Alabama Medicaid Nursing Home Rules

Medicaid is a health care program that is run in combination with state and federal guidelines. Although the program is funded by the federal government, it is up to each state to set the rules and requirements for any given person living in the state. Therefore, the requirements for health care facilities to be part of the Medicaid program, as well as the requirements for individuals using Medicaid coverage, are different for every state.

Definition of Nursing Home

• A nursing home can be a profit or nonprofit institution that is publicly or privately owned. These facilities are responsible for providing care to anyone, no matter what their age, who suffers from a physical or mental condition that does not allow him to take care of himself. However, a nursing home is not a primary facility for the treatment of mentally ill patients.

Alabama Rule No. 560-X-10-.02

• Alabama Rule No. 560-X-10-.02: Long-Term Care Program states that all nursing homes in Alabama that qualify for the Medicaid program need to operate efficiently so that optimal nursing services are provided to patients. This rule also states that the nursing facility must meet the requirements for licensing through the Department of Public Health, in addition to certification requirements of Title XIX and Title XVIIII of the Social Security Act. Additionally, under this rule, all workers must meet the specifications of the state for providing nursing care.

  Furthermore, according to this rule, all Medicaid certified nursing facilities must comply with Title VI of the Civil Rights Act of 1964, the Federal Age Discrimination Act, Section 504 of the Rehabilitation Act of 1973, and the Disabilities Act of 1990. All policies and procedures for providing care and collecting payment must remain the same for everyone, regardless of their method of payment. The rule further requires that all beds be in good operating condition and that the nursing facility must be certified for Medicare Title XVIII in order to participate in the state of Alabama's Medicaid program.

  Alabama nursing homes that qualify for Medicaid must produce two documents: the Provider Agreement and the Nursing Facility/Resident Agreement. Finally, nursing facilities are to accept payments in full and cannot require third-party information for payment.

Alabama Rule No. 560-X-10-.03

• Alabama Rule No. 560-X-10-.03: Enrollment and Participation requires that all nursing facilities that wish to partake as part of the statewide Medicaid program must meet certain state requirements. First, the facility must possess certification for Medicare Title XVIII. Second, a budget for the facility must be provided to the Alabama Medicaid Agency Provider Reimbursement Division. This will ensure that the facility has met certification requirements. Until the facility presents this information, the institution cannot be paid by that state Medicaid program. Additionally, in order to enroll and participate in the Alabama state Medicaid program, the facility must execute a Provider Agreement with Medicaid and a Nursing Facility/Resident Agreement with all of their Medicaid residents.

Alabama Rule No. 560-X-10-.06

• Alabama Rule No. 560-X-10-.06: Therapeutic Leave explains the requirements of the nursing facility to document the therapeutic leave of any patient under their care who is covered under Medicaid. A therapeutic leave is described as a patient leaving the nursing home to visit with friends, family or home. To be covered by Medicaid, each therapeutic leave may not be for more than three days at a time and cannot exceed a total of 14 days in a month. The rule further states that Medicaid is not required to keep records of therapeutic leave and the nursing facility is required to send a copy of this state Medicaid policy to the resident and the resident's legal guardian.

Alabama Rule No. 560-X-10-.07

• Alabama Rule No. 560-X-10-.07: Review of Medicaid Residents states that the Medicaid program in the state of Alabama has the right to audit nursing facilities regarding patients' records. The rule outlines the procedures for such auditing. First, the facility is notified by letter. The facility is given 10 days to produce the records requested. If the records being requested are not submitted within the 10 days, the facility is administered a $100 nonrefundable fine for each patient record not submitted. The facility can avoid such a fine by producing the records on time or requesting an extension. The Medicaid program will grant such extensions to facilities as long as they present good cause.