account Numbers

To be eligible for State SUP, an individual must either provide the Social Security account number when known, or apply for a Social Security account number when one has not been assigned, or is unknown or the individual is otherwise unable to provide an accurate account number. Failure of the individual to comply with this requirement will result in ineligibility for State SUP benefits.

(a) The worker will assist the client who cannot provide the Social Security account number to secure it through the Welfare Enumeration System. Assistance will not be denied/delayed/discontinued when the client has applied through the Welfare Enumeration System for a SSN, pending issuance and/or verification.

History

• Authority: Social Security Act Titles XVI and XIX; P.L. 98-369; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Emergency rule effective April 1, 1985. Permanent rule effective June 10, 1985.

Ala. Admin. Code r. 660-2-4-.26 Non-SSI Supplementation (SUP) Recipients

(1) Eligible non-SSI SUP recipients receiving optional supplementation as of March 7, 1986 may continue to receive a monthly payment to supplement their other income to help pay for the cost of their care. Eligibility continues only for as long as all optional supplementation program eligibility requirements as outlined in chapter 660-2-4 are met as well as the requirement of only being ineligible for SSI due to income.

(2) Eligibility on the factors of age, disability, blindness, residence, citizenship, resources and income is based on the criteria of Title XVI of the Social Security Act.

(3) A separate income and resource determination is necessary in these cases. Persons determined eligible receive a supplement in the amount of the difference in countable income and the amount of the applicable supplement payable dependent upon type of care needed. The individual must not have currently available resources in excess of the maximum established by Title XVI or gross countable income in excess of the limit established by the Alabama Medicaid Agency or total net countable income in excess of the appropriate supplement. (See attachments 660-2-4-.19a and 660-2-4-.26a.) Rules in 20 C.F.R. 416, Subpart K, govern types of countable income and income exclusions. Rules in 20 C.F.R. 416, Subpart L, govern types of countable resources and resource exclusions. The provisions of Title 20, Code of Federal Regulations, Part 416, Subparts K and L, such regulations being in effect October 30, 1972 through April 1, 1984, and as all of the same may be amended, are hereby adopted by reference. A copy of the adopted matter may be found in the attached Appendix A.

History

• Authority: Social Security Act, Title XVI, 20 C.F.R. 416; Code of Ala. 1975, Title 38.
• Emergency rule effective March 10, 1986. Permanent rule effective June 17, 1986. Succedent permanent amendment effective September 9, 1986. Succedent permanent amendment effective December 9, 1986. Succedent emergency amendment effective January 1, 1987. Succedent permanent amendment effective March 11, 1987. Succedent emergency amendment effective January 1, 1988. Succedent permanent amendment effective February 17, 1988.

Ala. Admin. Code r. 660-2-4-.27 Definition Of Specialized Independent Homelife Care

Specialized Independent Homelife care includes services incidental to a medical need to assist the functionally impaired individual with personal hygiene, dressing, ambulation, meal preparation, eating, self-administering medications and maintaining a safe and sanitary environment.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of Ala. 1975, Title 38.
• Effective January 9, 1987. Succedent permanent amendment effective January 15, 1992.

Ala. Admin. Code r. 660-2-4-.28 Definition Of Skilled Nursing Facility (SNF)

(1) Definition. As used in this section, "skilled nursing and skilled rehabilitation services" means services that:

(a) Are ordered by a physician;

(b) Require the skills of technical or professional personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists; and

(c) Are furnished directly by, or under the supervision of, such personnel.

(d) The beneficiary must require skilled nursing or skilled rehabilitation services, or both, on a daily basis.

(2) Criteria for skilled services and the need for skilled services.

(a) The service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.

(b) A condition that does not ordinarily require skilled services may require them because of special medical complications. Under those circumstances, a service that is usually non-skilled may be considered skilled because it must be performed or supervised by skilled nursing or rehabilitation personnel. For example, a plaster cast on a leg does not usually require skilled care. However, if the patient has a preexisting acute skin condition or needs traction, skilled personnel may be needed to adjust traction or watch for complications. In situations of this type, the complications, and the skilled services they require, must be documented by physicians' orders and nursing or therapy notes.

(c) The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.

(3) Examples of skilled nursing and rehabilitation services.

(a) Services that could qualify as either skilled nursing or skilled rehabilitation services.

1. Overall management and evaluation of care plan. The development, management, and evaluation of a patient care plan based on the physician's orders constitute skilled services when, because of the patient's physical or mental condition, those activities require the involvement of technical or professional personnel in order to meet the patient's needs, promote recovery, and ensure medical safety. This would include the management of a plan involving only a variety of personal care services when, in light of the patient's condition, the aggregate of those services requires the involvement of technical or professional personnel. For example, an aged patient with a history of diabetes mellitus and angina pectoris who is recovering from an open reduction of a fracture of the neck of the femur requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, an exercise program to preserve muscle tone and body condition, and observation to detect signs of deterioration in his or her condition or complications resulting from restricted, but increasing, mobility. Although any of the required services could be performed by a properly instructed person, such a person would not have the ability to understand the relationship between the services and evaluate the ultimate effect of one service on the other. Since the nature of the patient's condition, age, and immobility create a high potential for serious complications, such an understanding is essential to ensure the patient's recovery and safety. Under these circumstances, the management of the plan of care would require the skills of a nurse even though the individual services are not skilled. Skilled planning and management activities are not always specifically identified in the patient's clinical record. Therefore, if the patient's overall condition would support a finding that recovery and safety can be assured only if the total care is planned, managed, and evaluated by technical or professional personnel, it would be appropriate to infer that skilled services are being provided.

2. Observation and assessment of the patient's changing condition. Observation and assessment constitute skilled services when the skills of a technical or professional person are required to identify and evaluate the patient's need for modification or treatment for additional medical procedures until his or her condition is stabilized. For example, a patient with congestive heart failure may require continuous close observation to detect signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication(s) which serve as indicators for adjusting therapeutic measures. Likewise, surgical patients transferred from a hospital to a skilled nursing facility while in the complicated, unstabilized postoperative period, e.g., after hip prosthesis or cataract surgery, may need continued close skilled monitoring for postoperative complications, and adverse reaction. Patients who, in addition to their physical problems, exhibit acute psychological symptoms such as depression, anxiety, or agitation, etc., may also require skilled observation and assessment by technical or professional personnel to assure their safety and/or the safety of others, i.e., to observe for indications of suicidal or hostile behavior. The need for services of this type must be documented by physicians' orders and/or nursing or therapy notes.

3. Patient education services. Patient education services are skilled services if the use of technical or professional personnel is necessary to teach a patient self-maintenance. For example, a patient who has had a recent leg amputation needs skilled rehabilitation services provided by technical or professional personnel to provide gait training and to teach prosthesis care. Likewise, a patient newly diagnosed with diabetes requires instruction from technical or professional personnel to learn the self-administration of insulin or foot-care precautions, etc.

(b) Services that qualify as skilled nursing services.

1. Intravenous, intramuscular, or subcutaneous injections and hypodermoclysis or intravenous feeding;

2. Levin tube and gastrostomy feeding;

3. Nasopharyngeal and tracheostomy aspiration;

4. Insertion and sterile irrigation and replacement of catheters;

5. Application of dressings involving prescription medications and aseptic techniques;

6. Treatment of extensive decubitus ulcers or other widespread skin disorder;

7. Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress;

8. Initial phases of a regimen involving administration of medical gases;

9. Rehabilitation nursing procedures, including the related-teaching and adaptive aspects of nursing, that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs.

(c) Services which would qualify as skilled rehabilitation services.

1. Ongoing assessment of rehabilitation needs and potential: Services concurrent with the management of a patient care plan, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficits, speech and language or hearing disorders;

2. Therapeutic exercises or activities: Therapeutic exercises or activities which, because of the type of exercises employed or the condition of the patient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the patient and the effectiveness of the treatment;

3. Gait evaluation and training: Gait evaluation and training furnished to restore function in a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality;

4. Range of motion exercises: Range of motion exercises which are part of the active treatment of a specific disease state which has resulted in a loss of, or restriction of, mobility (as evidenced by a therapist's notes showing the degree of motion lost and the degree to be restored);

5. Maintenance therapy: Maintenance therapy, when the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient's needs, and consistent with the patient's capacity and tolerance. For example, a patient with Parkinson's disease who has not been under a rehabilitation regimen may require the services of a qualified therapist to determine what type of exercises will contribute the most to the maintenance of his present level of functioning;

6. Ultrasound, short-wave, and microwave therapy treatment by a qualified physical therapist;

7. Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool in particular cases where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications, and the skills, knowledge, and judgment of a qualified physical therapist are required; and

8. Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing.

(d) Personal care services.

1. Administration of routine oral medications, eye drops, and ointments;

2. General maintenance care of colostomy and ileostomy;

3. Routine services to maintain satisfactory functioning of dwelling bladder catheters;

4. Changes of dressings for noninfected postoperative or chronic conditions;

5. Prophylactic and pallative skin care, including bathing and application of creams, or treatment of minor skin problems;

6. Routine care of the incontinent patient, including use of diapers and protective sheets;

7. General maintenance care in connection with a plaster cast;

8. Routine care in connection with braces and similar devices;

9. Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator;

10. Routine administration of medical gases after a regimen of therapy has been established;

11. Assistance in dressing, eating, and going to the toilet;

12. Periodic turning and positioning in bed; and

13. General supervision of exercises which have been taught to the patient; including the actual carrying out of maintenance programs, i.e., the performance of the repetitive exercises required to maintain function do not require the skills of a therapist and would not constitute skilled rehabilitation services (see paragraph (c) of this section). Similarly, repetitious exercises to improve gait, maintain strength, or endurance; passive exercises to maintain range of motion in paralyzed extremities, which are not related to a specific loss of function; and assistance walking do not constitute skilled rehabilitation services.

(4) Criteria for "daily basis".

(a) To meet the daily basis requirement the following frequency is required:

1. Skilled nursing services or skilled rehabilitation services must be needed and provided 7 days a week; or

2. As an exception, if skilled rehabilitation services are not available 7 days a week those services must be needed and provided at least 5 days a week.

(b) A break in one or two days in the furnishing of rehabilitation services will not preclude coverage if discharge would not be practical for the one or two days during which, for instance, the physician has suspended the therapy sessions because the patient exhibited extreme fatigue.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Code of Ala. 1975, Title 38.
• Emergency new rule effective August 14, 1991. Succedent permanent new rule effective November 12, 1991.

Ala. Admin. Code r. 660-2-4-.29 Care_Provider_Requirements

Effective February 14, 1992, the care provider of independent homelife care or specialized independent homelife care must be an employee of a certified home health agency or (if the County Health Department does not make homelife services available in the county or to this individual) an individual who declares in writing that he/she has at least a 6th grade education; is physically and mentally able to provide care as evidenced by a medical statement; has not been convicted of a serious crime; and has not been fired or forced to resign from a position as a care provider due to dereliction of duty. The care provider cannot be of any of the following degrees of relationship to the applicant/recipient: child, stepchild, adoptive child, son or daughter-in-1aw; parent, stepparent, adoptive parent; spouse; or brother, sister, brother-in-1aw, sister-in-1aw.

A certified home health agency is an agency so certified by the Alabama Department of Public Health, Division of Licensure and Certification.

History

• Authority: Social Security Act Titles XVI and XIX; 20 C.F.R. 416; 42 C.F.R. 435; Title XIX State Plan; Code of_Ala. 1975, Title 38.
• Effective January 15, 1992. Succedent emergency amendment effective January 15, 1992. Succedent permanent amendment effective April 10, 1992.

Ala. Admin. Code r. 660-2-4-A Appendix A Attachments

APPENDIX A - CHAPTER 660-2-4 ATTACHMENTS (DELETED)

Attachment 660-2-4-.03a (DELETED)

DEPARTMENT OF HUMAN RESOURCES

OLD AGE PENSION

SUMMARIZED ELIGIBILITY REQUIREMENTS

APPENDIX A - CHAPTER 660-2-4 ATTACHMENTS (DELETED)

Attachment 660-2-4-.03b (DELETED)

DEPARTMENT OF HUMAN RESOURCES

AID TO THE BLIND

SUMMARIZED ELIGIBILITY REQUIREMENTS

APPENDIX A - CHAPTER 660-2-4 ATTACHMENTS (DELETED)

Attachment 660-2-4-.03c (DELETED)

DEPARTMENT OF HUMAN RESOURCES

AID TO THE PERMANENTLY AND TOTALLY DISABLED

SUMMARIZED ELIGIBILITY REQUIREMENTS

APPENDIX A - CHAPTER 660-2-4 ATTACHMENTS

Attachment 660-2-4-.19a

SPECIAL NEEDS OF APPLICANTS AND RECIPIENTS

APPENDIX A - CHAPTER 660-2-4 ATTACHMENTS

Attachment 660-2-4-.19b

BASIC REQUIREMENTS FOR MANDATORY MONEY PAYMENT NURSING HOME CASES

Table 4

APPENDIX A - CHAPTER 660-2-4 ATTACHMENTS

Attachment 660-2-4-.26a

FEDERAL BENEFIT RATE (FBR) CHART (Effective January 1, 1995)

Author: Statutory Authority: Social Security Act, Title XVI, 20 C.F.R 416; Code of Ala. 1975, Title 38. History: Emergency rule effective March 10, 1986. Permanent rule effective June 17, 1986. Succedent permanent amendment effective September 9, 1986. Succedent emergency amendment effective January 1, 1987. Succedent permanent amendment effective March 11, 1987. Succedent emergency amendment effective January 1, 1988. Succedent permanent amendment effective February 17, 1988. Succedent emergency amendment effective January 1, 1991. Succedent permanent amendment effective April 11, 1991. Succedent permanent amendment effective January 1, 1994. Succedent emergency amendment effective January 1, 1995. Succedent permanent amendment filed March 7, 1995; effective April 11, 1995.