Alabama Administrative Code Chapter 560-X-50 — Preventive Health Education

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-50-.01 General

(1) Preventive Health Education Services are services provided by a physician or other licensed practitioner of the healing arts (within the scope of practice), or by other qualified providers, which are designed to prevent disease, disability, or other health conditions or their progression; to prolong life; and to promote physical and mental health and efficiency.

(a) Prenatal and Pregnancy Prevention Education.

1. Prenatal Education consists of a series of classes which teach pregnant women about the process of pregnancy, healthy lifestyles, and prenatal care. These services are covered for Medicaid eligible pregnant women only.

2. Adolescent Pregnancy Prevention Education consists of a series of classes which teach nonpregnant adolescents about consequences of unintended pregnancy, methods of family planning, and decision making skills. These services are covered for all Medicaid eligible non-pregnant individuals of childbearing age who are eligible for services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, regardless of sex or previous pregnancy.

3. The purpose of these services is to reduce unintended adolescent pregnancies; decrease the rate of infant mortality; decrease the incidence of maternal complications, low birth weight babies, and other factors associated with the illness, disability or handicap, and deaths among infants and small children.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance; Title XIX Social Security Act;42 CFR §440.130.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995. Amended: Filed April 8,1996; effective May 13, 1996.

Ala. Admin. Code r. 560-X-50-.02 Provider Participation

(1) Eligible persons may receive preventive health education services through providers who are under contractual agreement with Medicaid to provide these services.

(2) Providers include clinics or other organizations which utilize licensed practitioners of the healing arts within the scope of practice under state law and/or federal regulations as described in section 560-X-50-.02(4).

(3) In cases where there is no licensing board for the instructors listed in 560-X-50-.02(4), the instructor must either work under the personal supervision of a physician or work in a facility that provides the services under the direction of a physician, such as in a clinic or outpatient hospital. "Under the supervision of" denotes that the physician is familiar with the Medicaid approved preventive information being presented to recipients and is available to the preventive health instructor by telephone, fax, or in person at the time the instructor is providing the preventive health education service. Providers must supply Medicaid with the name and resume of the physician supervising the instructor and maintain documentation sufficient to demonstrate their availability to the instructors.

(4) Professional instructors of the provider must meet the following qualifications (according to specialty) as listed below:

(a) A health educator must have graduated from an accredited four-year college or university with major course work in public health, health education, community health, or health/physical education/recreation with a concentration in health.

(b) A social worker must be licensed by the Alabama Board of Social Work Examiners.

(c) A registered nurse must be licensed by the Alabama Board of Nursing as a Registered Nurse.

(d) A nurse practitioner must have successfully completed a supplemental program in an area of specialization, and must be licensed by the Alabama Board of Nursing as a Registered Nurse and be issued a certificate of approval to practice as a Certified Registered Nurse Practitioner in the area of specialization.

(e) A nurse midwife must be licensed by the Alabama Board of Nursing as a Registered Nurse and a Certified Nurse Midwife.

(f) A nutritionist must be licensed as a Registered Dietitian by the American Dietetic Association.

(g) A nutritionist associate must have graduated from a four-year college or university with major course work in nutrition or dietetics.

(h) A professional counselor must be licensed by the Alabama Board of Examiners in Counseling.

(i) A health instructor must have a bachelor's degree with extensive experience in providing instruction in preventive health education supplemented by a training program approved by the Alabama Medicaid Agency.

(5) All provider instructors must have successfully completed a training program which is designed to prepare them to provide educational services. This training program must be approved by the Alabama Medicaid Agency.

(6) Providers must develop a specific written curriculum for their educational services, including specific course content and objectives for each class. This curriculum must be approved by the Alabama Medicaid Agency.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance; Title XIX, Social Security Act;42 CFR §§401, et seq.; 440.130.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995. Amended: April 8, 1996;effective May 13, 1996.

Ala. Admin. Code r. 560-X-50-.03 Recipient Eligibility

(1) Eligibility of recipients for preventive health education services varies according to the type of service being provided.

(a) Prenatal Education services are limited to those Medicaid eligible females who are pregnant (as evidenced by physical examination or a positive pregnancy test).

(b) Adolescent Pregnancy Prevention Education is available to all Medicaid eligible non-pregnant individuals of childbearing age who are eligible for services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, regardless of sex or previous pregnancy.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance; Title XIX, Social Security Act;42 C.F.R. §440.130.
• Emergency rule: Effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995. Amended: Filed April 8,1996; effective May 13, 1996.

Ala. Admin. Code r. 560-X-50-.04 Covered Services

(1) Preventive Health Education Services do not include services for which payment shall be made under other provisions.

(2) Preventive Health Education Services are covered when provided by a Medicaid enrolled preventive health education service provider.

(a) Prenatal Education visits are limited to 12 visits per recipient during each two-year period beginning with the first date of service.

(b) Adolescent Pregnancy Prevention Education visits are unlimited.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance, Title XIX, Social Security Act;42 C.F.R. §§440.130, 441.20, 441.57.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995. Amended: Filed April 8,1996; effective May 13, 1996.

Ala. Admin. Code r. 560-X-50-.05 Copayment (Cost Sharing)

Medicaid recipients shall not be required to pay and providers may not collect a copayment for any of these services. Refer to Rule 560-X-1-.25 for copay information.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance, Attachment 4.19B, page 12; TitleXIX, Social Security Act; 42 C.F.R. §440.130.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995.

Ala. Admin. Code r. 560-X-50-.06 Payment Acceptance

(1) The provider shall not charge Medicaid for services rendered on a no-cost basis to the general public except where such services are provided pursuant to Section 1903(c) of the Social Security Act or such services are provided by Title V Grantee pursuant to Section 1902(a)(11)(B) of the Social Security Act.

(2) Eligible Medicaid recipients are not to be billed for covered services once the recipient has been accepted as a Medicaid patient.

(3) It is the responsibility of the provider to follow-up with the fiscal agent or Medicaid on denied claims.

(4) The recipient is not responsible for any difference between billed charges and Medicaid allowed charges.

(5) The recipient may be billed for noncovered services.

(6) Preventive Health Education Services shall be billed on the HCFA 1500 claim form, utilizing locally assigned procedure codes. The appropriate ICD-9-CM diagnosis code shall be indicated on the claim form.

(7) Reimbursement to governmental agency providers will be based on a negotiated rate not to exceed actual costs as would occur through the efficient and economic operation by the provider. Reimbursement to nongovernmental providers will be based on Medicaid's established fee schedule, not to exceed the prevailing rate in the locality for comparable services offered under comparable conditions.

(8) Claims submitted for which there is no documentation, or for charges in excess or in violation of the provider's contractual agreement, are subject to recoupment by the agency, and to referral for investigation and possible prosecution for fraud.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance; Title XIX, Social Security Act;42 C.F.R. §447.15.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995.

Ala. Admin. Code r. 560-X-50-.07 Confidentiality

(1) The provider shall not disclose, except to duly authorized representatives of federal or state agencies, any information concerning an eligible recipient except upon written consent of the recipient, his attorney, or his/her guardian, or upon subpoena from a court of appropriate jurisdiction. See Rule 560-X-30-.05, Third Party, for additional requirements regarding release of information.

(2) The provider must safeguard clinical records against loss, destruction, and/or unauthorized use.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance; Title XIX, Social Security Act;42 C.F.R. §431.306.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992. Amended: Filed June 6, 1995; effective July 11, 1995.

Ala. Admin. Code r. 560-X-50-.08 Maintenance Of Records

(1) The provider shall make available to the Alabama Medicaid Agency at no charge all information regarding claims for services provided to eligible recipients. The provider 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 fiscal records which fully disclose the extent and cost of services shall be maintained by the provider.

(2) The provider shall maintain documentation of Medicaid clients' signatures. These signatures may be entered on a sign-in log, service receipt, or any other record that can be used to indicate the clients' signatures and dates of service.

(3) All records shall be maintained for a period of at least three (3) years plus the current fiscal year. If audit, litigation, or other legal action by or on behalf of the state or federal government has begun but is not completed at the end of the three (3) year period, or if audit findings, litigation, or other legal action have not been resolved at the end of the three (3) year period, the records shall be retained until resolution and finality thereof. Such records shall be kept in a form that will facilitate the establishment of a complete audit trail in the event such items are audited.

History

• Author: Dee Lockridge
• Authority: State Plan for Medical Assistance; Title XIX Social Security Act;42 C.F.R. §§431.17, 433.32.
• Emergency rule effective December 11, 1991. Permanent rule effective March 13,1992.