Alabama Administrative Code Chapter 560-X-8 — Independent Rural Health Clinic Services

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-8-.01 Independent Rural Health Clinic Services

(1) Independent Rural Health Clinics must be Medicare certified and contracted with the Alabama Medicaid Program, and be in compliance with Federal, State and Local Laws.

(2) Services covered under the Independent Rural Health Clinic Program are any medical service typically furnished by a physician in an office or in a physician home visit. Limits are the same as for the Physician Program.

(3) Independent Rural Health Clinic services are reimbursable if:

(a) performed by a physician,

(b) performed by a nurse practitioner, physician assistant, certified nurse midwife, or clinical social worker as an incident to a physician's service,

(c) a physician, nurse practitioner, physician assistant, or certified nurse midwife is available to furnish patient care at all times the clinic operates, and

(d) a nurse practitioner, physician assistant, or certified nurse midwife is available to furnish patient care at least 50 percent of the time the clinic operates.

(4) Independent Rural Health Clinic Services must also conform to any state requirements for the nurse practitioner, physician assistant, and certified nurse midwife regarding the scope or conditions of their practice.

(5) The Independent Rural Health Clinic must be under the medical direction of a physician. Except in extraordinary circumstances, the physician must be physically present for sufficient periods of times, at least every 72 hours for non-remote sites and every seven (7) days for remote sites (a remote site being defined as a site more than 30 miles away from the primary supervising physician’s principal practice location), to provide medical care services, consultation, and supervision in accordance with Medicare regulations for Rural Health Clinics. When not physically present, the physician must be available through direct telecommunication for consultation, assistance with medical emergencies, or patient referral. The extraordinary circumstances must be documented in the records of the clinic.

(6) The fiscal agent will be responsible for enrolling all Title XVIII (Medicare) certified Independent Rural Health Centers that wish to enroll as Qualified Medicare Beneficiary (QMB) only providers.

(7) In order to participate in the Title XIX Medicaid Program and to receive Medicaid payment, an Independent Rural Health Clinic (IRHC) must:

(a) Request an enrollment packet from Fiscal Agent as an IRHC Provider. Services to be provided should be identified in the enrollment application.

(b) Submit a copy of the following documentation of Medicare certification; the Centers for Medicare and Medicaid Services (CMS) letter assigning the Medicare Provider number and establishing the initial encounter rate. A copy of the facilities budget cost report must be sent to Medicaid’s Alternative Services Division.

(c) Submit a copy of the CMS Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver.

(d) Be operating in accordance with applicable Federal, State, and local laws.

(e) Certify compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and with the Age Discrimination Act of 1975.

(f) Execute a provider contract with the Alabama Medicaid Agency.

(8) The effective date of the enrollment of an IRHC will be the latter of the following: the first day of the month in which the written request for enrollment was received; or the date of Medicare certification.

History

• Author: Ginger Collum, Program Manager, Clinic/Ancillary Services
• Authority: State Plan; 42 C.F.R. §§491.8, et seq.; Title XIX, Social Security Act; Medicare Catastrophic Coverage Act of 1988 (Public Law 100-360); §6213 Omnibus Budget Reconciliation Act of 1989.
• Rule effective October 1, 1982. Amended: Effective July 13, 1989; June 14, 1990; effective May 11, 1993. Amended: Filed August 6, 1993; effective September 10, 1993. Amended: Filed February 7, 1996; effective March 14, 1996. Amended: Filed July 7, 1997; effective August 11, 1997. Amended: Filed March 14, 2002; effective April 18, 2002. Amended: Filed September 11, 2003; effective October 16, 2003.

Ala. Admin. Code r. 560-X-8-.02 Other Ambulatory Services

(1) The following services are covered as other ambulatory services furnished in an Independent Rural Health Clinic and are not billed as Rural Health Clinic services:

(a) Dental Services,

(b) Eyeglasses;

(c) Hearing aids;

(d) Prescribed devices;

(e) Prosthetic devices and

(f) Durable medical equipment;

(2) The services listed in Rule No. 560-X-8-.02(1) are covered separately under the respective program areas reimbursement practices. Refer to the Administrative Code Chapters 15, 17, 19, 13, 14, 43, 11, and 50 respectively for enrollment procedures and policies.

History

• Authority: State Plan; Attachment 3.1-A, Page 1.2; 42 C.F.R. §§401, et seq.; Section 440.20; Title XIX, Social Security Act.
• Rule effective October 1, 1982. Effective May 11, 1993. Amended: Filed December 7, 1994, effective January 12, 1995.

Ala. Admin. Code r. 560-X-8-.03 Reimbursement

(1) Independent Rural Health Clinics (IRHCs) will be reimbursed under a Prospective Payment System (PPS) as described in Chapter 56 of the Administrative Code.

(2) Encounters are all-inclusive and all services provided for the visit are included in the reimbursement rate. The only exceptions are claims for laboratory services and for the technical component of EKG’s and radiology services.

History

• Author: Calvin Binion, Associate Director, State Agency, Vision, & Clinic Services
• Authority: 42 C.F.R., §§447.371, et seq.; State Plan for Medical Assistance, Attachment 4.19-B, page 1.
• Rule effective October 1, 1982. Amended: effective December 6, 1984. Effective May 11, 1993. Amended: Filed April 11, 2001; effective May 16, 2001. Amended: Filed March 14, 2002; effective April 18, 2002. Amended: Filed July 12, 2005; effective August 16, 2005. Amended: Published January 31, 2020; effective March 16, 2020.

Ala. Admin. Code r. 560-X-8-.04 Change Of Ownership

Medicaid must be notified within thirty (30) days of the date of Independent Rural Health Clinic ownership change. The existing contract will be automatically assigned to the new owner, and the new owner shall then be required to execute a new contract with Medicaid as soon as possible after the change of ownership but in no event later than thirty (30) days after the new owner receives notification of Medicare certification. If the new owner fails to execute a new contract with Medicaid within this time period, then this contract shall terminate.

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Rule effective October 1, 1982. Effective May 11, 1993.

Ala. Admin. Code r. 560-X-8-.05 Medicare Deductible And Coinsurance

Deductible and/or Co-insurance will be reimbursed up to the full amount of the Medicaid encounter rate.

History

• Author: Carol Akin, Associate Director, Clinic/Ancillary Services
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Rule effective October 1, 1982. Amended: effective October 13, 1987. Repealed and New Rule: Filed March 14, 2002; effective April 18, 2002.

Ala. Admin. Code r. 560-X-8-.06 Copayment (Cost-Sharing)

(1) Medicaid and Medicare/Medicaid related recipients are required to pay and independent rural health clinics are required to collect the established copayment amount for each clinic encounter.

(2) The cost-sharing requirement does not apply to services provided for the following:

(a) Recipients under 18 years of age;

(b) Emergencies;

(c) Pregnancy;

(d) Family Planning;

(e) Nursing home residents;

(f) American Indians

(3) A provider may not deny services to any eligible individual on account of the individual's inability to pay the copayment amount.

History

• Author: Carol Akin, Associate Director, Clinic/Ancillary Services
• Authority: 42 C.F.R. §§ 447.50, 447.53, 447.55, et seq.; State Plan, Attachment 4.18-A.
• Rule effective June 8, 1985. Effective May 11, 1993. Amended: Filed January 19, 2011; effective February 23, 2011.

Ala. Admin. Code r. 560-X-8-.07 Billing Recipients

(1) A provider agrees to accept as payment in full the amount paid by the State, plus any copayment amount required to be paid by the recipients, for covered items and further agrees to make no additional charge or charges for covered items to the recipient.

(2) A provider may bill the recipient for the copayment amount and for noncovered Medicaid services.

(3) A provider may not deny services to any eligible individual on account of the individual's inability to pay the copayment amount.

History

• Author: Ronald B. Ressler
• Authority: 42 C.F.R. §447.15; State Plan, Attachment 4.18-A.
• Rule effective June 8, 1985.