Alabama Administrative Code Chapter 560-X-59 — Provider-Based Rural Health Clinic Services

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-59-.01 General

(1) A Provider-Based Rural Health Clinic (PBRHC) is a rural health clinic that is an integral and subordinate part of a hospital, skilled nursing facility, or a home health agency participating in Medicare and is operated with other departments of the provider under common licensure, governance, and professional supervision.

(2) Provider-Based Rural Health Clinics' claim(s) filing limit shall be 365 days from date of service. Claims received after this time limit will be treated as outdated in accordance with Rule 560-X-1-.17.

History

• Author: Carol Akin, Associate Director, Clinic/Ancillary Services
• Authority: 42 C.F.R. Section 405.2401-.2472, Section 447.371.
• Emergency rule effective October 1, 1993. This rule effective December 14, 1993. Amended: Filed May 11, 2001; effective June 15, 2001.

Ala. Admin. Code r. 560-X-59-.02 Participation

(1) In order to participate in the Title XIX

(Medicaid) Program, and to receive Medicaid payment, a Provider-Based Rural Health Clinic, including satellite clinics must:

(a) request an enrollment packet from our Fiscal Agent Provider Enrollment Unit;

(b) be certified for participation in the Title XVIII (Medicare) Program;

(c) obtain certification by the appropriate State survey agency;

(d) be in compliance with the Clinical Laboratory Improvement Amendment (CLIA) testing for all laboratory sites; and

(e) be operating in accordance with applicable Federal, State and local laws.

(2) Requests for enrollment in the Alabama Medicaid Program must be sent to the Fiscal Agent Provider Enrollment Unit.

(3) Satellite clinics must enroll separately and execute a separate provider contract with Alabama Medicaid.

(4) The effective date of enrollment of a Provider-Based Rural Health Clinic will be the date of Medicare certification but under no circumstance will the date be earlier than October 1, 1993. Providers who request enrollment more than 120 days after certification are enrolled on the first day of the month the enrollment is approved.

History

• Author: Carol Akin, Associate Director, Clinic/Ancillary Services
• Authority: 42 C.F.R. Section 491 Subpart A; Section 405.2401-.2472 Subpart X; Title XIX; Clinical Laboratory Improvement Amendment of 1988 (CLIA) 42 CFR Section 493 et. seq.; Public Law 100-578 (42 U.S.C. Section 263a); State Plan Attachment 4.19-B.
• Emergency rule effective October 1, 1993. This Rule effective December 14, 1993. Amended: Filed March 14, 2002; effective April 18, 2002.

Ala. Admin. Code r. 560-X-59-.03 Provider-Based Rural Health Clinic Services

(1) Services covered in the Provider-Based Rural Health Clinic are:

(a) Medically necessary diagnostic and therapeutic services and supplies that are an incident to such services or as an incident to a physician's service and that are commonly furnished in a physician's office or a physician home visit;

(b) Basic laboratory services essential to the immediate diagnosis and treatment of the patient that must include but are not limited to the six (6) tests that must be provided directly by the rural health clinic:

1. Chemical examinations of urine by stick or tablet methods or both (including urine ketones)

2. Hemoglobin or hematocrit

3. Blood glucose

4. Examination of stool specimens for occult blood

5. Pregnancy tests, and

6. Primary culturing for transmittal to a certified laboratory

(c) Medical emergency procedures as a first response to life threatening injuries and acute illness.

(2) Provider-Based Rural Health Services may be provided by a:

(a) Physician; or

(b) Physician assistant, nurse practitioner, certified nurse midwife, or a specialized nurse practitioner as an incident to a physician's service.

(3) A physician, physician assistant, nurse practitioner, certified nurse midwife, and specialized nurse practitioner must conform to all State requirements regarding the scope or conditions of their practice.

(4) A nurse practitioner, physician assistant, certified nurse midwife, or a specialized nurse practitioner must furnish patient care services at least 50 percent of the time the clinic operates.

(5) The Provider-Based 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 not 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 Provider-Based Rural Health Clinic must have in effect agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to its patients, including physician services provided in the inpatient hospital setting, the office, the patient's home, or a skilled nursing facility. If the agreements are not in writing there must be evidence that patients referred by the clinic are being accepted and treated.

(7) Rural Health Clinic visits and inpatient physician services are subject to the same routine benefit limitations as for physicians. Refer to Chapter 6 of the Administrative Code for details.

History

• Author: Ginger Collum, Program Manager, Clinic/Ancillary Services
• Authority: State Plan, Attachment 3.1-A, Pages 1.2 and 2.3a.; 42 C.F.R. Section 491 Subpart A; Section 491.8(a), Section 491.9(2), Section 405.2401-.2472 Subpart X; Section 410.45; Section 440.10-.20.
• Emergency rule effective October 1, 1993. This Rule effective December 14, 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-59-.04 Other Ambulatory Services

(1) The following services are covered as other ambulatory services furnished in a Provider-Based Rural Health Clinic and are considered rural health clinic services:

(a) Dental services;

(b) Eyeglasses;

(c) Hearing Aids;

(d) Prescribed devices;

(e) Prosthetic devices;

(f) Durable medical equipment;

(g) Family Planning;

(h) Prenatal;

(i) EPSDT (Early and Periodic Screening, Diagnosis and Treatment); and

(j) Preventive Health Education.

(2) The services listed in Rule No. 560-X-59-.04(1) are subject to billing, policies, and routine benefit limitations for the designated program area(s). Refer to the Administrative Code Chapters 15, 17, 19, 13, 14, 43, 11, and 50 respectively for procedures and policies.

History

• Authority: State Plan, Attachment 3.1-A, Page 1.2; 42 C.F.R. Section 440.10-.20, Section 447.371.
• Emergency rule effective October 1, 1993. This Rule effective December 14, 1993.

Ala. Admin. Code r. 560-X-59-.05 Reimbursement

(1) Provider-Based Rural Health Clinics will be reimbursed under a prospective payment system as described in Section 1902(aa) of the Social Security Act. Refer to Alabama Administrative Code Chapter 60.

(2) Inpatient and outpatient surgery is reimbursed as fee for service and is subject to the routine benefit limitations and policies as stated in Chapter 6 of the Administrative Code.

History

• Author: Carol Akin, Associate Director, Clinic/Ancillary Services
• Authority: State Plan, Attachment 4.19-B, page 1; 42 C.F.R. Section 405.2401-.2472, Section 410.152, Section 413 Subpart D, Section 447.371.
• Emergency rule effective October 1, 1993. This rule effective December 14, 1993. Amended: Filed December 7, 1994; effective January 12, 1995. Amended: Filed May 11, 2001; effective June 15, 2001. Amended: Filed March 14, 2002; effective April 18, 2002.

Ala. Admin. Code r. 560-X-59-.06 Medicare Deductible And Coinsurance

For Provider-Based Rural Health Clinic services, Medicare deductible and/or coinsurance 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, Attachment 4.19-B, page 10. 42 C.F.R. Section 405.2410; Section 413 Subpart D.
• Emergency rule effective October 1, 1993. This Rule effective December 14, 1993. Amended: Filed March 14, 2002; effective April 18, 2002.

Ala. Admin. Code r. 560-X-59-.07 Change Of Ownership

The provider must notify Medicaid within thirty (30) days of the date of ownership change of a Provider-Based Rural Health Clinic. The existing contract will be automatically assigned to the new owner. 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 tine period; then the clinic's contract shall terminate.

History

• Authority: 42 C.F.R. Section 405.2470, Section 405.2436-.2438.
• Emergency rule effective October 1, 1993. Permanent rule effective December 14, 1993.

Ala. Admin. Code r. 560-X-59-.08 Copayment (Cost Sharing)

(1) Medicaid and Medicare/Medicaid related recipients are required to pay and Provider-Based Rural Health Clinics are required to collect the established copayment amount for each clinic visit.

(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. Section 447.50; Section 447.53; Section 447.55; State Plan, Attachment 4.18-A and 4.19-B.
• Emergency rule effective October 1, 1993. Permanent rule effective December 14, 1993. Amended: Filed January 19, 2011; effective February 23, 2011.

Ala. Admin. Code r. 560-X-59-.09 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 recipient, 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.

History

• Authority: 42 C.F.R. Section 447.15; State Plan, Attachment 4.18-A.
• Emergency rule effective October 1, 1993. Permanent rule effective December 14, 1993.